National Health Service and Community Care Bill

HL Deb 19 April 1990 vol 518 cc183-223

House again in Committee on Schedule 1.

Lord Ennals moved Amendment No. 6: Page 63, line 9, at end insert ("of whom not less than one quarter shall be persons nominated by local authorities in the area concerned.").

The noble Lord said: In moving Amendment No. 6, I wish to comment also on Amendment No. 13. I hope that the Committee will permit me—it may speed up some of the later amendments—if for the record I make a few comments on where we have now reached, putting the amendment into context.

It is not my view that the health service will be necessarily improved by the new style business executive type of authority. The noble Lord, Lord Jenkin of Roding, implied that I was not totally converted; I am not. I have read all the reports of the debates in another place. Every proposal that was made from Members other than government supporters was rejected. One Conservative amendment was accepted.

Lord Henley

I do not think that any amendment was accepted. I believe that my noble friend said that she would take it back and consider it.

Lord Ennals

The amendment came back on Report stage. I cannot quote from the record at the moment; I shall inform the noble Lord. I believe that I am right. If not, I shall apologise.

On looking back, what happened when general managers were appointed? New people were appointed from outside the National Health Service on the basis of the recommendation of the first Griffiths Report. Most of those who applied from within the service did not obtain the posts, and those who were appointed were from business, retired from the armed forces and from other situations.

My impression is that most of the appointments did not last. Either the people were not up to the job, they did not find the job conducive because they did not understand the National Health Service, or they decided that they would go to some other field. There was a very high departure rate. I do not expect the Minister to answer now; but I should be very interested to know how many of those who were first appointed under the new structure of general managers still remain in post today and what happened when others left. In most cases administrators who had worked for some years within the National Health Service were appointed.

The Government now have the concept that everything must be run on business lines; that one does not need to have people who understand anything about the health service; that one needs to have people with executive, business and managerial experiences. Their concept is, "Out with the people who had been elected to local authorities and served on health authorities. Out with people who had worked with voluntary organisations." Such people had experience within various specialist bodies—welfare of patients, specialist knowledge of the disabled, and what-have-you. And in come who? At some stage today perhaps the Minister will tell us which people she expects to come on to these new slimline, streamlined health authorities. Who are these new people to be? Are they to be leaders of industry and commerce? I do not believe so. They would not come; they are too busy. One might obtain second or third rate people or those with a specific business interest for whom the health service might provide some business benefits.

Are the Government satisfied that these new authorities will be more efficient than present authorities? I must assume that the Minister is quite dissatisfied with the present performance of regional and district health authorities. I agree if she were saying that they could be improved; that they are too big. There is a range of issues with which I could agree. But what makes her believe that this business plan will be better? The performance of business these days leaves much to be desired, perhaps even more than the performance of health authorities. There seems to be a record level of bankruptcies. Standards in the City are not all that satisfactory. There do not seem to have been pilot studies on the new style health authorities let alone the internal market, NHS trusts, GP budget holding, and so on.

I am not convinced that the proposals in Schedule 1 are necessarily in the best interests of the National Health Service. I hope that the Minister may at some stage be able to say something to convince me. I am certainly open to being convinced if evidence is given. My impresssion is that it is a shot in the dark. On Second Reading I prophesied that there would be troubles and chaos. What makes the Minister so confident that I am wrong?

I refer specifically to the amendment before us. I understand the laughter from noble Lords—I am laughing myself. To get this off" my chest may make it a little easier for me to move some of the later amendments.

The Government's decision to remove all local authority members from membership of health authorities is in my view a very retrograde step. It can be argued that the performance of some local authority members has not been too high, and that those who are now appointed are not necessarily the best members of the authorities. There are many reasons why one can understand that that may be the position. There may be too many of them. Those are matters that we can consider.

However, I am deeply concerned at the thought that at one fell swoop we create bodies with no guarantee that anyone on these new bodies will have any experience of that part of the NHS and community care which is dealt with by the Bill. It is extremely important that health and community care are considered together. Personal social services are the foundation of care in the community. There is a very close link between care in the community and standards of health. We are talking about a continuum of care of people who become ill. They may not go into hospital. They may be under the care of their GPs. They may be under the responsibility of the social service department. They go into hospital; and they come out. It is a movement back and forth. I find it deeply disturbing that we have no assurance that there will be someone who is closely in touch with the performance of social service authorities.

It may have been an error of my predecessor, Mrs. Castle, in increasing the number of local authority representatives. However, she was well aware, as I am, that there was little accountability within the National Health Service. She wished to do something about it. The Government are ensuring that there is no accountability within the new structure that they propose. I introduced joint planning and joint funding;. That made a contribution but I expect that eventually it will disappear. There is little basis for that if one takes away from health authorities people who have had experience with local authorities, particularly in social service departments. It is disturbing that the situation is real.

It is strange that, while the Government have set as one of their aims the improved responsiveness of the service to consumers, they should at the same time seek to remove elements of local accountability from health authorities. That curious contradiction did not escape the attention of the Social Services Select Committee. In its eighth report (1988–89) it stated: If district health authorities are to be able to fulfil their public health role in identifying local needs and planning services accordingly, as well as responding to the needs and wishes of their resident imputation, some form of local representation must be retained". We have already argued about representation and I am not repeating that. I am arguing the case for drawing on people's experience and in this case those in local authorities. A later amendment relates to district health authorities.

The Royal College of Nursing endorsed that view. It stated: The college believes that it is essential that a public health service displays a high level of public accountability by all those responsible for taking key decisions. To this end the RCN would favour stronger consumer representation". We deal with different aspects of consumer representation; for example, people with local authority responsibility. One way of achieving that representation would be to increase rather than remove the proportion of local authority members drawn from people with experience of local government.

Finally, I wish to emphasise the point made about local accountability. The Government have used the argument to justify the community charge. However, it appears to be cut down to size if we seek to have no degree of accountability within the National Health Service. I hope that the Government will think again and recognise that there is an important role to be played in regional health authorities by people with local authority experience. It is disturbing to note that the Government appear to be moving in exactly the opposite direction. I hope that the Minister will explain the basis of government thinking. I beg to move.

8.45 p.m.

Lord Jenkin of Roding

We must be thankful for small mercies and for the fact that "twixt the syrup and the cup" one-half has become one-quarter. I only hope that as a result of our brief debate the other quarter will be removed.

A complaint that I heard particularly from clinicians but also from other professional people involved in the management of the health service was that in too many cases local authority participation was completely irrelevant. One has heard stories of local authority representatives arriving at regional or district health authority meetings obviously not having opened the envelopes containing their papers.

Perhaps I made a mistake in reversing the Castle reform by having half the number of health authority members on local authorities. Perhaps I should have had the courage to say that there was no role for them. Of course we can have joint funding. We built on that and I have always given credit to the right honourable gentleman for the initiatives that he and his predecessor took in that regard. Inevitably that hits a ceiling because health authorities cannot continue to pay their share unless other projects disappear at the far end. Nevertheless, considerable efforts have been made. However, the right honourable gentleman—I beg his pardon, I mean the noble Lord—

Lord Ennals

Both!

Lord Jenkin of Roding

That is right. The second part of the Bill dealing with community care adopts a different approach from what may be called "Griffiths 2". That proposes that a large part of the care in the community should be returned to local authorities with specific earmarked funding. In a sense, that is the solution for which we have been groping for a number of years and which, after some hesitation, has been adopted by the Government. Therefore, the main burden of the noble Lord's argument falls to the ground. If we are to have smaller professional managerial bodies running the health service it would be a nonsense to have statutory representatives. And what would they be but representatives of local authorities?

I hope that the Government will stick firmly by their policy and that we shall have seen the last of the local authority representatives appointed as such. It may be that in many areas competent local people with a considerable contribution to make will be councillors. That would be a happy coincidence and there is nothing in the Bill to prevent it. However, it would be a grave mistake to retain the statutory representation of local authorities on health authorities.

I wish to take up a further point made by the noble Lord and I believe that he will continue to make it throughout our discussions on the Bill. We should be aware that he will use the language of the City; that is "business management" and "profitability". Such metaphors will be used—

Lord Ennals

Buzzwords.

Lord Jenkin of Roding

Health authorities should have had budgets for a long time but in that sense this is not a commercial exercise. It is not simply a question of subjecting decisions to the test solely of value for money or of profit. Anyone who has read the White Paper will recognise that the quality of care will be equally important in the agreements which the purchasers will make with the providers. They will want to ensure that effective quality will be provided. Why else does the White Paper contain so much about medical and clinical audit? One must also ask the question: why are some doctors so terrified that some of their practices will now be subject to external scrutiny? It is so that we shall not have the situation of certain categories of specialists in some areas being able to carry out eight to 10 operations per week while others carry out only one or two. One will see quality at the heart of the proposals. I hope that as the noble Lord develops his arguments against the Bill he will not try to exaggerate and say that it simply sets up a market which will be determined on narrow commercial monetary grounds. No one reading the White Paper could conceivably argue that point.

In our first debate today the noble Lord, Lord Winstanley, said that there is a great deal of common ground on many aspects of the Bill. I hope that that will be so. As the arguments have unfolded some of the worst fears have been shown to be groundless. As the arguments have developed in another place and in the country as a whole some of the professional anxieties have been patiently and consistently answered. There are some issues about which we can argue perfectly properly, but to base the argument on the foundation that this is an entirely new commercial venture where profit, balance sheets and so forth will be the only criteria of success is to mislead the public and waste the discussion time. As regards local authorities the Bill has the right answer; good councillors should be appointed where appropriate but there should be no statutory representation.

Lord Kilmarnock

Did I hear the golden words "specific earmarked funding" fall from the noble Lord's lips in relation to that part of the Bill dealing with community care? Is that his understanding of the Government's intention? If that is so, is that the Government's intention?

Lord Jenkin of Roding

It may be that I used the word "earmarked" meaning that the money is used separately. That may have been an exaggeration. I was referring to the specific additional funding to fund an additional burden which is being placed on local authorities. That is as I understand the matter and my noble friend on the Front Bench will correct me if I am wrong. That funding will provide a substantial part of any additional expenditure incurred by local authorities for community care.

Lord Kilmarnock

I accept that, although I think the noble Lord went rather too far when he used the word "earmarked".

Lord Dean of Beswick

I did not intend to speak on this amendment. However, as a former councillor who was on the health authority representing the people of Manchester I take the opposite view to that of the noble Lord, Lord Jenkin of Roding. I became the last deputy chairman of Manchester executive council of health. As regards accountability to the customer, I do not believe that the health service has progressed one iota. In fact, it has gone in reverse by virtue of what the noble Lord who has just spoken has done.

In my time as deputy chairman of Manchester executive council of health I was chairman of certain service committees to which the people had ready access. That was to try to discipline general practitioners who were not behaving too well; and, by God, they need some controlling in the ways in which they operate.

I was also chairman of service committees dealing with cases of complaint against the dental and pharmaceutical professions. I believe it would be far better if we reverted to that situation. I may be told that the community councils are there as the watchdogs of the customer. However, they are nothing but talking shops. They carry no weight and are ignored in most instances.

I return to the former Secretary of State for Health. I heard him speak earlier and he made great play of appointing Sidney Hamburger as chairman of Manchester regional health authority. He made great play of indicating his neutrality by saying that he was opposed all along the line by local Conservative MPs and that he was further opposed when he suggested reappointing Mr. Hamburger. I do not wish to be brought into that particular debate but the people in Manchester who had the real interests of the health service at heart did not go along with what Mr. Hamburger was doing. In fact, he was carrying out without argument the policy of the noble Lord opposite and his successor.

Before I left the other place in 1983 I tabled a series of Questions to the noble Lord's successor, who has now stepped down from high office, as regards the removal of Labour councillors from certain positions and in almost every case their replacement by Conservative nominees. Of course, he was totally unbiased. Since I came to your Lordships' House a short time ago I have tried to identify who were those people placed in positions of importance as chairmen of local health authorities. I have never believed that a leader of a local authority should also be the chairman of the health authority. To me that would be absolute nonsense because the two cannot be reconciled. There could be areas of conflict.

Perhaps I may give an outstanding example of that. A few years ago there was a tragedy in Wakefield. I believe that 17 or 19 people in an old people's home died of salmonella or some other form of food poisoning or related complaint. What emerged from that indicated that I was not as wrong as Government Ministers thought. At the time the leader of Wakefield health authority was also the leader of the local authority. Strangely enough—and I am not attacking local Conservative politicians—the leader of the other district authority in the area, the Pontefract authority, was the deputy leader of Wakefield Metropolitan Council. When a distinguished QC was called upon to report on what had taken place and how those people had come to die there was, without any question, implied criticism of the chairman of Yorkshire Regional Health Council, who was a Conservative supporter and a former chairman of a constituency in Yorkshire, and the chairman of Wakefield health authority, who, as I said, was also chairman of Wakefield City Council and a member, I am sad to say, of my party.

That proved my argument. However, what did the Minister do? Members of the Committee can guess who were the only three people to be reappointed; namely, the three people who were criticised in the inquiry called for by the Minister into what had taken place. The other chairman from West Yorkshire, from Kirklees and Bradford who had good records were not reappointed. However, the people at whom the criticism had been directed for failing in their duties were reappointed.

I do not know whether the noble Lord, Lord Jenkin, has had close contact with and experience of local authorities. I am not saying that everything is right with local authorities. I was a critic of the Seebohm Report and the proposed huge social security departments. Rights of the local people who wished to complain about what was taking place were taken away from them. The reorganisation took away some of the responsibilities from local author: ties and placed them with unelected people. That was a disaster of the first magnitude.

We have now turned full circle. The Government are now saying that care of the elderly should be given back to local authorities. They are saying that it is not remedial medicine but concerns dealing with people who are at the end of their lifespan. That will happen increasingly. However, that was the case before with welfare homes.

As a young councillor in Manchester I recall the opening of the first welfare home. That was tremendously well received. Those homes were built in order to look after people who could, for the most part, care for themselves. What happened within a few years? They became dumping grounds for geriatrics. The National Health Service unloaded them into those homes. When I visited those homes as a Member of Parliament I was horrified because if those people were looked after properly that needed to be done on a nursing ratio of one to one. They became homes for people who did not know what day it was. That is what I believe the noble Lord, Lord Jenkin of Roding, has just tried to defend.

I am not for one moment saying that all local authority councils, whether Labour, Conservative or Liberal, do their job well. There are those which fail in that. However, to assume that the Minister has picked a good man for the team and can never be wrong is absolute nonsense.

Before I sit down I will give an example of something which took place a few months ago. I was sitting in the Pugin Room having a drink and there were some people there from the South West, not of my party. Among them sat a Member of Parliament who is a present Secretary of State in another department. As they broke up I happened to say to one of the Conservative Members of Parliament, "I think I know one of the gentlemen with you from my old local government days". He said, "No, I do not think he has ever been in local government. He is the chairman or secretary of our community health council". I said, "What is he doing here?" He said, "We have been objecting to the performance of our district council chairman"—a well-known figure in that particular area of the South West, a Conservative lapsed councillor. They solved the problem; they accepted the strictures of the people of the area that that Tory was doing a bad job. But a month later they made him the regional chairman. Their own Members of Parliament had asked to get rid of him and they appointed him regional chairman. One cannot get away with that and say, as the noble Lord, Lord Jenkin, said, politely, that it is wrong to involve local councillors.

I used to have a weekly surgery in a densely-populated area. If something went wrong involving general practitioners—not with the hospital service, which we never touched—that was the best and only way of keeping any form of control. One can forget the general practitioners' committees. I have just had an experience with them in Manchester. One morning I was informed that my two doctors had decided to retire and that if I wanted I could go a mile up the road and perhaps register there. That affected nearly 7,000 patients in the area where I lived. It happened because of appointments by Ministers of those they think are marvellous men. They may well be. I accept the point made by the noble Lord, Lord Jenkin of Roding, that he tried to be unbiased. I recognise that from some of the people whom he appointed. However, if he will look through the present list of regional chairmen of health authorities and district authorities he will find a totally unacceptable number of Conservative nodding donkeys. If that is his idea of how to democratise or make the National Health Service more accountable without hindering its progress, he is talking absolute rubbish and will have to do better next time.

9 p.m.

Lord Auckland

I believe that there needs to be a distinction in this amendment between urban authorities and rural authorities. In a large conurbation, although I have never served on a local authority, I should have thought that it is much harder to appoint suitable people with the time to serve on those authorities than it is in rural communities where local authorities and the local hospitals and the cottage hospitals may be much closer. I should be happier if the amendment was a little more flexible. I believe half is too large a figure; but, having said that, I believe every encouragement should be given for nominees from local authorities to become involved on these committees, particularly in rural areas. There is need for more flexibility so far as the amendment is concerned.

Lord Henley

I had not intended to digress on the subject of the role of regional health authorities. My noble friend referred to that at Second Reading and it is covered in the White Paper. Perhaps I can start by dealing with one of the points made by the noble Lord, Lord Ennals. He asked what type of people will be the new non-executive members of the regional health authorities. Will they be businessmen? The Bill says nothing whatever about who the non-executive members will be. Some will undoubtedly be drawn from the business world, but others will be drawn from a wide variety of backgrounds. In general they will all have links with the local community through either residence or work and will therefore be sensitive to its needs. I can only emphasise that suggestions for membership will be welcomed from all quarters. They will no doubt include people who, as my noble friend Lord Jenkin suggested, will be local councillors.

The noble Lord, Lord Ennals, said that he was not arguing the case for local authority representation. So far as I could make out he seemed to be doing just that. Councillors are elected to run their authorities and are accountable to their electors for the job that they do. They are not elected to run the National Health Service. The National Health Service is a national and not a local authority service. My right honourable friend the Secretary of State is fully responsible to Parliament for the National Health Service and he carries out his statutory duties through the health authorities. They are responsible to him and he accounts to Parliament.

The presence of local authority nominees undermines that line of accountability. The risk is that councillor-members will purport to represent their electors or their local authorities rather than carrying out their proper management role, which is to run the local health service in the light of local needs and circumstances and with the resources, policies and priorities established by the government of the day. That is a recipe for conflict and confusion and too often gives rise to political posturing which is not in the interests of the smooth running of the service.

The two amendments of the noble Lord concern regional health authorities. As the noble Lord knows, these are strategic bodies accountable directly to the Secretary of State. They are responsible for the oversight of their districts, for the allocation of resources and for the planning, monitoring and review of performance. It would be entirely inappropriate for these bodies to be dominated by local authority representatives for the reasons I explained.

I certainly share the view on the importance attached to collaboration between health and local authorities. However, it is entirely erroneous to maintain that that can be achieved through cross-membership. The important thing is active collaboration on the ground, based on a good working relationship.

Lord Dean of Beswick

Perhaps the Minister will allow me to ask how he will deal with the situation if there is a serious concern in an area about the performance of the health authority, be it district or regional, and no one, including the Secretary of State, is concerned? I made out a case concerning what was done in Yorkshire by a former Secretary of State for Health. There was an almost total lack of confidence in what had taken place. In such a situation is the Minister saying that the Secretary of State, whoever he may be, shall be deemed to be totally infallible and will do what is right? Does the Minister not understand that where things are going radically wrong the only safety valve is those people who face the ballot box—the local authority representatives?

It is no use the Minister saying that the Government have decided that it is a national service and that local authorities are there only to provide local services. Over the past 10 years the Government have removed from local councillors almost any vestige of the right to govern local authority areas, and have given increased powers in education, housing and so on to the Secretary of State to do what he wants. The Minister will have to do a little better than that.

Lord Henley

As I said, the regional health authorities are strategic bodies accountable directly to the Secretary of State. The Secretary of State is directly accountable to Parliament. Another place is filled with elected representatives from local areas. That gives the noble Lord all the accountability he asks for.

Lord Dean of Beswick

The Minister is missing the point. I know that Members of Parliament are available but they are not available at the same level, and because of other committments they do not have the same personal contacts as people who live and operate in the local area. The noble Lord will have to do a little better than that.

Lord Henley

A great many elected Members of Parliament live in their areas. I am sure that all good local Members of Parliament—I am sure the noble Lord was one when he was in another place—hold surgeries. They see local councillors. The Secretary of State is accountable to Parliament, and in another place there are elected Members. Having said that, I hope that the noble Lord, Lord Ennals, will accept that the amendments are not consistent with our efforts to improve the management of the NHS for the benefit of patients and will not wish to press them.

Lord Ennals

I am grateful to the Minister for his reply, which I found very unsatisfactory. I am not trying to suggest that local authorities should have powers to appoint councillors to health authorities. I am suggesting that among those who should be brought into membership of those health authorities, a significant number—I say up to a quarter—should have local authority experience.

Lord Henley

Perhaps I may repeat one point. Suggestions will be welcomed from all quarters. As my noble friend Lord Jenkin said, some local councillors might in time be appointed. But we do not accept the argument that at least a quarter should be appointed from the local authorities.

Lord Ennals

I know that I shall hear this argument on every amendment that I move this evening. The Minister will not say any more than he and his Secretary of State have said. He is keeping his cards close to him. Clearly he has decided what should be the size of both the regional and district health authorities. He will not move from that and so I shall hear that answer again and again.

I want to try to persuade the Government that the new authorities are more likely to do their job if they have 01 them people with a full understanding of the health service—I include professionals, a point which we debated on the previous amendment—and a full knowledge of the community for which the health service provides a service. In this amendment I want to try to persuade the noble Lord that there should be people not appointed by local authorities but with local authority experience, people who, as my noble friend Lord Dean said, have had to face election at the ballot box.

I have always felt that we ought to try to find ways in which our health service can be more responsive to the known views of the public, and in particular the public in the region or in the district. The Government are going in the opposite direction. The noble Lord, Lord Jenkin, suggested that somehow or other professionals working in the health service were being quietly persuaded of the wisdom of the Government's proposals. I do not know whether he has read the statement made by 25 professional organisations within the National Health Service, organisations such as the Royal College of Nursing, the Royal College of Midwives and the professions complementary to medicine. There is no sign that they have accepted the Government's proposals.

The noble Lord also said that there is growing public support for the proposals. I have before me the last five recorded figures of Gallup on public attitudes to National Health Service reform. In June last year 15 per cent. approved and 71 per cent. disapproved. By the time of the fifth survey in March, 11 per cent. approved, 77 per cent. disapproved and 12 per cent. did not know. All the signs are that the public is moving away from the proposals and is not in favour of them. It is doing so partly because the Government are being so insensitive.

I want to do some prescribing. I want to ensure that in some ways various groups do not have their representatives but people who are drawn from that body of experience. As regards this amendment, it is the body of experience of the people who work in local authorities and especially of those believing that their skills will be helpful in the whole field of community care and the relationship that will necessarily exist and which must develop between health authorities and elected local authorities. I do not intend to press this amendment to a Division. Therefore, I beg leave to withdraw it.

Amendment, by leave, withdrawn.

[Amendment No. 7 not moved.]

9.15 p.m.

Lord Ennals moved Amendment No. 8: Page 63, line 9, at end insert ("which shall include at least one person representative of such community organisations within the Region in question as seems appropriate to him;").

The noble Lord said: In moving this amendment I shall speak also to Amendments Nos. 21, 32, 40 and 50. They deal with the question of community representation. The words "community representation" are not the best ones. Representation refers to someone who is drawn from that body of experience who understands the views of the community organisations. I shall never argue that there should be any organisation that has the right to appoint anyone to any type of health authority.

When the Government launched their review of the NHS in 1988, which eventually gave rise to the White Paper and then to the Bill, they made a good deal of play about being responsive to the needs of the consumer. In her foreword to the White Paper the Prime Minister said simply: We aim to extend patient choice".

I want to ensure that that is done and that consumer choice is extended. That can best be achieved if there are, among those who serve on health authorities, those who have deep contacts with people in the local community. Given the general consensus that local communities need to be given a greater role within the NHS and not a lesser one, as seems to be suggested, it is all the more remarkable that there is not one practical proposal within the Bill which would facilitate this extension of consumer choice. Most significantly, there is no guarantee that local communities will have any say in the working of their health service at the planning level.

This amendment and those associated with it attempt to rectify that situation. In the new-look health service it is intended that authorities should act as purchasers for their local communities, having first assessed local needs. No two local communities have identical needs: each will have a series of unique and complex requirements. For example, on certain parts of the south coast it may be that health authorities will have to gear their services particularly to the needs of the elderly. In metropolitan areas it may be that the needs of ethnic communities are a special consideration. Services in new towns may have to reflect the demands of a larger child population than usual. What better way to assess such needs effectively than by securing input from relevant community groups which have direct experience of the elderly, ethnic minorities or children?

Therefore, it is essential that we should cement the links between health care and community care. I argued that point concerning the previous group of amendments. I argue it now in terms of helping to ensure that it is recognised that people who are particularly associated with voluntary organisations, because of their experience with the elderly, the mentally ill or the mentally handicapped, can have a valuable role and input into the membership of the health authority.

The bridge between the community and the health care system can be built more effectively by fully informing the voluntary sector; providing alternative forms of health care; changing public conceptions about health; acting as advocates for individuals and in developing the promotion of services. The health authorities will operate more effectively if part of their experience is drawn from those who are involved with community activities and who can bring that wisdom to ensure that the new health authorities fulfil their role. I beg to move.

Baroness Hooper

If no other noble Lord wishes to comment, perhaps I may respond by saying that the move away from representative appointments does not mean that health authorities and FHSAs will not have their finger on the pulse of their local communities—far from it. Non-executive members will usually have some connection with the local community, either through residence or employment or because they are active in local voluntary or community organisations. So we believe that they will be very sensitive to the local community needs. Indeed, as we have already established, they could include a local councillor appointed on an individual, personal basis.

Clearly, appointing bodies will wish to receive suggestions from as wide a variety of sources as possible, to find the best possible people. Precisely how that is achieved will depend on local circumstances and local needs. For example, the case of ethnic minorities or special inner city interests will be catered for in those areas where they are of importance. That is why we do not wish to be prescriptive about how it is done from the centre. Nor would we wish to limit the choice locally by giving any one organisation or group of organisations primacy, as is suggested by these amendments. I must reiterate that the key objective will be to appoint the best person for the job.

Community health councils provide and will continue to provide a valuable channel for the views of the health service consumer. Health authorities' meetings will continue to be open to the public so that people from the community will be able to attend and follow the proceedings. In addition, we are funding various initiatives and working with district health authorities in order to help them develop ways of ascertaining consumers' views.

For example, in England in 1990-91 £7-5 million has been allocated to regions and special health authorities for new programmes of local projects to enhance quality. Key themes for the projects will be: improving the environment of patients, assessing the quality of services, delivering a more personal service, improving communications, patient information, and so on. Also, £2.5 million is to be spent on an extended programme of demonstration projects for all, with a strong bias towards the consumer. In addition, among other initiatives the department is funding a project at the King's Fund to give advice and information tailored to health authorities' individual needs on consumer health issues.

Our reforms in the White Paper promoting public health to which the noble Lord referred have already placed great emphasis on responsiveness to local needs and views. As part of this process we have significantly strengthened local management by introducing high calibre general managers and by strengthening senior management, particularly in the areas of planning and service development. FPCs are already developing detailed profiles of local health indicators as a basis for service development planning. In addition, last autumn we issued guidance on how to assess and take into account local views and opinions on the services provided. The results of these initiatives will be to make local services more responsive to local needs than they have ever been in the past.

The Government are concerned about meeting the needs of the local consumer. I think that must be beyond doubt. Indeed, we firmly believe that the changes proposed in the Bill will make health authorities and family health services authorities more responsive to the needs of the local community and thus be for the benefit of the patients. I therefore advise the Committee to reject the amendments.

Lord Ennals

I am not surprised at the reply given by the Minister but I am not happy with it. I appreciate a number of the things that she has said, one of which was that there might even be a local councillor. I suppose there might even be someone associated with voluntary organisations. There might be all sorts of people, but it all rests with the Secretary of State and those whom he appoints.

I feel it is very unsatisfactory that the Government are not prepared to make much greater commitments as to the nature, the structure and membership of the health authorities. However, I realise that that is what the Minister is required to say and she did so most beautifully. I shall not press the matter to a Division. I shall, as always, read her speech with great care and I may well return to the broad issue of the membership of health authorities at a later stage of the Bill's proceedings. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 9 had been withdrawn from the Marshalled List.]

Lord Pitt of Hampstead moved Amendment No. 10: Page 63, line 9, at end insert ("to include at least one registered medical practitioner.").

The noble Lord said: In moving this amendment I shall speak also to Amendments Nos. 22 and 33. I must confess that I felt most depressed while listening to the tenure of the debate. I believe that the medical profession should be more involved in management. It is especially important now, at a time when the Bill proposes that health authorities take on an extended role, and when they will have additional powers, that the medical voice should be adequately heard.

As I said, I feel most depressed about the matter because I gained the impression that members of the health authorities would be selected on a basis which will exclude clinicians. I cannot really believe that that is what is proposed. I cannot imagine anyone setting up an architectural firm without having architects on the board. I do not believe that an accountancy firm could be set up without having accountants on the board. Moreover, you could not open an art gallery without having artists involved in the decision-making. A firm of engineers with no engineers on its board is bound to be inefficient. Therefore, I cannot understand the attitude about having medical practitioners involved in the decision-making in the health authorities. I wait to hear what the Minister will say because I find the whole approach quite absurd.

Decisions need to be taken with the benefit of the informed and practical medical advice of professiona1s who care for patients on a day-to-day basis. That is what is needed. There are in fact examples of this because at present the best run authorities are those which have doctors acting as their chairmen. I hope that on this occasion we shall get a change from the answers which we have received in respect of other amendments. As I said, I cannot really believe that this is what the Government mean to do.

The Minister spoke about ethnic minority representation. I am sorry, she did not in fact use the word "representation" in regard to ethnic minorities. There are plenty of ethnic minority doctors. I hope that when the Government consult they will consult not only the BMA, but also the Overseas Doctors' Association and the Afro-Caribbean Medical Society.

The doctors concerned do not necessarily need to be elected by any group; but it is important that there should be practising clinicians on the health authorities whose views, as the noble Baroness, Lady Seear, pointed out, would be weighed in the balance and who would play an active part in decision-making. they would sometimes be able to say to the authority, "This can't work; it is rubbish. Please try some other tack".

In most businesses there are people who are experts in the business. I am not just referring to the people who are employed because they would give professional advice. The board has to make decisions and therefore it should also have people with expert knowledge. That is what I am saying when I ask that there should be a medical practitioner on the authorities. As I said on Second Reading, where family health services authorities are concerned there should be more than one medical practitioner.

There should be two who can give expert views on both types of practice. There will be some doctors with their own budgets and others who do not have their own budgets. There should be people with both kinds of experience on the authority.

I plead with the Government to stop taking the attitude that there cannot be experts from the medical profession on the boards; otherwise it will be a matter of representatives and we do not want representation. Rubbish! There must be experts, people who know what they are talking about, involved in the issues. Therefore we need registered medical practitioners on all the authorities.

If in addition one wants to make sure that they are of one's own political persuasion, so be it. However, we must make sure that we recognise—I shall put it another way. I am sure that the Government will not appoint people without requiring them to have skills. Medical knowledge and medical experience are skills; therefore we must have them. That is what I am saying. It is no use saying that there is nothing to prevent us having them. We must be committed to having them. That is what the amendment is about. The Government must be committed under the Bill to make sure that the expertise which will come from clinical medical experience will be represented on the regional health authority, the district health authority, the family health services authority and the hospital trusts. They all require that expertise.

I do not need to go on at great length. I believe I have made the point. When the Minister replies I hope that she will not give me—I was going to say nonsense, but I shall leave it there. I hope she will not give me the kinds of answers we have heard so far because frankly—I shall be honest with the Committee—I have been getting more and more angry. I beg to move.

9.30 p.m.

Baroness Hooper

Nowhere in the Bill do we say that we shall not or should not have a doctor as a non-executive member. I believe that in many cases we shall have medical practitioners on the authorities. I share the noble Lord's concern that all authorities should have access to the best professional advice. We have already discussed this in some detail on a previous amendment but I must repeat that I believe that specifying details of membership in primary legislation is not necessarily the best way of guaranteeing the availability of professional advice to which the noble Lord referred.

Under our reforms, regions will take on the important new role of co-ordinating the provision of services by districts and family health services authorities. In doing so, they will need to draw on a range of professional and medical advice, including that of general practitioners. But that advice may be obtained in a range of ways, through the royal colleges or individual experts, by developing new advisory mechanisms or by building on existing ones. Non-executive members will be appointed in the light of differing local circumstances and differing local needs.

As purchasers of health care, district health authorities will also need a wide range of professional and medical advice to help them assess their local health needs, to appraise service options and monitor the quality and range of services and the health of their population. Again, however, we do not wish to be prescriptive about how they obtain that advice. The optimum means of obtaining appropriate advice will vary from district to district. We expect most authorities to appoint their director of public health as an executive member. In some health authorities it may be appropriate for a GP to be a non-executive member of the district health authority. In others some other representative of the medical profession may be appropriate. However, we believe it is firmly in the court of the appointing region in England and the Secretary of State in Wales to make decisions in the light of local circumstances. To prescribe medical membership in the Bill would simply impose one form of advice over a range of others that might be more appropriate in the circumstances.

I believe that our reforms will help bring about much closer collaboration between primary care and hospital services. I believe that is important. Through their involvement in the contractual process general practitioners will play a key role in promoting that relationship. It is a relationship which I believe will evolve differently to meet specific requirements in different areas. It would be wrong for us to channel it at the outset in the way proposed. I therefore hope that the noble Lord will withdraw his amendment.

Lord McCarthy

I have one or two questions to ask on this matter. The amendment states that regional or area health authorities should, include at least one registered medical practitioner". Therefore my first question concerns the position at the moment. Is it really the case that some regional and district health authorities do not contain a single medical practitioner representative? If that is not the case and they all have at least one, is it the intention of the Government that there shall be one or more health authorities without medical practitioner representatives? I should have thought that that was not the Government's intention. If such conditions exist already and the Government intend that they should exist in the future, why cannot they accept the amendment?

Baroness Hooper

The current position is that there is no statutory requirement on this matter although I understand that in practice all health authorities contain a medical practitioner representative at present. I have no doubt that most health authorities, if not all, will continue that practice in the future. There is nothing to prevent that process continuing.

Lord Pitt of Hampstead

The noble Lord has asked the questions that needed to be asked. I do not see any point in continuing with this matter. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Walton of Detchant moved Amendment No. 11: Page 63, line 11, after ("prescribed") insert ("to include the Director of Public Health.")

The noble Lord said: Amendments Nos. 11, 24, 34, 43 and 53 standing in my name and that of the noble Lord, Lord Hunter of Newington, all have similar objectives. Until about 20 years ago local authorities employed public health medical officers in local areas. However, under a previous reorganisation of the health service they were brought together with the regional and district medical officers into a category of consultant community physicians. They all became members or fellows of the Faculty of Community Medicine.

The profession has decided that it wishes to re-acknowledge the importance of the public health role of community physicians. The regional and district medical officers have now been renamed directors of public health. However, in Wales the comparable individual is called the chief administrative medical officer. The objective underlying these five amendments is to ensure that the executive members of the health authorities, both regional and district, will include under the prescribed number of officers the director of public health, or in Wales the chief administrative medical officer.

Since the inception of the National Health Service the chief officer of the authority and the regional or district medical officer have been regarded as individuals of comparable standing and status whose advice and administrative authority were regarded by the health authorities in question as being in all respects equal. The Bill now prescribes under the various schedules that the chief officer of the authority shall be an executive member. The purpose of these five amendments is to apply the same principle to the directors of public health and the chief medical administrative officer in Wales. I beg to move.

Lord Hunter of Newington

We are now talking about the new public health proposals which are to a substantial degree based on the chief medical officer's report to the department on the future of preventive medicine and public health. That report included a recommendation that the faculty should rename itself, reorientate itself, and retrain itself for a vital new purpose, which I understand the Government approve.

Perhaps I may ask the Minister whether the Government accepted the chief medical officer's report and whether they have any difficulty in accepting the amendments as detailed by the noble Lord, Lord Walton of Detchant.

Lord Winstanley

As briefly as I can I should like to support the amendment of the noble Lords, Lord Walton and Lord Hunter. Members of the Committee may recollect that on previous occasions I have mourned the loss of the old medical officer of health. That was a very important official. Everyone knew who he or she was. He or she was accessible and a person with great authority. I thought it unfortunate that that office disappeared.

I recollect the report to which the noble Lord, Lord Hunter, has referred. I seem to recollect that we debated it in this Chamber. I also seem to recollect that when we debated that report the Government said that they accepted it. If they accepted it then, they should accept it now. The group of amendments would be an improvement and would be helpful.

I do not in any way wish to criticise the newly titled community physicians, having worked closely with many of them, but I believe that the administrative change which led to the change in their official title weakened their authority and lessened their usefulness. If this measure, which is recommended by the profession itself, could restore some of that authority that would be for the public good.

9.45 p.m.

Lord Rea

To return to the earlier discussion about purchasers and providers, the director of public health, through his particular discipline, is the best informed person in a particular community as to the needs of that community. Therefore it is particularly important that he should represent the purchasers. He can inform them as to their epidemiological needs because his department will have made a study of the matter. Therefore his place should be representing people in the district as purchasers of health care. He should be a member of every authority—regional or district. I do not know whether he would have time to serve also on the FHSA, but it would be nice to think that he could also be a member of that authority.

Lord Ennals

With even greater brevity, I should like to support the new title of director of public health. I support the amendment and the arguments of the noble Lords, Lord Walton and Lord Hunter of Newington.

Baroness Hooper

We accepted the Acheson Report. We have acted upon it by appointing directors of public health. One of the duties of the director of public health is to prepare an annual report which will be very important to the deliberations of the health authority. We expect that most regional and district health authorities will appoint the director of public health as one of their executive members in the light of the recommendations of the Acheson Report concerning the public health function. However, we do not believe that seeking to prescribe that the director of public health should automatically be a member, as is suggested by the amendments, would in itself make medical advice any more effective.

It is important that the advice is offered in a timely manner and at the right level. District health authorities as purchasers of health care will certainly need advice on assessing local health needs, appraising service options and monitoring the quality and range of services and the health of their population. We have already established that. It is important that that advice is independent of the district's own provider units. However, in the case of DHAs in England, we would not wish to be prescriptive about how they should obtain that advice. A wide variety of sources are open to them. I have referred to some of them, but they include the royal colleges and professional equivalents, individual national and regional experts, local advisory machinery and local medical committees.

As regards FHSAs' membership, they will have major new responsibilities for assessing local health needs and for developing services to meet those needs. Clearly, that cannot take place in isolation and must involve close working with local directors of public health and their teams. That is particularly important in the key areas of shared responsibility such as health promotion and disease prevention. We recognise that in the past co-operation between DHAs and FPCs has not always been as effective as it could have been, although a great deal of good progress is now being made. For example, most FPCs are already drawing widely on the epidemiological skills and expertise of the directors of public health in developing health profiles and indicators of need for their local population as a basis for effective future planning.

The scope for collaboration and co-operation does not end there. Directors of public health and their staff must liaise closely and regularly with the FPCs' planning officers to carry out their own duties. Similarly, both FPC and DHA staff can participate in joint sub-committees or planning groups set up for the purpose. In addition, directors of public health will continue to be able to attend full FHSA meetings for any specific items of joint responsibility or mutual interest. Flexible local arrangements of that kind are preferable to rigid central requirements. They have the advantage of making maximum use of those valuable officers' time while at the same time ensuring the necessary public health input to FHSA planning.

A further issue that I should perhaps mention is that FPC boundaries, unlike those of other health authorities, correspond to local authority boundaries. Over half the FPCs in this country therefore relate to more than one DHA and, in one or two exceptional cases, up to as many as eight. It is clearly important that FHSAs should relate equally to and work closely with directors of public health in all the health authorities which relate to their locality. In most cases it would be inappropriate to appoint one director to the FHSAs over all others.

We do not therefore accept that there is any practical benefit to be gained from the amendment and I therefore trust that the noble Lord will feel able to withdraw it.

Lord Hunter of Newington

Perhaps I may ask the Minister a question: is the national reflection of the policy that she has outlined the fact that the Chief Medical Officer attends the National Health Service Policy Board not by right, but by personal invitation?

Baroness Hooper

Yes. That is a good example of the right appointment being made on a personal basis.

Lord Winstanley

Perhaps I may also ask the noble Baroness a question. She said that she expected most of the authorities to have the director of public health as a member. Would she like her expectations to be fulfilled? That is all that we are seeking to do.

Baroness Hooper

Yes, and I expect that they will be fulfilled, but without the kind of prescriptive arrangement proposed in the amendment.

Lord Walton of Detchant

The argument put forward by the noble Baroness in relation to the family health service authorities is persuasive. I accept the point that she made. However, I still cannot see why it is not possible to have the director of public health prescribed in the Bill as a member of the regional and district health authorities when the chief officer of those authorities is nominated in the Bill as such a member. However, I shall ask leave to withdraw the amendment today but retain the right to come back on this issue again at Report stage after further consultation.

Amendment, by leave withdrawn.

[Amendments Nos. 12 and 13 not moved.]

Lord Peston moved Amendment No. 14: Page 63, line 21, at end insert: (" () No person who is a member of the Regional Health Authority shall own shares in or be otherwise involved with the private medical sector. () A register of Regional Health Authority members' interests shall be established in which members will declare their business interests. This register shall be open to public scrutiny.").

The noble Lord said: This amendment is grouped with Amendments Nos. 27, 37, 47 and 57. In speaking to this amendment I think it is as well to reflect on the arguments that the Government up to this moment have put forward on other amendments. Essentially those amendments urge that on the various authorities that we are considering this or that expertise ought to find a place. It ought to find a place on the face of the Bill.

To appreciate the absurdity of the Government's response to the amendments, one must bear in mind that from the way in which the Government have been arguing it logically follows that if, for example, on a regional health authority there were no doctors, nurses or medical people whatsoever, the Government would regard it as a perfectly acceptable state of affairs. That is what the Government argue and logically that is exactly the Govenment's position. It is the one that the noble Lord, Lord Jenkin of Roding, put forward.

They have the concept of an efficient operating board on which they want to put the best people. If the best people happen to comprise a given number of managers of First Division football clubs, so be it. One ought to appreciate the nonsense that lies behind the Government's approach to these matters.

Lord Jenkin of Roding

I never said anything of the sort and nothing that I said could conceivably have been interpreted in that sense.

Lord Peston

I beg the noble Lord to read his own speech and appreciate the logic of his own position. The logic, which is also the logic of the noble Baroness's position, is just that. It may be one of those people will be appointed and the Government would like that; but it may be that it is not one of those people, in which case the Government could live with that as well. One ought to appreciate the nonsense that is being offered to us on amendment after amendment. I bring up that point as a preliminary remark to my amendment, which represents the reverse position. My amendment concerns who ought not to be on those authorities. There is now the converse case. I shall be interested to discover how the Government get round that point.

I do not believe that the question of conflict of interest and matters to do with standards in public life arise solely because of the Bill that is before the Committee today. It is a problem that those of us who are concerned about the National Health Service, to take an example, have looked at with some worry for a very long time. I am often concerned about the fact that on existing bodies one finds nominated people who do not use the National Health Service. I have often wondered what they personally feel is their role when they have not found the National Health Service appropriate for themselves, even though they feel perfectly happy to be appointed to those bodies.

That is one aspect. What worries me much more is the fact that people have been appointed or a fortiori are very likely to be appointed, so far as I understand under this Bill, who have conflicts of interest with their role on a regional authority, district authority or FHSA. The Committee is well aware of questions of standards in public life. In this Chamber these matters are taken very seriously indeed. On the whole, noble Lords try to remind colleagues when they have an interest. Also on the whole, to say the least noble Lords are chary of voting on matters which may affect their own interests. So we know about these matters.

I shall concentrate on the regional health authority for the moment because the logic of the argument applies everywhere. As I understand it, at the moment under the Bill it is perfectly possible to appoint to a regional health authority a person who has interests in, as it were, the private medical sector. I use the term broadly. Certainly it includes one who could make gains as a result of the contracts which are laid out or as a result of the success or failure—possibly the failure—of certain activities in the region. My view is that if a person who has such an interest had a proper standard of behaviour, he would simply say, "I am not qualified," and would not agree to be appointed. That is what one means by standards in public life. However, he may not say so. The reason for putting down the amendment is to provide that such persons should not be appointed, whether or not they say that.

I regard the related amendment as supplementary and second best. At the very least regional health authority members, district health authority members, and FHSA members should declare any business interests that are relevant to their sitting on these bodies. In other words, at the minimum they should be willing to make it public knowledge that they are aware of possible conflicts of interest, that the public would know that, and that they would not act in a way that was in their own interest.

Let me go further. I have tried to scrutinise the company legislation as it applies here. Much English law deals with conflict of interest. I have not yet been able to get the position straight; I am trying to obtain advice on it. Could someone who was, for example, part owner of a private sector hospital sit on one of these bodies? Would that properly fall within companies legislation? I have not been able to obtain an answer to that.

Those are my anxieties. No matter what argument may be put forward on the ground of efficiency, such people should not be appointed to these bodies under any circumstance whatsoever.

To return to my slight conflict with the noble Lord, Lord Jenkin of Roding, I do not believe that there is a great shortage of excellent people to serve. We can therefore do without any people for whom there would be any conflict of interest.

Baroness Hooper

I have tried to establish over previous amendments that we do not wish to be too prescriptive about appointments. I intend to be entirely consistent in relation to the amendment.

There are in any event safeguards. The membership and procedure regulations for both health authorities and FHSAs make it very clear that a chairman or member of a health authority is required to declare any pecuniary interest, direct or indirect, in a contract or any other matter that is the subject of consideration by the health authority. He or she may not then take part in any consideration or discussion of the contract or other matter or vote on any question in respect of it. This requirement also has teeth. The membership and procedure regulations empower the Secretary of State to terminate the appointment of a chairman or member who has not declared a pecuniary interest as required under the regulations. These provisions will be retained in the revised membership and procedure regulations. We do not therefore see any need to alter an arrangement that works well at present.

Individuals with connections with the private medical sector may well have experience that could be useful to the National Health Service. It would be pointless, and over-restrictive, to legislate totally to exclude such people from membership of all health authorities and FHSAs.

I have outlined the current provisions that adequately cover the declaration of interest when any contract is under consideration. As my honourable friend made clear during Committee stage in another place, health authority appointments will not be made where it is clear that there will be a substantial conflict of interest in relation to that authority. That might be because of the extent of the potential member's interest in private health care or some other matter concerned with the health authority's work.

A requirement to establish a register of members' interests can also raise more problems than it solves, particularly in respect of bodies which essentially are managerial and not representative. It would be difficult to draw up an adequate definition of what is an interest. It would also be a massive and expensive operation to police such a scheme across 14 regional health authorities, 199 district health authorities and 98 FHSAs. I fear that the introduction of such a scheme would create more problems than it would solve.

I conclude by emphasising the fact that we believe that the current arrangements which are based on statutory requirements work well. Therefore there is no need for the amendments.

10 p.m.

Lord Peston

I thank the noble Baroness for her reply. I do not accept that the present arrangements work well. As regards a conflict of interest, when the Bill becomes an Act the problem will be intensified. To say the least, I utter my normal warning as I have in respect of other legislation.

I am genuinely puzzled about the register. I do not believe that the question of definition arises. I should say to the relevant people, "I should like you to specify what your relevant interests are". I should assume that I was dealing with men and women of honour, and that they would state their interests. That is done in this Chamber where there are no definitions. I should simply rise and say, "I am the owner and director of a private hospital and I must declare that before discussing the NHS". I hasten to add that I am not the owner or director of a private hospital, but when I speak in this Chamber I am in no doubt about what I must say. As a university teacher, I dare not speak on the question of university pay. It is pretty bad but I never emphasise the point as Members are well aware. Therefore, I do not understand the Minister's point about the register.

Although I shall not press the amendment at this hour, I believe that the Minister should reflect on it. The question of standards in public life is not trivial. We must always be vigilant because difficulties are always likely to arise in this area. When we have the first of possible scandals in the next few years I do not want to be the one to say, "I told you that it was in danger of happening". However, I have made my point and moaned on for long enough. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Ennals moved Amendment No. 15: Page 63, line 21, at end insert: ("() Without prejudice to the generality of the preceding sub-paragraph at least one person appointed under sub-paragraph 1(b) above shall be a person with special knowledge of the needs of disabled persons and in selecting any such person regard shall be had to the desirability of the person with that knowledge being a disabled person.").

The noble Lord said: I wish to speak also to Amendments Nos. 26, 36, 45 and 55. I wish to read out the amendment in case any Member of the Committee believes that it is prescriptive about a disabled person having to be a member of an appropriate health authority. It states; Without prejudice to the generality of the preceding sub-paragraph at least one person appointed under sub-paragraph 1(b) above shall be a person with special knowledge of the needs of disabled persons and in selecting any such person regard shall be had to the desirability of the person with that knowledge being a disabled person".

We now know a great deal more about disabled people, especially since the publication of the OPCS survey which disclosed that in this country there are more than 6 million. Not all are seriously disabled or need special medical or social care. However, the problem of disability and the need to shape the National Health Service to meet the challenges is greater than we believed before the publication of the survey results. That is not only because we know more but because many handicapped people are living longer. They create a special problem because they live into their 40s or 50s when their parents are no longer able to cope. That is a community care problem but also an NHS problem because all too often such disabled people are being looked after by their families and then have to be admitted into the care of the National Health Service. Incidentally, that is another argument for involving lay people in health authorities to see the need for continuing care.

Further, as people continue to live longer the proportion of disabled people inevitably increases. Many disabled people are playing extremely valuable roles on health authorities and the noble Baroness, Lady Masham, is living proof of that. Those people, one fears, may be dropped from the new type of health authority which has been described. It may turn out to be this or that; the Government do not really seem to mind.

The fourth argument which many of us with varying degrees of disability can confirm is that for most people illness or accident is a temporary break in a pattern of good health. That is not so for disabled people;. For them it is part of their continuous pattern of life. Any of us who are disabled recognise that and are much more liable to call on the health service for assistance because of disability.

Fifthly, services for disabled people are still very patchy and should be improved. This amendment is consistent with the main thrust of the Disabled Persons (Services, Consultation and Representation) Act 1986 which refers to representation of disabled people. Unhappily, significant parts of that Act have still not been implemented. That is perhaps an important reason for this amendment to be accepted. I beg to move.

Baroness Hooper

All authorities will continue to attach great importance to the views and needs of disabled people who are, after all, a significant client group for the National Health Service. However, we do not believe that the interests of disabled people are best served by statutory representation on the membership of an authority. As I have emphasised, we shall welcome applications and recommendations for membership from many quarters. Of course there is nothing in our proposals to prevent the appointment of disabled people or those with a particular knowledge of a disability. In saying that, I recognise the wording of the amendment to which the noble Lord, Lord Ennals, particularly drew our attention.

At present, some members are disabled people and I am aware of the extremely useful contribution which they make. As has been said, we have an example in our midst in the noble Baroness, Lady Masham, who is a member of the Yorkshire regional health authority. However, I believe that people from all groups would prefer to be judged on equal terms on their merits rather than be appointed on some sort of quota system.

I have already emphasised that all authorities will be expected to obtain the best professional advice in order to meet the health needs of their population. That includes advice on how to obtain effective services for their disabled population working in liaison with social services authorities and voluntary organisations. Such advice would not necessarily be obtainable through one individual member of the authority whatever his or her expertise and experience.

Therefore, I believe that the proposed amendments would move back authorities towards making representative appointments. I also believe that the best interests of disabled people will be served by availability to the authorities of a wide body of advice and information. Therefore, I urge the noble Lord to withdraw his amendment.

Lord Pitt of Hampstead

Before the noble Baroness sits down, perhaps I may ask whether she agrees that we are better at dealing with the disabled than we would otherwise be because of the number of disabled people in this Chamber.

Baroness Hooper

I certainly agree with the noble Lord, Lord Pitt, that we have strong and very effective representation from the disabled Members of this Chamber. I equally underline the fact that there is no statutory requirement to have disabled Members of the Committee. That will apply equally to representation on health authorities.

Lord Ennals

I certainly did not intend to suggest that there should be a statutory requirement for a minimum number of disabled people in this Committee. We all eventually become disabled, if we do not die first. However, the point made by my noble friend Lord Pitt is correct—that we perhaps show a greater interest in disability and the services for disabled people in this place because we are forever conscious of the subject. I believe that that would also apply to a health authority if one of its members was constantly aware of how to meet the needs of disabled people.

I feel that it will be necessary, with some of my noble friends, to return to the issue of whether any part of the Bill should specify that some interests should find their place on health authorities. However, having made my case on this item and the Minister having made her traditional reply, I shall not press the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 16 not moved.]

Lord Hunter of Newington moved Amendment No. 17: Page 63, line 21, at end insert: {"(3) Before he appoints a member of a Regional Health Authority other than the chairman, the Secretary of State shall consult with respect to the appointment such bodies as he may recognise as being, either in that region or generally, representative respectively of medical practitioners, dental practitioners, nurses, midwives and health visitors, registered pharmacists and opthalmic and dispensing opticians, or representatives of such other professions as appear to him to be concerned.")

The noble Lord said: I should like to clarify my earlier remarks on Amendment No. 17. I said that the Secretary of State should consult those bodies which are representative of medical practitioners, dental practitioners, nurses, midwives, health visitors and practically everybody of importance, so that he is well briefed. I went on to say that what I suspected the Secretary of State was looking for in the persons to be appointed, whether they were health visitors, dispensing opticians or physicians, was management competence. I recognise that the wording of the amendment is untidy, and I may well bring it back at a later stage. I beg to move.

Lord Ennals

I warmly support the point made by the noble Lord, Lord Hunter. I presume that he was speaking also to Amendment No. 28. It is a way of dealing with some of the other problems that we experienced during the course of the evening—that there should be a pattern of consultation. I take my pattern of consultation beyond the professional bodies listed in the amendment, though I certainly include them.

I am glad that the noble Lord, Lord Hunter of Newington, said that he may wish to return to this amendment. Together with him, I may wish to return to it at a later stage in our proceedings.

Baroness Hooper

Briefly, since we have already discussed this amendment, I repeat that the people making appointments will naturally wish to seek nominations from and consult with the widest possible range of organisations to identify the most able candidates. However, in referring to specific bodies the amendment excludes other sources of professional nominations and other bodies which could perhaps provide useful advice about appointments. I reiterate that we do not believe statutory consultation is necessary.

10.15 p.m.

Lord Hunter of Newington

I have one point to make in the light of the Minister's remarks. A number of professional bodies mentioned in the amendment are on the way up. To be named as important professional bodies which should be consulted among others is an important fillip for nurses, midwives, pharmacists, opticians and others. That is why we shall bring the amendment back in this amount of detail. We shall do so not to exclude other people—the Secretary of State may consult whom he wishes—but to make it clear that these important professions on which the National Health Service depends so strongly, and on which in future it will depend in order to save money by not sending patients to hospital, should be named. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 18 to 37 not moved.]

Lord Dainton moved Amendment No. 37A:

Page 64, line 3, at end insert:

("Special Health Authorities

A Special Health Authority shall consist of—

1. (a) a chairman appointed by the Secretary of State.
2. (b) a prescribed number of persons appointed by him including at least one from those nominated by the University of London in consultation with the relevant Postgraduate Institute or Postgraduate School.").

The noble Lord said: The Bill makes it plain that the old order which established special health authorities is to remain in force and that therefore the special health authorities which are associated with the postgraduate institutes of the University of London and with the Royal Postgraduate Medical School are to continue and will continue to be funded directly by the Department of Health. I and those who support me in the amendment welcome that enormously. The arguments for having at least one member of the special health authority appointed from those nominated by the relevant postgraduate institute are just as cogent if not more so in the case of the special health authorities as they are in the case of regional and district health authorities. I gained the clear impression that the Committee thought that the arguments were cogent in this case. In the case of the Royal Postgraduate Medical School, where the chiefs of service are all full-time academics paid for by the university, the case is completely overwhelming.

The purpose of the proposed addition is simply to incorporate into the Bill provisions for universities' membership of special health authorities similar to those proposed in our other amendment for regional and district authorities. It would bring all the authorities into line with the NHS trusts over the matter of university membership.

I was delighted to hear the noble Baroness say in her reply to Amendment No. 5 and the amendments grouped with it—I hope I heard her correctly—that the Government accepted the arguments as they applied to special health authorities. Therefore, I look forward to an appropriate modification of the Bill when it comes to Report stage. I shall be very interested to hear what the noble Baroness has to say on that point when she comes to reply. I beg to move.

Viscount Bridgeman

As a special trustee of the Hammersmith Hospital, I suppose I owe my office to my noble friend Lord Jenkin. I add my support to the noble Lord, Lord Dainton. There is total inter-dependence between the Hammersmith Hospital and the Royal Postgraduate Medical School. I very much hope that my noble friend will accept that there should be academic membership on this and on the other special health authorities; not by regulation at the whim of successive Secretaries of State, but by statute incorporated in the Bill.

Lord Peston

I reveal yet again that I am connected with the University of London and with at least one of the postgraduate institutes. As the noble Lord, Lord Dainton, has just said, it follows logically that the reply given by the noble Baroness to the earlier amendments on university representation should carry over at least to the point of her agreeing to think the matter through further; namely, that she will consider this amendment with the others. Since there has been an interval of a couple of hours perhaps she has had time to reflect and is now willing to accept the amendments.

Baroness Gardner of Parkes

Can the noble Lord, Lord Dainton, tell us whether he has it in mind that it will automatically be the dean of the institute who is appointed? The special health authority of which I am a member has the dean of the associated institute as its member. Does the noble Lord wish to be as specific as that with a special health authority or is he simply wishing to have anyone with an academic calling?

Lord Dainton

I want only to have that person who is most competent to serve. I go back to the principle of competence rather than representativeness. In some cases it may be the dean or someone else. In the case of the Royal Post-Graduate Medical School, I believe the Minister knows already that we have a special problem. Under the Bill as it now stands, and since all the chiefs of service are full-time university employees, we are in an interesting paradoxical position. As I understand it, under the Bill the medical director will be ex-officio if it is a trust, and an executive director of the institution.

In the case of the Royal Post-Graduate Medical School the medical director is bound to be a university employee and not a trust employee. Therefore, a very interesting administrative paradox arises. From what I understand of private correspondence, the Government have already accepted that the matter can be resolved in that case. I mention that as an example of the complexities which can arise if one nominates a particular office holder. I want to see in all cases—and I am sure that it will happen if the University of London is approached properly—the person best fitted to serve through experience and competence chosen by the university as a nominee to fill the post on the special health authority.

Baroness Hooper

The effect of the amendment would be that all special health authorities, not just those for the London postgraduate teaching hospitals, would be required to have a postgraduate institute member. Clearly, that would not be appropriate. However, I appreciate the intention behind the amendment. I hope that I can reassure the noble Lords, Lord Dainton and Lord Hunter, and my noble friend Lord Bridgeman on that point.

The special health authorities for the London postgraduate teaching hospitals will be reconstituted along similar lines to the regional health authorities and the district health authorities. However, there will be some differences in order to reflect their national role and important academic and teaching links. As now, their membership will include someone from the relevant postgraduate institute who will be appointed as a non-executive member. I have already said this in response to my noble friend Lord Jenkin with respect to the Hammersmith. In fact, on the point of the medical membership of the Hammersmith, the Bill was amended in another place to allow for the particular problem to be resolved.

The non-executive member, as with all the new non-executive members of health authorities, will be appointed on the basis of his or her individual skills and experience rather than in a strictly representative capacity.

All special health authorities including those for the London postgraduate teaching hospitals are, as many of your Lordships must know, established by an order made under Section 11 of the National Health Service Act 1977 which specifies their constitutions. The terms of office of all the current members of the special health authorities for the London postgraduate teaching hospitals will be brought to an end under Clause 1(4) of the Bill and a new constitution order will then be laid under the terms of which the new members will be appointed.

I hope that with that information I have been able to reassure the noble Lords the movers of the amendment that their aims will be met in the procedure for the new order for the special health authorities for the London postgraduate teaching hospitals, and that on that basis they will feel able to withdraw their amendment.

Lord Peston

I certainly do not wish to press the withdrawal of the amendment, but I should like to have some clarification in case I did not quite follow what the noble Baroness said. Did she say that this matter would be dealt with by order and that the order will essentially meet what is said in the amendment? Is that a fair summary? I think that is what I heard her say.

Baroness Hooper

Yes, that is a correct interpretation of what I said.

Lord Dainton

Perhaps I may ask the noble Baroness a further question. Will that order be available for us to see at the Report stage?

Baroness Hooper

No, I do not think so.

Lord Dainton

But there will be a firm commitment to it at that stage?

Baroness Hooper

Yes. We are required under Section 11 of the National Health Service Act to have a constitution order and, as I understand it, it will be implemented through the negative procedures of Parliament; so it will therefore come before Parliament.

Lord Dainton

In those circumstances I am willing to withdraw the amendment at this stage.

Amendment, by leave, withdrawn.

[Amendments Nos. 37B, 37C, 38. 39. 40 and 41 not moved.]

Lord Winstanley moved Amendment No. 42: Page 64, line 11, after ("Authority") insert ("two of whom shall be general medical practitioners and one of whom shall be on the medical list of that Family Health Services Authority.").

The noble Lord said: I beg to move Amendment No. 42 which stands in my name and which I notice is grouped with Amendment No. 51 in the name of the noble Lord, Lord Peston.

Unless I choose my words with very great care, we shall shortly be back to talking about representatives. I have no wish to be discourteous to the noble Baroness, but I hope she will realise that I am not so naive that I do not realise that her reply to this amendment has been written long before I have spoken to it. Therefore, I shall forgive her if she refers to representatives, but perhaps she will let me say that I have no intention of suggesting representatives in this amendment.

All the amendment seeks to ensure is that the FHSA, which is the body which is responsible for domiciliary health services and particularly for general practice, has general practitioners on it, and I have proposed two. I want it not to be representative of anybody, but if it is to administer and be responsible for the general practitioners in its area it cannot possibly do that unless it has people on it who really know about general practice and by that I mean the general practitioners themselves. I realise that many patients think that they know all about general practice and, indeed, many of them do know a great deal; but the fact remains that if this body is going to be able to discharge its functions properly, it must have some general practitioners one of whom should be, in the words of the amendment, on the medical list of that Family Health Services Authority". I say that because authority areas vary greatly and the medical problems in many areas are different. A general practitioner for a different area may have a totally different view of matters. There is a need for someone who has practised, or who is practising, medicine in that particular area.

The amendment says nothing about how such people will be found: it is left to those who will make the appointments. However, it makes it a requirement that in assembling a team the Secretary of State shall ensure that such a team, which will be in charge of administering general practice in that area, will contain two general medical practitioners. I must point out to the noble Baroness that unless this is done the team will fail. Indeed, she may say that it will.

These people will emerge in some kind of way, as other people do in various political outfits, other than by being elected or appointed. But, however they appear, if the body which is responsible for domiciliary and family medical services does not contain general medical practitioners, it will not be competent to carry out its work. That is all I have in mind. I beg to move.

Lord Pitt of Hampstead

I rise to express my support for this amendment. I do not intend to delay Members of the Committee for very long. The new family health services authority will have great power over general practitioners. It is sensible—and I use that word advisedly—that the authority should contain people who practise medicine, who understand the problems involved and who can therefore make sensible decisions. I hope that the Government will accept the amendment.

On Second Reading, I suggested that there should be two such practitioners: one who would be a fund holder, and one who would not. However, that consideration does not necessarily matter. So long as we have two, one of whom is a practising member, I shall be happy. We must have people on the authority who are practitioners.

Lord Ennals

I wish merely to say that I support what has been said by my noble friend and by the noble Lord, Lord Winstanley.

Lord Henley

The noble Lords, Lord Winstanley, Lord Pitt and Lord Ennals propose that we should include two general practitioners on the FHSAs rather than the one proposed in the Bill. We do not accept that proposal. The professional members on the new authorities will not be the only source of professional advice which the authorities will have. No individual or even two individuals, whatever their background or experience, could ever provide the full range of comprehensive advice which FHSAs will need in the future.

Under Promoting Better Health, FPCs have already taken on new responsibilities for actively managing (as opposed to simply administering) family practitioner services in their areas. They will take on further new functions, such as indicative prescribing and monitoring GP fund-holding under the Bill, To fulfil those tasks effectively, they will need access to a wide range of independent professional advice from a variety of expert sources.

FPCs are already appointing independent medical advisers for that purpose. We provided additional funds in the current year—that is, 1990–1991—to enable them to do so. Some FPCs are now also appointing independent pharmaceutical advisers. In addition, FHSAs will have the freedom to appoint professional experts to any sub-committees or working parties which they decide to set up. Therefore, it is clear that appointing an additional member to the authority itself would not provide any wider professional input than can be obtained from these sources. Instead, it would simply increase the size of the authority, making it more cumbersome and a less effective management body. I trust that bearing that in mind the noble Lord will feel able to withdraw his amendment.

Lord Winstanley

I have listened carefully to what the noble Lord has said and not a word of it has taken me by surprise. With that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 43 to 45 not moved.]

Lord Pitt of Hampstead moved Amendment No. 46: Page 64, line 22, at end insert: ("(3) The Secretary of State, before he appoints a member of a Family Health Services Authority other than the chairman, shall consult with respect to the appointment such bodies as the Secretary of State may recognise as being representative of general medical practitioners in that particular locality.").

The noble Lord said: The amendment is self-explanatory. I await the reply of the Minister. I beg to move.

Lord Henley

The noble Lord made an admirably brief speech. He suggests in the amendment that local medical committees should have exclusive rights to be consulted over the appointment of all members of the new authorities other than the chairman. This we feel is clearly inappropriate. Under Promoting Better Health the FPCs, or FHSAs as they will become, have been given wider responsibilities than in the past for actively managing the family practitioner services and practitioners' contracts. It would be inappropriate therefore for local medical committees whose raison d'être is to represent the views of local doctors to have exclusive rights of consultation over appointing members to the authorities which will be responsible for managing the doctors' own contracts. It would be inappropriate even if the proposal were limited to the appointment of the GP member.

Lord Pitt of Hampstead

The amendment states: The Secretary of State, before he appoints a member of a Family Health Services Authority other than the chairman, shall consult with respect to the appointment such bodies as the Secretary of State may recognise as being representative of general medical practitioners in that particular locality". What is restrictive about that, except for the locality? The Secretary of State has the power to consult all the people whom he regards as representative of practitioners in the area. What is wrong with having such consultation? I cannot understand what is wrong with the Government. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 45 to 57 not moved.]

Lord Rea moved Amendment No. 58: Page 65, line 10, at end insert: ("(8A) At the end of sub-paragraph (1A) of the said paragraph 10 there shall be inserted— (1AA) Regulations or directions under sub-paragraph (1) above shall provide that the employment of staff in the house officer and the senior house officer grades shall be on terms which provide that:

1. (a) the number of hours which they can be required to work each week be subject to a maximum of 72, and
2. (b) they cannot be required to work for a continuous period of more than 24 hours, and
3. (c) they are provided with a minimum rest period of at least 8 hours between periods of duty."").

The noble Lord said: It is just over a year since your Lordships' House passed a Private Member's Bill which consisted of a measure very similar to the one suggested in this amendment. The hours and conditions of work of junior doctors have become known to wide sections of the public as a result of the publicity surrounding the passage of that Bill last year. Most people were surprised and frankly appalled that a group of responsible young professionals had to endure such stressful conditions, frequently leading to sleep deprivation and fatigue. These same professionals frequently had to make difficult decisions literally affecting the survival of patients.

I am aware that the Government themselves accept the goal of a 72-hour week for junior hospital doctors and are encouraging discussions between those most concerned, in particular managers and consultants. Mrs. Virginia Bottomley herself has taken this problem to heart. Junior doctors are hopeful that she will be able to improve the situation. But although average contracted hours may have been falling slowly—from some 89 hours a few years ago to 83 or 84 in the past few years—the actual hours worked and on duty do not seem to be falling. In a carefully conducted 1988-89 survey, commissioned by the Department of Health, Dr. Robin Dowie found that junior hospital doctors averaged 90 hours per week either working or on duty. That is more than the officially reported contracted hours because many doctors have to work more hours than they are contracted to get the work done. They do not go home at 5 o'clock but very often at 9 o'clock on the nights when they are not on duty.

This is not the time or place to go over the whole story again but it is clear that because of the increasing turnover of patients in hospitals and the increasingly sophisticated investigations and treatments available the intensity of the work of junior hospital doctors within their contracted hours is growing.

There are measures which could be taken immediately to improve the situation. However, that involves changes in working practices and perhaps more shift work for junior hospital doctors, more cross cover between consultant "firms", more teamwork and less layers of cover, and other such measures. I realise that the Government are pressing on with trying to ensure that those changes take place. The reason why the hospital junior staffs committee of the BMA is reluctantly pressing for legislation—I emphasise the word "reluctantly" -—is because of the slow pace of change. If there is a legal target to reach, problems, bottlenecks and habits which seem unchangeable suddenly become more malleable. That would be more likely to occur if there were penalties on health authorities, for example, for non-compliance with the law. I believe the Government should have some sympathy with the legislation sought by this amendment because it would help them to achieve their own avowed target of a 72 hour week for junior hospital doctors. Unfortunately, despite good intentions, the present situation is virtually a stalemate.

The longer-term aim is to achieve a 60 hour week. That would require an increase in the consultant grade at a rate of some 4 per cent. per annum over the next 10 years. Therefore achieving a balance in the hospital service could become a reality.

This country has a far lower proportion of recognised specialists compared with its total number of medical professionals than other developed countries. The projected increase of 100 consultants over the next three years mentioned in the White Paper amounts to only an extra 0.2 per cent. per annum over the current inadequate 2 per cent. increase.

There are many doctors at senior registrar level who are ready immediately to take on consultant responsibilities if the posts are created. They do not need a retinue of junior hospital doctors, senior registrars, junior registrars, senior house officers and house officers, each costing half a million pounds. They could be appointed as extras in a firm. I understand that I am straying from the point somewhat and that we are in a hurry. However, I fear very much that if the amendment is not accepted we may see increasing dissatisfaction among junior hospital doctors. I do not see the necessary changes occurring other than through legislation. I beg to move.

10.45 p.m.

Lord Pitt of Hampstead

I support the amendment. Members of the Committee will remember that I supported my noble friend when he piloted his Bill through this Chamber.

We now have an opportunity of forcing the other place to discuss the matter. The Bill that we passed was not discussed in the other place. If we put the amendment in the Bill, the issue will have to be discussed in the other place. My plea to the Government is not to resist the amendment and to let it be included in the Bill. If they wish to resist it when the Bill reaches the other place, they can do so, but let the amendment go into the Bill now.

As my noble friend has said, the Minister is apprised of the problem and is working on it. The inclusion of the amendment in the Bill will strengthen his hand.

Much of what my noble friend has said is true. Flexibility in terms of organisation could bring us to the 72 hour limit. If legislation states that doctors must not work more than 72 hours, ways will be found to make sure that that happens. I plead with the Minister not to resist the amendment.

Baroness Hooper

As the noble Lord, Lord Rea, said, the Government have accepted that it is sensible to work towards a target of an average week of duty of 72 hours for all junior hospital doctors. However, it would be irresponsible to agree to a maximum 72 hour week for any grade of junior doctors without a clear and agreed view from all the parties as to how that could be achieved.

As will be known to many Members of the Committee, a limitation on the hours of house officers and senior house officers could, for example, require a substantial increase in the number of doctors in those grades. It is by no means clear that they could be recruited in every case. Moreover, any uncontrolled increase in the number of house officers and senior house officers would run counter to current efforts to reform the staffing structure. The main task in achieving a balance, which was agreed with professional and National Health Service interests, is to increase the number of consultants while limiting the number of junior doctor posts to the number required to fill future career vacancies. In our view, there is no single solution to this long-standing issue.

That is not to say that considerable progress has not been made. We launched a further major initiative in June 1988. Regional reports indicate that by September 1990 approximately one-in-eight junior doctors will be on onerous one-in-three rotas. That compares very favourably with the situation at the start of the initiative when more than a quarter of junior doctors were estimated to be on rotas worse than one-in-three.

Of course more needs to be done, but passing the law will not of itself solve the problem. It requires a concerted attack from all the parties, including the profession itself, which has a major responsibility for organising juniors' training, setting local rotas and so on. It is for that reason that my honourable friend the Minister of Health recently met representatives of the Joint Consultants Committee—which includes the Royal Colleges, the British Medical Association and National Health Service management—to discuss a way forward, as the noble Lord, Lord Rea, mentioned. The meeting agreed that further progress required the active involvement of all the parties because of the complex nature of the problem.

As a first step a working group will explore a number of the key issues. It will report back to the main group, chaired by my honourable friend the Minister for Health, in the early summer. The working group will look at specific aspects of working practices, terms and conditions of service including remuneration and contracts, manpower, education and training issues.

I submit that my honourable friend the Minister for Health's recent meeting has agreed a mechanism for taking the work forward. We all hope that that will quickly lead to further progress. In order to sustain the commitment of all the parties concerned, the group should be given every opportunity and encouragement to move forward in that way. Considerable progress has been made since the Private Member's Bill of the noble Lord, Lord Rea, was discussed in this Chamber. On that basis, I hope that he will feel able to withdraw his amendment.

Lord Rea

Despite the Minister's words, I do not think that progress is fast enough or is likely to be fast enough without legislation. I shall perhaps seek an opportunity to divide the Chamber on the issue at a later stage. I do not think that this moment is right because, unless there are many people in the woodwork, I doubt whether we should even achieve a quorum. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 1 agreed to.

Clause 26 [Health Boards, the Common Services Agency and state hospitals]:

Lord Carmichael of Kelvingrove moved Amendment No. 59: Page 27, line 6, at end insert— ("(2A) In carrying out his duties under this section and section 27 and Schedule 5 below in respect of appointing members to Health Boards, the Secretary of State shall consult such bodies that seem to him to be representative of the medical and nursing professions, and organisations representative of consumers.")

The noble Lord said: This is the first amendment that deals exclusively with Scotland. It is a pity that we reach it at such a late hour because there are differences between the Scottish and English legislation.

As it relates to England, the Bill, is virtually a new Bill whereas, as it relates to Scotland, it basically constitutes a series of amendments to the National Health Service (Scotland) Act 1978. In addition the English and Scottish boards are quite different. They are quite dissimilar in construction. The 15 health boards in Scotland are all single tier and the responsibility for the appointment of board members lies with the Secretary of State alone. No other body makes direct appointments. The Minister must be aware that, with the power given to the Secretary of State in the Bill, he can dismiss all the members of all the existing health boards and appoint whomsoever he wishes instead all at one time, so he could effect a complete change through the Bill. That is a great power which could change the composition of all 15 Scottish boards overnight. It may not be done, but the power is there to do it and we are concerned about the ideological basis of such a sweeping change.

Our experience of recent appointments has reinforced that unease. Examples were given in another place during the Committee stage of the Bill of large areas of Scotland with little or more frequently no parliamentary or local government elected representatives from the Conservative Party, in which good, competent people were not reappointed when their time in office expired in order to make room for what could only be described as ideologically suitable or acquiescent people approved by the Under-Secretary of State responsible for health in Scotland.

There is no Scottish Minister on the Front Bench opposite and the Ministers there may not be aware of this. fact. It is a problem and the Scottish press is full of it all the time. There is a distinct difference between the Secretary of State and the Under-Secretary of State. What we would entrust to the Secretary of State we have less confidence in entrusting to the Under-Secretary of State responsible for health. That is not personal; it is purely ideological.

Lord Ennals

It should be the other way round.

Lord Carmichael of Kelvingrove

It should be the other way round, but I am afraid that it is not because the Under-Secretary of State also happens by sheer chance to be the appointed chairman of the Conservative Party in Scotland, a position which yields a certain amount of power. That is important and it is no use pretending that it is not so. The Scottish press, of all shades of opinion, is full of it. When we were in office, we as a party never behaved that way. We were never as partisan as that. If a future Labour Government behaved that way, I should be greatly disappointed.

We should like to emphasise the importance of consultation. That is what the amendment is all about It is mentioned in the Bill, but we want to emphasise the point even more so that the health board does not slide from what may in some cases be harmless patronage into something more sinister which we believe is the single-minded aim of some extremists in the party opposite, although I am sure that the noble Baroness who is to reply does not share that view. There is a great deal of dissatisfaction in Scotland with the way in which appointments are being made. If the noble Baroness knew the situation she would feel—just as I am sure the noble Lord, Lord Sanderson, would feel—uncomfortable trying to defend some of the decisions that are made. This is a very important point and I hope that the Committee will pay attention to my amendment. I beg to move.

Baroness Blatch

Statutory arrangements for consultation already apply to the appointment of Scottish health board members and are not changed by this Bill. I shall repeat my first sentence as it is important. Statutory arrangements for consultation already apply to the appointment of Scottish health board members and are not changed by this Bill.

Clause 26 brings to an end the appointment of current members of health boards and this paves the way for the new streamlined health boards which we intend. But it will be seen that the clause does not provide for the appointment of the new boards. That is because my right honourable friend the Secretary of State for Scotland will be using his existing powers under Section 2 and Schedule 1 of the National Health Service (Scotland) Act 1978 to appoint the new members just as he appointed the present members.

Subsection (3) of Section 2 obliges the Secretary of State, before appointing members to health boards, to consult local authorities, relevant universities and organisations representative not only of the medical and nursing professions but also the dental, pharmaceutical and ophthalmic professions, and such other organisations as appear to the Secretary of State to be concerned.

The Committee will see that the Secretary of State is already under a duty to consult representatives of the medical and nursing professions. Although there is no equivalent duty in relation to organisations representative of consumers, in practice the Secretary of State consults the local health councils which, under Section 7 of the 1978 Act, exist: to represent the interests of the public in the health service". There are no plans at all to change those arrangements.

Of course, Clause 27 of the Bill brings into the picture a new body: the special health board. Clause 27(b) gives the Secretary of State the power by order to apply, in relation to any special health board, relevant provisions of the 1978 Act which apply to the health boards. I agree that paragraph 3 of Schedule 1 to the Bill is not mentioned in Clause 27, nor would that be appropriate, because, for instance, it speaks of: each local authority in the area of the health board concerned and again: any university appearing to the Secretary of State to have an interest in the provision of health services in that area". Neither of those provisions sits happily with the kind of all-Scotland body dealing with health education which, as the Committee knows, it is the intention to create as a special health board. Nor would the two groups mentioned in the amendment necessarily be appropriate for all special health boards which one could imagine, although, as we have no other potential special health boards in mind at present, I can give no concrete examples.

It is therefore better to leave the flexibility which Clause 27 at present gives to the Secretary of State.

But I can certainly undertake that he would consult all bodies with a substantial interest in the subject of the special health board, and that would usually include the professional organisations and organisations representative of consumers, although the nature of the consumers might vary.

With that assurance, I hope that the noble Lord will feel able to withdraw his amendment.

Lord Carmichael of Kelvingrove

I thank the noble Baroness for her explanation. I was aware of the points that she made about what was contained in Schedule 1 to the Bill. I tabled the amendment to emphasise the great unease felt in Scotland about the way in which appointments have been made.

I do not wish to become too personal about the matter, but I can give examples of quite outrageous appointments that have been made in Scotland which I find totally unrepresentative of the people of Scotland. As I said in the course of my earlier remarks, well respected, very able people were removed in order that patronage by a particular group could be emphasised. I do not wish to continue further. Having put down the amendment again to emphasise its importance, and having aired it in Committee, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 26 agreed to.

Baroness Blatch

I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

House adjourned at eleven o'clock.