§ 3.30 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)
My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.
Moved, That the House do now again resolve itself into Committee.—(Baroness Hooper.)
On Question, Motion agreed to.
House in Committee accordingly.
[The CHAIRMAN OF COMMITTEES in the Chair.]
§ Schedule 5 [Health Boards, the Common Services Agency and State Hospitals]:
§ [Amendments Nos. 60 and 61 not moved.]
Lord Carmichael of Kelvingrove moved Amendment No. 62:
Page 77, leave out lines 31 to 34 and insert ("within
- (a) a Health Board; and
- (b) the Agency,").
§ The noble Lord said: Amendment No. 62 relates to the direction of labour for health board staff, for 441 the staff of the common services agency and state hospitals It will allow staff to be transferred from one board to another.
§ We accept that in the long term there must be allowance for flexibility, but as the Bill stands staff could be transferred between health boards. That could mean that a doctor or other officer or servant of the board could be moved against his or her wishes from, say, the north of Scotland to the Western Isles or from a rural area, a Border region, to an area such as Glasgow or Edinburgh, which might be quite unsuitable for them and their families. That could involve working with patients from different communities who require from their doctor a different expertise. The consultant surgeon in the Western Isles needs quite different surgical expertise from the specialist gastro-enterologist or vascular surgeon in Edinburgh or Glasgow. The people who were described to me as "super specialists" may not be the best people to serve the island communities.
§ Under the proposed legislation who will be responsible for such a transfer decision? On what basis will that decision be made? Will medical practitioners or other staff have a right of appeal against the decision? What will be the effect on continuity of care for patients? Where possible patients prefer—and I am sure that consultants will agree—to be under the care of one consultant for many years, particularly if certain progressive illnesses are involved which may entail a series of operations or other treatment.
§ There are examples in other fields where directions can be given to employees. In the education field it is possible to direct staff even within, say, Strathclyde, from Oban to Ballantrae. I do not know whether this is contained in any statute or conditions of service, but it is understood that common sense is applied and it is most unlikely that staff would be compulsorily moved more than travelling distance from where they already operate or work. I am not sure that that will totally satisfy the medical associations, the nursing associations and other staff working in the service. However, if the Minister were able to assure us that there was room for appeal if unreasonable transfers were contemplated by a health authority, that would go some way to satisfy them. I beg to move.
§ Baroness Carnegy of Lour
I understand why the noble Lord moved the amendment. I know that staff are anxious that the new arrangements should not result in their being unreasonably at the beck and call of the National Health Service in Scotland to work at the other end of the country, with all the upheaval for their families that that may entail. However, although to adopt the amendment might appear satisfactory at the moment, it could damage Flexibility for the future. It is important for the Bill to allow for new circumstances which may arise in the future: new boundaries of the areas which health boards cover in Scotland or perhaps new functions for those boards or other bodies. For the sake of patients and, one might say, for the sake of continuity of employment of staff, the amendment perhaps goes too far.
§ The Minister of State, Scottish Office (Lord Sanderson of Bowden)
I follow what the noble Lord, Lord Carmichael, said with regard to the concern of staff at the prospect that they may be transferred at the whim of the Secretary of State from one end of Scotland to another. I should like to assure him and other noble Lords, and the National Health Service staff, that that is not the intention. The new paragraphs which the schedule seeks to insert into Schedule 1 of the National Health Service (Scotland) Act 1978 are simply designed to bring Scottish legislation into line with that of England and Wales.
In England and Wales the Secretary of State already has equivalent power under paragraph 10(2) of Schedule 5 to the National Health Service Act 1977. I understand that those powers operated satisfactorily in England and Wales. There are no immediate plans to use those powers in Scotland, but they may be very helpful in the future if, as a result of the changes foreshadowed in the Bill, it was sensible to change the number of health boards or redraw the boundaries between health boards and the common services agency.
I stress that those are purely illustrations and that there are no such plans at present. Should the eventuality arise in future, the new paragraphs would be important in ensuring the smooth management of the National Health Service and in safeguarding the career and employment rights of the staff concerned. Therefore the power will be used to cope with a reorganisation of part of the National Health Service. Recent uses of the English equivalent power include the centralisation of schools of midwifery in Birmingham; the move of a school of physiotherapy from Wolverhampton to Coventry and the creation of centralised stores in the North West region. Those all involved some degree of staff relocation, but not more than National Health Service staff normally expect in the course of their careers. Such a transfer could involve no geographical move, but simply a change of employer within the National Health Service.
We do not intend to use the power, as the noble Lord may fear, to remedy a shortage of district nurses in Shetland by transferring some from Glasgow or vice versa. However, I must stress that such a transfer would not be carried out without consultation. It will always be the intention of the National Health Service as a good employer to consult staff regarding changes which might give rise to the use of the new power.
The noble Lord, Lord Carmichael, asked who was responsible for the decision. The Secretary of State is responsible for the decision because he makes the regulations. He also asked about a right of appeal. There is no formal right of appeal, but there is no question of unreasonable transfer. Health boards will act in a common sense way. The Secretary of State, in making the regulations, will be able to review that action in a way akin to a right of appeal.
What about the patients themselves? Yes, it will mean a change for patients, but staff changes take place all the time and it will be a rarely used provision. I understand the concern of the noble Lord; the matter was raised in another place, as was the importance which some people attach to it. In 443 the light of the amendment I am prepared to bring forward a government amendment on Report to require the Secretary of State to consult staff representatives before making any decisions about the transfer of staff under the new power.
§ Lord Carmichael of Kelvingrove
I am most grateful to the Minister for that concession. I look forward to seeing his amendment. In the meantime I beg leave to withdraw Amendment No. 62.
§ Amendment, by leave, withdrawn.
§ Schedule 5 agreed to.
§ Clause 27 [Special Health Boards]:
Lord Sanderson of Bowden moved Amendment No. 62ZA:
Page 27, line 37, after ("Act") insert ("or of any other enactment").
§ The noble Lord said: On speaking to Amendment No. 62ZA I shall speak also to Amendment No. 62ZB. This is a fine-tuning amendment, but I should like to explain it a little further at this stage because it is important. As the Committee is aware, the immediate intention of Clause 27 is to allow the Secretary of State for Scotland to set up a specialist body dedicated to the important task of health education in Scotland. While we have no other plans at present to set up other bodies, under Clause 27 we thought we should take the opportunity to give Scotland the benefit of a mechanism which has served the health service well in England and Wales for many years, the special health authority.
§ Potentially special health boards could come in many shapes and sizes dealing with various diffierent purposes, both national and local. We thought of applying to the new special health boards all the various powers and other statutory provisions which relate to ordinary health boards. We decided that that would be too wide. It could give highly specific special health boards, such as the health education body, access to powers which were unnecessary. We therefore concluded that it would be better to give each special health board access to a tailor-made set of powers. I stress that we do not want any special health board to have access to a wider range of statutory provisions than an ordinary health board. That is the reason the Bill contains the words in lines 38 and 39 on page 27 as apply in relation to health boards.
§ This clause does not give the Secretary of State a blank cheque to set up special health boards with sweeping powers. As I explained, we were anxious not to draw the powers of special health boards too widely. I confess that we went to the opposite extreme. The present wording of Clause 27 allows the Secretary of State to apply to special health boards only those provisions applying to ordinary health boards in the National Health Service (Scotland) Act 1978 or subordinate legislation made under that Act.
§ We have concluded that that is too narrow. Health boards have important powers under other Acts; for example, Section 7 of the Health and Medicines Act 444 gives health boards power to generate income for improving the health service. The House of Commons Disqualification Act applies at present to health board chairmen who receive remuneration and Clause 56 of this Bill extends that to cover all health board chairmen and non-executive directors.
§ I can well imagine that it would be sensible for a special health board to have access to these income-generation powers and for the chairmen and non-executive members to be disqualified from membership of the House of Commons. That is why we want to make this amendment, which I commend to the Committee. I beg to move.
§ On Question, amendment agreed to.
Lord Sanderson of Bowden moved Amendment No. 62ZB:
Page 27, line 38, after ("Act") insert ("or of any other enactment").
§ On Question, amendment agreed to.
§ Clause 27, as amended, agreed to.
§ Clause 28 agreed to.
§ [Amendment No. 62A had been withdrawn from the Marshalled List.]
§ 3.45 p.m.
Lord Dainton moved Amendment No. 63:
Before Clause 3, insert the following new clause:
["Chief of Research and Development.
.—(1) The Secretary of State shall appoint an officer to be known as the Chief of Research and Development to advise him with respect to matters affecting or otherwise connected with the implementation of this Act or any other matters which he shall determine.
(2) The Chief of Research and Development shall establish and maintain an Advisory Council for the purposes of assisting him with his duties under this Act which shall consist of—
- (a) a prescribed number of members nominated by the Secretary of State;
- (b) a prescribed number of members nominated by representatives of the medical and nursing professions; and
- (c) a prescribed number of members nominated by organisations representative of consumers.
(3) In consultation with the Advisory Council established under subsection (2) above, the Chief of Research and Development shall produce an annual report.").
§ The noble Lord said: This amendment, tabled by the noble Lords, Lord Nelson, Lord Hunter, Lord Walton, and myself, Amendment No. 62A having been withdrawn, has the purpose of ensuring that the NHS and the Department of Health has a proper research structure which is adequate for the large and important tasks which lie ahead.
§ In essence, the amendment proposes that the Bill should specify a chief of research and development who will be the major source of advice to the Secretary of State on the working of the health service and who will be equipped with an advisory council comprising persons of wide experience and acknowledged eminence in research and development as well as those who are knowledgeable about the delivery end of health care provision. The amendment also aims to secure that the chief of research and development produces an annual report.445
Perhaps I should say a few words on the history of events over the past few years. The Committee will recall that the Select Committee on Science and Technology of this Chamber issued in April 1988 a report on priorities in medical research. It was the work of a sub-committee under the chairmanship of the noble Lord, Lord Nelson, who unfortunately cannot be here today. The report was debated in this Chamber in June 1988, and in December 1989 the Government responded stating that while they accepted the "principal thrust of the recommendations" they rejected that part of the report which proposed a National Health Service research authority. Instead, the Government response proposed the appointment of a full-time chief of research and development to,
advise and act for the Secretary of State for Health across the whole range of his interests in research".
§ We have since learnt, of course, that this person is to be based in Leeds, somewhat remote from the centre.
§ The response indicates the range of duties of the chief of research and development and gives some idea of his position in the hierarchy of the Department of Health. These matters are further elaborated in the briefing information that is available to applicants for the post, which has recently been advertised.
§ We recognise that the Government's proposals represent a significant improvement on the present manifestly inadequate arrangements; but then I suppose almost any change would do that. The important question which we as proposers of this amendment have asked ourselves is whether the Government proposals are sufficient for an enterprise with the huge annual turnover of about £20 billion. It is because we do not consider them adequate that we have felt it necessary to table this amendment.
§ That there must be a chief of research and development is not in contention. One would expect that, as is the case in any business of this size or indeed businesses of a smaller size, the chief of research and development would have a seat on the main management executive. However, the Secretary of State clearly, but surprisingly, states that he does not intend the chief of research and development to have such a seat. The chief of research and development will be a member neither of the NHS management executive nor of the NHS policy hoard.
§ It is also crucially important to ensure that the benefits of the work which he commissions are carried through into the operation of the service. In our view, that can only be assessed if he is given an evaluative role; that is, he is able to make an appraisal of the efficacy, or otherwise, of existing practices and also, of course, of the utility of new experimental procedures suggested by the management executive or as a result of the application of some of his own organisation's research findings.
§ The chief of research and development must therefore be charged with the additional duty of monitoring and evaluation. As we all know, without 446 such a built-in function with an effective voice at the highest level in both the NHS and the department, any organisation as large as these two combined will lack that tautness and efficiency of operation that are vital if money is not to be wasted in substantial amounts. Therefore, that is the purpose of subsection (1) of the amendment.
§ The remaining two subsections are designed to strengthen the position of the chief of research and development, to assist him in devising a sound research strategy and to enhance the quality and authority of the opinions and advice that he is able to proffer. That high quality and authority can only accrue, in our view, when those most knowledgeable—many of whom work in the NHS and community care service but who are outside and distant from the Department of Health and NHS senior management—are convinced that, judged against their experience, the advice and opinions proffered are well-founded. They and the public will be satisfied on this matter and the advice will gain its necessary authority and credibility only if the advice is known to have been hammered out in a body whose members have high competence, who are professionally independent and who are allowed to pass judgment on the quality of the commissioned research and development work.
§ This is a far cry from what is called, in the Government's response, a "reconstituted Departmental Research Committee". In passing, I should say that I have always disliked materials which are reconstituted ever since I was forced in my early life to eat reconstituted dried egg. Such a departmental research committee may well be I needed, but it is all that the Government response now offers. Those of us who have had to perform in roles similar to that of the proposed chief of research and development know from our experience that the more independent and disinterested the advice, the higher its quality and therefore its ultimate utility and benefit.
§ The third subsection requires the chief of research and development to produce an annual report. By that we mean a report which is published and not a report which is, as the advertised job description specifies, merely to be produced for the benefit of the NHS policy board. It is obviously desirable that the report should be published and that it is made as a discipline, for accountability and for maintaining a focus on essentials in the minds of the chief of research and development and all his staff. Moreover, it will facilitate discussion and decision within the NHS management executive and its policy board.
§ However, a report would serve another valuable purpose. The NHS affects us all from time to time between the cradle and the grave. Indeed, I doubt whether there is any other aspect of government activity which arouses such public interest and concern. For this reason alone an annual report which shows how the NHS is working and in what directions it might change would be fully justified.
§ I fully understand the Secretary of State's dilemma. I am in a slight dilemma myself today because tomorrow the Select Committee on Scientific Research and Development of your 447 Lordships' House will be meeting the Secretary of State to discuss some of these questions. In a sense I should have preferred the order to be the other way round. The problem which the Secretary of State faces is how best to manage research and development in this huge enterprise to serve departmental policy or to improve the operation of that large, government-funded service called the National Health Service.
§ That kind of difficulty goes back a long way in that interface between government and the execution of research and development. It was very clearly articulated some 72 years ago by our first Minister of Health, Christopher Addison. Some Members of the Committee may recall that Addison was a very distinguished medical man before he became a Member of Parliament. He had been made a professor at the University of Sheffied at the age of 28 and Hunterian Lecturer of the Royal College of Surgeons at the age of 32. As Minister of Health he was very much concerned because he was tempted to take control of medical research in the country which was about to be institutionalised. He resisted that temptation in the following words, which will bear repetition in this debate. I have to be selective without in any sense spoiling the sense of what he wrote.
A progressive Ministry of Health must necessarily become committed from time to time to particular systems of health administration … A particular Minister may hold strong personal views on particular questions of medical science or its application to practice … A keen and energetic Minister will quite properly do his best to maintain the administrative policy which he finds existing in his Department, or imposes on his Department during his term of office. He would therefore be constantly tempted to endeavour, in various ways, to secure that the conclusions reached by organised research … which was substantially under his control should not suggest that his administrative policy might require alterations … It is essential that such a situation should not be allowed, for it is the first object of scientific research of all kinds to make new discoveries and these discoveries are bound to correct the conclusions based upon the knowledge that was previously available and, therefore, in the long run to make it right to alter administrative policy … This can only be secured by making the connection between the administrative departments concerned, for example, with medicine and with public health, and the research bodies whose work touches on the same subjects, as elastic as possible and by refraining from putting scientific bodies in any way under the direct control of Ministers responsible for the administration of health matters".
§ I consider that these are extremely wise words which are as valid today as they were 72 years ago. We would do well to remember them. That is why the proposers of this amendment regard it as so important to protect the independence of the advice which the chief of research and development can give to the Secretary of State. I beg to move.
§ Lord Hunter of Newington
A great deal of time has been spent recently considering membership of committees at various levels and whether professional members should be representatives or not. Whatever the arguments, there are no doubts that the key relationship vital to the future of the service is between doctors, the spenders and management. That has to occur at all levels in the National Health Service.
448 This amendment has to do with the input of research and development studies. It is particularly concerned with the top level relationship between the royal colleges, professional associations, research councils, charities and others. How can the results of their researches reach the management and policy boards of the National Health Service and the department and be effectively examined?
Traditionally, public health issues have been programmed through the chief medical officers' division. They have a range of other advisory committees as well. The need for high immunisation rates for measles to have any real impact on the situation is one very good example of this effective work. However, medical and surgical diagnostic and treatment methods, in contrast, have been presented in the main to professional societies. That has often resulted in individual units or districts deciding to develop and try new things.
About 15 years ago that gave rise to a great deal of concern in the National Health Service resulting in the introduction of a national funding policy for some key developments, the costs sometimes being too great to allow haphazard changes to take place. It took some time to persuade the Government to do that.
The Select Committee on Science and Technology studied these matters under the chairmanship of the noble Lord, Lord Nelson. It developed the idea of a free-standing research authority. With hindsight, I believe that that was not sufficient. The Government's response is likely to be more effective and to have a greater effect on the departmental and NHS system. The reason is the necessity to bring medical results to the attention of management so that consequences can be studied.
For example, should a particular finding be drawn to the attention of all hospitals for immediate examination? If so, what is the cost likely to be? Should further local studies be done? Should the new treatment be a local response or a national facility? Is the treatment effective or is it more expensive than the present measures? The prize example of that is the treatment of simple warts by laser beams. I believe the cost is 50 times greater than the present standard and perfectly reasonable treatment.
The proposal that there should be a chief of research and development with a specialist staff could only facilitate these matters and the examination of different proposals. The royal colleges, their faculties and the clinical medical schools have already developed the necessary research potential. They have increased their capacity to do this work particularly in relation to clinical audit.
However, there is another range of matters which is not strictly clinical and where research and development studies should be conducted in a businesslike manner. Those must be developed. Traditionally, some have been run by divisions of the Department of Health. The provision, examination and choice of X-ray equipment is an example. These are the kinds of changes which the department proposes should be taking place in the future.
449 There is an argument that this could be a much more efficient method for doing clinical trials. At present there is a tendency among some people to have a go. We discovered that in 1963 when the Safety of Medicines Committee was set up under Sir Derrick Dunlop. That is a very delicate area because there is the eternal accusation that there is interference with clinical freedom.
I now turn to the amendment. I totally support the proposal that substantial information about the chief of research and development and also the advisory council should be on the face of the Bill. I say again that there is a greater need to establish the correct relationship between the royal colleges and others doing this work.
§ 4 p.m.
§ Lord Walton of Detchant
In the light of the eloquence and force with which the amendment has been proposed by the noble Lords, Lord Dainton and Lord Hunter of Newington, little remains for me to say except to the effect that I warmly support this important and crucial amendment.
The appointment of the chief of research and development now advertised will be one of enormous importance to the future of our National Health Service. I hope the Committee will forgive me for using for just a moment a personal analogy. When I was appointed dean of the medical school in Newcastle in 1971 I discovered that the medical school, being the oldest part of the university, had acquired unto itself the statutes which had been originally established in 1834 in the then medical school of the University of Durham. They had been little amended since that time. Two of those statutes said, respectively, that the spending authority for the faculty of medicine shall be the dean, and that the planning committee for the faculty of medicine shall be the dean.
I am sure that every Member of the Committee will feel that there are times when it is an enormous advantage to have a committee of one. Nevertheless, my responsibilities soon became so onerous that it was perfectly clear that in order to fulfil them adequately and to take note of appropriate professional advice it was crucial that I should appoint a dean's advisory committee to advise me on how 10 fulfil those onerous responsibilities. How much more is it important that an advisory council should he established to advise a chief of research and development whose responsibilities to the National Health Service in the future will be so demanding in the light of all the developments which have taken place and are continuing to take place in medical treatment and research. In the light of these matters, I warmly support the amendment.
§ Lord Ennals
I support this important proposal and in doing so I shall concentrate on the evaluation aspect. The Committee will be grateful to the noble Lord, Lord Nelson. I am sorry that he is not present today. He and his committee recognised not only the crucial importance for the nation's health of medical research but drew attention to the inadequacy of research and evaluation in the NHS's own operations.
450 I regret that the Government did not accept the main recommendation of the report for the establishment of a National Health Service research authority. But they went some way to meet the Select Committee by their decision to establish a chief of research and development responsible to the Secretary of State but without an advisory council. I warmly support the proposal that there should be an advisory council with professional involvement and with representatives of consumer interests. This new body should take on board that part of research which so much concerned the Select Committee—operational research, including structures, methods and processes for improving the methods of providing for the delivery of care in the most effective possible way.
I want also to congratulate the royal medical colleges—the Royal College of Nursing, the Royal College of Midwives and the colleges of the professions allied to medicine—on their constructive proposals in the report The Way Forward for the NHS with its subtitle Proposals for an NHS Evaluation Programme. They considered the three novel and highly controversial proposals within the Bill—proposals for NHS trusts, fund-holding GP practices and NHS contracts—and said in unambiguous terms that there was no evidence that these changes would improve the standard of care, access to care, choice of care or the cost-effectiveness of care. They considered that the introduction of these changes across the National Health Service in 1991 was completely unrealistic and that a rapid and widespread introduction could seriously damage the service.
However, the colleges were very constructive in their approach. They told the Secretary of State that they were ready to support proposals if properly costed and funded which could be shown to provide a better service. With all the skills, knowledge and experience at their disposal, they proposed what is now before the Committee. It was their view that the new structure for NHS evaluation would have a crucial role to play in a partnership between government, the professions and the public. They said that the structure should not restrict change but should identify and foster those changes that could be shown to be beneficial and modify those that were shown to be less effective. I entirely agree with this hopeful and constructive approach. I want to see new ideas for the improvement and delivery of health care. I do not want to see the NHS standing still. It is essential that new ideas are effective and necessary and systematically evaluated. That is part of the proposal now before the Committee.
This sudden introduction of new structures to the National Health Service may prove to be extremely damaging to a service based on public service and responsibility for the needs of patients. In a later amendment we shall argue that new ideas must be tried out and evaluated before being applied across the country in ways which the royal colleges believe could,plunge the NHS into uncertainty, confusion and chaos".What is essential is to have an effective means of evaluation without simply trying it out on the patient.
451 The fundamental proposal is that, in addition to the medical research tasks which have been well explained, the new chief of research and development should have the responsibility for NHS evaluation. He should be advised by a carefully chosen advisory council consisting of representatives of the NHS management executive, the health authorities, the royal colleges and other recognised professional and staff bodies, together with appropriately selected representatives of consumer bodies and the general public. This new independent structure for NHS evaluation would have a crucially important role to play now and in the future. It might later take on the evaluation of community care policy and procedures, with the involvement of local authorities, health authorities and the voluntary sector.
The new structure would have the objective not of restricting change or restraining initiative but of fostering the development of new ideas and evaluating their impact. The work of the chief of research and development together with the advisory council would, in this way, stimulate imagination and initiative and, by reporting results of evaluations, would enable health authorities and providers to decide how best to serve their local populations.
To achieve this goal is a major task. Its acceptance by the Government would give new confidence to those who today are concerned about the future of the National Health Service in the light of current government policies. It would require the recreation of the mood of co-operation between the Government and all who work within the service which is so essential to the future of health care in this country. The acceptance of the amendment would go a long way to changing the disturbed atmosphere which exists at present within the NHS. I support the amendment.
§ Lord Carr of Hadley
The noble Lord, Lord Ennals, seems to assign the main role of the new chief of research and development to one of evaluation.
§ Lord Ennals
I am grateful to the noble Lord for giving way. I said that I would concentrate on that aspect. Others had concentrated on the medical research aspect. I agreed and associated myself with what others had said.
§ Lord Carr of Hadley
I am glad to have that clarification. I apologise to the noble Lord if I misunderstood him. While I would agree that evaluation of what is going on both in existing methods and in new methods might indeed be part of the role of the chief of research and development and his staff, I could not accept for one moment that it would be anything like the only role or the main role or that he should occupy most of his time with it. Moreover, I cannot accept that his role in 452 evaluation should be the only source of evaluation for the benefit of the Minister and everyone else.
I want to make quite clear the fact that, although I strongly support the amendment, I do not rate very highly the part played by the chief of research and development in the evaluation process. I agree that it is most important. No doubt he will wish to contribute more than this; in fact, more than contribute. But it ought not to be the main source of evaluation, nor should it be his main, or one of his main, jobs. In supporting the amendment I must make clear that my own interpretaton of the amendment puts a rather limited value on the chief of research and development's role in evaluating new proposals, important though his role may be. I hope that I shall have other opportunities to express i the importance which I, and I am sure others, attach to that role.
I think that the amendment is important for a much more fundamental reason. The Government rejected the Select Committee's proposal for a separate National Health Service research and development authority. Instead, they have come forward with this proposal. I believe that, providing they give it proper weight and status, they are right in making such a proposal.
My own passionate belief is that the function of research and development must be integrated into the very management of the health service from the highest level downwards. I do not want it to be seen to be floating around the periphery in a prestigious, but nonetheless essentially only advisory, capacity. I believe that it should be integrated fully with the management of the National Health Service. As the noble Lord, Lord Dainton, said, that starts by making the holder of that office a member of the policy board.
I cannot imagine any sizeable organisation, let alone one which is very strongly based upon results of research and development, having its chief executive or director, or whatever you may call him, in any position except as a member of the main policy board. In my view that is absolutely essential. All his work must be integrated into the management of the health service. I imagine that most of his work, and most of his advice, would flow straight to the National Health Service Executive, which sits immediately beneath the policy board.
I believe that the amendment is very important. I strongly urge the Government to accept it. Of course, I realise the slight delicacy in the situation, in that we are having this debate today while the Secretary of State is to meet your Lordships' Select Committee to discuss the matter tomorrow. I well understand that that may preclude my noble friend Lady Hooper from making any firm commitments today one way or another. However, I hope that she will at least give us an indication that what has been said will be taken on board and that it will be very seriously and constructively considered. I also hope that amendments can be produced at a later stage if she feels it impossible to accept the amendment for the reason I have just mentioned.
At this stage in our discussions—and I emphasise those words—and like 453 the noble Lord, Lord Carr, I have no wish to follow the noble Lord, Lord Ennals, too far in his remarks on the document produced by the royal colleges entitled The Way Forward for the NHS. I shall concentrate on this amendment. I rise simply to make it absolutely clear that this is an all-party amendment. Members on these Benches who have an interest in such matters have met and have discussed the amendment in detail. They are wholly in support of it. I want to make it absolutely clear that | Members of all parties in your Lordships' Committee support the amendment, so admirably moved, if I may say so, by the noble Lord, Lord Dainton.
We on these Benches would certainly underline the point made by the noble Lord, Lord Carr, about how essential it is that this officer should be on the main board. That is absolutely essential. I want there to be no doubt about the fact that this is an all-party matter. We all support it. We hope that our discussions will prove helpful, rather than the reverse, to the Secretary of State at the meeting tomorrow.
§ 4.15 p.m.
§ Lord Kilmarnock
We on this Bench also strongly support the amendment. As the noble Lord, Lord Dainton, mentioned in his opening remarks, the proposal was based on the report of your Lordships' Select Committee on Science and Technology, chaired by the noble Lord, Lord Nelson of Stafford. I should like to quote but one passage from the report. Paragraph 2.32 reads:A major area of concern for many witnesses was in public i health research and evaluation of practice".The burden of this section of the report was that there was a serious lack of public health and operational [research in this enormous organisation of the National Health Service. The point was made repeatedly by expert witnesses. For example, in the same paragraph. Professor Alan Williams said:Far too much money is being spent at the moment on scientific I and technical aspects of new developments, and far too little evaluating their cost effectiveness".In the following paragraph Professor Maynard of the Centre for Health Economics at York said:The Department of Health has spent a lot of money producing performan;e indicators which are measures of activity and not measures of outcome. The debate about health care in this country is obsessed about either spending money (with one side saying we are spending too much and the other saying too little) or it is obsessed about doing things to patients, but it is not really looking at the results of activities and this expenditure, and that is what we have got to be looking at: the cost and the outcome".Therefore all the expert witnesses were at one on that point in the evidence they gave to the Nelson Committee.
I entirely agree with what has been said about this officer. He must have more clout than is actually being given under the Government's proposals in their response to the Nelson Report. It is obviously essential, as the noble Lord, Lord Carr, said, that he should be on the management executive. It is inconceivable that he should not be. It is also vital that he should produce an annual report. I simply reiterate the fact that we strongly support the amendment.
§ Lord Auckland
The amendment is tabled in the names of distinguished scientists and doctors. However, it may be for the convenience of the Committee if someone from the second tier who is merely a Member of this Chamber intervenes at this stage. I believe that this amendment is of fundamental importance. Of course we must avoid overloading these committees with too many people. But it is surely the case that research and I development is the absolute crux of the health service. Without it doctors and nurses cannot function and for those reasons I hope that, notwithstanding what happens tomorrow in the Select Committee, the Government will give the most serious consideration to the amendment.
§ Lord Butterworth
I very much hope that the Minister will find it possible to accept the principles which have been expressed in the amendment. As the noble Lord, Lord Dainton, explained, there was no difference between the view of the Select i Committee on Science and Technology on the one hand and the department on the other. They are united in the view that the NHS should do more to identify and meet its own research needs and that it should be brought into the mainstream of medical research.
However, for perfectly proper reasons the proposal has been put forward that, instead of placing the responsibility for R&D on a national health research authority, such responsibility should be placed upon one person. Therefore, it would seem to me to be entirely proper that his appointment should rest upon statutory authority. It will enhance his position and give him a foundation from which to spring. It may also help with the subsidiary arguments which will now continue about how he should be resourced and what staff he should be given. The advisory council which the amendment proposes is clearly quite fundamental to the successful operation of the officer. I must express surprise that he does not have a seat on the management executive.
There is also a subsidiary reason why this office should be given statutory authority. Because of the history of the matter serious reservations have been expressed, especially among senior members of the medical profession with experience in the field. It would do much to reassure them if an amendment could be accepted that gave the officer statutory authority.
§ Lord Butterfield
I add my support to the general thrust of the amendment. However, I should like to say how much I sympathise with the noble Baroness, Lady Hooper. We have been talking without reference to the present leader of the medical profession in the Department of Health, the Chief Medical Officer of Health. I assure the noble Baroness that, whatever may develop on the research side, I hope that it will not be to the discomfiture or diminution of the influence of our successive gallant Chief Medical Officers of Health. I hope that it will be possible for a structure to be designed where these two men, women or man and woman are able to work together.
§ Baroness Hooper
I too am grateful to the noble Lord, Lord Dainton, for the thorough way in which he introduced his amendment on this important topic. Like him I am sorry that my right honourable friend's appearance before the Select Committee tomorrow does not pre-date this debate. However, I hope that what I am able to say today will advance matters.
The Government are firmly committed to research in and for the National Health Service. As has been said, it was last December that we announced the creation of the new post of chief of research and development to spearhead improvements in the area. I am extremely pleased by the general welcome that this initiative has been given by noble Lords and others outside your Lordships' House. There may still be concerns which we shall be happy to try to answer but the point remains that this new development has been welcomed. We are grateful for that and for the work of the Select Committee on Science and Technology, the report of which was most influential in our thinking.
We do not regard the creation of the post as the end of the matter. We continue to develop our thinking about the role of the post and the views of the post-holder will obviously be of great importance here. However, we are responding to arguments that have been advanced and some conclusions can already be announced. First, after some consideration we have decided that the title of the post should be Director of Research and Development rather than chief to emphasise the similarity with the directors of the National Health Service management executive.
More importantly, in the light of the generally welcome response to the announcement of the post, and in response to the criticism which has again been raised today by the noble Lord, Lord Dainton, by my noble friend Lord Carr and others, we have decided that the director should sit as a full member of the National Health Service management executive.
Non-executive members of the policy board, however, as Members of the Committee will know, are appointed on a personal basis. Research will inform discussion by the policy board and, as has been said on previous occasions, the director can attend relevant discussions. In any event, the presence of the National Health Service chief executive, the Permanent Secretary in the Department of Health and the chief medical officer, to whom the noble Lord, Lord Butterfield, has referred, as well as the other non-executive members, will make sure that research experience is represented on the board.
In addition to his new position on the National Health Service executive, we anticipate that the director will have a number of tasks relating to other responsibilities of the Department of Health. However, we believe that placing him on the National Health Service management executive will make clear his strong role in relation to research in the National Health Service and will strengthen the executive's work on evaluating and implementing our plans.
456 Turning to the amendment, the first part proposes to make the director a statutory appointment. Perhaps the Government should be flattered that within a few months of the creation of the new post Members of the Committee are asking to put the appointment on a more permanent basis. The difficulty is that times and circumstances change and what seems appropriate now may not seem to be quite so helpful in five, 10 or 15 years' time. As we all recognise, legislative time is always a scarce and precious commodity and limits our capacity to respond flexibly to changing needs.
However, I can assure the Committee that the Government intend the appointment to continue so far as they can see. I hope that that will provide reassurance on the security of the office, as is the case with respect to other offices held by distinguished individuals in the Department of Health.
The same arguments apply to the second part of the proposed clause, which provides for an advisory council to assist the director. I am sure that when the director is appointed he will wish to consult intensively and extensively in order to perform his duties. Indeed, we wrote in our response to the Select Committee's report that the director will wish to involve himself in the Medical Research Council, for example, and in scientific committees and advisory bodies. We also said that the director will maintain close contact with the research community and convene groups as necessary in the development of the programme in particular areas. He will also have an adequate back-up staff, including at least 20 who will have key senior professional roles.
I fear that the creation of a statutory advisory council could hinder the director in identifying and developing his preferred arrangements for consultation with the research community. Again, a statutory requirement could be unwieldy and inflexible, even more so than that suggested by the first part of the amendment.
The third part of the new clause provides for the director to make an annual report. The department already publishes an annual year book on its research programme. The latest was published in January. It is quite a bulky volume and provides a full account of the work done. I know that the director's responsibilities will go wider and I am sure that he will wish to consider how best to account publicly for his work. We shall certainly ask and expect the director to propose how best to account for himself But I plead again for the new appointee to be given reasonable freedom to give his views on how this public accountability is best provided.
This is an important topic. I hope that the Committee will feel that, with the important concession that I have been able to announce this afternoon, things are without a doubt moving in the right direction, and will therefore support the Government by accepting that there is no need for the amendment.
§ Lord Ennals
Perhaps I may respond straight away to the Minister. There are certain aspects of what she said that I welcome. I am glad to hear that the officer will be a director and that he will sit on the management executive.
457 I was much concerned about what the noble Baroness said about the recommendation which is fundamental for an advisory council. I believe that, with the responsibilities that are being taken on across the whole field of medical research, including evaluation, it is vital that there should be an advisory council. Not only will the director be strengthened but it will give the professions, others who work in the National Health Service and the consumers the opportunity of becoming involved in the work that he is doing. Simply to have an official who then decides for himself, or who consults the Secretary of State ahout whom he should talk to, is not good enough.
Although I am delighted to hear that the Secretary of State will be speaking tomorrow, it would be a pity if he gained the impression that the Committee was satisfied with the reply that has been given by the noble Baroness.
Before the noble Lord, Lord Dainton, decides what course to pursue with regard to the amendment, perhaps I may say that I was absolutely delighted to hear most of the reply of the noble Baroness.
However, I was puzzled by one point. On the question of whether this appointment should be a statutory appointment, the noble Baroness asked us to accept that times change and that the time for legislation was in very short supply, the implication being that, if we do not make this statutory now and later we wish to, it will be very difficult to find time. But surely the boot is on the other foot. If this office is made a statutory appointment of the National Health Service, I cannot see the remotest possibility at any time in the future of our suddenly deciding that we do not wish it to be a statutory appointment. I cannot see how that could arise.
In a sense, I think the argument of the noble Baroness, is on our side rather than on hers. As she said, time is short. I am convinced that this should be a statutory appointment. I am convinced that the time will shortly come when, if it is not made one, the Government will wish it had been made one, and then they will be in difficulties because they will be looking for legislation time. So I hope that the noble Baroness and her colleagues will change their minds on that point. Otherwise, I was delighted to hear what she had to say to us.
§ 4.30 p.m.
Lady Carnegy of Lour
Before the noble Lord replies to the debate, I should like to raise a matter with my noble friend. Looking at the amendment, I see that what is proposed is the classic statutory body with a few professional representatives and a few consumers, as if they can really say what it is that the public wants from the National Health Service.] am always a little cynical about that kind of amendment. At the same time, in a job like this I should have thought that such an officer would probably want, and indeed construct, a group of people with whom he or she worked in order to do the job well in a responsive way and to talk things through.
458 I do not know whether the noble Lord has it in mind to divide on this, but I wonder whether what the Committee wants would be for my noble friend to talk to her right honourable friend about what has been said by a number of people who know how this works, and also by politicians who are making political points in addition, and see whether it is necessary to put something about a support group into the Bill, or whether we could simply be given an assurance that that is the way that this very important official would be meant to work. I do not like this kind of amendment, and yet I see the need for the group.
§ Lord Carr of Hadley
Before my noble friend says any more and before the noble Lord, Lord Dainton, makes up his mind what he wishes to ask the Committee to do about the amendment, I should like to add a few further thoughts.
I too very much welcomed a lot of what my noble friend had to say, particularly concerning the position as a director. I talked about the main policy board, but I am not wanting to make a great issue about that. I am very satisfied with what my noble friend said about his position as a director, in title and as a member of the top executive. However, I was disturbed by something else that she said: that is, that being the director of research and development for the National Health Service would not be the whole of his job. She spoke about other responsibilities within the department. I am sure there are such responsibilities, but I find it quite astonishing that the director of research and development within this vast health service should not be a whole-time post and nothing but that. I would ask the Minister and her right honourable friend to think about that.
I know that we do not want to make too many analogies bwetween companies and the health service. In some ways it would be inappropriate, but in some organisational ways it is very appropriate to do so. Can anyone imagine ICI having its director of research and development also doing another job? He might be allowed or even encouraged to be a non-executive director of another company, but to have another executive job anywhere is beyond imagination. I really must ask my noble friend and her right honourable friend the Secretary of State to give further thought to that.
There is a final point about the advisory committee. Normally I would share the scepticism of the noble Baroness, Lady Carnegy, about advisory bodies of that kind. However, I think there are special circumstances within the health service. Surely the overriding need within the health service is to weld or meld—whatever the right word may be—into a single team the managers, the doctors and this function of research and development. That is not how the great hospital medical service has grown up in this country. There are the Royal colleges and their continuing great role, and other aspects of this, and in this area we need some body such as has been proposed—it may not be quite right as suggested at present—to bring all that together.
While agreeing with what my noble friend said, and being sceptical about such committees in almost 459 every other field I can think of, I behieve there is a special reason for doing this, or something like it, officially as a long-term commitment within the health service.
Lord Young of Darlington
I join other noble Lords in welcoming the statement, particularly for its tone, which I hope augurs well for what is to come, but I could not follow what was said about making the appointment a statutory one. I gather that the argument was that there might be a need to make a change at sometime in the future and it would not be so easy to make it if it were a statutory appointment. I cannot see how there could ever be the case in the future—as long as the National Health Service exists or as long as there is any concern for the health of the nation—that research would not be necessary and that it would not be necessary also to have someone in the Department of State concerned with health who was primarily concerned with looking after the research effort in the country. If one cannot envisage the circumstances in which there would be a change, surely that helps to fill out and reinforce the case for making the appointment statutory.
§ Baroness Hooper
Perhaps I should attempt to respond briefly to some of the additional points that have been raised. I should like to confirm particularly to my noble friend Lord Carr that there is no question but that this appointment will be a full-time appointment. The duties, other than those relating to the National Health Service which we envisage will in fact form the major part of the new director's duties, relate to policy development work which feeds into the National Health Service.
Perhaps I should remind your Lordships that this appointment will replace the existing appointment of chief scientific officer, which goes wider than the National Health Service as such. It is important that the kind of co-ordination which we envisage to be a major result of this appointment is there, and that the individual who is appointed will straddle not only the National Health Service, where we recognise the need as great, but also other aspects of the department's policy work.
On the question of whether or not the appointment should be a statutory one, I accept what has been said to some extent, but I reiterate that neither the chief medical officer nor the chief executive of the National Health Service are statutory appointees. I hope that nobody is suggesting that their roles need statutory support to ensure respect and effective work within and for the National Health Service.
As to the question of whether we should have the statutory advisory body, I hope that I was very clear in saying that we expect the new director to consult and take advice widely. However, we believe that when he is appointed he should have a say on how best he should carry out that function. In any event, an advisory council of the sort suggested in the amendment may not alone be sufficient to hear all the views. I reiterate that we fully agree with the aim of listening widely to the National Health Service and the research community. I believe that the Committee's anxieties in that respect are unfounded.
§ Lord Dainton
As the debate progressed I was greatly heartened by what seemed to be strong support for the amendment from all sides of the Chamber. Therefore, I was correspondingly somewhat disappointed with some of what the Minister said in reply. Clearly, we all welcome what is an obvious step—namely, that the director of research and development must, as the noble Lord, Lord Carr, said, have his seat on the executive and his proper place within the structure.
Reference was made to the existence of the chief scientific adviser, a post which is to disappear. That post is heavily engraved on my mind because in 1972 I was involved in giving advice to the Department of Health and Social Security, as it then was, on who should be the first chief scientific adviser. I have watched that post and its effectiveness—or I should say ineffectiveness—very carefully from then onwards. It was ineffective for a variety of reasons but the main one was that it did not have what has been so inelegantly, but aptly, described as sufficient clout within the department.
As I understand the position from what the noble Baroness has said, the chief of research and development will have the clout of belonging to the management executive. That is an important step forward. However, I remain unconvinced by the Minister's reply and her reasons for not providing a statutory advisory council. That is for a whole variety of reasons, not least of which is that taking advice is one thing; one goes to people whose advice one wants to hear. An advisory council is another thing; it is a body in which, whether one likes it or not, contrary opinions which one ought to hear may be expressed with great force. That distinction is a very important one.
It is also extremely important to have an advisory council which is established under statute. That would assure the world outside, and particularly the professional people—doctors, nurses, dentists and others—who work within the health service, that the director of research and development, as we must now call him, will be informed by the best advice available. It would ensure that he will have to argue his case with those people who are—to mix my metaphors—at the coalface of the health service—the doctors, the dentists and so forth. It is not satisfactory just to have an arrangement under which, when the director so chooses, he will be able to consult a body of uncertain duration and uncertain membership. That does not seem to me to meet the point.
I was also concerned with the reply regarding the annual report of the department. I believe that that is splendid. I have read the annual reports in the past. In a little book which I wrote some years ago I pressed for that change to take place and it happened, although I do not say that the two events were connected. One wants to see it given special prominence. All of us outside the health service feel that it is such a vast enterprise that it is very difficult for us to come to grips with its performance. How does it measure up? Is it, as some people say, a very wasteful body or is it an economical body? One would like to see some genuinely judgmental position taken by somebody standing back from the service, 461 informed by an advisory committee who make a fair judgment on such matters. That would enable us, as citizens no less than as Members of this Committee, to have some idea of the effectiveness or otherwise of the workings of the National Health Service.
As the Committee has appreciated, for which I am grateful, I am in a difficult position in view of the fact that your Lordships' committee on scientific research and development is to meet the Secretary of State at 11.15 tomorrow morning on this very subject of the position of what we must now call the director of research and development. Therefore I find it difficult to know whether or not to divide the Committee now. Am I likely to hear something tomorrow to my advantage or am I likely to hear nothing? All I can say at the moment is that I should be prepared to withdraw the amendment. However, I would also give notice that in case by the Report stage the situation appears to be little better or, alternatively, in view of what the Secretary of State may say tomorrow the situation has changed so markedly that I am content, I believe that I have to reserve my position. Therefore, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ 4.45 p.m.
§ Clause 3 [Primary and other functions of health authorities etc. and exercise of functions]:
Baroness Cox moved Amendment No. 64:
Page 3, line 10, at beginning insert;
("( ) It shall be a primary function of any Regional District or Special Health Authority only to enter into an NHS contract after such time as the conditions laid down in section 63 (2A) below have been met.").
§ The noble Baroness said: In moving Amendment No. 64 I must begin by making it plain that it is a paving amendment for the subsequent and substantive amendments, Amendments Nos. 119 and 121, which are the ones I shall be addressing primarily. The purpose of the amendments is to reflect and to respond constructively to the widespread and deeply felt concerns expressed very strongly by so many highly responsible senior and experienced professionals working in the National Health Service. They are motivated not by self-interest but by acute anxiety over the potential effects of the proposed changes on the patients whom they serve. I believe that never before has there been such a anited plea to the Government from the royal colleges and other professional bodies. It is a plea which I believe is eminently principled and rational and one which I believe it would be both unprincipled and irrational for the Government to ignore.
§ The essence of the plea, which is the basis of the amendments, is the requirement for some systematic evaluation to be built into the process of change. It is not the purpose of the amendment to prevent the implementation of the changes proposed in the Bill but to try to ensure that they are implemented on as sound a basis as possible with the information necessary to achieve the desired outcomes. Such information can only become available by systematic, empirical evaluation.462
§ In speaking to the amendments perhaps I may remind the Committee of the breadth of the support that they command, the reasons for that support and the potentially serious effects if they are rejected.
§ First, I do not believe that 12 royal colleges, five professional colleges and eight other reputable professional bodies can all be entirely wrong. Perhaps I may briefly remind the Committee of the prestigious and responsible bodies which are calling for some kind of empirical evaluation of the proposed changes. They include the Royal Colleges of General Practitioners, of Obstetricians and Gynaecologists, of Pathologists, of Physicians, of Physicians of Edinburgh, of Physicians and Surgeons of Glasgow, of Psychiatrists, of Surgeons, of Surgeons of Edinburgh, of Midwives and of Nursing. They include the College of Anaesthetists, the College of Radiographers, the College of Speech Therapists, the College of Ophthalmologists, the Society of Chiropodists, the British Dietetic Association, the British Orthoptic Society, the Chartered Society of Physiotherapy, the British Psychological Society and the Hospital Physicists' Association.
§ Those professional bodies have united in an unprecedented fashion, not to plead for any self-interested cause. They are not seeking to oppose government policy. They are merely requesting the Government to commit themselves to a programme of evaluation before opening up the gates to wholesale change when there is a dearth of adequate information on which to base that change or on which to assess its effects.
That point has been made very powerfully by Sir Henry Yellowlees, formerly Chief Medical Officer of Health, in his letter to The Times of 17th April. I should like to quote him, as he writes with the authority and direct experience of his responsible post. He said:
Over the past few weeks a series of reports published in January 1990 have been issued from the Department of Health on the detail of the information and information technology needed for the implementation of the reforms. The reports illustrate the complexity of the undertaking, and demonstrate the enormous gulf that still exists between the theory of these reforms and the practicability of the timescale proposed for their introduction. These documents—'Framework for Information Systems'—are full of phrases like 'it is difficult to introduce', 'time is not on our side', 'details of how the reforms will work are still not clear', 'lack of clarity about roles', 'responsibility for that function is not clear'".
I continue to quote from Sir Henry:
It has become evident that the Department's own advisers recognise that it is not at present possible to cost an out-patient's attendance or a course of in-patient treatment with any accuracy. How can it be sensible to introduce scattered NHS Trusts hospitals and fund-holding practices where those must depend on buying and selling a product which cannot be costed?
Sir Henry concludes:
even at this stage there is still time for the government to change the pace of their introductions, and not risk failure of the reforms, or possibly of the whole of the NHS, by insisting on a rushed timetable that appears to be potentially disastrous".
§ Surely the Government must heed such sober warnings. I therefore hope profoundly that they will respond as sympathetically to these amendments designed to help them to proceed with the changes proposed in the Bill, but to do so in a way that 463 maximises the chance of their succeeding in achieving their objectives—better patient care.
§ I now turn from the background of the amendments to a few brief words on their substance. In essence, they ask my right honourable friend the Secretary of State to establish some systematic programme of evaluation during the initial stages of the implementation of the proposed changes before giving the green light to wholesale, nationwide change without the benefit of the results of that evaluation.
§ The Committee may have noticed a change in the wording of Amendment No. 121 since it was first put down last week. In its original form, it put certain specific limits on the number of changes to be introduced, limiting those to two regional health authorities. It would also have delayed the national implementation of the reforms for a period of three years until evaluation of the effects of change in those two regions had been fully assessed.
§ I still believe that there was a sound logic in that original amendment in terms of systematic, rigorous research. However, it was suggested that it would be politically and practically unfeasible, given that there may be many hospitals and practices which have already been working hard to try to prepare themselves for the proposed changes and it would be unfair to exclude them from a such a limited sample. Therefore, the other noble Lords associated with the amendment and I agreed to modify the amendment to respect those concerns.
§ Since being catapulted, to my never-ending astonishment, into the political arena, I have devised a principle which I think is appropriate for any politician; namely, to have open ears, open eyes and an open mind before having an open mouth. I believe that the changes in the amendment reflect that principle. We have modified our amendments in the light of discussions that we have had and advice that we have received. We have modified them to an extent which we believe makes them unexceptionable and I hope that my noble friend the Minister will show a comparable openness of mind and flexibility on behalf of the Government.
§ We are aware that my right honourable friend the Secretary of State has until now made clear his resistance to the kind of evaluation programme which was put forward in the paper The Way Forward which was prepared by the royal colleges, and the other bodies to which I have already referred, although I believe that my right honourable friend has committed himself in general to the concept of evaluation. We have therefore now proposed amendments which ensure that the principles of evaluation will be implemented, but which give to my right honourable friend the Secretary of State maximum leeway in how that will be done, both in terms of locations and numbers of hospitals and practices and also in terms of the timescale involved. If he is committed, as he says he is, to the fundamental principle of evaluation, the amendments provide an opportunity to demonstrate that commitment, but in ways which he can choose. It no longer imposes the constraints which he previously appeared to find unacceptable.464
§ We cannot be more reasonable or accommodating than that. Perhaps I may conclude with a brief personal statement as to why I as a nurse, a social scientist and a Conservative, plead with my noble friend the Minister to give a sympathetic response. As a nurse, I know from working with my professional colleagues not only in nursing but in the other health professions, that their concerns are not self-interested in this matter. They are genuinely, deeply worried about the implementation of change in a system as complex as health care on the basis of inadequate information. In health care, mistakes cause suffering to vulnerable people. Every precaution must therefore be taken to avoid unnecessary detrimental side-effects of change. That can be achieved only by phased, controlled and systematic evaluation of change.
§ As a social scientist I have been deeply influenced by the work of writers such as Sir Karl Popper, especially his convincing arguments for the need for piecemeal reform rather than the imposition of wholesale, radical, untried change. Social systems such as health care are far too complex to anticipate and plan in advance for every contingency and, especially with a warning such as that sounded by Sir Henry Yellowlees to which I have already referred, it would be foolhardy in the extreme to proceed with such changes without any kind of controlled evaluation.
§ Finally, perhaps I may speak particularly to my noble friends on these Benches. I hope that they will understand that I support the amendments as a deeply committed Conservative. I shall just give two examples as to why I do; first, in terms of basic Conservative principles. My noble friend Lord Jenkin of Roding spoke eloquently last week of Conservatives being appropriately cautious about change and indicated that the onus of justification should be on those who advocate it. I agree, but part of that justification must be a commitment to rigorous testing of the effects of change. Theory must be tested in practice. The acceptance of the amendments on the face of the Bill would be a reassuring proof of that commitment.
§ That leads me into my second reason for supporting the amendments as a Conservative. I am sure that many noble Lords will have had the opportunity of talking to, and with, fellow Conservatives throughout the country. Wherever I go, I hear expressions of profound concern about the proposed changes to the NHS. Recent opinion polls demonstrate that too. A large majority of the electorate are very worried. Therefore, if the Government wish to reassure the public, including their own supporters and, more importantly, to avoid potential mistakes which might lead to human suffering and which would make them subject to legitimate criticism, I believe that they must take that step to commitment to some form of evaluation as they embark on the reforms.
§ The terms of the amendment are eminently reasonable and give great power to my right honourable friend the Secretary of State to determine the nature of the evaluation programme. I very much hope that my noble friend the Minister will be persuaded to respond sympathetically to the 465 amendments which reflect the sincere concerns of so many senior, responsible people working in and for the NHS and for the patients whom it serves. If the Government respond sympathetically, I believe that they can enhance their credibility with the professions and with the public. If they do not do so, I fear that their credibility will be severely damaged and I would have to say deservedly so.
§ I hope that my noble friend will therefore be able to respond in a way which avoids that potential damage but, much more importantly, in a way which will set the scene for a carefully programmed and systematically evaluated introduction of change which respects the wise advice of senior professionals and, most important of all, will best promote the interests of the patients, the clients, and the communities which the National Health Service exists to serve. I beg to move.
§ 5 p.m.
§ Lord Smith
This amendment, so admirably moved by the noble Baroness, Lady Cox, stems in part at least from a statement made by the presidents of the royal medical colleges. At the Second Reading of this Bill I listened with much enjoyment to the superb introduction by the noble Baroness, Lady Hooper. In that speech she paid tribute to the presidents of the colleges but as regards the fate of this Bill she held that their opinions were largely irrelevant.
The noble Lord, Lord Ennals, who spoke immediately after her, declaimed with emphasis what must have been apparent to the Chamber—that the opinion of the presidents must be respected and believed. Later the same day I overheard several remarks in this Chamber. While not in the least critical of the presidents, in the main they were to the effect: the presidents are doubtless very eminent in the medical profession, but I wonder how they were elevated to that position? Was it seniority, popularity, a reputation for knowledge, wisdom or skill, or was it medical authorship? What was it? Above all, what particular qualities had they developed which made them more trustworthy in predicting the future of the National Health Service? In deciding upon such vital issues, what weight should we attach to their views?
The same evening the noble Lord, Lord Nugent of Guidford, said with characteristic kindliness that he regretted the infrequency with which I addressed noble Lords. I answer that indirect question by replying that in recent years I have perhaps been unduly shy of speaking unless it is certain that I have some special knowledge which can briefly be stated, which will contribute to the debate and which may fill in the gaps that may prevent some noble Lords from making a fair judgment.
I know about royal medical colleges. The various colleges have many similarities but one or two differences in internal structure. I should like the Committee to come behind the scenes and visit just one Colllege in Lincoln's Inn Fields to find out what might be learnt. The colleges co-operate fully with other medical bodies. On the other hand, they are not allowed to argue on behalf of the self-interest of doctors. It is not traditional. In any event, were they 466 to do so, the college would lose its charitable status. Each councillor is elected by all the fellows of the college and learns straight away that he or she is there to put the interests of patients above all and to maintain and advance the standards of medicine. The hard work is largely done in the committees. I shall not bore the Committee with a list but I must mention two of them.
To foreshadow the first beginnings of audit, one committee sends round visitors to inspect all hospitals where training of surgeons takes place. When the visiting team of surgeons from the college arrives, all the staff surgeons are expected to give an account of their individual work and the training that they undertake: teaching clinical diagnosis, teaching operative techniques, pathology and radiology. The staff surgeons co-operate fully and cheerfully with the college's requirements which stimulate a higher standard of surgery throughout the country. Very rarely the standard of teaching proves inadequate and the college withdraws recognition of training from the hospital. That situation resolves itself, because when any vacancy for a trainee surgeon arises no young men or women will apply for it and a hospital cannot perform surgical work when there are no junior surgical assistants.
Of course the Department of Health thoroughly approves the college's inspection of hospitals. In a way that approximates to the beginning of surgical audit. In the college the most effective members on the committee later become chairmen—I dislike the word "chairperson"; and, for example, a lady is chairman of the Court of Examiners—and the most effective chairman ultimately becomes a president who is elected by the 30 councillors. It is a reputation for good judgment on critical issues that in the end decides the council.
To digress for a brief moment, looking back over the years it is not often that the council can have elected a president of wisdom and judgment as outstanding as the noble Lord, Lord Porritt, who commands respect and great affection throughout the medical scene in this country and the world. The president is expected to serve for a maximum of three years, although he can be turned out at a yearly election. I have the greatest respect for the wisdom and judgment of Terence English, the president, and for Margaret Turner-Warwick, the first lady to be elected president of the Royal College of Physicians—to name only two presidents.
Finally, I must mention one more committee because it is extremely relevant. There used to be a committee called the standing joint committee. It had only three members: the presidents of the Royal College of Physicians, the Royal College of Surgeons and the Royal College of Obstetricians and Gynaecologists. It seemed to me in the mid-1970s that that might be replaced by a conference of presidents of all the colleges in the United Kingdom, which would be a sounding board for colleges to make sure that every college knew what the other colleges thought about every thorny problem. Morever, should things go badly with the National Health Service it would give an opportunity to make sure that the Department of Health, the Government 467 and the public knew the conjoint opinion of all the presidents in the United Kingdom.
That prescience was well judged. The Secretary of State's White Paper and the text of this Bill were considered many times by the conference. Doctors are not famed for unanimity and although the many presidents come from a great number of colleges whose only common feature is medicine the conference agreed with no dissentient voice to state its case for the information of Parliament.
I hope sincerely that I have not repeated knowledge that the Committee already possess. If so, I apologise. My aim was to fill in a few possible gaps in knowledge.
In conclusion, I believe that Members of the Committee should not underestimate the passionate conviction of each president to do what is best for patients and for the National Health Service. The Committee should not underestimate the knowledge, wisdom and judgment that guide them. It should not underestimate the feeling of the conference to have the courage to issue the statement.
§ Baroness Robson of Kiddington
The noble Baroness, Lady Cox, has introduced the amendment in such terms that there remains very little for us to say. She has expressed what we all feel.
I am one whose name was on the original amendment. I am happy to accept the change that has taken place since we last met. This amendment is more realistic, and it would help enormously to allay the fears of people within the health service. Over the past few days I have been to various National Health Service establishments. The one factor about which all grades of staff within hospitals are concerned—doctors, nurses and administrators—is the impossible timetable set by the present Bill. The amendment would not only give us a chance to consider the outcome of the proposed changes, but it might also give everyone a little time to settle down and prepare more thoroughly for any change that is coming.
I have frequently been told by the Secretary of State and Ministers that various pilot schemes to test the system have been going on around the country. That may be so. However, to test these changes that are being introduced necessitates using at least a district. One cannot test the system by using a hospital somewhere in Manchester and a private practice with its own funds somewhere in East Anglia. One must test it within a district so that the interaction between a National Health Service trust hospital and a hospital that remains within the district health authority's jurisdiction is tested. One must test the interaction between fund-holding practices and single practitioners and those who do not wish to hold funds. Above all it must be tested against the ongoing community care provisions which also change under the Bill.
Unless we have a real test in at least a district, preferably a region, we face enormous problems. We should give ourselves the time to make certain that we are going in the right direction. I support the amendment.
§ 5.15 p.m.
§ Lord Ennals
The Members of the Committee who have spoken to the amendment have done so on the basis of special knowledge and experience. It was brilliantly presented by the noble Baroness, Lady Cox. I present my own party's point of view.
It is my fear that the National Health Service is in for a very rough ride in the next year or 18 months unless the Government take note of the recommendations that have been made. First, there are bound to be service cuts on a scale no less dramatic than two years ago. They are starting already in district after district. Members of the Committee will recall that it was service cutbacks which led to the Prime Minister setting up the working group that produced the Bill. I fear that we are in for trouble.
Secondly, the Secretary of State has set a cracking pace for changes which are not only unpopular and unproven but which seem destined to create chaos. That is what the royal colleges and others were saying. From my own knowledge, the information technology is simply not ready. The database will not be ready by 1st April. The staff are not trained. The vast additional administrative costs to put these schemes into practice can be available only at the expense of patient care. A King's Fund spokesman said at the conference last week that the authors of the White Paper had seriously underestimated the scale of change. That is what the colleges were saying in their very important statement. Since that statement literally dozens of other organisations within the health service, including the main trade unions, the voluntary organisations and community organisations, have endorsed the statement made by the colleges. I do not recall a consensus of opinion on any subject such as now exists. If we as Members of the Committee neglect or ignore what the colleges are saying at this time then it is at our peril.
I believe that the amendment expresses the mood of the nation at the present time. From all sides, including many worried Members of Parliament, and such responsible organs as the health service journal, Mr. Kenneth Clarke is being urged to take note of these growing concerns before it is too late.
No one is seriously expecting that he should do a U-turn and drop his latest crop of ideas which now form the basis of the Bill. We are saying, "Try them out. Get some experience in a limited number of selected districts. Have them tested the hard way by local experience and, when there is time to learn the lessons of experience, decide what is best for the health service as a whole". That is what the amendment is about.
None of us is opposed to change. However, what is proposed in the Bill is so new, so unlike any procedure carried out in the National Health Service over the past 42 years, so full of potential—it may be for good or ill—that we say, "For God's sake get it right before anyone plunges the National Health Service into new uncertainties".
At a time when the Government are obviously facing great unpopularity and severe criticism, surely someone somewhere must be learning the lessons of the poll tax. I imagine that many people will ask, 469 "Why was that not tested?" If it had been tested, we may have had something more serious before us. It is sheer common sense.
I make two concluding points. I am sure that the noble Baroness will say that to some extent there will be pilot projects, and that the lessons will be learnt about these new NHS trusts and so on as time goes on. It is not enough to say that we shall learn as we go along. Evaluation is extremely important in order that we learn the lessons before such schemes are introduced across the country.
I wish to emphasis a point that has already been made. It is not the same proposal as was made by the royal colleges. All those whose names are down to the amendment met the Secretary of State last week when he came to the House. We recognise his arguments that the proposal from the royal medical colleges for evaluation of the scheme in two regions of not less than three years was too rigid. While I do not suggest that he agrees with the new amendment, it reflects our wish for agreement, and our wish not only to be flexible but to leave the vital decisions of where and when to the Secretary of State.
If this proposal were to be accepted, I believe that it would take a lot of the venom out of the present debate about the National Health Service. It would be welcomed by the public and by the vast majority of those who work in the service. Equally if the noble Baroness when she speaks on his behalf refuses what several commentators have called a lifeline, I believe that he will come to regret such refusal. He must be aware that the polls show that three-quarters of his party's supporters would put their names to the amendment.
§ Baroness Hooper
It may assist Members of the Committee if at this stage I explain how the Government see the implementation of the reforms. I shall later attempt to respond to specific points raised in the course of what promises to be an important debate.
There is considerable agreement about the ends and objectives of the Bill. We all wish to see improvements in the National Health Service. We want those improvements to be soundly based, to command the support and respect of patients and staff and to have within them scope for further refinements over time. I hope to demonstrate that the Government's approach to implementation fully meets the spirit of all the concerns about which we are aware and which were expressed today by the movers of the amendments. I believe that our approach is more effective than the amendments proposed, the precise terms of which could not be satisfactorily translated into practice.
On Second Reading I spoke at length about the evolutionary nature of our approach to implementation. There will be no big bang, no overnight change, no disruption of services. Our proposals were carefully thought through before the White Paper was published and have since been carefully refined and developed. That process will continue until 1st April 1991, thereby guaranteeing that the reforms have the best possible starting base.
470 However, April 1991 will not be the end of the process. The careful preparations during the preceding year will give place to what will in effect be pilot projects. The noble Lord, Lord Ennals, says that that is not enough but I assure him that, for example, the first National Health Service trusts will be in operation from that date. There will be a few dozen drawn from the many units which have expressed interest. The first GP fund-holding practices will be in operation; that is, a few hundred from the 850 which have so far sought further information about the schemes.
In both cases strong candidates will be chosen—those whom we and the regional health authorities believe to be best able to meet the challenges inherent in the schemes. We shall not be coercing them into participating because that would be totally against the spirit of both schemes. Instead, we are looking for volunteers and enthusiasts. But by no means all those who seek trust or fund-holding status will be given that. They will need to demonstrate their competence. Therefore, the size of the first wave will be restricted to one which the National Health Service is satisfied it can handle and from which important lessons can be learnt.
We shall all learn from the first volunteers but not, I maintain, if we impose upon them too tight a monitoring or evaluating mechanism. By their very nature they will uncover new opportunities, find new ways of solving problems and identify difficulties and challenges which were not anticipated. They are the very aspects that the proposers of the amendments wish to see. Both schemes will be considerably refined as implementation develops, taking account of everything that we and participants learn as the pace of change develops. Bringing forward those schemes at a pace they can handle, and in a way that best promotes patient care, will be a heavy management task.
A similar process will take place in respect of the National Health Service contracts. Already the thinking on the implementation of the contracts has developed markedly in sophistication since the publication of the White Paper, the working paper and the recent operating contracts guidance. We shall continue to learn from experience in that area. Without doubt, in the initial stages some contracts will be in relatively simple block form and there will be little difference from existing patterns of service. What will increasingly happen, and has already begun to happen, is that further refinements will be made in the identification of quality standards and the definition of service requirements. Both aspects are most important to our plans. In time that will open up even wider opportunities for providers and suppliers of services.
I have said that we shall learn from experience. No doubt noble Lords will ask how we shall do so. First, we shall be monitoring through the National Health Service management executive and we shall keep in close touch with progress on the ground. Regional health authorities will be doing the same. I am confident that problems and good practice will be swiftly identified and solutions found and disseminated. Secondly, we shall be supporting the enthusiasts. We are not engaged in a world of 471 cut-throat competition. Throughout the 1990s we shall be working with trusts and fund holders, supporting them in their individual work and ensuring that lessons are properly learnt and information is spread across the country. In that respect regional health authorities will have a crucial role.
Thirdly, and most importantly, we shall be evaluating the changes as we go along. That is a central task for management at all levels within the National Health Service. I do not believe that it can be sensibly carried out by a separate body outside the National Health Service management. With the best will in the world, such an external body is likely to lack the resources and supply of information required in order to form a comprehensive picture. I shall develop those points further in dealing with the precise amendment. However, I emphasise that National Health Service management does not live in a vacuum. There will be many influential commentators on the reports and their effects and we shall ensure that their views are taken fully into account as part of our wider evaluation.
We need to ensure that we have the tools in place to act on that ongoing evaluation. The Bill allows for that. It provides arrangements by which a GP practice can relinquish fund-holding status and trusts can return to the directly managed sector. I do not believe that there will be many such cases but it is right that we should anticipate that they may happen occasionally and we should provide for them. More importantly, I emphasise that much of the detail of the schemes will be non-legislative or contained in secondary legislation.
As our debates progress, no doubt we shall discuss how the various regulation and direction-making powers in the Bill will be used. We tried to give a full indication of that in the Notes on Clauses. I shall try to provide further information where possible during the course of our debates. I emphasise that the powers can and will be used flexibly in the light of experience in order to ensure that the legal framework which the Bill brings forward is sufficiently dynamic and flexible to adjust to operational requirements and opportunities as they emerge during the coming decade. That gives us the right balance of evolution within a clear legal framework and not, I suggest to the noble Baroness, Lady Robson, an impossible timetable.
I believe that that is a realistic approach to implementation. It will allow the National Health Service to dictate the state of progress with districts, hospitals and GPs moving by locally determined and considered steps. It builds on experience already gained from within the National Health Service; for example, the delegation of functions to operational level, the contracting experience developed through the waiting list initiative and the improved information and resource management. Above all, it is a framework which seeks to encourage rather than to constrain.
The present proposals for implementation have the support of those working within the National Health Service. We have worked closely—
§ Lord Ennals
I thank the Minister for giving way. Is there any single hospital which has expressed an interest in becoming an NHS trust in which any but a small minority supported the proposal? Is there a single hosptial where there has been a ballot in which the majority of staff have said yes, they wish to go? Is there a single hospital where there has been a community ballot? Why is the Minister saying that that has been done with great enthusiasm?
§ Baroness Hooper
We have worked closely with the health authorities and managers. In turn, they have involved their clinicians and other health professionals. There are many individual members of the profession—and no doubt we shall hear from some of them during our debate this afternoon—who believe that our proposals are the way forward. We believe that we need to continue working with those people, taking their advice and learning with them. It is no part of our strategy to second-guess them by imposing our means over theirs.
Health authorities and their staff have a statutory duty to provide services and we believe that nothing should be interposed between them and that duty. I shall respond later to any other specific points raised in the debate in relation to this amendment.
§ 5.30 p.m.
§ Lord Rea
As we come to expect from the noble Baroness, those were conciliatory words. The tabling of this amendment has helped the Government to bring this issue into focus. However, I still believe that the amendment is very important and I strongly support it.
The changes in this Bill are supposed to make the National Health Service more efficient and businesslike. Leaving aside the question of whether we believe that the proposed changes which introduce financial incentives into the National Health Service actually do that, we should consider whether the way in which those changes are being introduced are businesslike in themselves.
I am sure that all Members of the Committee know far better than I that changes in the management of large-scale commercial enterprises are carefully tested in pilot or demonstration projects. New product lines are subjected to market research using tried and tested techniques and methods which are quite vigorous and are acccurately predictive.
Professor Alain Enthoven, who many Members of the Committee will have heard of, is a professor of public and private management at the Graduate School of Business at Stanford University. He made a study of the National Health Service in 1984 and published a Nuffield monograph on the management of the National Health Service. It is on his thinking as much as anything that the Government's plans are based, particularly separating the provider from the purchaser.
473 Professor Enthoven is quite critical of the way in which the Government are bringing in their plans. I should like to quote from an interview which he gave to Dr. Richard Smith in the British Medical Journal a year ago. He said:I cannot understand why the Government didn't choose to test these very promising ideas"—and those are his words:in a series of pilot projects. Health care is an institution which is very difficult to change. There is much uncertainty and so much is at stake so people are reluctant to change. That reluctance may be broken down by successful pilot projects".With regard to the timing of the National Health Service reforms he said:Considering the large changes that will have to be made—in informantion systems and culture—that's an amazing speed. Health care just doesn't change that fast".I am aware that the Government plan initially to introduce National Health Service hospital trusts and budget-holding general practice to volunteers. The noble Baroness confirmed that. However, I hope that those will be evaluated rigorously, preferably through the good offices of the director of research and development and, as we discussed on the last amendment, guided by an independent advisory body.
The introduction of a contractor/provider principle and capital charging looks set to be imposed universally in April 1991. I suggest that, as intimated by Professor Enthoven, that will not be possibile without the risk of great disruption or very great expense, and probably both. The resources needed are great and if all districts try to introduce costing and contracting systems simultaneously, there will be insufficient resources and expertise to go round.
It is far more sensible to concentrate on one or two regions, invest expertise there and carefully measure and assess the results. The bugs can be ironed out, the best information systems developed, costing systems which take into account outcome and effectiveness can be worked out, and initially methods of monitoring standards can be applied and carefuly evaluated in a few districts.
As I mentioned in my Second Reading speech, when major reforms of a not dissimilar nature were proposed in the USSR, three regions were first selected to try out those measures: Leningrad, Kuibyshev and a city in Siberia. As a result of that many changes were made before the countrywide reforms were instituted. They are now going ahead. The original changes which gave budgets to polyclinics, (similar to the general practice budgets here) to buy hospital services were found to be wildly impractical. It is impossible to go into detail here but the original projects were found to be extremely useful when evaluated before going ahead with nationwide schemes.
For all those reasons, we should insist on this amendment, otherwise we shall run into a dangerous situation.
§ Lord Hunter of Newington
Something which the Minister said seemed to me to be a brief glimpse of light in the darkness, and perhaps she will confirm that she said it. She conveyed to me that there 474 are quite a number of volunteers who have special hospitals and practices and she said that in 1991, 30 or so from each group would be chosen. The critical point is: are the Government prepared to say now that, having set that experiment going, until those experiments in hospitals and general practices are evaluated, nothing further will be introduced?
The Lord Bishop of Bradford
I simply and briefly support the amendment before us. Although in a sense I speak for myself at this point, I believe that I have the support of many Church leaders across the country. I say that because at the General Synod last July when the National Health Service and various proposals connected with it were debated, a resolution was passed which runs on almost similar lines, calling for this sort of evaluation.
That particular resolution was passed virtually unanimously. Therefore, I believe that in supporting this amendment I should have the support not only of my fellow bishops but also of the General Synod of the Church of England.
I support it for a second reason. Today we have heard the very helpful opinions of various colleges and great associations. Perhaps I may take Members of the Committee into the inner city of Bradford where I addressed a conference of community workers just a few weeks ago. There were some 90 or so professionals, some from the statutory service, some from the voluntary sector ranging right across the political, Church and inter-faith divides. One thing united that entire conference which I was very privileged to address: it was united in its determination to make the Bill work for patients. It was united in its anxiety at the lack of clarity and the vagueness surrounding some of the proposals. They were also united—very strangely because they did not know that this debate was to be held—in their plea for this kind of evaluation or pilot project so that they could see the end results before full implementation took place.
On the basis of my experience with the General Synod and on the basis of working at the coal face in that particular part of Bradford, I wholeheartedly support the amendment.
§ Baroness Young
It is extremely helpful to hear my noble friend the Minister explain how the Government see this amendment. Quite clearly, from the discussion which has taken place, it has considerable support in the Chamber. It is very helpful that the Minister has set out the Government's approach to the Bill. It is an evolutionary approach, and on re-reading the Bill and re-reading the White Paper before the debate, one is struck by that as the whole thread and principle behind the Bill. It is not as though everything will suddenly change on 1st April 1991. Even if that were possible—and I do not believe it is—that is not the case.
It is always very difficult for lay people to argue with doctors on any point. The battery of expertise which we heard today is a very daunting audience for those of us who are lay people taking part in the debate. Among the experts I include my noble friend Lady Cox, who speaks both as a nurse and a social 475 worker. We all listened to her and admire the sincerity of her beliefs.
That said, the amendment does not make plain the point which underlines the whole Bill, that after 40 years of the National Health Service—I speak as a great supporter—it is right to look at it again and make changes. The changes proposed are not of such a fundamental nature that somehow we will find that the National Health Service, as it exists today, will be completely changed. The noble Lord, Lord Ennals, shakes his head, but the debates which we have so far heard in Committee concerning Clauses 1, 2 and 3, set out the structure of the committees at regional and district level.
We then move on to the National Health Service trusts. There has been much argument about them, but they still come within the National Health Service. Nobody suggests that they should become private hospitals, except those who wish to frighten individuals. I regret to say that there has been a certain amount of that sort of propaganda, but they will not become private hospitals; they will remain within the National Health Service.
§ Lord Ennals
I am most grateful to the noble Baroness for allowing me to intervene. She referred to me nodding my head; perhaps I can explain why. She is aware that from April 1991 all health authorities will be obliged to contract for all services. They have never done that before; they are ill-equipped to do so and it will create, from my experience and discussions with health authorities throughout the country, terrible uncertainty. When the noble Baroness says that there will be no big bang, I fear that there will be a big bang. They are all being plunged into doing something which they have never done before without evaluation.
§ Baroness Young
I take the point, which is a matter of fact, that health authorities will have to contract for services. It is something new that they will do, but that will not entirely change the health service; it will change a part of it. It is an evolutionary reform which will give them more responsibility; it will give them, in a sense, more interest and, at the end of the day, it will not just obtain better value for money but help to improve patient care.
I said that I am a great supporter of the National Health Service; I am. It has problems but, as I said earlier, they are not problems of failure; they are problems of success. The National Health Service has been immensely successful. Nevertheless, anybody who looks at it objectively will realise that one cannot possibly pretend that it is absolutely the best and offers the best of all possible worlds.
I often listened in your Lordships' Chamber to criticisms of the health service on behalf of those who, for one reason or another, did not receive the services to which they were entitled, whether it be children receiving vaccinations, old people and home visiting or whatever it may be. The Bill is a very sincere attempt to raise standards throughout the health service. It recognises—and that is a fact for whatever government is in power—that there will never be enough money for it. Money has been poured into the National Health Service; to talk of 476 cuts is absurd. To pretend that every single request in the future will be met would be to commit oneself to something which is unfulfillable. I am certain that the amount of money going into the health service will increase every year, but we need to satisfy ourselves that it is being spent as well as possible.
I believe that the National Health Service is, among other things, the biggest employer in the European Community. That in itself gives rise to enormous problems of making the best use of its resources which, after all, are its employees. Whether we are satisfied that it has always done that and is still doing it is one of the questions which remains to be answered.
My response to my noble friend Lady Cox and others who spoke most eloquently on this point, is that this is an evolutionary Bill. As my noble friend made quite clear, there will not be some sort of "big bang" on 1st April 1991. Already many reforms have been introduced which presage that which will happen in 1991. For example, the National Health Service trust status is a logical further step in the devolution of responsibility which is already taking place in some hospitals at an operational level. The other examples given by my noble friend also illustrate that.
The point has been made by many people that we need these experiments, and that shows that they are being carried out. The effect of the amendment, should it be carried, would not be to enable the improvements in the health service to be made, but rather for there to be delay. That would be the end effect of the amendment.
The Bill is important. Perhaps I may comment on one other point. A great many people said in various polls that they are very much against the reforms. I am afraid that I am not surprised that that was the outcome. Some of the propaganda that has been put out by the BMA is little short of disgraceful. It has frightened a lot of people in a very unprofessional way. I think it right to say that. Some of its observations, such as the statement that the National Health Service has been starved of funds, are simply untrue. It ill befits a profession to go around making totally untrue statements. It is right that we should say so in this Committee and that we should say to people who have been frightened or alarmed that they should read the rest of those statements, recognising that some of them which are ascertainable are not true.
I am not surprised therefore that when many people read and hear all that propaganda, when asked they say that they are alarmed, because they think something alarming will happen. That is why it is important that we recognise that the Bill is an evolutionary measure. It maintains the National Health Service, because we all believe in it and it is a very good service, but it is designed to improve it.
§ 5.45 p.m.
§ Baroness Cox
Before my noble friend sits down perhaps I can ask whether she puts in the same class as what she refers to as "propaganda" the very serious professional representations put forward by all the royal colleges and professional organisations quoted in the earlier speeches?
§ Baroness Young
I was very careful in what I said in my remarks. I picked out that particular piece because it appeared in many national newspapers and a1 least one of the statements was completely untrue. I could say a great deal more regarding the other statements, but I will not take up the time of the Committee.
§ Lord McColl of Dulwich
Perhaps I may point out that if this was 1972 I would view these amendments very favourably. In 1972 I introduced a modest pilot study into the National Health Service simply to improve the lot of the junior staff of our hospitals throughout the country. It was a small pilot study which gave them security for the first time. The study looked at their families and family life. Was it right to move the staff around every year? Was it right that they should have absolutely no security? I had no axe to grind because I had been treated very well as a member of the junior staff in my time. Therefore, I introduced this scheme into a small part of one of the 14 regions of England. That was in 1972. No one was going to lose any money or prestige. All that would happen was that junior staff would get a better deal.
What happened to that pilot study? It operated for 15 years and was constantly attacked by people who should have known better. What was the basis of the attacks? It was said that security—which is what the scheme gave—was bad for young people; very good for old people and for consultants but bad for the junior staff. The scheme continued for 15 years until finally it was destroyed. I did not particularly mind because by then the Government had included it in their document Achieving a Balance, so it was going to be implemented eventually and in fact it will be soon—after 20 years! That is what is done with pilot studies. I would be very chary of any pilot studies or of the people who suggest them. We know what professions do with pilot studies. I believe it was George Bernard Shaw who said that a profession is a conspiracy against the laity. Of course, I would not go that far in regard to my own profession but I understand what he was getting at.
I am delighted at the reply we have had from my noble friend Lady Hooper, who suggested that perhaps 24 hospitals might become self-governing. That is a reasonable trial to start with. Only those hospitals that are fit, able and willing to undertake the scheme will be permitted to do so. Only those which in the future become able and fit will be allowed to proceed. That seems to me to be a suitable way of proceeding.
I underline what has recently been said about why the people of this country are so against the Bill. Have they read the Bill? Have they read the White Paper? Have the million people employed in the NHS read the White Paper? Remarkably few have done so. However, what they have been given by the media is the sort of information that has been scattered around by people who should know better. People have said that when the money for drugs runs out and you happen to be a diabetic there will be no more money for the insulin you need and you will have to die. Is it surprising that people are worried 478 about the Bill? We have had rumours that, if there is a change of government, who knows what will happen to those NHS managers who have been rather keen on the scheme? I do not think that is a particularly honourable suggestion to make.
I do not believe that these amendments should be supported. We should support the Government in going ahead carefully and steadily but not allow the NHS to drag its feet, which it has always had a tendency to do. We desperately need reforms in the National Health Service. The Committee may not be aware that many districts within the NHS do not even know what their budgets will be—and we are at the end of April—and will not know until May or June. How can one run a £50 million outfit without knowledge of the budget?
§ Lord Nugent of Guildford
I thank my noble friend the Minister for her very careful reply to an authoritative debate on this amendment. I also thank my noble friend Lord McColl, who has great expertise in this field, for his remarks. Nevertheless, I am still left with queries as to what will happen on 1st April next year.
I do not see how any hospital can decide that it wants to become an NHS trust until it has introduced a resource management initiative, established a complete system of modern technology for the information system of the hospital and a modern cost-accounting system which will enable it to produce its own budget. That will take four or five years to achieve and my noble friend Lord McColl will confirm that. Indeed, a Select Committee of another place, after experience in America, confirmed that to be the case. Therefore, I am sure that come 1st April next year nothing will change immediately.
Some hospitals will, I hope, have already opted for starting on a resource management initiative. That is the first step towards a strong and sound management. When that has been done, when costing has been carried out and the position is known, hospitals will be able to say whether they will become self-governing in an NHS trust. I do not see how they can decide until that has been done. It will not happen overnight. Hospitals cannot say, "Yes, we would like to become an NHS trust" because they will not have sufficient information to understand all the implications. My noble friend Lord McColl was one of the pioneers at Guy's Hospital and a marvellous job has been done with six pioneer hospitals. I believe that 50 or 60 other hospitals are making a start, but it all takes time because it is evolutionary.
In my judgment the proposals in the Bill, and the White Paper behind it, are good. I have no objection to self-governing hospitals. On the other hand, I must be realistic and recognise that not every hospital will want to become self-governing. Some will and some will not. However, every hospital can benefit if it has a resource management initiative because it will then be an efficient hospital which can produce its own budget, control its own costs and therefore receive its allocation of money on the basis of realism.
§ Lord Ennals
Why is it that 90 per cent. of the staff at Guy's Hospital, when given the opportunity of expressing an opinion, said that they did not want to become a self-governing trust?
§ Lord Nugent of Guildford
I need not answer the noble Lord's question. He must do that for himself. My guess is that some would want to and some would not. I believe that is a fact. The first thing they would want to do is to ascertain what it meant. They would need a modern management system so that they knew what they were dealing with.
The noble Lord rightly said that as the Bill stands, when it becomes law, the contract system will be introduced next April. I have to say that that alarms me a little. My noble friend has a monumental task in mastering the enormously authoritative arguments put to her by so many experts. She said that the scheme will be evolutionary. It cannot be anything else, but it is a good evolution. Perhaps my noble friend can put a little more emphasis on the evolution and a little less emphasis on something specific which is to happen on 1st April next year. That would certainly give me a little more confidence in believing that these ideas, which are so good, can develop gradually throughout the country—over the next decade, I should have thought—to improve the health service in many ways.
§ 6 p.m.
§ Lord Carr of Hadley
On two occasions—on Second Reading at the beginning of this month and in the first of our short general debates at the beginning of September—I have coupled strong support for the Government's proposals in principle with strong warnings about the dangers of trying to proceed too rapidly and treading on ground without testing it as one goes along. Therefore, I suspect it would be natural for the Committee to imagine that I support this amendment.
I support the spirit of the amendment but I must make clear that I cannot support it in the form in which it appears on the Marshalled List. I ask noble Lords to read the amendment carefully and imagine that they are the Secretary of State with the amendment included in the Bill and wondering what on earth they can or cannot do. It does not make practical sense as it stands.
If I am honest, neither do I believe that one can put into statutory form the careful and steady progress that I imagine the majority of the Committee wishes to see made in implementing the Bill's provisions. It is not possible to define in statute what you can or cannot do at a particular time. If that is done I hope that the result will not be as extreme as my noble friend Lord McColl indicated, but it will be a cause for delay rather than for progress. I want to see progress and to see these provisions implemented as fast as possible, provided that the speed is sensible and that the measures are tested step by step, as we go along. I would hesitate to lay down a timetable.
What I believe we all seek from the Government, both in Parliament and outside, is a clear statement of their intentions. My noble friend Lady Hooper has made a very helpful start this afternoon. But it 480 is only a start and not a completion. She will need to address herself to the question which the noble Lord, Lord Hunter, raised during an intervention.
It is comforting to know that, as at the beginning of April next year, there will be a relatively small number, not closely defined, of experiments started about budgeting practices and the National Health Service trusts. But when will the next wave come? I do not expect the Government to say that it will not come for two years or for any fixed time, but I expect them to give us an idea as to how the first wave of experiments will be watched, evaluated and reported on before the next wave.
My noble friend must also meet the point just made by my noble friend Lord Nugent. I too cannot help but be sceptical about whether a sufficient number of hospitals will have the sophisticated tools of management to embark on the National Health Service trust scheme as early as April next year, although I am not as gloomy as he is in thinking that the scheme might take four or five years.
I hope we can be assured that there will not be a deadline: come hell or high water, an unknown number of trusts must start work on 1st April or 15th April next year regardless of whether they are fully prepared. I have no objection at all to it being a target of ambition to get two or three dozen schemes started at that time. However, I do not want it to become a test of the virility of the Government or of anybody else to meet that target if the trusts are not ready to start.
We must make these experiments successful. Nothing would be more damaging than to rush into getting the schemes going only to find that we had failures on our hands. Premature failures could easily damn the whole development and undo a good deal of work. The Government must qualify a little further what they have said on those two points.
The third point which concerns me greatly is the contracting system within district health authorities. I accept that that is a vital part of the overall scheme. It is a very valuable and good part of the whole scheme, but I also know that it will be very difficult to implement. A week or two ago I spent two or three hours talking with the chairman of a district hospital authority. It would be unfair to name the authority or the person. He expressed great support for the idea, but great worries if he had to implement the scheme in his district from the beginning of April next year. He said that though he had willingly given a great deal of attention to how the scheme could be managed, he could not see how in his district he could have the necessary strength of trained middle management with the necessary technological expertise in place by that time. He thought that he could not start it as soon as that without a grave, unnecessary and unacceptably high risk of breakdown.
There is that worry. However, I do not want to confuse that worry with the Government regarding it as a cause for seeking delay for the sake of delay. That is why I do not want to fix timetables or procedures. I want the Government, by firm statements, to flesh out what my noble friend Lady Hooper has said this afternoon about this evolutionary process. It is an evolutionary process 481 and it is intended to be so. I hope she will say that it is an evolutionary process on which the Government wish to see progress as fast as possible but only at a safe and sensible speed.
If that can be repeatedly said and assurance given to those who are shying away through fear at all these new ideas—they are genuine fears about the welfare of patients; do not let us despise those fears—acceptance will gradually grow. I do not want to fix rigid and mechanistic timetables or methods of evaluation. The process must be governed by common sense, responsibility and, above all, care for the patients and the concern should begin with the Minister and go right down through the whole service to both lay and medical people.
§ Lord Kilmarnock
I have a slight difficulty with these amendments. They are less prescriptive in form than the idea that was originally discussed of an experiment in two regions and over a defined period of three years. To that exent I find the main amendment more attractive.
I am a passionate believer in formative evaluation. Recently I was responsible for editing a pamphlet on the topic. In an ideal world I would be happier if experiments and evaluations took place across the whole service and were not confined to one or more regions, while the rest of the country stood still. Across the country there are numerous health service bodies which are gearing up for change and they are eager to go. However, my support for universal and ongoing evaluation and what I believe the noble Baroness, Lady Young, called an evolutionary approach crucially depends on getting certain matters into the Bill.
For example, we have already discussed the powers of the chief of research and development and his power to conduct research, evaluation and measurement and to make proper recommendations. He should also have proper clout. I want to see those factors in the Bill. I also want to see quality control and the maintenance of standards included. We shall be discussing those matters shortly. I want to see a mechanism for those provisions in the Bill. I want to see the role of the universities also enshrined in the Bill. I wish to see all those matters in the statute.
The difficulty is that we do not have any of these provisions in the bag at the moment. We do not have guarantees that these reforms will take place with the proper quality controls, proper monitoring of results and unbiased response to those results undistorted by ideology. Unless I hear some very encouraging remarks from the noble Baroness when she makes her final reply in this debate, I shall have to consider very seriously whether to advise my noble friends to support the amendment.
§ Baroness Gardner of Parkes
I oppose this amendment mainly because, despite the very big names of the royal colleges which are behind it—I have great respect for their views—I believe that it is not right because the measures proposed are impractical. To start one or several pilot schemes is simply a method of delaying the whole matter. It would be unfair in terms of pressure on the people 482 in the pilot areas as opposed to other areas of the country. It will be almost impossible to determine which areas, regions or districts to use. How would one choose which would give a representative result at the end?
Many areas are now set to go. They will be very disappointed if everything is held up. Above all, the point which came through in the speeches of all four proposers of the amendment and of the right reverend Prelate the Bishop of Bradford was the anxiety that people have, most of which is created by uncertainty about what will happen. If the Bill is passed the plans could be made and people would know where they stood. They would be able to go ahead and implement these proposals.
There was a meeting in one of the Committee Rooms to which the Secretary of State invited all parties and all those who had spoken in the Second Reading debate. On that occasion he made it clear to us that this will be a process of constant evaluation. It will not be introduced in toto. It will come in gradually and it will be evaluated. What is good and successful will continue and what is not will be set aside. So many of the points that I could have made at this stage of the debate have already been made. I shall not delay the Committee, but I oppose the amendment as it stands.
§ Lord Harmar-Nicholls
I would not want to tell my noble friends on the Front Bench what to do, but having listened to the debate, I hope that on this occasion the matter is not allowed to come to a Division. We have heard from authoritative sources and we heard effective speeches from my noble friends Lord Nugent and Lord Carr of Hadley. I believe that purely from a parliamentary point of view enough has been said to show that a decision should not be taken at this stage, even though we may return to the point later on. Can my noble friend give an indication that it will be looked at and that some words can be found to end the fears genuinely expressed? That would be right.
I have always looked on the Committee stage of the Bill as much as a negotiating period as a time to come to a decision by a vote. It is one way of finding out what is in the minds of people who have something important to contribute. On this issue we have had contributions of the highest standard. To allow a decision on the principle behind the amendment to be settled by a vote at this stage would in a way be refusing the Committee stage of the parliamentary process. Can my noble friend find some words to end the fears of those who support the amendment? I do not say that I do, but from a parliamentary point of view enough evidence has been produced and doubt expressed from all sides of the Committee for at any rate the issue to be kept open for a period until we go further along the journey.
§ Lord Walton of Detchant
I do not propose to detain the Committee on this issue. At Second Reading I said how much I deplored the aura of confrontation which had all too often in recent months clouded the discussions between members of my profession on the one hand and representatives 483 of government on the other. I hope that we can proceed to look at this problem carefully, coolly and in a spirit of constructive collaboration, debate and assessment. Any noble Lord who heard the persuasive and cogent arguments adduced by the noble Baroness, Lady Cox, could not fail to be moved. I, like her, have been immensely impressed by the way in which the royal colleges have come together with many other organisations representing those in the health service to put forward their views. Having said that, I could not—I said this to a number of my colleagues—have supported the amendment as formally tabled, in which, despite the cogent arguments of the royal colleges and others, it was proposed that the assessment should take place in only two regions. I wholly accept the arguments made today against such a proposal.
I support the views expressed by the noble Lord, Lord Carr, that it is crucial at this stage that the method of implementation of these reforms, with particular reference to self-governing hospitals and to budget-holding general practices, should be looked at carefully in order that their effects in a limited number of areas, which as the noble Baroness said will be the effect of the Government's policy in the course of the few months after April 1991, can be carefully assessed and the further development and introduction of similar changes in the other parts of the health service can be examined and if necessary changes made.
I agree with the noble Lords, Lord Carr and Lord Nugent, that the complex accounting system and management structure still do not exist in many of our hospitals in order for them to be able to fully implement these changes. The noble Baroness said that it was likely that the self-governing hospitals would in the first instance be relatively few—some 20 or thereabouts. Secondly, she said that a limited number of general practices would be chosen from the applicants in order that they could become budget holders. If that is the case, it is very much in the spirit of the amendment even though its wording has been properly and rightly criticised by some noble Lords. If the Minister could assure us that that spirit and method of slow and gradual implementation which she and the Government now propose will be followed by the careful assessment of the effects of the introduction of those changes before the next tranche of self-governing hospitals and practices is introduced, the Committee would be greatly reassured.
§ 6.15 p.m.
§ Baroness Carnegy of Lour
I agree with the noble Lord, Lord Hunter, that we shall listen with great interest to what my noble friend the Minister has to say about evaluation, as time goes on, of the implementation of the Bill. However, the Committee should decide now whether it wants a formal pilot scheme, albeit in a number of places, or, as the Bill suggests, a brake—my noble friend Lady Cox said that the Government needed brakepower—the brake being the speed at which the Government accept or do not accept proposals from different hospitals and different GP practices. We should decide that.
484 Pilot schemes sound wonderful. They sound wonderful to the Royal College of Surgeons. But the Royal College of Surgeons thinks that there is no evidence that six or seven different aspects of these proposals for the health service would work. It says that in its paper with the green cover. It has not looked beyond the National Health Service to where all those principles are working in many spheres of life. It finds change difficult in the National Health Service. At least one noble Lord has said that it is exceptionally difficult to make changes in health care.
The Government should accept that they must proceed carefully in the way my noble friends Lord Carr and Lord Nugent suggested. In his Second Reading speech my noble friend Lord Carr talked about the importance of carrying with one all those who have to implement the changes. He spoke of building up their confidence, their trust and their understanding of how the system will work. That is about the speed of progress. It is not about pilot projects. One noble Lord pointed out that there was no pilot project for the introduction of the community charge. What happened? It was not intended as a pilot project, but Scotland went first. It saw itself being treated as a guinea-pig and disliked that very much. Any region or district where a pilot project was implemented would see itself as being treated as a guinea-pig. Some people would be delighted, others would resent it, and the scheme would be attacked by the whole country, and I suspect even by some noble Lords, while it went on.
We badly need this Bill. We must get it right and it must be implemented in the best possible way. I do not think that the amendment is the right approach, but I understand the anxieties which have brought it about. I disagreed with a great part of the remarks made by my noble friend Lady Cox; but I agree with her in that it meets the anxieties which have been expressed. I believe that the way to meet them lies in the timing with which the Government implement the Bill.
The contracts have to be implemented at once; they will not work in any other way. However, the process as regards self-governing hospitals and the budgets for GP practices can be implemented at any speed which seems satisfactory. That speed could be decided by Parliament or it could be decided upon pragmatic grounds as we progress. The issue of the need to carry out research as we proceed could be decided by Parliament. There are many alternatives. However, I do not think that the amendment is the right way to go about it. I hope that we shall decide the matter this afternoon.
§ Baroness Masham of Ilton
I have a very simple question for the Minister. What happens if the trust hospitals run out of money? Moreover, what happens if the budget holding GPs also run out of money? Much has been said about security in today's debate. I think that the Government should give some security to the patients because, after all, they are the most important people in the National Health Service.
I believe that the Members of the Committee all have heavy responsibilities resting on their 485 shoulders. I say that because what happens if the implementation goes wrong? Moreover, will the Government give some funds for the better tools and management which the noble Lord, Lord Carr, said were essential? At present many GP practices do not have computers. They are expensive items and, in any event, the staff do not have the skills necessary to operate them. If one considers some of the cherks in our National Health Service hospitals, it will be realised that they certainly do not have the ability to send bills out or to handle the money.
§ Baroness Hooper
I stressed earlier that our plans were largely based upon taking account of the working experience of the first waves of volunteers. I cannot sufficiently emphasise that fact. I do not believe that it is the intention of the proposers of the amendment to constrain enthusiasts within the National Health Service, but I greatly fear that that would be the effect of the proposals in the amendment. They may indeed have recognised this themselves by removing the earlier reference—and my noble friend Lady Cox pointed out that they did—to two regions and a three-year timespan, but I believe that the danger remains.
Isolating any individual area would prevent the benefits of any changes flowing to patients elsewhere. The enthusiasts in other regions would be held back, while the sceptical in the trial regions would be forced to comply. Moreover, a limited trial would create the maximum uncertainty for participating and non-participating regions alike. I am grateful to my noble friends Lady Young, Lady Gardner and, indeed, to my noble friend, Lady Carnegy of Lour for emphasising that fact. The effect of it would be to produce a blight upon all forms of development pending the outcome of the assessment, with a resulting deleterious impact upon staff morale and, therefore, upon retention, motivation and recruitment.
But there are more fundamental questions about the practicability of such a proposal. Organisational change cannot be tried out in the same way as one tests a new drug, however attractive that may seem. We benefited from the experience of my noble friend Lord McColl in his very vivid example. Perhaps I may illustrate a few of the difficulties. How could the assessor, for example, evaluate the outcome? What would be the criteria? At present standards of performance vary remarkably between districts and between different specialties within them. At best then there could be no single or simple baseline against which to monitor developments. In most cases there can be no baseline at all, because we simply do not know what existing standards are. Moreover, standards are not static. How would the assessor isolate a single proposal in the review as the cause of a change, whether advantageous or not? If the rest of the NHS were to act as a control group—and this in itself raises major difficulties—how would its standards be assessed against those in the selected regions concerned?
I turn now to the pilot areas. I should be interested to know how these would be selected. Would they, for example, include a Thames region and, if so, could the trial be kept separate from the complex 486 cross-boundary flows with other Thames regions and regions outside London from which there are many referrals to the centres of excellence? If the sample does not include a Thames region, however, it is rather difficult to see how it can be said to be representative. I believe that this particular illustration makes clear that the National Health Service is a national service, and that therefore no district or region can be fully isolated from the others. Likewise, no single element of the reform can be taken separately. Together they represent an organic, interdependent attempt at change.
I must say that I was rather taken by the suggestion that the proposals in this amendment are rather like trying out an experiment on right-hand driving in just a small part of the country. It sounds acceptable in theory, but it ignores the fact that we have a national road network.
I should like to respond to some of the criticisms which stated that we were not sufficiently prepared for the changes with which we propose to start this evolutionary process. As I said earlier, we propose to commence this on 1st April 1991. It was suggested, I think by the noble Lord, Lord Ennals, that health authorities have no experience of contracting. In my earlier remarks I recognised the fact that the introduction of the NHS contract system, which we believe must happen on a national basis so as to be in any way a useful experience, would nevertheless take place in what might be a somewhat crude form initially, with block contracts which would in subsequent years be worked upon and refined.
In any event, the suggestion that there is absolutely no existing experience is quite wrong. In my earlier remarks I referred to "the waiting-list initiative". Moreover, a report from the National Association of Health Authorities has illustrated that most authorities—some 62 per cent.—have some experience in this field. In saying that, I recognise that there is a great deal to learn and that, as I said, contracts may start in a relatively simple form and develop in sophistication. However, there is undoubtedly an existing base on which to build.
I have spoken about the experience contained within the National Health Service Management Executive, the interest in National Health Service trust status and GP fundholding. At local level, health managers and professionals are closely involved in all aspects of the planning process and independent organisations—such as the King's Fund, the National Association of Health Authorities and the Institute of Health Service Management—are involved in, and generally supportive of, the implementation process. Therefore much is already taking place. There is also the fact that we shall be making the process evolutionary as from 1st April 1991.
Before the Minister continues, perhaps she will explain one point with which I have been wrestling. She talked about contracts and when they would come into force. She said that they would be contracts between providers, purchasers and so on. She also said that initially these would have to be "somewhat crude" and then she referred to "block contracts". Does that mean that the costing of certain 487 services, which is a very difficult operation, will be carried out centrally or will it be the authority, which will either be a provider or a purchaser of the service, which will carry out that function? The question of who is to carry out the costing is one which is worrying me. It is also worrying the noble Lords, Lord Carr and Lord Nugent. Will the department carry out that function?
§ Baroness Hooper
The experience for the initial contracting arrangements will, of necessity, have to be based upon current referral patterns and arrangements. It will be on that basis that the initial year's contracts will be entered into in those areas where there is no more sophisticated arrangement already in place. In some areas, because there has been a certain amount of experience, the resource management inititative is in being and there is already a basis of experience on which to build.
I emphasise that the main work is not being done at national level but by managers and health professionals in districts and hospitals in the field. We are attempting to provide an environment in which their work can develop and be nurtured. I believe that we have the right recipe here to do that.
The noble Baroness, Lady Robson, asked me for some further information about how we plan to assess and test the reforms. I am happy to be able to reassure her that the National Health Service management executive intends to work with five or six districts to examine how all the inter-related components of the White Paper proposals are being implemented as a whole, not just the proposals contained in the Bill. Lessons from their experience will be disseminated throughout the National Health Service in the run-up to 1991 and thereafter. That is an extension of the work of management executives which is already extensive within many health authorities in the form of demonstration projects to explore the practical implications of a number of individual aspects of the report.
The noble Lord, Lord Rea, referred to capital charging being imposed without evaluation. I think that capital charging gives a good illustration of our particularly sensitive approach to implementation. A scheme has been run in shadow form in the current financial year to allow difficulties to be identified and ironed out. Moreover, after discussion with the National Health Service the Government have adopted a flexible timetable so that the introduction of the scheme can reflect practical factors such as differences in land values. Similar pragmatism underlines our entire approach.
The noble Baroness, Lady Masham, raised the issue of funding for GP practices. A GP practice may run out of funds. We think that that would be unlikely in view of the large number of practices applying; and the few that we are intending to start with will clearly be the strongest candidates. Nevertheless, should that contingency occur, the intention is that the practices will be helped by the region. Certainly no patients will be put at risk. The practices will be helped to manage their budgets more effectively in the future.
488 Self-governing hospitals will be required to plan their use of resources from the outset. Therefore there will be less risk of their running out of funds. It would be an improvement on the present system with little or no planning in advance, and crisis management at the end of each financial year which we have all experienced and which we all agree is deplorable.
I have spoken at some length because, like Members of the Committee, I believe that these issues are of great importance. I have tried to respond to all the concerns that have been expressed and to explain how I believe the Government's approach meets them. I welcome the view of my noble friend Lord Carr that the programme suggested by the amendment would not be helpful. I undertook to flesh out the general points that I made in my earlier intervention during the progress of the Bill through your Lordships' House.
We shall introduce these reforms as fast as we can, in the light of experience. To that extent I cannot give a specific time limit to the noble Lord, Lord Hunter, on how long it will take between the start of the first wave of candidates and their assessment and the introduction of the second wave of candidates. I remind him and all Members of the Committee that it will not just be the Government standing by and assessing within the National Health Service the way in which these so-called pilot projects progress. It will also be all the second wave candidates who after all will be volunteers and not obliged to enter into this. I think that the noble Lord should not have too strong concerns on that front.
I believe that the Government's position, as I have tried to explain it, is close to that outlined by many of my noble friends who spoke in the debate, particularly the noble Lords, Lord Nugent and Lord Hunter. I hope that my explanation helps to show how the provisions in the Bill underpin our approach. My right honourable friend and I will read the debate with great care to see whether anything more is needed. As I have tried to emphasise all along, the whole process is intended to be and will be evolutionary. However I cannot accept the amendment.
§ 6.30 p.m.
§ Lord Hunter of Newington
I thank the noble Baroness for her reply. There is one point about which everyone wishes to know and which in my view has not quite been answered. It is whether there will be a substantial examination of the hospital and general practice experiments which the noble Baroness told us this afternoon would be limited. Will there be substantial examination of them before further developments are initiated?
§ Baroness Hooper
I believe that I responded to that point, however I apologise if I did not do so adequately. Yes, I think that the observation, consideration and evaluation of the first wave of candidates will be substantial.
§ Baroness Cox
I am most grateful to all Members of the Committee who have taken part in this lengthy and constructive debate. I am also grateful to my 489 noble friend the Minister who has tried hard to meet our concerns. However I regret that I am not reassured by my noble friend.
In summing up the debate perhaps I may indicate those points on which I agree with Members of the Committee and then identify four outstanding problem areas as I see them and as I believe they will continue to be viewed by the professions working in the National Health Service.
First, on the two points of agreement, I agree with my noble friends Lady Young and Lord McColl that the National Health Service needs change and improvement. Perhaps I may emphasise that there is nothing in the amendments that is designed to inhibit or prevent change and the changes that are proposed in the Bill. So we are all in agreement on that.
Secondly, on the concept of evolution, my noble friend the Minister has said repeatedly that these are evolutionary changes. We respect and recognise that but evolution is not incompatible with the concept of evaluation. That is a false dichotomy. Evolution implies slow change with development allowed to occur on the basis of success, and modification being required where problems are identified and failures are found. Therefore that implies a process of evaluation to assess what is happening and also to publicise and put in the public domain the results of what has been found during the evolutionary process. We agree that the whole process is evolutionary, but that is an even stronger case for evaluation.
Regarding the outstanding problems which have emerged while listening to the debate, I must emphasise that the general commitment to evaluation which was given by my noble friend, while welcome, is not adequate. Evaluation as we go along—which I think was my noble friend's phrase—does not meet the requirements of rigorous, systematic evaluation of a representative sample, taking into account all the interlocking variables which need to be considered in any systematic evaluation. Such an evaluation programme also requires a systematic way of setting up that programme. It needs to be clearly specified and cannot really be developed on the run, as seems to be implied by the way it has been spoken about by my noble friend.
Secondly, with regard to the timescale, although the whole implementation of the Bill is designed to be evolutionary it is a fact—this point has been made but I should like to reiterate it—that the Government's schedule still means that the contracting for all services—that is, the internal market—will be introduced in April 1991 without the benefit of a great deal of the information which is not available at the moment. That was a point made a long time ago in my opening speech, and by Sir Henry Yellowlees in his letter to The Times. It is also a cause of great concern to the royal colleges.
If the contracts are initially to be crude and simple—I think those were the words which my noble friend used—they will not be able to take sufficient account of costs. They may lead to misallocation of resources. So why not evaluate and get it right when contracts are eventually—I hope it 490 will be sooner rather than later—introduced nationwide? Concerning the time-scale, perhaps I may point out that we respect the concept of evolution that is not incompatible with evaluation. These are not delaying tactics. It is a question of trying to get it right.
On the effects of an evaluation programme, I should like to respond to the point made by my noble friend Lady Carnegy when she suggested that evaluation could have a negative effect, an inhibiting effect, on the people who are ready to put themselves forward for an experimental and evaluative stage. In my experience evaluation is not something which deters people who are deeply committed to a concept or to a policy. They are only too keen to have it evaluated, and it does not have a bad effect on morale. Nor does it have an inhibiting effect on other people who would share that commitment.
§ Baroness Cox
I shall read Hansard and see what the noble Baroness said. If I have misrepresented her, I apologise, but that is what I think I clearly heard.
I regret very sincerely that the generalised assurances of my noble friend the Minister do not meet—and I do not think they will be seen to meet—the deep concerns which have given rise to the request for evaluation from so many responsible professional people working in the National Health Service.
My noble friend Lord McColl quoted George Bernard Shaw and his reference to professions as conspiracies against the laity. I think we are all aware of that. There have been times in history when the professional bodies have operated politically on grounds of self-interest. I do not think that this occasion is one of them. There is nothing in an evaluation programme which serves the interests of the professions. It only serves the interests of the professions in so far as they are keen to get it right for the people whom they serve. There is no self-interest in this.
Similarly, I should like to emphasise that I do not think that the representations which are being made by the royal colleges, by the professional bodies, have been propagandist. I agree with my noble friend Lady Young that there has been some propaganda around and I regret it as much as she does. But these are serious professional concerns being put forward by serious professional bodies in an unprecedented, historic unity of concern and expression of professional anxiety. So I would not say they are propagandist or that they are self-interested.
To conclude, perhaps I may say that the amendments merely put the principle of evaluation into the Bill. They give maximum leeway to my right honourable friend the Secretary of State to use his discretion as to how to set up that evaluation programme, and who to include in it. There are no constraints there as there were in the original amendment. My noble friend Lord Carr was worried about putting in a time-scale. I think it can be seen that the amendment has no time-scale. It actually 491 gives my right honourable friend the Secretary of State his own discretion in regard to the timescale evaluation. There is no implied delay to meet the point made by my noble friend Lady Gardner of Parkes. It leaves the discretion to my right honourable friend the Secetary of State.
I do not think we could be more reasonable in the way in which the principle of evaluation is being put into the amendment. The amendment has no unacceptable constraints whatever. It contains a principle to which there can be no objection; indeed, one to which the Government themselves are ostensibly committed. The effects of the amendment could only be beneficial, both for the professions and, more importantly, to achieve the objectives of the Bill itself to improve the National Health Service's service to patients, clients and communities.
§ 6.45 p.m.
§ On Question, whether the said amendment (No. 64) shall be agreed to?
§ Their Lordships divided: Contents, 86; Not-Contents, 109.492
|DIVISION NO. 1|
|Adrian, L.||Lawrence, L.|
|Airedale, L.||Listowel, E.|
|Ampthill, L.||Llewelyn-Davies of Hastoe, B.|
|Aylestone, L.||Lockwood, B.|
|Birk, B.||Lovell-Davis, L.|
|Blackstone, B.||Lucas of Chilworth, L.|
|Blease, L.||McCarthy, L.|
|Bradford, Bp.||Mcintosh of Haringey, L.|
|Broadbridge, L.||McNair, L.|
|Callaghan of Cardiff, L.||Masham of Ilton, B.|
|Carmichael of Kelvingrove, L.||Mason of Barnsley, L.|
|Carter, L.||Monson, L.|
|Cledwyn of Penrhos, L.||Morris, L.|
|Cox, B. [Teller.]||Mulley, L.|
|Crook, L.||Murray of Epping Forest, L.|
|Dainton, L.||Nicol, B.|
|Darcy (de Knayth), B.||Oram, L.|
|Davies of Penrhys, L.||Peston, L.|
|Dean of Beswick, L.||Phillips, B.|
|Dormand of Easington, L.||Ponsonby of Shulbrede, L.|
|Ennals, L.||Prys-Davies, L.|
|Erroll, E.||Rea, L.|
|Ewart-Biggs, B.||Richardson, L.|
|Falkender, B.||Robson of Kiddington, B.|
|Gallacher, L.||Rochester, L.|
|Galpern, L.||Russell, E.|
|Glenamara, L.||Sefton of Garston, L.|
|Graham of Edmonton, L. [Teller.]||Serota, B.|
|Grey, E.||Smith, L.|
|Hampton, L.||Stedman, B.|
|Harris of Greenwich, L.||Stoddart of Swindon, L.|
|Houghton of Sowerby, L.||Tordoff, L.|
|Hughes, L.||Turner of Camden, B.|
|Hylton-Foster, B.||Underbill, L.|
|Irvine of Lairg, L.||Wallace of Coslany, L.|
|Jay, L.||Walston, L.|
|Jeger, B.||Walton of Detchant, L.|
|John-Mackie, L.||Williams of Elvel, L.|
|Kilmarnock, L.||Winstanley, L.|
|Kirkhill, L.||Winterbottom, L.|
|Kirkwood, L.||Young of Dartington, L.|
|Arran, E.||Jenkin of Roding, L.|
|Bathurst, E.||Johnston of Rockport, L.|
|Bauer, L.||Joseph, L.|
|Beaverbrook, L.||Knutsford, V.|
|Belstead, L.||Layton, L.|
|Bessborough, E.||Long, V.|
|Blatch, B.||Lyell, L.|
|Boyd-Carpenter, L.||McColl of Dulwich, L.|
|Brabazon of Tara, L.||Macleod of Borve, B.|
|Bridgeman, V.||Malmesbury, E.|
|Brookes, L.||Manton, L.|
|Brougham and Vaux, L.||Margadale, L.|
|Butterfield, L.||Marsh, L.|
|Butterworth, L.||Merrivale, L.|
|Caccia, L.||Monk Bretton, L.|
|Caithness, E.||Mountevans, L.|
|Campbell of Alloway, L.||Munster, E.|
|Camegy of Lour, B.||Murton of Lindisfarne, L.|
|Carnock, L.||Napier and Ettrick, L.|
|Carr of Hadley, L.||Nelson, E.|
|Clanwilliam, E.||Nugent of Guildford, L.|
|Clitheroe, L.||Oppenheim-Barnes, B.|
|Colbrook, L.||Orkney, E.|
|Colnwyn, L.||Orr-Ewing, L.|
|Constantine of Stanmore, L.||Pender, L.|
|Crickhowell, L.||Penrhyn, L.|
|Cullen of Ashbourne, L.||Piatt of Writtle, B.|
|Davidson, V. [Teller.]||Radnor, E.|
|Denham, L. [Teller.]||Reay, L.|
|Denman, L.||Rees, L.|
|Derwent, L.||Renton, L.|
|Eden of Winton, L.||Renwick, L.|
|Elliot of Harwood, B.||Rippon of Hexham, L.|
|Elliott of Morpeth, L.||St. Aldwyn, E.|
|Elton, L.||Sanderson of Bowden, L.|
|Ferrers, E.||Sharples, B.|
|Fortescue, E.||Skelmersdale, L.|
|Gainford, L.||Stanley of Alderley, L.|
|Gainsborough, E.||Stodart of Leaston, L.|
|Gardner of Parkes, B.||Strange, B.|
|Gisborough, L.||Strathcarron, L.|
|Glenarthur, L.||Strathclyde, L.|
|Gray of Contin, L.||Strathmore and Kinghorne, E.|
|Gridley, L.||Swinfen, L.|
|Hailsham of Saint||Swinton, E.|
|Marylebone, L.||Thomas of Gwydir, L.|
|Harmar-Nicholls, L.||Trefgarne, L.|
|Hemphill, L.||Trumpington, B.|
|Henley, L.||Tryon, L.|
|Hertford, M.||Ullswater, V.|
|Hesketh, L.||Vaux of Harrowden, L.|
|Hives, L.||Whitelaw, V.|
|Holderness, L.||Wise, L.|
|Hooper, B.||Young, B.|
§ Resolved in the negative, and amendment disagreed to accordingly.
§ 6.53 p.m.
Lord Peston moved Amendment No. 65:
Page 3, line 17, at end insert:
("(1 A) Each Regional, District or Special Health Authority—
- (a) shall, within such period after the day appointed for the coming into force of this section as the Secretary of State may direct, prepare and publish an assessment of the needs of its resident population in respect of health services, which shall include a statement of which services are to be provided within the boundaries of the health authority;
- (b) shall keep the assessment prepared by them under paragraph (a) above and any future assessments prepared by them under this section under review; and
- (c) shall, at such intervals as the Secretary of State may direct, prepare and publish modifications to the current assessment, or if the case requires a new assessment.").
§ The noble Lord said: Amendment No. 65 is grouped with Amendments Nos. 68, 75, 76 and 86.493
§ I believe that it will be agreed that the amendments are interconnected and that the arguments that apply to one can be applied to all of the amendments. In dealing with the amendments I shall make some general points and I hope that the Minister will be able to respond in the same form.
§ The purpose of the amendment is to encourage good management within the health service. In particular, it is intended to emphasise a point which arose from the previous amendment and is part of the logic which the noble Baroness, Lady Cox, indicated was intrinsic to what she had to say. That is that good management involves both a statement of objectives and relating that statement both to performance and to whether the objectives themselves correspond to what ought to be done.
§ Under the current NHS legislation, which I do not believe the Government intend to change, the health authorities, and in particular the district health authority, will have to make a statement of performance. I hope that when he replies the noble Lord will reassure me that there is no intention on the part of the Government to move away from the need for a statement of performance. The essential point is that the authority—whether it is the regional, district or special health authority—should also prepare a statement of need for the area for which it is responsible. That would allow one to assess how the performance relates to the need. That is the main purpose of the amendment.
§ I have put forward the amendment without a great deal of confidence, not as to whether or not the Government will accept the amendment but because I believe that the Government's position on research and evaluation is very casual. It inspires no confidence in anyone who has ever had any research experience. I should not have made the emollient remarks which some noble Lords made about the statements coming from the government side because I do not believe that the Government have taken seriously the question of the examination of the problems we shall be confronting. Far from accepting the view of the Government that evaluating organisations is not as serious a matter as evaluating drugs or treatment, I believe that it is more serious and because it is so difficult it should be done more carefully.
§ Therefore, underlying my own position is a very serious concern about what the Government are up to. That is why I say that I propose the amendments with a modicum of trepidation. For the kind of managerial approach which I support to work one require:; very much greater support than the Government appear to be willing to provide.
§ The second aspect of the amendment which concerns me also relates to earlier remarks on research and the provision of appropriate data. The amendment requires health authorities to say whether particular services will be provided locally or elsewhere. Although I should like to go further if I thought it feasible and require a justification for the dectsion, that is not required by the amendment. I do not press the need for such a justification because, unlike the noble Baroness who spoke earlier and other noble Lords who took part in the debate.494
§ I believe that the database is not available for the kind of work that the system requires. Nor in my view is there the slightest possibility that the appropriate database will exist by this time next year. I go further. If we have to rely on the officials and expertise of the Department of Health there is even less hope of anything being done successfully because the department simply does not have the expertise to advise or to evaluate what we have in mind.
§ I press the amendment because the Bill has the advantage—and I regard it as a very strong advantage—of opening up a great many areas within the National Health Service. I regard that as very important. Perhaps I may add a word on the Government's behalf I am not one of those who defends the existing system uncritically. When I say that the database is not there I regard that as much as an indictment of the existing management within the health service as an indictment of the Government proposals for the future. It is extraordinary that in 1990 most hospitals have little idea in detail of what goes on within them in terms of the information that we should like to have.
§ That is the background to the amendment. The essence of the amendment is the desire to make a clear statement of need and to use the statement of need as a feedback to a related statement of performance, the two together being essentially the rational way to improve the management of the health service. That is the purpose of the amendments. I commend them to the Committee. I beg to move.
§ 7 p.m.
§ Baroness Robson of Kiddington
I too have my name to the amendment. Following the previous debate in which the Government attempted to calm our anxieties and tell us that everything is being introduced gently and that it is essentially a form of pilot scheme, there is one thing that we know; namely, that regional, district and special health authorities will become purchasers of health care on 1st April 1991.
The amendment attempts—and it is only an attempt—to enable those authorities to know what they need to purchase in order to fulfil their duties to the population that they serve. You cannot look at your financial allocation in a district or region and hope to provide a service which meets most of the needs within that district or region unless you have assessed the needs of that district or region and know how far you can go. You must set your own priorities as to what you can meet this year and how you can develop that.
An assessment offers an opportunity for health authorities to tailor the services to local needs, which differ from district to district. It also enables them, perhaps for the first time, to consider needs rather than demand, which is a different evaluation of what requires to be done within the district. It also enables the department or the new Director of Research and Development—one of the people responsible for looking at the overall picture in the country—to monitor and assess to what extent the different districts are meeting their commitments.
495 The fact that that assessment should be published and should be public knowledge is tremendously important because the Bill does not give sufficient opportunity for local interests and consumer interests to have a say, and that would enable them to monitor the performance of their local health authorities. Under Clause 44, local authorities will have to draw up a plan setting out the community care services that they must provide. It is only right that health authorities should do the same. I support the amendment.
§ Lord Jenkin of Roding
I shall be interested to hear what my noble friend says in reply to the amendment, but I would regard it as extremely surprising if any district could conduct its affairs without doing something along the lines spelt out in the amendment.
We must consider the amendments with some care. We must remember that throughout the Bill we are dealing only with those matters which require legislative change. The Bill does not, and probably should not, contain the entire programme of reforms on which the Government have embarked. A great many of those can be carried out under existing legislation and require no change. With the modicum of apprehension with which the noble Lord, Lord Peston, said that he approached the affair, he indicated that the existing powers may well enable those reforms to be implemented but that the Bill was therefore essentially a skeleton measure. One needs constantly to refer to the policy statements in the White Paper and the working documents with which noble Lords have no doubt equipped themselves in order to gain the full picture. That is inevitable.
I found it a difficult argument when the noble Lord, Lord Peston, said once or twice, 'But it is not in the Bill". Of course it is not in the Bill. There are many things which are not in the Bill because it is in that sense a minimalist measure to effect the necessary legislative changes to enable the reforms to take place. The danger is that, if we then seek to try to write into the Bill in some prescriptive form the details which may well have been spelt out or will be spelt out in ministerial guidance or in other forms of communication with the National Health Service, we may end up by putting the health service into an undesirable strait-jacket.
It is against that background that one needs to consider this and a number of other amendments. If they are put forward as a means of airing an anxiety and seeking a response from Ministers, that is fine. However, if they are put forward with the serious intention of amending the Bill and therefore of providing a new prescription of precisely how things are to be done, we would perhaps go some way to defeating the overall intentions.
I could not take part in the previous debate because I had been out of London on a social service exercise. However, I listened to a large part of it and was again and again struck by the number of people, including my noble friend Lady Cox, who repeatedly said how much they supported the main thrust of the reforms. That approach is now coming through 496 and goes some way, and will go some way, to offest the unreasonable fears that have been engendered by the black propaganda which has circulated in medical journals and doctors' consulting rooms.
However, at the same time it is important that we do not try to tie the thing down too hard. The group of amendments to which the noble Lord, Lord Peston, spoke may well do that. I shall be interested to hear my noble friend's response. Any manager will say that before you set out to use your resources you must spell out clearly what you seek to achieve and you must have a means of knowing how far you have gone towards achieving those aims. That is the essence of the management process. I cannot believe that it is any different for a hospital, a district health authority, a regional health authority or a special health authority. I do not want to spell out in the Bill exactly how they must approach matters and how much they must publish. That should effectively be left to those responsible for the management of the health service.
§ Lord Henley
These amendments go to the heart of the new role of the district health authority, which is to assess the services needed by its resident population and ensure that they are delivered in the most suitable way by the most appropriate provider. The importance of that cannot be underestimated. Neverthless, I hope to persuade the Committee that the amendments are unnecessary. I also hope to calm any anxieties, as the noble Baroness, Lady Robson, suggested that some anxieties might have been calmed on the previous amendment.
The DHA's new role is based firmly on financial responsibility for its resident population. Currently, DHAs are not concerned, financially or otherwise, with services provided to their residents outside their district boundaries. In future they will pay for such services and receive the money for doing so. In other words, DHAs will become fully responsible for all the services used by their residents. They cannot carry out that responsibility, for which they will be accountable, without first assessing the health needs of their residents and how best those needs can be met.
This new district role is certainly challenging. To help with the process of adapting to it, the NHS management executive is working with a number of DHAs on a comprehensive programme to produce assistance and guidance which will stimulate the development process in all DHAs. An important aspect of that work is the provision of information which will both enable DHAs to be held to account and allow them to demonstrate that they are securing the most appropriate pattern of services for their residents. That is the specific issue raised by the noble Lords' amendments.
Some existing arrangements are relevant and will be built on. In particular each district is already required by Health Circular 88(64) to produce an annual health report to be written by the district director of public health medicine. The report is compulsory but the director of public health has discretion to raise whatever issues he or she feels require attention. Within that context district directors of public health are already assessing their population's health needs in a variety of ways.
497 Secondly, each district is already required to publish annually its plans for service provision. That will continue and future reports will inevitably have a broader focus in line with the district's new responsibilities. Nevertheless the Government recognise the importance of ensuring that district health authorities make widely available details of the services that they have secured for their residents and where they are located. I am happy therefore to give an undertaking that every DHA will publish a list of he services for which it has contracted, whether from its own directly managed units or from other providers. This is in line with the requirement, announced in the recent guidance document Operating Contracts, that all contracts for health services should be publicly available.
The noble Lord, Lord Peston, also sought reassurance that DHAs will make statements of performance. I have just given the undertaking that they will publish a list of services for which they have contracted. Certainly the director of public health, as I mentioned, will continue to produce annual health reports and districts will publish plans for service provision. As I said, in future, DHAs will publish details of contracts that they have concluded and will provide statistics on activity and performance indicators. I assume that that is what the noble Lord asked for when he requested statements of performance.
I turn now to Amendment No. 76. There seems to be no value in particular in imposing a statutory requirement on health authorities to produce plans for one part only of their responsibilities. It would make the current flexible system, which works very well, unnecessarily formal and restricted. The NHS management executive is currently considering what the future shape and content of the plans which health authorities submit to the centre should be. But I can assure the Committee that the planning process will continue largely as now, although there will necessarily be changes to the content of plans following on from the changes to the health service which this Bill contains. I cannot therefore support Amendment No. 76 either.
I hope that the Committee will accept that the Government recognise the importance of the points addressed in the amendments and that adequate steps are being taken to meet its concerns. Nothing would be gained by imposing legislative requirements which could only inhibit the development work that is already in hand. In the light of that explanation, I hope that the noble Lord will feel able to withdraw his amendment.
§ Lord Peston
I thank the noble Lord for his reply. I also thank the noble Lord, Lord Jenkin of Roding, for his intervention. I thought long and hard about preisely the point that he made; namely, that essentially the districts which bear in mind good management principles would behave in exactly the way that I describe in my amendments. Given that the intention of the Bill, as stated strongly and clearly by the Secretary of State, is to devolve as much as can be devolved, I shall take his point. Indeed, I thought about it.
498 My problem is that in the new environment, which is a competitive and somewhat market oriented environment—there can be no doubt about that because that is what the Secretary of State claims—one has to ask whether it would be in the interests of management to reveal all the relevant information that would be of interest also to what one might call the consumer. The reason for laying down certain rules and criteria, as it were, is precisely because one could argue fairly rationally that it would not be in the interests of the district in the new environment to reveal under-performance or failure of performance.
It seems to me that in his reply the noble Lord went quite a long way toward reassuring me on many of the relevant matters. I shall certainly carefully read his remarks. I got lost at one point, however. I am sure that it is my fault and not that of the noble Lord. Amendment No. 68 includes the words:shall set out its assessment of the state of health of its inhabitants … and their need for health care".I was not very clear whether the noble Lord was reassuring me that that would definitely happen. It is an extremely important matter.
I take his other points, which I strongly welcome and for which I thank him. However, before I take the matter further and take a decision on whether to divide the Committee, perhaps I may ask him whether I missed anything or was he reassuring me on that point also.
§ Lord Henley
My first undertaking was that the DHAs would publish a list of services, which the noble Lord welcomed. I also reassured him that the directors of public health will continue to produce annual health reports and districts will continue to publish plans for service provision. Does that satisfy him?
§ Lord Peston
Obviously I do not want to bore noble Lords more than I usually do, but it will satisfy me if I could be reassured that within a district one would be seeing regular information on the health of inhabitants within the district rather than information just about the nation. In other words, the point I wish to make is that one does not want aggregate data; one is interested in data which are specific to the district. I understand that that is what the noble Lord said.
§ Lord Henley
I tried to reassure the noble Lord that the existing arrangements whereby each district director of health produces an annual report would continue to be built on.
§ Lord Peston
In that case, perhaps I may double my word of thanks to the noble Lord. I was particularly reassured by his remarks on services. I am certainly reassured by what he has just said. Therefore, although I was originally of a mind to divide the Committee, he has totally taken the wind out of my sails and I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.499
§ 7.15 p.m.
Lord Carter moved Amendment No. 66:
Page 3, line 17, at end insert:
("( ) It shall be a primary function of a District Health Authority to ensure there is continuity of care for patients discharged from hospital accommodation into the community.").
§ The noble Lord said: With this amendment we come to the crucially important question of continuity of care. We become used to a complete system of care if we are fortunate enough to be served by a good GP and local, district and regional hospitals. It is largely a local system and where it works well it is a seamless robe of care. Later in the Bill, after Clause 40, we shall be dealing with many aspects of community care, but this amendment emphasises the importance of an extended programme of care which provides continuity of care for patients when they are discharged from hospital into the community.
§ The development of the internal market could lead to problems. There may be questions of travel when a contract would be placed at a hospital some distance from the patient's home. The development of the internal market and so on might risk breaking the link in the local system of care that I have described. There may be a risk of the self-governing hospitals reducing the after-care for patients when they are discharged. Again, the existing links may be at risk.
§ Self-governing hospitals have to produce objective and verifiable financial information. They will not be able to do so unless they are required to show an integrated community health structure since the outcome and cost-effectiveness of the service must be monitored once the patient is returned to the community. The objective of the amendment is to ensure that it is a primary function of a district health authority to provide continuing care for patients discharged from hospital, whether or not it is a self-governing trust. I hope that the Minister will be able to reassure us on this point. I beg to move.
§ Baroness Robson of Kiddington
I also wish to support this amendment. In the National Health Service we can pride ourselves that over the years we have developed a closer link between community services and the hospital services.
The amendment does not run the risk of some of our earlier amendments. It does not lay down any hard and fast rules. It lays down the philosophy of how the health service ought to work. I do not believe that any government could object to the amendment. It does not tie any authority to doing anything in particular except to fulfil the basic philosophy that it is essential for patient care that health services and community services work hand in hand.
I believe that such care has been one of the major successes of our National Health Service in the past. However, with the new proposals for community care and the extended programme, one becomes somewhat nervous in relation to district health authorities who contract out or buy services outside their own districts. It should still remain their responsibility to make certain that those patients are 500 given the correct community care when they return to their homes. I consider this to be a very important amendment because it states the philosophy behind the Bill.
§ Baroness Masham of Ilton
I have also put my name to the amendment. I have pleasure in supporting it. I know only too well the frustrations of both patients and doctors when patients are ready to go home and cannot do so because the community is not ready to receive them.
Many hospitals have their acute beds blocked because the patients' homes have not been adapted or they do not have adequate help to look after them when they go home. If patients block acute beds or have to be transferred to a hospital near their home (if they have been to a specialising unit for some long-term condition), that will be very expensive for the health authority. It can also be demoralising and set back the rehabilitation process.
With the money following the patient, who will pay the bill if someone is in hospital many days longer than he should be because a local or housing authority has failed to make available suitable housing? The Government have accepted the principle of Section 7 of the disabled persons Act which requires hospitals to inform local authorities and health authorities of the date of discharge from hospital of people with a mental illness. Will it now accept that principle for all people leaving hospital after a lengthy stay? That would be a great help to overcome those problems.
When speeding up the process of getting patients home, one of the problems is not having enough occupational therapists in hospitals and in the community. They are one of the vital links. However, many of the occupational therapists seem to be drifting away to work in industry and with firms such as Boots. If the Government's words that patients should come first are really being taken seriously, the amendment is the kind of provision that they should take seriously. I hope that they will accept it.
§ Lord Auckland
There is particular concern regarding the amendment in areas such as Epsom and St. Albans where there are a number of long-stay hospitals for mental patients, and some uncertainty as to the future of those hospitals. In this area successive governments have done a great deal about community care for those who are discharged into the community. With her experience, the noble Baroness, Lady Masham, quite rightly said that there is often a lack of services, when people can be employed, for example, in industrial therapy.
I was on the housing committee of the hospital in Epsom for some years. It had a very good unit in that sphere. I am no longer on the committee, and I do not know whether that unit still exists.
The amendment may not apply to every hospital, although there are now a number of general hospitals with psychiatric units attached where the problem will also occur. However, in a number of what one might call conurbations, a number of hospitals, there is concern. I hope that the Minister will direct his attention to that aspect.
Baroiuss Elliot of Harwood
I should very much like to support the amendment. I had some experience of chairmen of health committees for a number of years. The need for after care and community care when patients left hospital, or whatever establishment they were in, was absolutely tremendous. If they required any care within a few weeks or months those people were back again in hospital. It cost far more money for the local health authority to take them back into hospital than to give them proper community care in their own homes to enable them to lead more or less normal lives, and to be with their families. I believe that that is of vital importance.
I hope that the Government will accept the amendment. It would make an enormous difference to patients and to local health authorities as well as to hospitals. The idea that we must have a very close association between community care, the health authority and the hospital is vital. I very much hope that the Government will accept the amendment.
§ Lord Jenkin of Roding
In moving the amendment, the noble Lord, Lord Carter, indicated that we were anticipating some of the debates that may take place under Part III of the Bill when we consider the community care proposals. We shall therefore have an opportunity to return to the subject.
On one point I agree with all those who have spoken. The bridge between the health service and the local authority social services is one of the most vital and difficult areas of policy. I see the noble Lord, Lord Ennals, who was my predecessor at the department, nodding agreement. He and his predecessor introduced joint funding as one of the ways in which to accomplish that. It fell to me to open many of the institutions during the Worcester experiment launched by Kenneth Robinson, several years before the closure of many of the hospitals and the provision of community care for many of the mentally ill and mentally handicapped people. One of the causes of failure—and there are failures—and why one sees a number of very unfortunate people with mental illness drifting about the streets, is that in the end nobody has been responsible for them.
I have refreshed my mind on the proposals in both the substantive White Papers. Those are Working for Patients with regard to the National Health Service; and Caring for People with regard to community care. I believe that it would be unwise if one were to have an amendment which appears to put the primary duty on the health authorities. I have read the amendment several times. If one puts a statutory duty on one group of people, it becomes all too easy for everyone else to say, "It is not my responsibility. The Act says that it is the health authority that has to do this". Yet if one reads the relevant paragraphs—and I shall bore Members of the Committee for one moment with one | paragraph—I am quite sure that that is a better way of approaching the problem. Paragraph 5.12 of Caring for People states:Health authorities will be expected to prepare plans setting out their community care policies and the arrangements they propose for securing community services and community care".502 The next point is important:It will be for health authorities to decide whether these plans would best form part of their overall plans or should be produced separately as a joint exercise with the relevant local authorities".I hope that on the basis of experience they will be joint plans with local authorities. The whole thrust of the Griffiths Report, which forms Part III of the Bill, is that local authorities will have more specific responsibilities in that regard. Therefore, we shall not have people falling through the wickerwork as they undoubtedly have in recent years with unfortunate results.
The amendment uses the word "function" and not "duty" but the implication is that the health authority will be in the lead. That would not necessarily produce the best result. We know what we want to achieve and the Bill goes a long way towards that. The Government's intentions as spelt out in the White Paper are wholly admirable. I hope that my noble friend will be cautious before accepting the tempting blandishments of my noble friends to insert the provision into the Bill.
§ 7.30 p.m.
I was delighted to see the amendment on the Marshalled List because it gives me an opportunity to fulfil a pledge which I made to the noble Baroness on Second Reading. She will remember that I raised the present difficulties in appointing hospital social workers. I drew attention to the fact that, as a result of the difficulties, some hospitals do not have a social worker in place. That is a disgrace. Indeed, many hospitals do not have sufficient social workers. I then told the noble Baroness that until the difficulty was solved I would raise the matter again and again. This is the first time I have done so.
I stress that the presence of an efficient and effective hospital social worker is essential if the proper arrangements are to be made before the discharge of patients from hospital. I hope that in reply the Minister will say that progress has been made.
In parallel, I wish to mention one other difficulty. The present acute shortage of hospital secretaries, particularly clinical secretaries, means that often it is a long time before a general practitioner receives a full report from a consultant about a patient who has been discharged from a hospital and technically is under his care. We all know about the problems of recruiting hospital secretaries but such provisions will not function unless there are sufficient secretaries and social workers. The problem will not be solved on 1st April 1991; it must be attended to now. I hope that I shall receive an answer from the Minister, just as I hope that the noble Baroness, Lady Masham, will receive a good answer to the Yorkshire googly which she bowled to the Minister a few minutes ago.
§ Baroness Cox
I support the spirit of the amendment. Its intention is to ensure that when patients are discharged from hospital their health and clinical needs are met. That is most important. However, there is concern that because community care has moved firmly into the hands of local 503 authorities and social service departments some of the staff are not clinically trained. There is a need to ensure that when patients are transferred from hospital into the community their clinical needs as well as their social needs are met. I support the concept of continuity of care and the need to ensure that both health and social needs are met as patients are moved into the community. I support the spirit of the amendment.
§ Lord Rea
As a GP representative on a working group which has been trying to draw up the district plans for discharge from hospital, I support the amendment. In answer to the noble Lord, Lord Jenkin, I agree that there must be joint planning between local authority and hospital. But how does the local authority know when a patient will arrive? The initiative must be taken by the hospital in order to alert the local authority and the general practitioners about when the patient is being discharged. It must take the first step, and therefore the district health authority should have a duty to do that.
§ Lord Colwyn
I support the amendment. The provision of continuing care following a period in hospital should be one of the primary functions of a district health authority. Of critical concern are the elderly and people with mental illness who often have a need for continued nursing and medical care for extensive periods of time. At present local authorities do not have, nor is it their primary function to have, the requisite nursing and medical staff to provide such care.
The level of care needed by our most dependent citizens must be the responsibility of the district and regional health authorities. It can be offered by the National Health Service or by independent health care agencies working under contracts to a district or regional health authority and offering the same type and level of service to those groups as does the NHS.
I am aware that health authorities are already divesting themselves of their continuing care responsibilities. Their actions will leave a major gap through which those most vulnerable people will fall. In its present form the Bill does not appear satisfactorily to close the gap. It will leave the elderly and mentally ill hostage to budget constraints and therefore it may become of the first incentive for both health and local authorities to avoid responsibility for financing and providing care.
I know of many local authorities and independent health care providers who share my concerns. Among them is Community Health Services, a company in which I must declare an interest because I have met its representatives and I am aware of the services it provides. There are also other companies which under contract to and at no capital cost to the NHS provide services to the elderly and people with a mental illness.
I hope that my noble friend will accept the amendment or give an undertaking that the apparent deficiency in the Bill is fully covered elsewhere; perhaps in Part III, as suggested by my noble friend Lord Jenkin.
Baroness Darcy (de Knayth)
I support the amendment because it is vital to ensure continuing care such as physiotherapy and speech therapy. I agree with my noble friend's comments about patients being stuck in specialist units. That is a matter which concerns the Spinal Injuries Association because there is a lack of suitable accomodation. For example, Eden Hall Hospital in Scotland has three patients who together have spent 500 unnecessary days in hospital, which must be expensive. Stanmore Hospital is a small spinal injuries unit with only 20 patients. Nine of those patients must at present stay with relatives or go to other hospitals. They cannot receive the specialist care they need because their homes are not suitable.
§ Lord Butterfield
I wish to join the Committee's deliberations only briefly. A most important person in ensuring the continuity of care when patients are discharged from hospital is the house officer. Those who have had responsibility for hospital beds, particularly those who have had responsibility for the teaching and training of people during their pre-registration year, know that there is a kind of house officer who pays enormous attention to the exciting process of admitting the patient to hospital. He organises all the investigations, considers all the diagnoses and tells elderly consultants such as myself about the latest treatment for the patient.
However, the young men and women who deserve promotion are those who impress one by the care with which they discharge their patients from one's care either to home, into Part III accommodation, or whatever. The greatest are those who know enough about the whole process of the care of people to realise the importance of writing in their own hand a note to the general practitioner explaining what has happened to the patient, his present treatment and the expectations for the ongoing care.
The amendment touches a most important part of the future of our service. The notes of every house officer who qualifies and joins a hospital should include the fact that it is necessary to ensure continuity of the care of patients they discharge from hospital. Those people find the social worker. If they are good they ring up or send a note to the general practitioner and make sure that relatives know what has happened. I know that sometimes patients leave hospital without knowing quite what has happened to them and the general practitioner does not know what has happened, which is terrible. Therefore, it is no surprise that such patients are readmitted to hospital, at great additional cost to the taxpayer. This is a very important amendment, I hope that in some way it will be stitched into the ethos of our health service.
§ Lord Henley
This amendment relates to continuity of care. It is a very important amendment and concept, but I hope that I can persuade the Committee that it is unnecessary. As the Committee will know, district health authorities are now subject to the requirement which the amendment seeks to impose. In passing, I should say that National Health Service trusts will operate under contracts to ensure continuity of care following the discharge of the patient.
505 District health authorities are already subject to the requirement. Health Circular (89)5 and its accompanying booklet on The Discharge of Patients from Hospital gave guidance on the arrangements to be made on discharge to ensure the appropriate continuity of care. It reminded health authorities of the need to set up and monitor procedures for the discharge of patients to ensure that proper arrangements are made for their return home and any appropriate after care.
Operating Contracts emphasised the need for discharge policies and for ensuring continuity of care by saying that providers should consider offering specifications of the admission and discharge procedures which they will follow. DHAs will wish to ensure, through their contracts, that the achievement of good practice in this area is monitored, particularly where the same patient may come under different contracts for hospital and community services.
The separation of the DHA's role as purchaser will allow it to focus on securing contracts which cover the full range of the health needs of its residents and developing close links with local authorities. Local authorities will assess patients' needs for community care provision and decide what services to provide on the same basis as people already in the community. There will be an opportunity later to discuss these arrangements in detail in Committee.
Local authorities will also have to prepare plans for community care services. Those plans will be prepared in collaboration with the NHS, which should ensure that continuity is provided for. Those will need to take account of planned programmes of hospital discharge. Perhaps I should comment on a point raised by the noble Baroness, Lady Masham. She asked what would be the position as regards money fallowing the patient; for example, if the patient was kept over long in hospital because a local authority had not made adequate provision in the form of housing or whatever community care was necessary. At present the health service pays and that will continue to be the case. However, one would hope that greater co-operation between health authorities and local authorities should prevent that in future
Local authorities will also have to prepare plans for community care services. These will need to take account of planned programmes of hospital discharge. If further funds are needed, health authorities can pass money to local authorities through joint finance arrangements. The Government have announced a specific grant to boost community services for people with a mental illness (including those leaving hospital). The legislativie cover needed is incorporated into the Bill.
I hope that, given this reassurance, the Committee will accept that the amendment is unnecessary. It is not by so general a provision in statute that continuity of care will be secured, but through the detailed specification of contracts and collaboration with local authorities at the local level. This is already provided for either within existing circulars or in the provisions of this Bill.
I also noted the suggestion made by the noble Lord, Lord Butterfield, that doctors should have a 506 copy of a code of conduct. No doubt if they would like to see a copy of Circular 89(5) that could be made available. Given those reassurances I hope that the noble Lord will feel able to withdraw his amendment.
Before the noble Lord sits down, will he say a few words on hospital social workers?
§ Lord Henley
My noble friend Lady Hooper will write to the noble Lord on that point but I shall not comment on it myself.
§ Baroness Masham of Ilton
Yesterday evening somebody telephoned me and told me that it would take the social services one year to process a patient. I thought that to process a patient sounded awful. Does that mean that a patient must wait in hospital for a year before the social services can carry out that "processing", which sounds like rather a lot of peas in a tin?
§ Lord Henley
I agree with the noble Baroness and would prefer that people should not use the word "processing", which, as the noble Baroness said, sounds like peas in a tin or a pod. I cannot comment on the particular case to which the noble Baroness referred. No doubt my noble friend would be prepared to look into that. However, I was trying to say that one hopes that, with the new co-operation between the local authorities and health authorities, that sort of problem will not arise.
§ Lord Carter
There is support on all sides of the Committee for the spirit of this amendment. We have touched on a very important aspect of the Bill. As I said on moving the amendment, it overlaps to -some extent with Part III of the Bill but we thought it important to consider it now when discussing functions.
The noble Lord, Lord Jenkin of Roding, with all the authority of a former Secretary of State, made the crucial point about the primary function of a health authority and pointed out that, according to the White Paper, it would be for the health authority to make the decision. However, there is concern and we shall return to this matter when we come to Part III of the Bill and consider the possibility of people in community care being shifted from a health authority budget to a local authority budget, or vice versa, depending on the state of the respective budgets.
A number of very important points have been made. I am not sure that the provisions in Part III meet the anxieties expressed in our debate. I am grateful for the Minister's remarks, but I am not completely satisfied with them and I am not sure that they relate to the real world of budgets under pressure. However, I shall read what the Minister said and, in the meantime, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness Blatch
This may be a convenient moment to take a break in the Committee's proceedings. I suggest that we reconvene at 8.45 p.m.
§ [The Sitting was suspended from 7.47 to 8.45 p.m.]507
Baroness Cox moved Amendment No. 67:
Page 3, line 17, at end insert:
("( ) Each District Health Authority shall ensure that the following services are provided within the district—
- (a) accident and emergency (A & E) departments;
- (b) immediate admissions to hospital from an A & E department, including a significant proportion of general surgery;
- (c) other immediate admissions, such as most general medicine and many hospital geriatric and psychiatric services;
- (d) out-patient and other support services which are needed in support of the first three categories, either on site or immediately available;
- (e) public health, community based services and other hospital services which need to be provided on a local basis, either as a matter of policy, for example, services for elderly, or mentally ill people, or on grounds of practicability, for example, district nursing and health visiting;
- (f) paediatric services; and
- (g) maternity services.").
§ The noble Baroness said: Unfortunately the noble Baroness, Lady McFarlane of Llandaff, cannot be here this evening and asked me to speak on her behalf in moving this amendment. I move Amendment No. 67, which I gather has been grouped with Amendments Nos. 70-72, 78, 83 and 84A in the names of other noble Lords. Clearly they will be speaking to their own amendments.
§ Amendment No. 67 concerns Clause 3 of the Bill, which sets out the primary function and duties of health authorities. Unlike the National Health Service White Paper, Working for Patients, it gives no details of the types of service the district health authorities will be required to provide. There is therefore no guarantee that any of the important services identified in the amendment will be provided locally.
§ This amendment is necessary because, although the White Paper indicates that the district health authority should ensure the provision of services identified in sub-paragraphs (a) to (e), that does not represent a legal requirement for them to do so. Moreover, the White Paper does not even mention paediatric or maternity services, so there is no reassurance that the district health authorities will be expected to provide those important services within their own areas.
§ In supporting the amendment I should like to deal briefly with the maternity and paediatric services as examples of the need for the amendment, because they were not even identified in the White Paper. I am sure that the Committee will agree that it is of the greatest importance to ensure that DHAs develop comprehensive and integrated maternity services for without that requirement there is a real danger that those services could become fragmented and/or inaccessible to some mothers.
§ For example, the Bill in its present state allows DHAs to purchase part or all of their maternity care from outside the district. That means that one group of professionals may provide care during delivery while another team provides antenatal and postnatal care in the local community. I suggest that that is a recipe for fragmented and disjointed care.
§ It could also mean the end of highly successful integrated schemes such as the so-called "domino" 508 schemes, whereby a mother develops a good relationship with and confidence in a team of midwives during the months of antenatal care. Those midwives accompany her to hospital and care for her during delivery. If all goes well they will accompany her home again as soon as she and the baby are ready. The same midwives continue to look after the mother and baby at home during the early postnatal days. That system of maternity care achieves continuity of care and the psychological support associated with it, together with the use of hospital resources for delivery, with everything to hand in the event of an unforeseen emergency as well as minimum time away from home surroundings and other family members. That excellent type of scheme could be jeopardised if a DHA or self-governing hospital were to contract services in ways which compartmentalise or fragment such care.
§ I make the same point very briefly with regard to paediatric services, which were also omitted from the White Paper recommendations. I am sure that the Committee will agree that it is of great importance that hospital facilities are available locally to facilitate easy access for treatment and visiting by parents. The psychological importance of maintaining close contact with parents is now known to be of enormous significance. I cannot believe that the Government wish to see that jeopardised. Hence, the purpose of the amendment is to ensure that the services listed are available locally and to reassure professionals and the public that those crucial services will not become fragmented or inaccesssible. I beg to move.
§ Lord Hunter of Newington
How does one provide a good service for patients? What are the vital and important ingredients for the future? We are talking about the future. Some of these should be provided in the enlarged general practice, the secondary care centre recommended so long ago by Lord Dawson of Penn in the first interim report of the emerging service in 1921. If one therefore is to expand what patients do, their treatment, investigation and management in general practice, obviously the dividing line between general practitioner services and district authority services begins to change.
Whatever we have in the future must make allowances. The dividing line may become blurred. The Committee should remember that experience in Canada has shown that to do this is cheaper than sending patients to hospital for investigation and treatment.
The second overwhelming need is the provision of a range of specialist and emergency departments at hospitals. Thirdly, and increasingly overwhelming, is the necessity to provide community-based services for the elderly and the handicapped. This means that a relationship must be developed between the health service and the local authority organisations, whatever they might be, which is capable of coping with that.
It is for those reasons that I wonder whether the Government, in this mood of evolution which we have been hearing about tonight, will consider an earlier rather then later amalgamation of local government services and the family practitioner 509 services. There would then be two services to cope with what is a complicated situation—the health authority services and the community service organsiations. This problem must be solved so that patients do not suffer.
This is an important and helpful amendment and I was delighted to attach my name to it. The noble Baroness will perhaps recollect that on Second Reading I said that I wholly accepted that it would be quite wrong to expect every hospital to do everything. I said that I fully understood that with certain highly specialised and expensive services it is right and proper that they should be concentrated in those hospitals. That is what has happened.
However, what are to be the so-called poor services, or designated services as they are now called? It always seems to me that what they are to be has been shrouded in mystery. I am delighted that the amendment spells out what I regard as essential items. I shall not quote them, as that has already been done, but I regard each and every one as essential and it is possible that others should be added; but that can be done in due course.
There are problems and I have already said that I accept that it is not possible to have certain costly, capital intensive services, such as heart transplant units, ill every hospital. It so happens that when I was in active general practice I dealt closely with Wythenshawe Hospital in Manchester. It is a splendid and very important hospital. As some noble Lords may know, it is now the fourth heart transplant centre in Britain. A statement was made to that effect by the Government and it has received special funding to run an effective and important heart transplant unit.
The unit is very successful. It receives a considerable amount of money which is subscribed from outside sources, which is right and proper, to ensure that the heart care unit and the heart transplant unit function properly. However, there is one aspect that has distressed me. It appears to me that at the same time the rest of the hospital is beginning to languish and provide almost nothing. The noble Baroness will probably know that many of the services at that hospital have been discontinued and transferred to Withington Hospital.
The hospital is architectually in a deplorable state. Speaking to officials at the hospital only a fortnight ago I was told that they are not allowed to have any repairs carried out until the next financial year because the money has run out. Everywhere one looks one sees buildings beginning to decay and fall into dilapidation while the specially designated part—the heart transplant unit—is in splendid condition.
I give that as an example of the dislocation that occurs when specialist activity is concentrated in one hospital while the remaining activities tend to become neglected and are allowed to become almost non-existent. It is important that we have these services specified. We have all received a document from the BMA and I note that it states:The BMA fears that competitive provision of services could lead to some services being no longer available within a district, 510 which would mean a move away from the concept of the district general hospital. Equally, it could lead to the unnecessary duplication of 'profitable' services at different hospitals within a district".Neither of those developments would be desirable. The amendment moved by the noble Baroness is a helpful move towards solving this problem.
§ Lord Jenkin of Roding
I apologise to my noble friend Lady Cox as I was not here for her opening speech. I found the remarks of the noble Lord, Lord Winstanley, intriguing. He describes a situation which can arise under the present system. It is one of the real drawbacks where the producers become obsessed or fixated by one particular speciality. If a powerful personality heads that department the other services are starved because the purchaser has no clout. Who is the purchaser at the moment; the taxpayer and the patient?
Under the new scheme the district will have to ensure that services are provided and contract for them. It will then be for the providers to decide how best to do it. We come back to the divorce of the two functions which lies at the heart of the reforms in the Bill and which seem to me to be fundamentally right. I am glad that this now seems to be receiving general support.
This is an interesting amendment. Most of it comes from paragraph 4.15 of Working for Patients, with the addition at the end of paediatric and maternity services. I found it surprising that there was no reference in the White Paper to maternity services. It is an area where there is a considerable amount of new thinking on what is best. I believe that the first baby should always be delivered in a hospital because one can never know what can go wrong. It is not a good idea to have a home birth until the mother has had perhaps one or two children and then the doctors can be confident that there will be no complications. I am certain that my wife would endorse the proposition that it is much nicer to have a baby at home.
However, if one is to go into hospital that hospital must have the full back-up facilities in case something goes wrong. If not, situations can arise which contribute to the statistics of neo-natal mortality which have figured in so many of our debates over so long a period. We want to get the peri-natal mortality down to as low a figure as is possible. That means sometimes being able to deal with high-tech medicine at very short notice in a case where one did not have the slightest reason to suspect that anything could go wrong.
Can that be provided in every district general hospital? I doubt it. Of course the district has to make provision for proper maternity services. That is what the Bill is about, but I hope it will not be argued that every district general hospital must automatically provide maternity services because that might not be the right answer for a particular locality.
I do not think one can generalise about paediatric services. There are some general ones which include ordinary surgery and so forth, which should form part of any district general hospital. When one is dealing with the special problems of child diseases 511 that is a matter for specialisation. When a health authority has been seeking to reorganise its services in order to provide highly specialised services in a few special regional centres, one knows how difficult it is when enormous public opposition is aroused. That happened in the North-East Thames Health Authority area two or three years ago when it established what seemed a sensible and far-reaching plan about cancer services. The district general hospitals would continue to manage the ordinary cancer diagnoses and some of the standard treatments, but it was far better that the highly specialised chemotherapy and other treatments of that kind, including radiological services, should be concentrated in a relatively few specialised units though they might be some distance away from people's homes.
It is essentially a case of horses for courses. For its residents the district health authority has to make sure that the provision exists somehow and somewhere. It seems to me that the core services to which, as the White Paper says, patients need guaranteed local access should be those which one would expect to find in every district general hospital. I suspect that that would not include all paediatric services. Nowadays it would certainly not include maternity services because there are reasonable maternity services at a reasonable distance. Most mums are in hospital for two or three days before they return home. Therefore it is not a great hardship if they are two or three miles away and they know that if something went seriously wrong the baby would have a very good chance of survival.
§ 9 p.m.
§ Lord Ennals
What the noble Lord, Lord Jenkin, has said is the basis of my fear; namely, that with the new commercialism the approach may well be that if the service is to pay then there will be concentration on that service. One recognises that no district hospital will be able to provide all the services. If what the noble Lord said is to become policy then one may see more and more people having to travel further and further for the treatment that they expect to get in their own district.
I speak to Amendments Nos. 70, 71 and 72. My noble friend and I added to the list a comprehensive health service for women, for elderly people and for children, about whom we have already been speaking. I should have thought that those provisions were absolutely essential. When one considers the needs of the elderly, if what the noble Lord has said is true they will have to move further away from their homes. They will not simply be moving further away from their homes but further away from their families and the friends who are likely to visit them when in hospital.
§ Lord Jenkin of Roding
The core services include many hospital geriatric and psychiatric services. Presumably they will cover the great bulk of services for elderly people.
§ Lord Ennals
The noble Lord takes me to my next point. He said these provisions are included in the 512 core services, but there is nothing in the Bill about core services. That is why the noble Baroness and others have tabled the amendments which I warmly support. I hope that when we hear from the Minister he will tell us why the Government have changed their mind, because they clearly did so.
The White Paper refers, at paragraph 4.15 to "guaranteed local access", to a set of services described as "core". I do not mind whether we describe them as core or designated. Clearly at that stage it was intended that there should be a set of services which the public would know they could rely on using. Now there are no services that the public know they can rely on. The noble Lord asked about that, but there is nothing on the face of the Bill dealing with the matter. That is the whole purpose of the amendment. The additional amendments are intended to add the needs of the elderly, women and children.
If the noble Lord is going to reject the amendments, as I suspect he is, I hope he will say why the Government changed their mind and left all this uncertainty. I believe that there will be a great deal of uncertainty among people as to what will happen, not just in the first year, but in the second and third years, when NHS trusts become more and more significant, as one supposes the Government intend that they should. The fear of the public is that they will not be able to get at their local hospitals the service that they got at those hospitals before the Government started this reorganisation.
§ Lord Auckland
It may well be an assumption of any government of any political party, faced with an enormous reorganisation such as this in relation to the National Health Service, that it is taken for granted that certain services are to be provided under legislation. We are told by the Government, and I think it is fair comment, that not all of this Bill is coming into force in April 1991. It is to be a phased Bill.
I take the point that perhaps some of the additions in this amendment may be superfluous. However, I certainly do not think that paragraph (a) is superfluous. At the present time there is grave concern about the provision of accident and emergency services in many of our hospitals, and not only in the rural areas. For example, where I live in Surrey there is the M.25 motorway, which has a large number of accidents on it. However, with no disrespect to the hospitals concerned, because they cope admirably, there is a paucity of emergency services, particularly as regards a major accident and especially should it take place in the early part of the morning.
Members of the Committee will also have read about the appalling number of accidents on the A.9 main road in Scotland. There are only two major hospitals north of Edinburgh, at Perth and Inverness. Though Scotland has its own provisions in this Bill, that is an example of rural areas and the problems that they have. Therefore, I believe that paragraph (a) of the amendment is very much justified in this Bill. I leave it to the judgment of other Members of the Committee who know much more about 513 hospitals than I to decide about the rest. I hope that my noble friend will give serious consideration to the proposals, and particularly to the provision of casualty departments.
§ Baroness Masham of Ilton
I have two amendments in this group. I shall speak to Amendments Nos. 78 and 84. Before the next stage of the Bill we shall have to reorganise the groupings, as some of the amendments are rather similar.
At present the Secretary of State has a duty to provide services—
§ Baroness Masham of Ilton
I apologise. I am speaking to Amendments Nos. 78 and 84A. I knew there would be a muddle.
At present the Secretary of State has a duty to provide services to meet all reasonable requirements. However, this would not ensure guaranteed local access should the district health authority decide not to continue with a particular service. It is therefore essential to have Amendment No. 78. To avoid duplication of services, it is not necessary to provide every form of treatment within each district. The regional and supra-regional services offer highly specialised care such as open heart surgery, brain surgery, bone marrow transplants, the care of spinal injuries and many other specialties. There are also certain circumstances where it is unnecessary to provide a service within the district itself as the service in the neighbouring district is easily accessible. The amendment caters for these exceptions to services being provided locally. However, there is concern that financial pressures could lead to a distortion of priorities within hospitals. There is also concern that some districts try to do too much without specialist knowledge. That can be very dangerous.
Children need highly integrated and flexible services. This question was raised in the report which the Social Services Committee published last summer on the Government's plans for the future of the National Health Service. One of the report's recommendations was that changes in the treatment and funding patterns of small client groups with complex service needs, such as severely disabled children, should be closely monitored to provide early warning of problems with the new arrangements and to assist in the evaluation by the Department of Health of the new system as a whole. The treatment of a child with cystic fibrosis could cost up to £40,000. A wide range of services is needed. They need to be integrated. A girl suffering from spina bifida may need many different care services to help her. At present, those are co-ordinated by one agency, but if services are fragmented the child may not get the care she needs. Health authorities might be reluctant to provide expensive long-term treatment for children, and organisations representing the interests of these children fear that families might have to move from area to area to get the right facilities.
514 When healthy patients are asked if they would be prepared to travel for their treatment, the answer is often yes. However, GPs find the position totally different when dealing with sick patients and their relatives. We have a fund in Yorkshire. We have had to give some parents money to visit their children who have had to travel long distances for treatment.
If sent away from home, patients are often concerned about how their relatives will be able to visit them. Surgical procedures may well require readmission into hospital or out-patient visits. Would the patient have to be referred once again to the hospital far away? How about follow-up treatment, such as physiotherapy? Would the patient receive this locally? If so, will the health service worker have easy access to the patient's notes? I do not think that we have yet discussed patients' notes. The position is bad enough at present with patients being transferred from one hospital to another local hospital. This point ought to be considered.
I turn to Amendment No. 84A. While it is obviously desirable that most medical services should be provided locally, there are times when services need to be provided outside the district. These regional and supra-regional services are for highly specialised care such as open heart surgery and heart transplants, bone marrow transplants, burns, head injuries, brain surgery and spinal injuries. There are sound clinical reasons for concentrating such services at specialised regional or supra-regional centres.
GPs often refer their patients directly to regional services, although this may also be done through a consultant at a district general hospital. For example, a GP in North Wales would frequently refer patients to cardiology services in Manchester, Liverpool, London or Birmingham, or to radiotherapy services in Merseyside.
On Second Reading I asked what the position would be about spinal injury units. Most of these are supra-regional units. On that occasion the noble Lord, Lord Henley, said:I assure the House that spinal units and, for that matter, all supra-regional services will be protected by a proportion of the costs being met centrally and the balance regionally. We shall consult interested parties on a system for doing this and will issue guidance in due course".—[Official Report, 3/4/90; col. 1385.]I am an interested party. I happen to be the president of the Spinal Injuries Association. I speak for many members who need further clarification on the matter. They are very fearful that this legislation is being rushed through without proper planning and thought about the results should the legislation go badly wrong. It is a very worrying situation when people's lives depend on what Members of this Chamber may or may not do to the Bill.
My noble friend Lady Darcy (de Knayth) and I would not be here today if it had not been for a supra-regional unit which we attended. We need clarification on these points. First, will this protection to which the Minister referred last for ever or will it be a short-term measure pending the time when the regions take on full responsibility? The latter is quite unacceptable as there is no reassurance that the service will continue. For 515 example, if a region finds its spinal injury unit unprofitable will it then close it down? Secondly, what proportion of funds is it expected will need to be found by the regions and what protection will there be against a region deciding that it cannot afford to run a spinal injury unit or send its patients out to other units?
Tied in with this is the question of budgeting. It is most difficult to budget for spinal cord injured people. For example, a health authority may have several spinal cord injured people in one year and none for several years afterwards. How will that situation be accommodated under the Government's proposals? Will district health authorities be entitled to take a management fee for managing spinal injury units or any other specialty? The spinal unit at Stanmore has been told that its health authority will want a 10 per cent. management fee. Where will that additional funding come from? Will patients have to pay as cutbacks are made within the units? These are very important questions for which we must have answers.
§ 9.15 p.m.
§ Lord McColl of Dulwich
Perhaps I may say a word or two about these constant references to commercialism and how terrible it is that patients may have to travel miles to reach other hospitals. I emphasise, once again, the fact that local GPs in a district will sit down with the district health authority officials, helped by experts such as epidemiologists, to decide what are the needs of the community and how best they can be met within the district, as indeed they have been for years.
I cannot understand why anyone can possibly object to this new arrangement. It has not been done before, but surely no one can seriously think that it is a bad thing for all the local GPs in a district to sit down and discuss with the officials of the district health authority how best to meet the real needs of the patients in that district. That is what this is all about. It seems to me to be a very good idea. The district patients are much more likely to get a better deal than they have ever had before. I cannot understand why we are continually plagued with these comments about commercialism.
It seems to me that the noble Lord—perhaps he will accept this fact—is speaking to us as a Londoner. Would he make precisely the same remarks if he practised in Cornwall, in the Lake District or in Scotland? Is it not a totally different problem? I accept what he said with regard to London, but it does not apply to rural areas.
§ Lord McColl of Dulwich
I thank the noble Lord for that comment. Let us take Cornwall—Truro. The local GPs all come into Truro from time to time. They can have a jamboree, sit down and discuss at a day conference with the district health authority how best the people of Cornwall can be served by their health authority. The hospital in Truro is extremely good. All the clinicians work very hard indeed and provide a marvellous service for the people in that community. It may well be that there 516 are not enough clinicians in the hospital. The conclusion from the discussions between the general practitioners and the officials of the district health authority may be that there are not enough clinicians and services at Truro hospital; therefore arrangements will have to be made to expand them to give the best possible service to the people in the district.
§ Lord Peston
Perhaps I may intervene for a moment to clarify one of the points at issue. I do not think that the issue is commercialism; it is that, when considering what is best for people in the locality, full weight should be given to their convenience. It is not obvious where in the decision-making mechanism any weight is given to the convenience of people in the locality. Those are not sums that enter into the accounting systems with which the GPs and the local officials will be concerned. That is precisely the point at issue.
From the point of view of the provider if may be cheapest to say, "You can go 100 miles down the road". However, that is not necessarily the cheapest solution for the receiver. None of us can discover where in the proposed legislation any weight whatever is given to the convenience not only of the patients but of those of us who are concerned with the welfare of the patients and who also feel that our convenience might be taken into account. The issue is not commercialism; it is a lack of the appropriat and correct mechanism. That is what the noble Baroness, Lady Masham, was concerned about with the groups she mentioned.
§ Lord McColl of Dulwich
Perhaps I may come back to that question. The noble Lord may be forgetting the altruism of the people who at present provide the services in the National Health Service. They work all hours of the night and day to provide the best possible service for people in the community. They will continue to do so. It is monstrous to suggest that we must have all these regulations to make sure that they continue doing what they have been doing.
§ Lord Peston
I was foolish to join in this debate. It seems to me that the noble Lord has put his finger on the precise issue. Many of us fervently believe in the National Health Service and are totally committed to the altruism of the providers. What we fail to see in the Bill—I say this in clear terms—is any back-up for that altruism. The Bill seems to wish to replace altruism by market mechanisms. Some economists believe that altruism is a bad basis for decisions and market mechanisms are good. Many of us who support the National Health Service do not take that view. The noble Lord has put his finger on one of the central issues that concerns us. Altruism will cease to be the leitmotif of the National Health Service. Perhaps that is too strong, I should put it differently. There is danger that altruism will cease to be the guiding theme of the National Health Service.
§ Lord Rea
The noble Lord, Lord McColl, paints a cosy picture of how the health authorities will sit down with the local GPs and have a chat to decide 517 what is best for the population. However, the new management arrangements in the Bill seem to preclude what discussions there are now between general practioners and the health authorities. I am not quite sure where in the Bill we see provision for these nice meetings which are to take place.
Baroness Darcy (de Knayth)
As my name is attached to Amendment No. 84A, together with that of my noble friend, perhaps I may support what she said about special units. I refer particularly to the spinal injury units and their crucial importance to people with spinal injuries. She asked a great many important questions but perhaps I may ask one more. As the Spinal Injuries Association made clear in the letter to Mrs. Virginia Bottomley earlier this month, there is a need for new spinal injury units. Under the government proposals, who will be responsible for building the new units? If it is the regions and it is unprofitable, do we assume that there will be no more new units?
§ Lord Henley
Perhaps I may respond on Amendraent No. 67 moved by my noble friend Lady Cox, after what the noble Lord, Lord Peston, described as a "foolish" intervention. I do not necessarily agree with that.
§ Lord Peston
If I may correct the noble Lord, I said it was foolish of me to intervene. I thought my intervention was really very good.
§ Lord Henley
I would agree with the noble Lord that it was foolish for him to intervene.
Turning first to Amendments Nos. 67 and 78, these amendments overlook the fundamental point that eacth district health authority will have a clear responsibility to ensure access to a comprehensive range of services for its resident population. I would expect many of those services to continue to be available in all or most districts.
But the decision on where services are best provided to meet the requirements of a district's population must be made by each DHA on the basis of its assessment of those requirements and local circumstances. The local decision should not be pre-empted by statute and certainly should not be determined solely by reference to administrative boundaries. In far-flung rural districts people living near the boundaries will often be more concerned about services in a neighbouring district. In London and other urban areas district boundaries have little influence on the services used by a DHA's population.
The key point is local access, which will be an essential consideration in placing contracts for; services. All DHAs will need to keep in mind the requirement for speedy diagnosis and urgent treatment in many cases. Convenience for patients and relatives is also important. But such factors can only be considered in the local context.
Perhaps I may deal with a point made by my noble friend Lady Cox, who seemed to be suggesting that the domino schemes were in jeopardy. I cannot agree that the proposals for contracting will put initiatives such as domino schemes in jeopardy; rather the 518 reverse. Such schemes contribute to high quality and co-ordinated care, and I fully expect that the DHAs will wish to contract with providers that can offer such facilities. Contractual specification will ensure that such standards can be explicitly required and performance can be monitored.
A point was raised by the noble Lord, Lord Hunter, on collaboration between general practitioners and hospitals. I agree with him on the importance of collaboration between family practitioners and hospital services. Proposals in the Bill will encourage that. The Bill does not propose structural change and it does not suggest, for example, a merger of FHSAs and DHAs, but the White Paper suggests that this could be feasible in the long term in some cases.
Turning now to the term "core service" which was mentioned by my noble friend and by the noble Lords, Lord Winstanley and Lord Ennals, I feel that that term has been greatly misunderstood. There has been a widespread misapprehension that to be defined as what we now call a designated service was an indication of a service's importance, whereas the term refers only to questions of access.
Problems for a DHA's residents can arise only where a locally needed service is supplied by one provider. If that provider is directly managed by the DHA or by an adjacent DHA, there is a management route by which the continuation of local services can be secured. If the provider is an NHS trust, the Secretary of State has taken reserve powers in the Bill to allow him to intervene to safeguard the services. I refer the noble Lord to the Schedule 2, paragraph 6(1). It is only these services that are designated services.
The object of the reforms is to give DHAs the flexibility to develop the pattern of services that best meets their residents' health needs. While many services may be best provided within a district boundary, others might, as now, be best provided outside.
Amendment No. 67 in the name of the noble Baroness, Lady McFarlane, and moved by my noble friend suffers from the defect that at present aspects of the services listed are not provided in every district. There are very good reasons for that: often it is important to husband the available medical expertise. Amendment No. 78 in the name of the noble Baroness, Lady Masham of Ilton, attempts to remedy this defect by referring to the pattern of services existing at the time directions are made. The effect of that amendment would be to feeeze health services into that configuration. Circumstances will certainly change over time in many areas, and DHAs must be free to respond to them in the overall best interests of their residents by changing the way in which they secure services. Moreover, few people, I am sure, believe that the pattern of services is now incapable of improvement. DHAs will frequently want to change the existing pattern for the better.
I turn now to Amendments Nos. 70, 71 and 72 in the name of the noble Lord, Lord Ennals. I can assure the Committee that the Government are committed to the provision of a comprehensive range of services for women, elderly people and 519 children. However, the amendments, which seek to write certain services into the primary functions of health authorities, are based on a fundamental misunderstanding of our proposals. I am grateful for the opportunity to set the record straight.
First, there is no question but that it will be the duty of district health authorities to promote comprehensive health services for women, elderly people and children, as the amendments propose. The Government wish to go further than that and include the rest of their local population as well. That includes myself and other noble Lords who are not women, elderly or children. I am sure that Members of the Committee would like the Bill to cover myself and other noble Lords who do not fall into those categories. As I understood the noble Lord, Lord Peston, to say, elderly Peers are very important. The amendments are therefore unnecessary and restrictive.
Secondly, the Secretary of State already has a clear duty to provide a comprehensive range of health services under Section 1 of the 1977 Act, which I am sure the noble Lord, Lord Ennals, will remember. That duty will be delegated to health authorities through the definition of their primary functions. District health authorities will have a central task of assessing the health needs of their resident population and arranging the placement of contracts for services accordingly. This will give them a more sharply focused role than at present and the Department of Health is supporting a good deal of developmental work to allow them to meet that challenge.
I turn now to Amendment No. 83 in the name of the noble Lord, Lord Ennals, and Amendment No. 84A in the name of the noble Baronesses, Lady Masham of Ilton and Lady Darcy (de Knayth). Both amendments raise issues of the continuity of care and the future funding of regional or supra-regional services.
The Government are fully seized of the need to ensure continuity of care for individual patients. Its importance is not limited to regional and supra-regional specialties or to patients with chronic life-long illness. All patients want to be able to continue to see the consultant who is familiar with their case and in whom they have confidence. The need to recognise that basic point is underlined in the recent guidance on contracts. That makes it clear that district health authorities and providers will need to ensure that the provision of services is not disrupted by contractual change such as the non-renewal of a contract. If necessary a separate contract will need to be arranged for the on-going treatment of existing cases.
However, I do not believe that regional and supra-regional specialist units are likely to find that districts no longer want to use their services. District health authorities must ensure that their residents have access to a comprehensive range of services. It will always be better, as I know the noble Baroness will admit, for certain services to be provided on a regional or multi-district basis, whether for reasons of volume or because particular skills or equipment are needed which it would be unnecessary or 520 impracticable to provide in every district or because a new method of treatment needs to be developed in a carefully controlled environment.
Factors such as these will weigh just as heavily once the proposals in the Bill are implemented. If a district was tempted to ignore them and go its way the regional health authority would be quick to intervene.
There is, however, a further factor in favour of regional and supra-regional specialties which is strengthened by the Bill; namely, patient choice. There is no doubt that specialist units offer the higher quality services that people want and that is the best guarantee of their future success. District health authorities will have to respond to the wishes of patients and their general practitioners by placing contracts with them.
I know that there is concern in some quarters about the mechanics of contracting when specialist units may have dealings with a large number of districts. We have been careful to avoid prescribing a particular approach so that those directly involved can agree the method most suited to the needs of each unit. In some cases that might mean contracts with regions rather than individual districts, at least initially. However, I should emphasise that it is those units which provide services across district boundaries which will benefit especially from contractual funding. Instead of depending on a single authority for their resources they will be able to obtain money from all who use their services.
The noble Baroness, Lady Masham, raised a number of detailed points about the future funding of supra-regional services. I cannot provide detailed answers to all those points at this stage because we are still considering important issues and we need to consult further to ensure that we get it right. However, I can assure the noble Baroness that the existence of services which are currently funded supra-nationally is not in doubt. I believe that I gave that reassurance on Second Reading. The Government's sole concern is to ensure that they continue to be available and continue to thrive.
In short, regional and supra-regional speciality units are likely to be in a stronger position under the proposals in this Bill than they are now. They certainly do not need the additional legislative safeguards contained in these amendments. Having spoken at some length on the amendments, I hope that my noble friend Lady Cox will feel able to withdraw this amendment.
§ 9.30 p.m.
§ Baroness Cox
I thank noble Lords who have spoken in support of the amendment in my name and those of other noble Lords and I thank my noble friend the Minister for his reply.
I believe that the case still stands for ensuring local access to local services as designated in Amendment No. 67. I have considerable sympathy for some of the other groups of people identified in amendments proposed by other noble Lords. Like other noble Lords, I also recognise that there is a case for some expensive specialist services which can only be provided at regional or supra-regional level, but in 521 general there is no substitute for locally designated services with ease of access for local communities and for ensuring their provision in the Bill, not just in the White Paper.
However, I was comforted to hear my noble friend. He used the words "local access" and appeared to be committed to them. I was also reassured by what he said about the domino scheme and maternity services. I shall read carefully what he said and consider its implications. I may wish to come back at Report stage, but in the meantime I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendment No. 68 not moved.]
Lord Peston moved Amendment No. 69:
Page 3, line 17, at end insert:
("(1A) In carrying out its primary functions including those provided under section 4 below, a Regional, District or Special Health Authority or a Family Health Services Authority must ensure that the quality of such goods or services that it provides, attains such standards of quality as may be determined by the Secretary of State for those particular goods and services and must publish an annual report giving details of its attainments in monitoring and improving quality standards.").
§ The noble Lord said: I am moving Amendment No. 69, but the grouping to which I am speaking—the muddle, as the noble Baroness, Lady Masham, might put it—includes Amendments Nos. 80, 85, 85B, 86B, 88A, 91,93, 93A and 94B. I believe that Amendment No. 87 is also included, but I am not certain whether that is right. I understand that the last four amendments are certain Scottish variants of the original English themes.
§ In seeking to speak to the amendments, I have looked for some kind of unifying factor. I suppose that the unifying factor is quality of service and how that is protected within what I take to be one of the fundamental principles of the Bill; namely, the NHS contract system and how that will proceed. Having said that I think that is the unifying factor, I believe that I would find it easier to speak to the different amendments one at a time and thus hope to make some progress.
§ Perhaps I may start with Amendment No. 69, which refers to the ensuring of the quality of the goods and services that are provided. I ought to have made one other point; namely, that all the amendments at this stage are intended to probe the Government's mind in the hope of getting some reasssurance. With this amendment we are clearly talking about the prudential use of government funds. It may be that under all sorts of regulations this amendment is unnecessary. Since the regional, district and special health authorities and FHSAs are using government funds, they are probably obliged under some rule or other to meet the conditions of this amendment anyway. I hope to receive from the Minister who replies to this amendment some assurance that that is the case.
§ I should also add, in case the noble Lord proposes to mention the point, that I am aware of what I might call the Lord Jenkin of Roding point about the Bill generally. After all, we are dealing with principles of good management and one assumption that we might make is that the relevant managers would engage in good management because they are 522 managers. That is at least a possibility that I bear in mind.
§ The point of Amendment No. 69 is simply to obtain some reassurance that within the context of the use of public money—and one ought to remember that it is all public money—those who use such moneys are obliged to do so correctly and prudentially. I should like some reassurance on that point.
§ I turn to Amendment No. 80, which is on the same general theme. It refers to at least minimum standards being laid down. Again, it is partly a matter of the form of words. I am less worried about the Secretary of State laying down minimum standards than I am concerned that there should exist some procedure by which standards can be queried, if one of the authorities about which we are talking is thought by interested people—particularly patients but also doctors—to be failing below those standards. I am not very clear as to how that will work. The purpose of the amendment is to enable some light to be thrown on that matter.
§ In my view Amendment No. 85 is more important and relates to some of our discussion on the previous group of amendments and to worries expressed by other people. Our fear about the Government's proposed reforms is that the decision-makers will concentrate exclusively or overwhelmingly on cost and not pay sufficient attention to benefit. I am not one of those economists who feel that it is wrong for people who take decisions in the public sector, first, to become acquainted with the costs of what they do and, secondly, to take account of those costs. It has never seemed to me that the public sector—and I do not refer to just the health service but to the public sector generally—should somehow be excused from a proper consideration of the cost of what it does.
§ To repeat a remark that I made earlier about hospitals—and certainly I make it about universities as well—I believe that we have gone on far too long managing systems the full detail of which in cost terms we have little or no idea about. I do not object to the Government's notion—it is not especially the Government's notion; all sensible thinkers are aware of it—that costs ought to be taken correctly into account. There are at least one or two consultants present in the Chamber. I am not one of those who believe that a consultant in a hospital should be able to buy any particular toy that takes his fancy at that time. I have never understood the argument that because Consultant x has one, Consultant y has to have one too. I do not believe that money does not matter—quite the contrary.
§ Having said that, the key point is that cost is not everything. What is relevant is benefit relative to cost. Perhaps I may dare to put on for a brief moment my economist's hat, after which I shall not return to the point. We need to know the marginal costs. We need to relate them to the marginal benefits of particular activities. That is the point of an efficient system.
§ On Amendment No. 85, one's concern is that within the budgetary constrained decision situation—if I may use that horrible jargon—the emphasis will be too much on costs and too little on 523 benefits, and that therefore decision-making will cease to be efficient. It will be less efficient than it otherwise would be. That is why we had to put that amendment down.
§ Amendment No. 85B again has its corresponding Scottish version. It refers to national codes of practice and such matters, together with the need to meet the specific requirements by the acquirer. The provision in Amendment No. 85B is obvious. I do not envisage it as controversial but I wait to hear the Minister's comments on that.
§ Amendment No. 86B seems perfectly sensible. It relates more generally to a question that has been raised before. The contracts in the sense in which we are using the expression in the Bill are not contracts in the commercial law sense. As I understand it, they are not negotiable contracts in law. Nonetheless, if they are contracts, one certainly believes that the contracting party—the person who agrees to deliver—is under some obligation to deliver. It is not yet clear to me—by the end of the Bill with any luck the noble Baroness will have enlightened me as she has done on other Bills in the past—how the provision will work. Because they are not enforceable contracts, I cannot understand the mechanism. One might argue, "You contracted to do this for me. I pledged this money. I now tell you you have not done it", to which there may be the replies, "Yes we have" and "No you have not". There seems no mechanism that ensures delivery on fair terms. I am not pressing the amendment per se but using it as a basis for argument. I seek some enlightenment on those matters.
§ Amendment No. 87 stands in my name and that of my noble friend Lord Kilmarnock and the noble Lord, Lord Walton of Detchant. I hope that one of my two colleagues will speak to that amendment. It comes within the standard of performance and quality of performance set of questions that I raised.
§ Amendment No. 88A is essentially one route to provide for that—I emphasise one route—which the Government might like to consider. It may be embarrassing to some noble Lords, but I am not a great believer in advisory committees, having sat on many of them. It has never been obvious to me what good one was doing other than to be able to say that one was on such-and-such a committee. On the other hand, I have occasionally sat on committees that seemed useful for a while. It is not the idea of a committee that I am in love with. The amendment provides one suggestion on how we might approach the problem of maintaining quality and meeting standards. It shows that that would be a feasible route. But I am more interested in what the Government have to say. I make the assertion that they will not accept the amendment. I do not feel strong enough at this hour to anticipate that the noble Baroness will accept the amendment. However, on the basis of the problem that the amendment and others address, I am more interested to know the Government's views on how these difficulties will be overcome.
§ That is the class of amendments. I do not need to speak specifically on the Scottish versions of them. I cannot think of any Scottish aspect of the question that is especially pertinent to the discussion.524
§ 9.45 p.m.
§ Baroness Cox
As Amendment No. 88A comes within this group of amendments, perhaps I may speak briefly on it. Perhaps I feel stronger than the noble Lord, Lord Peston. I am an optimist. I hope that the Minister may surprise us by responding sympathetically to the amendment. It reflects the intention expressed by her right honourable friend the Secretary of State. We were hoping to see a government amendment on the same lines for consideration during the passage of the Bill through this Chamber.
In speaking briefly to Amendment No. 88A I wish to describe the background to it, the need for it, the state of play with regard to relevant discussions and initiatives that have already taken place and its implications. The amendment introduces a new clause to set up an advisory committee with the power to establish minimum standards of care to be exercised through the Secretary of State. The committee will also have the power to assess hospital and other relevant establishments in order to assure their compliance with the minimum standards.
We believe that the provisions are necessary to ensure a safety net for the quality of care, the theme running through all the amendments. At present standards vary greatly between one part of the country and another. Indeed, such variation is one of the reasons given by my right honourable friend the Secretary of State for the reforms to the National Health Service.
There is no guarantee in the Bill as it stands that the proposed contract system will prevent such variations in standards and quality of care in the future. The Bill provides that standards of quality shall be arrived at in negotiations between purchasers and providers as they draw up contracts. Therefore, it is perfectly possible that different standards will still be set in different parts of the country. The only way to avoid unacceptable variations is to set a baseline for standards and to stipulate that no contract shall be let with standards below that baseline. Such a system would also prevent potential abusers of monopoly power in areas where providers are few and far between. In other words, this is the only way we can ensure a safety net for the quality of care.
Another important aspect of the new clause is that it provides for monitoring by giving the chairman of the advisory committee the ability to make assessments of hospitals. I argue that the power is essential. There is little point in having a power to set standards if there are no mechanisms for inspection to ensure that they are being upheld.
There are clear precedents for such a provision. The closest analogy is Her Majesty's Inspectorate for Education. In addition, when privatising the national utilities the Government have taken care to establish mechanisms for the protection of consumers. I hasten to add that I am aware that the Bill does not seek to privatise the NHS. It opens up new ways of providing services with the introduction of an internal market. Surely, therefore, it is appropriate to establish a regulatory mechanism so that the interests of the consumer, the patient, the 525 client can be protected and—this is very important—can be seen to be protected.
I dare to believe that the Government are already considering such mechanisms. For example, I understand that my right honourable friend the Secretary of State has met representatives of the royal colleges and the statutory bodies in order to discuss the possibility of setting up a multi-professional advisory group to establish, maintain and improve standards of clinical care. I also understand that during debates in another place reference was made to the Government's intention to bring forward proposals to that effect. Therefore, I hope that the amendment will be seen as being helpful to the Government in embodying their intentions.
I wish to ask the Minister three questions, two of which are possibly hypothetical. First, do the Government intend to bring forward a similar amendment? Secondly, if that is the case, what arrangements may be made to resource such a body? Thirdly, if the Government are considering such an initiative what powers would be given to such a body in respect of visiting and monitoring functions and its ability to initiate action as opposed to offering advice only on request?
I sincerely hope that my noble friend will tell the Committee that the Government are already committed to the important principle of quality assurance and that they are taking the necessary steps to implement it in law in the form of measures such as those outlined in the amendment. If so, I shall be delighted to regard the amendment as redundant.
§ Lord Kilmarnock
I wish to speak to Amendment No. 87. The noble Lord, Lord Peston, was right to refer to the group of amendments as dealing with quality of service, and the amendment falls fairly and squarely under that heading.
Amendment No. 87 introduces the concept of a national accreditation board. I shall not go into great detail but I wish to preface my remarks by asserting that there is widespread concern in the Committee about the maintenance and improvement of the quality of service which will exist in the NHS when the Bill becomes an Act. I believe that that sentiment is shared by many who support the basic principle of the Bill as well as those who are opposed to its underlying philosophy. It stands to reason that standards can slide on several grounds. An entrepreneurial hospital may cut corners to increase its throughput. The cash limited purchaser may well be tempted to seek the most economical contract and a languishing hospital may lose clients and the cash which they bring with them and not be able to maintain standards due to lack of funds, leading to the two-tier system which some people fear.
In the Bill there is nothing to allay those fears. There is no commitment to quality control. There are contracts but they are not legally binding and are not praper contracts in the legal sense. With quasi contracts of that nature standards can slip and, if core services are stipulated, they may well become the bare bones of such services.
526 There are various ways of plugging that gap in the Bill. One is reflected in the new clause spoken to by the noble Baroness, Lady Cox. That proposes an advisory committee on standards which would make recommendations to the Secretary of State and which could initiate inspections of the working practice of any hospital on its own initiative.
I believe that I am right in saying that in another place the Labour Party wanted something with more teeth and tabled an amendment proposing a quality control commission. In this Chamber the noble Lord, Lord Young, who is sitting close to me, has tabled an amendment which would set up for the health service something analogous to the HMI of the education service—an interesting and original suggestion, at which I am sure we shall all wish to look carefully when the time comes. If I detect no disposition on the part of the Government to take seriously this whole area of concern, I shall look sympathetically at his amendment and may well support it.
The amendment which I move with the support of the noble Lords, Lord Walton of Detchant and Lord Peston, states in subsection (1):There shall be a National Accreditation Board … whose duty shall be to provide recognition to health service bodies which are acquiring or providing goods or services under an NHS contract and which have voluntarily sought to be measured against high performance standards set by the Board and are in 'substantial compliance' with them".A national accreditation board would thus become the custodian of a national quality assurance programme.
Such a programme or variants to it are already in operation in the United States, Canada and Australia. Indeed, something largely based on the Australian model has already been put into motion by the King's Fund Centre in this country and is attracting support on an increasing scale. As I have suggested, it relies heavily on the voluntary principle. It is very cheap to administer and the version which we propose this evening would eventually be self-financing.
I shall leave to the noble Lord, Lord Walton, some of the details of how the accreditation system works and what it covers, because he is better qualified than I to speak to that. Because we are in Committee and we are discussing this as a probing amendment, I want before going any further to face two difficulties in my Amendment No. 87. First, the analogous schemes are independent of the government in all the countries which I have mentioned. Those who advocate an accreditation system believe profoundly in its essentially voluntary nature. We have preserved that in subsection (1), in which enrolment in the scheme on the part of health service bodies is voluntary.
The King's Fund scheme has, with its own and charitable funding, surveyed nine acute hospitals and has had inquiries from 50 more. Among those it expects to carry out a survey, or an organisational audit as it prefers to call it, on a further 18 hospitals in 1991 and a further 25 in 1992, as well as revisiting the original nine pilot projects. I gather that the royal 527 colleges are prepared to participate in that on a voluntary basis.
Admirable though all that is, I do not see how something in the region of or exceeding the 600 annual surveys carried out, for example, in Canada could be reached without initial support from public funds. Also, if we are talking of a nationally agreed set of standards, which is essential, clearly they must be accepted by the Government. That is why, though the amendment leaves it to the health service bodies voluntarily to seek accreditation, it obliges the Secretary of State to set up and at least initially finance the running costs of the accreditation board.
That brings me to my next difficulty. We had a shorter version and a longer version of the new clause. We decided on the shorter version, which is on the Marshalled List, as being a sufficient vehicle for a probing amendment. However, on reflection it gives excessive patronage to the Secretary of State over the composition of the board, whose strength should lie in a considerable degree of arm's length independence. Therefore, depending on the reply of the noble Baroness and any other opinions expressed in Committee this evening, we may wish to bring forward at the next stage the expanded version.
528 In that version the board is composed of 17 members—as specified in this amendment and this new clause—but the Secretary of State only has the power of direct appointment of four members. The others are directly nominated by the various health service organisations: the conference of the royal colleges, the Royal College of Nursing, the Council for Professions Supplementary to Medicine, the Institute of Health Services Management, the National Association of Health Authorities, the Association of Community Health Councils for England and Wales, the National Consumer Council and the Patients' Association. That version would give the Secretary of State some presence on the body, but would not give him the dominating role.
Whether or not that is a reasonable composition or an acceptable idea, I am convinced that the Committee will require something on quality to be written into the Bill. I strongly believe that we must insist on that before the Bill leaves the Committee. At this stage, as the noble Lord, Lord Peston, said, all the amendments are of a probing nature. It very much depends on what the noble Baroness says this evening as to how we decide to proceed at the next stage. I therefore look forward to hearing her response to the debate.
§ 10 p.m.
§ Lord Walton of Detchant
In supporting the principles underlying this amendment may I say that this group of amendments is related to quality assurance within the National Health Service. It is somewhat paradoxical that, whereas there are well-eslablished professional regulatory bodies that seek to ensure a proper standard of professional behaviour on the part of professionals employed within the health service, as yet we have no specific mechanism for inspecting the quality of services and care provided by hospitals in the NHS.
Three; possible approaches are available. One is to increase or extend the role of the present health advisory service which at the moment simply examines the services for the elderly and for mental health. A second approach, as suggested, might be a national inspectorate in some way comparable to Her Majesty's Inspectorate of Schools. The third would be the accreditation system to which Amendment No. 87 refers. I believe that that is the kind of principle and method to be preferred.
The benefits of that method are that it could provide the development, distribution and updating of national standards and the provision of a yardstick against which to measure organisational performance. It could provide a framework for co-ordinated quality assurance activities and an effective method by which to monitor organisational quality within the contracts to be provided and agreed between health authorities and providers. It could also provide the means of demonstrating to the public that services are of a specified quality.
Accreditation cannot deal directly with the clinical components of quality which contracts will seek to address. However, it can ensure that the necessary structures and processes exist in relation to professional staff and their activities which are likely to result in the provision of high-quality care. It can ensure that purchasers of organisational issues are addressed on a regular and systematic basis.
The noble Baroness will no doubt tell us that the Secreta:7 of State is considering the establishment of a quality assurance mechanism which is in some way comparable. If that is the case one would hope that it would be an independent body managed by a group of individuals—perhaps, as the noble Lord, Lord K.ilmarnock, said, nominated by the royal colleges and similar bodies—who could have the authorty to carry out the necessary inspections and to apply a common set of criteria allowing purchasers to make intelligent and informed choices. It would also give an assurance to other purchasers of services, the customers and general practitioners, that a hospital has met an acceptable level of performance. Hence, in supporting this amendment and its principle, I trust that the quality assurance proposals that the Secretary of State is considering will meet the concerns expressed by all those who have proposed these amendments.
§ Baroness Masham of Ilton
I speak briefly in support of Amendment No. 88A. A bad hospital might sell cheap contracts to fill its beds.
530 Amendment No. 88A is important. Good standards are essential for good results and satisfaction all round. By now the Government should have got the message that there must be safeguards included in the Bill. I hope they will accept the amendment.
§ Lord Butterfield
Perhaps I may make one observation to the Minister before she replies. I am sure that this will not be resented in any quarter. It is a fact that since 1517 the College of Physicians, and subsequently the other colleges, have jealously guarded the standards of professional behaviour in the various professions. I hope that the point made by the noble Lord, Lord Kilmarnock, and by my noble friend about bringing in colleges will be borne strongly in mind by the Secretary of State when he considers these matters, if only to ensure that we do not have a head-on collision between this Chamber and the people who for a long time have been concerned with the maintenance of standards in the health service throughout the country.
§ Baroness Carnegy of Lour
Before my noble friend replies, and I know that she is longing to do so, it is important not to confuse the control of a profession's professional behaviour by the profession itself and the concept that you can only assure standards in the work done by contract by having some sort of central control. My noble friend Lady Cox—a great devolutionist, I should have thought—believes that the National Health Service can only raise standards by having a central body, and other noble Lords have reflected that opinion during the debate.
If one is issuing contracts the whole aim is for the individual hospital which is issuing the contract to obtain the highest possible standard locally precisely by specifying high standards and obtaining the highest standards available. Those standards may well be higher than we have ever had in the health service and miles above the average. A central body will simply arrive at the lowest common denominator as the minimum. That is lowering standards, not raising them. The perception of noble Lords is limited by the present set up, which is not satisfactory. It is important to see the possibility of this specification for contracts, which in other spheres is proving so successful in raising standards.
§ Lord Young of Dartington
I refer briefly to Amendment No. 87. I do not intend to speak now about my Amendment No. 107, which I hope will be called when we reach Clause 20, but the two amendments are closely connected. If my amendment were not to succeed, I should certainly be in favour of this amendment because it would be better to have the national accreditation board which is proposed rather than nothing at all.
The great disadvantage of it is obvious and attention was drawn to that by the noble Lord, Lord Kilmarnock, when he emphasised the word "voluntarily" in his wording. If the board were set up it would be in relation to a voluntary system which would give it a weakness from which it would be very difficult to recover fully despite what we 531 have heard about the way these provisions work in Canada and the United States of America and despite the excellent preliminary work that the King's Fund has done.
If hospitals knew that they were well up on the scoring that is proposed by the King's Fund and knew that their standards of performance were reasonably high, they would be the ones that would go for accreditation. They would add the accreditation label to what was already a good standard of performance. Other authorities which knew that they were unlikely to reach the required standard would surely not put themselves forward as voluntary participants in this scheme since they would know that they would be unlikely to succeed. I do not know how this really important objection is to be easily overcome.
That does not mean to say that the scheme is not worth doing because the work of the accreditation board, by stressing high standards, and even though the worst hospitals were left out, would at least keep the issue of standards very much before people in the National Health Service. In its report on the accreditation proposals the King's Fund goes into very great detail. In some ways there is a quite alarming number of standards which are supposed to be conformed to. For example, under the heading of nursing one of the standards is:There is evidence that the delivery of nursing care is in accordance with agreed standards for nursing practice".Those are rather vague words. There are many vague words in the standards as set out in the King's Fund report. Is there not a danger that when hundreds and maybe thousands of standards are set out in this way the whole performance of a hospital, taken generally and as a whole, could somehow be put away into obscurity? A good score could be obtained on standards such as 6-2, 7-6, 15-9, and so forth. However, if the hospital were considered as a whole it might or might not be good. It might or might not be using to good effect the resources which it had available on behalf of its patients.
At an appropriate stage I intend to propose an inspectorate. It would not need to be caught up in an elaboration of individual standards such as would be the case if the King's Fund proposals in anything like their present form were adopted by the accreditation board which the noble Lord, Lord Kilmarnock, is proposing. I have doubts, but they are not such that if the circumstances were different I would not support these provisions as they are a step forward.
§ Lord McColl of Dulwich
I wish to emphasise something which may have been overlooked by the Committee. If they wish to have junior staff all the hospitals in this country are inspected regularly by members of the medical profession. That is done on a quite large scale. The inspection teams have teeth. Not only do they inspect the actual training posts but they go into the question of sleeping facilities for junior staff, food, library facilities and other matters.
532 Much more important is that the Royal College of Surgeons has managed to achieve the remarkable state of affairs whereby in every district in this country all the deaths and complications that occur as a result of surgery are discussed in great detail, usually once a week. That is a good quality assurance and it could be extended to other walks of life. Perhaps the press would like to discuss every week how many of its stories are actually true. Perhaps politicians might also meet weekly to discuss how accurate their statements had been in the previous week. A good deal is going on already on which we can build.
§ 10.15 p.m.
§ Baroness Hooper
The issues under discussion in this large grouping of amendments are relevant to my right honourable friend the Secretary of State's discussion with the royal colleges and other bodies on the possibility of establishing a statutory multiprofessional advisory group on the standards of clinical care for National Health Service patients. In this, we recognise the historical role of the royal colleges in maintaining standards, to which the noble Lord, Lord Butterfield, referred. I hope the Committee will understand that in responding to the debate I would not want to pre-empt the outcome of those discussions in any way.
I have said on a number of occasions that the search for improved quality lies at the heart of our proposals for the National Health Service. I realise that this aim also lies behind the amendments. But I do not believe that prescribing minimum standards for providers of services, as proposed in the amendments in the names of the noble Lords, Lord Ennals, Lord Peston and Lord Carmichael, is the way to achieve it. I agree strongly with my noble friend Lady Carnegy of Lour. Such a prescriptive approach would be unable to take account of the varying local factors that go to make up a quality service. I fear that minimum standards would quickly become the norm, inhibiting higher quality providers from seeking to improve their standards still further.
Furthermore, I can confirm that the first part of Amendment No. 69 would add nothing to the existing powers of direction of my right honourable friend the Secretary of State which are quite sufficient to require health authorities to meet any quality standards that he may lay down. However, I do not think that the way forward is to prescribe standards centrally for every single service. Improvements in standards will come from the specification of quality in contracts and other developments such as clinical audit.
Amendment No. 88A, which was referred to by my noble friend Lady Cox, would require the Secretary of State to establish a National Advisory Committee on Standards to advise him on matters relating to quality. I have sympathy with those who consider that, particularly at a time of change, we need to monitor the effect of our proposals on the standards of care that patients receive. That is why my right honourable friend is discussing with the 533 royal colleges and interested parties the establishment of a body to advise him on standards. I hop; that that gives some comfort to my noble friend Lady Cox. We have made clear that the possibility of a statutory base for such a group will be carefully considered in the course of those discussions. Furthermore, discussions will focus on the powers of the body. The level of resources will obviously depend on what the powers are, but clearly any body so set up would need to be properly funded. I hope that that answers the questions raised by my noble friend.
The key to improved quality in the health service lies in the work of, and relationships between, local health authorities. Work undertaken at national level can supplement this but not replace it. Our reforms will give greater choice to patients and greater freedom to health authorities to find local solutions to local needs. Districts will consider the specific health care needs of their resident population and arrange for the provision of specific services which best meet them. GPs who are best placed to know patients' needs and preferences will be closely involved in the process. NHS contracts will be awarded to those providers of services who offer the most effective and highest quality services. I believe that contracts will offer a more effective means of improving standards on the ground rather than prescriptive requirements made from the centre.
The noble Lord, Lord Peston, asked specifically how these contracts would be enforced. Although National Health Service contracts will not be legally enforceable in the courts—because, after all, the parties, the providers and the suppliers, are within the same body and therefore it would not be appropriate—they will still be an effective means of holding providers to account. Hospitals will be expected to deliver the standards of service required by purchasers. District health authorities will monitor providers' performance very carefully to ensure that it is in line with contract specifications. Contracts will also specify remedies for non-performance, giving providers every incentive to maintain quality standards. I am most grateful to my noble friend Lord McColl for drawing our attention to the role of inspectors in monitoring those standards.
Some of the amendments tabled in the names of the noble Lords, Lord Ennals and Lord Peston, would set out in the Bill a detailed specification of what is to be included in contracts; for example, quality measures and monitoring arrangements for providers' performance. There is no question but that the quality of standards will be included in contracts. The requirement on health authorities to place contracts in line with GP referral patterns is itself sufficient evidence that contracts will not go automatically to the lowest bidder. Equally, our guidance on contracts has made clear that contracts should include arrangements for monitoring standards and the information the provider will be expected to supply.
In the context of Amendment No. 80, Members of the Committee may be interested to learn that the midwifery committee of the English National Board for Nursing, Midwifery and Health Visiting has 534 recently commented upon the guidance which has been issued. It is entitled Operating Contracts. The board was especially interested in the quality specifications for maternity services contained in the specimen contract documentation provided by Maidstone Health Authority. It also commented that many of the statements in the specimen are admirable. I commend the specimen contracts to the Committee as examples of what can already be achieved in the way of specifying quality as part of the ongoing introduction of these proposals. However, I do not believe that such details need be spelt out in primary legislation.
The development of quality measures will be an evolutionary process. As experience grows, specifications of standards will, I feel sure, become more sophisticated. Clinical audit is another key element of our drive to maximise quality of care. This is an area where the medical profession is indeed supported by the Department of Health in developing arrangements which will be effective throughout the National Health Service.
Our reforms aim to create a health service which works for patients. Our package of reforms will create the right conditions for further improvements in standards of care for National Health Service patients. I do not believe that detailed prescription in the Bill of quality standards, the contents of contracts or the central mechanisms of quality measurements is necessary. I recognise that in introducing this grouping the noble Lord, Lord Peston, said that these were probing amendments. I hope that the assurances which I have been able to give him are satisfactory.
§ Lord Kilmarnock
Before the noble Baroness sits down and before we move on from this topic, can she say a few words about how the Government view the national accreditation proposals which I and the noble Lord, Lord Walton, put forward? She did not mention them in her reply. As they are the least bureaucratic and the most economical of all those which have been proposed, it would be interesting to have the preliminary view of the Government on the matter before we decide what to do at the next stage of the Bill's proceedings.
§ Baroness Hooper
I was interested to note the remarks made by the noble Lord, Lord Kilmarnock, and I shall read carefully what he has said. The same general response that I have given in relation to all the amendments applies here.
§ Lord Peston
I should like to thank all Members of the Committee who have contributed to this interesting little debate. If I understand the noble Baroness correctly she said that her right honourable friend the Secretary of State is meeting the royal colleges and some developments on the quality accreditation and the professional side may emerge from that. I shall wait to hear the results from that meeting; possibly amendments may flow from it.
I am a little confused about the enforcement of the contract. The noble Baroness said that there 535 would be an effective means of holding providers to account. I cannot quite yet see that but I shall look for another way of understanding the problem with a view to learning more about it.
I always listen carefully to the remarks of the noble Baroness, Lady Carnegy of Lour, as well as to the response of the noble Baroness, Lady Hooper. Essentially the statement of the noble Baroness was that when looking at this, if one lays down standards, the standards achieved will be the minimum laid down. I do not wish to be my usual acerbic self but I ask both noble Baronesses to recall our debates on the education Bill where they took exactly the opposite view.
It may well be that consistency is the hobgoblin of small minds, if the Committee will forgive the quotation. However, those of us who perhaps have small minds think that consistency is relevant. The Government ought to make up their mind: either the approach in the education Bill is correct or the approach of, "Let's devolve and let a thousand flowers bloom" is correct. One cannot pick and choose one's philosophy depending on which day of the week it is. Having scored that point, perhaps I may add that I do not regard the subject as over and done with. However, I think that we have gone as far as we can tonight. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ 10.30 p.m.
Lord Winstanley moved Amendment No. 69A:
Page 3, line 17, at end insert:
("( ) This section and section 4 below shall not come into force until each Regional, District or Special Health Authority or Family Health Service Authority is satisfied that the neecessary financial and other information is available to carry out the requirements under the specified sections.").
§ The noble Lord said: This amendment is self-explanatory and I shall not waste the Committee's time by reading it. It still deals with contracts and in many ways it takes us back to the lengthy and important discussion we had on the earlier amendment moved by the noble Baroness, Lady Cox, which was taken to a vote. This amendment focuses on anxieties which were expressed in the debate on the amendment of the noble Baroness, Lady Cox, by the noble Lord, Lord Carr of Hadley—and I am delighted to see him in his place,—and also by the noble Lord, Lord Nugent.
§ On 1st April 1991 we shall have an internal market in health. My recollection is that the internal market in health was one of Dr. Owen's bright ideas and perhaps that explains a lot. We shall have an internal market but as yet we know nothing about prices. Nor do we know in what way the different authorities will price their various procedures or whether they possess the expertise or the mechanisms necessary in order to evaluate and cost the procedures. It is an elaborate business.
§ I do not wish to go over again the earlier debate on the amendment of the noble Baroness, Lady Cox, but when I raised the matter with the noble Baroness, Lady Hooper, she more or less said that in the first 536 instance the contracts would be provisional and the costing might well be done centrally by the department. I think those were her words, but perhaps not.
I was interested in what the Royal College of Nursing said about the matter in a briefing paper which many noble Lords will have received. It stated that:
the rapid timetable envisaged for the operation of an internal market will leave the National Health Service ill-prepared. If providers have inadequate information from which to cost their services, they will either overcharge, causing financial problems for the purchasing DHA, or undercharge, leading themselves to financial ruin. In the case of a provider overcharging, then the eventual loser must be the tax payer, as the provider of DHA budgets. In the case of provider undercharging, the eventual loser may well be the patient, as the unit strives to restrict costs to stay within budget. Either of these scenarios could develop, not as a result of inefficiency in patient care, but simply because of a failure to be able to cost procedures fully".
I am worried about the business of costing these procedures. The Royal College of Nursing is not alone in this matter. The Social Services Select Committee went so far as to state in its eighth report, at paragraph 7.25:
We recommend that the Government do not attempt a full separation of purchasing from providing health care until the necessary infrastructure in terms of systems, equipment and staff is in place".
§ What is going to be the position? I do not know whether we shall get an answer to this now, but all my amendment does is ensure that none of those things come about until one is satisfied that the various authorities have the necessary information to make the appropriate decisions. It seems to me that there is no chance at all that they will have the necessary information. If the internal market starts on 1st April 1991, undoubtedly it will have to be under the control of the department centrally, which I do not think is the object of the exercise.
§ I do not want to be discourteous, but in his reply to the noble Baroness, Lady Masham, who put some very important questions earlier, the noble Lord, Lord Henley, said that he could not give her the answers because he did not yet know them; these were matters still being discussed. It is not very reassuring to hear that the Government do not yet quite know what they are doing or trying to do in certain of these matters.
§ Let me say immediately before any noble Lord intervenes that I am very glad to learn that the Government's mind is not finally closed on these matters. I hope that perhaps when I get a reply we shall hear that they have not finally made up their mind about whether it is within the bounds of possibility that the internal market can actually start to operate effectively on 1st April 1991. I am not against the market, but I do not think it could come in on that date. I believe that that is too quick. I beg to move.
§ 10.30 p.m.
§ Lord Ennals
I should like to support the amendment. In an earlier speech I said that I saw no chance that by April 1991 the health authorities would be ready to do this. I note that the royal colleges and the other colleges in their statement reached the same conclusion. The Department of 537 Health's own advisers recognise that there is an immense amount of work to be done before the information systems, which are the key to the internal market, are able to cope with the changes proposed. The statement also said that the depar;ment's study team was not aware of any work which had been carried out on the risks which may affect either purchaser or supplier organisation arising out of the lack of timely, accurate information with which to manage their business.
We may be in the worst possible situation if they plunge into doing something that is totally inadequate, leading to total confusion. I should like to hear from the Minister just how satisfied she is that it is going to be possible for the market effectively to begin on 1st April and, if not, what the consequence is. I am grateful to the noble Lord, Lord Winstanley, for tabling the amendment.
§ Lord Carr of Hadley
I must reiterate the warnings I have given on this very point, that to embark upon this market principle—a principle which I wholly support and want to see implemented as quickly as possible—without adequate preparation could do the utmost damage to the whole principle. I must repeat what I think I said earlier. A few weeks ago I had a long conversation with the chairman of a district authority who believes in the principle—he is already preparing for it—but who sees the greatest danger to it if he is forced to introduce it before he is ready, and as at the moment he cannot see how he can be ready by next April. All he said was "Don't let us have this deadline date hanging over our heads. Let us get ready as soon as possible. If we can be ready by 1st February let us start on 1st February, but don't make us start on 1st April if we are not ready".
§ Baroness Hooper
The Government have made clear their intention that all hospital and community health services should be funded through contracts from April 1991. This timetable was discussed with National Health Service managers, who considered it to be feasible. The Government are therefore confident that management capacity in the NHS is equal to the task. We believe that it is important that the benefits of contracting are seen as soon as possible throughout the service so that we can begin this evolutionary system of developing the service and making it more sophisticated.
From 1991, all units will need adequate systems in order to manage their own finances, activities and the contracts which they agree with district health authorities. The sophistication of those systems will depend on how complex and advanced the contracts are. It will be possible for block contracts to be based initially largely on existing information and systems, which I repeat to the noble Lord, Lord Winstanley, are currently available to district health authorities. More advanced hospitals are likely to offer purchasers contracts with a higher degree of specification. They may need more sophisticated systems to manage these. It is important that the basis of such systems across individual hospitals should be able to respond flexibly to their own needs.
538 After 1991 we expect that the stimulus of contracting will lead to an increased rate of improvement in financial and management information systems.
However, it will continue to be a management responsibility for district health authorities to satisfy themselves that their directly-managed units possess adequate systems to generate financial and management information. Before my right honourable friend the Secretary of State agreed to a unit becoming a National Health Service trust he would also need to be satisfied that its information systems were adequate. That is one of the points which will be considered when the NHS trust applications are considered.
The Department of Health also has a duty to stimulate and encourage improvements in financial and management systems. I should like, as one example of such work, to cite the NHS review proposals to speed up the roll-out of the resource management initiative.
With reference to that initiative perhaps I may remind the Committee that the aim of resource management is to allow total individual patient care to be planned and delivered cost-effectively. Doctors and nurses are involved in the management process and are provided with detailed information about patients' treatment costs and so on. Resource management has already been introduced into a number of sites and is to be introduced into all 260 large acute hospitals by 1993, beginning in 1989-90 with 20 sites. Resource management will provide those who deliver care with the information to make decisions. In terms of funding, £33 million was spent this year on resource management and assorted computer systems and a further £78 million is to be spent in 1990-91.
In addition, consultative documents covering the impact of the National Health Service review on information and IT were published on 11th January, with a deadline for comments of 31st March. Among other issues, the information needs of providers are considered. There is therefore a considerable amount of action taking place. For those reasons, we believe that the amendment would be unduly restrictive and I trust that the noble Lord will feel able to withdraw it.
I listened with great care to the noble Baroness's reply and I note that she has looked into the matter very thoroughly. She has thought about it. It is clear that her fellow Ministers in the department have thought about it and, after taking advice, she has decided that this timetable can be met. I wish that I could believe her. I am afraid that time will show that she is wrong and I am right.
I am not at all sure what course I should take now. I shall certainly not press the amendment now, but the matter is of the greatest importance and, in some form or another, it is essential that I should return to it at a later stage. With that, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.539
Lord Winstanley moved Amendment No. 69B:
Page 3, line 20, after ("may") insert ("after consultation with Community Health Councils and such other bodies as seem to it to be appropriate").
§ The noble Lord said: I am sure that I can deal with this amendment very rapidly. It concerns patients. As a doctor, you deal with them as rapidly as possible.
The amendment ensures that local opinion is consulted before certain steps are taken. The obvious people to express local opinion are the community health councils and,
such other bodies as seem to [the health authority] to be appropriate".
§ It is a simple amendment. I beg to move.
§ Lord Henley
Amendment No. 69B would place a duty on health authorities to consult community health councils and others before entering into contracts as providers of services to residents of other districts.
In considering Amendment No. 68, which, as the Committee will remember, we discussed with Amendment No. 65 before adjourning for dinner, the Committee examined the need for health authorities to consult in their role as purchasers. Purchasing health care on behalf of the resident population will be the key function of the district health authority. It will be essential that the DHA keeps its local community fully informed of its plans to acquire services through contracts and listens to the views of community health councils, other interested bodies and, of course, GPs and patients themselves. To that end, the Government have made it quite clear that there will be consultation, although that does not need statutory requirements and must not encumber the day-to-day management of contracts. I hope that I have said enough to satisfy the noble Lord.
I am most grateful to the noble Lord, who appears to say that what I have asked for will be done but that there need be no statutory requirement. I have always taken the view that patients play an important part in their illnesses. It is important to seek patients' views occasionally before we make fundamental changes to the medical arrangements in their area. I have always believed that the ideal body to represent the patient—you cannot speak to every patient—is the community health council. I am delighted to hear that those councils will be consulted on these matters. We shall await the outcome. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 69C to 72 not moved.]
Lord Walton of Detchant moved Amendment No. 73:
Page 3, line 24, at end insert—
("(2A) Each Authority shall identify within its financial allocations specific identifiable funds to be utilised on the authority of the Postgraduate Deans or other appropriate officers concerned with the provisions of teaching services to medical and dental practitioners, nurses and other health care professionals, for the support of postgraduate, vocational and continuing education programmes.
(2B) Each authority shall provide that appropriate financial allocations identified under the Service Increment for Teaching (SIFT) shall be made available to all authorities responsible for the provision of undergraduate teaching to medical and dental students and for the support of research activities, and that the Service Increment for Teaching shall be renamed the Service Increment for Teaching Research (SIFTR).").
§ The noble Lord said: This is essentially a probing amendment. Until the late 1940s, the Medical Act required that a medical practitioner should at the moment of graduation be expert in the practice of medicine, surgery and midwifery. It soon became apparent that the increasing range of knowledge required of those graduating in medicine and the increasing responsibility which was likely to be imposed upon them in their medical practice was such that a pre-registration year before doctors could become fully registered was introduced in 1950.
§ Since that time, medicine has continued to develop apace. The demands have increased and the range of knowledge is greater to such an extent that postgraduate and continuing education are now an essential part of all medical practice. Indeed there is a legal requirement now that any doctor wishing to become a principal in general practice should undertake a three-year vocational training programme before being able to practise independently in the National Health Service as a principal GP. Similarly, postgraduate and vocational training and continuing education are available to doctors as they are to other health care professionals in the service.
§ Since the National Health Service Act was passed in 1946 it has been the legal and financial responsibility of the National Health Service to provide the funds necessary for the support of postgraduate and continuing education for all health care professionals. An unfortunate development in the past few years has been that some health authorities, because of constraints on finance, have significantly and progressively reduced the funds available for such postgraduate and continuing medical education and for the education of other health care professionals.
§ It is upon such postgraduate and continuing education that the quality of medical practice and services depends. Without question the needs of patients require that such facilities, including facilities for courses, study leave and other special vocational and continuing education opportunities, should be available to health care professionals. The purpose of this amendment is to require that funds be separately identified and protected to support that major responsibility of the National Health Service.
§ The second part of the amendment, subsection (2B), relates to the service increment for teaching or SIFT, which is made available to those health authorities which are concerned with the teaching of medical and dental students. Just as in the universities there is a dual support system whereby the universities provide the infrastructure and environment for carrying out research, so in the National Health Service hospitals it has always been the convention that the environment, infrastructure and facilities necessary to carry out that research which nourishes the health service and which is 541 responsible for increasing improvement in patient care should equally be provided.
§ Therefore, the second part of the amendment suggests that that fact should be acknowledged formally in this Bill by calling this service increment for teaching not just SIFT but the service increment for teaching and research. I beg to move.
§ 10.45 p.m.
§ Lord Rea
I should like to support this amendment. As a practising medical practitioner under the National Health Service, I take advantage of the postgraduate courses which are available. There will be a new system whereby under the new contract for general practitioners they have to pay for the courses that they attend and they will be given money if they go to a sufficient number of courses. That is an incentive under the new GP contract. That still does not mean that health authorities do not have to put in a considerable amount of funds to provide the range of courses that are necessary for all grades of medical personnel, nurses and dentists, some of whom do not have the arrangement of paying and being reimbursed.
The second part of the amendment, subsection (2B), concerns something which your Lordships' Science and Technology Committee, in its report on priorities in medical research, said should occur; namely, that SIFT should become SIFTR. I believe that it should be service increment for teaching and research and the name should have an "and" in it. If I read it correctly, there is a small mistake in the printed amendment which could be put right. This amendment is an attempt to improve and somewhat stiffen the terms which will ensure that these absolutely necessary activities take place and are properly funded by district health authorities.
§ Baroness Robson of Kiddington
I should like to support this amendment most sincerely. I think it is a tragedy that it has come up for discussion at this hour of the night because I believe that it is one of the most important amendments for the future of the health service. In the health service we depend on the quality of the teaching and the quality of the research that goes on in our hospitals, and that is particularly applicable to the future.
I pray the indulgence of the Committee, despite the very late hour, because I wish to raise a subject that is related to the amendment but is not within its wording. I gave the Minister warning that I would raise it. Because it is a subject that is very close to my heart I am even more sorry that the hour is so late.
There is an additional problem relating to teaching and research in the NHS. Apart from the money provided under SIFT and the increased support, although small, that we have been promised under SIFTR, no account has been taken of the money provided by charitable funds at present carrying out research within the NHS. The MRC is now, I believe, funded to the tune of about £170 million a year. The Association of Medical Research Charities provides at least £150 million a year towards medical research. It is probably greater now.
542 Most of these medical charities support a growing number of clinical units in the NHS. That support was intended to be used to support clinical academic staff, clinical research fellows and research techniques together with the running expenses. However—and here I must declare an interest as a member of the Council of the Imperial Cancer Research Fund—mainly through the inability of district health authorities to find adequate finance, medical charities have found themselves having to pay for clinical secretaries, nurses, porters, the upkeep and maintenance of ward blocks, and even patient hotel costs and drug bills just to ensure the continuation of their clinical research.
Increasingly, the medical charities are becoming concerned about the considerable amount of research money that is being used to pay for basic patient care which in my view should properly be the responsibility of the district health authority. The Imperial Cancer Research Fund carried out a survey which indicated that at a minimal estimate at our unit at Bart's Hospital 35 per cent. of ICRF expenditure, and at Guy's 41 per cent. of expenditure, were spent on providing patient care. It is clear therefore that large amounts of charitable moneys were being used to take care of NHS patients.
We are all aware that the cost of treating a patient in a centre of excellence such as a teaching hospital or SHA is higher than in an ordinary district hospital. There is therefore a deep concern that under the new contracting system tertiary referrals—which are essential to teaching and research—will diminish to the detriment of advances in medical science.
Under the new arrangements, the costing of treating a patient in a district general hospital should shortly be available for the purposes of contracting for services by the district health authority. As most clinical research units are sited in teaching hospitals—although by no means all—SIFTR would be expected to meet the additional costs for undergraduate teaching as well as the cost of basic minimum research which all academic staff must undertake. The additional costs arising from research funded by charities have so far not been dealt with under the Bill.
In view of the large percentage of money spent by the research authorities on clinical support it would seem necessary that a sum of money over and above SIFTR should be made available both to teaching hospitals and to non-teaching hospitals where research takes place. It could be a fixed percentage of the external funding by which clinical research would be supported from central funds. That would ensure that central money for clinical research is where it is needed. In other words, central funding will in effect follow soft money funding.
Most, if not all, grant income from the MRC and major charities is awarded in competition by a process which is peer reviewed. Thus following the direction of soft money won in competition will direct clinical supplementation to units which need it. This could overcome the problem inherent in the present SIFT increment for research which relies on medical student numbers for its direction. There is no guarantee that the mere presence of medical 543 students will engender creative clinical research or that such research is directly proportional to student numbers.
Institutions, among them district general hospitals, which cannot boast the presence of undergraduate medical students make a considerable contribution to clinical research. While the France Committee has alluded to the problem, no mechanism outside the SIFT increment for research has yet been proposed.
The above formula would readily accommodate this problem. There is no question of the extra money being an open-ended commitment. The amount of money available for clinical research from the MRC and charities is finite and major increases in the funds are certainly not envisaged. If one assumes that 30 per cent. of research funds are at present spent on clinical support, this amounts to the sum of roughly £90 million. On the assumption that the research charities and the MRC spend in the region of 50 per cent. of their money within NHS institutions, it would need central funding to the tune of about £45 million.
I have raised the subject in the hope that the Minister will be able to explain the Government's thoughts on the subject. It is not exactly part of the amendment, but I should like an answer because something must be done about the problem. If the answer is satisfactory I shall be happy; if it is not I shall reserve the right to raise the matter again on Report.
I hope that the problem broached by the noble Baroness, Lady Robson, will be resolved. In another life I acted as vice-chancellor, first, at Nottingham and then at Cambridge. There was heavy pressure on the medical side to ask for overheads from any organisation which wished to introduce its research programme into the universities or medical schools.
It amounts to a strategic decision in the department whether it says to the public, "If you want this research into your illnesses carried on in the appropriate research environment you must recognise that for every pound you put in the tin something like 30p must go towards the overheads of the research". Alternatively, will the Government come to an accommodation so that there is not that stain on their charitable impulses?
As a man who has served on various authorities, I wish to explain briefly to the Committee why there have been the dreadful problems mentioned by the noble Lord, Lord Walton, about postgraduate training. One of the problems about cash limits and uncertain settlements of wages is that during the year authorities are always looking for what I might call the soft option. Regrettably, postgraduate education is a fairly easy soft option because everyone knows the salaries of the young men and women and of the consultants. They say, "Oh, Dr. Rea, Lord Rea will be able to pay for his postgraduate education". In a way one wonders whether, in the interests of the future, we shall have to indulge in some dreadful top slicing. I should like the noble 544 Baroness to know that there is one persor in this Committee who knows how complicated it is to get postgraduate fees and payments from local authorities which face the problem of being cash limited, particularly when there is inflation.
§ 11 p.m.
§ Baroness Hooper
The Government fully accept—and my right honourable friend the Secretary of State has been at pains to underline—their duty to provide a healthy atmosphere for medical research, and the education and training of all its staff. Discussion of training tends to centre on doctors and dentists, but our commitment to high quality training for nurses and other professions should not be doubted either. For example, we are providing substantial new funding for the ambitious Project 2000 programme.
If I may turn to medical and dental education, it seems to me quite unjustifiably alarmist to suppose that the changes to the NHS proposed in this Bill pose a threat. We should not expect any sudden reluctance among hospitals to support education. As the noble Lord, Lord Walton, said, the excellent reputation of many of the larger hospitals:s based on their teaching and research. As I said at Second Reading, it will help them to win NHS contracts. They are very unlikely to wish to forfeit this when they must rely on that reputation to secure the continued referrals they need. GPs' referral preferences will play the key role in deciding the shape of districts' contracts.
Let me underline that the Government are fully committed to the provision of high quality postgraduate and continuing education as well as undergraduate teaching. The duties, responsibilities and reserve powers which bite on the latter will also apply to the former. We accept that there is a need to ensure that this important subject is properly covered in the funding systems which we envisage for the reformed NHS. This is something that the Government are actively studying at the moment, assisted by a group of interested professionals led by the Chief Medical Officer.
One conclusion we have reached already is that there should be a clearly defined budget for postgraduate and continuing education, as suggested by the amendment. Further work will be undertaken to define the constituent parts of this budget—for example, should it cover both medical and non-medical education?—and to examine haw best it should be managed. The solution proposed in the amendment is certainly one that will be considered.
No amendment to primary legislation would be needed to operate such a budget. The powers under Section 97 of the NHS Act are sufficient to allow such funds to be allocated and protected. I hope that I have indicated that, while the Government will consider seriously the points made today, it is not right to be so prescriptive in legislation at present.
Turning to the second part of the amendment, hospitals are protected from the costs of medcal and dental education through the service increment for teaching. This was increased from 1st April this year, to meet 100 per cent. instead of the previous 75 per 545 cent. of the average excess costs of teaching hospitals. That means that all excess costs, including those attributable to research, will be covered. The increase in SIFT this year of over £34 million brings the total to over £350 million.
The steering group on undergraduate medical and dental education which met under the chairmanship of the permanent secretary at the department also made some useful recommendations on the distribution of SIFT and wider funding issues, which the Government have accepted. We shall soon be considering their final report.
The amendment is also too specific to serve the real needs of research. For example, we are about to start consultation with research interests on a scheme to support research in non-teaching hospitals. The amendment would not allow a separate scheme for those hospitals.
I am grateful to the noble Baroness, Lady Robson, for raising the subject of the medical charities, because it gives me the opportunity to recognise once again the important and valuable work done by these organisations. It is true, as the noble Lord, Lord Butterfield said, that certain charities proposed that the Government should fund the providers of services in proportion to the sums that they receive from charitable organisations for research, to cover the service costs of that research.
We are considering that proposal in the context of our review of SIFT, a scheme to support research in the non-teaching hospitals to which I have just referred. The proposal is attractive, but problems could arise because National Health Service costs vary so greatly. Providing fixed sums based on the amount of research funding received might unfairly penalise some providers. I should also point out that if a medical research charity considers that it will further its own objectives by contributing to or paying for National Health Service costs, that is clearly a matter for its own decision.
To answer a specific query raised by the noble Baroness about tertiary referrals, guidance has made clear that the decision to make a tertiary referral will remain that of the clinician responsible for the patient's care. It will be made solely on clinical grounds and not on grounds of cost. I hope that the noble Baroness finds that reassuring.
I believe that the noble Lord, Lord Walton, in moving the amendment said that it was a probing amendment. I hope I made clear that we agree with much of what was said regarding the objectives of the amendment and that we are actively addressing the concerns raised in those two areas.
§ Lord Walton of Detchant
In the light of the clear and unequivocal reassurances given by the noble Baroness, perhaps I may make two points. We accept the Government's commitment to the funding of postgraduate teaching, continuing education and research for all professional staff in the health service. However, I was concerned, as was my noble friend Lord Butterfield, that health authorities have tended to reduce the funds available for that purpose quite disproportionately in many circumstances. I was very pleased, therefore, to hear the noble 546 Baroness say that serious consideration is being given to a proposal whereby funds will be allocated specifically for that purpose.
With regard to SIFT and research, most hospitals throughout this country are in some respects teaching hospitals. Many of them, other than the old traditional teaching hospitals, now share in SIFT because they take medical students for training. It therefore follows that it would be reasonable to consider this increment—the increment for teaching and research—not only in teaching but also in many non-teaching hospitals.
Nevertheless, in the light of the assurances that we heard, which I found very reassuring, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 74 to 76 not moved.]
Baroness Masham of Ilton moved Amendment No. 77:
Page 3, line 24, at end insert—
("(2A) In carrying out its primary functions a District Health Authority shall provide a district wide incontinence service and shall identify a continence advisor and a consultant to take a special interest in incontinence.")
§ The noble Baroness said: Before I explain this amendment I should like to thank the Members of the Committee who put their names to it; the noble Baroness, Lady Cox, who is a nurse and who knows from a nursing point of view how important correct advice and equipment such as pads and inco-pads and various devices are to people suffering the immense problems of incontinence; the noble Lord, Lord Rea, who is a general practitioner and who knows from a doctor's experience how dangerous wrong treatment or neglect of the problem of incontinence can be to patients; also the noble Earl, Lord Swinton, who as my kinsman knows only too well what it is like when a severely disabled person suffers from Montezuma's revenge in Mexico, dysentery in Mauritius and salmonella poisoning caught in your Lordships' House.
§ To deal with these problems of extreme diarrhoea is not easy. Without the proper aids it would be even worse. Fifteen years ago I founded, with some colleagues, the Spinal Injuries Association. We have thousands of members in this country and abroad. All our members are paraplegics or tetraplegics—people with paralysis due to damage of the spinal cord. All suffer from the problems of incontinence which they manage to control in various ways. They will die an early death if their urinary problems are not looked after. They sustain pressure sores if they do not look after themselves in the correct way. They need help to do this by having the correct aids for their individual needs.
The wording of the amendment on incontinence is taken from the Department of Health notice of November 1988 on the development of services for people with physical and sensory disabilities which was sent to all health authorities. It states:
Provision of a district-wide incontinence service. Good practice would include a continence adviser acting as a focal point, provision for regular and adequate supply of incontinence
aids and reasonable access to a urodynamic clinic. Authorities should identify a consultant and physiotherapist to take a special interest in incontinence".
§ It is becoming increasingly evident that, far from improving the service, cut-backs are beoming increasingly the norm in many districts. This amendment would put into legislation what is already in a directive and we see this as necessary to prevent a continuous decline in the provision of incontinence services.
§ Cut-backs in the incontinence service are detrimental to good community care provision. For many people access to good advice and the provision of appropriate pads is central to their ability to retain their confidence and remain in their own homes in the community.
§ In some parts of the country problems have arisen where people are being restricted to one type of pad which is often not appropriate for a person's needs. There are examples of people trying to wash and re-use pads. People in nursing homes are increasingly being asked to pay for incontinence pads, despite the fact that circular HRC(74)16 clearly states that such aids should be included in the fees. There is also increasing evidence that people in residential homes are being rationed or offered inappropriate pads.
§ The cause of pressure sores, which can come from lack of care in this matter, costs the country millions of pounds a year in hospital treatment. That is obvious to the people who understand the problem. A little investment in the correct methods of care for the individual saves a great deal of hardship and expense which can arise if the subject is neglected. In this difficult subject of incontinence there is a great need to improve the service for patients, giving individual choice. There is a real risk that the matter might be shoved from health to social services, fall through the middle and be lost altogether.
§ This amendment has the support of Age Concern England, the Association for Spina Bifida and Hydrocephalus, the Association of Continence Advisers, the Multiple Sclerosis Society, the Spastics Society and the Spinal Injuries Association. I hope that the Committee will also support it. I beg to move.
§ 11.15 p.m.
§ Baroness Cox
I briefly but equally strongly support this amendment for three main reasons. First, incontinence is a serious social problem requiring skilled assistance if physical problems such as pressure sores and infection are to be avoided and if psycho-social problems such as loss of self-esteem, embarrassment, withdrawal and isolation are to be averted. Many people who suffer the affliction of incontinence are, however, enabled to lead lives where the physical and social complications are avoided. They will testify to the importance of necessary professional support and also appropriate resources.
The second reason for supporting this amendment wholeheartedly is the likelihood that the numbers of people with incontinence problems are going to 548 increase significantly in the years ahead, especially, for example, among growing numbers of elderly people more prone to illnesses such as strokes and among younger people with chronic illnesses such as multiple sclerosis or who now survive serious accidents which may well have proved fatal in earlier years.
My third reason for my belief that there is a need to ensure an incontinence service with specially trained and identifiable staff is the change in arrangements for community care. Many people with incontinence will be living in the community. The primary responsibility for their care will now reside with local authorities and social service departments. Their staff are not clinically trained to help people with such problems. It would be much easier for them to make satisfactory arrangements if there is a clearly identifiable service with trained staff whom they can contact direct.
I cannot emphasise too strongly the need 'or this specialist service to be available in every district. As the noble Baroness, Lady Masham, has said, the situation at present is far from adequate. For example, the system for the provision of incontinence aids is unequal and haphazard. In many places it is downright unsatisfactory. As the noble Baroness also said, many organisations have expressed concern over these matters. She has named many of them. Perhaps I may quote the way they have expressed their concern collectively. They say:We support initiatives encouraging people to stay in their own homes but fear that without adequate continence advice and provision, the policy of community care which enables them to stay in their homes may fail".This amendment will help to avoid such a tragic outcome to a well-intentioned policy. I beg to support the amendment.
§ Lord Rea
I support this amendment. I work in a district which a few years ago did not have a consultant in urodynamics and did not have a continence adviser who is a specially trained nurse. When a clinic began to operate it was very much appreciated by many of my patients. It is not the people with spinal injuries who make up the greatest number; it is very often older people or those who have suffered strokes. The clinic has made a tremendous difference to the lives and the dignity of the lives of a number of people in my practice.
It is quite difficult for a GP to deal with the problem of an incontinent person and it needs a specially trained nurse to do so. There is great benefit in having a specialist with the correct equipment and training to investigate the multiplicity of the causes of incontinence and to take appropriate action. The supply of incontinence pads is variable. There are embarrassing failures of supply. That is very sad in central London. Mostly, we do not have that problem, but when it happens it is very noticeable, embarrassing and undignified for many people.
§ The Earl of Swinton
Once in a blue noon I actually support something that my noble kinswoman moves. In even more of a blue moon I actually go through the same voting Lobby as she 549 does. I have had my leg pulled mercilessly today when some of my noble friends saw that I had my name to this amendment. I believe that it is a most important matter. I hope that my noble friend on the Front Bench will be very sympathetic towards it.
I can add little to what my noble friend Lady Cox, the noble Lord, Lord Rea, or my noble kinsperson have said. She mentioned a slightly embarrassing experience which we had many years ago when we went on holiday to Mauritius. We were staying at an hotel which was really a group of rondevels, and very little else. She picked up some terrible tummy bug. All I can say is, thank God, I had hired a car. I had to sleep for four nights in that car. The smell and everything else was so awful. She did not have the right aids because she had not taken them out there.
This is a purely practical matter and I am not ashamed of getting up and saying it. I am sure that I am not embarrassing my noble kinswoman by saying it. This is important. It is not a laughing matter. If I have been in the least flippant I apologise. I hope that my noble friend will have listened to the views expressed from all sides of the Committee and will not, because it is late at night, sweep the matter under the table. I thank God, am continent—at least I think I am. I think that I can stick the rest of the debate. But for those who are not, I hope that the Committee will support the amendment.
§ Lord Ennals
It is certainly not a laughing matter. For 13 years my quadriplegic incontinent mother-in-law stayed in our household. I shall say no more.
Baroness Darcy (de Knayth)
I strongly support the amendment and certainly declare an interest as a paraplegic. I know how essential it is to have good continence advice and no cut-backs in the supplies of, for example, pads, whether in the form of rationing or restriction to one type which may not be the most suitable.
My noble friend has already mentioned some of the problems identified by the voluntary organisations and the Association of Continence Advisers. I should like to mention two more. In some circumstances people are being told that their attendance allowance should be used to pay for incontinence pads. That is totally unacceptable. The Government should make it clear that that is not the purpose of the attendance allowance.
Furthermore, continence advisers do not at present undergo any specialist training. There is a two-week training course for nurses once they become advisers but the organisations think that this is far from sufficient and they would like to see their role upgraded. It may be a little difficult for the continent fully to appreciate the enormity of the problem. A hiccup in the incontinence supplies makes one almost as twitchy as if the ravens were seen to be preparing to leave the Tower.
I had a taste of the experience a couple of years ago. I stress that it was not a wilful reduction by the authority. As it was changing premises it ran down 550 the supply prior to the move. This resulted in a great many of us queueing up for a very few incontinence pads for the Christmas to New Year fortnight. It was not a pleasant experience. I was lucky enough to be able to track down some extra pads and afford to buy them from the chemist. Otherwise I would have been faced, like the others, with the choice either of drinking less—in the Christmas to New Year period, the Committee will appreciate—and running the risk of the possibility of a urinary tract infection, or changing less often, which is not good for the skin or for any potential pressure sores, or drying them off on the radiator and re-using them.
Much of disabled life takes place at a fairly basic level. It is something that one has to get on with because it is inevitable. But it is the situation that is not only detrimental but degrading, and avoidably degrading, which is unacceptable. That is why I hope the Minister will be able to say something very positive to this amendment. I support it wholeheartedly.
§ Baroness Blatch
If we have smiled a little during the course of this debate I hope that I can assure the noble Baroness, her noble kinsman and all Members of the Committee that it does not detract in the slightest from the seriousness of this issue. I thank the noble Baroness for raising this important issue which gives me the opportunity to offer reassurance and to emphasise that the Government recognise the importance of the issues she has raised.
The Department of Health has already provided guidance to health authorities along the lines of the amendment. Health notice (88)26, which is available in the Library, states that in planning services authorities should consider the provision of a district-wide incontinence service and gives advice on good practice. But the Government believe that in this as in other areas of health care provision district health authorities should be left free to determine the pattern and level of service in their districts in the light of local needs and circumstances.
The position will not change as a result of this Bill except that in future district health authorities will have a much clearer responsibility for their resident populations and resources will be allocated to them in line with this.
It is important to point out that one of the advantages of the new system over the old system is that inadequacies in the service, given that authorities have to publish plans to meet the needs of the community, will be much more exposed. That is an important aspect of the new reforms. I am sure that all health authorities will ensure that adequate resources are made available for incontinence services within their different priorities and budgets.
There is no disagreement between us about the importance of incontinence, but it would be wrong to pre-empt local decision-making in the manner of this amendment. I hope that I have given adequate assurances to the noble Baroness on the issue and that she will feel able to withdraw her amendment.
§ Baroness Masham of Ilton
I thank all noble Lords who have spoken in support of the amendment. I 551 should like to tell the Committee that tomorrow morning—that is, in a few hours' time—a meeting on this subject will be held in this place for the various organisations I mentioned. We feel that it is important to have such a provision written into the Bill. I say that because when a Bill becomes an Act of Parliament people look upon it as legislation and they forget everything else. They forget about White Papers and Green Papers and also, with the hurly-burly and the rush which ensue, they forget about the circulars issued by the department.
With the cutting down of the number of members of the authority, I am absolutely certain that the percentage of men will be increased and that of women will be decreased. This will happen because of the business emphasis on the whole matter. We may feel it necessary to bring the issue back at a later stage, but in the meantime I beg leave to withdraw the amendment.
§ Amendment, by leave withdrawn.
§ [Amendments Nos. 77A to 78 not moved.]
§ Lord Ennals moved Amendment No. 79:
Page 3, line 38, at end insert—
("(4A) It shall be the duty of the Secretary of State to give to each health authority and each Family Health Services Authority such directions under section 17 of the principal Act as it appears to him necessary for the purpose of securing that:—
(4B) Nothing in subsection (4A) above shall preclude an investigation under Part V of the principal Act in respect of any matter.
(4C) Nothing in subsection (4A) above shall preclude any award of compensation made to a patient under law or by any other procedure.
(4D) Nothing in subsection (4A) above shall preclude any disciplinary action being taken against an employee of a health services body as defined in section 4(2) of this Act or against any medical practitioner who is providing general medical services in accordance with arrangements under section 29 of the principal Act").
§ The noble Lord said: In moving this amendment I shall speak also to Amendment No. 94C, which is the Scottish equivalent. This is a probing amendment and at this time of night I shall seek to be brief It is a matter to which we may wish to return on Report. It deals with what I believe to be a very unsatisfactory system whereby patients' complaints are investigated.552
§ The system is at present very bureaucratic, cumbersome and long-winded. The patients often do not know how to complain. Moreover, rather naturally, the NHS does not encourage people to do so. There are currently at least seven possible channels for complaints and it is often unclear which route is appropriate.
§ The procedure is also very slow and it is usual for complaints to drag on for months or even years. It is most ineffective. The outcome of the different procedures are unclear and often very unsatisfactory. Complainants are usually seeking an explanation, an apology and an assurance that the incident will not be repeated. The existing procedure has clearly failed to meet these requirements.
§ The amendment seeks to ask the department to put in place a procedure which would require that patients have access to independent advice and support while processing their complaint; that complaints would be investigated by an independent complaints investigation service; that NHS employees and contractors would co-operate with investigations; that patients would receive a full explanation of the outcome of an investigation; that complaints would be investigated within a reasonable time; and that the system should be publicised so that patients know what are their rights, rather than simply suffering without knowing what they can do about the problem.
§ As I said, this is a probing amendment and I hope to hear something from the Minister because I believe that this is an issue which ought to be covered by legislation. Unless we do so now, it may be many years before another opportunity arises. I beg to move.
§ 11.30 p.m.
§ Baroness Blatch
This amendment calls for a unified complaints system for health service users. The National Health Service is not, however, a homogeneous body. It has two separate wings in the hospital and family practitioner services, each with its own structure and employment conditions, making the imposition of a single complaints procedure impracticable.
We are, though, fully aware of the importance of good complaints procedures, both from the point of view of the users of the service and as a means of monitoring the effectiveness of the services provided. In the past two years both the hospital and the family practitioner complaints procedures have been revised with these ends in mind. Or both occasions there was widespread consultation with interested bodies, including consumer organisations. We are satisfied therefore that our current procedures reflect a broad consensus of the views that have been received and considered by the department.
There are approximately 30,000 written complaints made each year about the hospital service alone. That figure is gratifyingly low when set against the huge number of patients who use the service. Nevertheless, to establish an independent body with the resources to investigate that number of complaints, plus those made in the family 553 practitioner services, would be a large task indeed. It would also remove from the local management of the service an element of their responsibilities which it is important for them to retain. Local accountability for the services provided, together with a quick and sympathetic investigation of any complaints made, must be better for both user and provider than the creation of a remote, and of necessity large, organisation such as is suggested here. I urge the Committee to reject Amendment No. 79.
I understand the noble Lord to have included Amendment No. 94C in his remarks. On that amendment, I absolutely agree with him that quality and patient satisfaction are very important aspects of the National Health Service contract system. We expect the contract system to play a part in the improvement in the quality of NHS services which is one of the key aims of the White Paper Working for Patients.
However, I have two difficulties with the amendment. First, the monitoring of patient satisfaction might not be meaningful for all NHS contracts. For example, if one health board contracted with another health board to carry out a series of laboratory tests, the patient might be completely unaware of the process and be in no position to comment on whether or not it was satisfactory. I fear that the amendment raises for me the spectre of bureaucracy: an infinity of surveys of patient satisfaction under every NHS contract which would deluge with information the people involved in making the contracts and the GPs who had referred the patients for treatment.
I would expect health boards and other purchasers to take steps to find out what patients and their GPs think about treatment which is given under contracts which involve direct patient care. The Government are very keen on monitoring patient satisfaction and they commissioned the first all-Scotland survey of patient satisfaction which reported a year or so ago. But these surveys need to be done selectively if they are to provide information of a kind which can be acted on. I do not think that this is best achieved by a requirement in the Bill for monitoring to be carried out for each NHS contract.
Secondly, perhaps I may turn to complaints on contracts. While we see NHS contracts as a way of positively improving services and therefore removing the motivation behind many complaints, I do not think that the NHS contract system should be used as an additional complaints vehicle. There are well-established arrangements for complaints by patients. Complaints procedures are already established by statute under the Hospital Complaints Procedure Act 1985 and Schedule 9 to this Bill applies that Act to NHS trusts. The Government are taking steps to strengthen the system of local health councils and again Schedule 9 to the Bill allows local health councils to visit and inspect NHS trust hospitals. there is, moreover, the health service commissioner, or ombudsman, who has been shown to furnish a very effective way of pursuing patients' complaints where clinical judgment is not involved. In short, I do not think that the complaints procedures need to be improved and it would in any 554 case divert NHS contracts from their main purpose if they were to serve also as a channel for complaint.
So, important though I agree patient satisfaction and complaints to be, I hope that the noble Lord will agree, on reflection, that it is not necessary to press for this amendment to be included in the Bill.
§ Lord Ennals
I do not agree with the noble Baroness's conclusion. I shall read her speech carefully but she must know that there is a great deal still to do. The problem has affected successive administrations. It was a problem when I was Secretary of State and is still a problem. The noble Baroness referred to local health councils: presumably she meant community health councils.
§ Lord Ennals
Certainly in England the community health councils are very dissatisfied with the present situation, and they are the best people, as we shall discuss on the later amendment, to represent the interests of the community.
I have had discussions with them concerning this amendment and in the light of what the noble Baroness has said I shall have further discussions with the community health councils. But I believe that this should be written into the Bill, and I include complaints about contracts. So, although I beg leave to withdraw the amendment now, I intend to pursue the matter at a later stage.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 79 and 80 not moved.]
§ Clause 3 agreed to.
§ Lord Ennals moved Amendment No. 81:
§ After Clause 3, insert the following new clause—
§ ("Community Health Councils Authority
.—(1) The Secretary of State shall by regulation set up an independent establishing authority for Community Health Councils in England and Wales, whose duty will be to represent the public's interests in the health service, and to provide resources to manage, monitor and assist Community Health Councils in the performance of their functions. The Secretary of State shall by regulation transfer the existing responsibilities of Regional Health Authorities with respect to Community Health Councils to the new independent establishing authority, and provide for the expenses of that body.
(2) The Secretary of State shall by regulation provide Community Health Councils with the power to:
- (a) Nominate one representative in each district to attend meetings of the relevant District Health Authority as an observer;
- (b) Nominate one representative to attend meetings of each NHS Trust Board within the relevant district as an observer, if such Trusts exist; and
- (c) Nominate one representative between them in each region to attend meetings of the relevant Regional Health Authority as an observer.
(3) The Secretary of State shall by regulation extend the existing rights of Community Health Councils with regard to entering and inspecting premises controlled by a relevant district health authority, to include all private hospitals and nursing homes within the relevant district with which any health authority has entered into a contract to treat patients.").
§ The noble Lord said: At this time there is not the opportunity for as long a debate as I believe the future of community health councils deserves. Both 555 in and out of office, I have always held the view that CHCs had a very important role to play. I greatly valued the degree of commitment of their members, including the voluntary organisations which they seek to represent in part. I think they have been very sensitive to the needs of patients and the communities they represent. Their role in the new-style NHS is going to be far more important than it has been up to now.
§ In our debates last Thursday we were repeatedly reminded that those slimmed down authorities would not necessarily include representatives of any particular group which we cared to propose. Thus the role of community health councils as the eyes and ears of the community who rely on the NHS is crucially important. I hope that the Government will recognise that. Yet the Bill makes no provision at all for CHCs. It was the Labour Government which in 1974 took action to create community health councils and provide funding, and which later extended their powers.
§ I know that there were assurances by the noble Lord during the course of our debates earlier today, and I am hopeful that the Government will feel that this amendment is one that should be supported. It seeks to improve the involvement of user representatives in the health service by setting up an independent establishing body for CHCs, by allowing CHCs to take part in RHA and NHS trust meetings as well as district health authority meetings, and by allowing CHCs to inspect private hospitals where NHS patients are treated.
§ This somewhat extends the role of the CHCs, but I believe that, for the reasons that I have given and because of the much less representative nature of the new health authorities, we need to see much more powerful community health councils as the eyes and ears of the consumers. I believe that the creation of a market system will lead to more complex, shorter term and more unstable relationships between hospitals and health authorities, which may require closer monitoring. NHS trusts need hold only one public meeting a year, and CHCs are effectively excluded from their decision-making process.
§ There was a Department of Health document reported in the Guardian on 17th April which clearly stated that trusts would not need to consult CHCs about service changes in the same way that district health authorities currently do. I hope that that is not the department's view, and I hope that in response the Minister will give some indication of the role that the Government see for CHCs so that, in the light of that reply, I can determine how best to proceed at a later stage of the Bill. I beg to move.
§ Baroness Blatch
The first subsection of the amendment is unnecessary because regional health authorities already perform the functions which the amendment seeks to transfer to the new body. The effect of the amendment would be to establish another national quango whose purpose would apparently be to separate regional health authorities from their responsibilities for funding and overseeing the work of community health councils.
556 Section 20 of the National Health Service Act 1977 charges the Secretary of State with setting up CHCs, and by Regulation 2 of the Community Health Councils Regulations 1985 the Secretary of State puts on regional health authorities the duty to exercise their functions under that section. The amendment would leave the Secretary of State as prime mover under the 1977 Act and the body it proposes would be only as independent as regional health authorities are now.
The remaining two subsections of the amendment extend the statutory powers of community health councils. The Government have already stated to the Select Committee on Social Services that they see no need for change in the role of CHCs. These subsections would change that role by giving them a locus in the affairs of National Health Service trusts and regional health authorities which they do not now have and which the Government do not agree they should have.
With only three exceptions, there is in England one community health council for each district health authority district. There are three districts which have two CHCs. Under CHC regulations the relationship of a community health council is with its district health authority. That is an arrangement which has worked well since CHCs began in 1974 and the Government intend that it should continue when district health authorities become purchasers of health services rather than providers. Community health councils will, as now, relay their concerns to their district health authorities. It will then be for the district health authority to alert regional health authorities and NHS trusts as necessary to the concerns of community health councils along with those of other consumer groups which it has consulted.
Meetings of district health authorities and regional health authorities are open to the public under the Public Bodies (Admission to Meetings) Act 1960. In view of the access community health councils have to regional health authorities via their district health authorities there is no need for admission to regional health authority meetings to be extended beyond that allowed by the Public Bodies (Admission to Meetings) Act as the amendment intends. CHCs already have the right, by arrangement, to send observers to district health authority meetings in addition to the rights allowed by the 1960 Act. I do not see the need to capture in statute an arrangement that is working perfectly well on a non-statutory basis.
CHC regulations give a community health council the right to enter and inspect premises controlled by its district health authority. This has proved to be a valued and important part of CHC work. Many community health councils have, in addition, come to amicable arrangements with owners or managers which allow them to inspect private hospitals or nursing homes which treat NHS patients. Again, I do not see the need for a law to intervene in an arrangement that is working well.
The amendment has parts that are unnecessary and parts which extend the law into areas in which it is demonstrably not necessary. I urge the noble Lord to withdraw his amendment.
§ Lord Ennals
I am grateful to the noble Baroness for her reply. I find it totally unsatisfactory. She does not seem to realise—or indeed she realises—that the Government are taking us into a new type of health service with new types of authorities. We debated that on the last day of the Committee stage. In those circumstances it is clear that community health councils must have a stronger role than they have at present. If that is to be done I believe that it must be on the face of the Bill.
Regarding the first subsection, the noble Baroness said that the regional health authority has that responsibility—but what is that new regional health authority like? It in no way resembles a community health council. It is a management body and the community health care councils are set up to be sensitive to the needs of the community, as they have effectively been.
I am grateful to the Minister for her reply, but I shall return with another amendment on Report. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Clause 4 [NHS contracts]:
§ 11.45 p.m.
Lord Carter moved Amendment No. 82:
Page 4, line 29, at end insert ("No contract shall be let for hospital care for children unless it provides for accommodation for a parent to stay in the hospital with the child.").
§ The noble Lord said: In moving this amendment, I shall speak also to Amendments Nos. 82A and 88B. This group of amendments deals with the importance of parents being able to visit their children in hospital and to stay there with them when they visit. I am sure that every noble Lord will agree with the importance of that. There has been a welcome change in recent years in hospital policy in that regard, but, for those parents with children in hospital, we know that it often means having to go backwards and forwards, sometimes several times a day.
§ Before the Social Security Act which was introduced in 1988, parents on supplementary benefit received a grant for their travel costs. Parents who are now on income support may apply for a community care grant from the Social Fund. This is certainly not the time of night to discuss the problems of the Social Fund. Parents on family credit cannot apply for a grant from the Social Fund. With the advent of the internal market, there is now the near certainty of longer journeys to hospitals outside the district.
§ The National Association for the Welfare of Children in Hospital has sent us a brief, attached to which is a long list of examples of harrowing cases of parents who have been refused help with the cost of visiting children in hospital. We should remember that every one of those cases is a family under intense pressure.
§ Perhaps I may give one example from my own experience when one of our children had to spend a long time in hospital. One gets to know the other parents very well. I clearly remember one mother 558 whose child was dying of cancer. In order to be able to visit the child each day, she took a job as a village postwoman on a bicycle. She had no car. She used to start work at 4 a.m. every day so that she could finish by early afternoon. There was then a two-hour journey from a rural area by inadequate public transport. However, she was there with her child every day from tea-time until 8 or 9 o'clock in the evening. She then had to make the long journey home and be up again at 4 a.m. to start work. Her husband was a farm worker, a stockman, and was able to visit only on alternate weekends.
§ Amendment No. 82A is designed to help parents in that situation who have difficulty in finding the cost of travelling to hospital. Amendments Nos. 82 and 88B, which deals with Scotland, are concerned with the important question of providing accommodation for parents to enable them to stay with a sick child in hospital. More and more hospitals are providing that kind of accommodation, often as a result of the work of the leagues of hospital friends. We believe that the requirement to provide such accommodation should be clearly stated in the Bill. I beg to move.
§ Baroness Blatch
I shall begin by speaking to Amendments Nos. 82 and 88B on accommodation. It has long been Government policy that hospitals should have facilities to enable parents to stay with children. Nothing in Working for Patients or this Bill changes that policy. However, the purpose of the Bill is to create the framework for contracting for health services, not to lay down the detail of achieving it. District health authorities and hospital boards in Scotland need to be able to respond flexibly to local circumstances and needs.
Guidance has made clear that all contracts should contain quality specifications and monitoring arrangements. District health authorities should bear in mind national policy on issues such as this when negotiating contracts, which can provide a benchmark against which to compare local practice.
One of the specimen contracts in the guidance document Operation Contracts refers to the guidelines drawn up by the National Association for the Welfare of Children in Hospital. No doubt other authorities will consider doing likewise. Whether they do so or not, however, all hospitals will have strong incentives to ensure that they have adequate facilities in order to win and keep contracts with DHAs and hospital boards. The amendment is therefore unnecessary and unduly restrictive and I ask the noble Lord to consider withdrawing it.
On the matter of visiting costs (Amendment No. 82A), which is again another very important issue in this debate, the hospital travelling expense scheme will continue in operation. It provides for the travelling expenses of children under 16 to be refunded by the hospital regardless of means. In addition, where an escort is medically necessary, his or her expenses can be repaid on production of evidence of low income. Help with hospital visiting expenses may be available from the Social Fund to families in receipt of income support. In addition, some hospitals give discretionary help with visiting expenses from trust funds.
559 Acceptance of this amendment would involve the extension of the patients' travelling expense scheme to cover parents visiting their children in hospital. This could only be achieved by the diversion of funds at present used for the care and treatment of patients. It would impose an additional burden on administrative staff whose role in deciding which parents could afford their travelling expenses would duplicate that of the social security office staff engaged in administering the Social Fund.
We recognise and encourage the contribution that parents can make to the care and recovery of children in hospital. We provide financial support to the National Association for the Welfare of Children in Hospital, which must take much of the credit for the major increase in facilities for parents to remain overnight with their children in hospital. But we do not consider that further statutory provision for assisting with the travelling expenses of hospital visitors can be justified in the light of the demands upon the resources available for development in the NHS.
The noble Lord referred to more travelling. I think that he suggested that new arrangements could result in more travelling.
§ Baroness Blatch
In the future, as now, the majority of patients will receive treatment locally. Under the new arrangements, when there is the opportunity to obtain a better quality of treatment, for example because it can be provided more quickly, a patient will be given the choice by his or her doctor of going to a hospital some distance away. A district health authority's objective will be to place contracts in line with GPs' preferences. That will ensure that patients do not travel for treatment unless it means better treatment.
I hope that I have given some assurance to the noble Lord and that he feels able to withdraw his amendment.
§ Lord Carter
I shall withdraw the amendment but I found the answer rather disappointing. It seems that the accommodation is to be left to the workings of the internal market. Visiting costs, it seems, are to be left to a combination of the Social Fund and charity. It is a little disappointing. We all agree on the importance of this matter. We are not very happy with the way in which the Government propose to deal with it. However, at this stage I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 82A and 83 not moved.]
Lord Morris moved Amendment No. 83A:
Page 4, line 29, at end insert—
("Notwithstanding this section, any person may, on referral from a doctor, or, in accordance with the normal referral pattern of the service or goods required, on referral from any other source such as consultant, clinical medical officer or health visitor, or by a representative of the educational services, social services or community nursing, or by specialists in other
districts, or through self referral, obtain goods or services at any National Health Service hospital, or other establishment or facility, or any National Health Service Trust, whether or not there is any National Health Service contract in existence which would cover the provision of such goods or services.").
§ The noble Lord said: This simple little amendment is a probing amendment.
§ The Deputy Chairman of Committees (Lord Cocks of Hartcliffe)
I appreciate that the noble Lord wishes to probe, but this amendment has already been debated. In the light of that, does he wish to pursue the matter?
The noble Lord will realise that the arrangement of the groupings, as the note quite clearly states, in only informal and not binding. In so far as Amendment No. 78 was not moved, I am by no means constrained by these groupings.
This amendment is a modest little probing amendment designed to do one simple thing; namely, to seek from my noble friend an affirmation of the undertakings given in another place by her, and my right honourable friend the Parliamentary Under-Secretary of State for Health in response to an adjournment debate in which his extremely concerned and, if I may say so, eloquent response gave great comfort to those anxious about the provision of health services in the area of speech therapy.
I shall give the reason why I believe that this amendment is necessary, although I am somewhat concerned by the drafting and the extremely broad-brush approach. It may come as a surprise to my noble friend Lady Hooper but administrations change. They may change in the future. I wish to make absolutely sure that I have not lost an opportunity either to establish within the statute, or indeed by regulation, some means whereby the provision of these services is entrenched in law. I refer in particular to the current system of open referral. In this field, it is of the utmost importance that referrals are made at the earliest possible stage with regard to children and not least to stroke patients.
I do not wish to delay the Committee any longer. However, I should like to quote the very moving words of the Member for Argyll & Bute in another place in the course of an adjournment debate. She said, in my view meaningfully:A speech and language problem is not visible to the world outside. Dysphasia is not supported by a zimmer; a stammer is not held in a sling; a laryngectomy is not in a plaster cast". [Official Report, Commons, 12/3/90; col. 133.]I would add that when a child is at a critical stage, achieving the greatest intellectual development in the whole of his life—namely, the acquisition of language skills—if a problem with regard to speech is not identified early on he will suffer very considerably throughout the whole of the learning process.
I know that my noble friend is very sensitive to the subject. I seek only an affirmation of the undertaking given by her honourable friend and indeed any assistance to provide such services to the nation as a whole.
§ Baroness Masham of Ilton
Before the Minister rises, perhaps I may ask this question. Who will be the provider of speech therapy? For instance, with children it could well happen at school. But with a person who has had a stroke who neeeds speech therapy after he leaves hospital, will it be the health department or the social services? There is so much confusion about this issue. It is a matter about which I wish to know because we are confused on so many issues.
§ Baroness Hooper
The Bill's proposals are designed to assist GPs and other health care professionals to obtain the best available services for their patients. We believe that contracts will be particularly helpful in this respect because they will allow resources to move more freely to the hospitals that are most popular with GPs and their patients and will give all providers an incentive to improve. They specify the standards of care that can be expected.
My noble friend Lord Morris has expressed concern about speech therapists in particular. I can assure him that the same principle applies here as applies to GPs. We have no plans to change such professionals' right to refer. Districts will so far as possible place contracts which secure the patterns of referral preferred by the referrers—speech therapists and other professional groups—themselves. All referrers should be made aware of the contracts that have been placed and of the arrangements for referring outside contracts.
I beleve that the system, with the improved arrangements for planning and arranging services that it brings, provides the basis for more effective and better integrated work by all health care professionals. I trust that this reaffirms adequately the assurance given by my honourable friend in another place to which my noble friend referred.
In answer to my noble friend Lady Masham, health authorities will continue to be responsible for speech therapy, I hope that my reply has helped my noble friend Lord Morris.
I am grateful to my noble friend for that response. I admire her stamina and the hard work that she has put into the Bill. However, the hour is late and I must consider carefully what she saic. This is not the right time to develop the argument and therefore I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 84 to 85 not moved.]
§ 12 midnight
§ Baroness Cox moved Amendment No. 85A:
Page 4, line 40, at end insert—
("2A) No health service body shall enter into an NHS contract without first consulting any relevant local advisory committees recognised under section 19 of the principal Act.").
§ The noble Baroness said: I am sorry to break the chain of amendments which are not moved. The amendment was grouped with Amendment No. 74, which was not moved, but I wish to move it as a 562 probing amendment in order that the reply will appear on the record.
§ Its aim is to require health care purchasers and providers to consult local district advisory committees during the process of drawing up contracts. It follows assurances given in another place that such consultation would occur and it probes to discover how the Government intend to ensure that this commitment will be honoured.
It may be helpful to the Committee if I quickly outline the background to the amendment. The purpose of local advisory committees was defined when they were originally set up in 1974 as follows:
to help authorities and officers to reach decisions on the provision of health services in the full knowledge of expert opinion and advice".
§ Under the new dispensation, the role of the advisory committees should be seen as vital in providing a professional input into the contracting system. The provisions of this amendment represent the only statutory safeguard which professional carers would have to express their professional views about proposed contracts.
§ I appreciate that the Government have, understandably perhaps, been wary of proposals prescribing too specifically the nature of contracts, seeing these as too restrictive. This amendment respects that concern, providing for a general duty to consult rather than a prescriptive requirement. It also has the advantage of using existing mechanisms and does not involve establishing new bureaucracies.
§ In short, the amendment is very simple but its implications are profoundly important, remedying problems stemming from the "missing link" in the Bill's provisions; that is, the link between the contract system and professional advice.
§ My right honourable friend the Secretary of State said in another place that he believes that the existing procedures of consultation will continue under the new dispensation. This amendment would provide that assurance. I hope, therefore, that my noble friend will welcome it. I beg to move.
§ Lord Henley
I have a good deal of sympathy with the point underlying the amendment. It is that the planning and provision of patient services need to be informed by the judgment and expertise of health care professionals. It cannot too often be emphasised that the principal object of the Government's reforms is to help doctors, nurses and other professionals to provide higher standards of service to patients.
However, I am not convinced that the formal consultation arrangements proposed in the amendment are the best way forward. They could prove to be most cumbersome and actually hinder the provision of improved services for patients. For example, on occasions a DHA may need to place contracts quickly in order to take advantage of an unexpected opportunity to reduce waiting times in a particular speciality. While the DHA is consulting all the different advisory committees the opportunity may well be lost.
Then again, DHAs will at times need to negotiate one-off contracts to suit the needs of an individual 563 patient who, for particular medical or social reasons, must go to a different hospital from those normally used by the district's residents. I am sure that the Committee will not wish to require the DHA to consult the various advisory committees before a contract is arranged in such a case. Health authorities certainly require professional advice in order to ensure that they obtain the right services and quality of care for their residents. Hospitals too must involve professionals in deciding what services to offer. However, professional advice needs to be available in a way which is flexible and does not create barriers.
There is a further point on the advisory committees. Their statutory right to be recognised is not changed by the Bill. However, their future role needs to be considered carefully in the light of the new purchaser/provider relationships. Advisory committees tend to be composed of professionals working in provider organisations. Care needs to be taken to avoid any conflicts of interest arising from the provision of advice to the DHAs either as purchasers or in relation to services provided by their directly managed units.
This is an important issue which we have already begun to discuss with professional bodies at a national level. I hope that, considering the role of advisory committees, the Committee will agree that the right approach is through discussion with the professionals themselves and not through statutory provisions. Having said that, I hope that my noble friend will feel able to withdraw her amendment.
§ Baroness Cox
I thank my noble friend for that reply. This is a probing amendment. We are all speaking extremely rapidly and it is difficult for me to take in all the implications of my noble friend's helpful reply. I shall read it with great care. In the meantime, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendments Nos. 85B to 86B not moved]
§ Clause 4 agreed to.
§ [Amendment No. 87 not moved.]
§ Lord Coleraine moved Amendment No. 88:
After Clause 4, insert the following new Clause:
("Application of Local Government Act 1972 to Health Authorities
.—(1) Sections 100A and 100D of the Local Government Act 1972 (access to meetings and documents of certain authorities) shall apply to a Health Authority established in accordance with section 8 of the principal Act as they apply to a principal council within the meaning of Part VA of that Act, but the references in sections 100B, 100C and 100D to the proper officer in relation to a principal council shall be construed as references to the person appointed for the purpose by the Health Authority.
(2) In section 100H of that Act (supplemental provisions and offences)—
(3) The power conferred on the Secretary of State by section 100I(2) of that Act to vary Schedule 12A to that Act (exempt information) shall include power to vary that schedule as it applies by virtue of this section.
(4) In that Schedule, as it so applies—
(a) Part I shall have effect with the insertion after paragraph 6 of the following paragraphs—
6A. Information relating to the physical or mental health of any particular person.
6B. Information relating to—
(b) paragraph 1 of Part II shall have the effect with the insertion after the words "paragraph 1 to 5" of the words "or 6B"; and
(c) any reference to "the authority" shall be construed as a reference to the Health Authority.
(5) In this section references to a Health Authority include references to a committee or sub-committee of such a Health Authority.
(6) In the Public Bodies (Admission to Meetings) Act 1960 (which makes similar provision to that made by sections 100A and 100B of the Act of 1972), paragraph 1(0 of the schedule shall be deleted.
(7) A Health Authority shall maintain a register stating—
(8) A Health Authority shall maintain a list—
but this subsection does not require a power to be specified in the list if the arrangements for its discharge by the officer are made for a specified period not exceeding six months.
(9) A written summary or rights—
which are for the time being conferred by virtue of section I above shall be kept at the offices of each such Authority.
(10) The register maintained under subsection (7) above, the list maintained under subsection (8) above and the summary kept under subsection (9) above shall be open to inspection by the public at all reasonable hours and without payment at the offices of each Health Authority and any person may, on payment of such reasonable fee as the Authority may determine—
§ The noble Lord said: The purpose of this proposed new clause is to improve, update and replace the provision of the Public Bodies (Admission to Meetings) Act 1960 which requires various local 565 government bodies including health authorities to open their meetings to the public.
§ The new clause would apply to regional and district authorities in England and Wales but it is not intended to affect special health authorities or the new family health service authorities. The clause as drafted follows in the footsteps of the Local Government (Access to Information) Act 1985 and subsequent open government legislation which updates part of the 1960 Act.
§ The Local Government (Access to Information) Act 1985 was introduced in another place as a Private Member's Bill by my honourable friend Mr. Robin Squire and in this Chamber by my noble friend Lady Carnegy of Lour. It provides for public access tc the committees and sub-committees of local authorities and to the agendas of those meetings, the background papers considered and the minutes of meetings. The 1985 Act did that by adding new Sections 100A to 100K to the Local Government Act 1972. Two later Acts, which both began life as Private Member's Bills in another place, have selectively applied those new sections to health service joint consultative committees and community health councils. The first of those Bills was introduced by my noble friend Lady Carnegy and the second by the noble Lord, Lord Stallard. Those Acts apply the relevant provisions of Sections 100A to 100K of the 1972 Act to the bodies in question. That is what my amendment seeks to do in relation to health authorities.
§ I hope that the Committee will support the principle of this amendment. For my part, I should welcome criticism, which will give me and those advising me the opportunity to make improvements to the drafting and content of the amendment should it be necessary to bring it back for further consideration at a better time of day on Report.
§ I should make clear to the Committee that the impetus for change comes from the community rights project. Its role in opening up local governments to public scrutiny to provide greater accountability and better administration is well known to the Committee. The recent Acts which I mentioned are testimony to its concern in this field and I owe to its members much of the advice I received, as well as the drafting of the clause.
§ I shall briefly go through the subsections. I apologise that an amendment which is meant to deal with open government should appear in the form of a very obscure set of subsections. That results from the way that legislation has taken place in the past, by reference, which seems to be the only way to achieve any reasonable result in this case.
§ Subsection (1) provides that meetings of health authorities are to be open to the public except to the extent that the public may legitimately be excluded when confidential information is to be considered. The ager da of meetings, the reports to be considered, the background papers to the reports and the minutes of the meetings are all to be open, again subject to legitimate exclusion.
§ Subsection (2) mainly consists of the technicalities needed to legislate by reference to the 1972 Act, but subsection (2)(c) provides that any defamatory 566 publication, as a result of the clause, shall be privileged unless malice is proved. Subsections (3) and (4) give the Secretary of State power by order to vary various classes of confidential information which may justify the exclusion of the public in any case. They provide the additional specific exclusions seen as necessary in the case of health authorities.
§ Subsection (5) applies the clause to committees and sub-committees of health authorities. In regard to the remaining subsections, it may be sufficient if I say that they follow the recent statutory precedents to which I referred and for the most part require health authorities to make available to the public various kinds of information about the authorities themselves and the rights of the public to have information. It is information which in my opinion any reasonable authority should make available as a matter of course to anyone inquiring.
§ The new clause follows recent research by the community rights project into the habits of health authorities regarding their openness to the public. There was a 94 per cent. response to a survey carried out during the past year, and that fact of itself seems to suggest that there is a willingness on the part of health authorities to be open. Unfortunately, habits of secretiveness are easily formed and only abandoned with difficulty.
§ The survey disclosed that 30 per cent. of the authorities responding go into closed session without observing the requirements of the 1960 Act, 88 per cent. take decisions in committees, which are always closed to the public, while 44 per cent. do not even make their committee minutes available to the full meeting of the authority. The results of the survey suggested to the community rights project that authorities are too often not heeding the guidance of the Department of Health that there should always be a presumption in favour of open and public discussion.
§ There seems to me to be an additional reason for change now. The new slimmed health authorities, stripped of local authority representation, stripped of operational function and given the sole task of planning and purchasing services for the benefit of patients, must in my opinion inevitably tend towards the paternalistic approach to those whom they serve. It has always been my experience that paternalism is the enemy of openness.
§ The new health authorities will be working in partnership or at least in conjunction with local authorities. But it is the local authorities which will have the responsibility for care within the community. We had a vivid example this evening in the debate on Amendment No. 66 in relation to the discharge of patients by district health authorities into the community. There was a clear example of the kinds of problems that arise as between the health authority and the local authority in that sort of case. I suggest that it would be unfortunately anomalous for health authorities not to come within the new regime of openness which applies to local authorities and other bodies carrying responsibilities as part of the overall health service.
§ The Committee will know that I do not normally speak on health matters in this Chamber and I 567 apologise if ignorance of the finer points of health administration shows only too clearly; but I would say that this amendment stands apart from health care and administration. It says nothing substantive about the operation of the National Health Service. It carries no resource implications. It is an amendment which should be supported. I beg to move.
§ 12.15 a.m.
§ Baroness Carnegy of Lour
I have a great interest in this matter, having, as my noble friend said, taken related Bills through this Chamber, and I therefore support the amendment. However, the Government should look carefully at this amendment. It is clear that there is unnecessary secrecy on the part of health boards throughout the country, with unnecessary exclusion of the public.
I realise that the hour is late and that we should not spend a great deal of time discussing the matter, but I hope that the Minister will pay considerable attention to what my noble friend said.
§ Lord Tordoff
I rise to support the amendment. I thought the phrase "the presumption of openness" was the important part of what the noble Lord said. It is easy to hide behind regulations of one sort or another and eventually it is not good for the health service, the patients or anybody else, to be more restrictive than is absolutely necessary in the interests of confidentiality for the individual person. There are obviously occasions when that is necessary but in general terms we should come down on the side of openness. I believe that the amendment does that and I certainly support it from these Benches.
§ Baroness Blatch
The Committee will be aware that this issue was debated in some detail during consideration of the Health and Medicines Act in 1988. The Government's position remains essentially the same. The vast majority of regional and district health authorities conduct their business in as open a manner as possible. They are already required by law to do so. All regional and district health authority meetings are at present, and will continue to be, subject to the Public Bodies (Admissions to Meeting) Act 1960. This requires health authorities to give public notice of the time and place of their meetings, to supply copies of the agenda to any newspaper that requests it, to provide them with reasonable reporting facilities and to open their meetings to the public unless the authority resolves they should be excluded because of the confidential nature of the business to be transacted.
Our guidance to health authorities on interpreting the 1960 Act, contained in circular HC(81)6, emphasises that there is a presumption in favour of open and public discussion wherever possible. Most health authorities in fact go beyond simply fulfilling the legal requirements. They understand the importance of involving the public in the running of the health service. Most major decisions are the subject of consultation documents and public meetings are held by health authorities about plans for local services. Community health councils in fact 568 have substantial powers to receive information from health authorities. This helps to ensure that health authorities carry out their business in as open a manner as possible.
My noble friend's amendment would place an additional administrative and financial burden on health authorities at a time when they will need to concentrate on implementing the reforms we are introducing. These reforms will in fact considerably increase the responsiveness of the health service to the public.
Under the proposed new clause, health authorities would have to give reasons for closing a meeting to the public. This is not an unreasonable proposition but it is already a requirement under the 1960 Act. Other provisions proposed would place an additional burden on health authorities. For example, they would be required to produce a list specifying those powers of the authority which are exercisable from time to time by officers (other than temporarily) and a written summary of rights under specified enactments to attend meetings and to inspect and copy documents. Copies of background papers and reports would have to be open for inspection by members of the public in advance; copies of minutes, agendas and reports would have to be available for public inspection for six years after the meeting and background papers for four years; and all these provisions would apply to committees and sub-committees of authorities as well as to the main meeting.
A number of the measures proposed, such as producing lists of the names and addresses of authority members and members of committees and sub-committees, are already common practice in health authorities. Other provisions, while very relevant for local authorities, will simply not be appropriate for health authorities and may well mean that they have to take on extra staff and incur extra costs, using resources that would otherwise be spent on patient services. Local health authorities are very different types of bodies from local councils. They are wholly funded by central government and are accountable to Parliament through the Secretary of State.
Following the reforms set out in this Bill, health authorities will essentially be not representative, but managerial bodies. As far as possible we wish them to be free to decide themselves how best to conduct their business without burdening them with excessive red tape. Sufficient safeguards already exist, and will continue to be provided, in the health authority membership and procedure regulations, as well as the Public Bodies (Admission to Meetings) Act 1960.
I know that my noble friend Lady Carnegy is concerned about secrecy. She hinted to me earlier that she was also concerned about a breach of the regulations. If any regional or district health authority is conducting its business in contravention of the Public Bodies (Admission to Meetings) Act 1960, that is totally unacceptable. I would be grateful if any noble Lord would inform me of any health authority that is acting in that way, and I will promise to look into the matter as a matter of urgency. The 569 Government regard it as a matter of the utmost importance that the 1960 Act is adhered to, and that regional and district health authorities do conduct their business in as open a manner as is reasonable.
Having said that, if the current law is being broken—and rest assured we shall take an extremely serious view if it is—I do not see how the application of a new piece of legislation would help. I promise the noble Lord and my noble friend Lady Carnegy, that I shall read very carefully what they have said. I hope that in the meantime they feel able to withdraw the amendment.
§ Lord Peston
Although my name is down to the amendment, I did not speak at an earlier point because I wanted to hear what the noble Baroness had to say. I was extremely disappointed with her reply. It seemed that the noble Lord, Lord Coleraine, had put the matter as clearly as he possibly could. His commitment to openness is shared by the noble Lord, Lord Tordoff, and by me, but, from listening to the noble Baroness, it does not appear to be shared by the Government.
I have no wish to press the matter at this time, but were it earlier in the day I would feel strongly enough to wish to divide the Committee on the basis of the reply given by the noble Baroness. I am not encouraging the noble Lord, Lord Coleraine, to do that now. However, I give warning that this is a matter which I do not think we can allow to rest on the basis of the Minister's reply. I shall certainly not tolerate that.
§ Baroness Blatch
I wish to make one comment. There is a very real commitment on the part of the Government to openness in all matters concerning the health authorities. In the course of my reply I spelt out a rather cumbersome and expensive system. It is a matter of striking a balance between getting the maximum amount of openness and not putting on health authorities an unnecessary financial burden. I have given a promise that I will read very carefully what has been said. In the meantime I hope that the amendment can be withdrawn.
I am sorry to delay matters. I was very pleased with the remark that the Minister made about locking at the matter again. Those of us who have fought for many years for openness find it particularly unattractive when we are told that it cannot be afforded, which was essentially her answer. My view is that there are few things that we need more than openness on these matters. That is what I understood those who spoke to the amendment to be saying. I wish to place on record that once she has thought about it further she will find that we have also done so.
§ Lord Coleraine
I have noted with interest what the noble Lord, Lord Peston, has said in reply to my noble friend on the question of expense. Let me deal with the question of expense as a result of my legal experience on the Courts and Legal Services Bill. There we discussed matters such as level playing fields. We felt that if one branch of the profession 570 was required to operate in a certain way then the other branch should do so in the same way on the basis of the level playing field. For the life of me I cannot see why, if local authorities are bound to incur the expense of openness, health authorities should not do likewise.
I am grateful to my noble friend for detailing at some length the various technical points she took in relation to the subsections of my amendment. Between now and Report stage I shall read what she said. I hope then to bring back a better amendment.
My noble friend said that because health authorities were management bodies rather than representative bodies that was a reason why they should not be open. If one looks at health authorities as management bodies and local authorities as representative bodies, the people whom they both serve—the public—would feel that on the whole they have better access to openness from local authorities, even without the provisions of the 1985 Act, than they will get from the health authorities, which are management bodies and are therefore inherently not open to be frank with the people whom they serve. I shall come back with this issue at Report. In the meantime, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendment No. 88A not moved.]
§ Clause 29 [NHS contracts]:
§ [Amendments Nos. 88B and 88C not moved.]
§ Baroness Carnegy of Lour moved Amendment No. 88D:
Page 28, line, 43, at end insert—
("(ba) the Scottish Dental Practice Board;").
§ The noble Baroness said: I shall speak at the same time to Amendment No. 88E. I tabled these amendments in order to ask my noble friend on the Front Bench one simple question. Clause 29(2) lists the various bodies in the Scottish health service which can make National Health Service contracts. It has been drawn to my attention that Clause 4(2) on page 4 of the Bill—the equivalent provision for England—includes in its list the Scottish Dental Practice Board, the Dental Practice Board and the Public Health Laboratory Service Board. Those bodies are omitted from the list in Clause 29. I wonder whether this is a deliberate omission or an inadvertent one. My amendments would add them. I look forward to hearing what my noble friend has to say. I beg to move.
§ Lord Sanderson of Bowden
I thank my noble friend for moving the amendment. I accept what she said about the desirability of bringing the Scottish clause about NHS contracts into line with the English ones. It is in practice unlikely that these three bodies will be involved in the contract system in Scotland but we should keep open that possibility. Therefore I have pleasure in accepting the amendment.
§ On Question, amendment agreed to.571
§ Baroness Carnegy of Lour moved Amendment No. 88E:
Page 29, line 3, at end insert—
("(ea) the Dental Practice Board;
(eb) the Public Health Laboratory Service Board;")
§ On Question, amendment agreed to.
§ [Amendments Nos. 89 to 94C not moved.]
§ Clause 29, as amended, 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 half-past midnight.