HL Deb 26 April 1990 vol 518 cc695-730

5.10 p.m.

Baroness Blatch

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 on the Bill. —(Baroness Blatch.)

On Question, Motion agreed to.

House again in Committee accordingly.

[The LORD AYLESTONE in the Chair.]

[Amendment No. 95 not moved.]

Lord Ennals moved Amendment No. 95ZA: Page 6, line 14, at end insert ("but the Secretary of State shall make no such order unless he has first held a ballot of all those working in the hospital or other establishment or facility and a majority voting in that ballot are in favour of the Secretary of State establishing a National Health Service trust.")

The noble Lord said: In moving this amendment I should like to speak also to Amendments Nos. 95A, 95C, 100E and 101EA, the last two being Scottish equivalents. The last vote in this Chamber showed a degree of concern about the Government's plans for NHS trusts which I believe that the Government would be unwise to ignore. The NHS is a service provided for the people. The resources that would be taken over by NHS trusts belong to the people. The NHS is a public service. If the Secretary of State is sincere and is not planning the privatisation of the service, in part, eventually or whatever, the NHS trusts must be responsive to the needs of the people.

It is essential that NHS trusts are approved by the Secretary of State only if they have the support of those who would principally be involved in their success. That includes the doctors, nurses, other professions, those who work within the health service, and the consumers. We are told that there are enthusiastic groups. It should not be for enthusiastic groups within a National Health Service to determine how things should be done.

The purpose of these amendments is to ensure that the views of those involved are taken fully into consideration and that decisions do not lie with a small group of enthusiasts—however enthusiastic they may be —be they managers or consultants. They must be able to create the same enthusiasm among both the staff and local community. If those enthusiasts are unable to carry their colleagues with them, it would be quite wrong for the whole hospital to cease to be under the control of the health authority.

Amendment No. 95B deals with staff. Amendment No. 95C deals with doctors and consultants. Amendment No. 95A deals with local community. In our Second Reading debate I asked the noble Lord, Lord McColl, who should decide. He gave the answer that the consultants should decide. It is in Hansard if he cares to look it up. He gave a straight answer: the consultants. Those are the only two words that he said in that reply.

Lord McColl of Dulwich

Will the noble Lord give way? I said that it should be management. It is a management decision. I believe that the decision should be made by those who manage the hospitals.

5.15 p.m.

Lord Ennals

I am sorry. It was a slip of the tongue. The noble Lord said, "the managers". Please forgive me for having misled the Committee. The noble Lord referred to managers and I thought that I had said "managers".

It cannot be right that managers should decide. It is the job of managers to manage. It would not be right for management to make a decision of such a fundamental resource, with massive capital assets and a huge staff fulfilling a great community responsibility. Such a fundamental decision cannot be for management alone. The Bill gives the responsibility to the Secretary of State. The amendment requires the Secretary of State to ascertain the views of those concerned before proceeding.

At col. 472 of the Official Report on Tuesday last I put these questions to the noble Baroness who was dealing with the amendment. I asked: 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 hospital where there has been a ballot in which the majority of staff have said yes …? Is there a single hospital where there has been a community ballot?". The noble Baroness said: I am aware of only a few ballots on the subject". I said, "No, no", because I know of 80 ballots that have been conducted in different parts of the country. I shall not refer to all of them. The noble Baroness said: There are many individual members of the profession … who believe that our proposals are the way forward". That is right. The noble Lord, Lord McColl, is here as evidence of that. She continued: We believe that we need to continue working with those people taking their advice and learning with them". The emphasis is mine. It is not good enough simply because a few consultants or managers have said, "This is what we should like to do", that it therefore should be done.

I shall be very interested to hear how the Minister justifies the Secretary of State proceeding to establish NHS trusts if their is no support for them among the consultants and others who work in the establishment. At one stage the Secretary of State said that hospitals would be accepted for self-governing status only if a substantial number—he did not say a majority—of senior staff supported the application.

There have been many ballots. I am aware of 80. Some have been in hospitals and involved only consultants, some have involved all staff, and some have involved local communities. Some were based on questions which most of us would consider were leading questions. One example is, "Do you believe that so-and-so will be damaging and harmful?" If one puts such a question one is leading people to say, "Yes, we think that it will be damaging and harmful." Many ballots have been undertaken systematically. Some have been organised by district health authorities; some have been organised by medical committees and some by reputable polling organisations.Some ballots have been supervised by the Electoral Reform Society. Most had massive majorities against the proposals that we are discussing. I did not consider the ballot in Mr. Kenneth Clarke's constituency —which showed 97.1 per cent. against with 2.9 per cent. in favour of Nottingham University Hospital becoming an NHS trust —as being scientifically conducted. I do not say that that is the best example. However, even the most reputable ballots have rarely shown more than 20 per cent. of any group in favour. They include many of our great hospitals, including many of our great London hospitals.

Perhaps we may consider St. Bartholomew's. The result of a ballot among 167 consultants out of 201 at Bart's and two other hospitals in the same district, St. Mark's and Homerton, showed only 30 (18 per cent.) approved plans to reorganise the NHS. They had a ballot at Bart's specifically about self-government. A total of 91 consultants (75 per cent.) voted against going ahead with an application to become self-governing.

Other votes have taken place. We have previously referred to Guy's. I shall not do so again. However, the official ballot of the staff of West Lambeth Health Authority a couple of weeks ago produced a vote of 82 per cent. against the plan for St. Thomas's Hospital to opt out of authority control. The ballot was the first to be called by a health authority on hat issue.

I have lists of ballots that have been held. They cover different parts of the country. At the Royal Scottish National Hospital in Larbet, the figure was 94 per cent. against opting out. In the Borders General Hospital 831 staff (80 per cent.) rejected a proposal for their local hospital to become an NHS trust. I can refer to York, Halifax, Doncaster and communty ballots up and down the country. I referred to Nottingham. In central Manchester, 93 per cent. were against opting out. I could refer to the Central Middlesex Hospital and Lewisham Hospital.

In Lewisham Hospital 90-2 per cent. of the staff were against opting out.

On the basis of such massive opposition by the staff, consultants, doctors, and other professionals, and by the community where there have been community ballots—of course with a handful of enthusiasts—it cannot be right that the Secretary of State should decide to proceed.

I know what the Government will say: that all these people have got it wrong, that they have all been misled by the doctors, and that the BMA with its terrible propaganda campaign has worked its influence. They will say that all these people, whether or not they work in the health service, have got it wrong. I suppose after general elections that we win or lose we say, "The people were wrong. They just did not understand our policy. We ought still to be in power." However, that does not wash. The amendments are in favour of genuine ballots organised on behalf of the Secretary of State so that he himself or the department can approve of the way in which the questions are put. I hope that some local authorities may do that in their local communities. If not, the health authorities should.

I believe that the enthusiasts for these particular changes must be able to convince their working colleagues of the wisdom of their recommendations. Until the Secretary of State can prove that there is real majority support at least among consultants, certainly among doctors and the rest of the staff and preferably among the community, he should not proceed. If those enthusiasts cannot convince their colleagues, they are like politicians who cannot convince the electorate at a general election and who afterwards say "The people were wrong". The people are always right. I beg to move.

Baroness Carnegy of Lour

I should just like to say—

Lord Winstanley

This is an all-party amendment and as one of the sponsors of it I thought I should make my position clear straightaway. The noble Baroness, Lady Cox, is not in her place but had she been there perhaps she could have spoken first from that side of the Committee.

Lord Ennals

The noble Baroness sent me a note to say that she was sorry that she could not be here but authorised me to say that she fully supports the amendment.

Lord Winstanley

I meant no discourtesy to the noble Baroness, Lady Carnegy, but as one of the sponsors of the amendment I thought I should speak first. It is right that the noble Baroness, Lady Hooper, should know that this is an all-party amendment which has all-party support. She should also be aware that on all sides of the Committee there are Members who believe that, properly carried out and with proper safeguards, the National Health Service trusts could be successful. There are also those who believe that there are great dangers in this unless it is done properly. That is our anxiety here.

I should like to refer to what I said on Second Reading. The noble Baroness will recall that I said at that time that I was in favour of the Manchester Royal Infirmary, from which I had just been discharged, opting for independent status. It had such monumental problems facing it that the only way of overcoming them was with an entirely new structure such as one of these trusts.

Where a teaching hospital is to become a National Health Service trust, I should like to see the university concerned becoming a trustee. That is not something on which an amendment has been tabled. However, I said that decisions as to which hospitals should opt for independent status were being taken largely by senior consultants. The noble Lord, Lord Ennals, said that those decisions are taken by managers, and I accept that. But it seemed to me that they were being taken largely by senior consultants.

I also said at that time that I thought that senior consultants were probably the best people to make those sort of judgments. I went on to say—and I repeat it now—that a new trust will not be a success unless it carries with it the confidence and support of all the people who will be working in it. There will not be that confidence and support if those people are bypassed in the decision-taking process. That is why I am strongly in favour of this amendment.

The noble Lord, Lord Ennals, has made much of ballots which have already been held. Perhaps he will forgive me if I say that I do not believe that they are relevant. What is relevant is the opinion of all those people when they genuinely understand that they are being consulted and what they say will have a bearing on the decision taken. When that decision is finally taken and the hospital opts for independent status under the trust, if all the people working there have been effectively and properly consulted and feel that they have had a say in the decision, that hospital will have an infinitely better chance of success than it would otherwise.

I also believe that once there is a statutory provision rather than the informal ballot to which the noble Lord, Lord Ennals, referred, the ballots will be conducted very differently. An amendment such as this would make those senior consultants and managers, who are so very important to the outcome of the decisions, approach their job in a slightly different way. They would make absolutely certain that at every stage they carried the staff with them. They would talk to them, consult them and persuade them. It will be impossible to persuade some. We should never persuade some Members of this Committee of some things even if we stayed here for ever because they can never be persuaded. However, I genuinely believe that, if it is in the interests of a hospital that it should be independently governed in this way, the senior consultants and managers should be capable of persuading the majority of the staff that that is the case.

I believe that they will be capable of so persuading them. Having persuaded them, they can then proceed. Then, when that hospital or group of hospitals is established as an independent trust, we shall have something which will be a going concern and will demonstrate the merit in this part of this Bill.

Baroness Carnegy of Lour

I apologise to the noble Lord, Lord Winstanley, that I attempted to speak before him. I am very glad that he spoke first because he has made half the points that I wanted to make. I wanted to answer the noble Lord, Lord Ennals, because I was bothered by his tone and the atmosphere which he seemed to be attempting to engender into the whole matter of changing the National Health Service.

I agree with the noble Lord, Lord Winstanley, that what is needed is to carry people along, persuade them, sell them the ideas and inform them. That is very important. I also agree with him that so far the ballots have probably been based on emotion, fear, misinformation or no information at all. We should not pay too much attention to them; but they show that we still have a long way to go.

However, I say to the noble Lord, Lord Ennals, that the very last way to achieve change in the National Health Service is to turn everything into a political, with a small "p", exercise. Amendment No. 95A suggests that those living in the community should be balloted as to whether there should be an NHS trust. I do not believe that that is practical. It is not possible to know what the community of a hospital is. Where I live there is a great criss-crossing between hospitals according to people's needs and preferences and the location of certain facilities. Therefore, I do not believe that a ballot of the hospital community would be possible or practical.

That does not mean that the people in the hospital who wish to create a trust will not have to do a great deal to carry along the community. Nobody wants to have a hospital which is resented by its local community. Where I live that process had begun and I assure the noble Lord, Lord Ennals, that it would not have been helped by the kind of ballot he suggested. He would not like that if he wanted NHS trusts, which he does not. He is trying to do all he can to stop them and his party does not like devolution down to the ground.

Lord Ennals

The position which I have taken is not that I wish to stop NHS trusts. I want them to be tried out and to see what are the advantages and disadvantages. However, I feel passionately about the right of people to be consulted.

Baroness Carnegy of Lour

I do not believe that anyone could conceivably try to set up an NHS trust without consultation and that consultation will have to be over a period of time. Much information will need to be given and the hearts and minds of people will need to be won. However, a ballot is no way to do that and I am sure the noble Lord knows that. I am not sure that he does want NHS trusts from the way in which he has spoken in the debate so far, but of course we take his word on that. The same situation applies to the amendments concerning ballots of doctors and consultants. It is not only doctors and consultants who need to be persuaded, but other people who work in the hospitals. I think I am right in saying that they are covered by other amendments, but everbody has to be persuaded. Their enthusiasm has to be engendered, as the noble Lord, Lord Ennals, said.

To use the divisive process of canvassing opposite opinions, the status quo, the new idea and finally bringing it to a vote and saying that the majority will win is not a satisfactory way to start a new enterprise in a hospital. Those of us who have tried to change anything know perfectly well that that is not the way to do it. The point is well made that enthusiasm has to be engendered and people need to be persuaded. If these amendments are probing amendments then I would agree, but to incorporate any of them in the Bill would be extremely unwise.

With regard to obtaining the agreement of consultants beforehand to work under the new arrangements in the hospital, anyone who tried to get a hospital off the ground without that agreement would find that they had a hospital without consultants. I do not think that that is likely to happen, To include that in the legislation is slightly insulting to the new trust.

If we want NHS trusts, we need to try them and see whether they work. We have already heard from my noble friend on the Front Bench that that will be done in a gradual way and that the NHS trusts will learn from their mistakes. We must leave them to persuade the local community, the people who work in the hospitals—doctors, consultants, dentists and the consultants who will come in—that it is a good idea and that they should work with it. If they cannot persuade them, then the trust will not be put forward. If by chance any hospital tries to do so without the necessary agreement, I am sure that it would not be agreed that they should be a NHS trust.

I do not think that any of these amendments are at all wise. I hope that the Chamber will not be asked to vote on them, because we will not accept them.

5.30 p.m.

Baroness Phillips

I support the amendment, but perhaps for slightly different reasons. The Minister may refute this, but to me the lovely name of "National Health Service trust" is just another form of privatisation by the back door.

I recently spent a period in Westminster Hospital. I cannot speak highly enough of the consultants, the doctors, the nurses, the radiographers; all the people employed directly under the National Health Service. The weakness was in the cleaning services that had been privatised. During the four months that I spent in hospital nobody ever cleaned under the beds. If we did not clean under our beds at home we would be told of the terrible germs we were harbouring there. The weaknesses of privatisation were shown very clearly. I do not complain of the people who did the work; they were charming people, but underpaid. I checked what they were paid and found it to be £1.50 an hour. That is what they were paid to clean the hospital. That is the way this project will work.

The nurses and the doctors, perhaps not so much the consultants—I am not certain that they have all the answers—are the people in the National Health Service who must be consulted on this issue. They will know what this is about. There is no evidence that the Government, bearing in mind all their changes, really want something that will be part of a public service. It all sounds marvellous, but it is privatisation by a back-door method. It is therefore essential to consult everyone in the hospital.

The Government are not keen to do that because they know that they will not like the results. We heard the noble Baroness say that it should be tried somewhere. When that proposal was suggested in connection with another Bill it was turned down. The Government did not want that. Of course they do not want it; they certainly do not want to listen to the practitioners. We had the debate on student loans and heard some splendid evidence on behalf of the practitioners. The Government did not want to listen to it. There is no reason to suppose that they will listen now. At least let us put a word in. The introduction of these trusts is a major change. It is all very well to talk of carrying people along, but they can only be carried along if they are consulted.

If I were to pick on the weakness of the National Health Service, I should say that it was the management. When people change things they never change the administration—the people in mysterious offices whom we never see. They always change the people on the line, the people who are producing and creating the services. They are the important people. Make no mistake, the important people are those who give the real service to the patient. Also, why cannot we ask the patients? After all, they are at the end of the line; they not only pay for the service; they are the consumers. I support the amendment.

Lord Nugent of Guildford

The atmosphere which has been created in the country has certainly been unfair and unkind. The NHS trust is seen, as the noble Baroness, Lady Phillips, said, as privatisation by the back door. But the National Health Service trust will be just as much within the National Health Service as district hospitals. Nevertheless, one must face the fact that the general feeling is that the creation of the trust is a step towards privatisation and therefore there is opposition even though people do not really know much about it.

I hope I shall not bore the Committee by repeating a point I made earlier. Before any hospital can become a National Health Service trust it must engage in what my noble friend calls her "resource management initiative", which means establishing modern technological information so that the whole hospital is under a comprehensive management system plus modem cost accounting. That will take several years to put into practice.

I do not believe that any hospital will want to become a NHS trust—in other words self-governing—until it has a strong enough management and can see how it will work. If my noble friend was prepared to consider establishing the trust in two stages—that is to say, inviting all hospitals to engage in resource management initiatives—there would not be many who would say that they did not want to do it. After all, my noble friend has said that she will pay for it and make a lot of new money available for it. That is absolutely necessary because it will be expensive.

When that has been achieved in the hospital, management will have an enormously improved grasp of the management of the hospital and the use of resources. Much better service will be given to patients; resources will be that much better used. Management will be able to prepare a budget which it can submit to the Secretary of State with its annual demands or requirements for funds based on that subject. That would be a marvellous improvement over the present hit and miss situation.

I should have thought that all hospitals and staff would say, "Yes, we will go for that". It may be said "Let us make that the first objective"; every hospital having achieved that admirable position of greater strength can then decide whether it wishes to become a NHS trust. Some may and some may not. As I said, a good deal will depend on the locality and how local people feel.

Strong self-governing hospitals will be able to give much better service within the National Health Service than those which are entirely within the present structure. Whether they become self-governing or not, they will still be within the National Health Service. There is no question about that. I urge my noble friend to take on board the point that there is a strong feeling of opposition to these trusts which the noble Lord, Lord Ennals, has very effectively deployed. But we are not giving the concept a fair chance by putting the proposal to hospitals and to the country in the present atmosphere. Most of them do not understand what they are being asked to decide upon.

I urge my noble friend to go for the bull —resource management initiative—which would massively improve the whole management structure of the health service and make better use of our resources. Having achieved that, we can then go for national health trusts for those hospitals which wish to do so. I am sure that that is the way forward. If my noble friend did that opposition would melt away like snow in the sunshine. However, to go ahead and put forward trusts as an option for hospitals throughout the country is asking for trouble.

Lord Rea

Perhaps I may make an analogy with the education service and schools which opt out. The three bodies concerned are the school governors, who can be taken as equivalent to the management of a hospital; the staff of a school, who can be considered as equivalent to hospital staff; and the parents who can be considered the equivalent of the patients.

I happen to have knowledge of what went on at a school in Camden —the William Ellis school —where the chairman of the governors was keen on opting out. He explained to the governors that it was a good idea. However, the staff then held a ballot and came out strongly against the proposal. The governors thought again and decided against opting out because they felt that there was no point in pressing the move against a strongly opposed staff.

I feel that that is exactly the point that the noble Lord, Lord Winstanley, was making about staff working in hospitals which might decide to opt out. The staff have to be carried along in favour of the experiment. It could be that the experiment will be worth making but everyone working in the hospital, and preferably everyone who is to use the services of that hospital, need to be carried along too.

Lord Wallace of Coslany

I know for a fact that many area health authorities—in fact, the management of the health authorities —decided to opt out in principle without committing themselves completely. However, I want to make the point mainly in regard to district hospitals. District hospitals serve the community and are part of the community in which they are situated. People regard them as such. Apart from taking account of the views of staff, the people of the district should have their views considered too.

I have another point to make. Hospitals are served by many voluntary workers—the friends of hospitals and other organisations. Will those workers be consulted as well as the staffs of the hospitals? I have a personal interest in Queen Mary's Hospital, Sidcup. Way back in 1947 the Minister, Aneurin Bevan, decided that the old cottage hospital was not suitable for the district. I saw him in the Division Lobby behind me and within a fortnight he had completely changed the Government's point of view and the hospital came into the National Health Service. I hope it will remain there.

I know personally many of the voluntary workers at the hospital and I realise to the full the value of their work. These people are the community and they should be consulted after the facts have been put to them appropriately and in detail. They should be consulted because that is the democratic way of deciding. I believe that the majority of people connected with a district hospital would opt to remain in the health service as it is today rather than for a trust.

It is a different matter for the teaching hospitals, though there is no unanimous opinion in that respect. I understand that Guy's Hospital is definitely against the proposals and other hospitals hold the same view. Therefore I hope the Government will agree that there should be a degree of consultation, not on a narrow scale but on a wide scale so that the people of all shades of opinion have the proposal before them, make their decision, and, whatever that decision, so be it.

5.45 p.m.

Lord McColl of Dulwich

It is my understanding that this country is not governed by referendum. Therefore, I am puzzled as to why the Labour Party now seem to be so keen on having ballots. I have always understood that the Labour Party have never believed in ballots in various walks of life. Indeed why did the Labour Government not have a ballot in 1974 on the controversial issue of phasing out pay beds? So why is the Labour Party now so keen on ballots?

The noble Lord, Lord Ennals, said that he does not want to stop some hospitals from becoming self-governing, but he knows very well that if we do have to rely on ballots of all the people who work in those hospitals the ballot will go against self-governing. But why will the ballots go against the proposal? It is because of all the propaganda that has been put out. The propaganda is, first, that becoming self-governing is to leave the National Health Service. That is not true. The second—

Lord Winstanley

Before the noble Lord deals with his seccnd point will he accept that this is not a Labour Party amendment? The amendment is supported by all parties. It bears the name of his noble friend Lady Cox. What the Labour Party happens to think or does not think has nothing to do with me.

Lord McColl of Dulwich

I withdraw, it is not a Labour Party amendment but to me it has the stamp of the noble Lord, Lord Ennals. I continue with my second point. The propaganda is that NHS trusts are privatisation by the back door. That is not so. We do not want privatisation of our hospitals. We have seen in other countries what privatisation does. We have seen the situation in the United States. The average American citizen has twice as much surgery done on him or her as the average British patient. Is that what we want? I am a surgeon and I am all for surgery, but do we really want our citizens operated on to that extent? Of course we do not. We want them to have the right amount of medical care. We want to focus on need rather than on demand. That is essential. Thirdly—

Lord Peston

I am sorry to intervene and it is unfair to interrupt the noble Lord so often. However, I want to say how much I agree with him. Almost everybody I have spoken to in the hospital service believes that devolution to self-governing trusts is the first step towards privatisation. There is no shadow of doubt that that is right. The question that the noble Lord might address himself to, and then might ask his noble friend on the Front Bench, is whether the Government will put down an amendment to guarantee that what he says, with which I agree, about moving in the American direction cannot possibly happen. If one were to ask for some way of reassuring those who work in the hospital service that there is no danger that trusts are the first step towards privatisation, one would ask for precisely that. There is no doubt that what the noble Lord said is right. In my experience all over the country people are saying that the Government are playing games and that they want to privatise.

Lord McColl of Dulwich

It is not for me to answer on behalf of the Government, but the noble Lord should perhaps ask the Secretary of State for Health whether he has private medical insurance. He has not. He relies entirely on the NHS. I believe that the Government do not want to privatise the health service. Health considerations are different from any other walk of life. To go down the privatisation line is to end up with the British people having twice as much surgery, and we do not want that.

We want people to be involved in every district by sitting down and trying to work out what are the real needs of the people in that district. This Bill will go some way towards that. It certainly starts off the process. I am very pleased for any noble Lord to interrupt at any point because we can then hammer home the difficulties. The noble Lord, Lord Ennals, has had difficulty in grasping some of the more modem concepts of management in the NHS.

The third point which has terrified patients and the people of this country generally is having been told in very clear terms that when the money runs out the drugs will no longer be available. They have been told: " The drugs will no longer be available. I am sorry, you will have to die". That is a wicked, evil lie. The people who put that about in no uncertain terms have a great deal to answer for.

The only way we can progress is to allow those hospitals which are in a position to become self-governing, which have put in the necessary equipment and accounting systems and which have the necessary financial control to go ahead if the mangement is willing and keen to do so. I suspect that what will happen is that those who work in these hospitals will be very pleasantly surprised. They will find that they are paid a proper rate for the job. Those who work hard will be rewarded. They will like that because basically the British people believe that a labourer is worthy of his hire. Ballots will be totally out of place. We should reject this amendment.

Lord Henley

I start by giving an absolutely firm assurance to the noble Baroness, Lady Phillips, who is not in her place, and to the noble Lord, Lord Peston, who intervened, that, as my right honourable friend the Secretary of State has said on many occasions, there is absolutely no intention other than that the National Health Service trusts shall remain part of the National Health Service. That is not privatisation by the back door, and it is positively mischievous to suggest that it is.

I greatly welcome the conversion of the noble Lord, Lord Ennals, to National Health Service trusts. Having said that, the noble Lord then spoke about massive opposition to what he referred to as opting out. There might be massive opposition to opting out, but as I and my noble friends have told the noble Lord before, these hospitals are not opting out. The noble Lord and others and various bodies have suggested that they are opting out, but those are purely scare stories. I do not believe that such stories are worthy of the noble Lord.

We have already had a very full discussion on consultation. I strongly emphasise our commitment to there being full consultation on National Health Service trust applications. I made that clear as regards the previous amendment which the Committee considered and decided on. I also made it clear that such consultation will cover a wide range of interests; namely, the local community, health authorities, CHCs, local GPs and the staff of the potential trust.

To be successful an NHS trust will need the support and commitment of staff. As I have already said, we have made it clear that they will be consulted on applications. We expect those hospitals that are developing proposals for application to discuss their plans with staff. For the reasons so cogently set out by my noble friend Lady Carnegy of Lour, I do not believe that staff ballots are the best way to proceed. It is important to win the support of the staff for trust status and not to divide them by ballot.

Lord Peston

I apologise for interrupting the noble Lord once again, but that is a terribly important matter. Is he saying that when the Secretary of State receives the documentation he will ask the people seeking to become self-governing trusts whether they have consulted all the various groups which the noble Lord mentioned and ask them to say what the consultations have produced? Will the Secretary of State then make clear the basis of his response as regards all the documentation? Can the noble Lord also say whether he is aware of the fact that there are hospitals which are preparing at the moment to become self-governing trusts, which have drawn up all the necessary documentation and which cannot wait for the Bill to become law so that the application can be submitted? Such hospitals have no intention of consulting. Is he not aware of that situation?

Lord Henley

It is for the region to consider consultations. The applicants will forward their applications for National Health Service trust status to the region. It is for the region then to consult. It is then for my right honourable friend and the region to take into account the consultations to the extent that is necessary.

I shall read out part of the document Self Governing Hospitals: An Initial Guide which was published last year: Any successful proposal [for a self-governing hospital] would need to demonstrate that it carried the substantial commitment of those likely to be involved in the new management". Once an application has been prepared the regional health authority, will seek the views of those with an interest, particularly the health authorities concerned, staff at the hospital, general practitioners, Community Health Councils and the local community". Each application will be subjected to careful consultation, given the complicated service, management and financial implications involved.

Before I turn to the amendments themselves I shall deal with a point made by my noble friend Lord Nugent about trust status not being possible without more resource management. We are extending the resource management to all major acute hospitals and investing £78 million in this financial year. Undoubtedly that will help to improve management in all hospitals, but I do not believe that full resource management has to be in place before trust status can be considered.

The information base and management systems available at present are adequate for trusts to fulfil their functions. That is a judgment shared by senior NHS staff Moreover, strength of management systems will be a key criterion in deciding whether to grant trust status. On Tuesday my noble friend described the evolutionary approach. He said that at first there would be only a few dozen units drawn from many which have expressed an interest. As part of that evolutionary approach improvements will continue to be made. I believe that we have a sufficiently firm basis to allow that first wave of National Health Service trusts to go ahead.

The amendments before us propose that there should be ballots of various groups of people. Amendment No. 95A refers to local residents, Amendment No. 95ZA concerns staff of the potential trust and Amendment No. 95C refers to medical staff. Those groups will have to be consulted before a trust can be established. I do not believe that this will be sensible for a number of reasons. First, applications for trust status will include complex and detailed proposals on service, management and personnel matters. These cannot be sensibly reduced to a few simple words as the basis of a ballot.

Secondly, such an approach would effectively give powers of veto to one or more groups of people on an issue where they are not the only people involved. The comparisons that have been made by the noble Lord, Lord Rea, concerning which schools wish to move out of local authority management miss the point. In the National Health Service there is no single clearly defined group of people which is or could be in a position to decide the most appropriate future management arrangements for a particular unit. For example, potential patients could be said to have an interest but such people obviously cannot be identified as a group let alone balloted. Ballots of the local population might be considered as a proxy but it would be a poor one, as some local residents will not be treated at the potential trust while others who live outside the area will be.

Thirdly, there are practical difficulties with the proposals for a ballot. For instance, it is unclear what would happen if the various ballots produced different results. If local residents voted against the trusts and the staff voted in favour, should local residents who may have less information on the proposals than the unit staff be able to prevent a unit opting for trust status against the wishes of its staff? If not, who is to decide between the ballot results? What would be the position if, as may happen, the turnout of local residents was poor but that of the staff was high? Finally, who is to decide the wording of the question and how are we to ensure that it is seen to be fair to all parties?

Ballots would undermine the purpose of the very consultation process which I have described earlier and which we intend to take place. Those consulted would know at the end of the day that their views could be completely discounted by the result of a ballot of a completely different group and could well conclude that the consultation process was a sham. We have heard much about the need for democratic decisions on trust applications but I do not believe that allowing the decision on applications to be subject to the veto of any group would be truly democratic. Rather, it seems to me that these decisions should be taken by the Secretary of State, who is accountable to Parliament, in the light of the views of all those consulted, weighing up carefully the various views which they have expressed. I hope that the noble Lord will feel able to withdraw the amendment.

6 p.m.

Lord Ennals

This has been an interesting debate. I am grateful to all those who have taken part. I have agreed with so much that has been said. I say to the noble Lord, Lord Winstanley, and my noble friend Lord Rea that we are not referring to past ballots.

Past ballots simply show an attitude of the public at that time. I do not suggest that they should be used as a means of determination. If those past ballots had shown a great enthusiasm I would perhaps be a little less worried. I would not wish to make ballots prescriptive in the sense that they would be part of the consultation process. I accept that the Secretary of State must himself decide. If ballots are to be used as a process of consultation, I would want the Secretary of State, a health authority or both together to determine the wording. Of course I want a ballot to be fair.

Lord Henley

This is important. I thought the noble Lord said that ballots should not be prescriptive and that my right honourable friend or whoever might be the Secretary of State would not be bound by them. My reading of the three amendments is that they are exactly that and that the Secretary of State would be bound by them.

Lord Ennals

If the noble Lord were to write into the Bill the words which he read out from the consultative document about the way in which consultation would be carried out, who would be consulted and how the decisions would be taken I should be very pleased. It may be that when I sit down he will say that he is prepared to write into the Bill what he has told me is just what the department intends to do.

Trusts are simply not proven. I would be impressed if, first, there were some system of evaluation. The Government have said that there will be no evaluation and that we must take it at its face value. Like it or not, that is what they are going to do. They are not going to evaluate. If there had been wholehearted support among those affected—doctors, consultants, patients and the community—that would be quite satisfactory. But all the evidence shows that there is great opposition. Perhaps it is based on inaccuracies. Perhaps the Government have not tried to persuade people. Perhaps they have tried and failed. Perhaps the enthusiasts have not tried. I agree with the noble Baroness, Lady Camegy of Lour, that a job of persuasion has to be done. All I have shown is that at the present moment, rightly or wrongly, there is a great deal of opposition.

I would be further impressed if the Secretary of State were prepared to make a statement in advance, as suggested by the noble Lords, Lord Hunter and Lord Carr, in an earlier amendment. The Government say no to all the proposals we have put forward. I would be happy if the noble Lord would give me an assurance that he will write into the Bill the wording that he read out about the method of consultation. At the present time none of the hospitals is advanced enough, as the noble Lord, Lord Nugent, pointed out, to go into this business. The experiment has not been tried. It is said that another two or three years —the noble Lord said four years—will be required. Perhaps he is exaggerating. I do not know. I would be delighted to see the initiative extended to other authorities.

This negative approach and this insistence that regardless of the views of consultants, of the other doctors and staff and of patients this will be done because it is in the wording of the Bill is something I shall not accept. I shall not withdraw the amendment unless the noble Lord tells me that he will put the words which he read out into the Bill itself.

Baroness Carnegy of Lour

Before the noble Lord sits down, does he not agree that this process of winning the hearts and minds of people to the idea, which is what it will be—he has accepted that the idea is a good one and that therefore this is a quite legitimate thing to do—may involve a series of meetings? It cannot be set down in legislation. Some of the hospitals that are thinking of becoming self-governing trusts are quite small. Some are cottage hospitals. That might happen in one meeting. Perhaps the vast majority would not be in favour of it but a considerable majority might. Then there would have to be a decision on whether it should wait and have another meeting. In a larger place it might take a long time to persuade people. I am not sure how things worked in the noble Lord's department when he was Secretary of State but anyone who has run a smaller and less important organisation knows that one achieves change only through consultations and talks and by seeing what other people are doing and receiving information from other places. That is not susceptible to legislation.

The noble Lord has not answered my point. Would not a ballot in a hospital which was narrowly won —I do not agree with my noble friend Lord McColl that ballots would necessarily go against the proposal —be immensely divisive and damaging to the hospital? That would be a very bad idea. I hope that the noble Lord will not press the amendment.

Lord Ennals

Neither I nor other noble Lords who have spoken would have put forward the idea if the Government had indicated that they were prepared to have effective consultation and be ready to take their time. I did not say that I was either against or in favour of NHS trusts. The case is unproven. I do not know whether or not this will be helpful to the health service. That is why I have been so involved over long months in seeking to persuade the Government that they should evaluate proposals before they start changing—whether the number is 36, 78 or 279—across the country. If the noble Lord will give an assurance that he will write those words into the Bill, I shall withdraw my amendment. Otherwise, I shall certainly proceed.

Lord Henley

The noble Lord will understand that I will not give him an assurance that those words will be written into the Bill. But I shall repeat, if the noble Lord would like it, the assurance I gave about the commitment of the Government and of my right honourable friend to have consultation. Would the noble Lord like me to repeat it now?

Lord Ennals

No, I have read it several times.

Lord Henley

The noble Lord says that he has read it several times. I repeat that assurance and that commitment. There will be further guidance as well, which will strengthen that. I hope that in the light of what I have said the noble Lord will feel able to withdraw the amendment.

6.8 p.m.

On Question, Whether the said amendment (No. 95ZA) shall be agreed to?

Their Lordships divided: Contents, 65; Not-Contents, 104.

Airedale, L. Kilbracken, L.
Ardwick, L. Kissin, L.
Birk, B. Listowel, E.
Blackstone, B. Llewelyn-Davies of Hastoe, B.
Bonham-Carter, L.
Bottomley, L. Lloyd of Kilgerran, L.
Callaghan of Cardiff, L. Lovell-Davis, L.
Carmichael of Kelvingrove, L. Mayhew, L.
Meston, L.
Cledwyn of Penrhos, L. Molloy, L.
Cocks of Hartcliffe, L. Murray of Epping Forest, L.
Cox, B. Nicol, B.
David, B. Oram, L.
Dean of Beswick, L. Peston, L.
Ennals, L. Phillips, B.
Ewart-Biggs, B. Pitt of Hampstead, L.
Ezra, L. Ponsonby of Shulbrede, L. [Teller.]
Falkender, B.
Falkland, V. Rea, L.
Gallacher, L. Robson of Kiddington, B.
Galpern, L. Russell, E.
Graham of Edmonton, L. [Teller.] Serota, B.
Shackleton, L.
Grey, E. Stallard, L.
Hampton, L. Stoddart of Swindon, L.
Harris of Greenwich, L. Thomson of Monifieth, L.
Hatch of Lusby, L. Tordoff, L.
Houghton of Sowerby, L. Turner of Camden, B.
Hughes, L. Underhill, L.
Hylton, L. Wallace of Coslany, L.
Jacques, L. White, B.
Jay, L. Williams of Elvel, L.
Jeger, B. Winstanley, L.
Jenkins of Putney, L. Young of Darlington, L.
John-Mackie, L.
Adrian, L. Crickhowell, L.
Aldington, L. Dainton, L.
Alexander of Tunis, E. Davidson, V. [Teller.]
Arran, E. Denham, L.
Balfour, E. Derwent, L.
Bauer, L. Elliot of Harwood, B.
Belhaven and Stenton, L. Erroll, E.
Beloff, L. Ferrers, E.
Belstead, L. Fraser of Kilmorack, L.
Blatch, B. Gardner of Parkes, B.
Boyd-Carpenter, L. Gisborough, L.
Brabazon of Tara, L. Greenhill of Harrow, L.
Brookes, L. Hailsham of Saint
Brougham and Vaux, L. Marylebone, L.
Butterfield, L. Hemphill, L.
Caithness, E. Henley, L.
Campbell of Alloway, L. Hesketh, L.
Carnegy of Lour, B. Hives, L.
Carnock, L. Holderness, L.
Clanwilliam, E. Hooper, B.
Coleraine, L. Howe, E.
Colwyn, L. Killearn, L.
Constantine of Stanmore, L. Kimball, L.
Cork and Orrery, E. Knutsford, V.
Craigavon, V. Lauderdale, E.
Cranbrook, E. Lloyd of Hampstead, L.
Crathorne, L. Long, V. [Teller.]
Lucas of Chilworth, L. Renwick, L.
Luke, L. Richardson, L.
Lyell, L. Romney, E.
McColl of Dulwich, L. St. John of Fawsley, L.
Mackay of Clashfern, L. Saltoun of Abernethy, Ly.
Mancroft, L. Sanderson of Bowden, L.
Merrivale, L. Shannon, E.
Mersey, V. Stodart of Leaston, L.
Mills, V. Strange, B.
Monk Bretton, L. Strathclyde, L.
Monson, L. Strathcona and Mount
Morris, L. Royal, L.
Mottistone, L. Strathmore and Kinghorne, E.
Mountevans, L.
Mowbray and Stourton, L Swansea, L.
Munster, E. Swinfen, L.
Murton of Lindisfarne, L. Terrington, L.
Nelson, E. Thomas of Swynnerton, L.
Nugent of Guildford, L. Thurlow, L.
Onslow, E. Trefgarne, L.
Oppenheim-Barnes, B. Ullswater, V.
Orkney, E. Vaux of Harrowden, L.
Polwarth, L. Walton of Detchant, L.
Prior, L. Whitelaw, V.
Quinton, L. Wolfson, L.
Reay, L. Young, B.
Renton, L.

Resolved in the negative, and amendment disagreed to accordingly.

6.16 p.m.

[Amendment No. 95A not moved.]

[Amendment No. 95B had been withdrawn from the Marshalled List.]

[Amendment No. 95C not moved.]

Lord Hunter of Newington had given notice of his intention to move Amendment No. 95D: Page 6, line 14, at end insert: ("(lA) Three months prior to making an order under subsection (1) above the Secretary of State shall —

  1. (a) publish a document setting out the reasons for establishing each NHS trust and including such detail as is required under this section;
  2. (b) seek the views of the relevant community health council and any other bodies or persons he thinks appropriate, on the document published under (a) above;
and he shall take into account the views expressed before making an order under subsection (1) above.").

The noble Lord said: I have been interested in what the Minister said on various occasions during this afternoon's debate. In my view if he thinks about what is proposed, and what he said, he may well wish to bring forward a provision to clarify the situation. However, if not, I shall be inclined to bring forward a proposal on Report concerned with the Secretary of State ensuring that this was published —that is, all this information about which the Minister has told us—but not that he himself should publish it.

[Amendment No. 95D not moved.]

Lord Walton of Detchant moved Amendment No. 95E: Page 6, line 19, after first ("directors") insert ("including within the latter a specified number of health care professionals employed by and providing clinical services to the trust").

The noble Lord said: In previous debates in this Chamber, and in Committee, I have made it clear that I do not oppose the principle of the formation of NHS trusts, subject to very specific safeguards which I believe are required to control their operation. Indeed, if it were the case that their structure, function and governance were to prove to be in some respects comparable to that of the old teaching hospitals under boards of governors, then there are many aspects about the trusts which I would strongly favour. I am also very much in favour of value for money in the health service, of the introduction of better accounting systems, of quality control and assurance and of the resource management initiative.

As I see it, the three main problems about NHS trusts—self-governing hospitals—are those to which this group of amendments relate. The chairman of such a self-governing trust is to be appointed by the Secretary of State. That is all well and good. However, there are to be a group of executive directors and a group of non-executive directors. As the Bill stands, Clause 5 and Schedule 2 make it clear that employees of the trust, employed in whatever capacity, cannot be appointed as non-executive directors.

However, in Schedule 2 there is a clear specification that in those self-governing trusts which have a major clinical teaching and research commitment there can be a non-executive director appointed by a university. I would hope to see two such university members in order to represent the interests of that university in relation to the teaching and research role of the trust. It is made clear that they shall not be regarded as employees for this purpose.

One of the anxieties that I know is shared by myself and many other members of our profession and the other health caring professions is on the requirement that members of the medical, nursing and other caring professions employed in the National Health Service cannot be appointed as non-executive directors of such trusts. That requirement makes it theoretically possible at least that the entire board of directors could lack a medical, nursing or other professional member employed within a hospital or authority governed by the trust.

I appreciate that in an earlier debate in Committee the noble Lord, Lord Jenkin of Roding, explained his reasons for opposing earlier amendments which we set out which proposed that doctors, nurses and other health care professionals should be specified as members of health authorities. He said that this was because in his view it could result in a potential conflict of interest between providers and purchasers. In self-governing trusts no such conflict of interest could arise, because the self-governing hospital trusts are to be providers.

Hence this group of amendments relates to a single objective: to withdraw the provision within the Bill which would exclude all health care professionals employed in a self-governing trust and its associated hospitals from the opportunity of being appointed as non-executive directors. I beg to move.

Lord Rea

The amendment is similar to the group of amerdments moved on the first day in Committee relating to the constitution of the various levels of the health authority. There is no point in going over these at great length.

I remind your Lordships of what the noble Baroness, Lady Seear, said. She pointed out that it is important when making management decisions for professionals who are actively involved and expert in the services provided to the board to be there with power to argue or discuss on an equal basis with the administration what is to be carried out in the institution. It is only through that action that decisions will be obtained that have a proper chance of being carried out and are based on reality. Otherwise, there will be erroneous decisions that are not likely to be correct. I strongly support the amendment.

Lord Richardson

For 16 years I was a non-executive medical member of the teaching hospitals and governors before they were abolished. I find it difficult to imagine how they could possibly come to the conclusions that would satisfy the non-medical governors if the experts were not present and if those experts did not have local significance as well as medical eminence. I strongly support the amendment.

Lord Ennals

We on these Benches totally support the amendment. I point out to your Lordships the phrase: number of health care professionals". We are not talking just about doctors; they could be nurses, occupational therapists or physiotherapists, but the concept of the professional should be involved. I totally support the amendment.

Baroness Carnegy of Lour

The noble Lord, Lord Richardson, knows everything there is to know about the subject. I am sure that we all appreciate and can imagine that it would be impossible for health service trusts to take decisions which would involve expert opinion without taking that expert opinion.

However, this kind of body takes greater account in many ways of expert opinion if the person is present and makes a professional input. Everybody will listen to it and take more account of it than if a representative is there all the time when sometimes he or she knows all about the subject and sometimes is doing it at second hand. I admit that my own experience was not in the health service. It was on boards running several big further education colleges, but it is not completely dissimilar. The principals of those colleges are not members but are in attendance. Very often principals prefer that because they feel that their opinion carries greater weight than if they are members. I can imagine a health service trust and the professionals getting far better value from the exchange of opinions if those experts come along when their area of interest is considered.

I disagreed with the noble Baroness, Lady Seear, when she made the point. She did so persuasively. She has the experience and holds the opposite view. But that is my experience. I hope that the noble Lord, Lord Walton, will take this point on board. It would lessen the influence of the professionals if they simply had a representative there. Everybody always thinks it best to have a representative present. They think, "That's all right, we shall be there". However, in reality it does not work that way with these bodies. I am inclined to hope that the provision stays as it is and that the professionals are brought in, as of course they must be.

Lord Nugent of Guildford

I disagree slightly with my noble friend Lady Carnegy, with whom I usually agree. I have been privileged to be chairman of a small religious hospital for several years. We formed a board with three consultants on it from the start who are enormously useful. They are high-powered people by their nature as consultants.

I feel that in the whole of this great development which my noble friend contemplates it is vital that leading consultants should be prepared to give time and energy to the management of trusts or to the hospitals which will not be self-governing. At present the management has a great problem in dealing with consultants who are able, high powered and extremely difficult to manage. If one can get a few of them on the board it makes it a little less difficult to deal with the others. That has certainly been my experience.

I hope that my noble friend will be able to give a helpful answer to the noble Lord, Lord Walton, who moved the amendment so cogently. It touches on an important point in the future development of the health service. Consultants generally should give some of their great abilities to the management of the service as well as to the vital part that they play on the medical side.

Baroness Carnegy of Lour

Would my noble friend say that to have one or two consultants as members of this small body is preferable to having them as assessors? I am interested that he has found this to be so. I understand what he says very well, but he has heard the point that I made.

Lord Nugent of Guildford

I speak from experience, although it is narrow experience. We have three powerful personalities who have been extremely helpful. They do not always agree with me, nor I with them; but the total outcome is that we have got things right as we have gone along. We have made major developments on this line that on a much larger scale the NHS trusts will have to make with modem management, computer systems, cost accounting and so on. We have to live with this with some difficulty. I hope that my noble friend will be able to give a helpful answer.

6.30 p.m.

Lord Walton of Detchant

Before the noble Baroness responds, I wish to take up a point that was raised by the noble Baroness, Lady Carnegy. These amendments are very carefully phrased and they do not seek to have a representative of the health care professions on the group of non-executive directors. They simply propose that the present provision in the Bill which excludes them from membership should be removed.

Baroness Hooper

Perhaps I should start by confirming that we are speaking to Amendments Nos. 95E, 95F, 100A, 100B and 100BA. Does the noble Lord, Lord Dainton, wish to speak?

Lord Dainton

I should like to speak on Amendment No. 100BA. This matter follows on rather nicely from the previous point. It is inconceivable to me, and it certainly would be inconceivable to the chairman of my special health authority at Hammersmith, that there should not be a medical man as a director in some form or another of the trust, were it to become a trust, for the simple reason that he handles a large budget. He has his own cost centre, which is extremely important. How he spends his budget is of vital importance financially to the operation of the hospital.

However, my Amendment No. 100BA relates to the question of persons who may be appointed executive directors of those NHS trusts which have responsibility for teaching hospitals. Clause 5(2)(a) makes it clear that executive directors must be employees of the trust. I underline the word "must". I think that has been explained. However, non-executive directors cannot be employees. Paragraph 3(2) of Schedule 2 to the Bill, to which all these amendments refer, underlines the latter point by stating that a person paid by a university, but who holds an honorary contract with the trust, must nevertheless be deemed not to be an employee of the trust and therefore may not be appointed an executive director of the trust.

The Committee may regard that point as being somewhat trifling and of little practical significance, and a matter that is of only academic importance in both meanings of the word. However, in some teaching hospitals some of the full-time academics are chiefs of service. They come into the category that I spoke about at the beginning. In one hospital, Hammersmith, almost every one of them is a chief of service. If there were to be a trust established at Hammersmith herefore, it is inconceivable that the person best suited to be an executive medicaldirector of the trust would not be one of those full-time academics. In my view, that they should be disbarred from that post is not only plainly ridiculous but would work to the great disadvantage of the trust and the operation of the hospital.

The effect of this amendment, if passed, would simply be to remove that barrier. I should explain that the problem has already been raised by the Standing Committee on the National Health Service and Community Care Bill in another place by Sir George Young. That committee tabled an amendment at the Report stage, but because of lack of time it was not discussed. In those circumstances this amendment, or some equivalent, seems essential if we are not to become the victim of a ridiculous situation. I hope that at the very least I can gain an assurance from the Government that they would be prepared to remove this obstacle to the appointment of a full-time academic clinician as an executive director of an NHS trust, where such a person is clearly the most suitable.

Baroness Hooper

I have listened with great care to the arguments on these amendments about the position of health care professionals and academics in relation to non-executive and executive membership of National Health Service trusts.

I shall deal first with Amendments Nos. 95E and 95F standing in the name of the noble Lord, Lord Walton of Detchant. The Government believe that health care professionals have a vitally important role to play on the board of directors of trusts. To that extent we are totally in agreement. However, we believe this can best be achieved through their appointment as executive directors, not as non-executives. We have made clear that in the majority of cases the executive directors will include a senior nurse manager and medical director, and we shall provide for this in regulations. This will ensure that the view of the professionals is properly heard on the board. That assurance was given in the White Paper and in the course of debates in another place and it is referred to in our Notes on Clauses.

Further, the appointment of health care professionals employed by the trust as non-executive directors would blur the distinction between executive and non-executive directors, which we consider to be important. In appointing non-executive directors we and regional health authorities, which will also be involved, will be looking to appoint people who can bring different skills and experience to bear on the complex job of managing a trust—my noble friend Lord Nugent emphasised that point—in the same way as companies do when they appoint non-executives. We shall also expect at least two of the non-executives to be drawn from the local community and thus to provide links between the trust and the locality. These very important aspects of board membership would be lost if the board were to consist largely of health care professionals, important and valuable as their input is.

As in the case of the district health authorities and regional health authorities that we discussed previously, we have made clear that the non-executives will be appointed for the personal contribution they can make to the management of the trust and not to represent any particular interest group. Again we are at one with the noble Lord, Lord Walton, on that. I do not wish to suggest that any professionals appointed as non-executives would not always act with the best interests of the trust in mind, but there must be a concern that they would be seen as representing particular professional interests.

I do not believe that the proposal contained in these two amendments would strengthen the management of trusts. Rather it may weaken it by depriving trusts of the variety of skills which they will need at board level. While I understand the noble Lord's concern, I hope that, in the light of the points I have made, he will not press his amendments.

Turning next to Amendments Nos. 100A, 100B and 100BA, I am much closer here to the noble Lords, Lord Walton and Lord Dainton, although I still cannot fully endorse their amendments. The Government are firmly committed to improving collaboration between the National Health Service and universities. We have already touched on this matter in our discussions. I hope to explain how we intend to act on this commitment in relation to NHS trusts in more detail when we come to Amendment No. 97 shortly.

For the present, let me stress that membership of NHS trusts will take account of their teaching role where appropriate. Each teaching trust will contain a non-executive member drawn from the university or medical or dental school. This member could also be an employee of the trust —the Bill contains special provision to allow for this. I believe it is right that this role is non-executive, so that its holder speaks clearly with a university voice.

Moreover, the Bill allows university employees who are also employed by the trust to be appointed as executive members of the board. We accepted amendments in the other place to ensure that this possibility was not inadvertently precluded—the amendment of my honourable friend Sir George Young may not have been discussed but it was accepted by the Government—for any potential trusts where senior doctors are primarily employed by the medical school or institute concerned. In the example mentioned by the noble Lord, Lord Dainton, I assume that although there was full-time employment by the university, some kind of honorary contract also existed with the unit.

There are therefore two routes—executive and non-executive—by which the voices of those having split contracts with both NHS trusts and medical schools can be heard on the NHS trust board. That is certainly our aim. I shall consider carefully what is now provided in the Bill as a result of amendments in another place and what has been said today, and if necessary I shall bring back suitable amendments at a later stage to make the position absolutely clear if it is felt that it is not.

The Bill does not prevent full-time university employees who are not also employed by the trust from filling other non-executive places on the board in a personal capacity. The criterion in such case will, as always, be finding the best person for the job. On that basis I hope that the noble Lords will be reassured and will feel able to withdraw their amendment.

Lord Walton of Detchant

In the light of the assurances given by the noble Baroness, and in particular in the light of her comment to the effect that the executive directors shall include by regulation a specified number of health care professionals, I am delighted to withdraw the amendment.

I am very pleased to hear that a university employee may be appointed as a non-executive director. That might even —and I speak surrounded by four past university vice-chancellors—on occasion be a vice-chancellor. I am therefore delighted to beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 95F and 95G not moved.]

[Amendment No. 95H had been withdrawn from the Marshalled List.]

Clause 5 agreed to.

Lord Hunter of Newington moved Amendment No. 96:

After Clause 5, insert the following new clause:

("Hospital Incentive Fund.

x2014;(1) The Secretary of State shall establish a fund to be known as the Hospital Incentive Fund ("the Fund").

(2) The purpose of the Fund shall be to encourage hospitals to develop new approaches to more effective management of hospital resources and to provide enhanced care for patients.

(3) The resources of the Fund shall come partly from hospitals and partly from the Secretary of State who shall contribute an amount equal to that contributed by hospitals up to a limit of £250,000 in each case.

(4) The provisions of this section shall apply to all hospitals including those falling within NHS trusts and authorised to hold a budget.").

The noble Lord said: It is obvious that the question of the trusts is a complicated business. One wonders what opportunities exist for modest initiatives in the health service to make employees feel that their own efforts can achieve something and also to help them change to meet the needs of the population.

This is being sentimental, but I remember well when we took over the Poor Law hospital in Dundee in 1948. As a result of all the help that we received, in 10 years' time we had a hospital which was worthy of the name.

It is suggested that there should be a hospital initiative fund. Such a fund has already been introduced in Canada with great success. Any hospital could apply to do something which it considers important in its own circumstances although it may be modest in relation to the formation of hospital trusts.

A few moments ago in connection with a previous amendment I cited the example of the hospital near a motorway which decides to change its role from that of simply a district hospital to one with a very heavy responsibility for accident and emergency surgery. It is suggested that the fund should be established and that it should be known as the hospital incentive fund. It should be open to all hospitals to encourage them to develop new approaches to more effective management or enhance the care of patients. The provision should apply to all hospitals, including those falling within trusts and authorised to hold a budget. Perhaps the Government might like to give the idea some consideration. I beg to move.

Lord Butterfield

Before the Minister replies I should like to say that I believe that this kind of fund could be of immense help, particularly to the young managers who will have to emerge to help the trusts forward. My only concern is whether what I take to be a total of £500,000 each year will be enough when divided between the total number of hospitals which might apply. I should like to support the noble Lord, Lord Hunter of Newington, and his proposals.

Lord Kilmarnock

I also should like to support the amendment. In times gone by my party had a commitment to a National Health Service development fund, with the somewhat ambitious sum of £500 million. Various National Health Service units would submit bids to the fund for the ideas that they put forward. On reflection I believe that the scheme proposed in the amendment is rather better because it is related to the individual hospital. According to my calculation, if 260 acute hospitals all took up the offer, putting their share on the table and requiring the Secretary of State to put his share on the table, the operation would be a great deal cheaper. It would also be more closely related to the needs of the individual hospital. I believe that that is an improvement on our idea.

The only query that I have relates to the fact that the noble Lord, Lord Hunter, referred to all hospitals. I am not sure whether he included small hospitals such as community hospitals and cottage hospitals. If not, I believe that some provision should be made for them, possibly at a lower rate.

6.45 p.m.

Baroness Blatch

I listened with care and interest to the points made by the noble Lord, Lord Hunter, and the support that he enjoyed from the noble Lords, Lord Butterfield, and Lord Kilmarnock. I note the points that he made including that relating to the experience in Canada.

The Government share the objectives of making the most effective use of hospital resources and improving patient care. They underlie the changes in the Bill and those already under way in the National Health Service. Perhaps I may give a small number of examples of the type of initiative already in hand.

Many Members of the Committee will be familiar with the resource management systems which will be introduced into large acute hospital sites by 1993. Those systems focus on organisational development and the involvement of doctors and nurses more fully in the management process. We are investing £78 million in resource management in the present financial year.

We are also investing in management development, and £60 million has been allocated in 1990-91 to help authorities to recruit and train staff. All regional health authorities are preparing integrated management development programmes. In addition the NHS Management Executive, the Institute of Health Services Management, the Open University and the NHS Training Authority are also playing their part.

In addition the National Health Service Management Executive has embarked on an ambitious programme to improve communications within the NHS. A series of regional meetings with chief executive Duncan Nichol has provided a strong launch pad for this exciting new development.

I hope that those examples demonstrate our commitment to improving quality and standards and our willingness to invest in them. Of course it is not a task only for central government. Health authorities often pioneer such developments themselves. We do our best to spread the results throughout the NHS.

I am not convinced that a special fund is essential to ensure that those developments take place. The Government already have power to fund developments such as resource management and there is nothing to prevent health authorities using their funds to support the innovative projects suggested by the noble Lord. Indeed there must be a theoretical danger that the existence of a central fund, far from acting to stimulate initiative, could hinder locally inspired and funded projects. Our proposals as a whole are designed to give local managers and doctors every incentive to take forward innovation and quality at the local level. I believe that they will rise to the challenge.

In putting the amendment the noble Lord, Lord Hunter, made a very important point. I hope that I have been able to reassure him that we share both the aims and objectives of the amendment. However, it is the view of the Government that they will be achieved in the way set out in my response to the amendment. Perhaps the noble Lord will feel able to withdraw his amendment.

Lord Hunter of Newington

In view of the Minister's very helpful reply and the great deal of information which she has supplied on what is going on in the management field which has not been available to all Members of the Committee, at this stage I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 2 [National Health Service trusts]:

Lord Dainton moved Amendment No. 97: Page 65, line 33, at end insert: ("(3) A draft of the first order to be made under section 5(1) of this Act in relation to NHS trusts which have a significant teachirg and research commitment shall be laid before each House of Parliament and that order shall not be made unless the draft has been approved by a resolution of each House.").

The noble Lord said: I am sorry that the noble Baroness, Lady Young, is not able to be present. Therefore, I must speak on her behalf In speaking to Amendment No. 97, I should also like to speak to Amendments Nos. 98, 99, 100, 101, and 101B to 101F.

I am quite clear from the debates on Second Reading and the earlier debates we have had during this Committee stage that your Lordships are fully seized of the vital importance of good teaching and research now in order to secure a high quality of health service in the future, however that health service comes to be delivered, whether through health authorities, as at present, or through the trusts proposed in the Bill.

The present position is that health authorities will still have a duty under that part of the 1977 Act which will still apply to provide the necessary resources and support for medical and dental teaching of high quality where that is required because of the operation of a university medical or dental school in hospitals which are administered by that health authority. However, the NHS trusts to be established under this Bill are not so required to provide these facilities. Instead, it is stated in paragraph 11 of Schedule 2 on page 67 that such a trust, may undertake and commission research and make available staff and provide facilities for research by other persons [and] may … make facilities and staff available in connection with training by a university".

The Committee will notice that this is purely permissive and does not represent a requirement on the trust. We who have put forward this amendment believe there should be a requirement. Amendment No. 101, which is the last of this group, would impose a specific duty on the trust to provide those facilities and staff which are reasonably required by the university for clinical teaching and research in medicine and dentistry.

Furthermore, because we believe your Lordships will attach great importance to any order which the Secretary of State may make under this Bill if it becomes an Act —-an order which relates to teaching and research commitments which the NHS trusts should have—we would also propose Amendment No. 97, which is the first of those I have mentioned and which would make such an order subject to affirmative resolution by each House of Parliament.

The intermediate amendments, Nos. 98, 99 and 100 respectively, provide for various other things. Amendment No. 98 couples research with teaching so that sight shall not be lost of the extra cost associated with research. That is a matter which I understand from discussions that members of your Lordships' Select Committee had with the Secretary of State yesterday is already under investigation by the department.

Amendment No. 99 strengthens the provision to secure not just one non-executive director but more than one. In view of what was said by the noble Baroness in reply to an earlier amendment, I take it that that can mean two medical people, if necessary. That is of particular importance in cases where there are both medical and dental schools and also where there is a very large medical school spread over many hospitals. Moreover, those likely to be appointed will usually have clinical patient care responsibilities which must necessarily have the first claim on their time. I know from my own experience, not as a clinician but having to chair a committee on which we want clinicians to be present, that quite often they are unable to be there. To have two members would ensure that at least one well-qualified university director would be present at all board meetings.

Amendment No. 100 would simply delete the words "medical and dental schools", for the simple reason that there is no medical or dental school in the country which is not part of a university. Therefore that phrase is redundant. Incidentally, this correction would also bring the phraseology of the Bill into line with that of the principal Act or those parts of it which are unchanged.

I very much hope that the Government will be willing to accept these amendments or to incorporate something like them in the Bill at Report stage. I hope that they may, because the Government's response to the report from the House of Lords Select Committee on Science and Technology states: Research is crucial to the future ability of the NHS to meet the needs of its patients".

It was also clear from the meeting of your Lordships' Select Committee with the Secretary of State yesterday and with the Minister responsible for higher education that the Government do indeed attach great importance to providing facilities for high quality teaching and research in hospitals where this is needed by a university medical or dental school. I beg to move.

Lord Walton of Detchant

I wish to support very warmly this group of amendments proposed by the noble Lord, Lord Dainton. The present position is that hospitals which do not opt for trust status have a duty to provide the necessary resources and support for medical and dental teaching of high quality under the National Health Service Act of 1977. However, there is no such requirement in this Bill where NHS trusts are concerned. All that is provided is a reserve power for the Secretary of State under Schedule 2, paragraph 6, which can be summoned up in the event of a failure of the discretionary powers contained in Schedule 2, paragraphs 10 and 12. A trust might be tempted to cut comers and save money by not supporting either the range or standard of disciplines and facilities required for teaching and research concerning medical and dental students and other professional staff.

I believe it is essential that research and teaching are maintained and enhanced by this legislation and that there are proper safeguards at all levels on the face of the Bill to ensure that this is the case. Research in the National Health Service cannot be separated from patient care and service delivery. There is a tripartite nature of medical practice: treating patients today, teaching and training future staff and undertaking research and development, since today's development in basic research is tomorrow's development in patient care—a point which I think was stressed by the noble Lord, Lord Beloff, in his contribution to the debate just a week ago tonight.

Finally, let me just say that Schedule 2 as it stands merely enables and empowers NHS trusts, even those which are at present in teaching hospitals, to undertake and commission research and to make facilities and staff available in connection with training. It does not require them to do either. Reliance upon reserve powers for the Secretary of State is not, in my view, sufficient. I therefore wish to support this group of amendments.

Lord Adrian

I too support this group of amendments. In doing so, I should like to cite just one example of the kind of research done in Cambridge. However, there are countless other examples that could be described. Everyone has heard of Professor Sir Roy Calne and the pioneering work he has done in liver transplants at Addenbrooke's Hospital. The work was developed at Addenbrooke's as a result of the efforts of a university professor and his team working in a teaching hospital. The approach is now known to be successful and the work is funded by a special supra-regional mechanism through the National Health Service.

However, the question arises: how would a new form of treatment, as liver transplantation was at one stage, untested and potentially very expensive, be introduced in tomorrow's health service? Managers will be under very great pressure to take a short-term view and they will be well placed to judge the costs of treatment, but will they have the wisdom to recognise the long-term benefits? This is especially likely to happen in a situation comparable to liver transplantation, as it was when Sir Roy Calne started his work, where the number of patients available in the district served by the hospital was too small to provide a sufficient financial return to offset the cost of developing the treatment.

It seems to me and, I think, to the other supporters of this group of amendments that unless teaching hospitals which become NHS trusts have a duty to provide facilities and staff for both teaching and research, research and teaching will suffer and ultimately the National Health Service itself will be the loser.

7 p.m.

Lord Peston

The group of amendments includes two separate sets of ideas. Amendment No. 97 deals with procedures in this Chamber and in another place with respect to affirmative resolutions rather than the other way round. The other amendments deal with matters of substance. We support the amendments by arguing that the best way is to put the matters on the face of the Bill.

I do not know what the noble Baroness will say in reply but if the amendments are not acceptable to the Government I hope that she will use the few minutes that we have to comment about two matters which would then be relevant. The first is the point made by the noble Lord, Lord Walton, about the reserve powers of the Secretary of State. If the amendments are not acceptable will she say that she is clear in her mind that the Secretary of State will use his reserve powers to guarantee that the interests of the teaching hospitals are fully protected?

The second point that the noble Baroness could clarify arose in our earlier debates about ballots and so forth. The proposed NHS trusts will be putting proposals to the Secretary of State. Will the noble Baroness state in terms that the Secretary of State will not accept from any hospital proposing to become an NHS trust a set of proposals which do not fully guarantee the position of teaching and research? Furthermore, will such a set of proposals, if accepted by the Secretary of State, then become binding? That is central to all of our concerns.

The easiest way is to follow the suggestions of the proposers of the amendments; namely to accept them. However, the alternative is to comment on how the Secretary of State will use his reserve powers, how the proposals will be treated and what will be the legal status of the proposals once they are agreed.

Earl Russell

I should like briefly but warmly to add my support to the amendments. A teaching hospital is a beast a little like a centaur. It is both a university department and a hospital for treating patients. If you wish to produce an immaculately turned out centaur you have to supply it with both a groom and a valet. In this context I hesitate to suggest which might be which but it is our suspicion that the Bill provides for one a great deal better than for the other.

The life of a teaching hospital depends on its being recognised both as an academic institution and as an institution for treating patients. It is the classic example of what academics have always said; that the processes of teaching and research cannot be separated. In that context, unless they are both equally secure, we cannot feel secure about the future of our teaching hospitals. Many of them have served this country with great distinction and I should like to see them continue to do so.

Lord Butterfield

I wish to support the amendments and to raise a further question. It harks back to some pointed and well chosen remarks made recently late at night by the noble Baroness, Lady Robson about research being carried out by the medical charities. The total number of people under the research umbrella in the direct university central teaching hospitals and in hospitals where university teaching: is carried out in the regions is rising and keeping pace with the research demands that are emerging. The work is being carried out more and more by young people who are supported by the medical charities. As regards the number of clinical teachers who are working for the universities there has been a 19 per cent. drop in the resources available to them from the university funding centres.

I hope the group of amendments will be bundled up and carried. I am anxious that there should be someone in a powerful administrative position able to keep an eye on and look after the future of the growing number of young people who are carrying out research which is a reflection of what people want. People make their contributions to research in cancer, the heart, lungs and kidneys—we have heard about Roy Caine —and they wish to have more research carried out in those fields. The people who come forward to carry out that work will be helped if hospitals have to have someone in the central administration who can understand the needs of those young people.

Baroness Hooper

We have previously touched on the important subject of the relationship between National Health Service trusts and universities. It will be as important for NHS trusts as for the rest of the NHS to develop effective and close working relationships with universtities. The Government are most concerned to build on these links at all levels in the NHS. That was made quite clear in the letter sent in February to all NHS managers by the Permanent Secretary at the Department of Health. The Permanent Secretary's steering group on undergraduate medical and dental education is continuing to work on the issue.

As I said previously, I do not share the fears of some that NHS trusts will somehow seek to abandon their teaching responsibilities and place universities in an impossible situation. High quality teaching will be a touchstone of the quality of service offered by a NHS trust. No trust which was seen to be reneging on its teaching commitments would inspire confidence in any potential purchaser of its services in order to survive. We recognise the anxieties that have been expressed not only today and therefore we are taking very clear steps to ensure that that does not happen.

If close working is to be maintained and enhanced clearly a voice with university experience is needed at the highest level in the decision-making bodies of the trusts. We recognise that. I hope that I have clarified the fact that clinical academics are now able to be appointed as non-executive or executive members of NHS trusts, depending on local circumstances.

Turning to Amendment No. 99 in detail, I am not convinced that in all cases there needs to be more than one person drawn from a university on the board of a NHS trust. The size of the boards will be limited in order to ensure that they operate in an effective and business like manner. It will not be necessary to designate more than one of the non-executive directorships to a university appointee. There is of course no reason why other non-executive members should not be drawn from a university if they have particular skills which can be used to help in the effective management of the trust. They would of course be serving in a purely personal capacity but would nevertheless bring their wider experience to bear.

Membership of the board alone will not be the only link which exists. Clearly, arrangements will evolve at working level between the two organisations. Many of the arrangements which evolve for working level co-operation will be non-statutory, but I draw the Committee's attention to the fact that NHS trusts will be able to form sub-committees composed of members and non-members of the main board to aid them in specific tasks. I am quite sure that in appropriate circumstances people drawn from universities will be involved.

The noble Lord, Lord Dainton, raised a particular question on the precise wording of the Bill and the phrase covering the appointment of a non-executive member "from a university or medical or dental school", which is based on precedent in the National Health Service Act 1977. I have not been made aware that that has caused problems in the past in any way, but I shall look again at this matter in the light of the points that have been raised.

With regard to Amendment No. 98, the effect of the proposed amendment would be to bring the provisions for membership which I have described into play only where a trust had a significant commitment to both teaching and research. The Government's commitment to research has consistently been emphasised in our debates including the one last Tuesday about the director of research and development and by my right honourable friend the Secretary of State at the Select Committee yesterday. I emphasise simply that the provision for the appointment of non-executive directors is intended specifically to cover the interests of undergraduate education. It is, of course, extremely unlikely that any trust with a significant teaching commitment would not also be involved in research, but there seems no reason to limit non-executive directors appointed from a university in this respect.

I now turn to Amendment No. 101. Because of the importance which we attach to undergraduate medical education and research, we shall specifically recognise it in the establishment orders of teaching trusts. The Bill contains express provision for that. This in itself is an improvement on the present legal situation, where there is no statutory definition of the teaching role of any National Health Service authority or unit. Secondly, we have made clear that National Health Service trusts will be expected to continue to play their part in making clinical facilities available, as I have already explained to the Committee. The Bill gives trusts specific powers to enable them to do that. Moreover, it gives the Secretary of State powers of direction in respect of the exercise of such powers by trusts. I do not believe that the behaviour of trusts will be such as to make the use of those powers necessary but it is important that they are in place so that any problems which arise can be tackled swiftly.

Moreover, as was pointed out in the Permanent Secretary's letter, to which I have referred. National Health Service trusts will be directly accountable to the Secretary of State, who will wish to satisfy himself not only that a trust has undertaken to provide adequate facilities for teaching and research and has made the necessary arrangements for collaboration, but, above all, that these undertakings have been met in practice. NHS trusts will be expected to include an outline of the provision which they intend to make for teaching and research in their annual reports and forward business plans. I am confident that this process and the process of monitoring a contract by district health authorities will ensure that the Secretary of State has ample early warning of problems. It is not therefore in my view necessary to make any further special provisions with regard to teaching NHS trusts.

Perhaps I may explain this by turning to Amendment No. 101 in detail. That duplicates, in part, Section 51 of the National Health Service Act 1977 which requires the Secretary of State for the whole National Health Service to make available such facilities as are reasonably required by a university medical school for clinical research. That section will remain in force. But it is a duty which bites on the Secretary of State. As far as National Health Service Trusts are concerned, the Secretary of State will ensure that his duty is met by the process of careful scrutiny of plans and performance and, if necessary, use of reserve powers to which I have just referred. I hope that in some way that reassures the noble Lord, Lord Peston. I believe that the amendment would not add to this and could in fact create a new and unnecessarily rigid system as well as undermining a trust's freedom to manage its own affairs.

As we have already discussed we believe that the correct way for health authorities to negotiate service delivery patterns will be through the contracting process. If we are to tie National Health Service trusts as rigidly as the amendment proposes, their ability to provide services through negotiated contracts would then be limited. I do not believe that that would be in the interest of the trust, nor of the health authorities which arranged services with it. Nor would it ultimately be in the interests of the medical school or university, as it might tend to ossify service patterns and prevent teaching being spread to centres away from the main university hospitals, a trend on which many Members of the Committee have commented with approbation. The necessary safeguards are, however, there in the duty and powers of the Secretary of State.

Finally, perhaps I may turn to Amendment No. 97, which proposes that the establishment of NHS trusts with a significant teaching and research commitment should be subject to affirmative resolution by both Houses of Parliament. As we have established, our plans for the creation of National Health Service trusts will be preceded by thorough consultation. The university and medical school will obviously have views on the subject and these will be most carefully considered. Similarly, all views from members of the public and local and community organisations will also be taken into account. I do not believe that additional scrutiny in this Chamber is a necessary addition to that process.

I say that for two reasons. First, the creation of a National Health Service trust is primarily a management change at operational level. It is not about an issue of principle. After all, the issue of principle is being debated today, as is the legal framework which is necessary to carry the principle into effect. I do not think it is right that the individual application of that principle, if the Committee agrees with it, should then be tested in case after case. It is the duty of the Secretary of State to manage the National Health Service, a task for which he is fully responsible to Parliament. Of course either Chamber can raise questions about his stewardship and both will no doubt want to track the progress of the National Health Service trusts with particular care. Indeed, I can certainly see one Member of the Committee who will do that. However, that is a rather different proposition from saying that they should second-guess him in each individual decision, which is the spectre that this amendment raises in my mind.

Secondly, such a move would be wholly unprecedented in the National Health Service. At present the Secretary of State has power to establish health authorities, vary their boundaries and create special health authorities. None of those powers is exercisable by affirmative resolution. However, I can assure the Committee that we shall take very careful account of any points made about any individual application for trust status when reaching a decision on whether it should go forward in the first place.

The Committee has been very patient and I have spoken at great length because I appreciate the depth of interest and concern that this issue arouses. I am pleased to have had an opportunity to put the Government's response fully on record and I hope that I have said enough about plans in terms of both management and legislation to persuade the movers of these amendments to withdraw them.

7.15 p.m.

Earl Russell

Before the noble Baroness sits down perhaps she could answer a question raised by the noble Lord, Lord Walton of Detchant. Can she say why, since the Government's commitment to research continues they have chosen not to continue the duty to undertake research which exists in present law?

Baroness Hooper

I am sorry but I am not sure that I follow the question of the noble Earl.

Earl Russell

It is very simple. I asked why the Government have chosen not to continue the duty on hospitals to do research which exists in present law. The point made by the noble Lord, Lord Walton, was that the duty exists at present. The Government are causing it to cease to exist. I wondered why.

Baroness Hooper

I am not aware that that is the case.

Lord Walton of Detchant

The point that I made was that under the 1977 National Health Service Act there was a duty to provide the facilities for teaching and research within NHS hospitals. It is not prescribed in the Bill as a duty upon NHS trusts. The Secretary of State simply has powers to take action if the trusts do not fulfil that function, which is binding on hospitals which will not be self-governing trusts.

Baroness Carnegy of Lour

As a total layman, my concern is to ensure that if a hospital trust takes on the task of being a teaching hospital, the requirement to do what a teaching hospital now has to do should not be weakened. That is the point, however it may be accomplished.

Members of the Committee may smile at my simple example but it is one which I know about. When I visit the dean of medicine at the university in Dundee, I go to his room at the hospital which the noble Lord, Lord Hunter, founded, Ninewells Hospital. If Ninewells Hospital was at any time to become a self-governing trust, I hope that it would be no easier for it to say, "We are short of money. We cannot give the dean of medicine a room", than it is now. That is basic to the way in which the hospital operates. It is a very small example but one that I am sure my noble friend will understand.

Lord Butterfield

Perhaps I may help the noble Baroness as she answers the question raised magnificently by the noble Earl, Lord Russell. We have to be very careful. Some of the NHS trusts may not be hospitals. In East Anglia the ambulance service in Norwich is anxious to explore the possibility that it should be a trust. I hope that that provides some excuse for the omission. Nevertheless I stand firmly behind my support for this very important amendment.

Baroness Hooper

I am most grateful to my noble friend and to the noble Lord, Lord Butterfield. I am sorry if I appeared obtuse. It seemed to me that I had responded to the question raised by the noble Lord, Lord Walton, in my reply when I said that the relevant section of the National Health Service Act 1977 would remain in force. That is a duty which bites or the Secretary of State. However, it is perfectly true that, while that duty will remain in relation to hospitals, some trusts will not be hospitals, as the noble Lord, Lord Butterfield, pointed out. It therefore cannot be a duty for all trusts in that sense.

Lord Dainton

I find myself in considerable difficulty. Although the noble Baroness has spoken at very great length and I have heard a large number of words, I am still perplexed at the reply. If she has stated that the Secretary of State in his approval of the trusts would ensure that the duty would in practice, by whatever means, fall upon those trusts which have within them responsibilities for providing the facilities for teaching and research at university medical and dental schools, I shall be satisfied.

Baroness Hooper

Perhaps I may clarify that that is the case.

Lord Dainton

I am greatly relieved to know categorically that that is the case. It makes my job a good deal easier. But it leaves me with the strange logic that one has two institutions—on the one hand the health authority and on the other the trust—performing very similar tasks. One has a constitution under which it is not required to provide facilities for university medical and dental schools and the other has nothing so prescribed within the Bill. I still find that extremely strange.

However, I shall read the noble Baroness's words with very great care. If the matter seems adequately covered at that stage I shall withdraw the amendment. I withdraw it at present, but I hope that it will be possible to return to the matter if on careful examination what has been said seems to merit a re-examination and a return to the point. It is rather complicated. I thank the noble Baroness for that long explanation. I believe that we are all ready for dinner now.

Amendment, by leave, withdrawn.

Baroness Blatch

I beg to move that the House do now resume. In so doing I suggest that the Committee does not reconvene on the Bill before twenty-five past eight.

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

House resumed.