National Health Service and Community Care Bill

HL Deb 12 June 1990 vol 520 cc240-84

Consideration of amendments on Report resumed.

[Amendment No. 120 had been withdrawn from the Marshalled List.]

Lord Young of Dartington moved Amendment No. 120A: After Clause 19, [In substitution for Amendment No. 120], insert the following new clause:

("Clinical and General Standards Board

.—(1) There shall be established in accordance with this section a Clinical and General Standards Board (in this section referred to as the Board) which shall have the following functions in connection with clinical and general care—

1. (a) in accordance with a request made by the Health Ministers or any one of them, to provide advice on the standards of clinical and general care for, and the access to and availability of services to, national health service patients and, in this connection, to carry out such investigations into such matters (if any) and to make such reports in relation thereto as the Health Ministers may require;
2. (b) in accordance with a request made by one or more health services bodies, to provide advice on. to carry out investigations into and report on the standards of clinical and general care for, and the access to and availability of services to, national health service patients for whom services are or are to be provided by or on behalf of the body or bodies concerned:
3. (c) to initiate and carry out its own enquiries as and when it deems necessary;
4. (d) to set clinical and general standards, assess trends and give independent advice to the Health Ministers on the performance of the health service nationally;
5. (e) to monitor and secure improvements in the quality of the health services at all levels and in all regions;
6. (f) to identify and make known more widely good practice and promising developments and draw attention to weaknesses requiring action;
7. (g) to make an annual report to Parliament:
8. (h) such other functions as may be prescribed by regulations.

(2) The Board shall consist of a chairman and other members appointed by the Health Ministers from persons nominated by the Royal Colleges, the other health professions and consumer orga[...]isations or other such body or bodies as may be specified in regulations; and

1. (a) such regulations may provide that one or more of the members who are not appointed from persons so ominated must fulfil such conditions or hold such posts as may be so specified; and
2. (b) regulations shall provide that the Board shall appoint a Director of Clinical and General Standards who shall report to the Board on particular bodies within the health service and make such reports public.

(3) Regulations may make provision as to—

1. (a) the appointment, tenure and vacation of office of the chairman and members of the Board;
2. (b) the appointment of and the exercise of functions by committees and sub-committees of the Board (including committees and sub-committees consisting wholly or partly of persons who are not members of the Board);
3. (c) the procedure of the Board and any committees or sub-committees thereof; and
4. (d) the attendance at meetings of the Board or any committee or sub-committee thereof of persons appointed by the Health Ministers and the extent of their participation in such meetings.

(4) Proceedings of the Board or of any committee or sub-committee of the Board shall not be invalidated by any vacancy in membership or by any defect in a member's appointment or qualifications.

(5) The Health Ministers—

1. (a) may pay to the chairman and members of the Board, or of any committee or sub-committee of the Board or any persons appointed as mentioned in subsection (3)(d) above, such sums by way of remuneration and travelling and other allowances as the Health Ministers, with the consent of the Treasury, may determine;
2. (b) shall make available to the Board and to any committee or sub-committee thereof such professional staff and other services or facilities as are necessary to enable them to carry out their functions; and
3. (c) shall defray such expenditure as is reasonably incurred by the board in carrying out their functions.

(6) Where the Board carry out an investigation or make a report in accordance with a request made by a health service body, that body shall reimburse, in such manner as the Health Ministers may determine, so much of the expenditure incurred by them under paragaphs (a) and (c) of subsection (5) above as they certify as being attributable to the carrying out of that investigation or the making of that report.

(7) In this section— clinical and general care" means any action which is taken in connection with the diagnosis of illness or the care or treatment of a patient; the Health Ministers" means the Secretaries of State respectively concerned with health in England, in Wales and in Scotland; health service body" means—

1. (i) a health authority, within the meaning of the National Health Service Act 1977,
2. (ii) a Health Board or Special Health Board constituted under section 2 of the National Health Service (Scotland) Act 1978,
3. (iii) a State Hospital Management Committee constituted under section 91 of the Mental Health (Scotland) Act 1984,
4. (iv) the Common Services Agency for the Scottish Health Service,
5. (v) a National Health Service trust constituted under Part I of this Act or under the National Health Service (Scotland) Act 1978, and
6. (vi) a Family Health Services Authority;

national health service patient" means any person for whom any services are or are to be provided by or on behalf of a health service body; regulations" means regulations made by the Health Ministers and any such regulations may make different provision for different cases or descriptions of case, including different provision for different areas; and services" means services provided—

1. (a) in England and Wales, by virtue of directions under section 13 or section 14 of the National Health Service Act 1977 or section 5 of this Act; or
2. (b) in Scotland, by a health services body under Part I or Part III of the National Health Service (Scotland) Act 1978; or
3. (c) pursuant to an NHS contract, as defined in section 4(1) of this Act or section 17A of the National Health Service (Scotland) Act 1978.").

The noble Lord said: My Lords, noble Lords will have noticed that there are two apparently very similar amendments in the Marshalled List—Amendments Nos. 120A and 198. Both concern the broad question of monitoring and quality assurance. Both fall for consideration, one being tabled by the Government and one by myself in conjunction with the noble Lord, Lord Kilmarnock, my noble friend Lord Ennals and the noble Baronesses, Lady Masham and Lady Cox. For once there are five and that seems a good precedent, especially on something so important.

The similarity is deliberate. The proposers of the amendment wish to show how much common ground there is between us. I understand that the Minister will speak directly after me and I express the hope—without telescopes or anything of that kind—that she will be able to stress the common ground to a considerable extent, perhaps going the whole way.

I must say at once that I am grateful to the Minister and the Government—I am sure that other noble Lords who have an interest in the question agree—for taking the action that they have since Committee stage when my amendment, which proposed the establishment of Her Majesty's Inspectorate of Health, was narrowly defeated. We should all rather have the Government's Clinical Standards Advisory Group than nothing. However, that does not go far enough in two crucial respects. As the name of the group makes clear, its concern will be with clinical standards. And it will be an advisory body. On both counts, according to our arguments, the government body will be too narrowly restricted. Its functions need to be widened.

In taking that view and putting forward an alternative amendment—even though there are not so many Peers present as one would like to express their support—I can say that we have the support of the Royal College of Nursing and other consumer bodies with which I am, and have been for a long time, actively connected. They are the College of Health, the National Consumer Council, the Patients' Association and the community health councils of England and Wales. They all want the functions of the new body to be widened so that it is not just advisory and is not concerned only with clinical standards but with standards of performance more generally.

The first issue on which there is a difference between the two amendments is about the new body being advisory. As I see it, the Government want I the body to be yet another body advising itself. We think that is wrong. A purely advisory body has no clout. We want the status of the body to be upgraded so that it carries more weight in the health service and beyond, generally, among patients. It should, in our view, be a board and not an advisory group, let alone an advisory committee, and as such the board and its professional staff should have a certain independence with the power to launch inquiries on its own initiative and not just when requested to do so by health Ministers and health service bodies. It should have the power to give independent advice to Ministers and to make an annual report to Parliament on the state of the health services.

When we discussed these matters in Committee I spoke about the admiration that I have for Her Majesty's inspectors of education. I refer to the kind of annual report which is produced every year by Her Majesty's senior chief inspector of schools, with the whole inspectorate behind him. It is always an important document in the current history of education. It summarises the state of the problems, and not only that but the achievements in any one year. It is very much what I hope this board, if it were set up, would be responsible for every year, and it would come to Parliament.

The second, more important, issue which divides us is whether the new body should be confined to clinical standards alone. This restriction suggests that the Government have still not grasped the point made by all the people who at various stages of this Bill have argued for accreditation, monitoring, quality control and inspection; and all of us have had our proposals rejected.

The royal colleges already monitor clinical standards, as the noble Lord, Lord McColl, pointed out in Committee. I would say that there is relatively little disquiet about clinical standards in the health service. It is recognised widely that our doctors and nurses are second to none. However, there is disquiet about other standards in the health services and particularly a fear that as a result of the extra pressure to get down costs which is to come from this Bill—indeed, it is in part a purpose of the Bill—the quality of the overall service given to patients could suffer.

The noble Lord, Lord Carr of Hadley—I am sorry to see that he is not in the Chamber tonight—put the point very trenchantly in Committee when he said: The bigger the downward pressure on costs, the more important it is to have a very strong quality assurance control. I beg my noble friends" — I join with the noble Lord on that— on the Front Bench and the Secretary of State to come forward with a convincing, credible system of quality control".

I am afraid that the form in which the government amendment appears has not satisfied the call made by the noble Lord, Lord Carr. It is still true that the public, patients and their families need to be reassured and have their confidence in the overall quality of the health service in these difficult times restored and maintained to the highest possible extent. Hence our amendment and the main difference between it and the Government's amendment.

Our amendment proposes that the board should be concerned with clinical and general standards. We want the new monitoring body to be concerned with both; that is, with standards generally.

I now come to my argument that I am not going to be able to set out at great length—no one would want me to—but I intend to give one or two examples which I hope will make the point clear. It is a nonsense to separate the two. The highest clinical standards cannot be maintained unless general standards are also maintained. However good the conditions, they depend on proper standards being observed by all the people concerned.

I am sure that on this point the noble Lords on my left—the noble Lords, Lord Walton and Lord Hunter—will agree (I hope they agree) that the conditions depend on all sorts of people if a good job is to be done: the cleaners, if cross-infection is to be avoided; the way in which the waiting lists are managed by administrators; and the efficiency with which medical records are kept and produced at exactly the right time, or as near exactly the right time as is possible. All their work may be brought to nought unless proper arrangements are made for the after care of discharged patients and unless patients are properly informed about what they need to do to look after themselves. Clinicians' letters and discharge summaries must be sent off to GPs before it is too late for them to be relevant.

Those are just a few examples but surely they are telling and bear out the general point that a hospital or a GP's practice does not just need high standards in one area, even if it is the most important area of all—clinical standards of treatment. There must be an array of standards and teamwork, with all the people in the team concerned with quality encouraged to maintain quality. If the government amendment is passed it will be a slight on all those people whose work in its own way is also vital even though their lot may be in some way humble compared with that of great clinicians and important doctors in hospitals.

What clinicians know, patients also know. Those of us who have been patients—and most of us have been patients at some time in our lives or have had relatives or friends who have been patients—surely know that our worries and their worries, if they exist, are not just about clinical treatment but about everything else that goes on in hospitals and GPs' surgeries within the community health services that need to be closely linked with the acute services.

I give one example before I conclude. It is of a lady whose case came to my attention recently. This elderly lady was waiting, like so many others, for a hip replacement. She knew that she had to wait for a long time because her doctor told her so, and in any case she reads the press. After two years of patient waiting she telephoned the hospital and asked when her turn was to come. There was a commotion at the end of the telephone and eventually the hospital staff apologised and said that they were very sorry but her papers had been mislaid. As they therefore had no record of her ever having been on the waiting list she had to go to the bottom of the queue.

She waited another two years and again contacted the hospital to ask when her turn was coming. Incredibly, again her papers had been mislaid. The poor lady eventually, after six years, had the hip replacement. She had to suffer protracted pain. She did not badger the hospital, as some people would. Her husband, seriously ill through much of that time, died. She felt that she was never going to get any help from the health service and was in despair; but she was not in despair about the clinicians.

I expect that the clinical standards at this orthopaedic hospital, for that is what it was, were of the highest possible level. But other things went wrong which stopped people getting the right medical treatment, reassurance or even a roughly firm date when they might get relief. The problem was nothing to do with the clinicians; it was to do with poor management. Good management and good management standards can be particularised in many different ways. They are a vital supplement and back-up to what clinicians do and can do.

The public need to be assured that in our great health service the overall quality will be maintained. The body proposed in this amendment will at least go some way towards giving that assurance. I appeal in particular to the Minister opposite to support this amendment, and, if necessary, I shall appeal more widely. If this amendment is supported it will achieve a double purpose. Noble Lords will be supporting the Government's amendment in the important essence of it. They will be going even further. It will be more than just simple support for the amendment, for noble Lords will be recognising that if clinical standards are to be maintained and improved we need more than just concern. In a sense we could achieve two ends for the price of one vote if it comes to that. I hope that there will be support for this line of thought. I beg to move.

9 P.m.

Baroness Hooper

My Lords, it has been suggested that it would be helpful if I intervene at this stage to speak particularly to Government Amendment No. 198. Since we are speaking to a much wider grouping, I will happily respond at the end to any points raised in the course of further debate.

During our debate on earlier amendments I said that the contractual process will focus attention on quality of care and on areas where improvements in health standards are needed. In the debate on this group of amendments we are considering what impact national bodies can have on quality. Local and national initiatives should complement each other in this key area. We see the role of national bodies as one of assisting, informing and encouraging work at local level.

Central action cannot replace detailed local effort but it can inspire and enhance it. I hope that these initial remarks help to place in context the Clinical Standards Advisory Group which Government Amendment No. 198 will establish. Your Lordships will know that the decision to establish the group was announced jointly by my right honourable friend the Secretary of State and the conference of royal colleges following a meeting on 15th May. I am pleased that the conference of royal colleges welcomes the decision to establish the group as a significant step forward in promoting high clinical standards everywhere in the National Health Service following implementation of our reform programme.

It might be helpful if I set out in some detail the way in which we envisage the Clinical Standards Advisory Group operating. The group will consist of a lay chairman, members appointed on the nomination of medical, dental and nursing royal colleges and the chairmen of the standing medical, dental and nursing advisory committees. It will have a wide remit to provide advice, carry out studies and submit reports at the request of the Secretaries of State on issues relating to standards of clinical care nationally, regionally or locally.

In addition, the group will be able to provide advice on specific local issues at the request of health service bodies. That will enable it to provide valuable help to districts seeking to monitor the quality of service obtained through a particular pattern of National Health Service contracts or to help a National Health Service trust looking for independent advice on aspects of the services which it provides.

The group's programme of work will be settled between it and the Secretaries of State. They will consider together proposals for studies, including those from health service bodies and other organisations; for example, the royal colleges. It will also give priority to those which they consider to be of the greatest value to the health service as a whole.

The noble Lord, Lord Young of Dartington, suggested that the group should have more clout. I believe that it will have ample clout. Both the Government and the nominating bodies will ensure that the membership will be highly experienced. Its reports will be authoritative. Nobody will want or indeed be able to leave its views sitting on the shelf. I do not believe that Amendment No. 120A which we are considering adds to this and might even detract from the group if lines of accountability and responsibility remain vague.

Lord Ennals

My Lords, is the Minister saying that the group will be able to act on its own or will it still act at the request of the Secretary of State or the health authority?

Baroness Hooper

My Lords, as regards the independence of the group, I believe that the expertise of its members will enable it to become a respected source of advice on clinical quality, complementing the drive to improve standards in the National Health Service both locally and nationally. In answer to the specific question which the noble Lord, Lord Ennals, has just raised, there will be nothing to prevent the group initiating activity, though we would largely expect it to respond to requests.

I believe that its establishment fully meets the concerns of your Lordships and others outside your Lordships' House who have sought ways of guaranteeing that our proposals have an impact where they matter most; namely, in connection with the quality of clinical care provided to patients. Therefore, I commend to the House the Clinical Standards Advisory Group and the new clause establishing it.

Perhaps I may comment on the amendment which has just been moved by the noble Lord, Lord Young of Dartington. I believe that your Lordships will agree that this board will operate in many ways in much the same way as our Clinical Standards Advisory Group in providing advice on standards of clinical care. The board would have power, to set general standards, assess trends and give independent advice to the Health Ministers on the performance of the Health Service nationally [and] to monitor and secure improvements in the quality of the health services at all levels and in all regions". These are worthy aims, but I fear that they would cast the board's role so widely as to reduce its effectiveness in examining any specific area and, in particular, in advising on the specialist matter of clinical care.

The wide remit advocated by this amendment would cut across the valuable work already being undertaken by the National Health Service management executive in monitoring and improving the performance of the health service generally. This role was neatly encapsulated in an amendment in the name of the noble Lord, Lord Hunter, which we did not, unfortunately, manage to discuss last Thursday. I say "unfortunately" because the National Health Service management executive has a key role to play in improving quality and performance in the health service. Indeed, it was established very much for that purpose. Quality was an agenda item on all the reviews of the regional health authorities' performance which were undertaken by the management executive last year. This trend looks set to continue in this year's review programme.

Additionally, the National Health Service management executive has earmarked £10 million for quality initiatives this year, with £7.5 million allocated to regions for local projects and £2.5 million retained centrally for national demonstration projects and centrally funded initiatives. Also, much has been achieved through a series of meetings between the director of operations and the medical director of the management executive with regional managers this year to discuss initiatives, to evaluate and to improve quality of care around the country.

I fear that the clinical and general standards board, with its director of clinical and general standards, would compete with rather than complement the work of the National Health Service management executive on quality. Quality is surely an inherent part of the work of each of the National Health Service management executive's directors. It should not be isolated and shunted off into the hands of a single individual or body. Indeed, doing so would only restrict the management executive's current range of activities in the field of quality improvements.

As I said earlier, the Clinical Standards Advisory Group's programme of work is intended to be settled between it and the health Ministers. This means that they will be able to decide together which studies would be of greatest value in enhancing clinical standards and giving benefit to patients. They will consider proposals from a whole range of sources—from the group itself and from the health Ministers but also from the health service bodies and other bodies such as the royal colleges.

Baroness Seear

My Lords, may I interrupt? The Minister has made a very important statement. She said that they will decide together. The whole point of our amendment is the independence of this body. The Minister said that they will decide together. But Amendment No. 198 states that the group shall have functions:

1. "(a) in accordance with a request made by the Health Ministers or any one of them…
2. (b) in accordance with a request made by one or more health service bodies…
3. (c) such other functions as may be prescribed by regulations."

They will carry out requests, which means orders sent down by the Ministers. The whole point of what the rest of us want is that these people should be as independent as possible, not creatures of the Minister, carrying out his requirements. This is a totally different concept.

Baroness Hooper

My Lords, that is why it is most useful to have this opportunity to explain the intentions behind this amendment. It was certainly on this basis that the agreement was reached with the royal colleges—an agreement which I hope your Lordships will all feel is very valuable and will be very important in having an effective body in this area.

I intended to go on to say that with the combined strength of the health Ministers and the advisory group in considering the programme of work, they will be in a position to consider proposals from a whole range of sources—from the group itself, from the health Ministers, as the amendment states, but also from health service bodies and other bodies such as the royal colleges. We hope that the clinical standards advisory group will include members with a wealth of experience of the health service on clinical issues in particular. The group will be perfectly able to put forward its own ideas in its discussions with the Secretary of State, without the need for the protective power proposed by this amendment.

I believe that the working arrangements that I have outlined pave the way for constructive co-operation between the health Ministers and the Clinical Standards Advisory Group; and that co-operation, I repeat, is surely the best guarantee of an effective role for the group. In urging your Lordships to consider sympathetically the Government's amendment when we come to it—and I feel that I almost do not need to urge in that way—I would say that I feel that Amendment No. 120A would add nothing to smooth working relationships, and it cannot therefore be helpful to our consideration.

9.15 p.m.

Lord Hunter of Newington

My Lords, the Minister mentioned the amendment that I put down for last week with the noble Lord, Lord Carr. For the reasons that were given I withdrew it, but it was substantially a question which asked the Government to say more about the management board. Some 18 months ago the Government announced the formation of this policy board and a management board for the National Health Service. The Secretary of State himself would chair the policy board, and among its members was the Chief Medical Officer of the National Health Service sitting there by personal invitation. There was no nurse on it, so far as I understood the matter.

The appointment of the chief executive of the management board, Mr. Duncan Nicol, was made shortly thereafter, and the board has been active in strengthening the management side of the National Health Service, particularly on the general practice authorities. More recently the Government decided that the chief of research and development, whom they had proposed in response to the report of the Select Committee on Science and Technology on medical research with reference to the National Health Service, should be redesignated Director of Research and a member of the management board. This would add to the R&D input to that board.

With other developments to which the Minister has referred, particularly the proposals about clinical matters agreed with the medical profession, there remain; a large and vitally important area of quality control that has been mentioned—that of the management of scarce resources provided by the National Health Service. Apart from these clinical matters there is this wide range of services where effective management is vitally important to the patients and the quality of service.

The research and development of this large enterprise will be the responsibility of the Director of Research and Development, with the input to the management board. It seems to me that the quality control designed to improve the general standards of orgalisation should be the responsibility of that board, and in fact its main function. The Minister has told us something about this. Perhaps she may wish to tell us more about it later.

Coming to the proposed amendment, I do not agree with the inclusion of clinical matters as just part of the general management function and control. I believe that the Government and the medical profession got it right in the amendment proposed by the noble Baroness, Lady Hooper, and if the management board is responsible for studies of management throughout the health service it should still hold that central role. It should decide if there is to be inspection or something of that sort, or other methods of control. A great deal has been spent on management in recent months, and it is important to find out if the managers are effective in a somewhat difficult role where close collaboration with clinicians is necessary for success. I have discussed this matter with the noble Lord, Lord Carr, who is unable to be here tonight. He has agreed that the general management should be dealt with in this way.

Baroness Cox:

My Lords, may I briefly intervene and say that I concur wholeheartedly with the noble Lord, Lord Young of Dartington, in welcoming the Government's amendment as a significant step in the right direction. It must be apparent, from the fact that my name appears mysteriously in, I think, an unprecedent fifth place as a supporter of the amendment, that I have some concern about the fact that the government amendment does not go far enough. I shall not spell them out, but I should like to reiterate four areas.

I have been appreciative of the account of my noble friend the Minister of the government amendment and the way it is intended that it should work. But I must confess that I am still not quite convinced by what my noble friend said about the genuine degree of independence in the board as proposed in the Government's amendment. Nor was I really convinced by the interpretation of the powers of independent initiative that the board should have in instigating inquiries of its own accord. It seems to me from the wording of the Government's amendment that the board would still depend upon an inquiry being instigated at the behest of others rather than having its own absolutely independent initiative.

Thirdly, while I welcome the focus on clinical standards—I am a great believer in any measure which will ensure and maintain the highest possible clinical standards—I support the wider interpretation in respect of quality assurance implied by including "general standards" with the word "clinical". It is not sufficient specifically to focus on clinical diagnosis, treatment and procedures. Other aspects of care must affect clinical practice; for example, standards of hygiene in clinical areas or the nutritional adequacy of diets for sick people.

Fourthly, it is important that the report should be published and be in the public domain. It is the basis of accountability and learning. What will happen under the new dispensation in the provision of health care? The amendment to which my name strangely appears in fifth place is an important addition to the Government's amendment. It does nothing to violate the spirit of that amendment; it would greatly enhance the board's effectiveness, including its effectiveness in monitoring standards of clinical care, which is why I support the amendment moved by the noble Lord, Lord Young of Dartington.

Lord Ennals

My Lords, I support the amendment. My name appears on the list. It has reached third place. The first time the amendment appeared, my name did not get there at all. Perhaps I got into the middle and pushed the others outwards. I too warmly welcome the Government's initiative, which is an important step forward. It is very much in line with concerns which were expressed on both sides of the House on Second Reading and in Committee. I agree with all that has been said: it is too small a step.

I should like to think that, having got that far, the Government might be prepared to be influenced by this debate and the debate which might conceivably take place on Third Reading. Who knows? I should like to express my views by asking questions which I believe will indicate where my concerns lie.

The first and most important question is how independent will the body be. The Minister said that it could initiate its own work. I intervened to ask the question and she gave an answer: "Yes, it could if it so decided". However, there is nothing in the amendment to suggest that it could initiate its own inquiries. If it can, that should be written on the face of the Bill. How will the body operate? Will it operate with teams of—I will not say inspectors—experts rather as the Health Advisory Service has operated? If so, how many hospitals and health service units would it expect to be able to visit in the course of a year? My real question is: how big a job is it going to do? I know that in the first discussion that the royal colleges had with the Secretary of State, he put in single figures the number of hospitals or units that might be visited in the course of a year. That seems to me to be inadequate. What goes with that point is: how many staff would the body be expected to have to do its job?

I believe that the Minister answered the question about how much the board would cost. She gave the figure of £10 million, plus £7.5 million, plus £2.5 million. If my arithmetic is right, that amounts to £20 million in the course of a year. Perhaps she will confirm that I have the figure right. How will the body be set up? I am aware that there will be some nominations by professional bodies, but does she not think that it should include—"representation" is a word that we dare not use—some persons who are known to have special experience of community and consumer interests? There is no reflection of that point which I believe would add to the degree of independence that the Minister suggests the body should have.

How will the body report? To whom will it report and, in particular, will those reports be made public? My last question is the same as my first. Is this body to be a tool of the Secretary of State, able to act at the request of health service bodies, or will it be a truly independent body? Many people, professionals and others, would be much more confident if they felt that it was an independent body which was not merely beholden to the Secretary of State.

Lord Mottistone

My Lords, my amendment is grouped with these amendments because unfortunately the printers were a little muddled last night. For those noble Lords who do not already know the secret, page 37 of the Marshalled List shows my name on Amendment No. 198A, which is correct. However, what was line 7 last night when I put the amendment down is line 6 of the new clause under Amendment No. 198. My other amendments are down under the name of the noble Lord, Lord Ennals, and his name has crept in more than once, as it crept in in the middle of the names on Amendment No. 120A. My other amendments arc Nos. 199B and 199C, which I put down last night.

Lord Ennals

My Lords, both our names are down, jointly.

Lord Mottistone

My Lords, yes, I accept the noble Lord's name. Normally I do not readily accept names from the other side of the House because they tend to diminish my amendments. I am cautious about it. However, that is another matter.

It is unfortunate that this happened. Thank heaven that I put the amendments down last night because otherwise they would not be there at all. As my noble friend the Minister knows, I normally like to tell her why I have put down amendments in order to give her and her officials a chance to understand their purpose and accept them. Unfortunately, my amendment has been grouped with the other amendment put down by the noble Lord, Lord Young. From my point of view, it is a disaster because it has given rise to the debate today instead of on Thursday when I would have been ready for it. So there is a bit of a muddle.

In passing, to cover the situation, I should say that Amendment No. 120A suffers from the same deficiencies in my terms as Amendment No. 198. My three amendments need to be inserted into Amendment No. 120A, if your Lordships decide to accept it as the alternative. I think that noble Lords will not do so because it seems to me that the difference between the two is nothing like as great as has been suggested. It is rather surprising that Amendment No. 120A was not put in the form of amendments to Amendment No. 198. The seven subsections are almost identical and it is muddling for those of us who are not in on the secret.

On Amendment No. 198, in my Amendment No. 198A I suggest seriously to the Government—and I hope that they will take it on board—that it is a good point that advice should be given on, the standards of clinical care for, and the access to, continuity and availability of services to, national health service patients". As your Lordships know, my guidance in this matter is given by the National Schizophrenia Fellowship. One of the great worries of schizophrenics is that there tends to be a break in continuity of services. It is sometimes caused by the patients themselves because part of their illness causes them to ask for a break in continuity when it is not in their best interests. That is the conundrum.

The reason for putting "continuity" into subsection (1)(a) and (b) is entirely to make sure that it is not overlooked in those areas in which continuity of health services is vital to the people concerned, even if at a particular time they say they do not want it.

So far I have spoken to Amendments Nos. 198A and 199C. However, my Amendment No. 199B is of a slightly different nature. Amendment No. 120A has the same aim as Amendment No. 199B. Amendment No. 199B asks that as well as provision for a request to be made to the Clinical Standards Advisory Group by one or more health service bodies, there should also be an opportunity for a request to be made by reputable voluntary organisations.

The two voluntary organisations with which I am associated, the National Schizophrenia Fellowship and Sane, both have the highest quality of medical and psychiatric advice at hand in the advisory groups that work with them. It must not be thought that we are talking about any old voluntary organisation that will not be well supported. However, as I see it, there is no reason why what one might call a less well supported voluntary organisation should not make such a request. The advisory group could give that request the respect that it deserved. After giving a lot of thought to the wording of the measure, I decided it would be better to refer to voluntary organisations in general.

Whatever people may think about the advisory group, I believe it will be made up of a reputable body of people. My noble friend the Minister made that point. That advisory group will be able to pay such regard to these matters as is necessary. We should not limit these requests for services to be provided by the advisory group purely to health ministers and health service bodies. Even though I have not been able to brief my noble friend the Minister in advance, I hope she will give consideration to my amendment. If she cannot give me an immediate reply now, I hope she will take the amendments away, think about them and perhaps come back with them on Third Reading.

9.30 p.m.

Lord Ennals

My Lords, I hope that before the noble Lord sits down he will not mind changing his last sentence to refer to "our" amendments. The amendments stand in my name and I fully support them, Therefore, I wish them to be known as our amendments.

Lord Mottistone

My Lords, as I have not yet sat down I shall stand up again. I take that generosity exactly as it is given and I accept it on this one occasion.

Baroness Masham of Ilton

My Lords, I believe my co se is simpler as I am one of five people involved in an amendment. It is encouraging that there has been some progress but, like other supporters of the amendment, I feel that an independent body is needed. I shall give the House an example of bad patient access to the National Health Service which came my way on Sunday. I was telephoned in Yorkshire and told that the access for people in wheelchairs to the sexually transmitted diseases clinic at the Westminster Hospital had been closed. Many people who have AIDS have to use wheelchairs when they are ill because of weakness. The route they used to take was by lift but now the only route they have is outside and runs past the morgue. How insensitive and uncaring can management become?

This matter has made me feel strongly that there must be an independent body so there is no cover up and these cases do not occur. For people in wheelchairs not to have access to any clinic in a National Health Service hospital must be bad practice. Will the government amendment grouped with this amendment consider standards of food and of transport to hospitals and other needs? Will it have any teeth?

Lord Walton of Detchant

My Lords, I have considerable sympathy with the principles underlying the amendment which has been proposed by the "famous five". Having said that, I am concerned lest the issue of clinical care on the one hand be confused with the issue of management control and quality assurance on the other. My concern is that, as the noble Lord, Lord Young of Dartington, said, clinicians are dependent upon all of the services within the NHS. Many of those he specified in proposing the amendment clearly have an impact on the standard of clinical care which clinicians provide.

The word "clinical" implying in its broadest sense services which directly affect the care of patients and services directly available to patients, it seems to me that the monitoring of the standards of such clinical care should be separated from the monitoring of managerial standards, which are, as the noble Lord, Lord Hunter, said, the remit of the NHS management board.

It is for that reason that I have reservations about supporting Amendment No. 120A. Therefore I am very pleased that the Government arc proposing their own amendment, Amendment No. 198. I wholly agree with the noble Baroness, Lady Cox, and the noble Baroness, Lady Masham, to the effect that this body must have a degree of independence, not only from government but also an independence enabling it to take action on its own initiative and to sponsor and initiate investigations into standard clinical care.

Some small points appear to be missing from the government amendment. They were raised at meetings between the conference of colleges and the Secretary of State. For instance, preventive services are not mentioned. I believe that it was understood by the representatives of the colleges that these would be included in the remit of the proposed body and also that the term "clinical care" should be interpreted to include continuing care.

Secondly, no mention is made specifically of the colleges or other similar bodies being able to ask the Clinical Standards Advisory Group to intitate studies. However, I was pleased to hear the noble Baroness, Lady Hooper, in her opening statement say that they would be among the groups that would be in a position to initiate studies. Nevertheless, that is not included in the amendment. Thirdly, as the noble Lord, Lord Young of Dartington, said, it is true that the noble Lord, Lord McColl, said previously that the royal colleges already monitor standards. They monitor educational standards. They monitor the standards of appointments held by junior hospital staff in relation to their educational content. At present they do not monitor directly the standards of clinical care provided for patients, although clearly that is relevant. It is very important that this new body should have that role at the forefront of its activities. The issue will not be solved simply by including colleges with health service bodies—which they are not. The colleges point out that under subsection (6) of the government amendment they would have to reimburse all the costs involved, which gives them certain concerns.

I wish to support the view expressed by certain noble Lords that the reporting system must be an open one. I believe that the colleges understood from their discussions with the Secretary of State that the reports of the advisory group would normally be published and that his response to the reports of that group would also be published.

With those reservations I wish to say how much I welcome the Government's initiative in establishing this body, but I do not believe that the amendment has quite got it right as yet.

Lord Kilmarnock

My Lords, as the only remaining member of the "famous five" who has not yet spoken perhaps I may be allowed to make a few remarks about the amendment. I cannot remember who first coined the phrase "famous five" but it is very appropriate. I believe that it is the first time that an amendment has had five sponsors in your Lordships' House. Perhaps it will become a precedent. The whole issue of quality assurance has united those who dislike the Bill very much, those who quite like it and even some who like it very much.

The noble Lord, Lord Mottistone, wondered why the noble Lord, Lord Young, had tabled this long amendment when it was so close to the Government's, but if he had read it carefully he would have seen that there were crucial differences. It would have been messy to take the Government's amendment and pepper it with a great number of minor amendments. That is not a discourtesy of the House; it is intended for clarification.

There are several respects in which the amendment is superior to the Government's version, some of which have already been mentioned. The first is the power to initiate. Unless the board, the group, or whatever it is to be called, can initiate inquiries, it will have no credibility whatsoever as an independent body. I discussed the matter the other day with an experienced regional manager who is sympathetic to the Bill. He told me that quality assurance must be systematic and comprehensive. That means that the board must have the power to initiate, otherwise there will be no belief in its independence. It is to the Government's advantage that it should be seen to be independent, otherwise it will simply be seen as the Government's poodle.

In her opening remarks the noble Baroness said that there was nothing to prevent the group from initiating activity. That provision is certainly not in the Bill. Subsection (1)(c) of the Government's amendment states that regulations may provide for other functions, but it does not state that the group can initiate activity. That is an important point which the noble Baroness might like to bear in mind when she winds up.

The noble Baroness also referred to the nominating bodies, but the Government's version does not set out any nominating bodies. They are left entirely to regulations, so there is no prescriptive right of any kind for consumers to nominate on to the Government's group. That is another weakness in the Government's version.

The amendment moved by the noble Lord, Lord Young, also incorporates a director, which the Government's version does not. That is important because if there is no director to select staff who are appropriate for the job, who will do it? Subsection (5)(b) of the government amendment states: [The Health Ministers] shall make available to the Advisory Group and to any committee or sub-committee thereof such staff and other services or facilities as are necessary to enable them to carry out their functions". Who will those people be? They will probably be civil servants, but they are not the right people to do the job. We need other health professionals. If there is a director on the scene, he will ensure that the right people are contracted to do the job. That is a further weakness in the Government's proposals.

There is also the important point regarding the lack of an annual report to which the noble Baroness, Lady Cox, referred. We should know what is going on.

Finally, we come to the objections that have been advanced to the inclusion of the word "general". The Government's version refers to "Clinical Standards" and the version of the noble Lord, Lord Young, refers to "Clinical and General Standards". It has been implied that that might muddy the pure waters of clinical standards.

When I consulted the experienced manager the other day, I asked him what were the main points of quality assurance. He gave me nine: control of infection; investigations of deaths; investigations of accidents; readmission rates; use of blood; peri-operative deaths; waiting lists; medical audits; and hygiene, food, and so on. He then gave me a number of what he called softer points; namely, those concerning customer relations, courtesy and all the other slightly less definable matters which are also extremely important.

At least five of those quality assurance points probably fall within the generic term "clinical". But there are several others which do not and which, as the noble Lord, Lord Young, said, are equally important to the final delivery of treatment and care in a hospital.

I do not think that we need go to the stake for the word "general". However, the intention behind it—that the powers of the body should be to investigate all those matters, whether or not under the label of the word "general"—is an important matter which we ought to have in consideration. It is the whole delivery of the service of the hospital. Obviously the strict clinical standards are the starting point of the whole thing, but there are wider circles which develop from those clinical standards. It seems to me that they ought to be incorporated. On all those grounds, it seems to me that the amendment moved by the noble Lord, Lord Young of Dartington, is in many respects superior to the Government's version. I agree with him that we are grateful for that so far as it goes.

I should like to make a final point following from the remarks of the noble Lord, Lord Mottistone. Also grouped with these amendments are Amendments Nos. 199 to 204 which are relatively minor amendments to the Government's version. Owing to misprints, to which the noble Lord, Lord Mottistone, has already referred, this group has become detached from its sponsors, who are in fact myself, the noble Lord, Lord Ennals, and the noble Baroness, Lady Cox. Although I do not want to speak to those amendments tonight because I think that we should address the rival merits of the general packages advanced by the noble Lord, Lord Young, and by the Government, I want to give notice at this stage that we certainly reserve the right to return to the lesser amendments at a later stage when they are called, which of course cannot be today.

Having said that, I hope very much that the Minister will be able to be helpful to us this evening. I hope that she will take on board some of the concerns that have been expressed and perhaps even come some way to meet us on some of the points. In particular I attach importance to the power to initiate inquiries. That seems to me practically the most important power that this board wants and currently lacks.

9.45 p.m.

Lord Ennals

My Lords, before the noble Baroness winds up the debate, with the leave of the House, I should like to make a proposal. As the noble Lord, Lord Kilmarnock, said, the series of amendments to the government amendment have not been taken. We have not spoken directly to them. I hope that at the end of our debates, whether it is today or on Third Reading, we shall not be making a choice between the Government's proposals and those of the noble Lord, Lord Young.

There was a degree of flexibility in the Minister's first reply which I certainly warmly welcome, particularly concerning the possibility of initiating inquires. Perhaps I may ask the Minister whether it would be possible for there to be a meeting of minds or persons—of amenders—between now and Third Reading in the hope that we might be able to find some more areas of agreement before we come to a final date.

Baroness Hooper

My Lords, I understood that we were discussing the whole grouping now. Certainly my noble friend Lord Mottistone has spoken to a number of amendments in the group, as indeed have other noble Lords. Naturally, if I am unable to satisfy any areas of doubt in noble Lords' minds this evening and at this stage, in order to avoid a rediscussion of the whole issue on Third Reading I shall certainly be willing to have a meeting as the noble Lord suggests

With the leave of the House I shall attempt to respond to a number of the issues that have been raised, specifically perhaps on Amendments Nos. 198A, 199,199C, 199A and 200, which seek to define more precisely what is meant by the Clinical Standards Advisory Group's function of providing advice on standards of clinical care in the health service. I have tried to make clear that the remit of that group is to advise on all aspects of the provision of high quality clinical care. In saying that, I point to subsection (7) of the new clause proposed in government Amendment No. 198. That gives a very clear and wide definition of clinical care. It was on the issue of clinical care that the anxieties of the medical profession and the royal colleges were so forcefully expressed. It seems an appropriate as well as an agreed remit which gives the group the freedom to agree a programme of work with the health Ministers in the way that I have described.

I can certainly give the noble Lord, Lord Ennals, the assurance that he seeks that the group's activities will be able to extend to the quality of clinical care in the community health services. But a list of specific functions defining the group's activities in the way suggested by the amendments would add little to its freedom of action and independence and might restrict it by excluding subjects not specifically mentioned in the clause. I hope that the noble Lords will not feel it necessary to press the amendments.

Much has been said in the short debate about the independence, or lack of independence, of the body proposed in the government amendment. But I have very little doubt that, with a membership consisting of distinguished nominees of the medical, dental and nursing royal colleges—I emphasise that to my noble friend Lady Cox—as well as the chairman of the standing advisory committee, the group will have no hesitation in providing forthright independent advice on the issues which it is asked to tackle. Certainly, representatives of those groups to which I have referred have had no hesitation, without such a statutory request.

I can assure your Lordships that the group will receive the necessary funding to enable it to discharge its functions effectively. However, it will not wish just to be asked. We expect it to be active in proposing a work programme to the Secretary of State. The scope of the group's remit has deliberately been drawn to cover standards of clinical care rather than care in general.

The clause makes clear that that includes the questions of access to and availability of high standards of clinical care. It is the single most critical aspect of the service that the patient receives. I believe that it is right to allot this field to the group, leaving other more general aspects of care—for example, the quality of hospital food, to which the noble Baroness, Lady Masham, referred—to be tackled through the NHS management executive's continuing programme of quality improvement, to which I referred earlier.

The noble Lord, Lord Ennals, and my noble friend Lord Mottistone, asked about other groups being able to commission work in deciding that programme. As I said earlier, the programme would be agreed between the Clinical Standards Advisory Group and the health Ministers. In deciding that programme it will be free to consider suggestions for studies from any person or body or make suggestions itself. It was in that sense that I said there was nothing to prevent the group from initiating discussion or consideration of an issue.

I also mentioned the royal colleges as a valuable potential source of suggestions. Voluntary organisations are another source. That is the best way to ensure that the group has a manageable and effective programme of work.

The noble Lord, Lord Ennals, asked how the group would operate. Its working methods will evolve over time, without a doubt. The use of ad hoc teams has worked very well in the case of the health advisory service and may be appropriate in this case. As I have said, the programme will be discussed with Ministers. We shall need to have the group in place before we can finally fix the scale of its activity in any one year. I assure your Lordships that the group's activities will be fully funded and that appropriate staffing support will be provided.

The £10 million to which I referred earlier was for a quality initiative to take place this year. The full cost of the group's functioning has yet to be determined and will depend largely on its work programme. I assure your Lordships that funding will be adequate for its purpose. Similarly, I cannot give firm figures for the number of visits that the group is likely to make. That would make no sense before at least the chairman is in place. However, I suspect that the amount will be more than the single figure sum suggested by the noble Lord.

The noble Lords, Lord Ennals and Lord Walton, asked whether the reports would be made public. We believe that the clinical standards advisory group will play a most constructive role in advising health Ministers and individual health service bodies on standards of care. Therefore, its report on specific and general areas will be of value to all parts of the health service. I expect that it will become normal practice for the reports to be published and made widely available in most cases, certainly as regards national issues. However, that matter must be decided between the group and the Minister or body commissioning a study.

The noble Lord, Lord Kilmarnock, quoted nine key areas. I assure him that, with the single exception of catering and hygiene standards, all the areas he mentioned will fall fairly and squarely on the remit of the group as defined in the Government's Amendment No. 198.

The noble Lord, Lord Young, asked about the ability to look at waiting lists. I assure him that the group will have the ability to look at access to services as well as at the services themselves. That is explicit on the face of the Government's amendment and therefore the group will be able to look at excessive waiting times.

I hope that I have touched upon and answered most of the points that were raised. I reiterate that it would not be helpful to spell out all the aspects of the advisory group's constitution and remit in excessive detail in the Bill because that would only restrict its activities in the long run. We have had a most useful discussion on this group of amendments. I hope that my comments have convinced the noble Lord, Lord Young of Dartington, and the co-movers of his amendment and that they will feel able to withdraw the amendment with the assurance that their anxieties are covered by the Government's amendment.

Lord Mottistone

My Lords, I do not believe that my amendments have been dealt with properly. I propose to speak to them and move them when we deal with the Bill on Thursday. I hope that arrangements can be made to accept that position.

Lord Kilmarnock

My Lords, before the Minister sits down, I wish to remind her of my question about her statement that there is nothing to prevent the group from initiating activity. I made the point that the Government's amendment contained nothing to that effect. Subsection (1)(c) of their Amendment No. 198 refers to: such other functions as may be prescribed by regulations". Other words then fell from the Minister's lips when she was winding up. She said that she assumed the group would be active in proposing a work programme to the Secretary of State. Is she prepared to put those two commitments onto the face of the Bill; that is, the right to initiate and the right to be active in proposing a programme to the Secretary of State? That is an important point. She has used both phrases and it would be most helpful if they could be put on the face of the Bill.

10 p.m.

Baroness Hooper

My Lords, with the leave of the House—our procedures on Report are becoming rather irregular—I have tried to convey that the best way forward is that the wording of the amendment should be as general as possible and as we have agreed it with the royal colleges. It is not necessary to do as the noble Lord suggests in order to meet his anxieties.

Lord Young of Dartington

My Lords, I very much welcome what the Minister said. It certainly went beyond what I was expecting or hoping for. I particularly welcome what I took to be an assurance that there will be further consideration and discussion before the Bill is finally put to bed on what action should be taken as regards the very difficult issues of monitoring, quality control and so on. I hope that as a result of that it will be possible for the Government to come back with a different amendment either when we reach Amendment No. 198 or at Third Reading. That would be very welcome. I hope that I am not expecting too much.

I should like to point out what seemed to be the implications of the attitude taken by the Minister, especially in her last remarks. Many of us, including the noble Lord. Lord Walton, have put a good deal of weight on the necessity, as we see it, for the board to have the power to initiate its own inquiries. If that could be written into the Bill, that alone would make a difference.

We have also placed a good deal of weight on the desirability of the board being able to make an annual report to Parliament. Again, that would make a difference.

The most important point still remains; that is, what are thought to be the boundaries of clinical care. My noble friend Lord Kilmarnock read out a list of matters which should be considered. If those could be brought within the purview of the board, then one would be very near to being satisfied about the matter.

The first function of the proposed group or board is that it will provide advice on standards of clinical care and access to and availability of services to National Health Service patients. It has never been clear whether the access and availability of services reference applies to clinical standards in the first place and whether or not the legal ejusdem generis rule applies. If it does not—and the Minister's remarks suggested that it does not—then the provision about access and availability of services could be taken out of that clause and put into a clause on its own. There would then be an extension of the functions of the board beyond clinical care but all related to it. We should then be sure as to how far the Government's remit to the board will extend.

If we go as far as that, then the question will rise as to what will be the name of the board or group. The name Clinical Advisory Group seems to be misleading. It would be much less misleading if it was ca led a clinical and general standards group or board.

Those are the points implied by what has been ably expressed in the debate. We hope that the Government will come back later. In view of that I am prepared to withdraw the amendment, but if things do not work out then I shall bring it back again at Third Reading. However, we hope that it will be with us before that time in the form of a government amendment.

Noble Lords

No!

On Question, amendment negatived.

Clause 20 [Extension of function etc. of Audit Commission to cover the Health Service]:

Lord Kilmarnock moved Amendment No. 121:

Page 21, line 11, at end insert: ("(1A) Section 27 of the Local Government Finance Act 1982 shall continue to apply to health service bodies.").

The noble Lord said: My Lords, Amendments Nos. 121 and 123 concern the scope of the work of the Audit Commission. The Bill very properly imports the Audit Commission into the scrutiny of its operations and extends the functions of that body to some extent to the National Health Service. As I pointed out on a previous occasion, Section 26 of the Local Government Finance Act 1982 will apply fully to the National Health Service.

Section 26 is the section under which the Audit Commission carries out what are generally called value for money studies. They are extremely useful but of limited scope. For example, the two which were initiated before the introduction of the Bill—although I understand work is in hand on them—concern energy use in hospitals (which is of great importance to the proper use of resources) and surgical dressings. Those arc useful but limited studies on specific topics.

The Bill as written largely prevents the operation of Section 27 of the Local Government Finance Act from applying to the health service. Section 27 gives the Audit Commission wider scope. It enables it to undertake studies on the impact of policy on the delivery of services. For example, the management arrangements may be scrutinised. In relation to schools the objective was to develop a set of indicators for monitoring performance under the new LMS regimes. The work of social services concentrated on the difficult area of monitoring performance in the care of children. Section 27 studies include reviews of auditors' project reports and management letters. They also focus on areas where the improvements achieved seem to be lower than expected.

From those few examples it will be seen that the Section 27 studies carried out by the Audit Commission are somewhat wider in scope than those carried out under Section 26. When I last raised the topic I ventured to suggest that it would be helpful for the Audit Commission to preserve its scope in that slightly wider field in relation to the health service, particularly at a time of far-ranging reform.

The Government replied. In fact, I am grateful to the noble Baroness, Lady Hooper, who wrote to me. The noble Lord, Lord Henley, in replying to the previous debate, made the same point; that the Government are not prepared for these powers to be construed as entitling the commission to question the merits of the policy objections of the Secretary of State. That was the phrase used: to question the merits of the policy objectives of the Secretary of State".

As a result of the previous debate I have taken that point on board. I am prepared to concede that it would not be appropriate for the Audit Commission to do that, However, it still seems to me appropriate that the Audit Commission should remain broadly with its Section 27 powers, which, incidentally, it will retain over the community care end of the Bill. Therefore, there will be a slight anomaly, which was pointed out by the noble Baroness, Lady Cox, last time round. The Audit Commission will have full Section 26 and Section 27 powers over community care but will only have, in effect, Section 26 powers over the NHS end of the Bill. That seems to be a slight anomaly.

It was also suggested to me when we debated this matter previously that, as the National Audit Office is the auditor of the National Health Service, it is not appropriate for the Audit Commission to be involved. My understanding of the role of the National Audit Office in relation to the NHS is that it audits the main accounts of the department. There seems to be no reason why the Audit Commission should not take over for the district and regional authorities.

The main point of the revised set of amendments which I have tabled is that I again seek to preserve the general scope of Section 27 in relation to the health service but I have accepted the Government's point that the main policy objectives, the broad thrust of the Government's policy, should not be questioned. That is embodied in Amendment No. 123, which states: Powers conferred by this subsection shall not be construed as entitling the Commission to question the merits of the policy objectives of the Secretary of State". Incidentally, in Section 27 there is in any case a power for Ministers to veto publication of reports which they do not think are appropriate. Therefore, the Secretary of State has the last word. All I suggest is that he does not deprive himself of this valuable management tool and that the Section 27 powers are broadly extended to the National Health Service. I beg to move.

Lord Mottistone

My Lords, I do not see Amendment No. 123 as being consistent with what the noble Lord, Lord Kilmarnock, has been saying. What the amendment does, before it puts in the reference to policy, is to remove everything from line 14 to line 28 on page 82. It takes out paragraph 19(2) and the new subsection (6) from Section 27 to which the noble Lord was speaking.

That removes an amendment which was accepted in the Commons to give the Audit Commission, as we saw it, more rather than less power to look into the effect of Government's statutory provisions, directions and guidance from the Secretary of State. It seems to us—that is, myself and my advisers from the National Schizophrenic Fellowship—that there is a great deal to be said for the commission having the power which Mr. Andrew Mitchell, who moved the amendment in the Commons, spent a long time explaining was a good way of strengthening the powers of the Audit Commission.

The Audit Commission is much admired in the caring world. It can be said that its report Making a Reality, of Community Care published in 1986 led to the Griffiths Report and in turn to this part of the Bill. On the whole, I strongly discourage support for Amendment No. 123. In the meantime I recommend the noble Lords who tabled it to take another look before striking out this rather important part or the Bill.

10.15 p.m.

Lord Henley

My Lords, I shall deal first with the anomaly which, according to the noble Lord, Lord Kilmarnock, exists between Part III and the health side of the Bill. I thought that I had made myself clear at Committee stage: if I did not, I do so now. There is no anomaly here. The community care services are managed by the local authorities. At the end of the day the NHS is directly accountable to Parliament through the Secretary of State. That is the key difference. Local authorities and the NHS are very different animals.

During our debate in Committee noble Lords expressed some uncertainty about what we are aiming to achieve in the provisions in Schedule 4 to the Bill relating to value-for-money studies. I shall seek to clarify this. In relation to local government, the commission has two distinct powers on value for money. One is contained in Section 26 of the Local Government Finance Act 1982. This requires the commission to undertake or promote studies into economy, efficiency and effectiveness. The Bill applies this provision in full to the commission's new role in the National Health Service.

The other power is the one in Section 27 of the 1982 Act which allows the commission to report on the impact of statutes, directions and guidance. Initially, we simply excluded this provision from the new arrangements for NHS audit because of the major difference between the accountability of local authorities to their electorates and the position in the NHS where it is Parliament which holds the Government to account on its policies. But in another place we did accept that we could strengthen the commission's hand by making it explicit that it could take full account of the implementation of statutes, directions and guidance, subject to its not questioning the policy objectives of the Secretary of State.

That is the provision contained in paragraph 19 of Schedule 4. This was agreed by all those concerned, including the commission, as reflecting a proper balance and the reality of the constitutional position. It also mirrors professional audit practice. It is the auditor's role to report on regularity and value for money in the implementation of policy rather than dispute the underlying objectives.

Let there be no doubt about the importance we attach to value-for-money studies. Indeed, the whole point of the transfer of responsibility to the Audit Commission is to put more emphasis on value for money and to make this work independent of government. We shall look to the commission to be vigorous and forthright in carrying out its new responsibilities, backed by the very considerable armoury of powers which the Bill contains.

Turning to the amendments of the noble Lord, Lord Kilmarnock, I recognise that he has reflected on the Government's position and has tried to find a way forward in the constructive spirit which we have come to expect from the noble Lord. I regret to say that his proposition will simply not work. It is inconsistent, on the one hand, to allow the commission to report on the impact of government policy and, on the other, to say that policy objectives shall not be questioned. The two are inseparable.

I do not believe that we should saddle the commission with a statutory basis that leaves so much room for doubt and dispute. What we want is a clear-cut power for the commission to take full account in its reports of the implementation of statutes, directions and guidance in a way which does not question the underlying policy objectives.

I hope that the noble Lord will accept that the Bill promotes rather than hinders the commission's essential value-for-money role and that he will therefore not press his amendments.

Lord Kilmarnock

My Lords, I am very grateful to the noble Lord, Lord Henley, for his reply. I say to the noble Lord, Lord Mottistone, that Amendments Nos. 121 and 123 had to be read together. The first restores the full power of Section 27 to the audit of health service bodies. Amendment No. 123 then restricted that power in the way that I described; in other words, inhibiting the questioning of the merits of policy objectives of the Secretary of State. In fact it would not have undermined the compromise that was achieved by Mr. Andrew Mitchell in another place but would have slightly extended it. That is my understanding of what the effect of these amendments would have been. So the noble Lord's criticism of the amendment on those grounds does not stand up.

Turning to the remarks of the noble Lord, Lord Henley, I should have thought there was somewhere a halfway house in which Section 27 studies could be made. After all, they are objective studies without overtly questioning policy objectives. If the Government then come to reflect on their policy objectives, that would be another matter, and I should have thought would have been quite a healthy thing for them to do.

In view of what the noble Lord said and of what has already been achieved by the amendment in another place, I shall not press this matter further and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 4 [Amendments of Part III of the Local Government Finance Act 1982]:

Lord Sanderson of Bowden moved Amendment No. 122: Page 80, line 7, leave out ("To the extent that") and insert ("In such circumstances and to such extent as").

The noble Lord said: My Lords, I beg to move Amendment No. 122 and will also speak to Amendments Nos. 124 to 129 inclusive. These amendments to the English and Scottish provisions of the Bill dealing with the statutory audit do two things. First, they phase the coming into effect of the audit provisions. In order to ensure continuity of the expertise, the Bill provides for the transfer to the English Audit Commission and the Scottish Accounts Commission of the civil servants working on National Health Service statutory audit. At present the provisions dealing with the transfer of staff cannot come into effect until the dates on which the two commissions take over the work. In practice, we want job offers to be issued beforehand, so that affected staff have time to consider them and, if they accept, transfer to their new employer on or before the operative date. Amendments Nos. 124 to 127 pave the way for that transfer.

The remaining amendments deal with the frequency of audit of individual GP practice funds. In general, we do not think it will be necessary for the auditor to do a detailed audit of the relevant accounts of each fund holder more frequently than once every three years because the accounts of every fund holder will be summarised and included in the accounts of the relevant FHSA or health board. That is why the Bill at present says, To the extent that regulations made by the Secretary of State so provide, this Part of this Act shall not apply to the accounts for any year of the members of a recognised fund-holding practice if those accounts are submittted to a Family Health Services Authority and summarised in that Authority's accounts".

But we also want to allow the auditor, if he is concerned about the financial affairs of an individual fund holding practice, to do a detailed audit more frequently than once every three years. These are the "circumstances" referred to in Amendments Nos. 122 and 129. I have no reason to think that it will often be necessary for the auditor to intervene in this way, but it is right that the Bill should make proper provision for the auditor to investigate any cases of concern about the spending of public money.

On Question, amendment agreed to.

[Amendment No. 123 not moved.]

Lord Sanderson of Bowden moved Amendments Nos. 124 and 125: Page, 82, line 43, leave out ("section 20 or) and insert ("paragraph 22 of Schedule 4 to"). Page 83, line 4, leave out ("section 20 or) and insert ("paragraph 22 of Schedule 4 to").

On Question, amendments agreed to.

Clause 35 [Accounts and audit of NHS trusts and fund-holding practices]:

Lord Sanderson of Bowden moved Amendment No. 126: Page 43, line 30, leave out ("subsection (1) above") and insert ("paragraph 14 of Schedule 7 to this Act").

On Question, amendment agreed to.

Schedule 7 [Amendments relating to Audit of Accounts of Scottish Health Service Bodies]:

Lord Sanderson of Bowden moved Amendments Nos. 127 to 129: Page 93, line 16, after ("or) insert ("paragraph 3(3) of"). Page 95, line 24, leave out ("(1A)") and insert ("(1B)"). Page 95, line 25, leave out ("1B) To the extent that") and insert "(1C) In such circumstances and to such extent as").

On Question, amendments agreed to.

Baroness Blatch moved Amendment No. 129A: Insert the following new clause:

("Schemes for meeting losses and liabilities etc. of certain health service bodies

(" .—(1) The Secretary of State may by regulations made with the consent of the Treasury establish a scheme whereby any of the bodies specified in subsection (2) below may make provision to meet—

1. (a) expenses arising from any loss of or damage to their property; and
2. (b) liabilities to third parties for loss, damage or injury arising out of the carrying out of the functions of the bodies concerned.

(2) The bodies referred to in subsection (1) above are—

1. (a) health authorities;
2. (b) NHS trusts; and
3. (c) the Public Health Laboratory Service Board;

but a scheme under this section may limit the class or description of bodies which are eligible to participate in it.

(3) Without prejudice to the generality of the power conferred by subsection (1) above, a scheme under this section may—

1. (a) provide for the scheme to be administered by the Secretary of State or by a health authority of NHS trust specified in the scheme;
2. (b) require any body which participates in the scheme to make payments in accordance with the scheme; and
3. (c) provide for the making of payments for the purposes of the scheme of moneys provided by Parliament.

(4) Without prejudice to any other power of direction conferred on the Secretary of State, if the Secretary of State so directs, a body which is eligible to participate in a scheme shall do so.

(5) Neither the Secretary of State nor any health authority or NHS trust administering a scheme under this section shall, by virtue of their activities under the scheme, be regarded as carrying on insurance business for the purposes of the Insurance Companies Act 1982.").

The noble Baroness said: My Lords, in moving Amendment No. 129A I shall speak also to No. 138A. These amendments flow essentially from the establishment of National Health Service trusts. They will give the Secretary of State power to make regulations to enable him, or regions acting under delegated powers, to meet the liabilities of trusts or other defined health service bodies, and for the Secretary of State for Scotland to do likewise.

As your Lordships will be aware, health authorities currently bear their own risks and do not insure. Many regions run arrangements whereby the costs of particularly large clinical negligence claims are met from funds held back by the regions, thus spreading the cost between districts. In Scotland and Wales pooling arrangements to share the costs of high value liabilities are operated by the Secretary of State. These arrangements will, in all probability, take on more significance in future as health authorities will be responsible for meeting liabilities arising from the medical negligence of their employees.

The National Health Service trusts will of course be liable to meet the costs of any claim against them. As the legislation stands they would, however, not be able to participate in existing pooling arrangements or any other arrangements that might be devised for sharing the risk of major claims between health authorities. There is no power for the Secretary of State or the regions to meet the liabilities of trusts in return for the payment of agreed contributions from them.

Trusts would effectively have to meet their own liabilities without the option of spreading the risk. We do not believe that it would be right for trusts, which will remain fully part of the National Health Service, to have to meet liabilities on a different basis from health authorities. These amendments therefore give the Secretary of State the necessary power to establish schemes for meeting the liabilities of defined health service bodies, including trusts. I commend both these amendments to your Lordships. I beg to move.

On Question, amendment agreed to.

Lord Ennals moved Amendment No. 130:

Before Clause 21, insert the following new clause: ("Exercise of primary functions with regard to homelessness . In Section 72 of the Housing Act 1985 (which provides that, on a request by a local housing authority for assistance in the discharge of certain statutory functions relating to homelessness, or threatened homelessness, a body of a description specified in the paragraph shall cooperate in rendering such assistance as is reasonable in the circumstances) there shall be inserted the following paragraph— (aa) request a family health services authority or district health authority within the meaning of the National Health Service and Community Care Act 1990 to exercise any of their primary functions under that Act with special regard to homeless persons and persons threatened with homelessness.".").

The noble Lord said: My Lords, I beg to move the amendment standing in my name on the Marshalled List. This new clause seeks to provide a more effective statutory framework for the provision of primary health care for the homeless. It places a statutory duty on health authorities and FHSAs to co-operate with local housing authorities in the care of the homeless. This will be brought about by amending Section 72 of the Housing Act 1985 which already exists to secure the co-operation of a range of other bodies and authorities with local housing authorities.

Under that clause, for example, social services departments are bound to help if a local housing authority makes a request. This amendment extends that precedent to the provision of health care. Under the Housing Act 1985 local authorities are under a duty to find suitable accommodation for homeless families. In 1988 local authorities in England accepted over 117,000 households as homeless under the terms of the 1985 Act, which Shelter estimated as translating into 337,000 people. This is the only official measure of homelessness,and it is generally agreed that it is simply the tip of the iceberg.

In 1988 local authorities actually turned away more families than they accepted under the relatively strict legislative definition of homelessness. The truth is that no one knows for sure how many people are homeless in the United Kingdom. Shelter puts the figure at over 500,000—half a million—while surveys carried out by the Salvation Army put the figure at 75,000 in London alone, Whatever the figure, everyone agrees that it is growing. I think there are signs that it is going to grow very seriously.

What can be done? The amendment is deliberately non-prescriptive as to the action that might be taken to improve health care services for the homeless. This is not because of a lack of ideas. The few specialist units already working with the homeless have provided many lessons such as using patient-held records to improve continuity of care and arranging special surgeries for homeless families. Health care professionals have also put forward positive proposals such as DHAs and FHSAs establishing objectives for monitoring and delivering health care to homeless families with a homeless persons' liaison officer in each locality.

The amendment does not prescribe any of those possible solutions because it recognises that in different cases different solutions may be necessary. Without the amendment it is doubtful whether such collaboration would be forthcoming in the new market-drive NHS. Pressures on health authorities, in particular, are likely to force them back to an old style curative model, neglecting policies of health promotion and illness prevention and forgetting completely the needs of the homeless. It would be wrong if the Bill were allowed on to the statute book without recognising that one of the major causes and consequences of ill health is homelessness, a scourge that is rapidly growing in our society. I beg to move.

10.30 p.m.

Baroness Blatch

My Lords, homeless people have exactly the same rights as anybody else to health and social care services and they too will benefit from the general improvement in services which will flow from the radical changes introduced by the Bill and from other recent measures.

However, we are conscious that some homeless people will have difficulty in gaining access to services. We know that some need to be encouraged to make full use of the services which are already available to them. We hope that the new fee payable to GPs under their revised contract for registering and giving health checks to new patients will encourage them to register homeless people as patients. The White Paper Promoting Better Health also lays a specific responsibility on family practitioner committees to assess the health needs of all their residents and actively to develop services to meet those needs. In areas where there are homeless people they will need to take account of their special requirements.

The pivotal role given by the Bill to district health authorities will also lead to specific improvements in services for homeless people. The Bill gives district health authorities specific responsibility for the provision of a comprehensive range of high quality services for all their population. That will, of course, include homeless people. In addition, the community care proposals in the Bill will ensure a better quality of care for all service users.

Those improvements are expected to take effect over the next few years. But the Government have already taken concrete action to help homeless people. They have set up the emergency assistance scheme for rough sleepers in severe weather. That scheme, which has already proved its worth, provides emergency shelter and food in harsh weather and is administered on behalf of the Government by the Single Homeless in London organisation.

There has been particular concern in recent years about how to make effective arrangements for the continuing care of mentally ill people being treated in the community. The plight of homeless mentally ill people has been singled out for particular attention. Ministers and officials at the Department of Health are currently in discussion with health and social services authorities and voluntary bodies in central London, where there is a particular concentration of homeless mentally ill people, with a view to identifying practical steps to get them the support they need. We hope that any approach developed for central London will prove a useful model for other parts of the country.

Given that all citizens of this country have full right of access to services, the Government can see no need for any specific mention of the entitlement to health care of homeless people to be enshrined in legislation. In the light of that explanation, I hope that the noble Lord will feel able to withdraw the amendment.

Lord Ennals

My Lords, the Minister is right. Homeless people have the same rights as others: the problem is that they do not have the same opportunities. I am afraid that for many years the Government have said that they recognise the problem of homelessness but have not taken action to deal with it. Homelessness has worsened year after year.

I do not take seriously the Minister's optimistic hopes that somehow things will come right in the end. They come right only when some action is taken which leads to their coming right. That is what the amendment is designed to do. It will not reach the statute book. I beg leave to withdraw the amendment, not because I am satisfied with the Minister's answer but because, having put the case and heard the answer, I do not want to go any further.

Amendment, by leave, withdrawn.

[Amendment No. 131 not moved.]

Lord Ennals moved Amendment No. 132:

After Clause 21, insert the following new clause:

("Services for the elderly and disabled

At the end of section 56 of the principal Act (which enables the Secretary of State to make special arrangements to secure the adequate provision of services) there shall be added—

"(2) In performing his duties under this section, the Secretary of State shall have special regard to the provision of services for elderly and disabled persons." ").

The noble Lord said: My Lords, this clause provides a safeguard against poor service provision and gives the Secretary of State special powers to correct situations where services are deemed to be inadequate. The background is that in the new market-driven National Health Service the elderly and disabled, whose chronic conditions are unpredictable and cannot easily be costed, are likely to be among the first to experience any problems which might occur. It seems only right, therefore, that the Secretary of State should have specific regard to protecting adequate service provision for them. That is what the amendment is designed to do.

The contracting system may lead to more rigid discharge policies by hospitals, with the effect that patients are discharged quicker and sicker. Elderly patients especially, who take longer to recover from hospital treatment, may find themselves in the community with inadequate support.

It is interesting that in the East Anglian simulation exercise, to which I have referred on a number of occasions, one of the causes of the market crash on the third day was the complete swamping of community services by patients discharged too early. I fear that that was an all too true prediction. Although it is not within the scope of the Bill, this new clause would also have the advantage of plugging any gaps in services caused by the new GP contract. In short, for any period of change there is bound to be some turbulence. It seems only right that an amendment of this kind should be written into the Bill as a safeguard, providing a safety net for some of the most vulnerable members of our community. I beg to move.

Lord Henley

My Lords, we share the noble Lord's view of the importance of services for elderly and disabled people which, as he would be one of the first to point out, do not have the glamour that certain other services possess. However, this amendment would provide a fairly poor mechanism for improving them. For a start, services would have to reach a demonstrably inadequate state before action would be taken to improve them.

As with other services in the National Health Service, the level of provision is and will remain a matter for individual health authorities to determine in the light of local needs and priorities and competing claims on resources. In planning these services, we expect health authorities to work closely with FPCs. This collaboration should be improved by the changes which we are introducing to FPCs to ensure that the best possible services are provided to local people.

Elderly people are already recognised as a priority group. Thus health authorities are required when preparing their service provision plans to give special consideration to their needs. The level of service to be provided is for each health authority to decide.

Under the community care provisions in this Bill, health authorities and local authorities will be required to plan jointly their service provision for all people who require social and/or medical care. FHSAs will be involved in this process. In drawing up these plans health and local authortities will have to take into consideration the needs of the local population and demographic factors such as the ageing population. We therefore already have a major programme of action in hand to improve services to people in these groups. No doubt we have a great deal of further debate still to come on community care. I hope in the meantime that the noble Lord will withdraw his amendment.

Lord Ennals

My Lords, it has been noted that during the Committee and Report stages I have endeavoured to ensure that there is written into the Bill the awareness of the Government and Parliament that we need to make special provision for the elderly and disabled and for other underprivileged groups. Successive Ministers have given reassuring answers. I have always had to say that I was not satisfied with those reassuring answers and that is what I say now. In a year's time, when the Bill comes into operation, we shall see whether the needs of these people, whether they be homeless, elderly or disabled, are better looked after or worse. I have my fears, but 1 shall not press the amendment to a vote tonight. I beg leave to withdraw it.

Amendment, by leave, withdrawn.

Lord Walton of Detchant moved Amendment No. 132A: Before Clause 22, insert the following new clause:

("Grants for health care research

—(1) Section 97 of the principal Act shall be amended in accordance with this section. (2) After subsection (1) there shall be inserted the following subsections—

1. "(1A) The Secretary of State shall make grants to each relevant authority to be used solely for the provision of postgraduate, vocational and continuing education programmes for medical and dental practitioners, nurses and other health care professionals.
2. (1B) The Secretary of State shall maintain a fund for the purposes of making grants to any hospital or other NHS establishment where research is undertaken using funds provided by a registered charity." ").

The noble Lord said: My Lords, in moving this amendment I wish to speak also to Amendment No. 142A. Those two amendments stand in my name and that of the noble Baroness, Lady Robson of Kiddington. I shall be brief because in Committee the noble Baroness, Lady Hooper, gave an assurance that finds available to health authorities for the provision of postgraduate, vocational and continuing education programmes would be protected. Considerable concern had been expressed over the fact that in the recent past certain health authorities, finding themselves short of funds to fulfil their obligations, had withdrawn support for a number of those activities for all professions. I have to say that there is still considerable concern on the part of the medical profession and on the part of postgraduate deans that funds which are available for the continuing postgraduate and vocational education of medical practitioners may in the future be under similar threat. I trust that we can have a similar assurance from the noble Baroness that these funds will in future be protected.

A second issue which is particularly related to Amendment No. 142A and to the proposed new Subsection (2)(1B) of Amendment 132A relates to research in the National Health Service. One of the fundamental features of our National Health Service and its support for medical research is that the NHS provides the environment, the situation and the facilities in which medical research can be carried out and in which the Medical Research Council and the research granting charities provide the funds for the direct costs of undertaking that research. However, there have been circumstances where health authorities have found themselves in great difficulty in accepting much needed funds to support research and where research funds have been perforce diverted into providing clinical services to patients and patient care for which they were not in the first instance intended.

The hope in the proposed new Subsection (2)(1B) of Amendment No. 132A is that the Secretary of State shall maintain a fund to provide the infrastructure against which the funds from charities and the research councils can properly be used for the support of research, which is what they were provided for. When the Secretary of State met the Select Committee on Science and Technology of this House he gave an assurance that the Government's commitment to the support of research in the National Health Service was absolute. We trust that his commitment will extend to the support of this particular provision. We also hope that in accordance with Amendment No. 142A the service increment for teaching might perhaps more properly be called—this has been the case in effect for a good many years—a service increment for teaching and research. I beg to move.

Baroness Robson of Kiddington

My Lords, in Committee I supported the noble Lord, Lord Walton, in an amendment similar to this one except that it did not include the proposed new Subsection (2)(1B) in Amendment No. 132A. I raised that issue because I am concerned about the amount of money devoted to medical research in the present day. At least 50 per cent. of the money devoted to research is raised by medical research charities. The noble Lord, Lord Walton, referred to the fact that the charities are having to spend a large amount of their funds not on pure research or clinical research but on paying for back-up services in National Health Service hospitals.

One of the biggest medical charities has carried out an analysis of its expenditure in two big London teaching hospitals. I referred to this in Committee. The expenditure comes to somewhere between 35 and 40 per cent. of its funds. The people who donate money to the research charities do not expect that money to be spent on back-up services. Moreover, we spend less on research than most other countries in the world. It is important that we use every penny that is raised by the medical research charities for research and not for back-up services.

This amendment came up at 10.50 p.m. at Committee stage. The noble Lord, Lord Walton, and I put it down again for Report stage in the hope that it might come up a little earlier. Well, it is five minutes earlier, but that does not make much difference. It is a desperately important amendment for the future of the National Health Service. It is a tragedy that it has again come up so late in the day.

Regarding the assurances that the noble Lord, Lord Walton, mentioned with respect to postgraduate vocational training, I hope that the noble Baroness will be able to assure us that the Secretary of State will maintain a fund for the purposes of making grants to other NHS establishments where research is undertaken by medical charities. That would not entail an enormous sum of money but it would make all the difference to the way in which the research charities could spend their money. It would also help to improve the research facilities that we so desparately need in the National Health Service.

10.45 p.m.

Baroness McFarlane of Llandaff

My Lords, at this time of night I do not wish to prolong the debate by repeating what has already been said so adequately, but I wish to support these two amendments. I see them as particularly important amendments. In particular I should like to underline the reference in subsection (1A) of Amendment No. 132A to the need to support the provision of postgraduate, vocational and continuing education programmes.

In the nursing profession there has been ample evidence of the way in which authorities cut back on the funding of post-basic education. This is leading to severe problems in manpower provision in the health service. I am thinking particularly of the cutting back on funding education for community nursing—district nurses and health visitors—and also the crucial under-funding for paediatric intensive care nurses of which we have been made so very much aware. Therefore I wish to add my support to the amendments.

Baroness Hooper

My Lords—

Lord Peston

My Lords, the noble Baroness will not wish to speak before I say simply that we support the amendments. I am not clear that they are of equal importance, but I should particularly like to agree with the noble Baroness, Lady McFarlane, in emphasising the importance of continuing education. I do not seek to undermine the importance of research, but nothing can be more important than that the Secretary of State should see to it that vocational and continuing education for all health care professionals is an obligatory part of the NHS in whatever new form it takes.

Baroness Hooper

My Lords, when we discussed a similar amendment at Committee stage I explained that the Government were looking actively at the funding of continuing and postgraduate education for the caring profession and that a group of interested professionals led by the Chief Medical Officer had helped in those deliberations. I also explained that we had already decided that there should be a clearly defined budget for postgraduate and continuing education and that we were examining further how best that budget should be managed. No amendment is needed to operate such a budget. The powers under Section 97 of the National Health Service Act 1977 are sufficient to allow the funds to be separately identified and managed at both regional and district level.

Your Lordships should also be aware that the Government are already consulting research interests about the establishment of a fund to be used for supporting charitably funded research. The fund would be available to those hospitals which do not have access to the service increment for teaching (SIFT), which since 1st April last year will also cover the service costs of research. The membership of the Association of Medical Research Charities on the steering group on undergraduate medical and dental education in the next phases of its work also shows our commitment to working constructively with the charitable sector, which makes such an important contribution in this area. I am happy to underline that point again. Again, Section 97 powers could be used to operate such a scheme. I hope that that goes some way to reassure the noble Baroness, Lady Robson.

Because the amendment commits the Government to a single fund for all hospitals when the problem of service costs of research is peculiar to non-teaching hospitals, we find that it is in that sense too prescriptive. In addition, it might cast doubt on the use of the power in Section 97 to which I have referred, which has been used for many years for the general funding of the health authorities and for the payment of sums to health authorities for specific purposes.

Turning to the second amendment, hospitals are protected from the costs of medical and dental education through the SIFT programme. This was increased from 1st April this year to meet 100 per cent. of the cost instead of the previous 75 per cent. of the average excess costs of teaching hospitals, including those attributable to research. The increase in SIFT this year of £26 million brings the total to £343 million.

The steering group on undergraduate medical and dental education made some useful recommendations which the Government have accepted and, as a result, SIFT will be clearly targeted to supporting undergraduate medical and dental education and research. That fulfils the aim of the second amendment, which we also believe to be rather too specific.

The amendment also seeks to make the regional health authority give everyone responsible for research, even in non-teaching hospitals, a slice of the cake. Yet we are looking at a quite separate arrangement for the non-teaching hospitals and this amendment would make us fund them twice. Because of the way SIFT is calculated, it would not make sense simply to increase its value and support all research anywhere from it: we strongly believe that we need the two separate schemes.

I hope that I have been able to make it clear that we share the same objects of supporting education and training, both undergraduate and postgraduate, and research. I hope that the noble Lord will not feel it necessary to press the amendment.

Lard Walton of Detchant

My Lords, in the light of the clear assurances given by the noble Baroness, for which I am most grateful—I am sure that the noble Baroness, Lady Robson, shares my view—I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 22 [Distribution of general medical services]:

Lord Ennals moved Amendment No. 133: Page 23, line 32, leave out ("for") and insert ("to fill a vacancy created by the withdrawal from the medical list of a single-handed practitioner in").

The noble Lord said: My Lords, in moving this amendment I shall speak also to Amendments Nos. 134 to 137.

The issue is simple. It is a question of the powers of family health service authorities in selecting medical practitioners. Clause 22(2A) states: If in the opinion of the Medical Practices Committee, a medical practitioner is required for a particular part of the locality of a Family Health Services Authority, then, in such circumstances, as may be prescribed,— (a) the Authority (instead of the Committee) shall, in accordance with regulations, select the medical practitioner whose application they wish to be considered by the Committee.

When that issue was debated in Committee, I believe that the Minister said in reply that the power would be used to fill a vacancy created by the withdrawal from the medical list of a single-handed practitioner and that that was not a general power which the Government wished to transfer from the Medical Practices Committee to the FHSA. I wish to write into the Bill what I think was an assurance that was given at that time. If that were done, I think that it would be of considerable assurance to the medical profession. I beg to move.

Baroness Blatch

My Lords, I shall reply to Amendment No. 133 and my noble friend Lord Sanderson of Bowden will speak to Amendments Nos. 134 to 137 inclusive. We understand the motives behind this amendment but it would not achieve what the noble Lord has in mind. There is a practical difficulty. We all know what we mean by "single-handed" but there is no definition of it in the 1977 National Health Service Act, nor indeed in the relevant regulations.

There are some occasions when a vacancy which is, to all intents and purposes, single-handed, has actually been shared, for example, by a husband and wife or by more than one part-time doctor. If this amendment were to be accepted, the FHSA would not be able to select the doctor to fill such a vacancy. In addition, when the Medical Practices Committee creates a new single-handed practice vacancy, the FHSA would not be able to select the doctor to fill it. I am sure that the noble Lord does not intend that that should happen.

I believe that there is no difference between us. The Bill will not permit FHSAs to appoint doctors seeking to set up new practices from scratch, not in response to an advertisement. I can inform the noble Lord that when the regulations are made they will define FHSAs' powers and will specifically exclude partnership vacancies. I can also undertake that we shall consult the Medical Practices Committee and representatives of the profession on these regulations in due course. I cannot commend this amendment to the House.

Lord Ennals

My Lords, I quite understand why the Minister could not do so. It is an unsatisfactory amendment. I was just doing my best. That is all it was. The Minister has convinced me that the amendment in its present form is not satisfactory; but she has gone further than that. She has given two very important assurances which I think will be very satisfactory to the medical profession. In particular I am glad that there will be consultation before the regulations are drafted. With that assurance, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 38 [Distribution of general medical services]:

Lord Sanderson of Bowden moved Amendment No. 134: Page 45, line 10, leave out ("Committee") and insert ("Secretary of State").

The noble Lord said: My Lords, this amendment is grouped with Amendments Nos. 135, 136 and 137. These amendments bring the Scottish Clause 38 into line with the English and Welsh Clause 22, which was amended in a similar way at Committee stage. They provide that the Secretary of State rather than the Scottish Medical Practices Committee should handle a doctor's appeal on a point of law against a health board decision not to select him for a GP practice vacancy. I beg to move.

On Question, amendment agreed to.

Lord Sanderson of Bowden moved Amendments Nos. 135 to 137: Page 45, line 12, leave out ("Committee allow an appeal under paragraph (c) they") and insert ("Secretary of State allows an appeal under paragraph (c) he"). Page 45, line 43, leave out ("for") and insert ("after"). Page 45, line 44, leave out from ("be") to ("and") in line 45 and insert ("inserted").

On Question, amendments agreed to.

Clause 23 [Limitations on right to be included in list of dental practitioners]:

[Amendment No. 138 not moved.]

Baroness Blatch moved Amendment No. 138A: After Clause 39, insert the following new clause:

("Schemes for meeting losses and liabilities etc. of certain health service bodies

. After section 85A of the 1978 Act there shall be inserted the following section:—

"Schemes for meeting losses and liabilities etc. of certain health service bodies

85B.—(1) The Secretary of State may by regulations made with the consent of the Treasury establish a scheme whereby any of the bodies mentioned in subsection (2) may make provision to meet—

1. (a) expenses arising from any loss of or damage to their property; and
2. (b) liabilities to third parties for loss, damage or injury arising out of the carrying out of the functions of the bodies concerned.

(2) The bodies referred to in subsection (1) are—

1. (a) Health Boards;
2. (b) the Agency;
3. (c) a State Hospital Management Committee constituted under section 91 of the Mental Health (Scotland) Act 1984; and
4. (d) NHS trusts,

but a scheme under this section may limit the class or description of bodies which are eligible to participate in it.

(3) Without prejudice to the generality of the power conferred by subsection (1), a scheme under this section may—

1. (a) provide for the scheme to be administered by the Secretary of State, the Agency, or a Health Board or NHS trust specified in the scheme;
2. (b) require any body which participates in the scheme to make payments in accordance with the scheme; and
3. (c) provide for the making of payments for the purposes of the scheme out of money provided by Parliament.

(4) Without prejudice to any other power of direction conferred on the Secretary of State, if the Secretary of State so directs, any body which is eligible to participate in a scheme shall do.

(5) Neither the Secretary of State nor any body administering a scheme under this section shall, by virtue of their activities under the scheme, be regarded as carrying on insurance business for the purposes of the Insurance Companies Act 1982.")."

On Question, amendment agreed to.

Clause 24 [Transfer to DHA of certain functions relating to private patients]:

Lord Ennals had given notice of his intention to move Amendment No. 139: Page 25, line 30, at end insert— ("(d) Notwithstanding paragraph (a) above, a District or Special Health Authority shall not make available accommodation and services for private patients which exceeds one quarter of all such accommodation and services at a hospital or hospitals for which they have a responsibility.")

The noble Lord said: My Lords, this is another simple amendment which is tabled in my name. It is clear—I do not think that any of us would doubt it—that the National Health Service has a positive duty to seek in every way that it can to eliminate racial discrimination.

Lord Peston

My Lords, perhaps I may interrupt the noble Lord. I think that we have got the amendments out of order. It was not intended to move Amendment No. 139.

Lord Ennals

My Lords, in that case Amendment No. 139 is not moved.

[Amendment No. 139 not moved.]

[Amendments Nos. 140 and 140A not moved.]

11 p.m.

Lord Ennals moved Amendment No. 141: After Clause 24, insert the following new clause:

("Exercise of functions

. It shall be a duty of every health authority, Family Health Service Authority and National Health Service Trust to make appropriate arrangements with a view to securing that their various functions are carried out with due regard to the need—

1. (a) to eliminate unlawful racial discrimination: and
2. (b) to promote equality of opportunity. and good relations between persons of different racial groups.").

The noble Lord said: My Lords, as I was saying, before I was so rudely but quite properly interrupted, it is clear that the National Health Service has a positive duty to eliminate racial discrimination and to promote racial equality. I have never produced such unity in the House by anything that I have ever said before.

At the time when the Bill was published, the Commission for Racial Equality was anxious that this concept should be written into the Bill, and I warmly agree. The CRE's social policy division director, Jean Coussins, said: We said in our response to the White Papers which preceded this Bill that inequalities and discrimination within the health service and community care provision, in both employment and service delivery, needed to be explicitly addressed. This has not happened. The Government should take the opportunity of fresh legislation to make it absolutely clear that their aims to improve patient care and value for money apply equally to all citizens". I am sure that the Government will say—and they are right—that that is their intention. As we have argued on a number of other issues, this is so fundamental, so important to our society, that in my opinion—and I know that others support it—that simple view should be written on to the face of the Bill.

In proposing the amendment, there has been consultation with and approval by the National Association of Health Authorities, the Overseas Doctors Association, the King's Fund Task Force on Ethnic Minority Health, the National Council for Voluntary Organisations and other health authority and local authority organisations.

It is a simple amendment. However, I believe that it would produce not only a good response by those who care about equal opportunities for racial minorities but would point out to local health authorities the need at all times almost to fall over backwards to show that they are being fair and equal in their treatment. I hope that the Government will give a favourable wind, or at least a favourable answer, to the amendment. I beg to move.

Baroness Seear

My Lords, I wish strongly to support the amendment. Everyone nowadays is an equal opportunities employer except when one examines the results, only to find that they are very difficult to discover.

I know that the Government will tell us that it is the law of the land and the policy of the authority. However, the fact remains that when one considers the detail very little happens. I hope that the Government agree that the principle should be on the face of the Bill.

Baroness Blatch

My Lords, I shall say that it is the law of the land and that there is recourse to law if there is any breach of the law. We have continually demonstrated our commitment to equality of opportunity in all walks of life for people from ethnic minority communities.

In employment, it is for health authorities, as for other organisations, including National Health Service trusts, to ensure that they comply with the law. It is for individual health authorities to determine how their responsibilities should be met. But I should like to stress that we have on many occasions emphasised to them the importance which we attach to ensuring that the particular needs of people from different racial groups are adequately catered for.

It was this commitment, coupled with our concern about the rate of progress within the health service in implementing the Commission for Racial Equality's code of practice, which led us to join with the King's Fund in 1986 in establishing a special Task Force on Racial Equality in the National Health Service. One of the main objectives of the task force (which is due to complete its work in December this year) has been to provide guidance and practical assistance to health authorities seeking to implement the code of practice.

On family practitioner services, we have been taking steps to increase the access to these services of people from ethnic minority communities. For example, first, details of GP practices at which languages other than English are spoken will be available from the new local directories of family doctors which we are requiring FSHAs to produce to help patients to choose a doctor. Secondly, the new GP contract will encourage more women GPs to practise, thereby helping women, including those from ethnic minorities, who prefer to see a woman doctor. Thirdly, doctors are now being better rewarded by the new deprivation payments for practising in inner city areas, where large numbers of people from ethnic minorities live.

On services for which district health authorities will be responsible, each authority will be responsible for ensuring that a comprehensive range of services is provided to its resident population. They will assess the health needs of that population, including any special needs of particular groups such as ethnic minorities, and agree contracts with providers for services to be delivered. In developing contracts for individual services, district health authorities will agree standards with providers of health care designed to improve the quality and responsiveness of care to all patients.

Through the regional review process we shall continue to pursue the adoption of action plan tasks on equal opportunities with regional health authorities. While there is still a considerable way to go, we are confident that these initiatives are having a strong impact and that we now have a firm base on which to continue to build. The amendment would not only be out of keeping with the spirit of the reforms by adding to the central direction of health authorities which are charged with ensuring the appropriate delivery of health services to all their community but it would also be unnecessary because it duplicates the effect of existing legislation and government policy on health authorities. I cannot commend the amendment to the House.

Lord Ennals

My Lords, I accept what the Minister said—that this would not be in conformity with the views of the Government about the errors of any central direction. That is where the Government, and I and those on these Benches, must part company. This happens to be one issue. I believe that there are certain issues which the Government must state as a matter of national policy. This is one such issue on the basis of equal treatment. I agree with the Minister and I am sure that everything she said is being done. I believe that she would have wished to have an even stronger impact provided in an amendment such as this.

During the Committee and Report stages we on these Benches have sought to argue that the Government should insist on certain matters. The ways in which the principles are carried out are for health authorities to decide. We have looked at the different aspects of society; for example, people who are facing particular difficulties and disadvantages, elderly and disabled people and now ethnic minorities. We have sought to say that there should be some central direction not on how it should be done but that it should be done.

Therefore, there is a difference between us. The amendment was my last attempt to persuade the Government to write into the Bill some of the essential principles. They have decided that they do not wish to do so and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 142A not moved.]

Lord Ennals moved Amendment No. 142: After Clause 24, insert the following new clause:

("Duty of health authorities etc. to promote preventative measures

. It shall be a duty of every health authority, Family Health Service Authority and National Health Service trust to make appropriate arrangements with a view to securing that their various functions are carried out with due regard to the need to provide information on preventative health measures and health promotion.").

The noble Lord said: My Lords, it would be extraordinary if the National Health Service and Community Care Bill said nothing about prevention. The amendment seeks to ensure that in carrying out its functions any health body has a role in preventing ill health. There is no difference of view as to whether our health service should also have preventive, educational and screening roles. As with the last amendment, it is a question of emphasis.

The Bill aims to make the health service more responsive to the health needs of the general population but it says nothing about health promotion. It is important that the value of health promotion is recognised by the health service providers and is seen as being an integral part of patient care. That applies at every level of the service, from primary care to post-operative discharge. Patients need to be informed about how to improve their health recovery and how to prevent further illness. Health promotion is an important part of a comprehensive health care system which aims to provide more than a curative service. That such a provision finds no place in the Bill is an extraordinary omission. I beg to move.

Lord McColl of Dulwich

My Lords, I am not sure what good it will do to put the words of the amendment on to the face of the Bill. People know what to do but it is impossible to force them to do it. For example, the noble Lord, Lord Ennals, is very keen on preventing people from smoking. And yet, on National No Smoking Day, there was a photograph in the press showing noble Lords and Members of another place smoking their pipes in defiance of that day.

Lord Ennals

My Lords, I was not one of them.

Lord McColl of Dulwich

My Lords, the noble Lord, Lord Ennals, was not among them nor was any noble Lord on this side of the House.

Baroness Hooper

My Lords, I remind your Lordships that it is World No Smoking Day this Thursday.

The legislative basis for disease prevention and health promotion is clear. Section 1 of the 1977 National Health Service Act makes clear the duty of the Secretary of State for Health, to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—

1. (a) in the physical and mental health of the people of those countries, and
2. (b) in the prevention, diagnosis and treatment of illness".

This places as much weight on the Secretary of State's responsibilities for prevention and promotion as it does for the provision of services for the diagnosis and treatment of disease. Legislation is not required to ensure that NHS authorities carry out diagnosis and treatment, and likewise it is not necessary for health promotion and disease prevention.

The Bill is concerned with the organisation and management of services rather than definitions of the elements which make up a comprehensive health service. This clause separates out health promotion from other responsibilities which fall to health authorities and family health services authorities to provide rather than ensuring that health promotion is an integral part of all their services to patients. Health promotion is an integral part of the work of all health professionals in their day-to-day dealings with patients and should be a core part of the role of the new authorities.

While I fully support the aim of the new clause, the Government are taking action in the field of preventive medicine. I need refer only to the new GP contracts in that respect. I trust that the noble Lord will be reassured by my comments.

Lord Ennals

My Lords, the Minister said politely and constructively what the noble Lord, Lord McColl, said in brief. He said, "I do not know what good this amendment will do". The Minister said the same and explained what the Government are doing. I respect much that the Government are doing in this area. I say to the noble Lord, Lord McColl, I do not know what good this Bill will do. It is before us. I should have liked to improve it and my success rate so far is pretty bloody awful. I have done my best. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 143 not moved.]

Baroness Blatch

My Lords, I beg to move that further consideration on Report be now adjourned.

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

House adjourned at fourteen minutes past eleven o'clock.