National Health Service and Community Care Bill

HL Deb 25 June 1990 vol 520 cc1325-426

6.13 p.m.

Read a third time.

Lord Coleraine had given notice of his intention to move Amendment No. 1: After Clause I, insert the following new clause: ("Application of Local Government Act 1972 to Regional and District Health Authorities —(1) Sections 100A to 100C of the Local Government Act 1972 (access to meetings and documents of certain authorities) shall apply to a Health Authority established in accordance with section 8 of the principal Act as they apply to a principal council within the meaning of Part VA of that Act, but the references in sections 100B and 1000 to the proper officer in relation to a principal council shall be construed as references to the person appointed for the purpose by the Health Authority. (2) In section 100H of that Act (supplemental provisions and offences)—

1. (a) any reference to any provision of Part VA of that Act or to any right conferred by that Part includes a reference to any such provision as it applies by virtue of this section or, as the case may be, to any right conferred by that Part as it so applies, except that references to section 100D shall not apply,
2. (b) in subsection (3) as it so applies the reference to a principal council shall be construed as a reference to a Health Authority and
3. (c) subsection (5) shall apply to any meeting of a Health Authority.

(3) The power conferred on the Secretary of State by section 1001(2) of that Act to vary Schedule 12A to that Act (exempt information) shall include power to vary that Schedule as it applies by virtue of this section. (4) In that Schedule, as it so applies— (a) Part I shall have effect with the insertion after paragraph 6 of the following paragraphs— 6A. Information relating to the physical or mental health of any particular person. 6B. Information relating to—

1. (a) any particular person who is or was formerly included in a list of persons undertaking to provide services under Part II of the principal Act or is an applicant for inclusion in such a list; or
2. (b) any particular employee of such a person.";

(b) paragraph 1 of Part II shall have the effect with the insertion after the words "paragraph 1 to 5" of the words "or 6B"; and (c) any reference to "the authority" shall be construed as a reference to the Health Authority. (5) In this section references to a Health Authority include references to a committee or sub-committee of a Health Authority where that authority has delegated to such a committee or sub-committee the power to discharge functions of the authority. (6) In the Public Bodies (Admission to Meetings) Act 1960 (which makes similar provision to that made by sections 100A and 100B of the Act of 1972), paragraph 1(f) of the Schedule shall be deleted. (7) A Health Authority shall maintain a register stating—

1. (a) the name and address of every member of the Authority and
2. (b) the name and address of every member of each committee or sub-committee of the authority for the time being.

(8) A Health Authority shall maintain a list—

1. (a) specifying those powers of the authority which, for the time being are exercisable from time to time by officers of the authority in pursuance of arrangements made under this Act or any other enactment for their discharge by those officers; and
2. (b) stating the title of the officer by whom each of the powers so specified is for the time being so exercisable;

but this subsection does not require a power to be specified in the list if the arrangements or its discharge by the officer are made for a specified period not exceeding six months. (9) The register maintained under subsection (7) above and the list maintained under subsection (8) above shall be open to inspection by the public at all reasonable hours and without payment at the offices of each Health Authority and any person may, on payment of such reasonable fee as the Authority may determine—

1. (a) make copies of or extracts from any such register, list or summary kept by it; and
2. (b) require the Authority to supply him with a photographic copy of or extracts from any such register, list or summary.").

Lord Peston

My Lords, I speak to this amendment with some caution because I know how very keen the noble Lord, Lord Coleraine, was to speak to the amendment. I see that the noble Lord has just walked in to the Chamber. Perhaps the most helpful thing that I can do for him and your Lordships is to sit down.

Lord Coleraine

My Lords, before moving the amendment I apologise for not having been in the Chamber when my amendment was called. It was only when I was passing through the Division Lobby that I discovered that the Report stage of the Social Security Bill was about to finish early.

In a notable maiden speech 30 years ago my right honourable friend the Prime Minister moved the Second Reading of what became known as the Public Bodies (Admission to Meetings) Act 1960. The Act gave some public rights of access to meetings of public bodies, including local authorities and health authorities. The amendment would extend public rights of access in the case of health authorities, at the same time providing what I hope are clear and improved statutory provisions under which health authorities may exclude the public from meetings where the circumstances justify their doing so.

The amendment would extend public access to the decision-making committees and sub-committees of health authorities, to the agenda and minutes of those meetings which are open to the public and to the reports presented to those meetings. Additionally, it would impose certain other requirements on health authorities as to the way in which they conduct themselves, a subject that we have debated when the matter has been before your Lordships at earlier stages during the passage of the Bill and which are minor matters which I need not mention now.

The purpose of the amendment may be transparent but the drafting follows precedent and is, regrettably, opaque. I therefore remind the House that the amendment follows the trail laid by the Member for Hornchurch in another place, my honourable friend Mr. Robin Squire, when he sponsored the Local Government (Access to Information) Act 1985, which added a number of sections to the Local Government Act 1972 to extend public rights of access to local authorities. Subsequent Private Members' Bills emanating from another place have extended public access in other fields. They have all been drafted by reference to the new sections in the Local Government Act. The amendment before the House this evening, although it has nothing to do with local government, is drafted in the same way.

Today I wish to deal only with that part of the amendment which covers the grounds on which a health authority may exclude the public. The existing grounds are to be found in Section 1 of the 1960 Act. That section provides that a health authority may, by resolution, exclude the public in one of two cases. The first is: Whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted". The second is where there are: Other special reasons stated in the resolution and arising from the nature of that business or of the proceedings". Those are vague and rather unsatisfactory criteria. They are frequently difficult to apply and difficult to challenge. They have been amplified in departmental guidance contained in Health Circular 6 of 1981, which explains that: It is a matter for the Health Authority to decide whether or when to close its meetings to the press and general public. It is, however, a general precept of public life that public bodies should not invoke the Act lightly, with a presumption of open and public discussion, whenever possible". That such guidance was found to be necessary surely indicates that the 1960 Act is in too many respects an open invitation to public bodies to continue to conduct their business in private.

The amendment would allow for the exclusion of the public in two much more clearly set out and defined types of case. That would be for the convenience both of health authorities and of the public, not least because the correct application of the present criteria must often call for costly legal advice, which may be wrong. The first case provided for by the amendment is that the public may be excluded on grounds of confidentiality where information is likely to be considered by the authority which has been supplied by a government department on terms forbidding disclosure or where disclosure is forbidden by statute or court order. The second case is where there might be disclosure in a meeting of exempt information. That is defined in the amendment and in the Local Government Act by reference to a specific list of descriptions of information. It is a list which can be amended by the Secretary of State from time to time by order.

The debates that we have had on the subject during the passage of the Bill were not the first occasions on which improved public access to health authorities was requested. During the passage of the Health and Medicines Act 1988 in another place, Mr. Fearn, the Liberal Member for Southport, moved a late amendment in wide terms and embracing a wider list of public bodies in the health field than does the present amendment. The then Minister, Mr. Newton (now the Secretary of State), said that time would be needed in which to consider the matter particularly in terms of the administrative implications and the cost.

Six months later the amendment was moved in this House by the noble Lord, Lord Ennals. He probed the Government's intentions. The reply of my noble friend Lord Skelmersdale was somewhat dismissive. He said: the Government have been doing much in the past six months, not least adding, mid-year, £2 billion to the amount of money they are prepared to make available for the health service. With that background, is this the moment to spend extra money on what is essentially … administration?".—[Official Report, 17/10/88; col. 998.] It is a suggestion that public access to the decision-making processes is merely an administrative detail that grates.

In earlier debates on the subject the Minister referred to the Government's commitment to public access to health authority meetings. However, that is only within the terms of the 1960 Act which I consider to be inadequate. The provisions of the amendment are said to be incompatible with the reforms being carried out in health authority membership and the Government's aim to make health authorities into more efficient management bodies.

It is my principal submission that the character of the new-style health authority, including its new managerial function and the fact that there will no longer be district health authority members appointed by local authorities or members appointed on the nomination of universities, should provide the strongest reason for more and not less public access to the meetings and affairs of health authorities.

At various times during the passage of the Bill through this House the Minister, in answering amendments, has declined to commit district health authorities to the provision of this or that service in this way or to that standard. Whether it involved the provision of an integrated and comprehensive child health care service or an incontinence service, we were told that the decisions were to be made by health authorities on the ground and not to be pre-empted. That appears to constitute a nearly cast-iron case for health authorities to be as fully open to the public as are local authorities, notwithstanding the fact that local authorities are elected and health authorities are appointed.

Local authorities will inevitably be closely involved in any integrated child health care service. As regards public access rights, it makes no sense for them to operate under regimes different from those of health authorities. Irrespective of their accountability to the Secretary of State, it is right that the new-style health authorities should also be accountable in terms of openness to the public which they serve and that more appropriate and comprehensive conditions than now exist should govern the circumstances in which public policy or confidentality may be invoked to set aside that openness. I beg to move.

Lord Peston

My Lords, I hope that I may have your Lordships' indulgence to make my speech rather then performing the holding operation in which I was previously engaged in order to enable the noble Lord, Lord Coleraine, to move his amendment. I congratulate the noble Lord for at last getting his amendment on the timetable in daylight. It appears to make the matter more serious.

The points to bear in mind are, first, that it is the application of the Local Government Act 1972. I hope that I do not have to remind noble Lords opposite that that piece of Conservative legislation was devoted to the idea of openness. The amendment applies that idea to health authorities. Secondly, openness—or "glasnost", as it is called—is in the spirit of the times and should apply as much here as elsewhere. Thirdly, central to the issue is the fact that the regional and district health authorities are not local authorities. However, they are authorities and we have not set them up as boards. I take the Government's word that they are fully committed to the preservation of the National Health Service. They have said that they are not using the Bill as a basis for privatisation and therefore do not regard the authorities as boards. As the noble Lord, Lord Coleraine, said, we must approach them in the spirit of openness. I hope therefore that the Government will accept the amendment.

The noble Lord, Lord Coleraine, has concentrated on the main issues before the House. However, I wish to draw your Lordships' attention to subsection (7) of the amendment. It provides that the name and address of every member of the Authority and … the name and address of every member of each committee or sub-committee of the authority for the time being shall be available on a register. People who choose to accept appointment to such authorities which are in the public domain, and choose to make their contribution by way of public service, should be willing to have their names and addresses stated publicly as are other people in similar walks of life. I do not know of the Government's position: but if they do not intend to accept the amendment in detail, why should that not be a mandatory requirement? From these Benches, I strongly support the amendment.

Lord Young of Dartington

My Lords, I too support the amendment. I am sorry that there has not been a little more give on the subject since it was discussed previously in this House. I hope that there will be more give tonight. From the beginning of the reform, as it is called, which the Bill represents, and since the publication of the White Paper, it has been said that its main purpose is to improve the service offered to consumers. The proposals for the internal market and other proposals are designed to improve the service to consumers—that is the patients and their families—and to do so at an economic cost.

If that is the declared and real purpose, I cannot see why representatives of the public—that is the consumers in one of their forms—should not be able to attend meetings of the district and regional health authorities. How are they to know in detail as well as in general whether the service is in their interest unless they are able to see and hear what the governors in their district are doing about the service? How can they know that unless they have access to the vital documents that will be available to members of the authorities?

It will always be the case that particular issues will arise in particular districts. Consumer and other groups will rightly wish to make their voices and opinions known. However, how are they to do so, and do so effectively, unless they have the information upon which the authority is acting and unless, in particular cases and in general if they are keen, they are able to attend the meetings of the health authorities?

As has been pointed out previously by other noble Lords, it is particularly objectionable that health authorities should be treated any differently from local authorities. Local authorities are at least elected. That gives the local public certain very important rights. Health authorities are not elected; they are appointed. There is therefore all the greater need for the public to have the right of access. If that does not happen—and I am afraid that it may not happen while this Government are in power, although we can always live in hope—much local distress may be caused to people who do not even know the basis upon which apparently unpopular decisions have been taken.

The district authorities need to have the full confidence of their local public even though they are not elected. One way to secure such confidence is to invite members of the public to see how well the authorities are doing their job and so to encourage the highest possible standard of local debate.

Margaret Thatcher, when an MP, went a long way towards accepting the principle in local government. It has been accepted since the 1972 Act that local authorities are not to be cabals meeting in secret. Therefore how can it be stated, as the Bill provides, that members of the public are not to be entitled to know what goes on within district authorities or to attend meetings?

Arguments may be put forward against the amendment. It is unlikely that those who take the view so ably put forward on our behalf by the noble Lord, Lord Coleraine, will be persuanded by them, because so much is at stake. It seems absolutely straightforward that where a local authority is appointed by the Secretary of State it should be open and accessible to the public. I hope that there will be some signs of give on the issue. If not, in a small way it will be a disgrace to the Government, although it will not be one that lasts forever because another government will eventually change the position.

6.30 p.m.

Baroness Seear

My Lords, as the noble Lord said, my honourable friend the Liberal Democrat Member for Southport moved an amendment which was rather more extensive in its application than this amendment. I should like to support the amendment as it has now reached your Lordships' House.

It seems quite extraordinary that the Government should resist the amendment. Only last Friday they accepted the need for access to medical records. They are therefore moving at a snail's pace towards greater openness. The Government have stated repeatedly that the public have misunderstood the reforms in the legislation. Some of us believe that the public have understood them only to well. However, if the public have misunderstood them, then surely there is everything to be said for giving the public access to the committees which will be dealing with the results of the legislation. There is all the more reason because the committees are not elected.

As the Government know, some of us are not without apprehension that certain of those committees will not be as strictly apolitical as we have been led to believe. I should have thought that the Government would wish to disperse that fear by allowing people to see how those non-elected committees operate. They will be dealing with a largely unpopular piece of legislation. In the interests of public accountability, of the ordinary people knowing what action is being taken on health, and of the Government establishing the correctness of their policies (if that can be established), I should have thought that they would be only too glad to accept the amendment.

Baroness Masham of Ilton

My Lords, as the National Health Service is funded from taxpayers' money, it seems right that they should know how the money is spent. Will trust hospital meetings be open to the public? They again are funded from taxpayers' money.

Baroness Blatch

My Lords, I too congratulate the noble Lord upon having his amendment discussed at a civilised time of day. We have twice previously discussed the amendment at a very late hour of the day.

I explained at Report stage that we recognise that the noble Lord has endeavoured to meet some of the Government's concerns about imposing additional burdens on health authorities. I shall not repeat the arguments that I put forward at Report stage as to the differences between local authorities and health authorities. It is because they are very different types of body that we believe it is not appropriate for health authorities to be subject to the provisions of the Local Government Act.

At Report stage my noble friend Lord Coleraine made the point that the requirements of the 1960 Act are not clear on the exact circumstances in which a health authority may exclude the public. It is true that, unlike the local government provisions, the 1960 Act does not impose a straitjacket. Rather, it provides a flexible approach giving scope for considerable openness when combined with unequivocal guidance from Ministers—currently contained in circular HC(81)6—that there is a firm presumption of open and public discussion wherever practicable.

During the Committee stage of the Bill my noble friend Lord Coleraine quoted research from the Community Rights Project which alleged that contravention of the 1960 Act by health authorities was widespread. I stress again that those allegations are of real concern to the Government. If evidence of misuse of the 1960 Act is brought to our attention, we shall look at it very closely.

My noble friend made reference to the particular Act saying that those breaches are difficult to challenge. I have to repeat again that, so far, no attempt to bring evidence before my department has been made. If there is evidence available I invite that it be brought to the attention of the department.

Perhaps I may conclude by saying that the Government have listened carefully to my noble friend on this issue. We shall certainly take all the detailed comments that he makes fully into account when framing our guidance to health authorities, which will be issued over the coming months. We share his determination to ensure that the local community is aware of and involved in the deliberations of their health authority which should operate in as open a manner as possible. However, at present we have no reason to believe that the current legal framework is faulty. We do not wish to introduce extensive and burdensome statutory provisions when a simple and clear cut one is sufficient.

The noble Lord, Lord Peston, made reference to health authorities being willing to have the names and addresses of their members made public. Many local authorities are already doing that. They issue booklets which contain names and addresses of health authority members. It is my department's intention to put in the guidance that all health authorities should do that, though we do not agree that it should necessarily be a legal requirement.

The noble Baroness, Lady Masham, asked about National Health Service trusts. I am advised that trusts will have an annual public meeting at which their accounts and plans will be discussed. It is a step forward from the present situation, where no management meetings at unit level are open to the public.

The noble Lord, Lord Young of Dartington, said that under the reforms the public would somehow have lees access to meetings and therefore less access to information. I am not absolutely certain how he comes to that conclusion, because that simply is not the case. The present arrangements are not changed by the reforms. In other words, the presumption of openness both for information and for meetings is not changed by the new legislation.

In the light of that explanation I hope that I have convinced my noble friend that he should withdraw his amendment.

Lord Young of Dartington

My Lords, I am sorry if I did not make myself clear. I argued that the Government have said on various occasions that the reforms will improve matters in various respects for the consumer. If that is so, as surely it must be, then it seems very odd that representatives should not be able to attend meetings.

Baroness Gardner of Parkes

My Lords, I believe that that intervention is out of order.

Lord Coleraine

My Lords, this has been an interesting debate and I am grateful to all noble Lords who have spoken. Noble Lords will appreciate that this is not a party political matter: it is a matter in which those who are interested in democratic processes take a very great interest.

My noble friend the Minister took the point, as she has done before, that local authorities and health authorities are different kinds of bodies. I submit that that is a logical misapprehension. What is significant is not the type of body that they are but the work that they do and the way in which they are perceived by the people they serve.

There is no doubt in my mind, and I am sure that there is no doubt in the minds of noble Lords who have supported me, that in the opinion of the public—the consumers of health services—there is this difference between a health authority and a local authority: a health authority is appointed by Whitehall whereas a local authority is directly accountable to the electors. Therefore, those who are interested in the provision of health services expect a greater standard of openness from health authorities then they would from local authorities.

I have suggested that breaches of the 1960 Act are difficult to challenge. The noble Baroness invited me and those advising me to draw to her attention any breaches of which we may be aware. I am not so much concerned with breaches of the Act as with the plain difficulty of interpreting a very general and difficult clause. The idea of confidentiality being in the public interest is bound to be subject to many interpretations by different lawyers. It would be a hardy member of the public who would say: "this is a breach"; he would say: "this seems to be a rather odd way of behaving but it may well be covered by the wording of the 1960 Act and there is nothing more I can do about it".

We have debated the matter on three occasions during the passage of the Bill. It is a subject that has previously been before Parliament and it is a matter upon which the opinion of the House should be sought.

6.43 p.m.

On Question, Whether the said amendment (No. 1) shall be agreed to?

Their Lordships divided: Contents, 72; Not-Contents, 108.

DIVISION NO. 4
CONTENTS
Allesbury, M.	Jeger, L.
Airedale, L.	Jenkins of Hillhead, L.
Ardwick, L.	Jenkins of Putney, L.
Attlee, E.	John-Mackie, L.
Aylestone, L.	Kilmarnock, L.
Blackstone, B.	Kinloss, Ly.
Boston of Faversham, L.	Lawrence, L.
Bottomley, L.	Llewelyn Davies of Hastoe,
Brooks of Tremorfa, L.	B.
Carmichael of Kelvingrove,	Lloyd of Kilgerran, L.
L.	Longford, E.
Carter, L.	McFarlane of Llandaff, B.
Cledwyn of Penrhos, L.	McGregor of Durris, L.
Clifford of Chudleigh, L.	McIntosh of Haringey, L.
Clinton-Davis, L.	McNair, L.
Cocks of Hartcliffe, L.	Masham of Ilton, B.
Coleraine, L. [Teller.]	Mishcon, L.
Craigavon, V.	Molloy, L.
Darcy (de Knayth), B.	Monson, L.
David, B.	Morris of Castle Morris, L.
Davies of Penrhys, L.	Nicol, B.
Dean of Beswick, L.	Northfield, L.
Denington, B.	Peston, L.
Ennals, L.	Pitt of Hampstead, L.
Erroll, E.	Prys-Davies, L.
Fisher of Rednal, B.	Richard, L.
Gallacher, L.	Seear, B. [Teller.]
Galpern, L.	Seebohm, L.
Graham of Edmonton, L.	Stedman, B.
Grey, L.	Stoddart of Swindon, L.
Hampton, L.	Taylor of Gryfe, L.
Hatch of Lusby, L.	Turner of Camden, B.
Hollis of Heigham, B.	Wallace of Coslany, L.
Houghton of Sowerby, L.	White, B.
Howie of Troon, L.	Williams of Elvel, L.
Hughes, L.	Wilson of Rievaulx L.
Jay, L.	Young of Dartington, L.

NOT-CONTENTS
Aldington, L.	Blatch, B.
Allerton, L.	Blyth, L.
Arran, E.	Borthwick, L.
Balfour, E.	Boyd-Carpenter, L.
Barber, L.	Brigstocke, B.
Beaverbrook, L.	Brougham and Vaux, L.
Beloff, L.	Buccleuch and Queensberry,
Belstead, L.	D.

Campbell of Alloway, L.	Mancroft, L.
Carnock, L.	Margadale, L.
Carr of Hadley, L.	Merrivale, L.
Cavendish of Furness, L.	Mersey, V.
Constantine of Stanmore, L.	Monk Bretton, L.
Cork and Orrery, E.	Mountevans, L.
Cox, B.	Mowbray and Stourton, L.
Craigmyle, L.	Munster, E.
Cullen of Ashbourne, L.	Murton of Lindisfarne, L.
Davidson, V. [Teller.]	Nelson, E.
Deedes, L.	Nugent of Guildford, L.
Denham, L. [Teller.]	Orkney, E.
Dilhorne, V.	Oxfuird, V.
Eccles of Moulton, B.	Pearson of Rannoch, L.
Elibank, L.	Pender, L.
Elliot of Harwood B.	Peyton of Yeovil, L.
Elton, L.	Quinton, L.
Fanshawe of Richmond, L.	Rankeillour, L.
Ferrers, E.	Reay, L.
Flather, B.	Renton, L.
Gardner of Parkes, B.	Rodney, L.
Gray of Contin, L.	Soultoun of Abernethy, Ly.
Gridley, L.	Sanderson of Bowden, L.
Hailsham of Saint	Shannon, E.
Marylebone, L.	Sharples, B.
Hanson, L.	Skelmersdale, L.
Harmar- Nicholls, L.	Stanley of Alderley, L.
Henley, L.	Stevens of Ludgate, L.
Hertford, M.	Strathclyde, L.
Hesketh, L.	Strathcona and Mount Royal,
Hives, L.	L.
Holderness, L.	Strathmore and Kinghorne, E.
Hood, V.	Swinfen, L.
Hooper, B.	Teviot, L.
Hylton-Foster, B.	Thomas of Gwydir, L.
Jenkin of Roding, L.	Thomas of Swynnerton, L.
Johnston of Rockport, L.	Trefgarne, L.
Joseph, L.	Trumpington, B.
Kaberry of Abel, L.	Ullswater, V.
Killcarn, L.	Vaux of Harrowdean, L.
Kimball, L.	Vinson, L.
Lauderdale, E.	Wade of Chorlton, L.
Lindsey and Abingdon, E.	Wedgwood, L.
Long, V.	Wise, L.
Lucas of Chilworth, L.	Woolton, E.
Lyell, L.	Wynford, L.
McColl of Dulwich, L.	Young, B.
Macleod of Borve, B.

Resolved in the negative, and amendment disagreed to accordingly.

6.50 p.m.

Clause 3 [Primary and other functions of health authorities etc. and exercise of functions]:

Lord Clifford of Chudleigh moved Amendment No. 2: Page 3, line 17, at end insert: ("( ) It shall be the primary function of a District Health Authority to ensure that budgetary provision allows for an integrated comprehensive child care service which links effectively with services delivered by the local authority.").

The noble Lord said: My Lords, your Lordships have read the amendment before. It is a text presented to this noble House on 7th June. Maybe the repetition has caused the obvious good attendance, as those present have said, "This has got to be seen through".

The finale I presented on 7th June requested a meeting with the Minister or a Department of Health official. The meeting was arranged for 22nd June but was rearranged at short notice, so I was unable to attend. Fortunately the noble Baroness, Lady Faithfull, and others qualified to speak about child care had a rescheduled meeting with the Minister on Wednesday, 20th June. The results are inconsequential unless they are followed through.

When talking about the health of children—the next generation—we are considering, in the words of so many businessmen, an investment. The manner in which we handle or manage this investment is up to certain parties to decide, and the most important of those parties is the parents. But this House and the other place have been given the opportunity and power to dictate, or to alter, how best the nation's health is managed through the national health system or the system of care for the health of the nation.

Politicians and businessmen talk about employing more mothers and establishing a crèche at the workplace. That is absolutely marvellous. But what if a child falls ill? Britain is the only member of the EC that does not give a statutory right to a parent or parents to paid sick leave when a child is ill. What about parents with permanently disabled children? Those children are very expensive to maintain, and, it seems, very much at risk under this Bill where contracts, incentives and trusts are major factors. In 1989, the Secretary of State for Health considered the sensitive subject of chronically sick or disabled children who were referred almost instantly from secondary to tertiary hospitals. He stated: The question of who authorises payment for the referral from secondary to tertiary hospital has not been resolved.

Let us help the good gentleman and ensure that paediatric advice to health authorities leads to each district health authority having a strategy to ensure a system where paediatric care in the hospital is integrated, and closely and regularly monitored wherever necessary, with community and primary health services. It may be of interest to your Lordships to ask whether hospital trusts will regard children as a profitable commodity.

Just over 9,000 beds were available for special care baby units and paediatrics in 1988, with 55 per cent. and 67 per cent. occupied respectively, demonstrating the unpredictable nature of child health care demands. In the same year, almost 55,000 beds were available for geriatrics—I ask your Lordships please not to take offence, but we know that geriatrics have a vote—and 89 per cent. of those beds were occupied.

We all understand that low bed occupancy in hospitals is uneconomic, but surely it is appreciated that a child of between zero and four years of age is as fragile, as delicate and sometimes as desparately disabled as a geriatric. In the financial year 1986–87, £280 per head was spent on that age bracket of children who were in need of hospital and community health care, as well as family practitioner services, while £1,190 per head was spent on the same services for those 75 years and over.

During the many stages when we have debated this National Health Service and Community Care Bill, many Members of the House expressed displeasure about the speed with which such a sensitive subject as national health is being rushed through and forced upon the beneficiaries, the electorate, the taxpayer. Many noble Lords feared the misuse of funds and urged that a definitive percent age should be ringed for specific needs, such as child health care.

At a hospital that I recently attended, the staff were appalled at the careless use of money. They said this to me and I did not ask them about it. That hopsital displayed inside the front door a sign saying that £38,000 had been spent on redecorating the reception area. Surely hospitals are functional facilities and not hotels. I am sure that the nursing staff would have appreciated a penny or two of that sum. The doctors and surgeons would dearly have loved to see more facilities available. Visitors to patients of all ages would have appreciated a larger parking area or accommodation for low income parents with acutely ill children in the hospital. It was somewhat sickening to see recorded in the local press that a casualty had driven himself to the hospital and had been admitted. When released he found that his car, which had been left in haste in the car park, had been clamped. Is that just desserts?

The electorate, the consumer, has every cause to be concerned about the proposal in the Bill, which we have just heard, that the only member of a health authority who is accountable to the public by election—that is, the local authority representative—is to go. Such people are no longer to be members of health authorities.

In this amendment I wish to underline the importance of the word "budget", for, as your Lordships are aware, the general practitioners' contract introducers three different payment fees for child health. The first is capitation for child health; the second is the incentive payment for immunisation; and the third is the optional fee for child surveillance. I ask your Lordships to recall the emphasis I laid on prevention rather than cure, and on immunisation, in my maiden speech on 3rd April 1990.

As child health care will depend upon fees paid—this figure is still under negotiation—it is clear that the world health authorities' target of 90 per cent. immunisation will be unattainable and a lower figure of 70 per cent. has been regarded as realistic. As I stated on 31st April, the greater the number of children without immunisation the more severe the cost to the National Health Service; the greater the number of children in tertiary hospital care the greater the unhappiness of the public, the taxpayer, the voter. Surely it is clear that an integrated service between hospitals and community and primary health services must be maintained; that a specialist child care team in all districts is vital; and that a comprehensive budget must be reserved for acutely ill children and for community and primary care services where specialists are required in the care of children.

We applaud and support the Government's insistence on medical audits, a procedure which our professionals can use to optimise their services following examples in other health districts. We also applaud it because it will engender healthy competition and naturally encourage commitment to improve the outcome of medical services.

The architects of some of the clauses in the Bill need a prescription themselves—a prescription to be taken daily after each meal and a prescription that will improve the patient's sense of responsibility and respect. I beg to move.

7 p.m.

Baroness Faithfull

My Lords, I rise to support the noble Lord, Lord Clifford. When he moved the amendment on 7th June, it was supported by my noble friend Lord Mottistone, by the noble Lords, Lord Ennals and Lord Peston, by the noble Baroness, Lady Masham, and myself.

Responding to that debate, my noble friend the Minister, Lady Blatch, said: there is no question but that it will be the duty of district health authorities to promote comprehensive health services for children as the amendment proposes". She went on to say: The Secretary of State already has a clear duty to provide a comprehensive range of health services under Section 1 of the 1977 Act".—[Official Report, 7/6/90; col. 1585.] At the moment there is no comprehensive service, although it is said in the 1977 Act that there should be. It is not underlined in the Bill that there should be a comprehensive health service for children and the position will therefore be much the same.

I was grateful to my noble friend Lady Hooper for arranging at short notice a meeting with her, her civil servants and medical adviser. I must apologise to the noble Lords, Lord Clifford, Lord Ennals and Lord Winstanley. The noble Lord, Lord Clifford, was in Devon, so he could not come except by helicopter, and I could not find the noble Lords, Lord Ennals and Lord Winstanley. I hope that they will forgive me. We were grateful to my noble friend Lady Hooper for arranging that meeting and I was greatly assisted by the presence of Dr. Logan of the Institute of Child Health to whom I give thanks for the help that he gave me.

Perhaps I may speak to the final sentence of the amendment which refers to a: comprehensive child care service which links effectively with services delivered by the local authority". We are worried about the future. Perhaps I may refer to a report entitled Public Health in England which is the report of the committee of inquiry into the future development of the public health function. That report gives no hope of a better service. On page 32 it is recommended that the public health doctor should not be an advocate. The report states: We therefore reject the view … that public health doctors … have a duty or a right to advocate or pursue policies which they judge to be in the public interest". We do not yet know whether that proposal will be accepted, but it will be the duty of the doctor responsible for the management to take up social issues. I quote, as I quoted last time, the issue of bad housing and bed and breakfast accommodation about which the health visitors said that there was not much point their visiting cases involving those terrible conditions and that, in any case, they were nervous about doing so. If the doctors are not able to take up such matters, it is a cause for great concern.

Paragraph 5.24 on page 34 of the report, which recommends the policy for the future, states: It is at regional level that there will need to be the greatest degree of specialisation and flexibility within the speciality of public health medicine". Epidemiology and communicable disease control, among other things, are mentioned, but child care and paediatrics are never mentioned. The only possible mention of them is in line which refers to: services for particular care groups". Paediatrics is a specialist subject in itself and special notice should be taken of children.

In the amendment we recommend that an overall manager with responsibility for all child health services should be appointed within a district; that there should be a clear organisational unit for children; that there should be a comprehensive budget for community and acute services; that there should be specialist staff trained in the care of children; that there should be an internal information system; and that there should be an information and contact point for families.

I realise that it may not be possible for my noble friend the Minister to give way on this amendment, but we all know that draft guidance forms or booklets have been printed. If my noble friend is unable to accept the amendment, perhaps she can assure us that the contents of the amendment will be included in draft guidance, as have other matters. I support the amendment.

Lord Ennals

My Lords, I want to be very brief in giving my total support to the amendment proposed by the noble Lord, Lord Clifford of Chudleigh, and so well argued by the noble Baroness, Lady Faithfull. I do not need to set out the arguments; I simply want the Minister to accept the amendment because she has said that it is government policy. The Secretary of State has said that it is government policy. The Minister cannot be against an integrated, comprehensive child care service; nor can she be opposed to the links with the local authority. It would be nice if on this day—this celebratory day—she were to accept what we know is already government policy and put it on the face of the Bill. I support the amendment.

Baroness Seear

My Lords, in the absence of my noble friend Lord Winstanley, I too should like to say briefly that we on these Benches give the amendment our strongest support.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, during our discussion of this subject at Report stage, my noble friend Lady Blatch made clear the priority that we attach to the development of effective child care services, as has been said by the noble Lord, Lord Clifford. On that occasion, she quoted the Secretary of State's letter of last year to the president of the British Paediatric Association which reaffirms our commitment to the proposals of the Court Report and in particular to the importance of co-ordination of child care services delivery by general practitioners, community health services, hospitals and local authority social services departments. I hope therefore that it is clear that, as I think has been admitted by those who have spoken this evening, we approach the amendment in a spirit of agreement on the way in which we all want those important services to develop.

My noble friend Lady Faithfull has cleared up the misunderstanding of the noble Lord, Lord Clifford, about the meeting which we had with my noble friend and a representative of the Institute of Child Health when I believe some progress was made. However, our discussion today must focus not on the objectives, on which we are all agreed, but on whether this amendment will help us to attain them.

The amendment refers to the responsibilities of district health authorities. It is the district which, under our reform proposals, will play the leading role in securing services geared to the needs of its resident population—children, adults and elderly people. Districts will be able to concentrate on deciding what health care services are needed and how these can best be dovetailed with primary and community care services. I would expect GPs and social services authorities to be closely involved in this process. The newly appointed district directors of public health will have a key role to play in drawing up specifications for services which draw together the hospital and continuing care needs of children.

Contracts are the mechanism which will give effect to districts' assessments of their residents' health care needs. I should emphasise again the impact of the new distinction between health care acquirers and providers. As acquirers districts will be able to set out in some detail their service requirements. Having accepted those requirements in the terms of NHS contracts, providers of services will be held to them. The contractual system puts the needs of the patient at the centre of health care delivery. Providers will need to meet contractual terms and not allow themselves to be put off course by the short-term operational problems encountered in delivering services.

I said earlier that we should focus on the need for this amendment. The amendment would make it a specific primary function of district health authorities to ensure adequate funding for an integrated child care service. It will certainly be a primary function of districts to provide comprehensive services for children. I should say specifically to my noble friend Lady Faithfull that regulations made under Clause 3 of the Bill will specify districts' primary function as providing a comprehensive health service for all its resident population—children, adults and elderly people. I have no doubt that if it proves necessary that will be spelled out in guidance. The amendment would add nothing to that broad power. Indeed, we cannot accept the amendment because we fear that it would cast doubt on whether it covered other vitally important services not mentioned in such specific terms. Cancer services and maternity services immediately spring to mind, as do the needs of elderly people and others to whom I have referred.

The amendment refers specifically to the need for effective links between health authority and local authority services. Since publication of the Court Report in 1976 it has been recognised that effective co-operation between these two bodies is indeed a prerequisite of a comprehensive child care service. We are planning to issue to health authorities examples of good management practice in the organisation and delivery of integrated services identified in a recent research project. But I doubt whether a reference in legislation exhorting all to greater efforts in this area would have much impact. It is surely at local level, in the development of close working relationships between the different planning and providing agencies, that the key to co-operation is to be found.

I find the drafting of the amendment a little confusing. It specifies only that districts' budgetary provisions should allow for, and not require, an integrated child care service. If this is indeed a permissive provision, which simply suggests that districts should proceed in this way, then its rightful place is surely in good practice guidance, and not in legislation. If, despite appearances, it actually places a requirement on districts, we would be prescribing operational arrangements in legislation in an unprecedented way. The function of legislation is to set out a framework within which regions and districts can provide services tuned to particular local circumstances and needs. It is not to tell them precisely how to deliver services.

The use of the term "integrated" provides a further example of the difficulty which can arise from a detailed provision such as this amendment. "Integrated" has no legal definition. At best, it would be taken to mean all things to all districts, depriving the amendment of any effect. At worst, it could be interpreted very narrowly in a court of law, casting doubt on the legality of services in districts where effective ad hoc co-operative arrangements have been built up over the years.

I have dealt at some length with the amendment because I recognise the importance which is attached to it. I have indicated some of the ways in which work is continuing to improve the delivery of child care services. I believe that that work will receive additional impetus following implementation of health service reforms. However, I repeat that this is a framework Bill. I hope that the noble Lord, Lord Clifford, and supporters of the amendment will recognise that, as well as recognising our commitment to their underlying objectives, if not to the amendment itself. I hope that the noble Lord will not feel it necessary to press the amendment.

7.15 p.m.

Lord Clifford of Chudleigh

My Lords, I am immensely grateful to the Minister for her remarks. One particular statement epitomised the fact that so many features of the Bill are too airy-fairy. The noble Baroness said that she "expects". We have been arguing that our children expect us to make the right decisions; hence this amendment.

I am very grateful to the Minister—as I am sure are other noble Lords—for enlightening me as regards the sometimes unsympathetic nature of the machinery which engineered the Bill. We have been talking about children. I know that the noble Baroness has given your Lordships absolute assurances that the Government will do their very best to see that child care will be looked after in the best possible way. However, nothing is in writing or in law to ensure that parents can have confidence in those assurances.

The answer is not couched in vague terms, unlike the phraseology of so many parts of the Bill. I thank the noble Baroness for that. When I proposed the amendment on 7th June I warned that we should deserve the title "careless" should we pay no heed to it. From listening to the noble Baroness it would appear that Her Majesty's representatives do not care two hoots.

I beg all noble Lords: listen to your consciences; not to the Whips, but to your consciences; not to the party allegiance, but to your consciences; listen to the story you tell yourself of your own childhood; think of your own children and the children of future generations; abstain if you cannot vote against your party's wish, but live with your vote if you forget the meaning of the amendment. I must divide the House.

7.20 p.m.

On Question, Whether the said amendment (No. 2) shall be agreed to?

Their Lordships divided: Contents, 56; Not-Contents, 102.

DIVISION NO. 5
CONTENTS
Addington, L.	Kinloss, Ly.
Airedale, L.	Kirkhill, L.
Allen of Abbeydale, L.	Llewelyn Davies of Hastoe,
Ardwick, L.	B.
Attlee, E.	Lloyd of Kilgerran, L.
Blackstone, B.	Longford, E.
Bonham-Carter, L.	McFarlane of Llandaff B.
Bottomley, L.	[Teller.]
Butterfield, L.	McIntosh of Haringey, L.
Carter, L.	Masham of Ilton, B.
Cledwyn of Penrhos, L.	Molloy, L.
Clifford of Chudleigh, L.	Monson, L.
[Teller.]	Morris of Castle Morris, L.
Clinton-Davis, L.	Nicol, B.
Darcy (de Knayth), B.	Northfield, L.
David, B.	Peston, L.
Denington, B.	Pitt of Hampstead, L.
Ennals, L.	Prys-Davies, L.
Erroll, E.	Rea, L.
Ewart-Biggs, B.	Richard, L.
Falkland, V.	Ross of Newport, L.
Fisher of Rednal, B.	Seear, B.
Gallacher, L.	Seebohm, L.
Graham of Edmonton, L.	Stedman, B.
Hampton, L.	Stoddart of Swindon, L.
Hollis of Heigham, B.	Taylor of Gryfe, L.
Jeger, B.	Turner of Camden, B.
Jenkins of Putney, L.	Williams of Elvel, L.
John-Mackie, L.	Young of Dartington, L.
Kilmarnock, L.

NOT-CONTENTS
Arran, E.	Bridgeman, V.
Ashbourne, L.	Brigstocke, B.
Astor of Hever, L.	Brougham and Vaux, L.
Auckland, L.	Buccleuch and Queensberry,
Balfour, E.	D.
Barber, L.	Campbell of Alloway, L.
Beaverbrook, L.	Carlisle of Bucklow, L.
Beloff, L.	Carnegy of Lour, B.
Belstead, L.	Carnock, L.
Blatch, B.	Carr of Hadley, L.
Blyth, L.	Cavendish of Furness, L.
Boyd-Carpenter, L.	Coleraine, L.

Colwyn, L.	Merrivale, L.
Cork and Orrery, E.	Mersey, V.
Cox, B.	Monk Bretton, L.
Craigmyle, L.	Mountevans, L.
Cullen of Ashbourne, L.	Munster, E.
Davidson, V. [Teller.]	Murton of Lindisfarne, L.
Denham, L. [Teller.]	Napier and Ettrick, L.
Dilhorne, V.	Nugent of Guildford, L.
Eccles of Moulton, B.	Orkney, E.
Elton, L.	Oxfuird, V.
Ferrers, E.	Pearson of Rannoch, L.
Flather, B.	Pender, L.
Gardner of Parkes, B.	Rankeillour, L.
Glenarthur, L.	Reay, L.
Gray of Contin, L.	Renton, L.
Gridley, L.	Renwick, L.
Hailsham of Saint	Rodney, L.
Marylebone, L.	St. John of Bletso, L.
Hanson, L.	Sanderson of Bowden, L.
Harmar-Nicholls, L.	Sharples, B.
Henley, L.	Skelmersdale, L.
Hertford, M.	Stanley of Alderley, L.
Hesketh, L.	Strathclyde, L.
Hives, L.	Strathcona and Mount Royal L.
Holderness, L.
Hooper, B.	Strathmore and Kinghorne, E.
Jenkin of Roding, L.
Johnston of Rockport, L.	Swinfen, L.
Joseph, L.	Teviot, L.
Kaberry of Adel, L.	Thomas of Gwydir, L.
Kimball, L.	Thomas of Swynnerton, L.
Kinnoull, E.	Trefgarne, L.
Lindsey and Abingdon, E.	Trumpington, B.
Liverpool, E.	Ullswater, V.
Long, V.	Vaux of Harrowden, L.
Lucas of Chilworth, L.	Vestey, L.
Lyell, L.	Wade of Chorlton, L.
McColl of Dulwich, L.	Wedgwood, L.
Macleod of Borve, B.	Wynford, L.
Mancroft, L.	Young, B.
Margadale, L.	Zouche of Haryngworth, L.

Resolved in the negative, and amendment disagreed to accordingly.

7.28 p.m.

Lord Ennals moved Amendment No. 3: Page 3, line 18, after ("functions") insert ("and subject to section 70 below").

The noble Lord said: My Lords, on moving Amendment No. 3 I shall speak also to Amendments Nos. 47 and 48. The objectives of these amendments are to postpone for 12 months the starting date for the new system of NHS contracts for health authorities, the new NHS trusts and the fund-holding practices, and the new provision for community care in Parts III and IV of the Bill.

Perhaps I may deal first with community care. If the Government intend to accept the crucially important decision taken by your Lordships' House to provide adequate resources to enable local authorities to fulfil their responsibilities under this Bill and to ring-fence the funding, then there is no case for postponement. Earmarked funding for community care will be crucially important from 1st April 1991. At that time local authorities will be trying to contain the cost of the poll tax at the beginning of a year in which I suppose we are bound to see a general election campaign. Moreover, they will be involved in the implementation of the Children Act, the Environmental Protection Act and the Food Safety Act.

So far as I can gather, local authorities are eager to assume the new responsibility for care functions as soon as possible if funding is available. But they face enormous problems. They are expected to plan services without any indication of the resources available and no indication of the minimum standards required by the Government which are set out in legislation but only in a sense in circulars.

If the Government are not prepared to commit funds for the crucial new role for the care of the elderly and the handicapped then the commencement date should be postponed. The Secretary of State implied in a speech he gave last week that he doubted whether local authorities would be ready. These doubts about the readiness of local authorities to move into action on 1st April 1991 are reflected also in the letters sent recently on behalf of the No. 10 policy unit to members of the London Boroughs Association.

As regards the health service changes, the House will be aware that from these Benches there have been very grave doubts expressed about the Government's plans. These doubts extend to noble Lords in all parts of this House and to Members of another place, not least to Conservative Members who know what chaos is likely to occur and the effect that will have on their electoral prospects. It is quite clear that there is a bitter row now going on between the Prime Minister and her Secretary of State for Health, Mr. Clarke.

The Economist said last week: Surgery has been postponed. The government has quietly ditched its plans to begin a radical shake-up of the national health service next April. The Health Service and the Community Service Bill will still get the royal assent within the next few weeks as scheduled. But it will bring few changes of substance in its wake. Mrs. Thatcher has ordered that nothing should happen in 1991–92 which would spark a political conflagration over the NHS and risk losing the Tories the next election".

Week after week some of us in the House and others in another place have been insisting, with mounting evidence in support from those in the services, that Mr. Clarke's implementation timetable for these untried organisational nostrums is hopelessly unrealistic. The planning is still in its early stages in some areas. Staff training is inadequate. The information base is simply not available. Preparations are being made at a time of very serious service reductions and the freezing of important staff posts.

Again, according to the Economist, which is not known for its irresponsibility or Left-wing bias, the new strategy was agreed upon at a series of meetings early last month between the Prime Minister, the Secretary of State and assorted officials. These were set up by the Prime Minister after representations by the chairman and deputy chairman of the 1922 Committee. They had told her that Back-Benchers were terrified of another big row with the doctors which they think would spell electoral disaster.

In spite of the Prime Minister's worries, Mr. Clarke went public at the National Association of Health Authorities' conference in Scarborough when he tried to scotch the rumours. He told the health authority members that the rumours were all nonsense, and that self-governing hospital trusts and other NHS changes would be up and running as planned. In contrast to a more cautious estimate by Mr. Duncan Nichol, the NHS chief executive, that 40 or 50 hospitals would opt out in favour of self-government, Mr. Clarke stuck to his earlier estimate of about 80.

Significantly, the Prime Minister has not been willing to give her Secretary of State for Health any public support since his pugnacious speech. It will be interesting to see on which side the noble Baroness comes down; namely, whether she is supporting the position of the Secretary of State or the Prime Minister. Regardless of these internal arguments, thinking Members of your Lordships' House know that the whole process is being rushed in a thoroughly irresponsible way which I have no doubt will do grave damage to the National Health Service.

If we are going to proceed with the proposal made by the Government, then the planning for it should be effective. It should start in a proper and efficient way. If that is to be done, then there has to be a delay. It is irresponsible for the Government to rush ahead, as has been said not only by myself but by other Members of your Lordships' House, without careful planning and preparation. I beg to move.

Lord Carr of Hadley

My Lords, at every stage of this Bill and in the debates before it, I have always coupled my continuing very strong support for the principles of this Bill with warnings about the dangers of going forward too fast. However, despite that I wish most strongly to oppose the amendment that the noble Lord has just moved.

In my view, he is getting practice and politics hopelessly mixed up. We want to start the implementation as soon as we can so long as we do not rush it unduly. There is nothing to be gained and a lot to be lost potentially by saying that nothing must happen before April 1992. For my part, I shall be happy to see something start happening next month if it were ready to happen in any particular district, but it is not.

I do not believe that it is too early to give the Minister authority to start as from April 1991. That is what should happen if we want to improve services to patients as quickly as we can. That is what this provision is all about. In order to improve services to patients, we must move down the road chosen with very great deliberation and care and step by step.

I have been saying that all along. I can see no argument in favour of putting off taking the first steps. They need to be taken at the earliest possible moment so long as they are properly prepared and pushed forward with great care, determination and supervision. That is what your Lordships' House should request of the Government and not put a block on anything being done for the good of patients for another year.

Baroness Gardner of Parkes

My Lords, I too oppose this amendment. Amendment No. 3 is nothing but a tag to bring us to Amendments Nos. 47 and 48. That is where the real essence of the argument lies. Amendment No. 48 is specifically designed to delay implementation. My noble friend Lord Carr put very well the case for the patients. What is important is that if you are proceeding with an improvement of some kind, you should get on with it.

Another aspect which I consider is equally important is one that I have come across in my own experience of the health service; namely, the staff. They want the certainty of knowing exactly what is going to happen, and that it will happen soon. To delay matters any longer would simply increase the great anxiety that some people have regarding their future. It is extremely important that this measure goes through.

I am sure that noble Lords all recall the delay that occurred when the paving Bill for the abolition of the GLC was lost. For another year there was uncertainty as to whether the GLC was to stay or go. Setting aside the argument of whether that was right or wrong, and all the political argument of that time, I remind noble Lords of the agony caused to staff. The GLC was run down and the staff demoralised. The staff did not know whether there was to be a new system or retention of the old. The situation was very unfair. It also resulted in a lowering of the standards of service. There should be no delay now that the Bill has reached this point and people are geared up. I do not accept the noble Lord's remark that people have given no thought to what is to happen—

Lord Ennals

My Lords, I did not say that.

Baroness Gardner of Parkes

My Lords, the noble Lord said that many people are not ready. But they have given great thought to what is to happen. They have made tentative plans and are waiting for the go-ahead. We had assurances at earlier stages. I was not present for the Report stage but I was here in Committee when we were told that matters would progress slowly and that after the implementation date there would not be one mad rush to change everything overnight. I accepted that statement. I believe that that is the wise way to approach the matter and I believe that the amendment is nothing but a wrecking amendment. I oppose it.

Lord Jenkin of Roding

My Lords, I too hope that the Government will not be tempted to go down the road suggested by the noble Lord, Lord Ennals. I agree with a great deal of what my noble friend Lady Gardner of Parkes has just said, though my memory of the events on the paving Bill for the abolition of the GLC may be a little different from hers. The Bill was not lost. An amendment was passed which made life a great deal more difficult for everyone concerned, including the staff. She was quite right on that point.

There is in these matters a momentum. The process of reform was started not just with the Bill but three or more years ago with the original Green Paper, with the discussions, with the then revised White Paper which has been the subject of considerable comment and discussion, and then through the process of legislation of which we are now nearing the end. Both my noble friends Lord Carr and Lady Gardner of Parkes were absolutely right in saying that expectations are now moving ahead sharply. Of course it will not all happen at the same time. That would be ridiculous.

The noble Lord, Lord Ennals, has assiduously and often with great skill sought to build up a case that somehow a massive transformation will happen overnight on 1st April next year. No one has suggested that that is what will happen. The proposals for health trusts, whether for units or for, as one is hearing rather more of now, the idea that entire districts should become health trusts—a concept which I and many others find attractive—are moving forward logically. People are working out the necessary steps regarding whether it will be first phase or second phase. I cannot conceive of a more damaging spanner to throw in the works than for the House to decide to accept the amendment and suddenly to stop the whole process, saying that it will have to wait until 1992. That would be an immensely retrograde step. I hope that the House will not accept the amendment.

I make my next point perhaps with some rashness as a fairly recent arrival in the House. This Bill has been debated for a great many hours in another place and for a great many hours spread over many weeks in your Lordships' House. It has been considered in minute detail at every stage. I seriously question whether it is appropriate at Third Reading in this House to propose an amendment which would have such a fundamental effect on the whole passage of the Bill. As I have always understood it, Third Reading is essentially for minor last minute changes and for tidying up the Bill. It is for matters of drafting and for following up undertakings which may have been given at earlier stages. It is not an occasion for, as it were, inserting an entirely new provision which would dramatically affect the implementation of the Bill. However, that is my view on this matter. The noble Lord, Lord Ennals, has been here for rather longer than I have. It may be that he has satisfied himself that such an amendment is entirely within the conventions of the House. I venture to doubt it.

I hope that the amendment will not be carried. To halt at this stage the process of progressive change on which we are now embarked and for which detailed preparations are moving ahead—timetables have been prepared and a mass of information collected and analysed in order to implement it—would be immensely damaging. I hope that the House will have none of it.

7.45 p.m.

Lord Pitt of Hampstead

My Lords, I wonder whether the noble Lord would be so kind as to tell me when the Green Paper to which he referred was published. I have never seen one.

Lord Jenkin of Roding

My Lords, I must apologise to the noble Lord. I do not have that date to hand. It was in fact some while back—two years or more.

Lord Ennals

My Lords, there never was a Green Paper. It was a White Paper.

Lord Jenkin of Roding

My Lords, there was the original Green Paper before that, was there not? My recollection is that there was a consultative paper. But I stand corrected from all sides. I am told that it was a White Paper.

Lord Winstanley

My Lords, the noble Lord, Lord Jenkin of Roding, was rather missing the point in telling us how many hours have been spent in this House and in another place discussing these reforms. It is not hours of debate in Parliament that matters—those can go on for ever. What matters is whether there has been sufficient consultation and discussion within the various professions which will in the end have to do the work. I do not accept his argument about how long we have had to debate these matters.

One of the principal complaints was the amount of notice we had of all these changes. The noble Lord will remember that when the White Paper and the eight consultation documents were published it was specified that responses had to be in within two months, which was quite impossible. The department accepted that it was impossible and that period was extended.

I rather regret the extent to which our discussions on the Bill have recently become more and more party political. I am not saying that in the direction of either side of your Lordships' House. I am sorry that that has been the case because I believe that so many of us in all parts of the House have the interests of the National Health Service at heart. I wish that we could talk about that rather than about who argued on which side in Cabinet and who made the mistake politically.

I have to say to the noble Lord. Lord Ennals, that a sudden delay now of a whole year would be very damaging. The only amendment that counts is Amendment No. 48. If we were merely discussing Amendment No. 48A, which seeks a delay in the establishment of NHS contracts, I would certainly support him. As I have said before, and as the noble Lord, Lord Carr of Hadley, implied earlier, one cannot have contracts unless one knows the price. It is my opinion that the actual work—it is highly technical work—of costing the various procedures within the National Health Service has not been completed. How can one enter into contracts when the prices are unclear or have to be guessed at? I accept the argument that to delay the matter for a year would be a mistake. Progress has been made in certain areas with the establishment of National Health Service trusts—I should say that discussions about the nature of trusts and how they will work in certain areas have been proceeding. It is possible—I shall not go further than that—that some of those trusts will in the end prove to be advantageous. We do not yet know.

I am sorry that we should suddenly have a great upheaval in the National Health Service. It has served us pretty well for 41 years. That does not mean that in 41 years we have not learnt lessons and that certain improvements could not be made. Many improvements could be made. It is possible that some of those improvements will come about as a result of the Bill. But as the noble Lord, Lord Ennals, said, those improvements will not suddenly be manifest on 1st April 1991. It will take a long time for some of the new procedures to work themselves into the system. That in itself may be damaging.

All I am saying—I am not sure that it has been worth saying—is that the whole procedure has been too hurried. However, having said that, to say here and now, "Let's stop"—because we will not be able to stop and start again—is not necessarily very helpful. Nevertheless, it would be helpful if a mechanism were to be found now whereby this business of the contracts could be deferred.

I am sure that the noble Baroness will say that contracts will be deferred in many areas where people have not assessed the pricing. Perhaps it will all be delayed and carried out on a general basis. However, I wait to hear the noble Baroness's response. In conclusion, I merely say to the noble Lord, Lord Ennals, that I support paragraph (a) of Amendment No. 48 but I could not support the rest of what is proposed.

Baroness Hooper

My Lords, I trust that I am right in assuming that the noble Lord, Lord Ennals, is speaking to all three amendments in this grouping. As the noble Lord, Lord Winstanley, pointed out, Amendments Nos. 47 and 48 contain the essence of the argument.

As has been said, we discussed the pace of implementation in one way or another on Second Reading, in Committee and on Report. Therefore, I am sorry that the noble Lord, Lord Ennals, feels it necessary to return to the subject yet again on Third Reading.

The Government always made clear that they intended to take a careful evolutionary approach to the implementation of their plans in both the health and community care spheres. Much legitimate preparation has already gone on ahead of legislation. Enactment of the Bill will allow further action to be put in hand. As my right honourable friend the Prime Minister said only last week in another place: It remains the Government's intention that the changes will get underway this coming year, as from April 1991". My right honourable friend the Secretary of State has also taken every opportunity to make that clear. Therefore, I am happy to be in the position of being able to support both of them. I suggest that it would be advisable for all noble Lords to concentrate on those messages coming direct from government, rather than on press speculation.

It is not necessary to repeat all our debates on the subject. Suffice to say that I can confirm that work is being taken forward gradually. I can assure my noble friend Lord Carr that we shall not rush it through. It is being taken forward in this way in consultation with those in the field.

As regards the length of time for discussions, we asked for responses to our working papers within four and not two months and discussions have continued since that time. To my knowledge there have been well over 100 meetings between Ministers, senior officials and the medical profession. National Health Service managers and authorities are working hard on their plans. They regard our timetable as feasible. At the same time, as has been said, a great deal of enthusiasm has been generated. For example, only last Friday in Oxford I was taken to task by a group of doctors who were extremely enthusiastic about their preparations. They asked for stiff resolve on the part of the Government to bring about the opportunity for much needed change in accordance with the timetable to which we have always held.

On the subject of contracts raised by the noble Lord, Lord Winstanley, I repeat assurances given on previous occasions. In some cases the initial contracting arrangements will be block contracts and these will be built upon and refined over the years. Similarly, we look forward to making gradual and evolutionary progress on the community care front. We look forward to hearing comments on our draft guidance from local authorities and others concerned with community care. We believe that April 1991 remains practicable as a major milestone in taking our plans forward. But it remains a milestone from which we shall continue to make further progress in future years.

I know that the head and the heart of the noble Lord, Lord Ennals, are in the right places. I am sure that he will not press his amendment to a Division. After all, he has spoken throughout our debates on the Bill of the areas where action is necessary to improve the quality and delivery of services to patients of the National Health Service and to users of the social services. The Government agree that there is much unfinished business and that we cannot be content with the present situation.

I do not believe that any government charged with responsibility for the caring services and believing that they have a strong future, as we do, can afford to concede to a policy of delay and inaction. I hope, therefore, that the noble Lord will not press his amendment.

Lord Ennals

My Lords, I am grateful to all those who have taken part in the debate. I am especially grateful to the noble Baroness for her kind words about my head and my heart being in the right places. It was reassuring to hear that because sometimes one wonders whether they have been overturned.

I must say that every time the noble Lord, Lord Jenkin of Roding, speaks I find his remarks intensely interesting. I always follow what he says with great interest. However, I must point out to him that it would have been rather absurd to table this amendment at any stage other than Third Reading. I say that because during the course of the debates we have to ascertain what progress has been made. In fact, we did not make much progress on the health service part of the Bill. As time has passed, we have seen the extent to which the National Health Service is not really ready to implement the proposals.

As regards enthusiasm, I do not know whom the Minister met in Oxford. As I visit different parts of the health service I find people insisting that they are not ready, that they do not yet have the required information available and that they have not carried out the costing referred to by the noble Lord, Lord Winstanley. It may well be that we meet different people in the service. Most of the people I meet are not involved in politics; I do not go around being political when I visit different areas of the service. I see that the noble Lords, Lord Jenkin of Roding and Lord McColl, find that remark amusing. I repeat: I do not go around being party political. The noble Lord, Lord McColl, misunderstands me. Most of my visits to the National Health Service are not carried out in a party-political capacity. I concede to the noble Baroness that there has been a great deal of thought about the proposals. However, most of the people I have met thought about them and turned away from them. There is very little enthusiasm. Indeed, everyone in the House and in the country knows that there is very little enthusiasm for what is proposed except among a small minority who have particular interests.

I am always fascinated by the noble Lord, Lord Winstanley. He thinks that there should be no politics in the matter. In my view, the whole Bill is a political Bill which comes from a political government who reached a certain conclusion which I think was politically wrong. It would be extraordinary if the Opposition, who have had as much experience over the years of the health service, did not react in a very positive way, bearing in mind the reaction of the doctors, the nurses and the other professions in the service. Of course, it has become a highly political issue. The Prime Minister is a highly political Prime Minister. She has the ability to act behind, under, around and over her Ministers. And whatever Ministers may say, it is the Prime Minister who finally decides what is to be done.

Some people may say that the passing of this amendment—if I can persuade your Lordships to accept it—would be in the interests of the party opposite in that it would escape for a year the chaos I prophesy will come about if these measures are implemented in the sort of timetable proposed. I do not believe that this will help the health service. Indeed, most of the people in the service and the public do not believe that it will help. I hope that colleagues will support the amendment.

7.59 p.m.

On Question, Whether the said amendment (No. 3) shall be agreed to?

Their Lordships divided: Contents, 43; Not-Contents, 97.

DIVISION NO. 6
CONTENTS
Airedale, L.	Kilbracken, L.
Ardwick, L.	Kirkhill, L.
Blackstone, B.	Llewelyn Davies of Hastoe,
Bonham-Carter, L.	B.
Carmichael of Kelvingrove,	Lloyd of Kilgerran, L.
L.	Longford, E.
Carter, L.	Morris of Castle Morris, L
Cledwyn of Penrhos, L.	Nicol, B.
Clinton-Davis, L.	Northfield, L.
David, B.	Peston, L.
Denington, B.	Pitt of Hampstead, L.
Ennals, L.	Prys-Davies, L.
Ewart-Biggs, B.	Rea, L.
Falkland, V.	Richard, L.
Gallacher, L. [Teller.]	Seear, B.
Graham of Edmonton, L.	Shackleton, L.
[Teller.]	Stoddart of Swindon, L.
Grey, E.	Taylor of Blackburn, L.
Hampton, L.	Taylor of Gryfe, L.
Hatch of Lusby, L.	Turner of Camden, B.
Hollis of Heigham, B.	Williams of Elvel, L.
Jeger, B.	Winstanley, L.
Jenkins of Putney, L.	Young of Dartington, L.

NOT-CONTENTS
Arran, E.	Jenkin of Roding, L.
Astor of Hever, L.	Johnston of Rockport, L.
Balfour, E.	Joseph, L.
Barber, L.	Killearn, L.
Beaverbrook, L.	Kimball, L.
Beloff, L.	Kinloss, Ly.
Belstead, L.	Kinnoull, E.
Blatch, B.	Lindsey and Abingdon, E.
Blyth, L.	Liverpool, E.
Borthwick, L.	Long, V.
Bridgeman, V.	Lucas of Chilworth, L.
Brigstocke, B.	Lyell, L.
Brougham and Vaux, L.	McColl of Dulwich, L.
Buccleuch and Queensberry,	Mancroft, L.
D.	Margadale, L.
Campbell of Alloway, L.	Merrivale, L.
Carlisle of Bucklow, L.	Mersey, V.
Carnegy of Lour, B.	Monk Bretton, L.
Carnock, L.	Mountevans, L.
Carr of Hadley, L.	Munster, E.
Cavendish of Furness, L.	Murton of Lindisfarne, L.
Clanwilliam, E.	Napier of Ettrick, L.
Coleraine, L.	Oxfuird, V.
Cox, B.	Pearson of Rannoch, L.
Craigavon, V.	Rankeillour, L.
Craigmyle, L.	Reay, L.
Crickhowell, L.	Renton, L.
Cullen of Ashbourne, L.	Rodney, L.
Cumberlege, B.	Saltoun of Abernethy, Ly.
Darcy (de Knayth), B.	Sanderson of Bowden, L.
Davidson, V. [Teller.]	Seebohm, L.
Denham, L. [Teller.]	Sharples, B.
Dilhourne, V.	Skelmersdale, L.
Eccles of Moulton, B.	Stanley of Alderley, L.
Elliot of Harwood, B.	Strathmore and Kinghorne, E
Elton, L.	Swinfen, L.
Faithfull, B.	Teviot, L.
Ferrers, E.	Thomas of Gwydir, L.
Flather, B.	Thomas of Swynnerton, L.
Gardner of Parkes, B.	Trefgarne, L.
Glenarthur, L.	Trumpington, B.
Gridley, L.	Ullswater, V.
Harmar-Nicholls, L.	Wade of Chorlton, L.
Henley, L.	Walton of Detchant, L.
Hertford, M.	Wedgwood, L.
Hesketh, L.	Whitelaw, V.
Hives, L.	Wise, L.
Hooper, B.	Wynford, L.
Hylton-Foster, B.	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

8.12 p.m.

Lord Kilmarnock moved Amendment No. 4: Page 3, line 49, at end insert ("and (c) where the condition of the individual is such that he requires a service where maintenance of open access and strict confidentiality is in the interests of public health, with particular reference to Genito Urinary Medicine, Drug Dependency Units and Family Planning Services.").

The noble Lord said: My Lords, I return to what I regard as an important topic and one which I raised previously on Report on 7th June. The essence of the argument is that there is an omission in the contractual arrangement upon which the Bill is based of a whole category of services where there is not necessarily urgent individual need, but where encouraging early contact with the service is in the interests of wider public health. For that group, the open access or self-referral services, include, in particular, clinics for genito urinary medicine, sexually transmitted diseases, drug dependency and family planning. In each case the open access nature of the service has developed for a good reason.

Widespread provision of open access, confidential, self-referral clinics for sexually transmitted diseases has been the corner-stone of the control of infectious diseases in this country since the 1916 venereal diseases regulations.

It is only by encouraging individuals to seek treatment at their earliest suspicions that they might have contracted an infection, that we can prevent diseases such as gonorrhoea, syphilis and herpes being passed on to subsequent partners. The clinics for genito urinary medicine and drug dependency, while attracting self-referral on the basis of personal need, also allow the high-risk users to be brought into contact with health promotion and disease prevention services. That is the basic case. The question is whether the Bill provides adequately for the continuation of these important services.

On the previous occasion when we debated this matter the noble Lord, Lord Henley, in opening his reply stressed: The Government fully accept the importance of open access to services such as genito-urinary medicine, drug dependency and family planning services".—[Official Report, 7/6/90; col. 1610.] He also accepted the need for confidentiality in these cases. Both statements are welcome so far as they go. However, he went on to state that there was no need to include specific provisions in the Bill. I cannot entirely accept that.

The Bill establishes that under the proposed arrangements most of the tasks that the district health authority will fulfil are the primary functions for its own residents or for the residents of other authorities for whom it has been contracted to provide such functions. There are two major exceptions to this: first, where the urgent need for care precludes the possibility of negotiating a contract in advance. That is dealt with in some detail in Clause 3(5)(b), and also in Clause 3(6). That covers the accident and emergency cases.

With regard to the group that I am addressing—the self-referral services—in my submission there is no provision. I believe that there is a major inconsistency here. These days the departments of genito-urinary medicine, for example, provide an important gateway for admission to hospital for patients such as those with AIDS. Some such admissions may be in the urgent or emergency categories, but others are elective. If these are to be billed respectively on a case by case basis with the authorities of residence as is set out in Clause 3(6), how can confidentiality possibly be maintained?

The second major issue making these amendments necessary in my view relates to the funding of block contracts by DHAs. The noble Lord, Lord Henley, in his response, unfortunately only highlighted the need for concern. He stated that the, DHA will be expected to provide funding in the same way as for accident and emergency services; that is by placing contracts which cover all patients who present themselves for the service regardless of district of residence".—[Offical Report, 7/6/90; col. 1610.]

Is it realistic to expect this when DHAs are only given a capitation based budget? Why should they be expected to pay for non-residents attracted by their services? While there is some suggestion that in the case of accident and emergency departments regions might increase the allocations to districts where there is a substantial cross-boundary flow, nowhere in the Government's guidance is any such statement made with regard to the self-referral services, except in paragraph 4.25 of the working paper in which RHAs are expected, to ensure that relevant units are funded in a way that allows patients to self-refer". However, there is no suggestion as to how this might be done. It is contradicted by the statement of the noble Lord, Lord Henley, on 7th June at col. 1610 where he stated that the Government, expect DHAs to decide themselves the most appropriate arrrangements for funding self-referral services".

This suggests a lack of real understanding of the problem. The point is that for many self-referral clinics district residents are very much minority users representing only 15 to 20 per cent. of those attending inner city facilities. Thus DHAs in these areas will be running and funding clinics mainly for the benefit of other authorities. Can such funding decisions therefore be the responsibility of DHAs? It is vital for the wider public health that a less parochial overview is maintained of the provision of such facilities. Otherwise, what are essentially regional and in some cases national resources may be threatened by the local need to balance the budget.

Surely the regional level, as suggested in these amendments, is a far more appropriate one for these funding responsibilities. Such an arrangement would also give regions the possibility directly to implement strategies; for example, gradually rolling out knowledge and skills needed for looking after AIDS patients from the specialist centres to the smaller districts' GUM clinics with a view eventually to reducing the necessity for so much cross-boundary movement. Such strategies are vital if the main centres are not to be swamped by the spread of that epidemic.

Can the Government intend such programmes really to depend on funding-based decisions of individual DHAs operating on a capitation based system? I suggest that this is simply not realistic. Self-referral and open access clinics are a vital tool of public health policy. I cannot believe that the Government really intend to surrender this tool which has been constructed so painstakingly over the years. But this is what will happen unless these amendments or something like them are written into the Bill. I beg to move.

8.15 p.m.

Baroness Cox

My Lords, I wish to speak in support of the amendments moved by the noble Lord, Lord Kilmarnock. I supported similar amendments at the previous stage of the Bill in your Lordships' House because they address significant problems spanning both individual and public health issues. Despite the reply given by my noble friend the Minister to similar amendments at Report stage, which I have since read carefully, I still believe that there is a need to ensure provision of these facilities because of the implications for confidentiality and anonymity. I shall not repeat the arguments that I and other noble Lords made previously, particularly with regard to family planning or drug dependency circumstances. I wish by way of example to re-emphasise the great importance of maintaining open access clinics attended by people from distant localities who choose them precisely because they will not be recognised, because anonymity and confidentiality will be assured.

The noble Lord, Lord Kilmarnock, has already pointed out that some inner city genito-urinary medicine and sexually transmitted disease clinics take up to 80 per cent. of their clients from distant places for reasons of anonymity and confidentiality. The noble Lord, Lord Kilmarnock, has spelt out the concerns on funding under the new dispensation, and I shall not repeat those concerns. I just wish to highlight that should problems of uncertain funding lead to a diminution in services it could have serious implications not only for the individuals at risk themselves but also for public health. Such diminution or uncertainty would be ironic and tragic at a time when so much is being invested in attempts to contain the spread of viral STDs.

It would be tragic in human terms and could ultimately be more expensive in the financial cost of care. I hope that my noble friend the Minister will be able to give more substantive reassurances than her noble friend Lord Henley felt able to give at Report stage on these important issues of public and private health.

Lord Young of Dartington

My Lords, I wish to support the amendment on the grounds that everything possible should be done to encourage early diagnosis and treatment of the kinds of diseases that the noble Lord, Lord Kilmarnock, mentioned. It would surely be a tragedy—and in this I agree with the noble Baroness, Lady Cox—if any district health authority were to say that it would not provide the services because it could not obtain repayment at a time of perhaps great economic and financial stringency.

The amendment would make it quite clear that it is in order (and to be encouraged) for health authorities to provide services to people who, on the ground that confidentiality must be preserved, do not disclose their names and addresses, so that repayment cannot possibly be obtained. These arguments which have been put forward before seem to me strong. I am therefore happy to support the amendment.

Lord Carr of Hadley

My Lords, I hope my noble friends on the Front Bench will be seized of the great importance of this subject. Both the availability of open access to clinics and the fact that they should be undeniably associated with confidentiality are factors of great importance for the future health of this country in many areas. I am afraid I have not had time to reread what was said on 7th June. However, I recall that while I was quite satisfied with the desire and the determination of the Government to provide both open access clinics and confidentiality, I felt that the statement of good intent did not go far enough in order to give the assurance which is needed. One must remember that the people who want to use these clinics will, to a large extent, be deeply suspicious about whether confidentiality is assured. That is why I believe the Government must find some way of going further than they felt able to go on the previous occasion that we discussed this matter.

Baroness Seear

My Lords, in the interests of brevity, I wish merely to say that we on these Benches totally support the amendment, and particularly the point just made by the noble Lord, Lord Carr of Hadley.

Baroness Masham of Mon

My Lords, for the people who have to attend these genito-urinary clinics and drug dependency units, it is important that the clinics are confidential. That has been said, but it needs to be stressed over and over again. If the patients who attend these clinics think that their details will be fed into a computer and bills will be passed across districts, they will not turn up at the clinics. Many of these people have infectious conditions such as gonorrhoea and syphilis. They may also be infected by HIV and hepatitis B. If patients keep away from treatment and counselling because of the billing process, they will become a serious public health risk. The Minister would be wise to spell out to us in detail how these clinics will work. This is a very important matter. However, there is a problem, because due to the hour at which this amendment is being discussed, most Members of your Lordships' House are having dinner. Their thoughts will unfortunately be far away from the problems of venereal disease.

Lord Swinfen

My Lords, I also wish to support the amendment. I have a feeling that where a health authority has a department that is serving a high proportion of people who do not come from its area, that department will say, "These are not our people. Let someone else look after them". Such a department could well be cut. I support the amendment.

Baroness Blatch

My Lords, I hope that by the time I have responded to this amendment I shall have addressed three important points. I believe those who refer themselves to centres should receive treatment, and that confidentiality should be observed in all cases. I shall also address the point of funding.

As was said on Report, the Government fully accept the importance of open access to services such as genito-urinary medicine, drug dependency and family planning. We also recognise the particular need for confidentiality in such cases. Therefore there is no need to include specific provisions in the Bill.

Guidance to health authorities on contractual funding has already stressed the need for district health authorities to give particular consideration to services which patients use on a self-referral basis. Contractual funding is no less appropriate for genito-urinary clinics or other self-referral units than for any other service. Patients can only benefit from the specification of quality in contracts and a close link between workload and resources.

Contracts for Health Services: Operating Contracts has made it clear that, unless alternative arrangements are agreed with regional health authorities, then district health authorities will be expected to provide funding in the same way as for accident and emergency services—that is by placing contracts which cover all patients who present themselves for services regardless of district of residence. This would avoid the need for a contract or exchange of information with the patient's own district health authority.

Different considerations may apply to different services in different districts, and we believe it is important that decisions as to what arrangements should be made to secure access to self-referral services should be made by districts themselves, in the light of local needs and circumstances. In view of the particular importance of these services however, Contracts for Health Services: Operating Contracts places a specific responsibility on regional health authorities for ensuring that district health authorities make satisfactory arrangements for all such services.

The noble Lord, Lord Kilmarnock, was worried that the point was not covered adequately in the Bill. As I have explained, we do not believe that this is an appropriate subject for primary legislation. However, I can assure the noble Lord that if serious problems arise, directions given under Clause 3(4) could be used to deal with them.

The noble Lord, Lord Kilmarnock, and other noble Lords said that funding was unrealistic. Again, I can assure the House that we expect regional health authorities' funding of district health authorities to reflect the usage of self-referral services. Therefore the funding of district health authorities will have to take into account accident and emergency services as well as self-referral services for all-corners and not just for residents.

The important point on confidentiality is that treatment will begin and end in one local authority. There will not be a cross-boundary flow of information back to the home authority of the patient who is receiving services.

I hope noble Lords will be reassured by what I have said and accept the Government have taken adequate steps to ensure that open access and confidentiality are secured in the case of self-referral services. I hope they will also accept that our approach, which aims to be flexible and not over-prescriptive, is preferable to the proposal for regional contracts contained in the amendments. I trust therefore that the amendment can be withdrawn.

Lord Kilmarnock

My Lords, I am grateful to everyone who has taken part in this short debate. It certainly has been a genuine cross-party issue. I am happy to count among my supporters three noble Lords on the Government Back-Benches. That encourages me to think that I am on the right track. As the noble Lord, Lord Carr of Hadley, said, the issue of confidentiality is vital to many aspects of the future health of the whole country. Statements of good intent are not sufficient to encourage us to believe that that anxiety is met. The noble Lord also asked the noble Baroness whether the Government could not go some way further on that point.

My difficulty is that I am not sure how much further the noble Baroness has gone. I believe she has gone a little way. She has spoken about guidance to health authorities. If I am permitted at this stage before the noble Baroness sits down, I should like to ask her whether the only guidance is that which is contained in the statement which I read out from the working paper on self-referral services which is contained in col. 1608 of Hansard of 7th June which states: 'RHAs will be expected to ensure that relevant units are funded in a way that allows patients to self-refer'", or whether further and more specific guidance is likely to follow that. So far as I can see, that is the only relevant text that we have at the moment.

The noble Baroness made the presumption that exactly the same system can be used in this case as that which covers accidents and emergencies. I did not think that that was entirely convincing because, after all, accidents and emergencies can be traced back to their districts of origin, whereas the cases of those who self-refer for confidential reasons cannot.

I was also a little worried about the phrase "local needs and local circumstances" which the noble Baroness used. To take an example, the Middlesex Hospital genito-urinary clinic clearly does not fulfil only local needs. If one talked to consultants in that unit one would find that the majority of patients for whom the unit fulfils a need come from outside the district. Local needs are not the only considerations in this important field of public health.

The noble Baroness said that she thought such a provision not suitable for primary legislation. I would probably be prepared to accept that, provided that I can be assured that the Government have taken on board what has been said from all sides of the House on this topic.

The noble Baroness referred to Clause 3(4) which would allow the Secretary of State to, give directions with respect to the exercise by health authorities or Family Health Services Authorities of functions under the National Health Service and Community Care Act 1990". That is a permissive clause. I hope very much that it will be brought into operation if there is any evidence of a collapse or serious diminution of the services concerned.

It occurred to me that I might have been too specific in the wording of my amendment. It reads: where the condition of the individual is such that he requires a service where maintenance of open access and strict confidentiality is in the interests of public health, with particular reference to Genito Urinary Medicine, Drug Dependency Units and Family Planning Services". I can see that the Government might consider that too specific for what is essentially a framework Bill. I should not have been too unhappy simply to take the first part of the amendment as far as the words "public health", so that there was a guarantee that that was the issue on which attention was focused.

Can the noble Baroness give me any further comfort regarding what I have said?

8.30 p.m.

Baroness Blatch

My Lords, the noble Lord seeks reassurance on three points: access to services, confidentiality and the mechanism for funding and whether there will be guidance. I can assure the noble Lord that there will be guidance. Work is also continuing on the making of contracts and the role of district health authorities in the making of those contracts. I can also give an assurance that all points that have been made throughout the debate on this subject will be taken into account.

My final comment is that should authorities not take cognisance of the guidance the Secretary of State has reserve powers to direct.

Lord Kilmarnock

My Lords, I am grateful to the noble Baroness. She has gone a little further than her noble friend did on an earlier occasion. I shall obviously read with very great care what she has said. Once the Bill has become an Act I shall keep an eagle eye on these issues and return to the matter in other parliamentary forms if it comes to my notice that matters are not going as well as they should. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 5 not moved.]

Clause 4 [NHS contracts]:

Lord Ennals moved Amendment No. 6: Page 4, line 40, at end insert: ("(2A) It shall be the duty of each health service body acting as an acquirer to take all reasonable steps to consult any relevant Community health council as to the general arrangements by which it shall secure goods or services under NHS contracts.").

The noble Lord said: My Lords, the whole question of consultation with consumer interests has been a bone of contention throughout the debates on the Bill. The amendment would place a duty on each purchaser of health care to consult its local community health council regarding the contracts that it places for a service. The intention of the amendment is that the consultation will be of a general nature on the strategic decisions behind contracting rather than the day-to-day business decisions.

This is the third time that I have taken up the issue. Each time I have taken account of the Government's reply and redrafted the amendment accordingly. At Committee stage I moved an amendment which required that the local CHC should be consulted on all contracts. The Government responded that that would be impractical in respect of, say, emergency contracts. Okay. At Report stage I moved an amendment to allow consultation with the CHC on most contracts where possible. The Government replied that it was inappropriate for the CHC to be involved in the day-to-day decisions of the contracting but that it should be involved in the formulation of the general strategy used by a health authority to draw up contracts. The noble Lord, Lord Henley, in replying said at col. 1627 of Hansard of 7th June: CHCs should expect to be consulted along with other interested parties on the strategic provision of services". The amendment seeks to put that commitment on to the face of the Bill.

The chairperson of the National Consumer Council, Lady Wilcox, has taken up the issue very strongly. I felt that we in your Lordships' House should take notice of what is being said. Addressing the annual conference of the National Association of Health Authorities, Lady Wilcox said: Just as individual patients have no real influence on choice, neither do their representatives, community health councils. In fact there are no formal means of consulting consumers at all, about where they shall be treated or what sort of quality they want". Lady Wilcox said that, instead, the choice would be made by district health authorities who would decide where to buy the services they thought were needed. Patients could be sent anywhere for treatment without anyone taking into account whether relatives should be able to visit. Lady Wilcox said that customers expected GP contracts, to bring services up to a standard not down to a price".

The main message coming from the National Consumer Council is that consumer health councils should be consulted. Since the noble Lord, Lord Henley, said that they should be expected to be consulted with other interested parties on the strategic provision of services, I hope that the Government will consider it appropriate to include that in the Bill. I beg to move.

Lord Young of Dartington

My Lords, I should like to support the amendment. The arguments advanced by Lady Wilcox on the occasion to which the noble Lord, Lord Ennals, referred were extremely powerful. They have been put forward before. They were put forward when I was the first chairman of that body, the National Consumer Council. And have been put forward on many occasions by the Consumers' Association, of which I am president.

Consumers have had a rough deal in the health service. Community health councils are their standard bearers. It would be in line with the whole purpose of the Bill if it was made quite clear that the community health councils were to be given the kind of information which the amendment, if it were included in the Bill, would require the authorities to provide.

Baroness Blatch

My Lords, the principle underlying the Bill is that district health authorities should seek advice from a wide range of authoritative sources before determining a pattern of services for their resident population.

The task of assessing local needs and demand for health care is by no means foreign to district health authorities. It builds on valuable work undertaken in the past by local directors of public health. Much work is under way to develop that role and relate it to the new commissioning responsibilities of districts. Consultation will form a key part of that process. The department's paper on the future, Role of District Health Authorities, makes clear that districts will need to seek the views of users—including consumer organisations, such as community health councils—on the provision of services. I would also expect districts to take account of community health councils' views on the services delivered by providers as part of their monitoring of NHS contracts.

There is no doubt that community health councils have an important role to play in representing patients' views under the new contractual arrangements. Districts are already required by regulations to consult the relevant community health council whenever they propose to make a substantial development in services. In future, that requirement will certainly cover any substantial changes in the pattern of services that districts acquire.

The amendment is also selective. Districts will be expected to consult closely with general practitioners over the services they propose to acquire. Indeed, the contractual system provides a unique opportunity for improving still further the integration of primary and hospital care. Yet this amendment would give community health councils a quite misleading position of primacy over all other sources of advice, GPs included.

I hope that what I have said reassures the noble Lord, Lord Ennals, that community health councils will have an important input into future decisions on the overall pattern of a district's services. The noble Lord referred to comments made by Lady Wilcox about there being no choice for patients. Lady Wilcox's remarks ignore the key role of the GP to which I referred. The pattern of contracts placed by the district health authority will need to reflect patients' preferences as reported to their GP. That will make hospital services far more responsive to patient choice than at present. I hope that the noble Lord is persuaded not to press his amendment.

Lord Ennals

My Lords, I am grateful to the Minister for her forthcoming response. I should not wish to give primacy to community health councils as opposed to GPs. I appreciated what she said about the role of GPs. However, I do not believe that their role is simply to convey the views of patients; it is to convey their own views as a result of their contact with patients.

I was glad to hear the Minister say that consultation with community health councils will be included specifically in the guidance. That is reassuring and, as the Minister said that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 6 [Transfer of staff to NHS trusts]:

Lord Ennals moved Amendment No. 7: Page 8, line 11, at end insert ("and no NHS trust shall alter the terms or conditions of any contract for a period of twelve months from the operational date without the consent of the person to whom the contract applies (or the relevant organisation representing employees in the case of a contract agreed in connection with a collective bargain).").

The noble Lord said: My Lords, your Lordships are aware of the deep anxiety felt by those who work in the National Health Service as regards the Government's plans to allow NHS trusts to have a free hand in tearing up national agreements on pay and conditions and in allowing the trust hospitals to compete for staff in the open market. Trust nurses, doctors and members of other professions have said clearly that they fear that the route will lead to a two-tier system within the National Health Service; first, the go-ahead, high-paid, hi-tech independent sector, and, secondly, the poorly-staffed, poorly-equiped second tier.

The amendment does not tackle the problems in a fundamental way. We tried to do so in the early stages of the Bill but did not succeed. However, it will ensure that carefully worked out agreements on pay and conditions will not be effected for an initial period of 12 months after the establishment of a self-governing trust. Trusts will be able to change contracts of employment within that period but only with the consent of the staff member involved or the appropriate staff organisation in the case of contracts agreed under a collective bargain. The amendment will prevent any unilateral action on the part of a trust in respect of the treatment of staff. Given the reckless timetable for the establishment of trusts, to which I have already referred, the amendment allows a sensible transition period in order that negotiations and careful planning on staff matters are conducted in an orderly way.

In my view, the amendment is fully in line with the thinking of the Secretary of State. In an interview in the Independent on 21st June 1990, he said: There is a need to get the balance right … without allowing change to get out of control and cause difficulties".

In another part of the interview he said: The message to everyone is don't try and drive this engine"— that is, the NHS reforms— at high speed".

I was trying to say that in respect of the amendment, and perhaps I should have quoted the Secretary of State then. At a time when staff recruitment and retention, especially among nurses, is high on the NHS agenda the amendment would bring an element of stability and reassure staff in what is becoming an increasingly uncertain situation. I hope that the Minister will look sympathetically at what lies behind the amendment even though she may not accept its wording. I beg to move.

Baroness Gardner of Parkes

My Lords, although we have covered the ground before I wish to repeat that I am in favour of the right for changes in staff terms. The board on which I served for many years, and which is now a special health authority, found that in London it was almost impossible to obtain and maintain good nurses because it was unable to compete in the open market. It was unable to design its employees' conditions in a way that would have been to the employees' advantage as well as to that of the hospital. One of the good aspects of the Bill is that there will be an opportunity to look at the staff situation differently and to reassess it. One can decide where the need lies and where there should be more pay. One can also decide where the need does not exist and where people are being paid to do something which is of no benefit to patients or to anyone else. The provisions in the amendment would be restrictive and I hope that the Government will not accept them.

8.45 p.m.

Baroness Hooper

My Lords, your Lordships will recall that throughout the passage of the Bill we have given categoric assurances that the employment rights and contractual terms of staff being transferred from the employment of a health authority will be protected on transfer. Clauses 6 and 7 already provide for that. We certainly expect trusts to act in accordance with good employment practices when negotiating any changes to contracts and setting up the industrial relations machinery for doing so. There is no need to place them under a special legal requirement not applying to any other employer. Trusts are in the same position as any other employer as regards employment legislation. There is also no justification for requiring changes to be approved by trade unions when the individuals concerned have said that they are willing to accept them.

I do not wish to go over ground which has already been covered. However, I point out that it is fundamental to the whole concept of NHS trusts that they should have scope to formulate local employment packages which will attract staff and encourage them to develop their skills so that the highest quality of patient care is assured.

The evolutionary approach on which the noble Lord, Lord Ennals, sought assurance is one that we have discussed. It will not be achieved by such an amendment but by gradually accepting hospitals for trust status and in future increasing their number and building on the experience which has been derived from the first wave. I hope that the noble Lord will withdraw his amendment.

Lord Ennals

My Lords, the Minister will not be surprised to hear that I profoundly disagree with the conclusions of the Government. I said that during each stage of the Bill. I have had consultations with bodies such as the Royal College of Nursing and other nursing bodies, with the British Medical Association and other trade unions representing groups within the National Health Service, and with a number of bodies representing professions allied to medicine. They are all deeply disturbed by the proposal. They all believe that the Government are going in the wrong direction. I promised them that at every stage of the Bill I would argue their case. I have done so and I have failed and achieved nothing. However, the Government will rue the day that they took the decision. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Hooper moved Amendment No. 8: Page 8, line 28, leave out ("solely") and insert ("(whether solely or otherwise)").

The noble Baroness said: My Lords, I speak also to Amendments Nos. 9, 14 and 15. The amendments complete the amendment to Clause 6 of the Bill which your Lordships agreed on Report. I beg to move.

On Question, amendment agreed to.

Baroness Hooper moved Amendment No. 9: Page 8, line 34, after ("if") insert ("he were a person to whom this section applies and").

On Question, amendment agreed to.

Clause 18 [Indicative amounts for doctors' practices]:

The Minister of State, Scottish Office (Lord Sanderson of Bowden) moved Amendment No. 10: Page 20, line 18, leave out ("the amount specified") and insert ("that indicative amount").

The noble Lord said: My Lords, I shall speak also to Amendments Nos. 16 to 20. When on 12th June we debated the amendments tabled in the name of the noble Lord, Lord Butterfield, about changing the name "indicative budget" to "indicative amount", my noble friend Lady Hooper promised that I would bring forward parallel Scottish amendments to achieve the same effect. The first four amendments to Clause 35 fulfil that undertaking.

The final amendment to Clause 35 and the amendment to Clause 18 in the name of my noble friend are slight consequential drafting changes which my noble friend mentioned would also be needed. Taken together, the amendments complete the task of changing the name of the indicative prescribing budgets to indicative prescribing amounts. I beg to move.

On Question, amendment agreed to.

Clause 21 [Schemes for meeting losses and liabilities etc. of certain health service bodies]:

Baroness Blatch moved the Amendment No. 11: Page 24, line 12, leave out from ("scheme") to end of line and insert ("by the Secretary of State").

The noble Baroness said: My Lords, in moving the amendment I should like to speak also to Amendments Nos. 12, 13 and 21 to 24. At Report stage your Lordships agreed new clauses in Parts I and II of the Bill giving the Secretary of State powers to establish schemes for meeeting the liabilities of defined health service bodies including National Health Service trusts. The amendments make small changes to new clauses. They bring the power for the Secretary of State to pay for or contribute towards the discharge of liabilities within the scope of the money resolution in Clause 67 of the Bill.

They give the Secretary of State a power to direct health authorities, health boards or National Health Service trusts to assist him with the administration of a scheme under the clauses. Such assistance might involve, for example, the collection of premiums from participating health service bodies. The new power will give the Secretary of State flexibility to choose the most efficient means of running a scheme.

Finally, the purely Scottish amendment defines correctly the liabilities that fall within the meaning of the new clause. I beg to move.

On Question, amendment agreed to.

Baroness Blatch moved Amendments Nos. 12 and 13: Page 24, line 14, after first ("State") insert ("(a)"). Page 24. line 15, at end insert ("and (b) where a scheme provides for it to be administered by the Secretary of State, a health authority or NHS trust shall carry out such functions in connection with the administration of the scheme by the Secretary of State as he may direct").

On Question, amendments agreed to.

Clause 31 [National Health Service trusts]:

Baroness Hooper moved Amendments Nos. 14 and 15: Page 35, line 49, leave out ("solely") and insert (", whether solely or otherwise,"). Page 36, line 8, after ("if") insert ("he were a person to whom this section applies and").

The noble Baroness said: My Lords, Amendments Nos. 14 and 15 were spoken to with Amendment Nos. 8. I beg to move.

On Question, amendments agreed to.

Clause 31 [Indicative budgets]:

Lord Sanderson of Bowden moved Amendments Nos. 16 to 20: Page 44, line 8, leave out ("by way of a budget"). Page 44, line 10, leave out ("budget") and insert ("amount"). Page 44, line 32, leave out ("budget") and insert ("amount"). Page 44, line 35, leave out ("budget") and insert ("amount"). Page 44, line 37, leave out ("the amount specified as that budget") and insert ("that indicative amount").

The noble Lord said: My Lords, I spoke to Amendment No. 16 when moving Amendment No. 10. I beg to move Amendments Nos. 16 to 20 en bloc.

On Question, amendments agreed to.

Clause 41 [Schemes for meeting losses and liabilities etc. of certain health service bodies]:

Baroness Hooper moved Amendments Nos. 21 to 24: Page 49, line 23, after ("damage") insert ("(including solatium)"). Page 49, line 45, leave out from ("scheme") to end of line 46 and insert ("by the Secretary of State"). Page 50, line 2, after ("State") insert: ("(a)"). Page 50, line 4, at end insert: ("and (b) where a scheme provides for it to be administered by the Secretary of State, the Agency or a Health Board or NHS trust shall carry out such functions in connection with the administration of the scheme as the Secretary of State may direct.").

The noble Baroness said: My Lords, I spoke to Amendment No. 21 with Amendment No. 11. I beg to move Amendments Nos. 21 to 24 en bloc.

On Question, amendments agreed to.

Clause 43 [Timetable for implementation]:

Baroness Masham of Ilton moved Amendment No. 25: Page 50, line 38, at end insert: ("(3A) In making any determination as to the adequacy or otherwise of resources under subsection (3) above, the Secretary of State shall have regard, in particular, to the need to secure the continuation of the provision of residential care services provided by voluntary organisations to persons who are now, or have been in the recent past, dependent upon drugs or alcohol, and shall consider how to use his powers under section 44 below to assist in securing the continuation of those services.").

The noble Baroness said: My Lords, this amendment builds on the principle that community care provision can be implemented only if adequate resources are available. Particular concern has been expressed by drug and alcohol projects, and confirmed by many social service departments, that resources will not be available to meet the needs of these clients because of the low priority generally accorded them. The amendment recognises the potential problems which may be encountered by drug and alcohol projects and requires the Secretary of State, in exercising his powers under Clause 44, to have particular regard to their needs and circumstances in order to ensure their continued existence.

Residential services for people with drug or alcohol related problems are presently funded predominantly by income support allowances paid by the Department of Social Security on a per resident per week basis. The 1,041 alcohol beds and 820 drug beds provided nationally by the voluntary sector are funded in that way.

From April 1991 social security payments will be reallocated to local authorities through the standard spending assessment mechanism. Unlike services for the elderly, the effect of the loss of income to alcohol and drug concerns are immediate. The average client turnover in drug residential places is 20 weeks, and in relation to alcohol 33 weeks. Therefore it is the total present level of income support, presently paid to alcohol and drug projects, which needs to be redistributed to local authorities in year one. The standard spending assessment, however, will phase in the transfer of income support payments over several years on calculations of turnover in elderly and mentally handicapped residential homes.

There clearly will be an immediate shortfall in the funding available to local authorities to provide residential services for people with drug and alcohol problems. That shortfall, given the existing lack of priority afforded by local authorities to people with alcohol and drug problems and the insurmountable difficulties presented by the timetable for implementation convince Alcohol Concern, Turning Point and SCODA that services will have to close.

The standard spending assessment mechanism, used to allocate funds to local authorities, does not take account of the incidence of drug and alcohol problems. Nor can it take account of the fact that residential projects are not spread evenly around the country. In many areas one project will serve eight or 10 surrounding local authorities and will also take clients from further afield.

For local authorities, the responsibility to provide drug and alcohol services is a new one. For most of them, with the pressures that they are facing, it is also unwelcome because of the extra burden that it places upon them. Social service departments have no statutory duty to provide drug and alcohol services and those contacted by Alcohol Concern have indicated that even though they will be obliged to put them in their community care plans they will not be allocating any resources for the provision of those services.

Alcohol and drug problems have never been a high priority for social services departments despite the massive harm caused to both individuals and families by substance misuse. Problem drinkers are a largely hidden population who because of the stigma make very few direct and explicit demands upon social services. They are far more likely to approach a specialist alcohol agency. Alcohol problems are often seen as self-induced and are not a politically attractive option when set in competition for resources against other vulnerable groups, children of course being of paramount concern.

With the added pressure of new systems and new responsibilities, the evidence from all sides is that this history of neglect is certain to continue with the result that funds currently being allocated to drug and alcohol projects through the Department of Social Security payments will be lost to this client group. All that is being asked is that these funds should be safeguarded during the period of uncertainty that will occur during the transitional phase.

Voluntary organisations and no doubt local authorities would be very pleased to evolve mutually acceptable ways of working. But evolution is a slow process. Given time, no doubt satisfactory arrangements can be evolved. The purpose of the amendment is to afford the time to prevent the unnecessary closure of over 100 projects around the country.

I hope that the Government will accept the amendment. If they do not, I shall be very interested to hear their reasons. Substance abuse, unless tackled, is a menace to society. The work with addicts is both difficult and draining. The people working in this field need encouragement and a certain amount of security. The most tired and drained person I have ever seen in my life was a young charge nurse working at City Road's drug centre. I beg to move.

9 p.m.

Lord Allen of Abbeydale

My Lords, I should like to support the amendment. Unless something can be done along the lines of the amendment I am concerned about the future of a number of voluntary organisations.

As the noble Baroness, Lady Masham, has explained, drugs and alcohol do not rank very high on the priority list of local authorities. The financial help that has been referred to on previous occasions would not be in point in that context. The noble Baroness, Lady Blatch, referred to that situation as being a possible hiccup, but it is much more than a hiccup. The future of approximately 100 organisations is at stake and there is a real possibility of most of them having to close down unless something is done. I assume that the Government would like those organisations to continue to operate, although when I put that question in a different context on an earlier occasion, I did not receive a categorical reply.

It may be said that that situation will be covered by the guidance. It is tucked away in one line at the end of a long paragraph. It states: Plans must include services for mentally ill people and those who abuse drugs and/or alcohol". To find the words "and/or" in an official document fills me with alarm, but I shall not pursue that matter. It states that the plans must include services for mentally ill people, who are covered by the Bill, and those who abuse drugs or alcohol, about whom the Bill is silent.

I very much hope that the Government will be able to offer something in relation to the proposal which is designed to provide safeguards during the uncertainty of the transitional phase.

Lord Carter

My Lords, I was very pleased to add my name to the amendment. I apologise to the House for not being in my place initially when the noble Baroness ably moved the amendment.

The alcohol and drug agencies are not seeking additional funding; they are trying to secure their existing funding for drug and alcohol residential services.

It is extraordinary that the Minister should have stated at Report stage that the organisations that she had met intimated that they had been considerably reassured by what she had to say to them, when we learn that no fewer than 118 projects in the voluntary sector are at risk if the Bill is unamended.

We do not believe that the standard spending assessment can provide the funding protection that the projects require if they are to continue. Throughout the passage of the Bill we have all been concerned about the problems of mentally ill people being discharged into the community before proper provision is made for their community care. I think we can all agree that it would be tragic if people with drug or alcohol problems were to be discharged without proper provision for community care, but only because the Government refuse to accept the force of the argument that lies behind the amendment.

Baroness Young

My Lords, I appreciate that the point made by the noble Baroness, Lady Masham, is a very important one in regard to the care for those who are on drugs or suffering from problems with alcohol. However, I should like to ask the Minister to clarify how the situation would work under the Bill. I may not be right in my reading of the Bill, but when social services departments draft their plans I understand that they would have to include provision, where there are such services, for the continuation of those services. As I understand it, they could not make a plan and decide to take them out. That would be a serious matter. Clearly a provision which is extremely important would then disappear. I cannot conceive that that is the intention of the legislation. If that is the case, in determining the amount of resources that are required the local authority must include resources that are required to look after various establishments, wherever they may be.

If that were the case, I should have thought that the amendment was unnecessary. An important point has been raised and I hope that my noble friend can reassure us.

Baroness Seear

My Lords, if the noble Baroness, Lady Young, is right, why has such an anxiety grown up in over 100 institutions? There must be some way of bridging the two statements. I ask for information.

Lord Mancroft

My Lords, the noble Baroness, Lady Young, has raised a very important point and indeed answered the most important point; and the noble Baroness, Lady Seear, leapt up—she being more nimble than I—before me and asked the question which I was going to answer.

The problem that was debated in Committee and on Report is the problem of communication between voluntary organisations, local authorities and the Government. To give my noble friend her due, when I first spoke to her about the Bill before it came before the House, she explained to me the Government's thinking. I have no doubt that she will do so now much better than I can. I repeated what the voluntary organisations with which I work were saying to me about their worries and concerns. They had developed those worries and concerns from the local authorities. Such organisations exist on a very fine edge of funding. That is why we have debated the matter and are quite right to be doing so again.

The noble Baroness, Lady Masham, spoke about the length of stay. In many of the places with which I am connected—and I am trustee of eight of them, for their sins and mine—the patients stay for six to eight weeks but never more than that because after that period of time they become institutionalised. That is another problem. If the new community care Bill came in on the first bang, by the end of April the pre-changeover patients would have gone through and out again and new patients would have come in. If there was a hiccup in funding, those places would go bust overnight because they exist on a shoestring. That is what they have been frightened about. If I were them—and I represent them and I am them in some very small way—I, too, would be very frightened. As an ordinary citizen, if I thought that my finances would dry up within a month, I would start to be very frightened. That is where the problem has occurred.

It is rather like this matter of budgets and the GMA stirring things up and frightening patients with misinformation—whether deliberately or not does not matter in this context. But certainly these organisations have, and still have, enormous worries over this area which transmit through the whole field.

Though my noble friend has in many ways assured me—and I am delighted that she was able to bring forward her own amendment at Report stage on the emergency assessments—the voluntary sector is still worried, which is why it is seeking assurance. I very much see this amendment as an insurance policy. If the system works as my noble friend thinks it will work, and says it will work—and I have no doubt she is right about that—then the insurance policy will never be called upon. On the other hand, if it does not work the insurance policy will be called upon. As the noble Lord, Lord Carter, said, this insurance policy is no more expensive than it has been up till now because it is the same sum of money. That may be so—I do not know.

But if my noble friend can assure the House, and therefore the voluntary organisations, that, as she said, the Government will be watching this matter like a hawk; if local authorities really have to put their policies forward for examination in good time; and, if it appears from those statements that they issue that the voluntary organisations are not included, the Secretary of State will then jump in and say, "Hang on, you have got to include them", then this insurance policy will not be needed, because the problem will be solved before it takes place.

On the other hand, if that does not happen we have a problem. But my noble friend has assured us that that is what will happen, and the result of that is that voluntary organisations have said, "Yes, we see that. But we are still frightened".

So this exercise is back to the old point of reassuring a very frightened group and—the noble Baroness, Lady Masham, quite rightly put the case—they are very important. They carry a very large burden of the responsibility in this area, and we need to ensure that they go on fulfilling that work. Otherwise, it will cost a great deal more if they go bust and if that area of care has to be picked up by the statutory bodies. So it is in all of our interests that they continue. I think that the Government realise that now. I believe that some of them did not realise it at the start, but they realise it now.

But if my noble friend can assure us that the mechanism by which the community care policies are scrutinised before they come into force is there and will work, then this insurance policy will not be necessary.

Baroness Faithfull

My Lords, briefly may I say that there seem to me to be two problems. One is the here and now of people in a home, and the other is the future. Under past amendments to the Bill, a local authority will have to agree to somebody going somewhere so that they will always be able to pay. Secondly, as the noble Lord, Lord Mancroft, said, a lot of people are in homes at present, and that is where there is great anxiety and worry.

Baroness Gardner of Parkes

My Lords, I have listened to this debate, and I am slightly puzzled by it. Are we talking about voluntary organisations that are funded through local authority voluntary grants, such as the London boroughs grants body, that determine where they will give their money? If that is so, I think that they would very much resent the fact that their right to decide where the money should go would be taken away from them. Or are we talking about different types of organisations?

This amendment is slightly confusing. We all have great sympathy with the classes that are described as being urgently in need, but I could go through another dozen classes that local authorities think are also urgently in need. There is always a very difficult decision as to where local authority grant money is given. But if it is not grant money, and is community money or ring-fence money, that is a different matter. I shall be grateful for some clarification.

Lord Swinfen

My Lords, these are people for whom local authorities have responsibility to provide community care. Generally speaking, that care is not available within the local authorities themselves and it is the voluntary organisations which provide that care, and which are then paid by the local authorities for the care of the individuals for whom the local authorities are responsible. That does not mean to say that local authorities dictate to the voluntary organisations how that money must be spent and how they operate. They have to be satisfied that the money is well spent and wisely spent, but not exactly how it is spent. It is like me as a husband being satisfied that my wife has bought a dress that she can wear on more than one occasion, rather than just on one occasion. A dress that is suitable for only one occasion and is then finished with is a total waste of money, whereas one that can be used on several different occasions in probably an investment. That is similar to the way in which local authorities consider the funding of voluntary organisations.

I hope that my noble friend on the Front Bench will assure the House that there will be proper funding by the local authorities for the work that the voluntary organisations do on their behalf.

Lord Rea

My Lords, I am sorry to have joined the debate on the amendment at so late a stage. Things moved rather faster than I had expected.

I should like to speak as a general practitioner who has to deal with the problems that drug addicts and those who have an alcohol problem present. Residential care rehabilitation is often the only course that is open and likely to help the people involved. I have a great deal of difficulty in finding places for those people. They often have to wait weeks, if not months, before a suitable place for rehabilitation can be found. I am advised by many people who work in those institutions that things are not very good at the moment. They are extremely worried that, unless a special provision is included in the Bill, such as is suggested in the amendment, their future will be very difficult. They have pleaded with your Lordships to ensure that, if the amendment is not incorporated in the Bill, it will at least elicit from the noble Baroness an extremely helpful answer.

9.15 p.m.

Baroness Hooper

My Lords, I shall do my best. We have been over the ground of this amendment on a number of occasions, and I have paid tribute to those of your Lordships who have throughout our debates made the case so effectively and eloquently on behalf of those who may be or have recently been dependent on drugs or alcohol. As my noble friend Lord Mancroft said, we responded by meeting specific anxieties on emergency treatment.

I understand that, in spite of our reassurances, a number of voluntary organisations continue to be concerned that local authorities and/or health authorities may not continue their support facilities, although those fears are not fully justified. I also know that they have been largely reliant upon the social security system to provide financial support for their clients, and that, under our new funding mechanism, they fear that resources will not come their way so readily. I can only confirm again that those dependent on drugs and alcohol are very firmly and clearly among the client groups for whom local authorities have to plan and make arrangements in their social care services, as my noble friend Lady Young said.

Now that our draft guidance on plans has been published—I emphasise to the noble Lord, Lord Allen of Abbeydale, that those plans are still in draft form—it is clear that we make specific reference to those groups and that the Secretary of State will direct local authorities to cover those clients in their plans and in the execution of their duties. I can give a firm assurance on that point. Those clients who are eligible to receive support via the social security system for residential care provided by the voluntary sector will continue to be eligible for that support.

Reference has been made to there being 118 projects at risk. As my noble friend Lord Mancroft said, they already operate on the fine edge of funding. The new system will be better for them because it gives greater transparency in relation to the plans on which consultation will have to take place and which will have to be published, and because they will in turn be backed up by contracts. In the long term, there will be greater security for those groups.

However, I agree that there is a problem as regards the transitional period and that it is important that the transition is handled smoothly. To assist that, we can bring the provisions on assessment in the Bill into force before the appointed date so that authorities can manage the run up to the new arrangements with a greater length of time at their disposal.

When we discussed local authority powers on Report, we said that we would be issuing new guidance to local authorities explaining their powers under Schedule 8 of the National Health Service Act 1977 to provide services for those groups. We intend to do that.

Local authorities will need to agree to fund care in residential centres, although in an emergency case care can be given without such agreement, as we have established. Those in residential care on 1st April 1991 will have preserved entitlement to income support on the same basis as currently exists. As I have said, that means that local authorities will not be required to agree to treatment in those cases.

I can go no further. I reconfirm that those client groups and the organisations which provide support for them are very much part of our policy towards community care. On that note, I ask the noble Lord to withdraw his amendment.

Lord Carter

My Lords, before the noble Baroness sits down, let us suppose that a local authority is required to provide services in an area where that is not now the case. If the standard spending assessment is unable to take that into account, is not the only way in which the local authority will be able to provide the service by an increase in the poll tax?

Baroness Hooper

My Lords, we have always said that adequate resources will be provided for the community care provisions in this Bill. I stand by that.

Baroness Masham of Ilton

My Lords, I thank all noble Lords who have spoken. There is anxiety, and that has arisen because these projects are funded by social security. There is to be a changeover. It is as regards that changeover that there needs to be some security.

This is a new venture for social services departments. They have not hitherto had that responsibility. Drug abuse is still on the increase and is a world-wide problem. As regards alcohol, that is a huge industry involving a great deal of money. Alcohol is pushed at society through advertising. Is it not an ethical duty to provide a service for those who become ill through that legal drug? Is not the family important? Alcohol and drug abuse break up families, destroy relationships and cause violence and unhappiness. This amendment would help social services departments to organise themselves during the changeover period.

With every respect to the Minister, she does not sound very convincing. There is such strong feeling outside this House and such anxiety that I would rather go down fighting, as many of us will do this evening. Therefore, I wish to ask the opinion of the House.

9.21 p.m.

On Question, Whether the said amendment (No. 25) shall be agreed to?

Their Lordships divided: Contents, 36; Not-Contents, 71.

DIVISION NO. 7
CONTENTS
Airedale, L.	Kinloss, Ly.
Allen of Abbeydale, L.	Lawrence, L.
Carmichael of Kelvingrove,	Longford, E.
L.	McFarlane of Llandaff, B.
Carter, L.	McNair, L.
Clifford of Chudleigh, L.	Mancroft, L.
Craigavon, V.	Masham of Ilton, B. [Teller.]
Darcy (de Knayth), B.	Peston, L.
David, B.	Pitt of Hampstead, L.
Dean of Beswick, L.	Rea, L.
Dormand of Easington, L.	Ross of Newport, L.
Elliot of Harwood, B.	Saltoun of Abernethy, Ly.
Ennals, L.	Seear, B.
Faithfull, B.	Seebohm, L.
Glenamara, L.	Shackleton, L.
Graham of Edmonton, L.	Swinfen, L.
[Teller.]	Walton of Detchant, L.
Hollis of Heigham, B.	Winstanley, L.
Kilmarnock, L.	Young of Dartington, L.

NOT-CONTENTS
Arran, E.	Ferrers, E.
Astor of Hever, L.	Fraser of Carmyllie, L.
Balfour, E.	Gardner of Parkes, B.
Beaverbrook, L.	Glenarthur, L.
Beloff, L.	Gray of Contin, L.
Belstead, L.	Harmar-Nicholls, L.
Blatch, B.	Henley, L.
Borthwick, L.	Hesketh, L.
Bridgeman, V.	Hives, L.
Brigstocke, B.	Hooper, B.
Brougham and Vaux, L.	Jenkin of Roding, L.
Buccleuch and Queensberry,	Johnston of Rockport, L.
D.	Joseph, L.
Butterfield, L.	Lindsey and Abington, E.
Carlisle of Bucklow, L.	Liverpool, E.
Carnegy of Lour, B.	Long, V. [Teller.]
Carnock, L.	Lucas of Chilworth, L.
Cavendish of Furness, L.	Lyell, L.
Clanwilliam, E.	McColl of Dulwich, L.
Cork and Orrery, E.	Mackintosh of Halifax, V.
Crickhowell, L.	Macleod of Borve, B.
Cullen of Ashbourne, L.	Margadale, L.
Cumberlege, B.	Merrivale, L.
Davidson, V. [Teller.]	Monk Bretton, L.
Eccles of Moulton, B.	Mountevans, L.
Elton, L.	Munster, E.

Napier of Ettrick, L.	Stanley of Alderley, L.
Oxfuird, V.	Strathclyde, L.
Pearson of Rannock, L.	Strathmore and Kinghorne, E
Pender, L.	Teviot, L.
Rankeillour, L.	Thomas of Gwydir, L.
Reay, L.	Trefgarne, L.
Renton, L.	Tryon, L.
Sanderson of Bowden, L.	Wade of Chorlton, L.
Sharples, B.	Wynford, L.
Skelmersdale, L.	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

9.32 p.m.

Clause 49 [Local authority plans fOr community care services];

Lord Kilmarnock moved Amendment No. 26: Page 56, line 17, at end insert ("giving consideration to the religious persuasion, racial origin and cultural and linguistic background of inhabitants").

The noble Lord said: My Lords, we revert to a matter I raised at Report stage on the desirability of including both in Clause 49, the community care plan, and in Clause 50, which is the assessment clause, something to the effect that consideration must be given, to the religious persuasion, racial origin and cultural and linguistic background of inhabitants". I believe that it was the noble Baroness, Lady Blatch, who said in response that these factors would be stressed in the guidance and that the guidance could be reinforced by directions.

It may be that I have the wrong document, but I do not see anything very specific in that area. There are many nice professions of intent in the paper CCI No. 8, which is the Draft Guidance: Assessment and Case Management. Paragraph 7.2 states that one of the objectives is to treat people with dignity and respect and to provide equal opportunities for all. Paragraph 8 states that services need to respond flexibly and sensitively to the needs of individuals and their carers. There are various other perfectly decent aspirations. Paragraph 16 says that procedures should be sufficiently comprehensive and flexible to cope with all the various kinds and levels of need presented in a variety of ways by all client groups.

We do not find anything very specific such as the requirement to publish the community care plan in minority languages or anything of that kind. This matter cannot be brushed under the carpet. The Commission for Racial Equality has noted that in its experience many local authorities would take little or no account of racial origin in performing their functions without being reminded of their duty under Section 71 of the Race Relations Act 1976. A further example quoted by the commission is a survey in 1988 of 116 social services departments in areas of substantial ethnic minority populations, of which only 70 responded. Of those only 26 per cent.—18 authorities—had a written policy which made any reference to the needs of ethnic minority children and appropriate placements. The record is not all that brilliant.

The noble Baroness, Lady Blatch, also suggested, when I mentioned the question of people with AIDS facing discrimination, that they should invoke the Race Relations Act. It is highly unlikely that anyone with HIV or AIDS would seek to invoke an Act in the courts which would attract mass publicity. In particular black people with HIV and AIDS are often less visible in HIV and AIDS organisations and so would not pursue this avenue.

The invocation of the Race Relations Act would not be particularly appropriate in those circumstances. Not to consider the need for confidentiality of people with AIDS is seriously to underestimate the complexity and emotional trauma involved in invoking the law, particularly if one belongs to an ethnic group whose first language is not English. I do not believe that that suggestion was quite as helpful as it was intended to be. The inclusion of my amendments in the Bill would leave no one in any doubt that discrimination is not acceptable and it would give added strength to the guidance, which, if it were left alone, would leave room for authorities to avoid dealing directly and unequivocally with these difficult issues.

We debated this matter before the noble Baroness invoked the guidance. She also invoked the Secretary of State's power to enforce that guidance. She has already pointed out to me that that power is contained in Clause 3(4). That perhaps is a small step forward. The guidance on which I have been able to put my hands is extremely vague and unspecific. It does not mention ethnic minority problems. The only comfort I can draw is that it is described as draft guidance. Therefore I take it to some extent to be a consultation document and that it is not the final version. Am I correct in saying that; and if I am correct, and a final version is to be issued after consultation, will it take into account the matters that I am raising in these two amendments? I beg to move.

Lord Ennals

My Lords, the noble Lord has set out the arguments clearly. I rise to say that I support the case and I support the amendment.

Baroness Blatch

My Lords, evidently I was not quite persuasive enough at Report stage to deter the noble Lord from raising the matter again today. On the earlier occasion the noble Lord argued that the need to take into account religious persuasion, racial origin and cultural and linguistic background was not sufficiently recognised. He mentioned the importance of information being available in languages the local community could understand and that services were offered in a way which was sensitive to cultural, religious and ethnic differences. We fully accept that there are some short-comings in these respects which need to be rectified. What divides us is whether it would be helpful to expand the text of the Bill in the way the noble Lord proposes.

The Government have long recognised that personal social services should be delivered in a way which takes account of the sometimes different needs of people from ethnic minorities. For example, for some three years they have funded the work of the Race Equality Unit which, under the chairmanship of the noble Lord, Lord Pitt, has carried out valuable work in advising local authorities and in disseminating good practice. Perhaps I should also mention the new arrangements being introduced for the operation of Section 11 of the Local Government Act 1966. As many noble Lords will know, under this power grants are payable to local authorities for extra staff where, because of the presence of significant numbers of people of Commonwealth origin, special provision is needed. The new guidance, recently issued for comment, includes policy statements for each area in which the grant may be payable. The policy statement on social services makes particular reference to the community care proposals that we are discussing today.

There are, of course, all sorts of individual needs. On the previous occasion, and again this evening, the noble Lord referred to people with particular diseases who might be victimised. These people could be members of any community. The Bill is not the place to list all these individual needs. I spoke at Report stage about the strength that the guidance we are producing will have and I remain convinced that reliance on the guidance is the best way forward.

I should say that the draft guidance which we have issued is subject to consultation. If, as a result of consultation, it seems that the guidance should be expanded, or made specific, we shall revise it. If the noble Lord wishes to make contact with the department as regards the guidance, we shall of course welcome his comments. The noble Lord and the Government share the same goal. It is one which the Government are determined shall be achieved—that in both planning and assessment, the particular needs of individuals, including those arising from religious, racial, cultural and linguistic backgrounds, will be properly considered.

The noble Lord, Lord Kilmarnock, made reference to ethnic minorities in the guidance and also referred to those suffering from AIDS and those who were HIV positive. The planning guidance mentions specifically the need to identify the core needs of the local population, including those ethnic minority groups in paragraph 29 of the section on assessment and services. Services for people who are HIV positive and those who are suffering from AIDS are also mentioned in that paragraph. I hope I have convinced the noble Lord that this issue is taken most seriously by the Government and that expanding the text of the Bill in the way suggested in the amendment is unnecessary.

Lord Kilmarnock

My Lords, I am grateful to the noble Baroness for her response. In fact, it is the second occasion this evening that I have been grateful to her. I hope that we shall continue in this manner throughout the rest of the Bill's proceedings. She has gone a considerable way towards allaying some of my concerns. I was especially encouraged to hear that the noble Lord, Lord Pitt, who is sitting behind me in the Chamber, is chairing a unit which is looking into such matters. I was also glad to hear about the extra staff among whom there are significant numbers of people of Commonwealth origin.

We have many policy statements and guidance documents to digest. I am glad that the noble Baronss has confirmed that this guidance is a draft document and that it is in effect a consultation document. I shall be most happy to take up her offer and make some suggestions for the final version. She referred to paragraph 29 where some reference is already made to these needs. However, because of the plethora of documents available to us I was not quite clear as to which document she was referring. However, no doubt when I read the report of her remarks in Hansard I shall be much wiser. I shall look closely at what was said before I get in touch with the department as she suggested. I am grateful for the reply. In the circumstances, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

9 45 p.m.

Baroness Seear moved Amendment No. 27: Page 56, line 33, leave out ("a substantial amount of care on a regular basis") and insert ("care").

The noble Baroness said: My Lords, heavy burdens can fall on carers—burdens which could not always be described as substantial or regular but which are nonetheless severe. Those arguments have been advanced on many occasions. I beg to move.

Lord Carter

My Lords, I am pleased to support the amendment from these Benches.

Baroness Hooper

My Lords, I am happy to accept the amendment moved by the noble Baroness. Our intention in relation to Clause 49(3) has always been to ensure that local authorities consult the appropriate bodies when drawing up plans, and the amendment helps that process.

Baroness Seear

My Lords, I thank the Minister for accepting the amendment and for keeping the proceedings so short.

On Question, amendment agreed to.

Baroness Hooper moved Amendment No. 28: Page 56, line 34, leave out ("who are living at home and").

The noble Baroness said: My Lords, I speak also to Amendment No. 41. The amendments will enable local authorities when preparing their community care plans to consult organisations representing all carers and not merely those caring for people living at home. I commend this small improvement to your Lordships. I beg to move.

On Question, amendment agreed to.

Clause 50 [Assessment of needs for community care services]:

[Amendment No. 29 not moved.]

Lord Kilmarnock moved Amendment No. 30: Page 57, line 16, at end insert: ("( ) In the event of change of residence any existing assessment shall apply in whichever local authority the person becomes resident for a period of 28 days in default of a new assessment.").

The noble Lord said: My Lords, again I return to a matter to which I referred on Report. I have of course read carefully the Minister's reply on that occasion. The amendment relates to the effect of a portable assessement when people have to move in a hurry. I have narrowed the scope of the amendment from its previous version and have put a limit on it so that: In the event of change of residence any existing assessment shall apply in whichever local authority the person becomes resident for a period of 28 days in default of a new assessment".

The commitment is not open-ended or unlimited. The measure is designed to take care of the type of cases of harassment that I mentioned. I went into the matter at some length on Report, and I shall not repeat the arguments. The cases were sufficiently harrowing to be picked up at some length in The Times. They obviously had some effect on that journalist.

The amendment addresses circumstances in which people need to move in a hurry because of harassment and where the person's medical condition is such that continuity of care is vital. On that occasion the noble Lord, Lord Henley, agreed that there should be a continuity of provision, but he did not like the form of the amendment as I then advanced it. As I said, I have since modified it.

The suggestion made by the Minister on that occasion, that people who contemplate moving across a boundary should see the prospective authority in advance to arrange for an assessment of their needs, does not meet the problem when some of those moves take place at great speed. Again, I consulted the draft guidance as to the time lag in the assessment process that one might expect to have. There was nothing there except a sentence in paragraph 14 which suggested that the assessment arrangements should ensure that reasonable time limits can be maintained and performance should be monitored. The proposition about negotiating one's move in advance, if one is being harassed or threatened by neighbours, is not realistic.

I have not been able to find anything of great comfort in the draft guidance. It seems to me possible that a consortium of authorities might conceivably agree to honour one another's assessments for a limited time. That would both give a safeguard to the person needing to move in a hurry and would also in the long run probably save money. Failing anything that encourages local authorities to behave in that way, it is much less likely that such liaison will happen. Again we return to guidance country. I hope that following the noble Baroness's response to my last amendment she will say that the draft guidance is susceptible of amendment and that she or the department will be prepared to receive a further approach from me on the matter. I beg to move.

Lord Renton

My Lords, the proposition that the person in need of community care services who happens to move—perhaps only a few miles—into the area of another local authority should obtain a fresh assessment within 28 days surprises and, I must confess, worries me. I should have thought that one local authority could have sufficient confidence in the assessment of another local authority to allow that assessment to continue indefinitely until such time as the new, receiving authority thinks that a fresh assessment might well be made.

Naturally I shall be interested to hear what my noble friend has to say about this, but we must not only consider the feelings of the people in need of community care. We must also be careful not to be over-zealous in causing extra trouble and expense to local authorities.

Lord Swinfen

My Lords, I should like to think that assessments are portable. At Report stage I mentioned the possibility that when an assessment is carried out, it should state when the next assessment is likely to be needed unless there is a serious deterioration in the individual's condition.

I wonder whether my noble friend can confirm, first, that the assessment will be portable; and, secondly, whether the Government will recommend in regulations that when an assessment is carried out, a time should be set for the next assessment.

Baroness Blatch

My Lords, I suspect that the noble Lord, Lord Kilmarnock, will be kept busy responding to the draft guidance—I hope so, because he raises many important points. As I explained when we discussed the issue previously, we think that the best arrangement would be for the receiving authority to be approached before someone who needs community care services moves into its area.

My noble friend Lord Renton hinted that one assessment should prevail until it is necessary and appropriate to have a second assessment. It is necessary for one authority to liaise with another in order for there to be continuity of treatment. However, I appreciate that, as the noble Lord has again explained, there may be circumstances where it is not possible. In that event, the amendments which the Government have already made to the clause to provide for urgent treatment could be invoked if the person required care as a matter of urgency. I agree that continuity of provision is essential and that every effort should be made to maintain this where it is required for an individual's continued well being. However, I think that the arrangements already in the Bill are about as far as we wish to go in this connection. The amendment lays upon local authorities not just a provision which I believe would be burdensome to them but also an automatic continuation of treatment. That would not be appropriate in all cases.

The noble Lord, Lord Swinfen, asked about review assessment. Our guidance on assessment specifies that the timing of the review should be decided when the assessment is made. In the light of that explanation, I hope that the noble Lord will feel able to withdraw his amendment.

Lord Kilmarnock

My Lords, on this occasion the noble Baroness has given me a little less joy than she did on the previous two amendments. I suppose that I cannot expect to be lucky all the time. However, this is an important point. I wish to assure the noble Lord, Lord Renton, that there is no obligation in the amendment to make an authority carry out an assessment within 28 days. It simply means that a person has 28 days in which his existing assessment can apply. The new local authority obviously cannot be dragooned into providing an assessment before it is ready or able to do so. The intention of the amendment is to provide a period of grace or a breathing period for someone who is trying to escape from intolerable conditions of harassment or threat. That is the point of the amendment.

I hear what the noble Baroness has said about the provisions that are already contained in Clause 50 and I shall have to read them again as they did not strike me as covering this case. As regards the guidance, the idea that the noble Baroness has reiterated about people approaching another authority in advance is not by any means always a practicality. That is the point behind the amendment. If one is suffering intolerable conditions in one authority, one will want to move very fast. Therefore the idea of setting up a meeting and an assessment which may take place several days later is not terribly helpful in those conditions.

However, the noble Baroness has shown sympathy with some of the points that I have put forward this evening and therefore I am led to hope that she and her noble friends will consider this matter when they come to determine the final state of the guidance. I shall read carefully what the noble Baroness has said and for the moment I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

10 p.m.

Baroness Faithfull moved Amendment No. 31: After Clause 50, insert the following new clause: ("Provision as to court orders .—(1) Where it appears to a local authority that a person is suffering from grave chronic disease or, by reason of age, illness or disability is living in conditions which give rise to an immediate and serious risk to the life and safety of that person, the authority may apply to a court for an order under the following subsection. (2) Following an application made under subsection (1) above the court may—

1. (i) make an order for the removal of the person to suitable premises under section 47 of the National Assistance Act 1948 as amended;
2. (ii) order the provision to the person of any service under Part III and Part IV of this Act.

(3) (a) An order made under subsection (2) (ii) above shall be applicable for a period not exceeding seven days; (b) at the expiry of seven days the court may direct that an order be extended by such period not exceeding seven days as it thinks fit; (c) an order made under subsection (2) (ii) above may only be extended once. (4) Where an order is made under subsection (2) above a local authority shall be required within a period of seven days from the granting of the order to make an assessment of the said person's need for services under section 50 above.").

The noble Baroness said: My Lords, this amendment deals with emergency protection for vulnerable adults. It was discussed in Committee and on Report. However, this amendment places an additional power but no duty on a local authority. There is a significant difference here in that this amendment would open up the possibility of intervening in a crisis by delivering services to the home.

In as much as it is possible to categorise people, this amendment deals with three different types of persons. There is the type of person who is living in his own home and who is known both to the social services and to the health authority to be dangerous both to himself and to other people. Such cases can be dealt with under Section 47 of the National Assistance Act 1948. My noble friend Lady Hooper said at the previous stage of the Bill that the main problem with Section 47 of the National Assistance Act is that it offers no interim action and no halfway house. Section 47 provides only for removal from the home. There are very few such cases. Local authorities do not use Section 47 to any great extent. However, there are two other types of cases. There are those people who are known to neighbours, relatives, doctors and to the social services and who are living in their own homes but are dangerous. At the same time they are not so dangerous that they should be moved. In such cases it is possible to ask the courts for an order to provide help for such people in their own homes. That does not happen very often.

There is another type of case, in which it is well known to the social services, to doctors and to health visitors, that people need help but are unable to ask for it for themselves. The Beverley Lewis case was such an example. The girl was mentally handicapped and was looked after by her mother. The mother died. The girl simply remained in the house, never going out or asking for help. She subsequently died.

The amendment would make it possible for such cases to be helped by the social services. As a social worker who has had to deal with such cases, I know that it is extraordinarily difficult to help in such matters when one has no terms of reference under any Act of Parliament. Such cases can be helped in their own homes.

I know that there is a difficulty over the question of civil rights. However, if anything ever infringed civil liberties, it seems to me that it is Section 47 of the National Assistance Act 1948. I should have thought that a permissive power to help people in their own homes would be far better. Helping people in their own homes is a far gentler way of delivering what might be a life-saving service. I hope that my noble friend the Minister will feel able to accept the amendment. I beg to move.

Lord Carter

My Lords, I am very pleased to support the amendment from these Benches. Indeed, I had intended to add my name to it. As the noble Baroness said when she moved the amendment, we discussed similar amendments at both Committee and Report stages. The Government, while recognising that a very real problem exists, felt unable to accept them.

The new clause provides an alternative means of support and care to a Section 47 order, and provides the half-way house which the Minister said at Report stage was missing. It envisages a more acceptable means of providing support than either a Section 47 order under the National Assistance Act 1948 or the relevant sections of the Mental Health Act 1983 by providing the urgently needed services in a patient's home.

As we know, the Minister expressed concern about the effect on civil liberties when the subject was discussed at Report stage. It is a question of a balance between civil liberties and the care of the patient. The provision of a seven-day limit in subsection (3)(b) of the new clause should deal adequately with that particular fear. I hope that the Minister will feel able to accept the amendment.

Lord Renton

My Lords, I am sorry to say that I have a real doubt or two about the amendment. The first point is that my noble friend Lady Faithfull mentioned people who are dangerous to themselves and others—to their neighbours. There is nothing in the amendment which refers to that situation.

What worries me about the amendment is that under its terms people who are sane—not dangerous but very ill, and perhaps dying—could be taken from their homes against their will under an order of the court. It is unfortunate that the court should be placed in the position in those circumstances of necessarily having to make such an order.

I should have thought that there are some cases, perhaps more than our imagination enables us to contemplate, of people who have lived in the same house for years, and through age, illness or disability, or a combination of all three, their lives may be at risk as a result of their living conditions. Other people may believe that they should be taken from home. However, in my opinion the person concerned has a right to continue to live at home if he wishes, even if his life is in peril. We should not contemplate placing the court in the position of having to take such a decision.

Lord Rea

My Lords, I speak from personal experience. On about three occasions during my professional lifetime I have had to invoke Section 47 of the National Assistance Act 1948. It was an extremely difficult performance requiring the permission of a justice of the peace and the medical officer for environmental health. Often those people are not available in the middle of the night when a crisis arises.

As the noble Baroness said, there are many occasions on which the problem could be dealt with by the provision of services to the patient in his home. I am not a lawyer but I am fully aware of some of the pitfalls and difficulties mentioned by the noble Lord, Lord Renton, as regards the infringement of civil liberties. I can see nothing wrong with the amendment. I believe it to be excellent, and from the point of view of a doctor practising in the community I should wish to see it passed. However, I shall be interested to hear what the Minister has to say in response. I support the amendment as it stands. I believe that it would make the lives of doctors and patients and their relatives a great deal easier.

Lord Swinfen

My Lords, if the Government had a mind to do so they could accept the amendment. The only way in which it can be improved is to accept it and send it to the other place. Members there can reject it or improve upon it and send it back to this House.

Baroness Hooper

My Lords, it is a difficult situation. I know from earlier discussions that my noble friend Lady Faithfull is concerned that civil liberties should not be infringed by expecting people to receive services that they do not want. However, she is also concerned about the provision of care for those who are unable to ask for the services that they may require. I recognise that my noble friend has altered the drafting of her amendment in order to achieve that. However, I am advised that there remain deficiencies in the drafting. For example, subsection (2)(ii) would be unworkable.

My noble friend is suggesting that it should be possible for a local authority to apply to the court for an order requiring it to carry out a community care assessment. That provision is unnecessary. The provision that we are making for community care assessment in Clause 50 states: where it appears to a local authority that any person for whom they may provide or arrange for the provision of community care services may be in need of any such services, the authority … shall carry out an assessment". In other words, if a person's case is drawn to the authority's attention it must assess him or her. That is my noble friend's objective. That includes personal application but it is by no means limited to that alone. The local authority is required to carry out an assessment of anybody who appears to it to need community care services, regardless of how that person is drawn to the authority's attention.

I agree that there is a problem as regards people who do not present themselves to the local authority and whom, it appears, no one else knows or cares about. But surely that remains a problem and will not be resolved by my noble friend's new clause. The local authority must become aware in some way that a person is in need of care before it can consider applying to the court for an order. That is the crunch issue as to how we overcome the difficulty in the case of someone who is not under constant attention or in constant contact with people.

I believe that our proposals for community care and for assessment in those conditions and the last resort measure to be found in Section 47 of the National Assistance Act 1948 are as far as we can reasonably go in ensuring that the people who need help receive it. I must therefore ask my noble friend to withdraw her amendment.

Baroness Seear

My Lords, before the noble Baroness sits down, perhaps she will clarify a point for me. She states that under the legislation an assessment has to be made if the authority is told about a person. Let us suppose that the person who needs to be assessed says, "I'll not let you in," and slams the door in the visitors' faces. What will happen? Do they force their way in? That is the reality. The kind of person about whom we are talking will not let them across the doorstep. What will the position be then?

Baroness Hooper

My Lords, in that case there would have to be the fallback of the last resort situation of Section 47 of the National Assistance Act 1948.

Baroness Faithfull

My Lords, I thank noble Lords who have spoken. Perhaps I may say to my noble friend Lord Renton that he has somewhat misunderstood the position. The amendment lays emphasis on keeping people in their homes, not taking them from their homes. That is the main point of the amendment.

Perhaps I may also take up the point of the noble Baroness, Lady Seear. No social worker or health visitor has a right of entry into anyone's home. Therefore if the milk bottles pile up outside the door, representatives cannot enter, and they know that someone is inside, someone has to go to the court to ask for a right of entry into that home. If a right of entry is obtained, it does not mean that one wishes to remove the person but that one wishes to help him in his own home so far as is possible and practicable. Beverley Lewis died in her home. No one had gone in. She could not have asked for anyone; she would not have understood who to ask for even if she had been told.

This is a most important amendment. It would save a number of people and bring a certain amount of richness to the rest of their lives if it were possible to gain entry. Of course no social worker, health visitor or doctor would wish to go to court, and would not go to court, unless he could not enter the house. However, if one sees milk bottles piling up and cannot get into the house, knowing that someone is there, then it is right that one should be able to go to the court for an order to enter the house.

I hope that I have made the point clear to everyone at all stages of the Bill.

Lord Renton

My Lords, will my noble friend give way? It is important to ask her this question before she reaches a conclusion. She states that the objective of the amendment is to keep people in their homes. But the priority that is given in subsection (2) is to invite the court to make an order: for the removal of the person to suitable premises under … the National Assistance Act". That is the first suggestion made to the court. The alternative—which comes later, and therefore I should have thought is of less priority—is to: order the provision to the person of any service under Part III and Part IV of this Act".

Baroness Faithfull

My Lords, I thank my noble friend Lord Renton. Perhaps we ought to have put it the other way round. The emphasis would then have been on keeping people in their homes instead of taking them out.

However, honesty compels me to say that there are times when it is absolutely essential to move somebody from their home. I have lately been dealing with a man who turns on the gas throughout the house. If something is not done, that man will blow up the house and himself, and goodness knows what he will do to the neighbours. I regret to say that there are cases when it is necessary to move a person from their home for the sake of themselves, their house and their neighbours. However, they are very few in number. The practice of health visitors and social workers is, wherever possible and practicable, to keep a person in their own home.

We have debated the matter throughout the various stages of the Bill. I realise that my noble friend the Minister will not accept the amendment. We have made our point. We hope that the Ministry will take note of what has been said. I see the noble Baroness nodding her head. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

10.15 p.m.

Baroness Darcy (de Knayth) moved Amendment No. 32: After Clause 50, insert the following clause: ("Payments for care of disabled persons in receipt of attendance allowances . Notwithstanding the provisions of section 29(6) of the National Assistance Act 1948 or of paragraph 2(2) of Schedule 8 to the National Health Service Act 1977 a local authority, having regard to any guidance issued by the Secretary of State, may make payments for the purchase of care or personal assistance services to a disabled person who is in receipt of an attendance allowance payable under section 35 of the Social Security Act 1975.").

The noble Baroness said: My Lords, the amendment would allow local authorities to make payments directly to those relatively few and severely disabled people who have the will and ability to make their own care arrangements and achieve more independence and control over their lives. A number of local authorities currently make such payments either directly or through a third party and, therefore, the scheme works well. The amendment is required to make the legality of their position clear, since Section 29(6) of the National Assistance Act 1948 prohibits cash payments.

During the passage of the Bill through both Houses Ministers have expressed a great deal of sympathy for the purpose behind the amendment. However, at Report stage the noble Baroness, Lady Hooper, stated that Ministers had reluctantly concluded that they could not enable direct payments to be made. I am most grateful to the Minister for arranging a very useful meeting last week. I hope that we have resolved some of the problems. I should like to sketch in some of the things that we discussed and leave others to fill in the gaps.

The first point that was discussed related to accountability. I think that the Minister now agrees that that is no longer a sticking point. The independent living fund makes direct payments and there are no problems in that regard. The same situation applies to local authorities which make direct payments. I was given an example of how the situation worked. The client receives £15,000 per annum. There is a written contract with the local authority which has a right to inspect the client's books over five years. The client has to produce an annual financial statement and the local authority can ask for an audit of the accounts. That answers objections about the bureaucracy required to run a dual accounting system: the same procedure is employed for private or voluntary service providers.

I hope that the Minister now agrees that there should not be difficulties in determining who are suitable clients. In the case of the independent living fund, when social workers assess a client's care needs they also determine whether he could cope with direct payments. As one local authority which has been making direct payments for over 18 months said in a letter to my noble friend Lady Masham, it should be used in appropriate circumstances based on professional social work assessment which takes account of the individual's view, supported by an on-going accounting and review process.

The cost of the individual package would not change because it would be agreed by the local authority at the time of assessment. It would agree how many hours of care a person needs, the rate at which it would expect to pay for that care and then agree a sum on that basis.

Concern was expressed about possible abuse of funds. If the money were to be misspent it would be obvious fairly soon since clients have contact with social workers. In any event, it must be remembered that we are talking about very severly disabled people. If they do not spend the money on care, they literally will not be able to get up in the morning. One does not go through the hassle of contracts and accounting simply to get ill with pressure sores. That is not a realistic situation.

The amendment was always intended to apply only to very severly disabled people who need large amounts of care. As a result of a very useful discussion at the meeting, we have redrafted the amendment to exclude people who may only need a few hours' support. I stress that in no way would all attendance allowance recipients be suitable for the scheme, or wish to be suitable. It is merely that the few who are suitable must come from within that group.

The amendment allows further modification and guidance. One matter that we discussed was that it could appply only to people who need more than X amount of care per week. That category could be specified. I hope that the Minister feels able to accept this more narrowly defined amendment. It is, like its predecessor, only an enabling amendment. It is for the local authority to make the final decision.

I feel very strongly that direct payments should be an option for severly disabled people who are able, prepared and keen to take on management of their care arrangements, and that we need to make it clearly legal for those local authorities who adopt the scheme. I beg to move.

Baroness Masham of Ilton

My Lords, if accountability is the stumbling block of this amendment, it does not seem a strong argument as it would be the choice of the local authority to allocate funds in this way. If they found that the system did not work, they could discontinue direct funding and provide care in a different form. The amendment just gives the local authority some flexibility, and as my noble friend Lady Darcy said, it gives the disabled person the chance to be more responsible for his own life.

My noble friend has said a little about the very great cost of severe disability—£15,000 a year. Perhaps I may take this opportunity to say how very important it is to do something about accident prevention. With the summer holidays coming along, how many young men will dive into the shallow end of a swimming pool or into the sea or a river and break their necks? Such people are the very severely disabled, and if such accidents can be avoided so much the better. I should like to support this amendment.

Lord Renton

My Lords, I support this amendment. I am very surprised that local authorities do not already have the power that the amendment proposes to give to them. But if local authorities do not have such a power, then we need the amendment or something like it.

Lord Ennals

My Lords, may I, too, support this amendment? I want first to say that I admire the way in which the noble Baroness, Lady Darcy (de Knayth), has plodded on and has taken this amendment through each of the stages, but always in conjunction with the Minister. I hope that she has totally satisfied the Minister, but this has all been done within the guidance issued by the Secretary of State. The amendment is very much limited now to those in receipt of an attendance allowance.

I do not know what is the sticking point. I think that we have dealt with the question of accountability. The Minister knows that it is a very small matter, and she and her honourable friend Mrs. Bottomley obviously think that, in principle, it is all right. I have seen statements made by Mrs. Bottomley in which she has supported what is being done.

The noble Lord, Lord Renton, is right. Local authorities that are doing this need to be given the legal cover to do what is obviously right. No one can doubt that, if one is very severely disabled, one wants the freedom to act in this way, the freedom to make a choice about whom to employ.

I was pleased to be at the meeting between the Minister and the noble Baroness; but, as to the question of cost of care for a given number of hours, it is cheaper for a disabled person to make his own arrangements with his own staff, rather than use private or voluntary agencies which have the additional cost of running an office and providing the care. I should have thought that the cost factor worked the other way. I should have thought it was cheaper to do it in this way, rather than have an intermediary. I hope the Minister feels that this time she can support the amendment.

Lady Kinloss

My Lords, I should like to support the amendment. The amendment would give severely disabled people the independence and, above all, the dignity which can sometimes be missing or denied them with other types of care schemes. It may not suit everyone, but it should be an option for those who are able to manage this kind of scheme. In order that the local authority can check, if they so wish, how money is spent, the recipient could have a specific bank account open to inspection. This would enable the local authority to be accountable for the money that is spent.

If this amendment were accepted, it would be consistent with the Government's aim in the White Paper Caring For People, by giving people a greater individual say in how they live their lives and about the services they need to help them to do so.

Baroness Faithfull

My Lords, a fortnight ago I went to a conference at the King's Fund Centre and sat between two severely handicapped people. Neither of them had legs, but they lived in a flat on their own. The woman was a writer and the man was in the publishing business. They were perfectly capable of looking after themselves mentally and of ordering their own lives. I should have thought that, in such circumstances where people are able to look after themselves, the amendment would meet the case.

Lord Seebohm

My Lords, I strongly support the amendment because, by chance, I spent a full day last Wednesday at a seminar on community care. There was a lady speaker on the platform who spoke from her wheelchair. She spoke about case management and said, "The first thing I want to say is that I do not like being called a case. The second is that I do not like being managed".

When I returned from the conference, I looked up the draft guidance to see what it said on assessment and care management. It states that local authorities are to improve and extend their present arrangements for users by, treating them with dignity and respect and providing equal opportunities for all". The next paragraph goes on to state: Local authorities are to intervene no more than is necessary to foster independence". That seems to prove the case for the amendment, but there are other reasons. If the user engages and pays the carer, he or she will have some authority, if the situation proves unsatisfactory, in getting rid of that carer and employing another. On the other hand, if the carer is engaged and paid by the local authority the situation is very different. This is therefore an important amendment and should certainly appear on the face of the Bill.

Lord Carr of Hadley

My Lords, I have now heard that argument several times. Every time I hear the case made by the noble Baroness, Lady Darcy (de Knayth), and by the noble Baroness, Lady Masham, I feel that it becomes stronger. Every time I hear my noble friends on the Front Bench resisting it, I feel that their case becomes weaker. I simply do not understand why a government who have as one of their main principles to help people to stand on their own feet and manage their own lives should so obstinately refuse the amendment. Even at this last stage, I beg the Government to give way.

Lord McColl of Dulwich

My Lords, I have a great deal of sympathy with this amendment. It is exactly the kind of encouragement that we need to give to disabled people.

Those of us who were involved in the McColl Report of 1986, regarding the provision of artificial limbs and wheelchairs, became aware of the problems and obstacles in introducing some form of new provision. The noble Lord, Lord Holderness, and I wished to provide special electrically-powered wheelchairs that could be used by severely disabled people, both indoors and outdoors. We soon came up against a brick wall. I shall not say where it came from but slogans such as "It will open the floodgates" soon came on the horizon. We got round that by introducing two pilot studies—one in Newcastle and the other in Manchester—for severely disabled people. Within a year, we worked out how much it would cost: throughout the country it was a mere £13 million.

We have the pilot studies going here. There are authorities which are doing that very thing, although it may not be legal. We should at least make it possible for them to continue and perhaps do even more.

Lord Swinfen

My Lords, I too should like to support the amendment as my name is associated with it.

The Government have indicated elsewhere that they are interested in some of the unusual experimental schemes going on at the moment. The amendment will deal only with legalising some of those schemes—those where money is paid to individuals. There are other instances of disabled people in National Health Service-owned property who should not receive social security but who receive it. I hope that in due course that matter will be dealt with; but the least said about that at the moment the better because we all want those experiments to continue. They all improve community care and this amendment is a method of putting into practice what the Government want—to bring care out of hospitals and into the community.

Baroness Hooper

My Lords, I listened with interest and considerable sympathy to the points that have been made. This is an important area, as we established in our previous discussions on similar amendments. Indeed, the meeting to which the noble Baroness, Lady Darcy (de Knayth), referred, and to which I agreed on Report, was useful and constructive. I very much appreciate the time and effort which has been put in to assist Ministers to understand better the aspirations of these groups and the practicalities of achieving them.

However, as I said during our earlier deliberations, reluctantly we have concluded that it is not possible to find a formula to enable payments to be simple and unbureaucratic for local authorities and recipient clients, on the one hand, and which, on the other, can prevent expenditure from running out of control.

I appreciate that the mood of this new clause has sought to meet some of these difficulties by limiting the scope of potential recipients, but the basic difficulties I have described on previous occasions remain. I am sorry to have to say that the Government are therefore unable to accept the amendment.

Baroness Darcy (de Knayth)

My Lords, I thank all noble Lords—and I mean practically all noble Lords who are now in the Chamber—for giving me such terrific support from all sides of the House. The support has been overwhelming. We do not need to go into all the arguments again. The noble Baroness will not be surprised to hear that I find her answer unsatisfactory, although I again thank her for the time and trouble she has taken in endeavouring to bring forward an amendment. The noble Baroness probably feels, along with the noble Lord, Lord Carr, that her argument gets weaker each time. I must ask the opinion of the House.

10.32 p.m.

On Question, Whether the said amendment (No. 32) shall be agreed to?

Their Lordships divided: Contents, 36; Not-Contents, 41.

DIVISION NO. 8
CONTENTS
Airedale, L.	Clifford of Chudleigh, L.
Butterfield, L.	Cox, B.
Carmichael of Kelvingrove, L.	Darcy (de Knayth), B.
Carr of Hadley, L.	David, B.
Carter, L.	Dormand of Easington, L

Elliot of Harwood, B.	McFarlane of Llanduff, B.
Ennals, L.	McNair, L.
Faithfull, B.	Masham of Ilton, B. [Teller.]
Glenarthur, L.	Peston, L.
Graham of Edmonton, L.	Pitt of Hampstead, L.
[Teller.]	Rea, L.
Grey, L.	Renton, L.
Hatch of Lusby, L.	Saltoun of Abernethy, Ly.
Hollis of Heigham, B.	Seear, B.
Kilmarnock L.	Seebohm, L.
Kinloss, Ly.	Swinfen, L.
Lawrence, L.	Winstanley, L.
Longford, E.	Young of Dartington, L.
Macaulay of Bragar, L.

NOT-CONTENTS
Arran, E.	Joseph, L.
Balfour, E.	Lindsey and Abingdon, E.
Beaverbrook, L.	Long, V.
Belstead, L.	Lucas of Chilworth, L.
Blatch, B.	Mountevans, L.
Borthwick L.	Napier and Ettrick, L.
Brougham and Vaux, L.	Pearson of Rannoch, L.
Carlisle of Bucklow, L.	Pender, L.
Carnock, L.	Rankeillour L.
Cork and Orrery, E.	Reay, L.
Davidson, V. [Teller.]	Sanderson of Bowden, L.
Denham, L. [Teller.]	Skelmersdale, L.
Ferrers, E.	Strathclyde, L.
Fraser of Carmyllie, L.	Strathmore and Kinghorne, E
Gray of Contin, L.	Thomas of Gwydir, L.
Harmar-Nicholls, L.	Trefgarne, L.
Henley, L.	Wade of Chorlton, L.
Hesketh, L.	Whitelaw, V.
Hives, L.	Wise, L.
Hooper, B.	Wynford, L.
Johnston of Rockport, L.

Resolved in the negative, and amendment disagreed to acccordingly.

10.40 p.m.

Clause 51 [Inspection of premises used for provision of community care services]:

Lord Carter moved Amendment No. 33: Page 58, line 22, at end insert— ("(1A) Nothing in this part of this Act shall give any power to any person authorised by the Secretary of State under subsection (1) above, to have right of entry to any premises other than premises managed by a local authority, a voluntary organisation or a person other than a local authority providing or proposing to provide community care services professionally or by way of trade or business. (1B) Any person authorised by the Secretary of State under subsection (1) above may enter a dwelling occupied as the home of a person for whom community care services are or are proposed to be provided but only after obtaining the consent of that person.").

The noble Lord said: My Lords, in moving Amendment No. 33 I shall speak also to Amendments Nos. 34, 35 and 36. I am sure that the Government will feel able to accept this group of amendments. They deal with an important aspect of civil liberties which are threatened by some features of the Bill. The Government are concerned about the civil liberties aspect of Amendment No. 31.

If accepted, the amendments would prevent inspectors having the right to enter the homes of private individuals to inspect those homes. At Committee stage in another place the Government appeared to accept the argument and undertook to deal with it. That does not appear to have happened and the amendments are intended to remedy that deficiency.

The present wording of Clause 51(1) allows an inspector to, enter and inspect any premises". Clearly that would cover a person's private home where they were receiving home help or other domiciliary care. At Report stage the Government added the words, and the facilities and services provided therein". That would enable the inspection of both the premises and the services. It is reasonable that the inspectors should be able to inspect the quality of the services provided, but they should not have the right to enter anyone's home without permission, except where the home is expressly providing residential care. Even a police officer requires a warrant to enter a home. It would be a breach of fundamental liberties if the arm's length inspectorate had such powers.

What is needed is that in a private home only the services and not the premises can be inspected, and then only with the client's permission. I beg to move.

Baroness Hooper

My Lords, I am advised that this amendment is not required. Clause 45, which amends the various provisions under which local authorities can provide or arrange the provision of services, has the effect that services must be arranged either with private or voluntary residential care homes which are registered under the Registered Homes Act 1984, homes which are not required to be registered by various provisions in the Registered Homes Act 1984 and, for day and domiciliary care, voluntary organisations or persons carrying on, professionally or by way of trade or business, activities which consist of or include the provision of the services in question. That means that the premises to be inspected will be managed by one of the bodies mentioned in the first part of the noble Lord's amendment unless they are a private dwelling house.

In the case of private dwelling houses I am advised that the clause as at present drafted does not give the inspectors any right of entry to such premises. Private dwelling houses can only be entered, by common law, with the consent of the occupier unless access is specifically authorised by an Act of Parliament or by an order of the court. Any person who enters a private dwelling with the consent of the occupier must conduct himself in accordance with any instructions given by the occupier and therefore would be unable to carry out any inspection of the premises without being invited to do so. The effect of this is that where an inspector was invited into a private dwelling house by the occupier he could inspect only what went on there or the premises themselves with the consent or at the invitation of the occupier.

In the light of that explanation I hope the noble Lord will feel able to withdraw his amendment.

Lord Carter

My Lords, I am extremely grateful to the Minister. That was exactly the assurance we required and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 34 to 36 not moved.]

10.45 p.m.

Lord Kilmarnock moved Amendment No. 37: Page 59, line 7, after ("records") insert ("or other records identifying an individual's medical status except on an anonymous basis or with their prior consent").

The noble Lord said: My Lords, I come back to a problem that I aired at Report stage. It is concerned with the inspection of records on premises devoted to community care in one form or another. The Government's objections to the amendment that I tabled at the previous stage of the Bill were that the restriction in favour of confidentiality would extend to any record which identified an individual's medical status. The noble Baroness, Lady Hooper said that, The amendment might in some cases inhibit the proper inspection of services". [Official Report, 18/6/90; col. 672.] One has no wish to inhibit the proper inspection of services. But the Bill is somewhat draconian in its present form. Although the power of inspection provided for in the Bill may be intended to apply only to residential units, it does not specify the very wide power conferred by the Bill in Clause 51 on, Any person authorised by the Secretary of State to enter, any premises in which community care services are or are proposed to be provided", and to obtain such information as he may request on, any person for whom community care services have been or are to be provided". That gives some cause for concern. The Bill provides that medical records may only be inspected by registered medical practitioners.

However, there are other records held by local authorities and voluntary organisations which contain medical information. The very wide power of access to these records conferred by the Bill could deter those in need of community care who are particularly concerned about confidentiality. I am referring especially to people with HIV and AIDS whose legitimate concern about confidentiality is well documented and justified.

One needs to strike a balance between providing for proper inspection and respect for the right of privacy and confidentiality of medical information including medical information held in records other than medical records. The Bill does not strike that balance correctly. It is possible that the previous amendment I moved was defective in that respect.

To deny inspectors access to any records containing medical information might be denying them access to information they need to carry out their duties. Therefore, as a compromise, and in order to attempt to define the proper balance, I am suggesting that the Bill should be amended to provide that information disclosing the identity of individuals shall be deleted from the records made available to inspectors unless those individuals consent to that information being made available. If an individual is incapable of giving consent, then that consent can be sought from whoever has been appointed to take decisions on that individual's behalf.

There is a relevant passage in one of the many guidance papers. Guidance paper CCI 8 entitled Draft Guidance: Assessment and Case Management, states at paragraph 38: The Data Protection Act 1984 and orders made under it, the Access to Personal Files Act 1984 and related Regulations and obligations to safeguard health information will all affect the use authorities make of information they receive or hold, and the circumstances in which this can be disclosed. Proper assessment and the design of appropriate packages of care will sometimes depend on agencies being able to share information. The need for this should be explained to the user and his consent first obtained". That is one of the provisions of the amendment. Detailed guidance is given in circulars: I shall not repeat their numbers. I see no reason why the provision should not be incorporated on the face of the Bill. It would be an improvement to get the informed consent of the person whose records are to be inspected.

I return to my original point. This could be a considerable deterrent to people who for one reason or another have a deep personal interest in preserving the confidentiality of their condition. Incidentally, so far as I can understand from the guidance on inspection, there does not seem to be a great need for inspectors to know in detail the medical condition of a resident, user or a client. The guidance paper on inspection units lays great stress on the quality of care and the quality of life. Those appear to be the two main features of any establishment—whether residential or a day establishment—which the inspectors are supposed to inspect. I cannot see why lay inspectors should necessarily need detailed medical information. I beg to move.

Lord Butterfield

My Lords, I am concerned that the Bill does not make it difficult for those working for public health officers to secure information for epidemiological studies. What intrigues me about the noble Lord's amendment is the phrase: or other records identifying an individual's medical status except on an anonymous basis". That is what the epidemiologist is looking for. I am anxious that we should not produce a Bill which blocks the very kind of work required in trying to assess general needs based on an epidemiological approach. If the noble Baroness cannot respond tonight perhaps she will write to me.

Baroness Hooper

My Lords, I must point out that the persons authorised by the Secretary of State to carry out the inspections to which Clause 51 refers will be drawn for the most part from the social services inspectorate and from other members of the staff of the Department of Health. When such people are not doctors they are almost certain to be qualified in one or other of the caring professions—for instance, nurses, social workers or therapists. Such people would be bound by their own professional codes of conduct which place clear limits on the unauthorised disclosure of information gained in the course of professional activities. Even where this might not be the case the people concerned would still be covered by the codes of conduct covering the use made by civil servants of information gained in the course of their employment.

At Report stage I said that some limited medical information could be essential if the inspector was to have sufficient understanding of the individual's condition to enable him to evaluate the appropriateness and quality of the care provided. The noble Lord, Lord Butterfield, has now raised another issue in terms of epidemiological research. For those reasons I do not think that the amendment would make a useful addition to the clause. I feel that the concerns of the noble Lord, Lord Kilmarnock, are covered in the way that I have outlined. I ask him to withdraw the amendment.

Lord Kilmarnock

My Lords, perhaps I may refer, first, to the point raised by the noble Lord, Lord Butterfield. I do not think that the amendment would interfere with the extremely valuable collection of epidemiological evidence to which he referred. That would not be affected.

I am slightly less than happy with what the Minister said. She referred to the professional integrity of the social services inspectorate. But we have to remember that we are not talking about the social services inspectorate. We are talking about social services units which are being set up, under, I suppose, the general supervision of the social services inspectorate, by local authorities. The inspectors can be drawn from a wide range of walks of life. For example, people who have previously run homes may well be one possible element in the local inspectorate.

The guidance at which I am looking actually states that a local authority can depute another agency on its behalf. The noble Baroness did not mention that aspect of the matter; but that is referred to in paragraph 10 of the draft guidance. Therefore, it does not seem to me to be quite as water-tight as the noble Baroness suggested. As she will know, I have a deep concern for the preservation of confidentiality in the particular sphere in which I am involved; namely, HIV and AIDS.

I must confess that I am not 100 per cent. happy with what the noble Baroness said. But again I am pinning my hopes on the further development of these draft guidance papers. Therefore, if my fears are realised, I shall on future occasions be pressing the Government on this point in an endeavour to achieve some kind of amendment of the guidance. However, I shall not press this amendment to a Division at this time of night. In the circumstances, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 53 [Powers of the Secretary of State as respects social services functions of local authorities]:

Lord Carter moved Amendment No. 38: Page 60, line 22, at end insert: ("(1A) In addition the procedure established under subsection (1) above shall be available to any person, whether or not a qualifying individual under subsection (2) below, where that person is dissatisfied by any finding by the local authority under section 50(1) that he is not a person for whom they may provide or arrange for the provision of community care services, or that he is not in need of such services.").

The noble Lord said: My Lords, in moving this amendment, I have a certain difficulty because I understand that the Government had it in mind to accept it, or something along the same lines, but that there are now some problems. I am not clear as to whether the problems concern the drafting or another aspect of the amendment. In the circumstances, I think it would be best if I were to explain to the House very briefly the purpose of what is proposed and then wait to hear what the Minister says in reply before deciding how to proceed.

The amendment would provide a right to complain to a person who was refused pre-assessment for community care. At present the complaints procedure is not available to those who have been refused a pre-assessment. That is because such a person almost certainly cannot be a qualifying person and the making of a complaint is an option open only to such a person. A qualifying person is defined as someone for whom, the authority have a power or a duty to provide, or to secure the provision of, community care services and whose "need or possible need" has come to its attention. These words are almost the same as those which define the restrictions on pre-assessment.

It occurs to me that if there is in fact a problem over the wording of the amendment but the Government are, nevertheless, prepared to accept the principle, I should be happy to withdraw it on the understanding that they would proceed to amend the provision in another place. I beg to move.

Baroness Blatch

My Lords, the amendment before us tries to deal with two different cases: first, where the local authority decides that a person is not a person for whom they may provide community care services and, as a result, declines to carry out an assessment; and, secondly, where a person is dissatisfied with the result of the assessment. In the second case, the complaints procedure as set out in Clause 53 of the Bill already covers that contingency.

As regards the first possibility of a decision by a local authority that a person is not a person for whom they may provide services, as I understand it, that is a matter of law. Matters of law are to be decided by the court. It is not appropriate for a complaints procedure to be established, as is the case under Clause 53, by the Secretary of State.

I turn for a moment from the legal complexities. There is a real danger that widening access to the complaints procedure to include someone who is not a "qualifying individual" could open up the procedure to anyone who thought he ought to be entitled to receive such services, although he was not qualified in any way. In the hands of someone so disposed, the opening could be used vexatiously and thereby waste the authority's time.

It is perhaps worth adding that the complaints procedures, welcome and important as they are, will not be the only means by which clients and others will make representations about the actions and decisions of social services departments and other service providers. At present, people can have recourse to their local councillor or to elected members of the social services committee or, in cases of alleged maladministration, to the ombudsman. Such routes will remain open and may sometimes be the better option.

The debate has given us a welcome opportunity to examine in a little more detail the complaints procedure clause. We must qualify the word "qualify" in the amendment, because all people in a health authority area qualify provided that they satisfy the ordinarily resident qualification. I am aware that the noble Lord has been bored by a long letter describing that qualification. The measure includes of course the homeless and vagrants who happen to be in that authority's area at that time. It also includes, in any authority's area, people who were the subject of an earlier amendment this evening—the self-referrals.

Those people are entitled to a service and if there is a breach in the provision of that service, it is a matter for law. If such people are ordinarily resident and do not receive a service they can have recourse to law.

I am grateful to the mover of the amendment. I hope that I have persuaded the noble Lord that his thoughtful amendment is not necessary and that he will now be prepared to withdraw it.

11 p.m.

Lord Carter

My Lord, until this morning I believed that the Government were going to accept the amendment. The Minister has produced a curious argument. The only thing that I can do is to withdraw the amendment. We have drawn attention to the problem. I was hoping that the Minister would say that they would take the amendment to another place. The Government still have the chance to do that and to amend the provision in line with the agreement that I thought there was on it. However, I have listened to what the Minister said. I thank her for the explanation, and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Seear moved Amendment No. 39: Page 60, line 27, at end insert ("; and (aa) he is the private carer of a person to whom paragraph (a) applies;").

The noble Baroness said: My Lords, I shall speak also to Amendments Nos. 40 and 42. The purpose of the amendment is to extend to a carer the definition of "qualifying person". The carer is not included as a qualifying person and is therefore not allowed to use the complaints procedure, but there may be many circumstances in which it is the carer who believes that an assessment is needed. Circumstances may have changed from what they were when the assessment was orginally made. In our view it should not just be the person needing the service who should make the appeal through the complaints procedure for an assessment or re-assessment, but the carer as defined in Section 41 should be able to use the complaints procedure. I beg to move.

Lord Carter

My Lords, I am pleased to support the amendment from these Benches. We have been over this ground before. I hope that as earlier today the Government were able to accept an amendment which related to carers, they will be able to accept this group of amendments.

Lord Sanderson of Bowden

My Lords, as the noble Lord has said, we have discussed at considerable length the role of carers in Committee and on Report. I believe that it is recognised that the Government want to ensure that carers receive adequate support. Let us consider what would happen if a carer was not given adequate support. The care that he could offer would diminish and the person for whom he was caring could have legitimate grounds for complaint that the local authority was not discharging its statutory functions properly.

The complaint could of course be made by the carer or by the person for whom he is caring. In short, the failure of an authority to support a carer adequately would clearly affect the person being cared for and would be grounds for complaint under the procedures envisaged by Clauses 53 and 55.

There is another angle to this issue which I mentioned on Report in response to the noble Baroness, Lady Seear. The needs of the carer himself or herself, may, merely because he or she is caring for someone else, qualify him or her as a: person for whom the local authority has a power or duty to provide, or secure the provision of, a service"— to pick up the wording of Clause 55, line 17 on page 63. Let us take an example: we have an elderly couple with the wife frailer than the husband. The wife needs a community care service possibly to do with lifting or dressing her or sharing some of the cooking or shopping which the husband cannot do. The local authority may, in effect, be providing support for the family as a unit, thus the role of carers and the person requiring the care in their own right may coalesce. The provisions in the Bill as it stands are sufficiently flexible to allow that.

I should like to summarise what the Bill does. If carers have community care needs of their own, the Bill allows them to complain on their own behalf because under Clause 55 they would be, any person for whom the local authority have a power or a duty to provide … a service, and whose need or possible need for such a service has (by whatever means) come to the attention of the authority". On the other hand, if carers have no community care needs of their own and cannot draw the authority's attention to any possible such needs, they can still complain on behalf of the person for whom they are caring.

I hope I have explained that the clause will cover anyone, including carers or persons acting on their behalf, for whom the local authority has a power or a duty to provide a service. This appears to me to provide all the safeguards envisaged under the amendment which the noble Baroness moved. I hope that my further explanation will satisfy her on the subject.

Baroness Seear

My Lords, before the noble Lord sits down, perhaps I may raise one further point of clarification. As I understood him—and I was listening as carefully as I could—he spoke on the assumption that the needs and actions of the carer and the cared for would be the same. However, there could be a difference of opinion between the carer and the cared for. In those circumstances one wants to be sure that the carer has an independent right of access to complain, even if not supported by and in disagreement with the person being cared for. This can occur, and surely does.

Lord Sanderson of Bowden

My Lords, I am absolutely certain that, as I said last time, the carer, of his or her own volition, has a right to make representations to the local authority, irrespective of the views of the person for whom he or she is caring.

Baroness Seear

My Lords, I am very much reassured by that last statement of the noble Lord. I should be happier if it were on the face of the Bill in some shape or form. I am not fully aware that it is. However, I shall read very carefully what the noble Lord said. I am sure that it is his intention that the wishes of the movers of the amendment are stated in the Bill. I shall have to examine it carefully before I am absolutely certain that what the noble Lord said and what the Bill says are precisely the same. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 40 not moved.]

Clause 55 [Local authority plans for community care services]:

Lord Sanderson of Bowden moved Amendment No. 41: Page 62, line 31, leave out ("who are living at home and").

The noble Lord said: My Lords, I have already spoken to this amendment. I beg to move.

On Question, amendment agreed to.

[Amendment No. 42 not moved.]

Clause 56 [Inspection of premises providing accommodation]:

Lord Carmichael of Kelvingrove had given notice of his intention to move Amendment No. 43: Page 64, line 5, at end insert: ("(1A) In subsection (1) after "place" insert "the facilities and services provided therein").

Lord Sanderson of Bowden

My Lords, perhaps the noble Lord, Lord Ennals, will move this amendment in the name of the noble Lord, Lord Carmichael.

Lord Ennals

My Lords, I beg to move.

Lord Sanderson of Bowden

My Lords, for the first time on this Bill, I have very great pleasure in accepting the amendment of the noble Lord, Lord Carmichael.

Lord Ennals

My Lords, I am most grateful. This is the first time that my arguments have really convinced the Government! I am deeply touched.

On Question, amendment agreed to.

Clause 65 [Clinical Standards Advisory Group]:

Lord Ennals moved Amendment No. 44: Page 72, line 18, after ("concerned") insert: ("(bb) to initiate and carry out its own enquiries into the matters specified in paragraphs (a) and (b) above, as and when it deems necessary;").

The noble Lord said: My Lords, I hope that I shall have the same success with this amendment. I wish to move Amendment No. 44 and speak also to Amendments Nos. 45, 46 and 58. From all parts of the House there has been a welcome for the initiative to establish the clinical standards advisory group. It was a response both to the discussions with the royal colleges and to points made by noble Lords in this Chamber.

There has throughout been concern that there should be a strong body to preserve and have a care for clinical standards in a new NHS which will be based more on commercial standards and perhaps cost cutting than in the past. Although we welcome that, there has been concern about the ability of the group to act independently. In explaining the amendment on 12th June the noble Baroness, Lady Hooper, said at column 246 of Hansard that the group 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". I asked: 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"? The Minister replied that, there will be nothing to prevent the group initiating activity, though we would largely expect it to respond to requests".

Concern was expressed by the noble Baronesses, Lady Seear and Lady Cox, about the question of independence. I asked whether the Minister would be prepared to have a meeting to clarify whether the group could initiate inquiries on its own and whether it could publish reports. I was grateful to the Minister for agreeing to see me. She was, as always, courteous and helpful, but she made it quite clear that the power of action would be dependent on the authorisation of the Secretary of State. If he said no, that would be that. Therefore there is no independence at all. That is not a satisfactory position.

Let us suppose that the group wished to inquire into some issue on which the Secretary of State may have taken a decision; for instance, the allocation of resources or the question of waiting lists or some other controversial matter. If the Secretary of State decided the group could not inquire into such matters, it would have to accept his words. The group's hands would be tied and it could only speak if asked to do so. That is not a satisfactory basis on which to establish a new initiative. It is a case of people being free to comment provided they agree with the Secretary of State and being able to speak up only if they echo the Secretary of State's words.

The Minister may say that the Government have an agreement with the royal colleges and they cannot go outside that agreement. However, she may know—if she does not know, I shall inform her of it—that the royal colleges want as much freedom as they can obtain. It is the wish of the royal colleges that they should have freedom to make their own inquiries. I hope that the Minister will feel that that is right.

The Minister said on 12th June at column 259 of Hansard: 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".

When I discussed this matter with the Minister, she said that the group could only publish a report if the Minister agreed. I find that unsatisfactory. I should have thought that if there was to be a new initiative, it should hold out prospects for greater confidence. I believed the Government were trying to meet the concerns and the lack of confidence that was being expressed. I therefore think this amendment is necessary. I am grateful to the noble Lords who support the amendment. The noble Lord, Lord Walton, apologised to me for the fact that he cannot be present this evening but explained that he totally supports the two amendments we are considering. I beg to move.

Baroness Cox

My Lords, I wish to speak briefly in favour of Amendments Nos. 44 and 45. I do so reluctantly because of my continuing dissatisfaction with the reply given by my noble friend the Minister on Report. As regards Amendment No. 44, I believe that the freedom to initiate inquiries or investigations is fundamental if the clinical standards advisory group is to have enough independence to respond to concerns which members may identify from their own or colleagues' professional experience at the front line of the delivery of care. Without this freedom there is a real danger that the group will be seen as a puppet of the Secretary of State. Given this freedom, the group will have much more credibility as the watchdog of clinical standards.

Regarding Amendment No. 45, I believe that freedom to publish reports is also essential, for at least two reasons. The first is public accountability and the opportunity to reassure the public of the Government's commitment to the safeguarding of clinical standards. The second is the very important need for the dissemination of information that is gathered by the group so that good practice can be disseminated and built on or, conversely, problems can be identified and remedied and perhaps prevented from occurring elsewhere.

If the Clinical Standards Advisory Group is to be able to perform and, equally important, to be seen to perform its functions effectively, I believe that the provisions of the two amendments are necessary. Any resources that might be involved would be well spent in terms of the enhancement of the work of the group and as insurance that clinical standards are being maintained. They would also do a great deal to reassure the professions and the public of the sincerity of the Government's commitment to the effectiveness of the operation of the Clinical Standards Advisory Group. Therefore I hope that at this very late stage my noble friend the Minister will be able to assure the professions, patients, clients and the public that the work of the Clinical Standards Advisory Group will be enhanced through the acceptance of these two amendments.

11.15 p.m.

Lord Kilmarnock

My Lords, this is another all-party series of amendments. I confirm that, as the noble Lord, Lord Ennals, said, the noble Lord, Lord Walton—who had to leave to catch a train—told me that the conference of the royal colleges was concerned with three issues. Those were publication, that the advisory group should be able to initiate inquiries on its own initiative and that not enough importance is given to prevention under the general concept of clinical standards. However, the third point is not the subject of the amendments.

The question of the Clinical Standards Advisory Group being able to initiate its own work is by far the most important covered by the amendments. There is a possibility that that might creep in under Clause 65(1)(c), which refers to: such other functions as may be prescribed by regulations", but that again would be dependent on the Secretary of State prescribing those regulations.

It is rather curious that such a power has not been given to that body. I agree that, as has been said, it is a step forward. There was some doubt when we first discussed these matters whether there would be any statutory provision in the Bill, and the Government have moved on the issue. That is welcome. However, the restriction of the powers and the freedom of movement of the group is still very considerable. It is possible that the royal colleges are being punished for their initial opposition to the Bill, but that is not a very grown-up way of going about legislation. Once the Bill is an Act I am sure that the royal colleges will do everything within their power to make it work successfully in the interests of the service and the patient.

I remind your Lordships that almost all foreign countries which run some kind of system of this type have completely independent bodies. That is the case in Canada, Australia and in parts of the United States.

There is a very real danger that without this power the body will be seen to be the poodle of the Government. Paper tiger is a term which the noble Baroness used on an earlier occasion when denying that.

More important than any of those considerations is the fact that it would go a long way towards allaying public disquiet. It is in the interests of the Government that the public should be satisfied that a truly independent watchdog is looking at these matters. I cannot see why the Government should not welcome the opportunity to give the advisory group that power and to obtain for it the credibility that would stem from the additional powers that are proposed here, which are not very draconian. I find it very hard to understand why, in simple self-interest—in terms of gaining acceptance for their reforms—the Government do not concede the point regarding the power of the body to initiate its own inquiries rather than the inquiries simply being triggered by the Secretary of State or health service units using it on a consultancy basis. I find that very hard to understand.

There is one other point. Subsection (2)(a) provides that: one or more members of the Advisory Group shall be appointed from persons nominated by such body or bodies as may be specified in the regulations". We have heard about the negotiations with the great and the good of the royal colleges. However, it will be interesting to hear that the Government intend to incorporate some representatives of consumers and patients in order that their views may also be heard. That will go some way towards allaying some of our disappointment about the scope of the body. I look forward to hearing the Minister's reply.

Lord Young of Dartington

My Lords, I too support the amendment. There are three main advantages in giving the group the power to initiate and report. First, it would improve the quality of the people who could be attracted as members of the group or as staff to work for it. That would be the case if the group were entrusted with the power to choose its own subjects to inquire into in addition to acting on the remits of the health Ministers. Secondly, it would improve the confidence of the public, as was said by the noble Lord, Lord Kilmarnock, if it were made clear that the group had at least a degree of independence. Thirdly, it would improve the quality of the work that is done because it would raise the standing of the group in general. That would occur if it were accepted that the group had the degree of independence which would be implied if it were able to choose at least some of the subjects for inquiry.

Without those not very grand powers, the Government could, if they were so minded, make an almost complete cipher of the group by giving it a series of inquiries to undertake. I do not say that they would, but they could. The inquiries could be important but also relatively minor in character. The Government could keep them away from the big issues, particularly if they had any taint of politics about them or were thought of as being controversial and affecting the general structure and character of the health service.

For those three reasons, it appears to me and to all noble Lords who have spoken in the debate during all the stages of the Bill, that it would be most advantageous for the reform, and the confidence that may be built up in the public in the reform, if the group were given that measure of independence. Several noble Lords have spoken of poodles, and the like. We certainly do not want a rottweiler which would attack the Secretary of State without provocation. Certainly, none of us want the group to be merely a creature of the Government. We could ensure that it was not such if it were given the ordinary powers of inquiry that one would expect any such group to have. This is the third occasion on which the measure has been discussed in your Lordships' House, and again I support the amendment.

Baroness Seear

My Lords, from these Benches I support the amendment. Unless such powers are given go the group, it is improbable that it will recruit as members the kind of people who will command public respect. Without the ability to initiate and report, high-calibre people will feel that they are wasting their time.

Lord Carr of Hadley

My Lords, the Clinical Standards Advisory Group, whose powers and functions we once more seek to amend, was one of the glimmers of hope of what might have been in the Bill—I am sorry to have to say what I now say, but I shall say it nonetheless—if only the Government had been a little more prepared to listen to opinions other than their own. I welcome the group because it is a great deal better than nothing. It is a great move forward. It seems a pity that there is this grudgingness around the edge. I believe that at some point in the future that will be changed. It seems a pity that we cannot have a little more give now.

I am sure that the Secretary of State and his colleagues, and the Government, do not wish to make this body their own tame poodle. I have enough faith in the people of whom the bodies will be composed to know that their appointed members would quickly resign if they found that they were being treated in that way. The position may therefore be alright, but why not put it alright in the eyes of the people of this country? Why not show a little more confidence in the good will and desire of people to make it our National Health Service?

Baroness Hooper

My Lords, Amendment No. 58 in this grouping is a government amendment. I hope that your Lordships will support the change in the Long Title to the Bill proposed by this amendment to take account of the proposed establishment of the group, as the proposal to set up a group has been generally welcomed.

I turn to two fundamental questions. First, on the origins of the group, as your Lordships know, the group was established in response to the concerns of the medical, dental and nursing royal colleges about clinical care standards following the reforms. Our view is that those standards will benefit from the greater stress on quality that the new contractual arrangements will bring. However, my right honourable friend the Secretary of State agreed the establishment of the group with the royal colleges as an additional means of safeguarding those standards. That agreement defines the group's remit as being, to advise and assist in the assessment and monitoring of clinical standards for all NHS patients". This remit is faithfully reflected in the proposed new clause.

The purpose was not to create a watchdog—and certainly not a rottweiler—but to provide the Secretary of State and health service bodies with a source of impartial and authoritative advice on clinical care standards in the National Health Service. Advice and assistance works best when provided in response to a specific request. That is why the group's work will be determined in agreement with the Secretary of State. In that way it will have a programme of work looking at areas which it and the Secretary of State together consider to be most important for the improvement of clinical standards throughout the National Health Service.

As for the group's credibility, that will be established by the authoritative advice it provides on subjects agreed with the Secretary of State or health service bodies. Public confidence in the group and in the quality of care provided by the National Health Service will not be helped if the group sets off on studies without the support of the health service bodies or Ministers. Co-operation, not confrontation, is the key to an effective role for the group and to respect for its work.

Amendment No. 45 refers to publication of an annual report and individual reports as the group wish. As I have said on a previous occasion, reports produced by the group will normally be published. It is surely right that the decision on publication should be taken in conjunction with the body or person commissioning the report. I do not believe that it would be right to prescribe centrally the detailed working arrangements for studies commissioned by health service bodies.

For instance, it may be that a report for a health service body names one or more individuals. In such a case it may not be proper for the report to be published. An annual report would be little more than a summary of such ad hoc reports. In the early years of the group's work such a report might consume valuable time which ought perhaps to be spent on work in the field. Should the Secretary of State and the group agree in a few years' time—as my noble friend Lord Carr suggests as part of this evolutionary process—that an annual report would be useful, there is nothing in the Government's new clause to prevent one from being produced.

Amendment No. 46 would allow health service bodies to commission studies without bearing any proportion of their cost. That could mean that the group finds its time taken up sifting through large numbers of commissions, some of them possibly ill thought-out or inappropriate. Health service bodies would find it easy to commission studies as a panacea for problems relating to standards which should perhaps be tackled by completely different means or put to the group only as a last resort. The amendment could prejudice the smooth working of the group without bringing any tangible corresponding benefits.

The arrangements proposed by the Government's new clause follow the agreement between the Secretary of State and the royal colleges. They provide the basis for an effective, positive relationship between Ministers, health service bodies and the clinical standards advisory group. I fear that the amendments before us, other than the government amendment, would only damage that relationship and put in doubt the raison d'être of the graoup. I urge your Lordships to resist them.

11.30 p.m.

Lord Ennals

My Lords, we must accept a very substantial gap between noble Lords who spoke tonight and in earlier debates and the Minister.

If the Secretary of State has confidence in this group, and if he is confident that the Bill will raise clinical standards and health service standards in general, why does he not permit the group some scope for its own work? The noble Baroness said that the group would be impartial and authoritative. That is not so. It would not be impartial because its hands would be tied. It could only do what it was asked to do and report if it was agreed that it should report. The noble Baroness said that it was best that it should answer specific requests. Let us suppose that specific requests either from the Secretary of State or from health service bodies did not come at a time when the group felt it had a deep concern about some aspect of clinical standards in the health service. It shows an extraordinary lack of confidence in this group of highly reputable, professional people, to say: 'No, you must not think for yourself. Only do what you are asked to do.'

I find myself very much in agreement with the noble Baroness, Lady Seear. I find it difficult to think that people of high responsibility, competence and skill in the National Health Service would be prepared to take on a task which was so confined by the Government. If the Secretary of State had confidence in the people who would serve in such a group, he would give it some authority, freedom and independence to enable it to decide for itself.

The decision of the Government—I assume that it is not just the decision of the noble Baroness but that of the Secretary of State—is very sad. It is a very bad start. As the noble Lord, Lord Carr, stated, this was a good initiative that we all welcomed. Some people thought that the group might be a watchdog. I have never used that word, but it was thought that it would be a protector of standards. That position has now been taken away as a result of the reply given by the Minister.

There is no point in pressing the matter to a Division. Time will tell. Perhaps the noble Lord, Lord Carr, was right when he stated that the time may come when some future Secretary of State will see that it is best for the service to have a body with some degree of independence. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 45 and 46 not moved.]

Clause 70 [Short title, commencement and extent]:

[Amendments Nos. 47 and 48 not moved.]

Schedule 1 [Health Authorities and Family Health Services Authorities]:

Baroness Hooper moved Amendment No. 49: Page 77, line 45, leave out from ("is") to end of line 46 and insert ("appointed by the Secretary of State or a Regional Health Authority").

The noble Baroness said: My Lords, in moving Amendment No. 49 I shall also speak to Amendments Nos. 52 and 53. These amendments correct an anomaly by allowing remuneration to be paid to all the non-executive members of an authority. I beg to move.

On Question, amendment agreed to.

Schedule 2 [Natonal Health Service trusts]:

Lord Pitt of Hampstead moved Amendment No. 50: Page 80, line 25, at end insert: ("(ee) the employment of medical practitioners, or dental practitioners, or any class or classes of such practitioners, or nursing staff, shall be on the National Terms and Conditions of Service from time to time applicable to the employment of such practitioners by a Health Authority,").

The noble Lord said: My Lords, I am sorry that I am moving this amendment so late at night, but I regard it as very important. This is the last opportunity that Parliament will have to ensure that our health service remains a National Health Service. Although the amendment refers only to medical and dental practitioners working in NHS trusts, the concerns I am about to express also extend to other staff working in the National Health Service.

In speaking I shall concentrate on the consultants, because they are the kernel of the issue, but the same arguments apply to other professional staff. The consultant is legally and professionally responsible for clinical decisions about the care of individuals, and the consultant must answer to the courts and to the General Medical Council if those decisions fall short of acceptable standards. Consultants therefore are central to any plan for an even distribution of health care.

We must look back before the advent of the National Health Service. In 1941, Ernest Brown, then Minister of Health, commissioned an independent inquiry into the state of the country's hospitals and their ability to provide adequate facilities. That inquiry confirmed the prevailing belief that there were great inequalities in provision, that many of the public's needs were not being properly met and, above all, that without thorough co-ordination of effort there would be insufficient improvement.

In an endeavour to resolve these grave inequalities and to meet the needs of the public, the introduction of a National Health Service was formally approved, and it was recognised that the proposal would require a supreme co-ordination of effort. The 1944 White Paper The National Health Service identified the need for a more even spread of consultants to improve standards in all areas of the country. I stress that fact. Therefore, from its inception a fundamental principle of the National Health Service has been a more uniform distribution of standards of provision, and a crucial factor in determining improved equality has been the distribution of consultants.

The 1948 report of the inter-departmental committee on the remuneration of consultants and specialists noted that equality could be achieved only by increasing the mobility of specialists throughout the service and facilitating the interchange of staffs between teaching and non-teaching hospitals. The report emphasised the importance of area hospital centres not being inferior to teaching centres, stating that both should be able to attract specialists of the highest calibre and concluding that the same range of remuneration for clinical work should apply to specialists in both teaching and non-teaching hospitals.

Equality of status between specialties was also examined in that report. It was concluded that all consultants should be remunerated on the same salary scale, and that the highest remuneration—merit awards—should be open to consultants in all specialties, stating: We are certain that, unless all specialists, in whatever branch of medicine they practise, have an opportunity of reaching the highest levels of remuneration, the ancillary specialties, however important, will find it difficult to attract sufficient recruits of suitable calibre". In introducing equality of salary scales for all consultants, it was stressed that that would enable all hospitals and specialties to attract the best possible candidates.

Forty years later those considerations continue to apply. National salary scales lead to a more equal distribution of talent, both geographically and by speciality. A better spread of ability is advantageous to patient care. Inequality in the provision of health care was identified as a major problem before the introduction of the National Health Service. A movement away from national salary scales could result in the best consultants being concentrated in areas where the highest salaries are paid and a consequential reversion to inequality in standards.

However, although salary is probably the greatest attraction of all, it is not the only potentially variable benefit. National terms and conditions of service mean that consultants are employed on the same basis across the country. In addition to the protection offered to consultants themselves, national terms and conditions of service contribute to uniformity in standards of care by ensuring that individual hospitals are not able to offer greater attractions to consultants than other hospitals.

Thus, in all areas, consultants enjoy the same superannuation benefits, equal access to annual and other leave and are subject to the same restrictions regarding the right to undertake private practice. If employing authorities were able to vary those terms and conditions of service, that would affect the distribution of consultants to the detriment of patient care.

The national conditions governing consultant appointments are based on the principle that a consultant grade with professional independence and the corresponding professional accountability is a vital protection for patients. However, it is not only for consultants that national terms and conditions of service are essential; they apply equally to junior doctors.

Mobility is an important factor in ensuring that consultants are well trained through providing experience in different hospitals and related specialties. Junior hospital doctors have to be able to move between hospitals, secure in the knowledge that they will not suffer from fluctuations in basic salary. Potential extensive experience must be available to all hospital staff to provide equality of opportunity. Junior staff should apply to work in a particular hospital for the benefit of the experience that they would gain and not for the attraction of salary. That can happen only if salary scales are agreed nationally.

There is then the national negotiating machinery which makes economic and administrative sense. Local bargaining on pay and conditions will involve considerable manpower in terms of health managers and representatives of the various professions. Similar negotiations will be occurring across the country, using what is a major National Health Service resource—that is, the time of the people concerned.

Structures have evolved over many years to deal effectively and objectively with NHS salaries and terms and conditions of service. The independent Doctors' and Dentists' Review Board, for example, has an important role in looking at remunerations in the whole medical profession in relation to comparable groups outside the service in order to ensure the recruitment of high calibre individuals into the profession. It also undertakes a valuable task in adjusting internal relativities within the profession; for example, between general practice and the hospital service.

A single hospital board of trustees would not be in a position to take those wider factors into account in determining salaries for its staff. The argument that relativities will be determined by market forces cannot apply when recruitment is from a fixed pool of medical graduates within a controlled manpower structure.

Finally, there is the question of morale. One of the strengths of the National Health Service as an employer is the team spirit which unites its employees. Moving from national salaries and terms and conditions of service to local agreements could adversely affect that team spirit. Variations in pay and benefits are, because of the staff they attract, likely to lead to considerable differences in the standards of care that hospitals are able to provide. Widely perceived inequalities in hospitals and in the conditions for staff will be detrimental to the morale of staff working in the poorer centres. The supreme co-ordination of effort which was regarded as required in the early 1940s is still needed today in order to avoid a return to a fragmented health service.

The implications of the provision in Schedule 2(16)(d) which would give the hospital management in NHS trusts power to determine pay and conditions of service for staff without reference to national agreements is inconsistent with the principle in the National Health Service of uniform standards and should be rejected. The spread of medical staff throughout the country and by specialty has won international recognition and is one of the most impressive achievements of the National Health Service. We must not throw that away. National agreements for staff must be maintained. This amendment is essential. I beg to move.

Lord Carmichael of Kelvingrove

My Lords, I merely want to say that the Scottish amendment is almost identical to that moved by my noble friend Lord Pitt of Hampstead, and I give my full support to his amendment. We have received representations from the British Medical Association and others in Scotland. I hope that the Government will see their way to accepting the amendments.

Baroness Gardner of Parkes

My Lords, I should have liked to speak at length on this amendment. However, as the noble Lord has given what was almost a Second Reading speech which lasted 15 minutes there is not time to do so. I do not agree with him at all. He has overlooked the point that by paying people on national scales employees become hard to find in areas of great need. There is a strong case to be made for freedom of bargaining by which a better service would be delivered to patients because it would be possible to pay incentives in order to attract people to those areas in which they are really needed.

I shall not go further into the matter at this late hour but there are many arguments against what the noble Lord said.

Lord Rea

My Lords, the reverse would occur. Lower salaries are often paid in the areas in which there is the greatest need. Independent trusts are likely to be set up in the most attractive areas where perhaps the pay would be higher. I do not believe that the point made by the noble Baroness, Lady Gardner of Parkes, is valid.

Baroness Hooper

My Lords, in Committee we had a full discussion on a group of amendments including an amendment in the name of the noble Lord, Lord Pitt of Hampstead. On a Division, an amendment tabled in the name of the noble Lord, Lord Walton of Detchant, in similar terms to this amendment was lost.

These amendments add little to those already debated. It remains the Government's view that NHS trusts should be able to offer terms and conditions of employment which reflect their needs and priorities. We do not see a case for excluding any group of staff from that freedom. Your Lordships have already accepted that there should be a general power for National Health Service trusts to set their own pay and conditions. If trusts are capable of exercising that general power sensibly and responsibly, then there is no reason why it should not apply also to nursing and medical staff. To suggest otherwise makes a nonsense of your Lordships' earlier decision. I hope that the House will follow that earlier course of action. I trust that the noble Lord will feel able to withdraw his amendment.

Lord Pitt of Hampstead

My Lords, I shall not withdraw the amendment. I commend it to the House.

11.52 p.m.

On Question, Whether the said amendment (No. 50) shall be agreed to?

Their Lordships divided: Contents,13; Not-Contents, 45.

DIVISION NO. 9
CONTENTS
Butterfield, L.	Ewart-Biggs, B.
Carmichael of Kelvingrove, L.	Graham of Edmonton, L.
[Teller.]	Hatch of Lusby, L. [Teller.]
Carter, L.	Hollis of Heigham, B.
Ennals, L.	Longford, E.

Monson, L.	Rea, L.
Pitt of Hampstead, L.	Young of Dartington, L.

NOT-CONTENTS
Arran, E.	Hives, L.
Balfour, E.	Hooper, B.
Beaverbrook, L.	Jenkin of Roding, L.
Belstead, L.	Johnston of Rockport, L.
Blatch, B.	Long, V.
Borthwick, L.	Lucas of Chilworth, L.
Bridgeman, V.	McColl of Dulwich, L.
Brougham and Vaux, L.	Monk Bretton, L.
Carlisle of Bucklow, L.	Pearson of Rannoch, L.
Carnegy of Lour, B.	Rankeillour, L.
Carnock, L.	Reay, L.
Cavendish of Furness, L.	Sanderson of Bowden, L.
Clanwilliam, E.	Skelmersdale, L.
Colwyn, L.	Strathclyde, L.
Cox, B.	Strathmore and Kinghorne, E
Darcy (de Knayth), B.	Swinfen, L.
Davidson, V. [Teller.]	Thomas of Gwydir, L.
Ferrers, E.	Trumpington, B.
Fraser of Carmyllie, L.	Ullswater, V. [Teller.]
Gardner of Parkes, B.	Wade of Chorlton, L.
Harmar-Nicholls, L.	Wynford, L.
Henley, L.	Young, B.
Hesketh, L.

Resolved in the negative, and amendment disagreed to accordingly.

12 midnight

Schedule 5 [Health Boards, the Common Services Agency and State Hospitals]:

Baroness Carnegy of Lour moved Amendment No. 51: Page 91, line 8, at end insert— ("1A. After paragraph 2 of that Schedule (membership of Health Boards) there shall be inserted the following paragraph— 2A. In the case of a prescribed Health Board at least one of the persons appointed under paragraph 2 above must hold a post in a university with a medical or dental school."")

The noble Baroness said: My Lords, the purpose of this amendment is to ensure that where a Scottish health board has a teaching function, at least one of the appointed non-officer members must be a person holding a teaching post in a university that has a medical or dental school. The amendment will tidy up a situation which has arisen since Report stage. I am sorry that it comes so late in the Bill's progress, but matters have not been straightforward.

I shall not reiterate the very full discussions that we have already had on the joint management responsibilities of the National Health Service and the universities with medical and dental schools and how the decision-making bodies can best be equipped for that. For the purposes of this amendment it has to be emphasised that under existing legislation the position in Scotland has been very different from that in England and Wales, reflecting the different National Health Service structures.

In Scotland under Schedule 1 of the National Health Service (Scotland) Act 1978, the Secretary of State is required to consult the relevant Scottish universities about membership of health boards. It is a requirement that has been fully implemented. The requirement still stands and it is not altered by the Bill that we are now discussing.

However, in England and Wales under Schedule 5 of the 1977 Act, there is a requirement that regional authorities include on district health authorities a specified number of members nominated by relevant universities. In addition, the Secretary of State has been required to consult universities on the appointment of members to regional authorities.

Your Lordships will remember that the effect of the present Bill for England and Wales was to remove both these requirements. That gave rise to concern. The matter was taken up, notably by my noble friend Lady Young. At Report stage she told us that she had received assurances from the Government that it was their intention to ensure by means of regulations that district health authorities with an important teaching role shall include a member drawn from a relevant university with a medical or dental school, and that the Government expected the regional authorities to include a university member, too.

Nevertheless, my noble friend felt it right to move amendments in respect of England and Wales which would put this expectation on the face of the Bill. In my view, the Government very sensibly accepted those amendments. The amendment I am now moving simply brings the Scottish arrangements into line with the amended arrangements in England and Wales. The Scottish universities are concerned that unless that is done they may be less well placed than their colleagues south of the Border to play their full part in implementing all the changes that lie ahead.

I share with my noble friend Lady Young the belief that health authorities will work best if members are appointed for themselves and not as representatives. This is not really a matter of representation. Some Scottish universities, by virtue of their medical and dental schools, share with health boards managerial and policy-making responsibilities in the National Health Service. That has to be reflected in the membership of those particular boards. I suggest that, as in England and Wales, that is best done on the face of the Bill. I beg to move.

Lord Carmichael of Kelvingrove

My Lords, I have great pleasure in supporting the amendment which I hope is uncontroversial. In my view it attempts to tidy up the Scottish provisions for university membership of the health boards to bring the position more in line with that in England and Wales. As the noble Baroness said, an amendment for England and Wales, moved by the noble Baroness, Lady Young, at Report stage, was accepted. I hope that the Government will accept the amendment.

Lord Sanderson of Bowden

My Lords, this is more than a tidying up amendment. Because of the special position of the university medical and dental schools, my right honourable friend the Secretary of State for Scotland, has always appointed to the Scottish health boards someone drawn from a university with a medical or dental school. This is indeed a two-way process: the Chief Medical Officer and the Chief Scientist in the Scottish Home and Health Department have occupied chairs at Scottish medical schools. My right honourable friend the Secretary of State has no intention of changing these arrangements. The White Paper Working for Patients envisaged somewhat smaller health boards as my noble friend said, with members appointed on the basis of the personal contribution which they can make. Since the White Paper was published in January last year, we have already somewhat reduced the size of health boards. But neither that reduction, nor the insistence on the personal contribution of members, threatens the appointment of members from universities. The Secretary of State does not find it difficult to identify people from universities who can make the personal contribution that is required; and there will be a seat even on the smaller-sized "teaching" boards for the present and for the future.

I am somewhat reluctant to write this provision into the 1978 Act, the Act passed by the Government of noble Lords opposite. My reluctance stems not from any desire to change the present arrangements which I have described, but because of the very different wording of the Scottish legislation. Noble Lords will see from Schedule 1 to the Bill that the membership of health authorities in England and Wales is specified in very considerable detail. The equivalent provision in the National Health Service (Scotland) Act 1978 dealing with the membership of health boards is much briefer. It simply says: A Health Board shall consist of a chairman appointed by the Secretary of State and such … other members so appointed as the Secretary of State thinks fit". I take the point that this says nothing about the appointment of someone from a university. But noble Lords will see that Schedule 1 to the Bill says many other things about which the Scottish Act is silent. That includes the appointment of general managers to boards, which is a step we have already taken in Scotland. The Scottish Act also obliges the Secretary of State to consult, before making appointments, any university appearing … to have an interest in the provision of health services in that area". Schedule 1 imposes no equivalent duty in England and Wales.

So the wording of the Scottish legislation is different. That is perhaps an explanation of why the Government did not move in line with the amendment for England and Wales of my noble friend Lady Young. However, I have looked again at the speeches of my noble friend and of the noble Lord, Lord Dainton. I note that my noble friend (at col. 1536 of the Official Report of 7th June 1990) said that we should avoid representative appointments so as not to detract from the key management role which new authorities are expected to play. She went on to say that the role of universities is different and unique.

I have considered the matter carefully. It is a very nice judgment as to how we should approach it. On that basis—by that I mean my noble friend's speech and her understanding of what was wished for in relation to those appointments—and on that basis alone, I am prepared to accept the amendment.

Baroness Carnegy of Lour

My Lords, I thank my noble friend. This is a very pleasant surprise indeed. I have been held in suspense until this moment. It will be very much appreciated north of the Border. I beg to move.

On Question, amendment agreed to.

Baroness Hooper moved Amendments Nos. 52 and 53: Page 91, line 10, leave out from ("to") to end of line 11 and insert ("such other members of a Health Board as may be prescribed"."). Page 92, line 17, leave out from ("to") to end of line 19 and insert ("such other members of the management committee as may be prescribed".").

On Question, amendments agreed to.

Schedule 6 [Schedules to be inserted after Schedule 7 to the National Health Service (Scotland) Act 1978]:

[Amendment No. 54 not moved.]

Schedule 9 [Minor and Consequential Amendments]:

Baroness Blatch moved Amendment No. 55: Page 115, line 40, at end insert: ("The Child Benefit Act 1975 14A. In section 3 of the Child Benefit Act 1975 (meaning of "person responsible for child") in subsection (3) (certain days of absence disregarded) in paragraph (c) for the words following "under" there shall be substituted "section 21 of the National Assistance Act 1948, the Children Act 1989 or the Social Work (Scotland) Act 1968."")

The noble Baroness said: My Lords, this amendment, together with Amendments Nos. 56 and 57, removes what would be an incorrect repeal of Section 3(3)(c) of the Child Benefit Act 1975 and reinstates the effect of the current provision. I beg to move.

On Question, amendment agreed to.

Schedule 10 [Enactments Repealed]:

Baroness Blatch moved Amendments Nos. 56 and 57: Page 129, leave out line 8. Page 130, line 20, column 3, leave out ("and 63") and insert ("63 and 67").

On Question, amendments agreed to.

In the Title:

Baroness Hooper moved Amendment No. 58: Line 13, after ("authorities") insert ("to make provision for and in connection with the establishment of a Clinical Standards Advisory Group").

On Question, amendment agreed to.

Baroness Hooper

My Lords, I beg to move that this Bill do now pass.

Your Lordships have, quite rightly, insisted upon examining every detail of this Bill in great detail and have made significant improvements to it, as well as raising issues upon which we have been able to give clarification and reassurance. The Bill has therefore received very thorough examination and its provisions have been properly tested and improved.

Perhaps I may now take this opportunity to thank all those concerned with the passage of the Bill. I should especially like to extend my thanks to my noble friends on the Front Bench. I refer first to my noble friend Lord Sanderson of Bowden who, together with the noble Lord, Lord Carmichael, has played a Scottish symphony. Then there is my noble friend Lord Henley whose specialty has been the social security side of the matter but whose brief has ranged much wider. Finally, there is my noble friend Lady Blatch. This has been the first major Bill with which she has dealt since coming to join us on the Front Bench. Much work has also been carried out behind the scenes and in the corridors. I thank all those involved.

Out of a number of improvements made since the Bill entered your Lordships' House, I should like to pay particular tribute to the work of my noble friend Lady Young and those who have helped the Government to set out clearly on the face of the Bill their intentions as regards medical education and research, and in recognising the role of universities with medical schools. Many noble Lords also thought that it would be helpful to make clear the Government's intentions as regards consultation on the establishment of National Health Service trusts. Again, we have been happy to do so.

On the community care side of the Bill, we have responded to many points raised in both Houses, and have made a number of changes dealing with complaints procedures, consultation with carers' organisations on the making of community care plans, the right for the views of disabled people and their carers to be considered before a decision is made to hold an inquiry and clearer powers of inspection for the Secretary of State's appointees. I believe that some 27 concessions have been introduced.

We have not only responded to comments made in your Lordships' House, we have also continued to discuss our plans and proposals widely with interested parties. In this respect, I highlight in particular the amendment introduced on Report to establish the Clinical Standards Advisory Group.

The Government recognise that there is anxiety about the impact of their plans on the quality of care. However, we strongly believe that the anxiety is misplaced and that the changes in both the health and the community care fields will work to make further improvements in quality—and not put obstacles in the way of those striving to achieve this aim. Nevertheless, we realise that there is concern and therefore we have succeeded in reaching agreement with the medical Royal Colleges on the establishment of the Clinical Standards Advisory Group.

I have emphasised where improvements have been made. However, the passage of the Bill in your Lordships' House has also been helpful in allowing us to dispel lingering misconceptions about the aims and purpose of the changes.

I hope that we have disproved the myth that implementation is being taken at breakneck speed. As I said on Second Reading and on many subsequent occasions, we are in the business of making revolutionary changes but it is revolution through evolution. I explained that the first wave of NHS trusts and GP practice funds would in effect be pilot projects. The pace of change and the introduction of NHS contracts will be carefully monitored and handled responsively and responsibly by the Government. I might add in that context that the additional resources, over and above the record sums already devoted to patient care, set aside for the review implementation in 1990–91 will further help smooth the path of implementation.

We have debated similar matters in respect of community care, and again we discussed the practicalities of implementation carefully with the local authority associations and other interested parties. As with the NHS, we shall be building on much relevant experience and good practice. Also, as with the NHS, we shall not be seeking to run before we can walk, but the Government believe that there is a need to put the framework for those important reforms in place as soon as possible. Your Lordships have urged upon us the need to ensure that adequate resources are available before implementation begins. We have always made clear that the implementation of those proposals will be resourced adequately. At this stage we must wait to see what the other place thinks about your Lordships' amendment in that area.

There are other misconceptions which I believe our debates have helped to dispel. I am pleased that the hoary old canard that patients will somehow be denied the drugs they need has finally been put to rest.

In our debate on the NHS trusts it has been made crystal clear that units are not being privatised. We have also been able to set out how they will continue to play their vital role in relation to teaching and research. I hope, although I am not entirely sure, that we have been able to reassure those concerned with drug and alcohol abuse that the interests of their clients will not be overlooked when the new community care plans are drawn up and implemented both in the planning process and in the provision of care in an emergency.

I have deliberately concentrated on hard examples of where the Bill has been improved and where the Government have listened and responded to valid concerns. I have deliberately not talked in general terms about objectives, because I believe that we are all in full agreement about what those objectives should be: better managed services and the delivery of a higher quality of care in a more flexible way to the individuals concerned.

Your Lordships' task has been to ensure that the Bill hits that target, and, as I said, I believe that our scrutiny has helped us to achieve the common goal. Thanks in no small part to your Lordships' efforts the Bill is now, I believe, the right vehicle to achieve our aims and I commend it to the House.

Moved, That the Bill do now pass —(Baroness Hooper.)

Lord Ennals

My Lords, we have had more than 100 hours' debate on the Bill in your Lordships' House. I want to thank noble Lords on all sides of the House for the time and the trouble they have taken during the course of those long debates. I want to thank my colleagues on the Front Bench, my noble friends Lord Peston and Lord Carter, and noble Lords from all parts of the House with whom we have been able to work, sometimes successfully and sometimes not, but always with a good spirit and a positive will. I give special thanks to the government team—the noble Baroness, Lady Hooper, the noble Lord, Lord Henley, and the noble Baroness, Lady Blatch—who have always been courteous and concerned. If I say that they have done their best they will realise that I am not being condescending. Obviously, they were given no freedom to do just what they wanted. They fought for an extremely contentious and controversial Bill. They have listened to our arguments and responded sometimes with useful concessions, as the noble Baroness, Lady Hooper, said.

I wish to add my thanks for the support of many professional and voluntary organisations which have kept us briefed and well informed on all the issues covered in the debate. I am thinking of the local government information unit, the Association of Metropolitan Authorities, the National Council of Voluntary Organisations, the British Medical Association and the royal colleges. The Royal College of Nursing played a particularly valuable role in helping to co-ordinate and to brief us in our activities. We have been well served. Apart from the concessions referred to by the noble Baroness, we have achieved some major victories which I hope will remain when they are debated in another place on Wednesday.

In conclusion, throughout the country, among those who work in the service, their patients and the public, there is a great deal of concern about the future of the health service and still much opposition. However much the Government have tried to win over the public, they have significantly failed to do so. At every opportunity the public have had of expressing their views, they have shown that they believe that the Bill will do damage rather than good to the National Health Service. I believe that the opposition is greater now than when the Government first put forward their proposals.

I attended an inter-disciplinary conference on co-operation in the National Health Service last weekend. I found almost total opposition from an entirely non-political group of participants. I fear for the future of the National Health Service and I believe that the passing of the Bill is the strongest possible argument for a change of government.

Lord Winstanley

My Lords, I am sure that this is not an occasion for a long speech and I have no intention of making one. It is in a way a rather sad occasion—sad because it has become increasingly apparent, as we have discussed the Bill at great length, that all noble Lords in your Lordships' House, in all parties and in none, are committed to the preservation of the National Health Service and to its improvement. That is the point I was trying to make when I was so misunderstood by the noble Lord, Lord Ennals, when I was talking about policies. To that extent, we are united. It has become apparent that all noble Lords in your Lordships' House are committed to the National Health Service and would like to see it preserved in the form or on the basis on which it was originally introduced. Of course it is politics, but it does not need to be party politics if we all agree on it.

It is sad because while we are all committed to improving the National Health Service, few of us can leave tonight feeling that we know that we have done so. We may have damaged the National Health Service. Personally, I believe that it might have been possible to have made sure that some of the proposals would work before we finally committed ourselves. Without making sure, we run the risk of doing damage. However, time alone will show.

The efficiency of the National Health Service depends on four things: the number and quality of the people who do the work—that is, the doctors, the nurses and other people; the adequacy of the places in which they work—the hospitals, the clinics, the surgeries; the tools with which they work—the drugs, the instruments, the heart machines and so on; and finally, the administration through which the other three are moulded together and delivered to the patient.

Frankly, I doubt whether this Bill, as it is, will effect improvements in any of those areas, except possibly the last, administration. It is possible that some hospital trusts may make vast improvements in administration through being a little freer and away from the clutches of the department. It may be that some of the general practices will improve their administration. It is possible that there may be some clinical improvements as a result of audit, but that could have been introduced without the Bill. The medical profession asked for it. However, we do not know yet whether there will be any improvement.

There is a second part to the Bill which concerns community care. Really we should have had two Bills. We are all united on the principle of community care. We all believe it is right that more people should be cared for in the community than in institutions. However, despite all the time we have spent on that part of the Bill none of us can be certain that that principle will work unless we are also absolutely certain that the resources will be available to local authorities to carry the burdens which have now been placed upon them. For those reasons I am uneasy and a little sad as I think we may have caused damage in this area.

My real knowledge of the health service lies in general practice. I shall judge this Bill by what it does to general practice. Holding budgets may make certain general practitioners a little better off, but I do not think their patients will notice any difference. However, I should like to see patients notice a difference. At an earlier stage of the Bill I talked about what some patients thought of their doctors and what some doctors thought of their patients—the doctor-patient relationship. I have considered that relationship in a few practices recently. Frankly, in so far as I can detect any relationship it seems to me to have become one of mutual and undisguised hostility. That is because the health service lets people down almost every day. The patient blames his GP for that. If the hospital is deficient, he blames his GP. Therefore I believe it is inevitable that there has been a decline in the relationship because patients have felt unsatisfied.

I should like to see a change in that position, but we shall only see such a change when patients feel that the service is serving them better. I genuinely and honestly hope that this Bill will have that result. However, I cannot honestly say at the moment that I believe it will. I hope it will have that result, and if it can be improved I hope that will happen. I too wish to thank all the government spokesmen on the Front Bench for their courtesy and their help and for doing their best to answer the points that we made. Obviously the Bill will pass and I wish it well, but I wish I had more faith that it will do good rather than harm.

Baroness Cox

My Lords, I wish the Bill well for the sake of the patients and clients it is designed to help and for the sake of those who work in the National Health Service and those who provide community care, who will be responsible for implementing it. I sincerely hope they will find it achieves its objectives of providing better quality and more cost-effective care. Therefore I welcome in particular those provisions which have been agreed to in your Lordships' House which will enhance patient and client choice and help to ensure high clinical standards. I especially welcome those amendments which establish the Clinical Standards Advisory Group. I express appreciation for that, but I regret the Government's parsimony this evening with regard to two of the key issues. I hope, however, those will be resolved de facto if not de jure.

In wishing the Bill well and in congratulating my noble friends the Ministers on all their hard work in taking it through your Lordships' House, I must confess that I still have profound anxieties especially on the lack of provision for a systematic evaluation of the implementation of the reforms and on many aspects of community care. I deeply regret that the Government were not more receptive to some of the concerns expressed by health care professionals as well as by those representing clients and carers. Many of those concerns were not party political and had nothing to do with party politics but were sincere attempts to build in safeguards for the most vulnerable people.

Finally, for conscience sake I must for the last time restate my own deep anxiety about some aspects of the implementation of the community care part of the Bill. I have not yet been reassured by my noble friends the Ministers that the health needs of clients will be adequately met, either at initial assessment or on a continuing basis. I have not been reassured that the needs of carers will be taken fully into account and I profoundly wish that there were some systematic method of monitoring community care. Without those safeguards I fear for vulnerable groups of people in the community such as the disabled, the mentally ill, the mentally handicapped and the elderly. The latter group will increase both in numbers and in dependency over the coming years. I fear that in many cases the social services are not equipped or ready to receive those people.

In the fields of health and welfare, administrative problems result in real suffering for those who are vulnerable and those who care for them. Those who are least capable of articulating their needs or asserting their rights are most likely to sink into isolation where their predicament may remain unidentified. I therefore hope there is some substance in the rumour that implementation of some of the community care provisions may be deferred until it is certain that local authorities are in a position to provide adequate care.

With that expression of a final, personal, perhaps faint hope, and with reluctant ambivalence, I support the Motion that this Bill do now pass.

12.30 a.m.

The Earl of Longford

My Lords, these days I like to be in bed by half past ten but I have waited until half past twelve because I had a very important matter to raise concerning the whole question of the Government's attitude towards hospices. No one can say that hospices are not relevant to a Bill concerned with health and community care. However, the noble Lord the Leader of the House, for whom my respect is unbounded, has said in the famous words of Mr Attlee (as he then was) to Professor Laski "A period of silence on your part would be welcome". In other words, he has asked me not to speak. In deference to the noble Lord I shall not. However, as people concerned with hospices are interested in what I was going to say I must let them know that I shall raise the matter, which is a very urgent one, at the soonest possible moment.

The Lord Privy Seal (Lord Belstead)

My Lords, the noble Earl, with his customary courtesy, made a copy of what he was going to say available to the department and I had sight of it. It is true that I passed a note to the noble Earl reminding him that the Companion to the Standing Orders says that the debate on Third Reading and Bill do now pass should be relevant to the Bill in the form in which it has emerged. The noble Earl has not risen to his feet during the course of the Bill to mention hospices, and no other noble Lord has mentioned hospices. It was on those grounds that I suggested that a speech devoted entirely to hospices on Third Reading this evening would be inappropriate, despite the fact that support for hospices is to be found on all sides of the House.

Baroness Young

My Lords, at this late hour I shall be very brief.

Unlike almost all those who have already spoken on the Motion that the Bill do now pass, I have supported very strongly the principles of the Bill. I should like to congratulate my noble friend Lady Hooper on the way in which she has managed this long and complicated Bill. I should also like to congratulate her colleagues on the Front Bench.

I believe that it was right that 40 years after the start of the National Health Service we should have looked at it as fundamentally as we have. Like my other noble friends, I support the National Health Service. However, our National Health Service, like those of every other advanced industrial country, faces all kinds of complications, with an ageing population and almost unlimited demands being made upon it. It is right that we should address those major problems.

Your Lordships' House has had an opportunity to make a great many improvements to the Bill. It is right that we should do so. I should like particularly to place on record my thanks for the help that I have received from my noble friends and from my right honourable friend the Secretary of State, particularly in relation to the amendments which have affected universities with medical schools. I believe that that is greatly appreciated in the university world, and I am sure that the amendments have greatly improved the Bill and will contribute to better patient care.

I make it a point never to speak about Scottish business as I am a mere Englishwoman. However, as I was referred to very kindly by my noble friend Lord Sanderson, I must also say on this occasion that I am very grateful that he was able to accept the amendment of my noble friend Lady Carnegy on the same point. That series of amendments, affecting all parts of the United Kingdom, not only improves the Bill but will ultimately improve patient care.

Lord Kilmarnock

My Lords, I should like to add my thanks to the Government team for their courtesy during the 100 hours of the Bill, which the noble Lord, Lord Ennals, mentioned. I should also like to congratulate the noble Baroness, Lady Blatch, on her first major Bill and the way in which she has handled it. She has been extremely helpful to many of us.

Some improvements have been made, as the noble Baroness, Lady Hooper, said. The upgrading of the role of the chief of research and development is important; so is what has been achieved for the universities. Some amendments at the community care end of the Bill are also important although it remains to be seen whether they survive their return to another place.

It is interesting to remark that the Cross-Bench peers have had the best batting average on this Bill, and that gives me some food for thought. I won no amendments but found some satisfaction in the response that I received to some of my anxieties, particularly this afternoon in relation to the self-referral and open-access services. I regard them as being crucial to the public health of this country. The Government went a little way with me in that view.

I regret that the Government did not listen a little more to noble Lords such as myself who are by no means wholly opposed to the Bill and who believe that some of the reforms can be beneficial. I hold that regret particularly in relation to the Clinical Standards Advisory Group. The Government could have reassured the public by dispelling some of the lingering misconceptions referred to by the noble Baroness, Lady Hooper. In so doing they would have strengthened their hand but they have missed an opportunity to win hearts and minds.

I do not believe that as a result of the Bill alone the Government will lose the next election, although it may be true if combined with certain other measures. But that is not my concern. My concern is that the National Health Service continues and improves throughout the rest of the century and beyond. The Government are on record as willing that too and some noble Lords present will concentrate on keeping them up to the mark.

Baroness Masham of Ilton

My Lords, during the passage of the Bill several of us have struggled to add more customer participation. Perhaps we should have been more successful if a few more Members from all parts of the House had had the energy and interest to stay after their usual going home time.

The National Health Service is a most important service for everyone throughout the country. Even those who are covered by insurance schemes use the emergency services and are generally exceedingly grateful for them. The new National Health Service will have greater emphasis on market forces and paid management. Of course we need a cost-effective service which does not waste money but the demands are great. As new doors open to advanced procedures and the increase of sophisticated technology, the costs of the service will rise.

I am sorry that we lost by only one vote the amendment that I moved providing more protection to patients who believe that they may be at risk in being accepted and retained on GPs' lists. I believe that 80 per cent. of general practitioners are caring and professional people. However, as in every profession, a few may not be so kind and willing to help and to tolerate patients with special, difficult and sometimes expensive needs. I wrote to the Secretary of State about the issue and today I received a reply. I am grateful for his courteous letter.

I hope that districts do not become too parochial and that if necessary they will continue to send their patients to the specialist expert services wherever they are. I also hope that the regional and supra-regional units will continue to provide the excellent service which is also important as a teaching and research resource. A serious situation will arise if costs take priority over quality when districts and GP fund holders draw up contracts with hospitals.

I shall quote from a letter that I received from a consultant physician at the Oxford Haemophilia Centre which treats many patients from many different health districts. He stated: If as a consequence of this Bill the Oxford region has to recover the costs from the different patients' home districts, I can foresee great difficulties. These home districts may be unaware of the costs incurred in treating the patients in their regions and may not have taken account of this cost in planning their budgets. As a consequence there may be little or no money to follow the patients and the home districts may opt, therefore, to treat the patients in their own locality". He fears that this would lead to a reduction of service to the patients as it takes many years to build up experience and to establish facilities for comprehensive haemophilia care with all the relevant specialists keyed in. The same can be said for spinal injury specialties and many others. I hope that all these services will find a quick and efficient way of collecting the money from districts and that not too much will be spent on accounting and administration in a complicated and bureaucratic system.

The health service must be user friendly. If there is only a hard-bitten business approach and all tender, loving care disappears, then I feel there will be problems. It will be a tragedy if the goodwill which many people give to the National Health Service is lost. I hope that everyone concerned will work together in harmony rather than at each other's throats. For the good of the patients a working balance must be found. I hope that there will be a working co-operation between health and social services.

As the Bill leaves your Lordships' House, several of us would have liked a few more safeguards written in. For example, the community health councils are waiting for clarification of their roles. There will be many people watching progress in the future.

Lord Swinfen

My Lords, I should like briefly to welcome the Government's efforts to bring community care genuinely into the community. However, I doubt very much whether their efforts for disabled people will work unless they put into operation, at the same time as the community care part of the Bill, Sections 1, 2 and 3 of the Disabled Persons (Services, Consultation and Representation) Act 1986. That is slightly wider in scope and is designed specifically for such a purpose. It is not a catch-all measure as is the Bill that we are discussing tonight.

The Government also have to consider some way of legalising the innovative methods of providing care in the community that are being tried out on an experimental basis in many areas. Soon, someone will ask what is happening and who has authorised the spending of money, and there will be difficulty. We have to consider that aspect. It has to be legalised one way or another as soon as possible.

Lord Dainton

My Lords, I rise with some hesitation but also with a great sense of gratitude to the Government for the way in which they have handled the matter in relation to the universities. That comes from me perhaps more easily as a Yorkshireman once defined as a Scot with the generosity squeezed out of him. Your Lordships can imagine my surprise when there was such a quick response from the Government this evening to the amendment of the noble Baroness, Lady Carnegy of Lour. That seems to me to typify the way the Government have met points that have been put forward. It was stated by the noble Baroness, Lady Young, that they were put on behalf of the universities. I do not think that points made by many speakers in your Lordships' House on education and research can or should be considered as being on behalf of the universities. Those of us interested in the issue have been trying to ensure the success of the National Health Service in its various forms 20, 30 or 40 years from now. That will depend solely on the quality of the doctors whom we produce and the resources which are available. Those resources include the knowledge that will be won by research.

It is in that sense that I feel extremely grateful to the Government. I feel a great deal more comfortable about the likely effectiveness and efficacy of the health service, not for myself at my great age, but for those who will follow. I wish to express my gratitude and, I am sure, that of other Cross-Bench Peers who have taken the same line but who are not present this evening.

12.45 a.m.

Lord Rea

My Lords, I should like to make a few remarks that will take half a minute. I make no bones about the fact that I am deeply unhappy about the Bill. There would have been widespread acceptance by those working in the National Health Service of many of the proposed changes if one or two regions or an equivalent number of districts had been chosen as pilot zones, as proposed in an amendment. In that situation the changes could have been fully and scientifically evaluated without a commitment to press ahead willy-nilly with those changes. In effect the Government have been forced to agree to a radical introduction of the changes because the data and the physical means of implementing them are not yet in place.

I believe that the Government will rue the day that they decided to press ahead on a national scale with these untried changes. I have a feeling that this measure will join the poll tax in being another albatross which will probably follow the Government to their graves.

Lord Colwyn

My Lords, I should like to congratulate the Minister on the way in which she has dealt with the Bill in all of its stages and use this opportunity to remind the House how close the noble Earl, Lord Baldwin, the noble Lord, Lord Ennals, and I were to making it possible for fund-holding medical practitioners to utilise the services of complementary therapists. There is no doubt that, had we wished to search the House for supporters, we could have easily won the vote. However, I did not feel that that was the correct way to press a point that will, without doubt, eventually become possible by public demand. I am sure that my noble friend will be pleased when the Bill is passed, but I ask her to carefully consider our arguments in favour of complementary medicine when she deals with health matters in the future.

We discussed the cost effectiveness of the therapies and reminded the House about the absence of side effects of the treatments. It still seems more sensible to me that practices that control their own budgets and buy services should be allowed to avail themselves of the best possible treatments for their patients. We all know that this should take account of the complementary therapies. The Government have lost a valuable opportunity to demonstrate their far sightedness. The complementary therapies will eventually become available for everyone, and I regret that the innovations of the Bill have not included measures to make that situation possible.

Lord Butterfield

My Lords, I rise simply to say, as a relatively new boy, how proud I have been to be a member of your Lordships' House during the debate. I congratulate the Minister and her colleagues for the manner in which they conducted the business. I offer my congratulations too to the Opposition on their presentation of important points.

I do not want to make a bid for anything else or look back. The main concern now is the basic principle of the health service. It is necessary to infuse into all the people who work within it the principle of service for the patient. That was the concern at the beginning of the review and I hope that we shall be able to redirect our attention to that concern in the immediate future.

Lord Carter

My Lords, I should like to say a few words about the community care aspects of the Bill. Those aspects have been my responsibility on this side of the House. We welcome the Government's agreement to some of the points that have been put to them—the consultation with the housing agencies, voluntary organisations and carers groups. We welcome the institution of the complaints procedure and of procedures to deal with emergency situations. We welcome the agreement by the House to the ring fencing of community care funding, the implementation of community care on the basis of adequate resources and the provision by the Government of help with start-up costs. We welcome the acceptance by the House of the requirement for the disclosure of criminal convictions of proprietors of residential homes. We cannot believe that the Government will reject that position in another place, particularly not on the grounds that the Association of Chief Police Officers does not like the extra work. We welcome the decision of the House that there should be a housing dimension in the planning process.

Of course, we feel that there are still some major deficiencies in the Bill. We still do not know exactly for whom community care is intended, and in many cases there are powers to provide local community care but no duties. We have tried hard and failed to get the Government to recognise the situation of those who are now in residential care, who lack the resources to meet the costs of such care and who perhaps face eviction, and our attempts to amend that situation have been resisted throughout. As the noble Lord, Lord Swinfen, said, after four years the Government are still resisting attempts to bring into action the crucial Sections 1, 2 and 3 of the Disabled Persons Act 1986.

One thing we have learnt is the difference between guidance and guidelines. We have been told that the Government expect that guidance will be followed but hope that guidelines will be followed. In regard to guidance and guidelines, it seems that we now have a new version—the triumph of hope over expectation.

We pointed out to the Government on Second Reading that with all the problems they face over public expenditure, such as the poll tax and all the rest of it, we are deeply sceptical, as I know a number of your Lordships are, there will be sufficient resources next year for the proper implementation of community care plans. If the Government would only accept it, this House has given them the opportunity they need to get themselves out of this dilemma. I am referring to Clause 43 which deals with the timetable for the implementation of community care plans.

In conclusion, I should like to add my words of thanks and appreciation to the Government team for the unfailing courtesy and good humour that they have shown during the passage of the Bill, demonstrating, as this House usually does, that we can disagree quite strongly without falling out with each other.

Lord McColl of Dulwich

My Lords, perhaps I may say how very pleased I am with this Bill. We can now move forward to implement it without further delay. I believe that these reforms will work, as I have already had personal experience of most of them for some years.

I very much look forward to the newly created district health authorities sitting down with the local general practitioners, and consultants, public health experts and nursing officers to work out the quality and quantity of the services needed for the local population. I hope that one of the first things they will do is to realise that, in a population of one-third of a million, there will be 120 severely disabled people who will require these special electrically-powered wheelchairs that can be used both indoors and outdoors. That will cost only £⅓ million.

I also look forward to doctors and nurses running their own hospitals without the practice of shroud waving, an unfortunate sport which makes patients apprehensive, demoralises staff and hampers recruitment. This Bill will change the attitudes in the National Health Service and make the patient the most important person in the service.

I add my congratulations to those already expressed to the Ministers for their stamina, their meticulous attention to detail and their courtesy in piloting this Bill through.

Baroness Hooper

My Lords, I am grateful for the kind words which have been expressed, both on my own behalf and on behalf of my noble friends. I am grateful too for the more or less general welcome given to the Bill and very grateful for the brevity of the latest contributions.

I think that the reforms will prepare our National Health Service and community care system for the challenges that lie ahead and I am sure that the worst fears expressed by some people will not be justified. I know that we all regret very much that we have not had the benefit of the expertise and commonsense approach of the late Lord Trafford, who would no doubt have dealt with great authority with many of the issues raised.

I have already thanked my noble friends here on the Front Bench, and I am indeed grateful to everyone for their contributions. We have been fortunate in having contributions from former Secretaries of State for Health, including the noble Lord, Lord Ennals, and from other giants in the medical world. As I said, I think that the Bill goes forward a better Bill.

On Question, Bill passed, and returned to the Commons with amendments.

House adjourned at five minutes before one o'clock.