National Health Service and Community Care Bill

HL Deb 03 May 1990 vol 518 cc1140-99

3.32 p.m.

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

My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.

Moved, That the House do now again resolve itself into Committee.—(Baroness Hooper.)

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Clause 19 [Amendments relating to funding of health authorities etc.]:

Lord Ennals moved Amendment No. 105A: Page 20, line 47, at end insert: ("( ) After subsection (4) there shall be inserted— (4A) It shall be the duty of any health authority in receipt of funds from the Secretary of State under this section to require for administrative and financial purposes that hospitals for which they are responsible shall seek the following information from appropriate patients who have been admitted to those hospitals or from their close relations—

1. (a) whether the patient is prepared to accept an organ transplant;
2. (b) whether the patient would be willing to donate an organ in the event of his death." ").

The noble Lord said: This amendment relates to organ donation. Perhaps I may first congratulate the Minister's honourable friend, Mr. Roger Freeman, on organising a seminar on improving the voluntary donation of organs on November 16th last year which I was very pleased to be able to attend.

Although kidney transplantation is the most common, and heart and lung transplantations gain greater publicity, this amendment covers any human organs which can be transplanted to save the lives or improve the quality of life of patients. It may interest Members of the Committee to know that one of my honourable friends in another place returned there yesterday following a lung transplant and took part in the debate. I think that that was a notable achievement; not just for Dr. Galbraith, but also for those who carried out the operation.

Most of us are aware of the life saving, though exhausting and draining, experience of dialysis for kidney patients. In so many cases where people survive on dialysis they are waiting and hoping for a kidney transplant. Around 1,000 kidney patients die every year without receiving treatment. They die not because treatment is unknown, but because no treatment is made available to them. The problem is partly lack of funding and partly the shortage of donor kidneys for transplantation. A recent Gallup survey commissioned by the British Kidney Patients' Association showed that while 74 per cent. of the adult population were willing for their kidneys to be used after their death for transplant purposes, only 27 per cent. owned donor cards and only 20 per cent. of those people actually carried the cards with them.

The donor card is a means of securing sufficient calibre kidneys for transplantation; but it is not the only means. We always have to look for other means of ensuring that the information is available so that the doctors concerned will know which organs are available, either by decision of the patient or of his family. The organ donation system in the United Kingdom is based upon the legal framework of the Human Tissue Act 1961. That essentially provides for people to opt into organ donation in two different ways.

First, they may do so by indicating their wish in writing it any stage during their life. That would include signing and having an organ donor card. Secondly, they can indicate their wish to do so orally in the presence of at least two witnesses during their last illness. In that way the person concerned can indicate his desire to become an organ donor. I warmly support the system of donor cards. I always carry mine with me in my wallet. However, the fact is that the vast majority of people do not do so.

Therefore we must look for every conceivable way to improve the situation, not only by publicising the donor card system; we must also find other ways whereby doctors and the health service can know about organs which could be made available. I would support legislation to apply the opting-in—or the opting-cut—principle more liberally than at present. I should like to have seen it included in this legislation, but it was not possible to do so.

I am grateful to the noble Lord and also the two noble Baronesses who have supported the amendment. It proposes a modest method but one which might be most helpful in building up a database so that when a patient comes into hospital he is automatically asked—as is set out in the amendment—whether he is prepared to accept an organ transplant and, more important, whether the patient would be willing to donate an organ in the event of his death".

It is often much easier to obtain this information by way of a routine method rather than waiting until a patient is near to death. It is most difficult for doctors to approach families at that time because they are deeply distressed. One of the interesting factors is that patients are much more willing for their organs to be used for transplantation purposes than are their relatives.

My amendment is a simple one. It makes it easier to seek this information on admission to the hospital either from the patient or his relatives. Obviously this would be done only where it was appropriate. One would not do this in respect of a patient who was being rushed into hospital, or with a patient who was very elderly or suffering from a particular type of disease. However, this amendment would be a contribution to improving the database of willing donors. I beg to move.

Baroness Masham of Ilton

The rather strange name which appears on the Marshalled List together with the other supporters of this amendment is meant to be mine. However, as people always seem to get my name wrong, I am not surprised that it has happened in this Chamber.

Lives can be saved by a transplant or the quality of life can be improved. The development of organ transplants will no doubt increase and expand in the future. Therefore, it seems wise not to overlook this very important matter. While supporting the amendment, I feel that it is important to encourage a patient, or his next of kin if he cannot do so himself, to give permission for use of his organs so that they are not wasted. That permission must be obtained in a very careful and sensitive way.

People who come into hospital are often very nervous. They should not be made to feel more so by being made to feel that they may die. The necessary permission could perhaps be obtained by way of a question being included on the admission form which the patient fills in when he enters the hospital, along with other questions such as, "Who is your next of kin? What is your religion?" and so on. In that way the patient would not feel that he was being singled out. I hope that the Government will consider this matter seriously. I support the amendment.

Baroness Cox

I support this important amendment. The noble Lord, Lord Ennals, has spelt out the implications of its contents so clearly that I have little to add to his wise words and those of the noble Baroness, Lady Masham, except perhaps just to highlight the great importance of any measures which would facilitate the availability of organs which would alleviate the suffering of those people who are waiting to benefit from transplant treatment.

I should like to highlight that point by referring to a recent newspaper report which gave some indication of the order of magnitude involved. According to that report, 3,700 people are currently queueing for a kidney transplant and 470 people are awaiting either a heart, or a lung, or a heart/lung transplant. Those figures compare with 1,800 renal transplants which were performed last year and 400 of the heart or heart/lung transplants. So there is a serious discrepancy between the availability of organs and the number of people awaiting the opportunity to have that life-saving and alleviating J of suffering procedure.

Given the great hardship experienced by those people suffering from illnesses which can be alleviated or cured by transplants, and given the human and financial costs involved in the waiting due to the non-availability of those organs—in human costs: someone on dialysis, for example does not experience a good quality life; and of course the financial cost involved when people are receiving treatments or awaiting transplants—any measures which would facilitate procedures for the donation of life-saving organs would be warmly welcomed and would greatly help those in need.

Lord Winstanley

I support this essentially all-party amendment. In doing so, I support everything that was said in moving it by the noble Lord, Lord Ennals, and in supporting it by the noble Baroness, Lady Cox. She was right to draw the Committee's attention to the fact that things have changed. There was a time when we discussed this subject when the whole discussion focused on kidney transplants. We discussed the deplorable fact that patients were tied to dialysis machines merely because there were no kidneys available.

The noble Baroness is right. Now that new techniques have developed for heart and heart/lung transplants we find that opportunities are being missed because people are not donating the organs which they would have been happy to donate, had the opportunity arisen.

I should like to underline carefully the last few words in the first paragraph of the amendment: or from their close relations". Those words are extremely important. The Committee will know, and the Minister's legal officers will confirm it, that the law is somewhat ambiguous about who owns the body when a person has died. As a general practitioner I have often had to tell patients that there is not the least point in putting this, that or the other instruction in one's will because by the time that anyone looks at it, the moment will have passed. Organs are needed quickly.

Whether a patient has the legal right to determine everything that is done with his or her organs after death is doubtful. No hospital will proceed if there is any question of the next of kin objecting and so those words: or from their close relations are important. That provision would assist a hospital greatly.

I agree with the noble Baroness and the noble Lord, Lord Ennals, that to ask patients once they are in hospital whether they will sign a form is difficult. It is difficult for a house surgeon to go to a patient and say, "Look, Mr. Smith, you are doing absolutely splendidly. We hope that you will be home soon, but just in case you cannot get home do you think we could have your kidney?" That is not the kind of exercise upon which the average doctor wishes to embark. It is important that all these points are structured and fixed well in advance.

A great deal has already been done, as the Minister knows, especially in Manchester, with movements towards computerisation of donors of kidneys and other tissues. The more that is done the better. It will give doctors in all hospitals the opportunity to know where there is an organ available which might match in type and tissue the patient's needs. The new computerised scheme is assisting greatly.

I ask the Committee to bear carefully in mind the words "from their close relations", because that is an extremely important point. Whatever may be the intentions of the patient who might carry a donor card and exhibit it proudly in his hospital bed, if the next of kin objects then the hospital will find itself in difficulty. That is a point which should be emphasised. I support the amendment.

3.45 p.m.

Baroness Phillips

I do not wish to disassociate myself in any way from the amendment since it is an all-party one, but I have reservations. The noble Lord, Lord Winstanley, underlined them. When I had hurt my hand I remember saying to one of my grandsons, who is a surgeon and who wanted me to go to hospital, "No, thank you. I will go in there with my hand and you will have all my organs out". He said, "No, they are useless. They are too old". That was one consolation!

To be serious, we do not want enthusiastic surgeons putting pressure on people. If a patient lying in hospital is asked about donation he might think that he is about to die or why else is he being asked. The subject must be handled with great care. I was at a party recently with a surgeon who had a little list in his pocket of people who might die, so that he could operate. He was keen, but one wondered: "I shall not strive too much to keep alive". I have reservations about the amendment. The wording needs to be much tighter. The principle is marvellous. In practice it could be dangerous.

People in hospital are impressed by the doctors, surgeons and nurses. One would need only one enthusiast and the patient might say, "Oh yes, certainly".

Lord Ennals

Perhaps my noble friend will give way. The purpose of the amendment is to have the point clarified on admission when one gives one's age, address and so forth. A young doctor does not ask the question; it is part of the administration—the information one gives when one arrives in hospital.

Lord Rea

I agree that the way the amendment is worded minimises the emotional difficulty of asking relatives for permission. The Committee might be interested to hear the description of an experience I had when the 29 year-old son of a close friend was knocked down. He suffered severe head injuries and was taken to the local hospital where, six hours after life support measures were instituted, he died. At no point were the relatives asked whether they would be willing for him to donate his kidneys. His mother and his brothers and sisters would have been delighted to have given that permission. It would have helped them to know that the kidneys were living on although the young man who was a gifted Ph.D graduate was no more. If such questions are asked routinely when patients are admitted to hospital, in the way that my noble friend suggested, those difficulties could be overcome.

Lord Walton of Detchant

I support the principle underlying the amendment. It is an exceptionally sensitive and difficult issue. It has exercised those bodies which are responsible for giving ethical advice to the medical profession for many years. Several years ago of course grave anxieties were expressed about transplantation programmes, their cost-effectiveness, and their benefits to human health. There were no serious reservations about kidney transplantations which have proved their usefulness.

Over the course of the past few years, this country has had an exceptional and proud record in the field of transplantation surgery, and even the healthcare economists have now produced figures to demonstrate that cardiac transplantations and heart/lung transplantations are extraordinarly cost-effective in the long term. One of the problems the medical profession faces is the serious shortage of organs. As the noble Baroness, Lady Cox, said, many people are now waiting for organs to be transplanted, and I fear some awaiting cardiac transplantations die merely because the conditions from which they are suffering are so serious that they do not survive until an available and suitable heart can be found. Hence transplantation has had inestimable benefits to human health.

It is exceptionally difficult for any doctor, however, caring, compassionate, experienced and senior, to have to go the relatives of a patient in extremis. He may do so at a moment when they have just been bereaved or are about to be bereaved. It is difficult to ask them whether organs from their much loved relative may be used for transplantation purposes. In the face of grieving individuals, some doctors shy away from the task even though they recognise how important it is that they should ask the question.

The whole purpose underlying the amendment is one which I believe the medical profession is beginning to support in principle. Instead of people having to opt in at a stage when there is no question of their being asked to consider a sensitive issue, they may simply be invited at the time of admission to hospital to say whether, should the situation ever conceivably arise in their case, they accept transplant or their organs being used for that purpose. Despite all the publicity given to donor cards, the number of people who carry them is woefully small. I hope that the Government assure us that even if the amendment as phrased is not acceptable, they will pay careful attention to the issue and try to improve an unfortunate situation.

Baroness Blatch

We have considerable sympathy with the aim of the amendment which is to improve the availability of organs for transplant surgery. The Government are committed to the organ transplant programme and are anxious to see the supply of donor organs increased.

I am not convinced, nor are one or two of those who have spoken in the debate, that the amendment is the best way forward. It would require health authorities to seek two pieces of information from every patient entering hospital. The first, which asks whether the patient is prepared to accept an organ transplant, is only appropriate in certain cases. This would be where a patient was giving consent to the specific care and treatment proposed, and when all the procedures and possible risks were being explained and discussed. For most patients who are unlikely to require an organ transplant the question is irrelevant.

I accept that the second part of information concerning the patient's attitude to organ donation might facilitate an approach to relatives if the patient died and the organs were suitable for transplant. We would, however, not wish to coerce all hospitals into collecting this information for a number of reasons.

First, most people admitted to hospital are unlikely to be suitable as organ donors. They may be elderly—a point made by the noble Baroness, Lady Phillips. However, I must say to her that I do not think that noble Lords think of her as a "very old person". Nevertheless, the elderly are unsuitable as are those receiving relatively minor treatment from which they will recover. That point was also made by the noble Lord, Lord Winstanley. To ask such patients or their relatives on entry to hospital about their views on organ donation could be interpreted as a presumption that they were not expected to live. This would add to the anxiety experienced by many patients on admission to hospital.

Many patients who are potential donors are unconscious on admission and never regain consciousness. They are therefore unable to articulate their wishes. The doctor will need to approach relatives to inquire about the patient's and their own views on organ donation. If their response is positive, permission will then be sought for organs to be removed for transplant. Any alteration of this procedure, which would bypass the important counselling role of the medical and nursing professions, would be unlikely to be accepted, and could have a negative effect on the transplant programme. For these and other reasons, Sir Raymond Hoffenberg, past president of the Royal College of Physicians, and his committee which reported in 1987 came down against this solution.

Finally, it has never been our policy to impose uniform admissions precedures on all hospitals. This kind of detailed decision is essentially local. The amendment would create an unwelcome precedent. As the Hoffenberg Committee pointed out, there is no single panacea to boost the number of donor organs but the Government are taking active steps in a number of areas. For example, a major audit is under way for potential organ donors in hospitals to check how potential donors are being missed at present. This important point was made by the noble Lord, Lord Walton of Detchant. Almost £1 million has been spent on nationally funded publicity campaigns over the past three years. A video has been produced aimed at heightening awareness of clinical staff. There has also been a range of measures designed to encourage the public to carry donor cards. For example, the Driver and Vehicle Licensing Centre includes donor cards in correspondence when drivers' licences are renewed.

We welcome any promotional ideas that would help in this sphere of influence. I thank the noble Lord, Lord Ennals, for the generous comments he made about my honourable friend the Under-Secretary of State, Mr. Freeman. It is all designed to achieve the objective which I know is behind the amendment. I believe that these moves show that we take the problem very seriously. We should allow the measures already taken to run their course before considering any precipitate legislative education.

The matter is not as simple as answering questions such as "What is your name and age?"or "Where do you live?" The specific question about organ donation is in a different category. There is a sensitivity here to which we must respond. I hope that in the light of that reply the noble Lord will feel able to withdraw the amendment.

Lord Ennals

I am grateful to the noble Baroness for her sympathetic reply. It was not sympathetic to the amendment: I understand that. However, I hope that she will consider it again. I am not at all certain that the report of Sir Raymond Hoffenberg's committee applied itself to this proposal. I have no intention of pressing the amendment at this stage. I wish to consider the matter further.

Most patients, when admitted to hospital are not in extremis. Most of them are not likely to be in comas. The majority of patients admitted to hospital are not necessarily desperately ill at that stage. If patients are desperately ill when they arrive, such questioning may be inappropriate. It is designed in order to build up a data base. Let us say that I go into hospital because I have broken my ankle. All right, I shall not need an organ transplant; however, it is one way of putting on to the data base whether a particular person—myself in this case—is prepared to be an organ donor. It is a matter of storing the information so that it is available to doctors who will thus be spared the need to go scurrying around, as the noble Lords, Lord Walton and Lord Winstanley, said, on an embarrassing, difficult and sensitive task when someone is extremely ill.

It is better to collect the information when we can, when patients are not necessarily extremely ill and when we are asking questions on other matters. Perhaps the Minister will reconsider the amendment. I beg leave to withdraw it at this stage.

Amendment, by leave, withdrawn.

Lord Ennals moved Amendment No. 105B: Page 20, line 47, at end insert: ("(6) The system of joint finance shall be protected and extended at the level of 3 per cent. above the prevailing level of inflation").

The noble Lord said: This is a probing amendment. Inevitably I have a special interest since I was responsible for introducing joint funding as a means of promoting joint planning between the health authorities, the local authorities and the voluntary organisations when I was Secretary of State. The latest figure I have seen shows £120 million in health resources devoted to schemes involving joint agreements between RHAs, DHAs and voluntary organisations. In 1987-88, 42 per cent. of the resources were spent on the care of the elderly, 43 per cent. on the care of the handicapped, and only 5 per cen., on the care of the mentally ill and the disabled.

There is some anxiety about the future of projects that exist on the basis of joint finance. Over the past 12 years since it was introduced a great deal of good work has been done as a result of joint funding. I find it hard to see how in a contract system joint finance projects would be safeguarded and the services that they provide secured. I do not see how a contract could be used, for example, for a drop-in advice bureau which might be funded from joint funds. Who would work out who uses a drop-in service in which people constantly come and go?

Typically joint-funded projects help people with AIDS, alcoholism and drug-related problems as well as well-known schemes involving mentally handicapped people. Such schemes provide a very useful link between the statutory services and the voluntary services, and indeed between the health and social services. As I said, this is a probing amendment to secure some indication from the Minister as to what is to happen in the future regarding jointly funded schemes.

4 p.m.

The Parliamentary Under-Secretary of State, Department of Social Security (Lord Henley)

I hope that I can give the noble Lord the assurance that he asked for. Perhaps I may begin by giving him some figures. He mentioned his latest figure. My latest figure for joint finance resources for 1990-91 is £125 million.

As the noble Lord will be aware, in the White Paper Caring for People (in paragraphs 6.13 and 6.14) the Government announced their intention to re-assess the role of joint finance in the context of the wider changes set out in the White Paper. That work is now in hand. Whether that review leads to any change, and if so of what sort, has yet to be decided. To pre-empt the outcome would be inappropriate, and therefore I am pleased that the noble Lord does not intend to press the amendment and is merely seeking assurances from me. I can assure him that there will be no change to the present arrangements until such time as any new proposals are brought forward. Our allocation of £125 million to the scheme for the current financial year makes that abundantly clear.

Although joint finance has had a mixed record of achievement, we recognise that it has provided a real incentive for health and local authorities to work together. As a mechanism for shifting resources across administrative boundaries it has pump-primed many valuable and innovative joint social and health care developments. We believe that the original objectives of joint finance continue to be important.

Perhaps I can reassure the noble Lord further by quoting my honourable friend Mr. Freeman in Committee in another place. He said: Options include: giving the money to local authorities; giving it to the regional authorities; making no change in the procedure, which means allowing the DHAs to spend the money by making grants to local authorities; or something like the new clause 20—". That was proposed in another place at that time. That would involve a centrally organised pump-priming initiative aimed at developing innovative projects by local authorities, housing authorities, and so on. When we have reached a conclusion later this year, we shall bring proposals back to the House, including any necessary legislative changes".—[Official Report, Commons, 27/2/90; col. 1294.] I hope that with that assurance, the noble Lord will feel able to withdraw his amendment.

Lord Ennals

I am grateful to the noble Lord for his very helpful reply. I assume therefore that until there has been a review or until there is some new proposal the present system will continue unchanged. However, I wonder whether the Minister can make any comment as to the wording of the amendment: The system of joint finance shall be protected and extended at the level of 3 per cent. above the prevailing level of inflation". Joint-funded schemes are suffering as a result of the higher than expected level of inflation. Will the noble Lord say something about the terms of the amendment?

Lord Henley

I do not accept the terms of the amendment. As I said, funding for 1990-91 will be £125 million. I cannot make any promise that that will be increased by 3 per cent. I do not believe that the noble Lord would expect me to isolate any form of finance for special protection.

Lord Ennals

I did not expect the Minister to be able to give that kind of assurance. However, I thought it important to emphasise that joint funding would dwindle away if there was not some form of protection against inflation, and particularly higher than expected levels of inflation. I am grateful to him for his help and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

On Question, Whether Clause 19 shall stand part of the Bill?

Lord Ennals

I am sorry to leap to my feet again. I originally gave notice of my intention to oppose the Motion that the clause shall stand part of the Bill because of my wish to explore the new system of weighted capitation which the Government intend to introduce as a substitute for the RAWP formula, in which I was also involved when I was Secretary of State. That was designed to bring greater fairness to regional and district resource allocation in view of the gross inequalities in health care provision in different parts of the country, and particularly the extent to which there had been under-provision for the North-East, North-West and Trent regions. To a large extent the passage of time and the RAWP formula have helped to achieve that. It was never a popular measure. Those who received more than they might have expected without the RAWP formula did not seem to notice it—they were never satisifed—and those who received less were extremely angry. It is comparable to the poll tax except that my formula produced results.

That was the matter which I originally intended to raise. I am now deeply disturbed by a statement that was made yesterday by the junior Minister, Mr. Roger Freeman, in a speech in Huddersfield. I shall quote it in a moment. We know that this will be a difficult year for the National Health Service because of under-funding. Whenever I refer to under-funding, the noble Baroness inevitably says that there is no such thing as under-funding because there is a constant steady increase in resources from year to year. That is a reply which we have had on many occasions.

In a debate last night I had reason to point out the massive cost overrun on the new Westminster and Chelsea Hospital which is being built on the site of St. Stephen's Hospital in Fulham. The cost has increased in just over 12 months from £135 million to £226 million. In the debate, I pointed out that at the same time the number of beds was being reduced all over London and in other parts of the country. In central London alone the figure is almost 500.

Yesterday, according to a report in The Times: Mr. Roger Freeman, the junior health Minister, said that due to higher than expected levels of inflation, there would be no net development and some genuine reductions in services. 'This year, with inflationary pressures, we will have a year of no service developments in aggregate.' He acknowledged that some authorities in London would have to resort this year to bed reductions … His comments, during the visit to a hospital in Huddersfield, came hours before Parkside health authority, West London, agreed to close St. Mary's Hospital for four weeks in the summer and two weeks at Christmas for non-urgent admissions. In addition, authority members voted last night to stop routine outpatient referrals to St. Mary's and strictly control elective admissions by giving consultants monthly targets. The result will be a 10 per cent. reduction in the number of patients: 2,500 fewer cases. A spokesman for the district emphasised that managers had concentrated on trying to save money on restricting caseloads rather than by cutting bed numbers". However, it was accepted that there would be a recurrent reduction of 170 beds at St. Mary's Hospital.

What is going on? We have before us a Bill which, in my considered view and that of many others, could cause chaos in the National Health Service with the speed at which it is proposed to introduce the internal market, the proposed self-governing NHS trusts and the new budget-holding GP practices.

If, at the same time, we are to be faced with cuts in the National Health Service—accepted for the first time by Ministers in a statement-last night—we are heading for trouble. I want to know whether that statement was made by the Minister in Huddersfield yesterday. If so, why was it not made by the Secretary of State in another place and repeated here? It is wrong that information as to what will happen in the health service this year and the likely effects of the higher than expected inflation rate should be issued in a statement up in Huddersfield. This is a matter of national importance. I want to know, if the statement was made, whether it was correctly reported in The Times. If it was not made, or if it was incorrectly reported, we must ask The Times to correct the facts. I want to know whether that statement was made. If that is the situation, that is a good reason why I shall oppose the clause—as a protest against the way in which the Government are acting and are handling both Houses of Parliament.

Viscount Massereene and Ferrard

Is the noble Lord aware that, as the number of organ transplants increases, so will the cost? I do not know anything about heart transplants, but I understand that such a transplant can cost up to £4,000 or £5,000. If the cost of heart transplants is added on to the cost of other organ transplants, the health service will soon run out of cash and it will be by far the most expensive organisation in the country, far more expensive than education. You cannot go on and on increasing the number of transplants. How do you choose who is to have a heart transplant if there are, for example, six people all wanting such transplants? How do you choose the first person if money is getting scarce? Perhaps I have not expressed my point very well, but money does not just fall from heaven. It might appear to do so in this country, but it does not. It must be earned.

Lord McColl of Dulwich

Does the noble Lord, Lord Ennals, not understand that the reduction in bed numbers that he now sees is simply part of the reduction in bed numbers which has occurred since 1948? There has been a steady decline, irrespective of which government has been in office. If you look at a graph, you can see that it is a straight line decline. The noble Lord cannot persist in saying that the Government are closing more beds than any other previous government. It is a trend.

The noble Lord is entitled to say that he considers that the number of beds has reached the right level and that it should not decline any further. He may well be right in saying that, but he cannot go on thumping the Dispatch Box and saying that the Government are closing more beds than any other government, because the number of beds has declined steadily. The reason for that is that we are treating more and more patients on an out-patient basis because it is better to be at home than in hospital. Your bed at home is more comfortable and the food and company are better. The noble Lord must acknowledge that fact.

Baroness Phillips

Before my noble friend replies, I should like to take issue with the noble Lord, Lord McColl of Dulwich. Surely it is true that the number of beds is declining. People leave hospital having had serious operations. I am interested to learn that it is better at home. It is only better at home if there is a good back-up service. I find distressing the speed at which some people are dispatched from hospital these days. The number of beds is declining, but, as a layman and a person who has been a patient, I suggest that that is for the wrong reasons.

Lord McColl of Dulwich

Perhaps I may answer the noble Baroness. In 1948 there was a marvellous surgeon called Rex Lawrie, together with a spendid paediatrician called Ronnie MacKeith. They decided in 1948, before there was all this hullabaloo about costs and beds, that the best way to treat children, having operated on them, was to send them home the same day. That was part of the policy. It had nothing to do with saving money or beds because no one knew how much money or how many beds were there. It was a distinct, definite policy. It is most certainly better simply to keep children in for the day and then send them home rather than to keep them in for the night.

I agree entirely with the noble Baroness that some patients should not be sent home after major surgery if the facilities at home are inadequate. If a lady has 10 children in a small house in Bermondsey, we keep her in much longer than normal until she is fighting fit, if necessary for a week or so. We therefore tailor the length of stay to meet the needs of the patient. If you tell patients, "You can go home the same day. You need only be in for an hour or two for the operation", most patients will be delighted. However, I agree entirely that the facilities at home must be adequate.

4.15 p.m.

Lord Young of Dartington

I agree with almost everything that my noble friend Lady Phillips said. However, does she agree that provided that the support services are good, it is better for people to leave hospital as soon as they decently can—partly because hospitals can be dangerous places? The emphasis should not be so much by way of criticism of the hospitals, but of the support services linked to the hospitals. All those concerned with the health service know that those services are by no means adequate. People are sent out before they should be, but you cannot lay the blame entirely at the door of the hospitals.

Baroness Masham of Ilton

I read the article in The Times today, but I was not sure which hospital was involved. It is said that it was St. Mary's. Is that St. Mary's, Paddington, or another St. Mary's? I was anxious because the article stated that the hospital would stop taking patients from other districts. The situation is a serious one if it is St. Mary's, Paddington, which offers certain specialities for which other hospitals do not cater. The Minister should answer this question so that the Committee is aware of the situation. The issue of cross-boundary flow for specialities is of the utmost importance for everyone who has a serious problem which is not catered for by district hospitals.

Lord Ennals

Perhaps I may say a few words before the Minister replies. Obviously, I did not make myself clear and was misunderstood by the noble Lord, Lord McColl of Dulwich, and my noble friend Lord Young of Dartington. There is no fixed level of beds. I was simply quoting one or two examples. I raised the issue at this stage because the junior health Minister, Mr. Roger Freeman, is quoted as saying that there will be no net development and some qenuine reduction in services. I am concerned about the reduction in services. It is a serious statement made by a Minister to the effect that, during this year, we shall see a reduction in services at precisely the time when many of those same people will be involved in trying to organise themselves to cope with the consequences of the Bill. It is not just an example of one hospital. I do not have a fixed idea of what should be the bed level. As I understand it, unless I am told that the information has been incorrectly stated—I gave the Minister notice some hours ago that I would raise the issue—a Minister has said that there will be a reduction of services in the National Health Service. That is the point.

Lord McColl of Dulwich

Perhaps I may answer the noble Lord, Lord Ennals. When he introduced the RAWP formula, it resulted in a reduction of services in some districts, but it resulted in an increase in services in those districts to which the money was redistributed. The noble Lord's RAWP formula would have been a good thing if there had been sustained growth in the economy. Unfortunately, there was not sustained growth in the economy, so RAWP became an appalling hardship in many areas. That was the mistake, but it was not the noble Lord's mistake. There is no doubt that his RAWP formula resulted in a reduction of services in some districts.

Lord Henley

Quite obviously the noble Lord will not expect me to accept that there is under-funding throughout the health services. I said earlier at this Committee stage—and I shall repeat it, because I think these figures bear repetition—that there has been real terms growth in National Health Service expenditure between 1978-79 and 1990-91 of 45 per cent. Spending per capita in England will be £486 in 1991. It was £345 on the same price base in 1978-79. That is a real terms increase of 41 percent.

The noble Lord mentioned the article, which I think he has rather blown up, on page 3 of The Times. As he said, my honourable friend Mr. Freeman spoke while on a visit to the Royal Infirmary, Huddersfield. That hospital is taking part in a resource management initiative. In response to questions from journalists, my honourable friend accepted that some districts need to make temporary reductions in service developments in order to balance activity levels with the resources available. But my honourable friend said that some districts had overcommitted themselves and there were unlikely to be major service developments in those districts. He pointed out that there continues to be activity growth in the National Health Service and many districts are able to pursue their service developments.

The reforms about which we are talking in this Bill make those sort of problems less likely. It is precisely because of cases such as the one mentioned by the noble Baroness, Lady Masham, where hospitals find it difficult to treat patients from beyond their boundaries, that we are introducing the National Health Service contract system.

Again, I fail to see why the noble Lord, and indeed all noble Lords on the other side, object to these reforms. They will resolve those problems.

Lord Peston

Perhaps I may interrupt the noble Lord since we are on an important matter. In fact we are discussing two important matters on the economic side. He quoted data—and such information usually emanates from the Government—about increasing real expenditure on the National Health Service. Having put that data forward, the Government always have difficulty in accounting for all the crises that the National Health Service seems to be going through at the same time. That has always been a paradox.

When considering the real increases, the noble Lord might also consider addressing the point raised by his noble friend Lord Massereene and Ferrard, who put the essential point—although he only referred to organ transplants—that the sort of things that the National Health Service does become relatively more expensive compared with the RPI in general. Therefore, for that precise reason most of us do not accept the calculation that the Government give because it is not indexed properly according to a proper price index.

The other point that the noble Lord ought to bear in mind, which relates to the claims for reform, is that in so far as these reforms are all about cash limited budgets of all sorts and at all levels (which is precisely the point to which my noble friend Lord Ennals referred and which concerns the statement of his honourable friend in another place), the difficulties that arise when the inflation rate goes well above the Government forecasts hit those cash limited budgets very strongly and give rise to precisely those problems mentioned by my noble friend.

Far from these reforms solving problems for the National Health Service, they produce them for the National Health Service. They solve problems for the Treasury. The noble Lord should not be confused between solving problems for the Treasury, which likes cash limits, and solving problems for the National Health Service, which needs real resources.

Lord Henley

The noble Lord implies that there was no real terms increase.

Lord Peston

I certainly did not say that. I simply say that 40 per cent. definitely does not measure what used to be called the volume terms real resources available to the National Health Service. Far from it.

Lord Henley

The noble Lord seemed to be implying that there was no increase. He seemed to imply that the inflation figures for the health service should be measured by a different index. But we have increased the number of patients who have been treated. I do not have the figures before me; but if he would care to have those figures, I shall certainly make them available.

There has been a real growth in the activity of the health service and in spending on the health service. However, the health authorities need to relate the level of resources available to service activity. As I just said, the health service is receiving more resources than ever before in the current financial year and more patients are being treated. Districts need to be realistic and to relate their service activity to the resources available.

Ministers have never denied that individual health authorities encounter in-year financial problems—often through mismanagement. Again, I fail to understand why the noble Lord opposes these changes which should make it so much easier, with money following the patients, to end those end-of-year crises which will exist whatever level of resources is put into the National Health Service.

These reforms will enable the health service to provide an even better standard of care for patients and make better use of resources through greater efficiency and effectiveness. I hope that the noble Lord does not intend to press his Motion that Clause 19 do not stand part of the Bill.

Lord Carr of Hadley

Before the noble Lord sits down I wonder whether he could promise us a little more information. If I understood him aright, he said that the report in The Times was at least an incomplete report of what his honourable friend Mr. Roger Freeman said, apparently in answer to a question—it was not a prepared speech. If I understood rightly, that incompleteness was very important. Certainly when I read the report in The Times today it seemed to imply something much more serious than evidently it is. Since it was an off-the-cuff reply, no doubt we cannot have the text; but if we could have an authoritative statement summarising what Mr. Freeman in fact said, it might give a little perspective to the matter.

As I read the article this morning it was alarming. However, I do not think it is as alarming as all that because it was evidently not a prepared statement but an answer to a question which itself may be incomplete. It may be accurate in so far as it goes, but it does not put what Mr. Freeman said in the context in which he said it and was surrounded by qualifications which he evidently made.

Lord Ennals

I am grateful to the noble Lord for his confirmation that he was concerned—though not necessarily as concerned as I was—when he read the report in The Times. I raised this matter in order to obtain an indication of whether or not what was reported was actually said by the Minister. He made other remarks as well of course, but, as I understand it from the noble Lord, he said that: due to higher than expected levels of inflation, there would be no net development and some genuine reduction in services. 'This year, with inflationary pressures, we will have a year of no service development in aggregate'. Of course he said more but, if that is what he said, I shall not withdraw my Motion and I shall proceed to a Vote.

Lord Henley

Perhaps I may give my noble friend some reassurance. I was trying to say that the noble Lord had somewhat exaggerated the tone of the article. I have not seen the exact words used by my honourable friend and I shall certainly write to my noble friend when I have done so. My understanding was that he was referring only to individual districts and not to under-funding in the National Health Service as a whole (to which the noble Lord refers).

I repeat that Ministers have never denied that individual health authorities encounter in-year financial problems. But as regards funding for the whole National Health Service, we can continue to rely on our record, which is seen as steady growth over the past 10 years.

Baroness Masham of Ilton

Before the noble Lord, Lord Ennals, decides what he will do, perhaps I may ask what the Government will do if districts stop taking patients from districts other than their own.

That question must be answered. Districts are now just doing what they want to do.

Lord Henley

That is the very point of the reforms. The money will follow the patients. Districts will have an incentive to take those patients.

Baroness Masham of Ilton

But they are not doing it.

Lord Henley

That is because the reforms have not yet been enacted. They will be enacted in time and districts will have the incentive to take those patients.

Lord Carr of Hadley

I am sorry to have to intervene again. However, we want to know whether what Mr. Freeman said yesterday means something new or not. We know—and I fully support the belief—that these reforms will assist in regard to the urgent need which the noble Baroness emphasises. Did or did not the words used yesterday imply that there would be some reduction of present movement of that kind? If so it is serious. I think that they probably did not, but neither of us know it.

I think that it is important that we should know; otherwise, alarm will be spread far and wide in increasing waves. There is probably no basis at all for the alarm, but it needs to be taken hold of quickly before it is allowed to spread and puts false ideas into people's minds.

Lord Henley

My understanding, and I repeat it, is that my honourable friend was referring only to individual districts and not to the health service as a whole.

4.29 p.m.

On Question, Whether Clause 19 shall stand part of the Bill?

Their Lordships divided: Contents, 117; Not-Contents, 84.

DIVISION NO. 1
CONTENTS
Abinger, L.	Cawley, L.
Aldington, L.	Constantine of Stanmore, L.
Alexander of Tunis, E.	Cottesloe, L.
Ampthill, L.	Cox, B.
Arran, E.	Crook, L.
Auckland, L.	Cross, V.
Balfour, E.	Cullen of Ashbourne, L.
Barber, L.	Davidson, V. [Teller.]
Bauer, L.	Denham, L. [Teller.]
Belhaven and Stenton, L.	Downshire, M.
Belstead, L.	Eden of Winton, L.
Bessborough, E.	Elles, B.
Birdwood, L.	Elliot of Harwood, B.
Blatch, B.	Elliott of Morpeth, L.
Blyth, L.	Erne, E.
Boyd-Carpenter, L.	Erroll, E.
Brabazon of Tara, L.	Ferrers, E.
Brougham and Vaux, L.	Fraser of Carmyllie, L.
Butterworth, L.	Fraser of Kilmorack, L.
Caithness, E.	Gardner of Parkes, B.
Campbell of Alloway, L.	Hailsham of Saint
Campbell of Croy, L.	Marylebone, L.
Carnegy of Lour, B.	Hankey, L.
Carnock, L.	Havers, L.
Carr of Hadley, L.	Henley, L.

Hesketh, L.	Pym, L.
Hives, L.	Reay, L.
Holderness, L.	Renton, L.
Hooper, B.	Rochdale, V.
Howe, E.	Rodney, L.
Hylton-Foster, B.	St. Davids, V.
Jenkin of Roding, L.	Saltoun of Abernethy, Ly.
Joseph, L	Sanderson of Bowden, L.
Kinnaird, L.	Sandys, L.
Lauderdale, E.	Seebohm, L.
Lindsay, Is.	Selkirk, E.
Long, V.	Sempill, Ly.
Lucas of Chilworth, L.	Skelmersdale, L.
Lyell, L.	Smith, L.
McColl of Dulwich, L.	Somers, L.
Macleod of Borve, B.	Strange, B.
Malmesbury, E.	Strathcarron, L.
Mancroft, L.	Strathmore and Kinghorne, E.
Massereene and Ferrard, V.
Merrivale, L.	Sudeley, L.
Mersey, V.	Swansea, L.
Middleton, L	Swinton, E.
Monson, L.	Terrington, L.
Mottistone, L.	Teviot, L.
Mountgarret, V.	Trefgarne, L.
Murton of Lindisfarne, L.	Trumpington, B.
Nelson of Stafford, L.	Ullswater, V.
Norfolk, D.	Vaux of Harrowden, L.
Nugent of Guildford, L.	Walton of Detchant, L.
Orkney, E.	Whitelaw, V.
Orr-Ewing, L.	Winterbottom, L.
Pender, L.	Wyatt of Weeford, L.
Platt of Writtle, B.	Yarborough, E.
Porritt, L	Young, B.
Prior, L.

NOT-CONTENTS
Addington, L.	Kilmarnock, L.
Airedale, L.	Leatherland, L.
Ardwick, L.	Listowel, E.
Aylestone, L.	Llewelyn-Davies of Hastoe, B.
Birk, B.
Blackstone, B.	Lloyd of Kilgerran, L.
Blease, L.	Lockwood, B.
Bonham-Carter, L.	Longford, E.
Bottomley, L.	Lovell-Davis, L.
Bruce of Donington, L.	Mcintosh of Haringey, L.
Campbell of Eskan, L.	McNair, L.
Carmichael of Kelvingrove, L.	Meston, L.
	Mishcon, L.
Carter, L.	Nicol, B.
Cledwyn of Penrhos, L.	Ogmore, L.
David, B.	Oram, L.
Dean of Beswick, L.	Perry of Walton, L.
Diamond, L.	Peston, L.
Dormand of Easington, L.	Phillips, B.
Ennals, L.	Pitt of Hampstead, L.
Ewart-Biggs, B.	Ponsonby of Shulbrede, L. [Teller.]
Ezra, L.
Falkender, B.	Prys-Davies, L.
Falkland, V.	Rea, L.
Fisher of Rednal, B.	Ritchie of Dundee, L.
Foot, L.	Robson of Kiddington, B.
Gallacher, L.	Rochester, L.
Galpern, L.	Sainsbury, L.
Gladwyn, L.	Seear, B.
Graham of Edmonton, L. [Teller.]	Sefton of Garston, L.
	Serota, B.
Hampton, L.	Shackleton, L.
Hanworth, V.	Stallard, L.
Hatch of Lusby, L.	Stedman, B.
Hirshfield, L.	Stoddart of Swindon, L.
Houghton of Sowerby, L.	Strabolgi, L.
Hughes, L.	Taylor of Blackburn, L.
Jacques, L.	Underhill, L.
Jay, L.	Wallace of Coslany, L.
Jeger, B.	White, B.
Jenkins of Putney, L.	Williams of Elvel, L.
John-Mackie, L.	Willis, L.
Kearton, L.	Winstanley, L.
Kennet, L.	Young of Dartington, L.

Resolved in the affirmative, and Clause 19 agreed to accordingly.

4.38 p.m.

Clause 20 [Extension of functions etc. of Audit Commission to cover the health service]:

Lord Kilmarnock moved Amendment No. 106: Page 21, line 11, at end insert: ("(1A) Section 27 of the Local Government and Finance Act 1982 shall continue to apply to health service bodies.").

The noble Lord said: I propose to speak also to Amendment No. 108 because the amendments hang together.

Amendment No. 106 attaches to Clause 20, which extends the functions of the Audit Commision to cover the health service. It is a clause which we unhesitatingly support in principle. It was one of the better ideas in the Government's reform package to extend the writ of this respected body to include the NHS. Under Clause 20, Part III of the Local Government Finance Act 1982 is extended to give the commission similar functions in relation to health authorities and other bodies established under the Bill as it already has for local government. In these amendments I am concerned with Sections 26 and 27 of the Local Government Finance Act 1982.

Section 26 of that Act is fully applicable to the present Bill, with the effect that the commission may make recommendations for improving the economy, efficiency and effectiveness and the financial and other management of its new recruit in just the same way as it does for local government. Under this section it can undertake and publish studies relating to the NHS in exactly the same way as it publishes Section 26 value-for-money studies, as they are known, on such local government services as housing, highway, social services, and so forth. Since 1984 the commission has published more than 30 such studies. I have a list of them and they can be found in the Library. I look forward to some interesting and no doubt equally valuable studies in the health service management field. So far, so good; we applaud that.

Now I come to the catch in the Bill whereby the application of the next section of the Local Government Finance Act, Section 27, is severely restricted in relation to the health service. In its original form the section enables the commission to undertake or promote studies on the impact of statutory provisions or any directions or guidance given by a Minister of the Crown on the economy, efficiency, effectiveness and financial management of local government. Thus it is somewhat wider than Section 26; it bites less directly on local administration and more directly on the effect of central government policy on local administration.

The section has given rise to a different set of Section 27 studies also consisting of between 30 and 40 excellent publications since 1984. Again, they are listed in the leaflet. They have included such useful studies in the local government field as those on capital expenditure controls, making a reality of community care, preparing for compulsory competition, personal social services for people with a mental handicap, and so forth. They all focus on the impact of central government policy on those important fields. One would have thought that nothing could be more useful at a time of rapid change and evolution in the NHS. Yet virtually all the teeth of that section are extracted by the present Bill.

That is made clear, first, in the Explanatory and Financial Memorandum to the Bill. It states: the Commission may take into account the implementation by NHS bodies of statutes, directions and guidance in carrying out its value for money studies, but shall not question the merits of the policy objectives of the Secretary of State".

On page 76 of the Bill, at Schedule 4 paragraph 19(1), the phrase: other than health service bodies",

is inserted into the original Act thus excluding the NHS from this type of study.

At the Report stage in another place the Government accepted an amendment originally tabled by Mr. Andrew Mitchell. It appears in lines 11 to 22 on page 76 of the Bill. It is a weak alleviation or relaxation of the ban on Section 27 studies. In fact, it goes out of its way to specify that: the power conferred by this subsection shall not be construed as entitling the Commission to question the policy objectives of the Secretary of State".

The phrase is the same as that in the Explanatory and Financial Memorandum.

The object of the amendments taken together is to restore the full force of Section 27 to the commission's responsibilities vis-a-vis the National Health Service. I apologise for having dealt with the matter at length, but it was a necessary preliminary to pointing out that in the schedule to the Bill the Secretary of State is deliberately depriving himself of the advice of a valuable body of expertise which is probably about as objective as you can get in the whole field of public policy. Would it not be excellent to have the commission's view after a suitable time on, for example, the operation of the new capital rules governing hospitals or of the greater freedom, particularly of NHS trust hospitals, to raise money outside the public sector? Such a study or studies might confirm to the Government that they are on the right lines and confound their critics. Would it not be useful to hear the Audit Commission on the problems of nurse recruitment? That is becoming a central challenge to the NHS and the commission may give good advice. Would it not be valuable to hear the Audit Commission on the results and advisability of extending trust status to units other than hospitals which we understand is in the Government's mind in some cases? No doubt other Members of the Committee will be able to think of equally important topics for investigation.

Sadly, the Secretary of State appears to have decided to deprive himself of such studies. However, he deprives not only himself, for Parliament will also be deprived because Section 27(4) of the Local Government Finance Act 1982 requires the Comptroller and Auditor General to lay before the House of Commons a report of any matters which, in his opinion, arise out of any studies of the Commission under this section and ought to be drawn to the attention of that House".

He cannot do that if such studies are not made. This Chamber is not directly involved in that procedure, but it brings such matters into the parliamentary arena and thus into the public domain.

However, if that appears to be a terrible threat to the Government, we have only to move on to Section 27(5) of the Local Government Finance Act to discover that the Secretary of State has a strong safeguard. The Commission must consult not only the Comptroller and Auditor General but also, any Minister of the Crown who appears to be concerned

before undertaking any study under this section. In other words, the Secretary of State for Health would have a veto. He would not have to authorise any study that he did not want or he considered to be superfluous. So, what is he scared of?

Perhaps I would have made less of an issue of the subject if the Government had shown themselves to be more favourably disposed to other amendments designed to provide the NHS executive with the type of advice that would be considered essential in running any other business of a comparable size and complexity. So far the Government have blithely rejected—at any rate on a statutory basis—some of the sensible proposals that have been made towards that end. Here nothing regulatory is proposed; simply that the Secretary of State should, if he feels so inclined, subject his policies to objective scrutiny by a body which is appointed by the Government.

In view of some of the major lacunae in the Bill, I and my noble friends feel strongly that the watchdog role of the Audit Commission should not be weakened and that the length of the watchdog's chain should be exactly the same for the National Health Service as it is for local government. I beg to move.

4.45 p.m.

Baroness Cox

I support the amendments. I shall not speak at length because the arguments have been put so comprehensively by the noble Lord, Lord Kilmarnock. The situation as now reflected in the Bill is anomalous. It appears to be inconsistent and I hope that that is an oversight. I am particularly concerned by my perception that the Audit Commission's present remit will enable it to study the effects of the new legislation on community care because that will become the responsibility of local authorities. But perhaps by default there is no comparable provision for the Audit Commission to study the effects of the new legislation on the National Health Service.

I hope that the anomaly can be rectified. Like the noble Lord, Lord Kilmarnock, I have great confidence in and respect for the quality, value and impartiality of the work of the Audit Commission. I hope that its remit will be extended along the lines suggested in the amendments. Therefore, I hope that my noble friend will be able to clarify the situation and perhaps even accept the amendments.

Lord Monson

I intervene merely to point out that the amendment is incorrectly drafted in that it refers to the "Local Government and Finance Act 1982". There is no such Act. The word "and" is redundant.

Lord Peston

I accept the last remark about which I was as ignorant as anyone else. Four amendments are grouped together, but that standing in my name is more limited than those standing in the names of the noble Lord, Lord Kilmarnock, and the noble Baroness, Lady Cox. Their amendments are better than mine; but they are all good amendments which the Government should be looking eagerly to accept rather than to damage.

The noble Baroness referred to the Government's position as being anomalous—and she is right. However, it is worse than that because it wilfully embraces inefficiency. Whatever else underlies the Bill, there is certainly a desire for efficiency. In pressing the amendments on the Government, we are following the logic of introducing the Audit Commission into the area. We strongly support that introduction, but we are puzzled by the Government's fear of the commission. If the Government truly believe that this represents the great next new stage in the development of the NHS—and I do not—they have nothing to fear.

I now turn my attention to my particular anxiety. Lines 20 to 22 state that the commission cannot question the merits of the policy objectives of the Secretary of State. One possibility is that that is a completely trivial statement. Essentially, if we say that the Secretary of State is fully committed to the National Health Service—which he says he is and which the Government say they are—and to the service being freely available to patients and publicly funded, and if those are the policy objectives of the Secretary of State of course the commission should not question them and would not dream of questioning them. If beyond that the Secretary of State says, "I wish to do that as efficiently as possible", that again makes the sentences completely trivial or vacuous because that is precisely what the Audit Commission would be doing.

We had all sorts of enjoyable discussions on other Bills last year, on bits in legislation that had no role whatsoever. It seems to me that those particular lines in this Bill have no role whatsoever. That is one objection to them.

The role of the Audit Commission is to scrutinise the way in which resources are being used, and particularly to ask if they are being used properly and if they serve the ends that they are supposed to serve. In other words: the Government wish to do this; is; this the better way of doing it? It is to expose waste and all that sort of thing. Therefore the Government should simply welcome "he Audit Commission to do its job, which is the spirit of the amendment, with no "ifs", "buts", or long paragraphs.

I will not bandy words on whether this wording is good. This is not a party matter at all; it is a matter which concerns government, and it seems to me that the Government simply ought to get up and say, "We welcome wholeheartedly the Audit Commission involving itself in all these matters. The Secretary of State, far from worrying about whether it will get in his way, particularly wants it to intervene and do this job".

I think the case is overwhelming here, and the best way that the Government can deal with it is, as the noble Baroness said, just to say, "yes".

Lord Henley

I take it that the noble Lord, Lord Peston, was speaking purely to the two amendments, that of Lord Kilmarnock and his own, Amendments Nos. 108 and 108YZA. Alternatively, was he speaking also to an amendment that comes later, Amendment No. 107D, which I understand has been grouped with these amendments? He did not seem to address it.

Lord Peston

The answer is yes. I must apologise to the noble Lord. The lettering of the amendments has now become so complex that I am having great difficulty in keeping up with which is which. One day I hope that we shall have a debate on the lettering of amendments. I believe that I was speaking to all the amendments, but I was concentrating on what I saw as the central issue because I thought it would help your Lordships to concentrate on that and on the amendments of the noble Lord, Lord Kilmarnock, and the noble Baroness, Lady Cox. They seem to get to the heart of the matter, which is what I wanted to do.

Lord Henley

I certainly agree with the noble Lord on the lettering of amendments. I should like to join him in a debate on that, which might produce a great deal of consensus.

The reason why I intervened was because the noble Lord seemed not to have addressed himself to Amendment No. 107D. He appeared to be concentrating largely on the amendment of the noble Lord, Lord Kilmarnock, and that of my noble friend, as well as on his own Amendment No. 108YZA. I too shall concentrate on those.

Perhaps I may start by saying that I do not accept that the position is anomalous. Local government and the health service are very different, with different management and different accountability. We have taken the view from the outset that the provisions of Section 27 of the Local Government Finance Act—and I thank the noble Lord, Lord Monson, for correcting the Committee and reminding us that it was the Local Government Finance Act and not the "Local Government and Finance Act"—should not apply to the audit of health service bodies because Section 26 of the 1982 Act gives the audit Commission all the powers it needs to undertake value-for-money work in the National Health Service and because of the significant differences in accountability between local authorities and health authorities.

The Committee will be aware that local authorities are autonomous bodies, accountable to their electorate and not to the Government. The commission's powers under Section 27 do not, therefore, duplicate a departmental function. In contrast, health authorities are managed by the NHS Management Executive, which has the responsibility for managing the impact of health policy. The executive is responsible to the policy board, chaired by the Secretary of State, and the latter is responsible to Parliament for policy and management of the NHS. The chain of command leading to public accountability is therefore complete in itself.

We do not wish to cut across this chain of accountability nor to create conflict and confusion between the role of the Audit Commission, as the statutory auditor of local NHS bodies, and the National Audit Office, as the auditor of the Department of Health. Indeed,to do as suggested by these amendments would allow the commission to comment upon the impact of policy in a way previously considered by Parliament to be inappropriate to the National Audit Office, which is precluded from commenting on the merits of the policy objectives of the Secretary of State.

During the proceedings in another place, to which the noble Lord, Lord Kilmarnock, referred, honourable Members raised the question of extending Section 27 powers to the commission in respect of the audit of the NHS. This mirrors the proposal now being put forward by the noble Lord. The Government concluded that, in the light of the arguments put forward, the commission should be entitled to take into account the implementation by a health service body of any particular statutory provision or directions or guidance given by the Secretary of State when undertaking value-for-money studies, but not to question the merits of the underlying policy objectives. This took the form of an amendment to Section 26 of the Act introduced by paragraph 19(2) of Schedule 4 to the Bill. This is consistent with the role of the National Audit Office and provides ample scope for the commission to carry out its role within the framework of the accountability of Ministers to Parliament.

It is not the Audit Commission's job to criticise national policy objectives. That is a role for Parliament. But we do not propose to stifle expression—the National Audit Office is covered in the National Audit Office Act 1983 by a provision similar to the one which the noble Lord, Lord Peston, seeks to delete. The National Audit Office works very effectively within that framework, not least in the NHS, and does not prevent any audit findings from being a valuable tool in policy development. But we do make clear that the commission's clear focus is on value for money and the three "Es" of economy, efficiency and effectiveness in hard practical terms which will bear immediate fruit on the ground, rather than on more abstract questions of policy objectives.

Lord Peston

Perhaps I may interrupt the noble Lord because I think he is misunderstanding me and his noble friend Lady Cox. We are not seeking to extend the powers of the Audit Commission. We are questioning whether the words mean anything. I do not think they do, and I think that the noble Lord, Lord Henley, is saying that they do not add anything new. Therefore, since the words do not appear to add anything new, they are otiose and should not be in the Bill. One is asking for them not to be in the Bill because one has a suspicion that maybe they mean something, but the noble Lord has just confirmed that they do not mean anything at all.

That is why they ought to be taken out—which is a remark often made by Members on his side about many aspects of many Bills.

Lord Henley

I think the noble Lord misunderstood me, unless there is misunderstanding on both sides, which is always possible. I was trying to say that the National Audit Office is covered in the 1983 Act by a similar provision to the one which the noble Lord is seeking to delete.

Lord Peston

Perhaps I should make it clear that I am not suggesting that the Audit Commission should query the objectives of the Government. It is for Members of your Lordships' House and those in another place to query the objectives of the Government. I am not suggesting that deleting this will enable the Audit Commission to query the objectives of the Government. I am simply saying that, since the Audit Commission would never in any circumstances involve itself in considering the objectives of the Government, the issue does not arise. In other words, what the Government are seeking to stop is not there to be stopped, because it does not happen.

The Audit Commission and auditing are concerned with efficiency and with how well the Government are achieving their objectives. Therefore one does not need to add these peculiar additional words to tell the commission not to do something which it is not within its remit to do. I am simply saying that, since the noble Lord has confirmed that the Government have no desire to limit it other than to doing what it should do, there is no point in having these words; the problem does not arise.

5 p.m.

Lord Henley

We shall look at the matter. I should stress that the provisions as drafted were agreed as satisfactory by all who raised them in another place and the wording was agreed by the Audit Commission, which will have to carry them forward. If the noble Lord feels that he would like me to have another look at the matter, I shall take it away. For the moment I would certainly prefer the noble Lord to withdraw the amendment.

Lord Boyd-Carpenter

I hope that my noble friend will have a further look at the matter. I have been listening to the debate with some care. I was a little surprised to find that the possible exclusion of Audit Commission surveillance from this large area of public expenditure seems to be contemplated. Can my noble friend say, before he goes on to reconsider the matter, whether as the Bill now stands the Audit Commission will still have its normal function, which as he rightly said a moment or two ago relates to efficiency? If as the Bill now stands there is a doubt about that, it surely seems sensible to put in something along the lines of the amendment.

If, on the other hand, he can assure the Committee that its normal function of reviewing efficiency in respect of this large expenditure is already provided for in the Bill, the argument for the amendment, except from the point of view of obtaining certainty, is diminished. I hope my noble friend will not feel that concern for proper supervision of this large area of public expenditure is confined only to those who have supported the amendment.

Lord Henley

As my noble friend knows, we are a listening government and we shall certainly have another look at this point. What I have been saying is that the Audit Commission will be able to undertake value for money studies but not to question the merits of the underlying objectives. If the wording agreed in the compromise from another place is not satisfactory—I should stress again that the Audit Commission was fully consulted before the present wording was arrived at—we will be prepared to take it away and have another look at it.

Lord Kilmarnock

I am grateful to noble Lords who have taken part in this short debate. I must apologise to the noble Lord, Lord Monson. He is perfectly correct. An "and" crept in where it should not be. It does not change the sense. I spend quite a lot of my own time correcting proofs and it is amazing what tremendous howlers can pass under one's nose without one noticing them. The noble Lord is perfectly correct.

The noble Baroness, Lady Cox, made an important point when she suggested that the Bill was anomalous. Before I move on perhaps I may ask the Minister to confirm that the writ of the Audit Commission will extend fully to the community care parts of the Bill though it is more restricted with regard to the National Health Service. That is the anomaly to which the noble Baroness referred. Possibly our understanding is incorrect, but that is my reading of the Bill. In so far as community care has passed under the aegis of local government, presumably the Local Government Finance Act 1982 will empower the Audit Commission to exercise its full functions in relation to the community care part of the Bill. Is that the position?

Lord Henley

That is correct. As I stressed at the beginning, local authorities and health authorities are different animals. Health authorities have their accountability to Parliament through management executives and the Secretary of State. Local authorities have to be viewed differently. There is different treatment.

Lord Kilmarnock

I take the noble Lord's point. Section 27 of the Local Government Finance Act concerns not so much the purely audit function of the Audit Commission but the studies which it is able to make on aspects of government policy. I tend to agree that the word "merits" is perhaps inappropriate in regard to questioning the merits of the policy objectives of the Secretary of State. As the noble Lord, Lord Peston, said, that is not the intention. But it seems to be rather cutting one's nose to spite one's face not to listen to a watchdog when it says, "Hey, Secretary of State, have you thought about this?" The Secretary of State might be inclined to say that it was an interesting suggestion. If Section 27 studies are not available for the National Health Service that situation cannot develop. That is the point I am trying to make.

I am grateful to the noble Lord, Lord Boyd-Carpenter, who stressed the importance of proper supervision of this absolutely enormous undertaking. Anything of this size in the commercial sphere would have an enormous number of safeguards and supervisory mechanisms. Those are lacking here. The Minister has taken on board the concern expressed from all sides of the Committee, from his noble friend Lady Cox, from the noble Lord, Lord Boyd-Carpenter, and from noble Lords on the Opposition Benches, and has said that he will look at the matter.

He has also reaffirmed that he is a member of a listening government, which is very good to hear. For those reasons, I do not intend to press the amendment at this stage. However, I give the noble Lord notice that after consultation with my noble friends and if the Government do not come forward with something to satisfy us before the next stage of the Bill—I very much hope they will—I may have to bring the matter forward at Report stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 20 agreed to.

Lord Young of Dartington moved Amendment No. 107: After Clause 20, insert the following new clause: {"Her Majesty's Inspectorate of Health

There shall be established a body known as Her Majesty's Inspectorate of Health whose duty it shall be to monitor and report annually to Parliament on the quality of the health and community care services provided for patients and consumers in the statutory, voluntary and private sectors.").

The noble Lord said: The amendment proposes the appointment of Her Majesty's Inspectorate of Health, a new body. It concerns an issue which is of as much importance to consumers as it is to professionals in the health service. I refer to the issue of patient care. In this respect at any rate we are together. I am glad that the amendment has the support of several other noble Lords and also of several consumer bodies concerned with health. They include the College of Health, the National Consumer Council, the Association of Community Health Councils for England and Wales and the Patients Association.

I have a special interest in a way as I am the president of the Consumers' Association and the chairman of the College of Health and was the founding chairman of the National Consumer Council. I should mention the support that has also been expressed in forthright terms by the Royal College of Nursing. I greatly hope that, as the amendment is relatively uncontroversial and non-political, it will be accepted by the Government. In a few minutes we shall know.

We have just heard that the Government are a listening government, a statement made with justifiable pride, particularly if it is true. I hope that the Government or at least important parts of the Government are listening to what is said and that if they find it persuasive, as I hope they will, they will be able to accept the amendment in a few minutes' time.

I propose that the inspectorate bodies should be reorganised and strengthened—I am thinking of the Health Advisory Service, the Social Services Inspectorate, the Audit Commission and the Clinical Standards Advisory Board—because the consumers of Britain are worried (some of them are very worried) that the introduction of an internal market in the health service will lead or could lead to a fall in standards. There will be far more pressure to reduce costs. A legitimate fear is that in some cases quality of care will consequentially be reduced.

In this new market, consumers will not be protected against falling quality by competition; most of them will continue to attend the same GP and hospitals and use the same local services. They will not switch about or even necessarily be allowed to switch about in the search of higher quality. In some respects local monopolies may be entrenched by the Bill. That is where the district hospital, most obviously in a rural area, becomes a self-governing trust. In some ways it could be a law unto itself since the local district health authority and local patients will have nowhere else to go.

In those circumstances, an independent inspectorate, helping to lay down standards of quality and monitoring the extent to which they are observed, could give consumers some protection. As it becomes more well known and develops common working methods with community health councils and other bodies, the new inspectorate could give patients and their families greater confidence that a national effort was being made to maintain and improve standards. A tight monitoring system—perhaps the kernel of my argument—is a proper counterpart and counterweight to a tight monetary system.

The independent inspectorate would be concerned with standards. It may not have been quite so necessary if a proposal for a National Health Service supervisory board, which was contained in the 1983 Griffiths Report, had been acted upon. That supervisory board could have had general oversight of the NHS management board, so helping to maintain quality. Without the supervisory board, a high powered inspectorate becomes more important than ever.

So far I have been trying to describe, although only in the form of a sketch, the general case for the proposed inspectorate. I shall now say something with regard to the way in which such a new and comprehensive body, with teeth, could produce a streamlining of the existing monitoring body; that is, a reduction of bureaucracy. At the end of my remarks I should like to say how much there is to be learned from another great public service, Her Majesty's inspectors of schools. Existing monitoring bodies will not abolished; rather, they will brought together. I do not want to decry them. They have done good work. Their staff will be needed in the new, more integrated and more comprehensive service. However, their remits, one way or another, are either too limited or inappropriate. I should emphasise that I refer to existing governmental inspection bodies and not to the royal colleges and their inspections of hospitals. The noble Lord, Lord McColl—I am glad to see him in his place—spoke last week, I believe, against a proposal put forward from this side of the House when the subject of inspection and accreditation was first raised in Committee. I do not want to take issue in any way with what he said. Before he became a noble Lord he was a noble doctor and an admirable surgeon of great skill, as I am sure he still is. On one occasion at Guy's Hospital I feel that he saved my life; I hope that he does not now regret it. Perhaps I should therefore declare an interest in my own life, as it were. I am greatly indebted to him. Although he sits on the opposite side of the Chamber he certainly does not sit on the opposite side of my affections.

I hope the noble Lord will agree, not just because I am striking this personal note but because of the force of my argument, that, important though the work of the royal colleges is in inspecting the training regime of junior doctors and in other ways, they do not and cannot cover all the activities of the National Health Service—standards of management, value for money, studies in depth, nursing, private hospitals, GPs, community health services and so forth. I agree completely that they have an important job to do. That job will continue. I naturally hope that there will be fruitful co-operation between the royal colleges and the new inspectorate, the merits of which I hope the noble Lord will see.

The first government bodies I should mention are the health advisory service and the NHS drug advisory service, the latter's particular concern being the elderly, the mentally ill and problem drug users. There should be no great difficulty in fitting such work into that of the new inspectorate.

As the noble Lord, Lord Kilmarnock and other noble Lords have mentioned, the Bill proposes important new functions for the Audit Commission. Its name is to be changed from the Audit Commission for Local Government to the Audit Commission for Local Authorities and the National Health Service. I do not feel quite as hopeful about the commission in its new role as other noble Lords who have spoken. In my mind it raises the question why a body which above all has been concerned with the important function of financial auditing, economy and effectiveness in local authorities, should necessarily be the main body to carry out the same functions in the whole vast apparatus of the National Health Service.

I was impressed when the noble Lord, Lord Kilmarnock, drew my attention to something I had not noticed within the Bill, which shows how much more diligent he is in reading the small print. The noble Lord referred to Schedule 4 which says that the Audit Commission shall not be allowed to question the merits of policy. An inspectorate or monitoring body that is never allowed to question the merits of overall policy would be severely restricted in what it could say or do. I should like it to have a much more open brief. I am not convinced by what the Bill says on that point.

The new staff who have already been taken on in the Audit Commission to conduct value for money studies—I am sure that these can be very valuable—will be able to do so even more effectively as part of the new comprehensive service that I am proposing. That service will cover much wider issues with regard to quality than simply value for money studies, important though they are.

Another monitoring body is soon to be on the scene. We do not yet know much about it. The Secretary of State agreed to set it up when he was besieged recently by royal college representatives. That body is the Clinical Standards Advisory Board. It does not yet appear in the Bill. The new board will be concerned with standards in NHS hospitals, self-governing hospitals and the private sector. Its work will fall fairly and squarely within the sphere of the proposed inspectorate.

Lastly, there is the Social Services Inspectorate formed in 1986 out of the former Social Works Service. As far as I know it is an excellent body, but the new functions it will perform as a result of the community care sections of the Bill, if they are passed—I expect that most or all of them will be—could properly be discharged by the new Her Majesty's Inspectorate. With regard to community care—an issue which will certainly arise when we reach the relevant part of the Bill—the new inspectorate should be able to relieve local authorities placed in the embarrassing and invidious position by the Bill of being both inspectors and administrators of their own homes and institutions.

To conclude—I say this for the benefit of any noble Lord who, despite the persuasive effect of my argument, hopes that my remarks will soon end—I hope that the Chamber will allow me to say something with regard to the educational HMIs who are the main model for the proposed new service. The inspectors are one of the ornaments of public service in this country and enjoy a world wide reputation for their professionalism and public spirit. I have had occasion over the past 25 years or so to become aware of the high regard in which they are held in many countries. I believe that some of their characteristics could well be incorporated with advantage into the new health inspectorate. I am glad that my noble friend Lady David is present because she knows a great deal more even than I do—if I may put it that way—about HMIs and might like to say a word about it if there is time.

The first characteristic is that the education inspectors are appointed by Her Majesty the Queen; as would the health inspectors. This would help to give them the standing that they will need to maintain their independence and to give them respect. Their regular reports to Parliament would, because of that, be important annual events in the story of the health service.

The second characteristic of Her Majesty's inspectors is that their remit includes the private sector as well as maintained schools. They inspect Eton as well as the comprehensive schools of Lambeth—and so it should be in the health service; the private hospitals and the like, not Eton!

The third characteristic is that the professional independence and judgment of HMIs is essential, and will be essential in the new service. The fourth characteristic is that HMIs have regional and local offices and work closely with the advisers and inspectors in local authorities. The fifth is that the Secretary of State for Education and Science regards the inspectorate's work as indispensible in the process of making educational policy; and so, I believe, it should be in future in the health field.

The sixth characteristic is that Her Majesty's Inspectorate constitutes a career service which draws into itself some of the best and most experienced teachers and educational administrators in the country. They can influence the quality of education because of their own quality as people and their own experience. In just the same way, an inspectorate of health would need, and I believe should be able, to attract into its service experienced clinicians, nurses and managers from the NHS and give them a sense of real mission.

Finally, the overall purpose of Her Majesty's Inspectorate's work is to achieve an educational system more actively concerned with the quality of its work and more cost conscious. A very important part of the inspectorate's work is to spread good practice, and so it should be with the inspectorate for the health service.

In accepting this amendment I believe that the Committee would be establishing a new arm of the health service—Her Majesty's Inspectorate of Health—which would eventually have the same respect and high standing that Her Majesty's Inspectorate already enjoys in the other of the two greatest public services that this country possesses. Health and education would then be on all fours with each other and, across departmental boundaries that governments are never too adept at marching across, we would be able to learn in one great department of state the experience of about 100 years in another great department of state.

I hope that the Committee will be tolerant enough and will accept the case enough to put to our lords and masters and our ladies and masters that here there is a proposal that should be considered and taken very seriously indeed. I beg to move.

Lord Winstanley

I support this amendment. The noble Lord, Lord Young, began by reminding us that we have been told that we have a listening government. That being the case, the less I give them to listen to the better. We have had so many explanations as to what the last group of amendments meant that by the end none of us knew what it meant at all. Frankly, I doubt whether the Minister did, and so I do not wish to complicate this issue because I believe in it very much.

I begin where the noble Lord, Lord Young of Dartington, finished; that is, with Her Majesty's Inspectorate in regard to schools, a body with which I have had some connection since I was a small boy. One of my uncles was an inspector. Whenever he was spreading terror throughout the schools of Manchester he would be staying at our house. I was conscious of the extent to which HMIs were respected and regarded as being entirely independent. As a schoolboy, I could see what happened. Once it was rumoured that HMIs were on the way the whole place was cleaned up, altered and polished.

The inspectorate has immense influence. Why is that? It is because it is independent; and it is independent because it does not belong to the Department of Education and Science. The inspectorate belongs to the Queen. It is Her Majesty's Inspectorate. I seem to recollect that way back when the educational inspectorate was originally founded there was no Department of Education and Science; it was the Board of Education.

I hope that if we have an inspectorate of this kind it becomes Her Majesty's Inspectorate and is not part of the department. If it once becomes part of the department its usefulness would largely be dissipated; and that was spelt out in great detail by the noble Lord, Lord Young. We know about the various advisory bodies and we know how much notice is taken of their advice—sometimes a geat deal, but often not so much. We all know the respect and care with which we look at HMI reports on education and schools. Ministers consider them very carefully. They accept that it is a body that is entirely independent, and that is what we need here.

I was delighted to read the brief that came from the College of Health explaining the details of this amendment. I was also delighted to see that among the vice-presidents of the College of Health is the noble Lord, Lord McColl. Perhaps at the end of the day we will find that he supports the amendment. The introduction of this amendment would be of immense benefit to patients. If I have any criticism at all it is with the wording. It should perhaps state: There shall be established a body known as Her Majesty's Inspectorate of Health and Community Care". I know it may be said that that is implicit but I believe that it would be helpful if it were to be spelt out. I support the amendment.

Baroness Cox

I briefly, but wholeheartedly, support the amendment. The major arguments for it have been put admirably by the noble Lord, Lord Young of Dartington, and amplified by the noble Lord, Lord Winstanley. All I wish to do is emphasise the importance of the amendment, both in principle and in practice.

The fundamental rationale for the proposed inspectorate is the principle of quality control to which I imagine my noble friends in the Government are deeply committed. However, I emphasise the importance in the provision of services for the people who are inherently vulnerable and in situations where they are least able to acquire or evaluate the adequacy of standards of care, or to complain about poor quality of service. It is this characteristic of vulnerability which is so important in considering the concept of an inspectorate. It applies to all who are on the receiving end of services; not only patients and clients who are ill, injured or infirm but also to their families. I highlight that aspect for one moment.

There are, of course, many reasons for this vulnerability. Patients and clients are often not in a sufficiently robust state, psychologically or physically, to assert themselves. I follow the precedent of the noble Lord, Lord Young of Dartington, with a brief personal reminiscence. Many years ago I had to spend six months in hospital. I will always be grateful for the high standards of care I received from medical, nursing and ward staff.

Of course, over a long and serious illness there were bound to be some times when one was anxious and there were causes for concern. There was one occasion when I had to have a major investigation under general anaesthetic. Unfortunately, the surgeon undertook the investigation on the wrong kidney. Luckily it was not a nephrectomy. When I reappeared in the theatre for my second general anaesthetic I did not receive an apology but just a rather tart rebuke that the surgeon was not there for fun. I was feeling far to weak at that time to retort that neither was I.

The point of that personal anecdote is not that it relates directly to the broad concept of an inspectorate but that it highlights the enormous importance of an inspectorate where there are patients who are vulnerable and not necessarily in a position to express their fears, concerns, and anxieties. In my own experience of nursing I have seen many cases where patients are frightened, where there are causes for complaint and where they have not felt they are in a position to raise their concerns or even to think about asserting themselves and complaining.

Similarly, relatives are also often frightened by the predicament of the person whom they love. They too do not feel in a position to be assertive. Moreover, lay people are often daunted by the formality of organisations such as hospitals or by the demeanour of professional staff. There is the inherent impossibility of lay people having sufficient professional knowledge to judge the quality of care being provided for them, especially in aspects of technical and professional competence.

Like noble Lords who have already spoken, I wholeheartedly support the comprehensive nature of this amendment, covering as it does both hospital and community care, and the full range of statutory, private and voluntary sectors. There is going to be an especially urgent need for the monitoring of quality, given the massive changes in arrangements for community care. There is the need to ensure continuity of care and for adequate provisions for both health and social needs for the vastly increasing numbers of people who will require care in the community in the years ahead.

I hope that my noble friend the Minister will not say that such a mechanism for quality assurance is not necesary or that it is bureaucratic. I believe that the case for some form of inspectorate is incontrovertible. Noble Lords who have spoken before have highlighted the precedent in Her Majesty's Inspectorate for education. I wish to point to the very valuable function that that inspectorate has performed in highlighting examples of both good and bad practice. It is an extremely valuable form of accountability and monitoring.

I believe that the establishment of such an inspectorate would reassure everyone, including the professionals and other staff who work in the health and community care services, the public who ultimately pay for these services; but, most important of all, it would go a long way towards protecting those who have to rely on them. Therefore, I wholeheartedly support the amendment.

5.30 p.m.

Lord Ennals

I wish to add a few words from this Bench in total support of the amendment and the admirable presentation made by my noble friend. At one stage my name was among the sponsors of this amendment. I withdrew it in order that the noble Baroness, Lady Cox, could add her name to the proposal. I am very glad that I did so because she has made her comments with all her authority.

A case could be made out for an inspectorate without this Bill. Looking back over my own experience in the National Health Service, I would have felt more confidence in our standards if we had had something like HMIs within the health service. I feel strongly that the nature of this Bill and the changes that are being made greatly increase the argument for an inspectorate. The health authorities are being given a pretty free rein in quality standards and systems of monitoring that they write into their contracts. Some hospitals will become NHS trusts. It is important that there should be a body which looks at those as well as hospitals which will continue to be managed by the health authorities.

There will be new GP practices with their own budgets. It is important that the standard of care that they provide should be independently monitored. The essence of the matter is that the inspectorate must be independent. This amendment may well prove to be one of the most important to the Bill. It also gives me the opportunity of asking the Minister to say what is the present situation of the proposed clinical standards advisory group. I am sure that it was an initiative that was intended to move in this direction.

I understand that when the president of the royal colleges met the Secretary of State who was asked how many hospitals might be visited by the new advisory group, he said that it would be perhaps 10 a year. If that was a correct answer it was totally inadequate. The inspectorate may have a separate role to play but it should be established. It will have a relationship with the health advisory service, if it continues, with the Audit Commission and the social services inspectorate. I give my total support from these Benches to my noble friend's amendment.

Lord Kilmarnock

Members of the Committee may recall hat when we last discussed this topic I moved an amendment concerning the accreditation of hospitals. I was supported by the noble Lord, Lord Walton of Detchant. I believe that many people considered that to be a much weaker amendment than the one which the noble Lord, Lord Young of Dartington, is now proposing.

We did not get very much joy in that debate. At that time I was not in favour of any measure as draconian as the present one. On that occasion the Government's response certainly moved me towards the views expressed by the noble Lord, Lord Young. I echo what the noble Lord, Lord Ennals, has said. On that earlier occasion the noble Baroness, Lady Hooper, said, when referring to the National Advisory Committee on Standards: We have made clear that the possibility of a statutory base for such a group will be carefully considered in the course of those discussions. Furthermore, discussions will focus on the powers of the body".—[Official Report, 24/4/90; col. 533.) It would be very helpful if the noble Baroness can tell us what stage those discussions have reached and whether there is any intention to embody anything in statute as a result of that initiative. That will help us in the way forward.

There is a considerable weakness in relying entirely, as the Government appear to be doing, on the contracts for the assurance of quality. I have picked up today a document called Developing Districts. It is one of the working papers which stems from Working for Patients. In this connection I ask the noble Baroness to ensure that in future the department does not make press releases before a document is available to Parliament. This document was reviewed in the Independent on Monday of this week, 1st May, but it was not available in your Lordships's House until today. There was one copy in the Library and a batch came in today. I had to ask for it. It is nothing to do with the PPO. Perhaps the noble Baroness will look into that matter. It is improper that we should read comments in the press about departmental publications which are not available in Parliament itself.

Having said that, there is a section in the document headed "Quality and Views of Users". It is quite clear in the document that contracts are envisaged by the Government as the main means of quality control. The difficulty of confining quality control to contracts is embodied in 2.11(d) which states: To use contracts in this way DHAs need to: (d) ensure that each provider sets local targets, acceptable to the DHA for improving quality whether for services generally or for one particular element". That sounds fine. However, the problem is that the DHA then becomes the sole arbiter of quality and it may face a conflict of interest between shopping around for the lowest price and buying as cheaply as it can besides maintaining standards. The DHA is not the appropriate body to exercise quality control. If it is in financially difficult circumstances, the DHA may find itself with a conflict of interest.

We have explored accreditation and the idea put forward by the noble Baroness, Lady Cox, in the last debate for an advisory body besides the new clause which the noble Lord, Lord Young of Dartington, has proposed. All these suggestions are extremely relevant. It will be very difficult for us to make up our minds which provision we prefer and which way we should proceed until we hear from the Government what they are planning to do. We need to know whether they are planning any statutory provision on quality control in the Bill.

Lord Carr of Hadley

If I am honest, I am not sure whether I do or do not support this amendment. Like the noble Lord, Lord Kilmarnock, who has just spoken, I observe several ideas in the arena but I am not sure which is the right one or whether any of them is right in its present form. We have the accreditation idea, the HMI idea and we also have the initiative between the Secretary of State and the royal colleges. We are to have more. I am not yet sure what the right answer is. However, I feel sure that there is a great need to assure the public at large—that is, all patients of the health service both actual and potential—and all those who work in the health service at every level that the maintenance of quality is the top priority.

On the whole, over the past few decades, whether we look at industry or anything else, we have not carried the conviction of the country; but we put quality at the top of the list. We must do so in this service, of all services, for the most obvious reason. When we talk about major changes I am quite sure that it is natural for people to have fears. People fear change in any event, and in an intimate and fundamental matter such as this—whether it is those who work in the service and deliver it at a professional or lower level, or whether it is those who will receive the service—people will have fears as to whether such a change may mean some reduction in quality. I am sure that the proposals about which we are talking need not give rise to such fears, but we should not be surprised if they exist. They need to be set at rest. It is almost a case of meeting a psychological need, but I believe it to be important.

There is a more real need we must face which was mentioned by the noble Lord, Lord Young of Dartington. We are undoubtedly putting a downward pressure on costs. That is something we ought to be doing. Indeed, it is immensely important that we should do so if we are to produce the maximum volume of health care from whatever resources are available in any particular year. As I said, there must be a strong downward pressure on costs. We are suffering at present because there has not been a sufficiently strong or effective and sophisticated downward pressure on costs since the health service began.

When you put a downward pressure on costs, whatever the service or provision of goods concerned, you run risks—or you may do so. The bigger the downward pressure on costs the more important it is to have a very strong quality assurance control. Therefore, I believe that this assurance is important for psychological reasons but it is also important for concrete reasons. I beg my noble friends on the Front Bench and the Secretary of State to come forward with a convincing, credible system of quality control. It is very important both psychologically and in reality to put the establishment and maintenance of quality health care at the top of the list.

I am not yet ready to make up my mind as to which is the right system. I hope that my unwillingness at present to back one system or the other does not lead my noble friends on the Front Bench to think that they can get away with not doing anything substantial to reassure everyone in the country about the matter.

5.45 p.m.

Baroness Seear

I should like briefly to express my wholehearted support for the amendment. However, I agree with the noble Lord, Lord Carr, that it is possible there may be a better way of achieving the same highly desirable result. I hope that the Government will not tell us that we do not need anything of the kind because market forces inside the service will ensure that if good quality is not offered patients will not go there.

We should remember that buying health care is not like buying fish. If the fishmonger serves you with bad fish one week you will go elsewhere the next week. We are not in the market for health care, except in very exceptional circumstances. We do not learn what the market is like until we are practically dead—or quite dead in some cases. Therefore, the analogy with the market can only be pushed a very short way. I hope that that argument will not be produced as a reason why we do not need such an independent body.

The second argument which I hope will not be presented is that the DHS will carry out this function. The department is the parent of the scheme. It is deeply involved in it and is committed to it. I do not believe that anyone who is the parent and guardian of a scheme initially is also the best person to inspect its quality. Of course the department should carry out its own quality inspection; but we also need another body which is independent of the DHS.

We cannot have a better example of such an independent body than HMIs for the schools. Their strength over a century of history—if my memory serves me correctly—is that they are Her Majesty's inspectors and are completely independent of the department. No one who has had anything to do with schools will deny the contribution that HMIs have made over the years. One still reads their reports which go back over decades to find out what has gone on in the schools. But one cannot deny the contribution that these independent inspectors have made to the development of education. If the health service is to be reformed in this way, we need precisely the same kind of independent watchdogs; that is, knowledgeable, professional, skilled and, above all, independent people.

Baroness Masham of Ilton: It is vital that the quality of health and community care, however it is provided, should be of an acceptable standard. There is so much emphasis in this Bill on the marketing of services without any safeguards as to the standards. Can the Government truthfully say that no doctor or health district will buy services because they are the cheapest, even though they are below standard? The Royal College of Medicine, the Royal College of Surgeons and the nursing colleges know what a good and reasonable standard should be. I hope that they will help in providing standards for the inspectorate. All units ought to aim for excellence, but, to be realistic, all do not reach excellence. However, we need a good standard.

I am pleased to see that the private sector is included in the amendment. It is of concern that there is no body like a community health council or an inspectorate for the private sector. I feel that some private patients do not always get a good buy. In my view, some of them are being ripped off. Some Members of the Committee may remember that I took the Prohibition of Female Circumcision Bill through this Chamber. That horrible operation is now outlawed, but I wonder whether any such operations are still carried out behind the closed doors of a private hospital.

I feel that the inspectorate could help in so many ways. When there is to be so much buying and selling of services, we must have a body which will ensure that a balance of interests is kept so that consumers do not suffer. If the Government were to accept the amendment, many people would feel happier about the Bill and those of us in this Chamber who are interested in such matters would feel that we had improved the legislation.

Lord Butterfield

I wish to make a few remarks mainly because I feel that there are many people who are busy doing exactly what Members of the Committee have been referring to. I should not like the record of this debate to pass by without some tribute being paid to the work of such people. I shall begin by saying to the noble Lord, Lord Young of Dartington, that my favourite schoolmaster became an HMI inspector. I should put my hand in the fire to defend that man's assessment of anything to do with a school or education. Indeed, I should be happy for him to move on to hospitals. In my view, if the likes of him could be recruited in the professions—that is, medical, nursing, laboratory technicians and so on, and also the catering side—I should be most happy if they were welded together.

I realise that the noble Baroness and the Secretary of State have something of a problem. I shall try to explain my concern. The examiners in medicine, surgery, obstetrics—that is, the whole gamut of exams for medical students—the examiners on the nursing side, the midwifery examiners and the laboratory technician examiners are all going in and out of our hospitals and keeping a pretty close eye on the standards. That is why, if you have a test of some kind carried out in Darlington, in Dartington or in Stetchford, where I come from, the answer will be the same whichever laboratory is used because the internal standards are the same.

There is a great deal of similarity because it is a national health service with regard to the quality of a large; proportion of the services that it provides. That is not to deny what the noble Baroness, Lady Cox, pointed out: that some people are frightened of complaining in hospital. The great sadness I feel is that the matron no longer walks around the hospital every day to hear those complaints, but that may be something that the inspectorate could encourage.

I speak now as someone who has been on a regional health authority in East Anglia and Trent and on the area health authority for Cambridgeshire. One of our problems was mentioned by the noble Lord, Lord Winstanley. There is often a warning that the inspector is coming. It would be indicated that during the following year someone might visit, but in the event the member of the authority would just appear and make his or her observations. I shall not go into too much detail, but I am aware that there were members of the authority who joined the out-patients and who were appalled by how long they had to sit before anyone found out that they were there merely as a regional health authority visitor. That makes the mind boggle.

I am anxious to read into the record that we give credit to all those people who since the service began have been going in and out of hospitals and other parts of the health service to maintain the standards. One could and should pay great tribute to the many people who have served on community health councils. We have heard little about them in our discussions. I should like to record how much good work they and many of the organisations that they represent have been able to do. I am sure that the Government are well aware of that fact. That is the careful integration that the idea put forward by the noble Lord, Lord Young, will require. I agree that if the proposal could be explored and woven together it could be a great jewel in the crown of this reorganisation.

The noble Baroness, Lady Cox, mentioned community care. Having listened to the regional health people in East Anglia who have made visits, and having looked at the complaint books, my hunch is that the institutions, having been visited by so many people, are tidy. I worry about how this wonderful idea can be brought to bear on the community care service. I do not want to trespass too deeply into that subject. I have been interested in the care of the elderly. There is a great deal of good inspectorate-type work that people like my old schoolmaster—if I may complete the circle—a much revered man of wonderful judgment and superb courage, who was willing to open any door to see what was going on inside, could do. It would be a fruitful field and I support the idea, although I see that the job will be complicated.

Baroness Carnegy of Lour

I do not know enough to know whether this general idea is applicable in practice to the health service, although I know how the education inspectorate works in Scotland. That example prompts me to ask the noble Lord, Lord Young of Dartington, whether he or other noble Lords envisage the inspectorate publishing reports for the public to read. If it does, and if an inspector is critical of a nursing home, a hospital, or some aspect of general practice, would the professionals be happy to have their methods criticised? I am sure that they would not mind professionally, but would such criticism affect their relationship with their patients? Would nurses in a hospital feel that strong criticism of their methods of working would affect their work? I wonder whether the model is correct.

Lord Young of Dartington

Perhaps the noble Baroness would allow me to answer her. As I understand it, since 1982 when the practice was changed on the directions of the Secretary of State, HMI reports are made available to the public. HMIs have had to develop the skills of tact and diplomacy. They are aware that if they cite individual teachers and other people unfavourably it will not necessarily have a good effect. In most of the reports that I have seen, they manage by and large to make it clear that some things are not right in a school, college or whatever it may be; but they almost always refrain from pinning the blame on individuals. The people inside who receive the report know much more about what is written between the lines than the people who read it on the outside. If there are parents—in that case—or other people who are interested they can also do a certain amount of reading between the lines, although they never do so in the spirit of wanting to find victims or scapegoats inside a school.

Baroness Carnegy of Lour

I understand what the noble Lord says. I understand how the HMI operates in schools. The same thing happens with community education in Scotland. A report on a small school or community centre reflects directly on the individuals—although the noble Lord is right, the matter is put forward tactfully. Parents are interested to know whether their children might be better taught and are keen that they should be; but to be told that one might die if one went to hospital because it is badly run is different.

Baroness Seear

Is it more important that you should not die than that you should not be badly taught?

Baroness Carnegy of Lour

A report on one's local cottage hospital, for example, which suggests that it is not well managed and that this and that might happen would have a different effect, I am sure the noble Baroness will agree, than to be told that there could be improvements in the way one's child is taught. I am merely expressing a thought. I do not believe that the two things are the same. I have no idea what my noble friend the Minister will say in answer to those questions.

Baroness Cox

Before my noble friend sits down perhaps I may reassure her by answering her question as to how professional people, especially nurses, might feel about that concept. The whole concept of the inspectorate has the full support of the Royal College of Nursing which is keen for professional accountability to be in the public domain.

6 p.m.

Baroness Blatch

I have listened to the debate and I am encouraged by the narrowness of the gap that divides the Government's views from what has been said during the debate. The nature of the gap relates to how public accountability and quality assurance are achieved. That is the issue. The issue is not that there should not be some monitoring of the quality of service.

The amendment aims to improve the quality of treatment that patients receive in the NHS and from the community care services. I am glad to be able to agree unreservedly with the noble Lords, Lord Young of Dartington, Lord Perry of Walton, Lord Winstanley, Lord Ennals, and my noble friend Lady Cox about the importance that attaches to quality. I hope to convince them that our reforms, together with the Secretary of State's existing powers, will guarantee standards of care in the NHS and community care services and help to improve them further.

I shall turn to one or two points that have been mentioned during the course of the debate. The noble Lord, Lord Young, asked why no action had been taken on the NHS supervisory board. The supervisory board was established in 1984, after the first Griffiths Report. However, the National Health Service policy board chaired by the Secretary of State has now taken over the functions of the supervisory board.

The noble Lord, Lord Young, also referred to the internal market possibly leading to a fall in standards. Again the Government believe that the effect will be precisely the opposite. District health authorities will have every incentive to put quality first when placing contracts, and likewise GPs will also have a greater incentive because patients have greater freedom to choose.

The noble Lord, Lord Young, went on to make generous comments about the role of the social services inspectorate. I am happy to agree with him, and join him in his tribute to the work of that inspectorate. However, its role is rightly confined to local government social services and there is no reason to expand their role to cover health. The noble Lord, Lord Ennals, referred to the clinical standards advisory group making only 10 visits a year. I think that was what he said. The number of visits of any such group is a matter for discussion with the royal colleges as part of the present series of meetings. That discussion will continue.

The noble Lord, Lord Kilmarnock, referred to the publication Developing Districts, its timing and the placing of copies in the Library. He acknowledged that copies were available in the library on the day of publication. Nevertheless clearly sufficient copies were not available and I apologise to him unreservedly for that. I shall note his comments and make sure that more copies of any future publication are available.

The noble Baroness, Lady Masham, referred to quality control in the private sector. Perhaps I may assure her that private hospitals are already controlled through the registration system which is enshrined in the Registration of Homes Act 1984.

Our commitment to quality lies at the heart of our reform proposals. The reforms will give greater choice to patients, and greater freedom to local health authorities to find solutions to local needs. Districts will consider the specific health care needs of their resident population and arrange for the provision of services which best meet them. GPs, who are best placed to know patients' needs and preferences, will be closely involved in the process. National Health Service contracts will be awarded to those providers of services who offer the most effective and highest quality services. I believe that they will offer a more effective means of improving standards on the ground than infrequent visits from a rather remote national body.

High standards of quality depend on accurate means of measuring quality and monitoring its provision. In this, we will be building on valuable initiatives already under way in the health service to make the consumers' interest more central to the management and delivery of health care. For instance, all regions now include quality goals in their annual statements of objectives, against which progress can be assessed. Quality standards will be clearly set out in National Health Service contracts, and districts will monitor services to see that those standards are attained. The National Health Service management executive's recently issued guidance, Operating Contracts, provides valuable advice on how quality measures can be built into contracts. We expect districts to develop their own increasingly detailed measures in the light of experience.

Clinical audit is another key element of our drive to maximise quality of care. This is an area where the medical profession is in the lead, supported by the department in developing arrangements which will be effective throughout the National Health Service.

A commitment to improved quality also runs through our community care proposals. By freeing the funding and mangement systems we will allow innovation to flourish and encourage local authorities to take the lead in arranging services that best meet local needs. When we turn to the community care clauses, I am sure that there will be opportunities to discuss at some length the new arm's length inspection units which we are encouraging all local authorities to create to oversee their own services and those provided under contract to them.

Specific reference was made to this issue and the Government have emphasised that all local authorities should set up arm's length inspection units divorced—and this is important—from their service provision. I believe that this will protect against any conflict of interest, together with all the other means of monitoring performance.

I believe that local enthusiasm, not central prescription, is the best means of guaranteeing and improving quality. But I can understand the views of those who consider that, at a time of change, we need to monitor the effect of our proposals on the standards of care patients receive. As my noble friend mentioned during our debate on Clauses 3 and 4 in the second session of the Committee, the Secretary of State has recently announced proposals to establish a clinical standards advisory group to advise him on standards of clinical care for National Health Service patients, whether in a directly-managed unit, and NHS trust, or in the independent sector. I can assure all noble Lords that constructive discussions are continuing with interested parties on how best to secure this. It may just be precipitate to make a definitive decision at this stage until those discussions are complete. I know that this was a concern of many Members of the Committee.

I do not believe that health and the local authorities' role in securing quality can or need be undertaken at national level. The National Health Service management and the Government in discharging this duty are far from convinced that an additional, expensive body would significantly assist in this work.

The noble Lord, Lord Carr, said that he was not so concerned about a specific resolution of the problem. He suggested that we need to be absolutely certain that there is public accountability of quality assurance for the health service and community care services. I promise the Committee that we see the need for such accountability. The noble Baroness, Lady Seear, also hinted at other ways of achieving the objective, but I wish to continue to emphasise that the objective is well shared by the Government.

There may be points that I have missed on account of time and I hope that Members of the Committee will forgive me if I have done so. No doubt I shall be reminded of them by noble Lords and I shall write to them.

A major point raised was the comparison between the National Health Service and schools. I believe it is right that the schools comparison is one that I understand. I appreciate many of the points made about the comparison between schools and the health service. However, the HMI for schools functions in areas where direct responsibility does not rest with Ministers, as it does with the health service. I believe that health authorities have a crucial role to play in guaranteeing the quality of services provided to their residents and I am sure that they will carry this out effectively. Moreover, the proposed inspectorate of health would cut across the work of the social services inspectorate, and may even cut across the work of many other organisations which have been mentioned in the course of the debate.

I believe that the noble Lord, Lord Young, undercuts his own arguments by illustrating the number of bodies which he mentioned specifically and which are already working in the field of quality assurance. I do not see that bringing all these agencies together in a single, monolithic body will necessarily be the most appropriate way forward.

Finally, the noble Lord, Lord Butterfield, referred to an important point—the professional associations for all the different disciplines working within the health service where monitoring and overseeing of standards take place. We do not have that in the school sector; that is another comparison with it. There has been much debate about whether the school sector should have a special body doing that work. However they exist in the health service.

Our reforms are aimed to create a health service that works for patients. Our package of reforms will create the right conditions for further improvements in standards of care for National Health Service patients. However, I emphasise that while sharing those objectives I do not believe that, for the reasons I have given, the establishment of a single inspectorate is the most appropriate way forward. We shall read everything said during the course of the debate; I shall report back and take account of it. I believe that it is about the means to an end rather than an argument about objectives. I hope that the noble Lord will feel able to withdraw his amendment.

Lord Kilmarnock

Before the noble Lord, Lord Young, replies to the debate can the noble Baroness clear up one point? As I have already pointed out, on 24th April, at col. 533 of Hansard, her noble friend Lady Hooper, talking about a possible advisory body on standards, said: the possibility for a statutory base for such a group will be carefully considered". Is that still in the Government's mind?

Baroness Blatch

I referred to that point specifically. However, perhaps I did not mention the noble Lord, Lord Kilmarnock, in doing so. That is an on-going debate with the relevant people. Again, it concerns the issue of monitoring and quality assurance. Whether or not that should be undertaken by a single body will emerge from the discussions.

Lord Ennals

The noble Baroness has dealt very effectively with the argument that we need to monitor standards, "we" being the department, regional and district health authorities and the professionals. She did not really apply herself to the thought that perhaps an independent body needs to monitor "our" standards.

Baroness Blatch

I addressed myself at length to the issue of monitoring standards. I still believe that the debate centres on how that should be achieved. I also mentioned that some bodies will be as indpendent as possible from the National Health Service. One hopes that the professional institutions operate at more than arm's length from the accountability and managerial responsibilities of the National Health Service.

Lord Carr of Hadley

Before the noble Lord advises the Committee what he wishes to do about his amendment, and I hope that he will not press it to a Division at this stage of the Bill, I must say to my noble friend that I cannot be wholly satisfied with the way in which she replied to the debate. Of course I accept, and I hope that all noble Lords accept, that the intention of the Government is to put quality at the top of the list. I do not doubt that for one moment. However, I have a feeling in my bones that in a matter as vital as health care there needs to be a genuinely independent element in the supervision of the service.

I do not in any way want to belittle the tremendous work which is done by the professional bodies and the royal colleges. However, the overall quality of an institution is different from the sum total of its individual parts. The standard of the surgeons, doctors, nurses and other specialties may be very high; nevertheless, certain institutions do not achieve the highest quality even though their individual parts are good enough to do so. Therefore, someone needs to take a dispassionate overall view.

With respect to my noble friend, I do not feel that she quite took the point about the effect of downward pressure on costs. She seemed to suggest that that would be one of the overriding tests of the new role of the district health authorities. I find that difficult to accept, not as the intention but because the district health authorities represent one of the major areas in which the downward pressure on costs will occur.

The Secretary of State has said that if he has on those authorities representatives of both acquirers and providers there will be a clash of interest. The district health authority has a very clear interest of its own in obtaining its service at the lowest possible cost. I am not sure why there is not seen to be a potential conflict of interest between obtaining the service at the lowest possible cost and also achieving the highest quality.

I agree that competition and market forces in the long run press towards better services and better quality for consumers. However, the way in which the market operates tends to produce aberrations and departures from the long-term trend. The long-term trend may be genuinely healthy but in any short-term period there are downward pressures on costs which produce a tendency to skimping on quality. I therefore beg the Government to take the matter seriously.

If the Government look outside the National Health Service to the commercial world, although I know that some people are afraid of bringing too many aspects of the commercial world into consideration of the health service, they will find that what I say is true. I do not believe that it applies only to the commercial world. It is natural that sometimes, possibly inadvertently, when organisations are struggling to achieve maximum quality from a limited quantity of resources, this leads to the cutting of corners on quality in the short term.

Perhaps I may say to my noble friends on the Front Bench that the Government need to think more deeply before Report stage about the fundamentals involved in the subject. I believe that some fundamentals have not yet been fully considered. If they have been considered, that has not yet been made apparent to us. I believe that before the Bill leaves this Chamber it will be necessary for those fundamentals to be disclosed much more deeply than has yet been the case.

6.15 p.m.

Baroness Blatch

Perhaps I may make two brief comments in response. First, there will be an incentive for the district health authorities to obtain the best value for money. I know that that causes concern, but the two factors that will have to be taken into account are the quality of services and the cost effectiveness of those services.

Secondly, the most important point that I wish to make is that discussions on the establishment of an independent group, or a group which can make an independent judgment of quality, are continuing. Until we have heard a view from those involved in those discussions I believe that the amendment is premature.

Lord McColl of Dulwich

Perhaps I may say how grateful I am to my noble friend Lord Young for his kind remarks about me. I should also like to say what a splendid patient he was. He taught us how difficult consumerism is in the medical sphere. If one is nice to the patients they will never say anything that could possibly be construed as criticism of doctors, nurses, or even administrators.

It was interesting that after my noble friend's stay with us at Guy's as a patient he formed the College of Health. I shall never forget that he wrote to one of the national newspapers saying that it was while he was recovering from treatment at Guy's that he realised that there was a great need for a consumers' organisation for patients. However, he did not mean it in that way. He taught us how difficult the subject of consumerism is.

All the discussions in the last half hour have emphasised that there is an enormous amount of work taking place in terms of quality assurance, collection of data, and measuring the quality of care. The problem is getting anything done about it at the coal face. Some hospitals have been collecting data for years about when the consultant arrives for his clinic. Some consultants routinely arrive rather later then they should, but no one has been able to do much about it. That is the basic problem.

I suggest that the Bill before us gives us the means to achieve action at the coal face and to make people working in the health service realise that if they do not give a high quality service to patients they are slightly more at risk than they were before. Human nature being what it is, that kind of incentive will encourage them to give a very much better service. After all, the cheapest service is often the best service because courtesy and kindness cost nothing. The discipline imposed on us by the Bill will compel us to sit down and work out the best way of using that sum of money for those patients. Lord Rutherford said many years ago that economies and shortage of money concentrate the mind wonderfully in using the money in the best possible way—in his case in research but in our case by providing a good service for the patients.

Lord Young of Dartington

I should like to thank all noble Lords who have contributed to the debate. I should also like to thank the Minister for the reply that she has given, although I did not find it as convincing as I had hoped.

I should like to mention one or two of the contributions which I found particularly impressive. I shall start with what the noble Lord, Lord McColl of Dulwich, said at the end of his speech because it is most vivid in my memory. He said that courtesy and kindness cost nothing. In a sense, they do not. Certainly, when I was in his care I saw courtesy and kindness of a most remarkable quality applied not only to me but to all the other patients in the ward. To some extent, the radiance of what went on there extended to other parts of the hospital.

One finds courtesy and kindness in deplorable conditions such as one sees as one goes round the health service. Sometimes there has been penny-pinching which makes it difficult for people not to lose their temper. It has nothing to do with the patient but is a result of the conditions and the pressure which the management imposes on the clinicians. Again, that is not necessarily due to the management but to the shortage of resources. It shows that, although saintly people can be courteous and kind in the most impossible conditions, ordinary mortals, like most of us here in the Committee, find in easier when the circumstances around us are reasonably favourable and we are treated with courtesy and kindness by our lords and masters.

Consumerism is certainly difficult to bring off and has not been brought off as an important force in the health service. I am the first to admit that, but at least I believe that the objective is right and the pressure is right. Once patients become more demanding and take their courage in their hands and talk on as equal terms as possible to doctors and nurses, that will have a tonic effect and will perhaps help us more than anything else to raise the standards of the service. I agree that we have not got there yet, but we should try to keep on the road.

I was impressed by the comments of the noble Lord, Lord Butterfield. I apologise if I gave the impression of not giving credit to all the people in the health service who have done marvellously over the years to maintain and, in the light of scientific inquiry and other experience, to raise standards. I did not mean to say that at all. It is only because things are so good and because there are such remarkable people who have inherited both a medical and a scientific tradition, which perhaps constitutes the greatest ornament of Western civilisation, and because those people will not be much affected one way or another by the Bill, that we feel we are generally in good hands. However, they need more support. The public need much more assurance that things are on the right lines than I believe they often have at the moment.

I want to refer to the comments of the noble Lord, Lord Carr of Hadley, because I was particularly impressed by them. He made an excellent point when he said that not only is there downward pressure on cost but there must be downward pressure on cost. It is impossible for all the money which must be spent, as it were, to be spent, although there has been too much penny-pinching and there is a need for expansion. However, even if there is expansion in public expenditure on our health service there will still be a need for downward pressure on cost. We cannot afford any unnecessary waste. I accept that point.

I also accept what the noble Lord, Lord Carr, said about the consequential need for the monitoring which the inspectorate would help us to perform. I believe that, if not from the bottom of my heart, then from not too far off the bottom of my heart. The National Health Service has had a terrible buffeting in the past few years and the confidence of many millions of patients and their families has been to some extent undermined. The National Health Service reform Bill, whatever its merits, has been introduced with more aggravation, more criticism and, I fear, in some quarters with more bad feeling than I remember attending any major reform of the health service. Even what happened in 1948 does not stand comparison with this.

Whatever comes out of the Bill and out of our political situation in the next two years or so, there is an urgent need to restore the confidence of ordinary people in the quality of the health service at all levels. Perhaps the doctors and nurses are on the front line. They need support if people's confidence is to be fully regained. That is necessary because, among other things, confidence, not just in individual doctors and nurses but in the whole system, is one of the necessary ingredients for good health. It will help people to get better and it will put more stamina into people who otherwise might go under, so it is extremely important.

An inspectorate is not the full answer by any means, but it could do something. It is important to help to restore public confidence. If it was handled right and backed by the Secretary of State and the Government, it could do a great deal for people in community health councils and consumer groups and ordinary people throughout the country to know that those people with a measure of independence were on their side with the knowledge that ordinary laymen do not have behind them and were doing their best to maintain standards and to keep an eye on bad practice when there is bad practice. In a few years' time, once it has shown its mettle, many doctors, nurses and other people would be grateful to it for the feeling of support that it gave them. It would not just be a buffer between the clinicians and members of the public. It would be a positive support for them.

I have been asked what I intend to do. We should show that the feeling of the Committee—it has been expressed on nearly all sides of the Chamber—is that we are not satisfied with the answer that we have received. Nor are we satisfied when all the proposals on accreditation and the like have been turned down at different stages in the Committee. We believe that the issue should be reconsidered in the light of setting up the clinical advisory board, but it should go wider than that. There is no special importance attached to the words that I have used. I should like to see the Government come back at a later stage of the Bill, having reconsidered the matter and the feeling in the Committee and having produced a proposal that would carry more conviction and support than the one before us.

I say to the noble Lord, Lord Carr, that I believe that the way in which that could best be done is by showing that we are not satisfied by and large with how this matter has been handled so far and, in the Division, voting for the amendment, knowing however that the amendment itself will not figure exactly as it is in the Bill. We should make our feelings known not only to Members on the Front Bench but to those behind them and those who might consider that there is something still to be done and a gap to be filled that could be filled by what I might call noble action which could happen in the next few weeks.

6.31 p.m.

On Question, Whether the said amendment (No. 107) shall be agreed to?

Their Lordships divided: Contents, 62; Not-Contents, 64.

DIVISION NO. 2
CONTENTS
Addington, L.	Fitt, L.
Airedale, L.	Gallacher, L.
Bancroft, L.	Galpern, L.
Birk, B.	Graham of Edmonton, L.
Blackstone, B.	Hanworth, V.
Bottomley, L.	Hatch of Lusby, L.
Brightman, L.	Holderness, L.
Carter, L.	Houghton of Sowerby, L.
Cledwyn of Penrhos, L.	Hughes, L.
Cox, B. [Teller.]	Irvine of Lairg, L.
Darcy (de Knayth), B.	Jay, L.
David, B.	John-Mackie, L.
Diamond, L.	Kilmarnock, L.
Dormand of Easington, L.	Kirkhill, L.
Ennals, L.	Lauderdale, E.
Ewart-Biggs, B.	Listowel, E.
Falkender, B.	Lloyd of Kilgerran, L.
Fisher of Rednal, B.	Lovell-Davis, L.

McFarlane of Llandaff, B.	Seear, B.
McGregor of Durris, L.	Serota, B.
Mcintosh of Haringey, L.	Shackleton, L.
Masham of Ilton, B.	Smith, L.
Mulley, L.	Stoddart of Swindon, L.
Nicol, B.	Underhill, L.
Ogmore, L.	Wallace of Coslany, L.
Perry of Walton, L.	White, B.
Peston, L.	Williams of Elvel, L.
Pitt of Hampstead, L.	Winstanley, L.
Ponsonby of Shulbrede, L.	Winterbottom, L.
Porritt, L.	Young of Dartington, L. [Teller.]
Rea, L.
Rochester, L.

CONTENTS
Abinger, L.	Hooper, B.
Ailesbury, M.	Hylton-Foster, B.
Aldington, L.	Jenkin of Roding, L.
Arran, E.	Long, V.
Balfour, E.	Lyell, L.
Bauer, L.	McColl of Dulwich, L.
Beloff, L.	Malmesbury, E.
Belstead, L.	Merrivale, L.
Blatch, B.	Mersey, V.
Blyth, L.	Mottistone, L.
Boyd-Carpenter, L.	Murton of Lindisfarne, L.
Brabazon of Tara, L.	Norrie, L.
Brougham and Vaux, L.	Orkney, E.
Caithness, E.	Orr-Ewing, L.
Campbell of Alloway, L.	Platt of Writtle, B.
Carnegy of Lour, B.	Reay, L.
Carnock, L.	Renton, L.
Clanwilliam, E.	Rochdale, V.
Clifford of Chudleigh, L.	Saint Albans, D.
Colwyn, L.	Saltoun of Abernethy, Ly.
Craigavon, V.	Sanderson of Bowden, L.
Davidson, V. [Teller.]	Seebohm, L.
Denham, L. [Teller.]	Skelmersdale, L.
Downshire, M.	Strathmore and Kinghorne, E.
Elles, B.
Ferrers, E.	Sudeley, L.
Fraser of Carmyllie, L.	Swinfen, L.
Gibson-Watt, L.	Trumpington, B.
Halsbury, E.	Ullswater, V.
Hemphill, L.	Vaux of Harrowden, L.
Henley, L.	Vinson, L.
Hesketh, L.	Young, B.
Hives, L.

6.38 p.m.

Lord Peston moved Amendment No. 107ZA: After Clause 20, insert the following new clause: ("Occupational Health for NHS Employees —(1) In addition to carrying out its primary functions, a District Health Authority shall draw up a plan detailing an occupational health policy for NHS staff working within the district. (2) The plan may include directions on—

1. (a) comprehensive counselling services;
2. (b) nutritional standards for employees;
3. (c) health information and education services;
4. (d) screening facilities, including cervical and blood pressure;
5. (e) exercise and fitness facilities;
6. (f) smoking, alcohol and drug abuse cessation programmes, including implementation of DHSS HC(85)22.

(3) The Secretary of State may offer guidelines as to how the district health authority shall fulfil its functions under this section.").

The noble Lord said: We are proceeding very slowly but I regret to say that I regard this amendment as extremely important, and it is not one that I feel able to rush, although I am now concerned as to whether we shall finish today's proceedings within a reasonable time. The fact is that the subject before us, which is occupational health is not one that we can neglect.

In moving this amendment, which stands in the names of my noble friends Lord Ennals and Lord Hunter of Newington, I must emphasise again a rather paradoxical point; namely, that the National Health Service is not noteworthy for looking after the health of its own employees. Indeed, there is the strange state of affairs that at best, in terms of occupational health within the National Health Service, it would be very hard to claim that the NHS is a first-class employer. Indeed there are employers in the private sector who to my knowledge take occupational health a good deal more seriously than some in the NHS. I do not labour the sociology of the matter nor the fact that there are so many illnesses, often stress related, from which a high number of National Health Service employees at all levels seem to suffer. However, that factor brings out clearly the enormous pressure under which people in the health care professions work. The health of the health care profession should concern us.

In considering the question of occupational health we are not discussing a party political matter. All governments for the past 20 years have been concerned about occupational health. I shall concentrate on the NHS. Governments have tried to give guidance. My view does not depend on the political colour of the parties in power. I have tried to persuade, but the fact remains that the outcome is not satisfactory. I agree that that reflects on the current unchanged health service. We must address ourselves to the NHS as it will be, on the assumption that the Bill is passed into law.

I believe that the amendment is fairly minimal. I have a sense of gloom, however. Having listened for several days to Members on the Government Front Bench, I have no difficulty in working out exactly what they will say. Indeed, having spent some years of my life in the public service I do not consider that I am any less expert at drafting useless, unhelpful replies than the officials currently sitting in the box. The replies are the straight-backed responses that Government Ministers require when they are defending a rather sticky Bill on sticky wickets. However, on a number of occasions they have not addressed themselves to our amendment. I assume that the reply to the amendment will be, "We are decentralising. We favour local enthusiasms," and various other bits that are fed by the word processor directly into the answer. However, in this case I do not think that that will do. We have had the decentralising to which the Government refer and it does not work. There is no reason to believe that it will work in future. There are no incentives in the Bill to provide an occupational health service. That is not to say that some of the districts will not do something; but there is no reason to believe that they will do so, or to the standard required.

I go further. If I were a supporter of the Bill I would still wish to consider the role of the Secretary of State. What areas would the Secretary of State wish to concern himself with? He might wish to lay those down in statute so that things would happen in the way he wished.

It seems obvious from past experience that simply saying, "Occupational health is important. You ought to do something about it," will not work. Guidance will not work. Leaving it solely to the market—as defined in terms of the Bill, not the market mechanism in the private sector sense—will not work. The Committee has a responsibility to state that occupational health is important. The least that we can do in the first instance is to require that an occupational health policy should be set up for NHS staff.

The amendment indicates the nature of such a plan. It also adds the use of guidelines. Although I am unable to change the amendment at the last minute, I believe that the amendment does not go far enough. It lays down what ought to happen but does not include the mechanism of feedback which would ensure that what ought to happen will happen. On reflection I believe that the amendment needs to be stronger rather than weaker. In other words, my noble friends ought to have followed our logic, and to have taken it further.

The amendment emphasises an area of importance. No one denies that. No one will rise to say that occupational health is not important. No one will say that it is not important a fortiori within the National Health Service. That is not the problem. The question is how one accomplishes it. In this case, one provides for it at district level. One ensures that an occupational health policy within the district is made to work. I beg to move.

6.45 p.m.

Baroness Blatch

I note the noble Lord's comments about what he deemed to be the inflexibility of the Government's response to points made. He attempted to pre-empt my reply. Perhaps I may say that this Chamber does an effective job as a revising Chamber. Much legislation leaves it revised and better for the effectiveness and flexibility of the responses from these Benches.

The amendment would make it mandatory for health authorities to prepare policy plans for the ! provision of occupational health services to National Health Service staff. As one of the largest employers in Europe, and as an organisation whose primary concern is health care, it is right that the National Health Service should be concerned about matters affecting the health care of its own skilled and highly valued work force. Health authorities are well aware of the contribution that occupational health services make to their overall policy or good working practices. Long-standing guidance on the organisation and development of such services in the NHS recommends that they should aim to promote, maintain and improve the physical well-being of all employees and advise both staff and management on protection against hazards, contribute towards workers' physical and mental adjustment to their jobs and advise on the job for which each is best suited. It gives clear and comprehensive advice on pre-employment assessment, health records, immunisation, environmental conditions, health guidance and education, treatment services, health assessment on return to work, and planning and organisation. Aided by that comprehensive guidance which has recently been endorsed by both the management and staff side of the National Health Service General Whitley Council, it is quite proper that health authorities should be free to make appropriate provision in the light of local circumstances and priorities. It is also worth noting that the Health and Safety at Work Act applies. Of course there are public health regulations that also apply. A very important point is that Crown immunity for the National Health Service is to be lifted.

Whether the noble Lord pre-empted my reply accurately, I hope that, with the shared objective of what he is trying to achieve with the amendment, he will feel able to withdraw it.

Baroness Masham of Ilton

I should like to add my support to the amendment. As the Minister has stated, the NHS is one of the biggest employers in Europe. I refer to paragraph (f) on smoking, as an example. Nurses have won a very bad reputation because they are heavy smokers. Perhaps the excuse is that they work in a stressful situation. However, one of the other recommendations is counselling. Therefore, if they are working in a stressful situation, counselling should overcome the need to smoke. That shows how important it is that nurses should set an example to the many patients they treat. If they were doing the right things they could pass on those good practices to the patients under their care. That would make us a healthier nation, which is what we should be aiming for.

Baroness Blatch

I agree with almost everything that the noble Baroness said. There are a number of initiatives and campaigns; one has only to think of the "Look after your heart" campaign. Smoking has an impact on heart conditions. No smoking in hospitals should be the norm, and the Government's 1985 circular asked all health authorities to introduce no-smoking policies. An increasing number have done so and we are aware that the anti-smoking activities of health authorities have increased in recent years. We are reconsidering how to update our advice to health authorities.

They are most important issues, as is counselling for stress. However, such counselling is also a managerial responsibility for those who are responsible for employing people in the health service.

Viscount Hanworth

I am appalled that we should go into the detail that is suggested. Perhaps we should take that "nanny" attitude towards the whole of our population. I am a smoker and I resent being constantly criticised for that. I am sorry, but such detail in the Bill is wholly wrong and it should not be included.

The Earl of Balfour

I am also a smoker but I see that the amendment includes alcohol. I must say that when living in Scotland one occasionally needs a little anti-freeze.

Lord Peston

As a vigorous anti-smoker I am tempted to rise to the bait but I shall not. The amendment has nothing to do with nannying but with the saving of life, and that is a duty. As regards alcohol, I draw the noble Earl's attention to the fact that the word "abuse" is at issue. I assure him that I have no objection to alcohol in quite reasonable quantities. However, here one has in mind a different point. The noble Earl will be aware that it is a different phenomenon for those who are alcoholics.

I thank the noble Baroness, Lady Masham, for going into detail. I am always greatly embarrassed by such matters as they appear within the health care professions. I am always astonished by the behaviour of the medical profession towards nutritional standards, for example. Its members are always good at telling the rest of us what do, but when I look at some of them—and I see exceptions in the Chamber—I think that they might first consider taking their own nutritional advice. I did not wish to go into detail but what the noble Baroness said was right.

I was not happy with the Minister's answer. I object to the fact that the noble Baroness appears to be saying that the Bill is about decentralisation and that she would rather stick to its principle than look at the substance of the problems. That is what I am complaining about. In some areas we can argue about the case, but as regards occupational health the Government's response as given by the Minister is complacent. Despite what she said about the relevant bodies, the professional bodies with which I have been in touch take the matter seriously. They would like to see us move along these lines.

I shall withdraw the amendment only because I do not believe that this is the time to divide on such an issue. I should have been much happier if the Government had considered that they could reflect on the matter more seriously than they appear to be willing to do, with a view to coming back and i ensuring that something will happen rather than saying that advice will do the trick. It is with a heavy heart that I withdraw the amendment, but I do not withdraw the argument.

Amendment, by leave, withdrawn.

Baroness Cox moved Amendment No. 107ZB: After Clause 20, insert the following new clause:

("Nursing education: strategic plan.

—(1) Not more than one year from the date of this Act coming into force, the Secretary of State shall publish a strategic plan for nursing education, which shall include—

1. (a) a statement in respect of the future governance of schools and colleges of nursing education; and
2. (b) a timetable for the full introduction for the reform of nursing education curricula under the "Project 2000" proposals.

(2) The Secretary of State shall carry out his duties under this section in consultation with—

1. (a) the United Kingdom Central Council for Nursing, Midwidery and Health Visiting;
2. (b) the National Boards for Nursing, Midwidery and Health Visiting in England, Scotland, Wales and Northern Ireland;
3. (c) the Royal College of Nursing; and
4. (d) any other such bodies concerned with nursing as appear to him appropriate.").

The noble Baroness said: I stress at the outset that this is a probing amendment tabled to ascertain the Government's intentions on the important matter of nurse education. In so many ways it affects the operation and quality of care provided in the National Health Service and in the community. That itself may be affected by the changes introduced by the Bill.

First the profession warmly welcomes some of the recent initiatives which have been supported by the Government. It especially welcomes the introduction of the fundamental change in nurse education to what is called "Project 2000". It will give nurse students the opportunity to have more time to study the theory behind clinical practice. It will also enable them to have more systematic, better-supported and more effectively supervised clinical experiences than were possible when they were primarily employees rather than students. The professional is grateful for the development which represents a historic change in nurse education in this country. It goes a long way towards bringing it into line with many other comparable countries.

But there is concern over certain aspects of the future of nurse education especially in view of some of the recent changes in policy with regard to the timescale of the implementation of Project 2000. Hence the reference in the amendment to the need for a statutory timetable. I wish to give three examples of acute concern. The first example is in Wales Project 2000 was to have been introduced throughout Wales simultaneously in all the colleges involved. Now Ministers have decided that it should be phased. This decision has come after all nine districts in Wales had reached the stage where they were ready to go ahead with their plans to implement Project 2000.

The main reason for the change in policy is financial. Therefore I wish to point out that the cost of Project 2000 in Wales is relatively small compared with the enormous sums being spent on introducing other changes in the National Health Service and community care. There is also deep concern that the change of timing in the implementation of Project 2000 in Wales will have an adverse effect on the recruitment of nurses in Wales. Without an adequately staffed nursing service any other improvements in the provision of health care must be seriously jeopardised. An article in yesterday's South Wales Echo emphasised the seriousness of the situation. I wish to quote briefly from the article. Mr. George Bolton, the general manager of Mid-Glamorgan Health Authority, said that the decision to delay the implementation of Project 2000 left a potentially serious nurse manpower problem into the next decade". My second example comes from Gloucestershire. The Gloucestershire College of Nursing and Midwifery and the Cheltenham and Gloucester College of Higher Education succeeded in their application for a Project 2000 course. I was part of the visiting panel which assessed the application and I can vouch for its excellence. The colleges were intending to start the Project 2000 course this autumn but have recently been informed that funding will not be forthcoming and that they cannot go ahead with recruitment for this year. That was a cruel blow for all the staff who worked so hard under the pressure of time and with great success. It also has serious implications for nurse recruitment and staffing. The district health authority gave such strong support to Project 2000 that other existing courses were discontinued. Consequently, there will be virtually no new nurses qualifying in Gloucester in 1993. That is an appalling potential deficit in the nursing workforce.

My third example comes from the Dorset Institute, and I must declare an interest as a governor. Its staff had worked extremely hard to prepare a proposal for Project 2000 which was subsequently put on a back burner. Again, that was apparently as a result of financial restrictions in the region. That will deprive the region of an opportunity for nurse education in a college which is becoming a centre of excellence and which has recent approvals for full-time honours degrees in clinical nursing and midwifery.

It is important to stress the enormous amount of work that is required for the preparation for Project 2000 courses. It requires extensive consultation with health authorities because of the service implications in the transfer of students to supernumerary studies. It also involves an enormous amount of work by all concerned in the colleges and schools of nursing for the change in the curriculum to diploma in higher education work. The pressure on all concerned to achieve those changes within the timetable originally described has been formidable.

As chairman of the health studies committee of the Council for National Academic Awards, I have been intensively involved in validating many Project 2000 proposals, so I know at first hand the huge amount of work involved and the time pressures under which the Project 2000 proposals have been achieved. I have been deeply impressed by the dedication, commitment and calibre of staff who have been working on many of the schemes. Therefore, I believe it is quite unacceptable to change the goal posts in the middle of the game. As I have indicated, it could also have very serious repercussions in staffing in the National Health Service which, after all, cannot operate effectively without an adequate nursing workforce.

I know that my friend, the noble Baroness, Lady McFarlane of Llandaff, will speak to other important issues covered by the amendment, but I sincerely hope that in her reply my noble friend the Minister will be able to reassure not only the nursing profession but all who are concerned about the adverse effects of shortages of nurses on the provision of health care in the NHS and in the community.

It is well known that there are already perilous shortages in many places. This amendment, together with a renewed commitment to implement Project 2000 on the original timescale, could do something to help in this serious situation. I beg to move.

7 p.m.

Baroness McFarlane of Llandaff

In supporting this amendment I should like to underline and support all that the noble Baroness, Lady Cox, has said about the present situation in nursing education. If we look at some of the background that led up to those proposals, the case for change was made as far back as 1986, following extensive consultations with the profession on the part of the UKCC and subsequently with the health service. Part of those consultations included exercises on the manpower implications of the proposals, as well as a management study carried out by Price Waterhouse on the costing of the whole enterprise.

That went to the department in 1986 and a positive response was received in 1988. I understand that was after the department had carried out its own costing exercises. Therefore, it is regrettable that we are experiencing delays in 1990, four years after the original proposals, and that the situation in recruitment to nursing and nursing education is deteriorating quite considerably.

Added to those proposals from the UKCC, in the chief nursing officer's Strategy for Nursing paper that was supported by the Secretary of State there are proposals and strategies for the nursing profession that underline the importance of Project 2000. Some of the strategy's recommendations are that all staff delivering health care should be appropriately prepared for their practice. Surely that is a minimal expectation in our National Health Service. It is recommended that there should be strategic and operational plans to meet the education needs of the future professional workforce, and that the proposals for educational reform detailed in the UKCC document Project 2000 should be implemented. Those are among many of the proposals put forward in the Strategy for Nursing, again commended by the Secretary of State for Health.

Unfortunately, there seem to be many impediments in our realisation of those aims. The reality of what nursing is seeing is very far from the expectations that have been raised from various times.

First, there has been a reduction in the number of entrants to the Register for Nursing. In 1988-89 there was a 20 per cent. reduction. Secondly, authorities are presently unwilling to second students needing to undertake post-registration clinical training. That is a short-term response to their immediate needs to reduce costs. The English National Board funding for the preparation of nurse teachers has been cut, and I understand from a conference held earlier this week that some hundreds of students are waiting for and being refused access to nurse teacher education courses because of the cuts.

All this is militating against an effective system of nursing education, and although we would not expect such things to be written on the face of the Bill I believe that the plans that the Government have for the future of the health service cannot proceed without effective means of recruiting and retaining nurses.

I suggest that the proposals in Working Paper 10 for education and training in no way reassure the nursing education.

Firstly, the purchaser and provider roles are vested in the same body, that is the regional health authority which would both manage schools of nursing and place contracts for education. I have to say, having worked quite intimately with the education people at my own regional health authority, that their present staffing leaves them inadequately prepared to go into the whole business of manpower and educational management at regional level.

Then I see in Working Paper 10 a fragmentation of educational governance between the English National Board, the regional health authorities and health authorities. The present tendency to short-term planning and economies would be enhanced in the new situation.

I believe that a false assumption is made that recruitment to schools of nursing needs to be largely at a local level. In any event, the mobility of the nursing workforce is extremely great, and it would be better to look at the nursing workforce as a national asset rather than a local asset, particularly at post-basic level in clinical specialties. So the preferred model for the profession is one in which funding for pre-registration education would be administered through the English National Board, the statutory body in England, with the governance of colleges devolved to a local level. That may well be an evolutionary step to further developments, but in this respect one could see the English National Board as analogous to the PCFC or the UFC in funding schools or colleges of nursing.

At post-registration levels of education it is doubtful whether crude market-place principles will ever work in providing an effective specialist nursing working force.

In this amendment we would press for an effectively timetabled introduction of Project 2000 and a greater degree of consultation with the profession for the future strategy for nursing education in view of the future manpower needs.

In considering the introduction of Project 2000, I think it is well to remember that there are over 20 schools of nursing and departments of nursing in university departments and polytechnics, and with the exciting things that are happening in the development of links with higher education elsewhere their needs have sometimes been forgotten.

I am not at all reassured by the single paragraph in Working Paper 10. In fact, the service costs of teaching and research experienced in medical and dental education are the same in nursing education. I believe that one has to take that aspect even more widely than nursing education, since all the health professions being educated in higher education have service costs for teaching and research. The departments of nursing in particular are suffering because they have been denied any kind of resources for the servicing of teaching and research within the service sector.

Lord Peston

My Lords, in supporting the two amendments I congratulate the two noble Baronesses on the excellence of their contributions, which have enabled me to cross off most of what I was going to say. It is a pity that we should discuss a matter as important as the future of nursing education in a rather empty Chamber at this hour. I hope that the fact that not many noble Lords are present will not be taken to be a measure of the importance of the matter. It is enormously important for the future of the National Health Service.

I have been involved with nursing education on the periphery for a great many years. My involvement is derived from the general need to enhance the role of the nurse within the health service. At Queen Mary College for a few years we had a joint degree in economics and nursing. I was enormously impressed with the students who took the course because in taking the degree no concessions were made. They took the full degree which all the other students took and became qualified nurses at the same time. I regret to say that after a few years students decided that they would rather take sociology and social studies as the degree part of the course. However, there are in this country a number of nurses to whom I taught economics who I hope one day will do more to revolutionise the National Health Service than all the provisions in the Bill put together.

I strongly support the amendment. I am bound to say—and I believe the two noble Baronesses agree—that we must see nursing education in the context of the whole role of the nurse. I shall not take time to explain again that within the context of the reform of the National Health Service as the Government see it we can do the manpower planning that is required. During the Government's period of office we have made progress on the career structure of nurses. We have moved in precisely the right direction. Although there have been many trials and tribulations over nurses' pay, again there has been some movement there as well. Many of us who are interested in this field, particularly in the question of pay and decentralisation, wonder what will happen with the NHS trusts. We must see this within that context, but this is not the time for me to speak on all those matters.

I simply wish to commend the amendment to the Government and to note the words "which shall include" in line 3 of the amendment. The amendment makes no attempt to make a complete list. It merely draws attention to important matters. If we had more time, many of us—and certainly the two noble Baronesses—could mention other matters which could be included in the amendment. I hope that we shall have a sympathetic response to the amendment from the Government.

7.15 p.m.

Baroness Hooper

This is an important matter. We are concerned about nurse education and training and we are certainly not losing sight of the need to make progress. As part of our commitment to review non-departmental public bodies, the four United Kingdom health departments commissioned an independent review of the United Kingdom Central Council and the four national boards for nursing, midwifery and health visiting which were established under the Nurses, Midwives and Health Visitors Act 1979.

The report, by management consultants Peat, Marwick, McLintock, was published in August 1989 and recommends among other things that the national boards for England, Scotland and Wales should take over management of schools and colleges of nursing and midwifery from the health authorities. The report has been the subject of wide-ranging consultations, the outcome of which is currently being analysed. We asked those who commented to do so in the context of the document which was referred to by the noble Baroness, Lady McFarlane. This document—Working Paper 10 on education and training—was issued as a follow-up to the Working for Patients White Paper.

It proposes that the responsibility for allocating funds for pre-registration nurse training should in future rest with regional health authorities rather than being top-sliced nationally as at present and allocated via the national boards. In the light of those proposals the working paper suggests a number of models for the future management of schools and colleges of nursing, of which management by the national board is only one.

I can assure the Committee that the Government are fully apprised of the need for early decisions on the issues floated both in the Peat, Marwick, McLintock report and in Working Paper 10. A number of complex matters are being considered in the light of the various views which have been put to us in response to those two documents. We shall be making an announcement as soon as we are in a position to do so. I can assure the Committee that we have already received detailed comments from everyone concerned, including the statutory nursing bodies and the Royal College of Nursing. I can further assure the Committee that the views expressed today will also be taken into account in our consideration. We will come to a view but further discussion with the statutory nursing bodies on the detailed implementation of any changes will be necessary. I mention that because it affects the timetable part of the amendment.

Project 2000 has been generally welcomed and was welcomed by my noble friend Lady Cox in introducing the amendment. The part of the amendment dealing with Project 2000 calls for all United Kingdom health departments to commit themselves to full implementation by a given date. In England, we have already given 16 Project 2000 courses, covering 29 district health authorities, the go-ahead to start during 1989-90. We shall shortly be advising regional health authorities of a second tranche of schemes to start during 1990-91. We are committed to introducing these important changes in nurse education and training while ensuring that patient and client care is not jeopardised. It is not practicable to set out a firm timetable for completing the implementation of the reforms at this time.

I have noted the examples quoted by my noble friend Lady Cox but I emphasise that the speed of implementation must to a large extent be determined by the funding available both now and in the future against other competing needs. The total cost of introducing Project 2000 is very substantial. We must also have regard to the size of the management and planning tasks involved at a time when we all recognise that the National Health Service is undergoing many other changes. The Government's commitment to Project 2000 is clearly demonstrated both by the fact that we are going ahead with a second tranche and by the fact that £38 million has already been set aside in England in 1989-90 and 1990-91 to help in implementing these reforms. In England, the statutory nursing bodies are already involved in the implementation of Project 2000 and are represented on the Project 2000 implementation group.

For these reasons we do not feel that the amendment would necessarily help in progressing the scheme. We hope that my noble friend and the noble Baroness, Lady McFarlane, will feel able to withdraw it.

Baroness Cox

I am grateful to those who have taken part in this short debate. I am especially grateful to my noble friend Lady McFarlane for her comprehensive coverage of the issues involved. She put them in an historic context while highlighting and reminding us of some of the current problems which are matters of great concern. I refer in particular to the downturn in the numbers entering nurse education which will create real problems for staffing the National Health Service in the future, and also to the reduction of funding for the education of nurse teachers. It is helpful to have those points on the record.

I thank the noble Lord, Lord Peston, for his support. As an old Londoner I remember very well the appreciation for that combined course of nurse qualification at the London Hospital and economics degree at the Queen Mary College. It was one of the best combined courses; I was sorry to see its demise. I hope that one day it might reappear. It was an excellent example of the way in which one can take forward nurse education in an academic context.

I thank my noble friend the Minister for her very helpful review of the Government's initiatives, her reference of the consultations currently under way, and her assurance that the Government are aware of the need for early decisions regarding ways forward. I regret that she was not able to give assurances with regard to the problems of delay and to phasing in the implementation of Project 2000. However, I heard her assurances and she has noted the examples and the issues we raised. I hope that her assurances will become reassurances very shortly. With thanks all round I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Blatch

I beg to move that the House do now resume. I suggest that the Committee stage of the Bill be resumed at 8.20 p.m.

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

House resumed.