HL Deb 30 January 1991 vol 525 cc770-86

7.20 p.m.

Lord Belstead rose to move, That the draft order laid before the House on 22nd January be approved.

The noble Lord said: My Lords, in broad terms the order does for Northern Ireland what the National Health Service and Community Care Act has achieved for the rest of the United Kingdom. As such it is the most significant item of legislation in this area since the Health and Personal Social Services Order of 1972.

The main purpose of the order is to build on the strengths of the existing system in Northern Ireland and to give the highly trained and dedicated people working within the services concerned greater freedom to use their skills to the benefit of patients and clients. It seeks to do that by introducing a new flexibility into the system and by delegating responsibility as much as possible to those directly involved in providing care.

At the heart of the order are the provisions which will allow the Department of Health in Northern Ireland to re-define the responsibility of health and social services boards. That power will be used to direct that the primary functions of the boards should include providing, directly or through contracts, services for their resident populations. That change is central to the Government's reforms and will allow the development of a system of contracting through which boards, by commissioning services, will secure those services from a range of providers. In future the primary responsibility of boards will be to identify and make arrangements through contracts to secure access to a comprehensive range of good quality, value-for-money services which will best meet the needs of their resident populations.

To facilitate that, the order makes provision for health and social services contracts. Those contracts will be analogous to the contracts in Great Britain. They will enable boards and other health and social services bodies to make agreements with each other for the provision of services to agreed standards in return for money. They will allow much greater flexibility in the provision of services and will remove one of the major problems of the present system. At present a hospital which improves efficiency and effectiveness and attracts more patients can find itself in financial difficulties because budgets have been set on an historic basis. In future money will follow patients and the successful hospital will be resourced according to the work it is doing.

The order also provides for the reconstitution of the health and social services boards. It will allow the department to appoint smaller, management-oriented boards comprising an equal number of executive and non-executive members and a non-executive chairman. At present boards are unwieldy bodies comprising up to 30 members or more. The new smaller boards, with no more than 12 members and a non-executive chairman, will have a membership which we believe will reflect the skill and experience required for the efficient and effective planning and delivery of health and personal social services. In the case of the Eastern Board one of the non-executive members will be drawn from the Queen's University medical school. The boards will not include direct nominees or representative members. Thus the boards will be better placed to fulfil a strong executive role which will be to plan and obtain the optimum range of services for their local populations.

Undoubtedly, the new, smaller health and social services boards will need advice from the public and from users of the services. To that end the order requires the department to set up four health and social services councils, one relating to each board. They will replace the existing structure of 16 district committees.

Plans for health and social services councils have attracted the most attention during the consultation period. After careful consideration of the comments we have received the order provides that each board, in its role as a commissioner of services, must have a single, coherent source of strong public and consumer advice. It will be the duty of the four individual councils to ensure that they retain strong ties with users and the public. They will be able to do so through publicising their activities and providing the necessary means of communication. They will also be able to set up committees, which could be either on a geographic or subject basis, and will be able to co-opt people to them.

The order does not include an advisory tier at regional level but the new health and social services councils will be able to co-operate with one another and will be free to form an association if they wish to do so. To put that beyond any doubt the order includes a specific provision enabling councils to collaborate freely with one another. The initiative for such collaboration must come from the councils themselves but the Government are committed to ensuring that they have the necessary resources to develop an association if they wish.

During consultation we have been reminded of the importance of ensuring that the new councils get into their stride as quickly as possible. Therefore, initially the department will appoint the chairman of each council. However, it is our firm intention that in future chairmen should be elected by the members, and that will not be prejudiced by the regulations.

The order will also allow the creation of health and social services trusts. Those bodies are a practical expression of our determination to delegate responsibility to those directly involved in the care of patients and clients. The hospitals or facilities which opt for self-governing status will remain firmly within the health and personal social services. The freedom they will be given will be a freedom to manage. It is for that reason that they will be outside the direct management and control of the boards. Their freedom will include an ability to create their own management structures, to determine the terms and conditions of staff, to borrow money within limits and to acquire, own and dispose of assets to ensure that the most effective use is made of them.

Despite that managerial freedom they will be required to continue to play their part within the health service. For example, they will be required to participate fully in medical and other education and research. There will be powers to ensure that they continue to provide services which must be available locally. The department will be able to step in if there is evidence that the freedoms are being abused. However, in practical terms the main control will not be departmental diktat but the fact that the success of self-governing hospitals will depend on their ability to meet the needs of health boards which will be the main purchasers of the services they provide. There will be no virtue in trusts concentrating exclusively on high cost, high turnover services as has been suggested. Instead, they will have every incentive to provide the wide range of services which boards require.

Trust status is voluntary, but hospitals and services which aspire to it will need to meet strict criteria. They will need to be able to demonstrate that they have the management ability, the professional involvement and the financial capacity. Most importantly, they will have to demonstrate that genuine benefits and improved quality of service will flow from trust status.

The order will also enable certain large general medical practices to opt to have their own practice funds. That will allow them to buy services on behalf of their patients, including a defined range of services direct from hospitals. The scheme will be entirely voluntary and practices that have joined will be free to leave at any time.

The funds will be set at a level which will ensure that patients get the services they require. As an additional safeguard there will be an upper limit of £5,000 on the cost to a practice fund of hospital treatment for an individual patient in any one year. Fund-holding GPs should have no good reason, as some have suggested, for keeping certain patients off their lists.

Complementary to that provision, the order will also enable boards to give all general medical practices which are not fund-holding practices an indicative prescribing amount. The aim is to make GPs more aware of their prescribing practices and to eliminate wasteful prescribing. The scheme will be administered in such a way as to ensure that patients will always get the drugs they need. Furthermore, indicative amounts themselves will be adjusted where necessary to take account of patients with special needs for medication.

During consultation on the draft order considerable public attention was given to the proposed power to restrict the overall number of general medical practitioners in Northern Ireland, which will only bring Northern Ireland into line with the rest of the United Kingdom. I assure your Lordships that the power that we intend to take is a reserve power. If at some future date there were to be a disproportionate growth in the number of doctors entering general practice the department would be able to make regulations limiting the number of GPs entering the list. In the meantime, boards already exercise control over the distribution of GPs and that should be sufficient for the foreseeable future.

Finally, perhaps I may say a word about the community care services. The draft order contains only a small number of community care provisions designed to achieve the Government's policy objectives for developing and improving community care services. The reason for the order's comparative silence on this enormously important part of the whole subject is that since the reorganisation of local government in Northern Ireland in 1973 there has been a fully integrated structure for the delivery of both health services and personal social services by the four health and social services boards. There is therefore no need in this order to make new or special arrangements for co-operation, communication and joint planning between the health service and the social services.

There is also no need to make separate provision in the order to require boards to undertake certain duties, such as the assessment of care needs or the establishment of complaints procedures. Unlike local authorities in Great Britain, the four boards in Northern Ireland are already agents of the DHSS, and the department already has wide powers of delegation and direction in regard to them.

When implemented, the new provisions will significantly enhance the role of the boards in the development and funding of community care services. Their role will change from being primarily the direct providers of some community care services to being orchestrators of all such care services. They will also become the holders of the community care budget. In effect, a framework will be created within which boards will assume direct responsibility for assessing the total health and social care needs of individuals and for strengthening co-operation between themselves and other public, voluntary and private organisations involved in the provision of community care services.

I believe the draft order ensures that the health service in Northern Ireland will remain a comprehensive service funded primarily from general taxation and that that will continue to be the guiding principle of the health and personal social services in Northern Ireland in future. I commend the order to your Lordships' House.

Moved, That the draft order laid before the House on 22nd January be approved. [Lord Belstead.]

7.30 p.m.

Lord Prys-Davies

My Lords, I must thank the noble Lord, Lord Belstead, for his clear and comprehensive explanation of this complex and extremely important order which reforms the NHS in Northern Ireland broadly along the lines of the NHS on the mainland. The order consists of 35 articles and six schedules which will provide the framework for the new services. In addition, according to my count, at least 20 important matters within that framework will be governed by regulations subject to negative resolutions. Of course we have not seen the details of those regulations.

Moreover, the order gives wide order-making powers to the department. There are about 200 pages of notes on articles. Clearly, this is a very large subject. There can be few Northern Ireland orders coming before your Lordships' House that are more important than this one, and I am sure that that would be the evidence of my noble friend Lord Fitt and my friends on the Liberal Benches. It will affect everyone in Northern Ireland because everyone is a patient or potential patient. We say that to introduce this legislation, of all legislation, by an Order in Council instead of a Bill is totally inadequate. The procedure does not give the House the opportunity to give the legislation the detailed and careful consideration over two or three days which it warrants. No improvements can be made because amendments cannot be tabled. Our task is indeed a frustrating one. All we can do is attempt briefly to highlight what we see as the principal changes which are a cause of concern.

I am very grateful that the noble Lord, Lord Belstead, on two occasions in the course of his speech admitted that there had been concern on certain matters. We can ask for certain matters to be clarified. Surely in a democratic society there must be a better way of dealing with Northern Ireland legislation. It seems to me that the political parties in Northern Ireland should not remain silent on this issue for much longer.

Regrettably, there is another preliminary point which it is my duty to make. We were not told until last Thursday afternoon that this order would be discussed tonight. Although the department was able to give us at least 14 days' notice of the Road Traffic (Amendment) (Northern Ireland) Order 1991 which we discussed earlier this evening, seven days' notice for an order of this magnitude is far too short for the debate. I know that the notice came too late for some noble Lords to rearrange their timetable, and that explains their absence from the House tonight. I do not blame the Minister at all. We have always had an excellent relationship with Northern Ireland Ministers. But I believe that this failure to give adequate notice of the debate perhaps draws attention to difficulties within the department itself which may deserve urgent examination. I do not have the evidence to go any further than that. Perhaps I may thank the noble Lord, Lord Belstead, for making available to the Opposition parties the extremely helpful 200 pages of notes on articles when he became aware of our difficulties last Thursday afternoon. Tonight the Minister spelt out the main objectives of this order: to introduce flexibility into the service, to delegate responsibility, to improve services to patients, to promote better value for money and to improve the management of health services. Who can disagree with those objectives? I believe they are and should be the objectives of every hospital, surgery and clinic in Northern Ireland.

The NHS is a big business and, like any other big commercial undertaking, should manage its resources with the greatest possible effectiveness. I accept that there are many competent and imaginative managers in the NHS in Northern Ireland, but it could be argued that to some extent in the present system the quality of management of the NHS in Northern Ireland is more at fault than the administrative structure itself. Yet the new structure, as the consultative documents and notes on articles make clear, will require even more sophisticated managers than the present one. Is the department satisfied that by 1st April it will have in post the senior staff and middle managers fitted for these difficult tasks? It would be helpful if the Minister could tell the House what will be the cost of introducing this new structure in the Province and indeed how much has been spent already on preparing the way for the changes.

I referred to the similarity between the NHS and large commercial undertakings. On the other hand, unlike other large-scale undertakings, the distinguishing characteristic of the National Health Service is that the work done in clinics, wards, hospitals and surgeries is person work. It is people and not chattels or goods that are being treated. It is the patient or, in the ca se of a severely disabled or child patient, his representative who decides when and to whom he presents himself for treatment and how much treatment, if any, to accept. It is the patient who knows best how well the system is working or is not working at the point of delivery. So in a sense the patient himself is a potential manager. Yet the role of the patient is almost overlooked in the structure that is assembled by this order, so that, notwithstanding the rhetoric, the problem of making the service accountable to patients will remain.

I noticed that under Article 5 there will be representative committees of the GPs of the area, the opticians of the area, the dentists of the area and the pharmacists of the area. But having rightly recognised the role of certain professions, why is the role of patients not recognised in a similar fashion in Article 5? The Minister will recognise that I am now developing a point which has powerfully and vigorously been made to the department by the Association of District Councils, but it may have been too imaginative for the authors of the consultative papers to grasp its significance.

I accept that the personnel who are active patients vary all the time. I appreciate that patients as such are not organised. But within the body of patients and potential patients there are many health voluntary organisations as well as charitable organisations which could form an electorate.

Although I very much regret that the opportunity to set up a representative committee of patients under Article 5 has been lost, it may still be possible for the board itself to establish a sub-committee representative o r patients under paragraph 5 of Article 3 (or perhaps it is Schedule 3). I should be grateful if the department would consider that possibility. Indeed, in introducing the order the Minister spoke of the power that is vested in the boards to appoint sub-committees. I urge them to appoint sub-committees which will be representative of patients.

There has been a long tradition of lay involvement in the running of hospitals which pre-dates the creation of the NHS. It is clear that the role of the layman will be substantially reduced in the new structure and that has given rise to widespread concern, if not anger. I believe that the Minister has acknowledged that concern. To a large extent the order rests upon the notion that the voice of lay opinion has been too strong within the NHS. I have no evidence that the development of the NHS has been retarded because of the presence of strong lay opinion. Indeed, without strong lay opinion would many of the existing hospitals of Northern Ireland ever have been built?

Lay opinion has been substantially undermined by this order in two ways. First, as the Minister explained, the new area boards will be smaller bodies consisting of executive members, including the chief officer of the board, and certain non-executive members. There is no requirement that at least one member shall be a district councillor and another a trade unionist. Indeed, there is no requirement, apart possibly from the north eastern board, that one member shall be associated with the universities. I quote the words current in departmental circles: The new boards will no longer have representatives of bodies which have traditionally been hostile to government policy". If the department has experienced hostility from district councillors and trade unionists, surely the safe inference that the Government should draw from that has to do with the failure of the Government to design policies which retain the confidence of elected members and trade unionists. The evidence should certainly not be used to silence their voice or to silence honest criticism at board level.

Again, lay opinion will also be substantially weakened when the present 16 district advisory committees are abolished and replaced on 1st April with four area advisory councils, with one council for each board and each council consisting of about 24 members appointed by the department. So overnight the number of lay persons involved in the advisory health machinery in Northern Ireland will be reduced from about 300 to about 100. We think that that is disturbing.

We hear a great deal from health Ministers about the need to devolve power and decentralise units of administration at the unit level. As the district is the lowest level at which it would be possible to make a comprehensive assessment of the health needs of the community and to plan and deploy the range of health services required to meet those needs, why does the district in Northern Ireland not continue as a point of accountability to the people of the district? We suggest that responsibility to the people who live in the district seems essential if officials are to be aware of the beliefs, feelings and experience of people concerning the way they are being treated in surgeries, in clinics and hospitals.

In our view it is also to be regretted that the opportunity has not been taken to establish in Northern Ireland a health advisory council. I am grateful to the Minister for having explained the potential in this order for the area councils to collaborate together to that end. But there has been and is a demand for a Northern Ireland health advisory council. I am sure that the Minister will know that that demand has been voiced by the Northern Ireland Consumer Council and the Association of District Councils in Northern Ireland. But in so far as there is to be a regional voice, it is left, as the Minister explained, to the four area councils to collaborate together under paragraph 2(f) of Schedule 1. That is at best second best, and some would say that it is a poor second best.

We take that view because the area councils will be concerned mainly with the ongoing day-to-day operations and the planning of the service for their areas. Surely, what is required at the Northern Ireland level is an advisory body, supported by a research and intelligence unit, to monitor the service, undertake or commission research and advise the Secretary of State about priorities and future changes. Although that is missing from the order, I hope that the department will encourage the area councils to collaborate and co-operate to provide a regional advisory service, even though it will be a second best service.

Before leaving the subject of the area health councils I wish to ask the Minister questions about two of their functions. I note that members of the area council will have the right to enter and inspect NHS premises. But that right is subject to such conditions as may be prescribed. Can the Minister say whether it is intended that the council members should not have the right to make unannounced visits? I should be concerned if they were prohibited from carrying out an unannounced visit. However, if council members are to see what surely goes on at the point of delivery in hospitals, clinics and surgeries, it is important that their visits should be unannounced.

There is a second point on which I should be grateful for clarification. In a speech made on 23rd January the Health Minister said that a health council will be able to act on behalf of patients and clients in connection with complaints. I have searched for the statutory basis of that statement. It seems to me that I have searched in vain. I have been unable to find a specific reference to the council's right to assist complainants to lodge a complaint. Is there a specific reference or a specific statutory authority? If so, where is that authority? It would also be helpful if the Minister could clarify the significance of his colleague's reference to "clients". What is the distinction between a patient and a client?

Time does not permit me to deal at length with NHS trusts for self-governing hospitals. However, I must record the deep concern felt by Members on this side of the House about that development. We are worried that NHS trusts could lead to a two-tier service, and not merely a two-tier service but one being inferior to the other. If that were to happen it would undermine one of the fundamental principles of the NHS. We on this side of the House trust that the proposal will not be implemented until there has been an opportunity to evaluate experience on the mainland and until appropriate safeguards are introduced.

The major risk that we see with a fundholding practice is that over time it could damage the doctor-patient relationship of trust. It was the late Lord Cohen, the eminent medical Peer, who spoke of the doctor-patient relationship of trust. It is essential to the overall relationship. If the patient came to believe that in prescribing treatment his doctor was influenced by what his budget could afford rather than what was best for the patient that trust would be undermined. On the other hand, I am not so worried about indicative budgets for drugs provided that they remain as guidelines to help the GP to monitor and examine his prescribing practice, as was indicated by the Minister.

I wish to raise one issue about voluntary contributions. I welcome the new powers contained in Article 23. However, as I understand the article, a condition imposed by a donor and attached to a gift can be overridden or overreached by the department. If that is a correct interpretation of one of the paragraphs of Article 23, is it wise that the department should exercise that power unless it is clear that in the circumstances the condition has become unreal? Usually donors intend that an attached condition to a gift shall exist in perpetuity. However, if a department were too easily to override a condition, that could discourage people from making substantial conditional donations in future.

I have been keeping my eye on the clock but I do not believe that I alone have spoken for 36 minutes. Although we can approve the main objectives spelt out by the Minister, for the reasons that I have given we cannot approve many of the major proposals introduced by the order. The service exists for patients and I must hope that it will bring benefits to the people of Northern Ireland.

8 p.m.

Lord Holme of Cheltenham

My Lords, I wish to associate Members on these Benches with the expression of gratitude to the Minister for his clear introduction of the order. However, I too must express regret at the extremely short notice given to the House on this important matter. The Minister could not have been more courteous in his personal expressions of regret and he has done everything possible to compensate but, in my view, the House should not be treated in this cursory manner on such an important matter.

This is a very dense order with profound implications for the health of the community in Northern Ireland. It is based on an Act to which we on these Benches were opposed. Therefore, the Minister will not be surprised to hear that we do not like the proposals in the order any more than we liked many of the proposals in the parent Act. Nor, it should be said, are we alone in our reaction. As a result of this measure the Government can claim the extraordinary achievement of uniting all parties in Northern Ireland against them. The consensus that this is not the right way for the health service to go in Northern Ireland is extraordinarily broad-based and impressive. We in this House must give voice to that and, even now, ask the Government to think hard about the way in which they handle implementation of the order.

There are many proposals, some of which are radical. One can understand why the Government have proposed them; they fit in with their general approach. However, where the Government are producing radical new initiatives I urge them to experiment with pilot and test schemes. They should not rush wholesale into their general imposition, for ideological reasons, of every single line in the order. I should like to concentrate on Articles 3 and 4 to which the noble Lord, Lord Prys-Davis, gave specific attention. I question the composition of the boards and councils and their connection with the local communities of Northern Ireland. The boards are now to be overwhelmingly managerial in composition. They will no longer have that broad-based representation of trade unions, local authorities, and interested groups, with government appointees.

As regards the councils which shadow the boards and replace the district committees, the connection which the district committees had with the local communities will disappear both because the councils are much larger bodies covering much larger areas and because they will not have that representation of local people and patients. For example, will representatives on those new health and social security councils have the time to visit local facilities, to take up individual cases and have that close and intimate connection with the services offered which is so important to good health care? I am extremely sceptical. One effect of the order which must be feared is that it will end up cutting off services from close connection to the local community.

Your Lordships will recall that in the original White Paper one of the criticisms of the district committees was that they had a localised focus. That is one of the advantages of the present system; it has a strong localised focus. If we lose that in the provision of health care, we lose a great deal.

On the whole, our anxiety is that the composition of the new bodies will mean too little representation of consumers, communities and carers and too much representation of bureaucrats and businessmen. I am not opposed—nor are other noble Lords on these Benches—to good managerial experience on the bodies. That will be an asset. However, it should be recognised that management does not stop short at techniques of management, but embraces fully understanding the people who work in the service, the people who are the patients of the service and, most notably, the wishes of the local communities. I fear that we shall lose accountability through the implementation of these proposals.

Considerable responsibilities are to be exercised by the new boards and their shadow councils. They have very considerable powers. In our opinion, it would be much better if those powers were more directly accountable to the local community. I am sure all sides of the House want every effort to go into fostering those elements in Northern Ireland which represent a civic society and encouraging institutions where people come together and work together locally for matters of local importance. Therefore, we must regret the replacement of the present work able system of district committees by a managerial imperative and larger, more distant bodies.

Finally, I hope that we shall recognise that the Government have a duty when implementing the order to ensure that they do not throw out the baby of human contact and care with the bath water of inefficiency.

Lord Fitt

My Lords, I welcome the noble Lord, Lord Belstead, in his new role as spokesman for Northern Ireland. I remember him when he first came to Northern Ireland after the imposition of direct rule in 1972. As he has rightly said, we are discussing the major reform of a state of affairs which has existed since 1972. The reform brings with it a great deal of anxiety as to how health and social services are to be operated throughout the 1990s.

Northern Ireland is a small geographical area. Elected representatives have a very close relationship with their electorate. When I was an elected representative I recall that 60 or 70 per cent. of my constituency surgery activities were related to health and social services and every aspect of them in relation to sickness, social security benefits and so on. I can tell the Minister that there is a great deal of anxiety as to what the proposed changes may mean in relation to community involvement which has existed hitherto in Northern Ireland.

When I was a Member of the Stormont Parliament, we discussed contentious issues dating back to the formation of the state and, indeed, before that. However, if there was one issue on which we could find substantial agreement across the broad political divide—and there were serious disagreements on many other matters—it was in relation to health and social services. On those matters we could overcome our political differences.

As my noble friend on the Front Bench said, were any other political system in operation, a major piece of legislation would be called for. We should be having a First Reading, a Second Reading, Committee and Report stages. However, because of the vacuum which now exists in Northern Ireland, the only way in which this matter can be dealt is by an Order of Parliament.

I do not blame the Government for that because a good deal of responsibility for the present impasse must rest on the shoulders of elected representatives of the various political parties in Northern Ireland. It must be said, even though I am in total agreement with them in opposition to the order, that if a form of local administration could be agreed upon, then responsibility for this type of legislation would be taken away from this House and given to those elected representatives.

What is the answer? Is political opposition within Northern Ireland so deep that the parties are prepared to continue with a system which allows for an order such as this? Or are the parties prepared to find a political accommodation which would make the order totally unnecessary?

The noble Lord, Lord Belstead, will be aware of the political atmosphere in 1972 following the abolition of Stormont. As regards the present situation, there seems to be no great political advance. Stormont has gone. There was an Executive in 1974 for a few months. Since then no possible opportunity of agreement to bring about devolved government has appeared on the horizon.

The elected representatives are finding unanimous support among political parties in their total opposition to the way in which this legislation is brought about. Therefore, would it not be possible to form a committee in the other House, whether or not it be a Northern Ireland committee? At least that would allow more time to discuss and amend, if necessary, legislation such as this before it becomes law in Northern Ireland.

That suggestion, I realise, is loaded with dynamite. One of the main political parties in Northern Ireland—the SDLP —would regard the setting up of such a committee as being a step along the road to integration. In that situation, that party would have its friends. The representatives from the Irish Government on the Anglo-Irish intergovernmental council object to such a step being taken. They do not want a committee set up at Westminster to discuss this type of legislation. Therefore, as has rightly been said, a good deal of unanimity has been found in opposition. However, the means of doing away with orders such as this lies with the Northern Ireland elected representatives. I do not believe that the Government can be blamed for persisting with this type of legislation in the absence of agreement in Northern Ireland.

When the Government bring forward an order such as this there is justification for so doing in the absence of agreement in Northern Ireland. But they say, "We have consulted all the interested bodies. We have discussed the implementation of the order, and after listening to all the representations we now introduce the order". However, the Government have not done that. They have not consulted with any of the interested parties. Interested bodies such as the local community group, trade unionists—some people may ask what trade unionists have to do with health and social services; they have a lot to do with them because all their members at one time or other will be in receipt of them—Churches and all other interested groups have made representations. But they have not been listened to.

The Government cannot have it both ways. They cannot say that they have listened to representations from interested parties and have produced legislation which was agreed when they have introduced legislation in the face of total opposition from elected representatives right across the political spectrum in Northern Ireland. They cannot have listened to the elected voice of the communities under which the legislation will be imposed.

I wish to highlight that point. The noble Lord, Lord Skelmersdale, was the spokesman for health and social services in Northern Ireland last year. Many representations were made to me regarding a hospital in a constituency that I did not represent: the Moyle Hospital in County Antrim. At the time a proposal existed—and still exists—to remove the acute services from the hospital in County Antrim and transfer them to another hospital to be built in two stages in Antrim, in an area in an entirely different part of the county. The first stage would be completed in 1994 and then the second stage would be built.

When the proposal first became known to the people in East Antrim all the community groups referred to by my noble friend voiced their opposition. They included Catholic and Protestant Churches, Catholic and Protestant churchmen, Catholic and Protestant schools, social community groups, industrialists and trade union groups in the area. The hospital had existed for many years, and from 1984 to 1988 there had been an increased number of acute operations which had taken place there. The figures produced by the hospital were justified.

Those groups made representations but realised that they were not being heard. I asked the Minister in this House whether he would be prepared to meet a deputation representative of those groups to hear the case why the hospital should continue to provide acute services. The Minister said that a sub-committee of the Northern Ireland board had been set up to hear objections. The personnel of that sub-committee consisted of four members, each with an interest in ensuring that Moyle did not retain those acute services; in ensuring, in fact, that the acute services were transferred to the new hospital.

I do not regard that as listening to the anxieties of the people in the area. All the people in the area were so concerned that they obtained a grant from the council. In a roundabout way the money came from the ratepayers. Under a regulation which exists, where there is anxiety in regard to any given subject, a proportion of the rates can be given to the local authority to carry out their own inquiry. A proportion of the rates was given and money was obtained from voluntary sources. A total amount of £40,000 was obtained.

So concerned were those people that they commissioned a report from an eminent company in Britain, Touche Ross, which has vast experience in the administration of hospital care on the mainland. They paid £40,000 to carry out an inch by inch investigation into the anxieties of the people in East Antrim. After making all the necessary inquiries with all the experience at its disposal and all its administration experience, Touche Ross came to the conclusion that the people of East Antrim were right to voice their concerns; there was no justification to take away the acute services from Moyle Hospital and transfer them to what the people of East Antrim regarded as a totally inaccessible place in Antrim.

My noble friend on the Front Bench said that it is patient care which must be paramount in legislation of this type and that some means should be found to organise patients. How much better organised could those people have been? They included every community group in the East Antrim area—the Churches, the schools and the trade unionists. After failing to make successful representation themselves they commissioned an eminent organisation to produce a report, and the report fully supported the anxieties expressed. The ministry did not even look at it. It did not even ask to see the report.

That was totally different from the attitude that was taken in relation to another acute appraisal taking place in another part of Northern Ireland in Coleraine. An organisation was set up to investigate the commissioning of a new hospital in Coleraine at the cost of £100,000. It involved far more personnel, and 14 people from the local area were involved also. That was very different from the consideration given to the Moyle Action Group's report, where four people with a direct vested interest in promoting the transfer of the services were the people who made the decision not to listen to the Moyle Action Group.

I make an appeal to the Minister, and I do not think I ask a great deal. In his new resurrected role as Minister for Northern Ireland would he be doing any harm if he were to meet a delegation from the East Antrim area and discuss with them the recommendations made in their Moyle Action Group report in association with the report commissioned from Touche Ross? It will not cause any delay in implementing the present proposals. It may mean that after listening to the concerns of people who will operate the health and social services in that hospital and in that area there will be no necessity for stage two of the. Antrim development.

Health and social services are personal to the people of Northern Ireland; it is something about which there is very little, if any, political disagreement. The fact is that all the representatives in another place, and Members here, have voiced their opposition to the way in which this legislation has been brought before us. It is totally wrong that an order of this description should be brought before us on a take-it-or-leave-it basis and that it cannot be amended. Its contents are of vital importance to the people of Northern Ireland concerning their health and many other aspects.

I have illustrated the case of the Moyle hospital to show how its representations have been totally disregarded. Its representatives were not given the opportunity of putting their case to the Minister. They prepared the Moyle Hospital Action Committee report. Representations were made by all the community groups, but they were totally cast aside. That is a very bad way to plan for the future of health and social services in Northern Ireland. Many representations have been made to the noble Lord on all aspects of this order. Before making a final decision on the dispersal of the acute services from that hospital it would be in the Minister's interests, besides those of democracy and democratic accountability in Northern Ireland, if he were to meet representatives of the Moyle Hospital Action Committee to see whether at this late stage some other decision can be made.

Lord Belstead

My Lords, although considerable criticism has come during the remarks of noble Lords who have spoken on this order, nonetheless I wish to thank your Lordships for the care which you have taken in speaking about an order which the noble Lords, Lord Prys-Davies, Lord Holme and Lord Fitt, have quite rightly said is extremely important. The fact is that we are the prisoners of the constitutional position in which we find ourselves. Your Lordships would not thank me if I expanded one that except to say this evening that the noble Lord, Lord Fitt, mentioned one possible way in which an order of this kind might be dealt with in another place. However, in the same breath he said that he thought it probably would not be a way forward because it would be resented and disliked by one of the political parties.

I shall not say anything further about that. We have the order under the legislation of 1974 and we have to deal with it in that way. I unreservedly give an apology to the noble Lords, Lord Prys-Davies, Lord Holme and Lord Fitt, and to your Lordships' House that there was such short notice. Once again I thank noble Lords for the way in which they couched their criticisms on that matter.

Having said that, I shall endeavour to answer some of the points which have been put to me. The noble Lord, Lord Prys-Davies, asked me a direct question about the cost of implementing the reforms, particularly the changes in management structure. The cost will not be at the expense of patient and client care. We have already spent an additional £3.5 million in the past financial year on implementing the health reforms. We have allocated no less than £7 million this year so far. We hope that further resources will be available. Unit general managers have been in post since 1st April 1990.

I now move on to the point made by the noble Lord when he asked whether people of the right quality will be there. Unit general managers have been in post since 1st April of last year bringing the health and personal social services in Northern Ireland into line with the health service in Great Britain. That will provide effective management of resources at unit level. It has cost £250,000 in a full year. Four boards only have already recruited about 200 additional staff this year in key areas such as finance, personnel, needs assessment, medical audit and contracting at a cost of £3.5 million. I hope that that goes some way towards meeting the points which the noble Lord made on that matter.

The structure of the reforms has come in for considerable criticism this evening from the noble Lords, Lord Prys-Davies and Lord Holme, when speaking about the boards and the health and social services councils. I say on behalf of the Government that it is a plus that we are going to have the appointment of executive members, including actual managers, on the boards for the very first time. It is right that they should at least be represented as executive members on the new boards given the background of what I have said about having tried to build up in a sensible and prudent way at considerable cost in order to achieve exactly the same objective as that which the noble Lord, Lord Prys-Davies, put to me across the House; namely, that the management needs to be first-class.

The noble Lord then moved on to talk about representatives of the general public and asked about the patients and the general public at large.

Lord Prys-Davies

My Lords, I spoke specifically about representation by the patients, or the users as they are described by the Association of County Districts, and whether there could be a representative committee for them in the same way as there is for doctors, chemists, pharmacists and dentists. That is one issue. There is also the broader issue of the representation of the public generally.

Lord Belstead

My Lords, I shall do my best to answer that very simply. As the noble Lord himself recorded, there is the right to appoint sub-committees and the right to co-opt. I believe that this right will be used. I shall be extremely surprised if it is not. We shall also find on the social services councils the kind of representation which the noble Lord has spoken about. Both the noble Lord and the noble Lord, Lord Holme, were also critical of the fracturing, as they saw it, of the link with the local community by the removal as of right of district councillors from the boards.

I do not believe that community links are going to suffer as a result of these reforms. The area health and social services councils on which district councillors will have an important role will represent the interests of the local community. It is worth bearing in mind that in Northern Ireland health services are not organised on a district basis. Having said that, perhaps I may briefly give chapter and verse. For example, it is envisaged that the council for the eastern board will have about 30 members after April. The other three boards will have 24 members. Forty per cent. of the membership of each council must be reserved for district councillors. One member must be appointed on the nomination of each district council. I believe I am right in saying that that will be done by regulations.

This is a serious attempt to ensure that the district councils are well represented and fully representative, with no exceptions, on the new health and social services councils. The noble Lord finished that part of his remarks by asking about an association. I wish to repeat what I said when I moved the order. I said that the Government are committed to ensuring the necessary resources for the formation of an association of councils if that is what the councils feel that they want once the reforms have come into effect.

The noble Lord moved on to talk about the trusts. He made the familiar criticism that there is the danger of a two-tier service. Although trusts will be run by their own board of directors independent of other tiers of health service management and will have wide-ranging freedoms not available to units which remain under board control, they will be absolutely required to comply with certain departmental guidance on ethical, public health, patient health, patient safety and emergency and contingency planning issues. I cannot say it too frequently: they must continue to provide free care at the point of delivery.

The noble Lord also asked me a number of technical questions. He said that he could not find anywhere in the order the provision for the assistance by councils with complaints. This will be contained in regulations to be made under paragraph 2 of Schedule 1 to the order. The noble Lord also asked about the the difference between patients and clients. Technically, "clients" cover those in receipt of social service functions; "patients" are those in general receipt of health care. The noble Lord also asked me whether health and social services councils should have the right to make unannounced visits. The noble Lord has a great deal of specialist experience of public matters and quite rightly said that an unannounced visit is probably worth 10 times as much as an announced one. I must just say that the councils are not inspectorial bodies. It is not appropriate that they should have powers to visit unannounced. There are, as I think the noble Lord will well realise, other ways in which inspection of high standards in the health service is undertaken, but it is not through unannounced visits of the health and social services councils.

In answering these questions about district councillors and about the representation of patients and of the public at large, I should have mentioned more frequently the name of the noble Lord, Lord Holme, as it was he who also directed most of his remarks to the way in which the new boards and indeed the councils will be structured. I hope that I have covered most of the points raised by the noble Lord. If I find I have not, I promise to write to him.

That leaves me with one last point. The noble Lord, Lord Fitt, spoke at some length about a matter of which the noble Lord knows at first hand. I refer to the future of the Moyle hospital and proposals for the dispersal from it of acute services. I am aware that there has been a considerable amount of feeling which has resulted in a campaign of opposition in the area to any plans to remove acute services from the Moyle hospital. The report of the Moyle Hospital Action Committee which is presently being considered by the northern board and the Department of Health and Social Services is the culmination of that campaign. The board has deferred making a decision about the pattern of services to be retained at the Moyle after 1993 and has given a commitment that for the time being it will seek to maintain the services at present provided there. Final proposals for future services will be subject to the approval of the department and the action committee will be afforded an opportunity to make any representations which it considers appropriate.

I give the noble Lord an undertaking that I shall draw to the attention of the department and the Minister who is responsible for the department the speech which he made this evening. What the noble Lord said was important and we should take it seriously. But this evening I can go no further than that. I commend the order to the House.

On Question, Motion agreed to.