HL Deb 24 April 1995 vol 563 cc706-62

3.15 p.m

Report received.

Clause 1 [Abolition of RHAs, DHAs and FHSAs and duty to establish HAs]:

Baroness Jay of Paddington moved Amendment No. 1:

Page 1, line 11, at end insert ("and to establish for each of the English health regions and for Wales an Advisory Committee on Appointments to advise on the selection and appointment of non-executive members to those authorities.").

The noble Baroness said: My Lords, the above amendment is designed to ensure that the appointments to the new, very powerful, health authority boards are made more openly and more objectively than is the case at present. It would bring the appointments system for the new authorities that would be established in England and Wales into line with the practice that already exists in Scotland.

Noble Lords will be aware that there is considerable disquiet about the present methods of appointment in the health service. That has led, at worst, to accusations of political cronyism and patronage and, at best, to a widespread feeling that sometimes inexperienced or inappropriate people have been appointed simply because they are known to senior people in the health service, to Ministers or to others involved.

There are fears that that situation will become worse under the new Bill with the abolition of the regional health authorities because all local appointments will then be directly in the hands of the Secretary of State—involving about 900 appointments a year. The Government seem to have accepted that some reform of the present system is necessary. New guidance on appointments was published in February and the Chief Executive of the health service, Mr. Langlands, in his evidence to the Committee on Standards in Public Life of the noble and learned Lord, Lord Nolan, spoke of change, somewhat coincidentally on the same day that the new guidance was published.

It is now suggested that appointments will be advertised and that candidates will be formally interviewed. But all of that has taken place since the Health Authorities Bill was published and after it had finished its passage through another place. There is nothing on the face of the Bill as it now stands to make the appointments system open and more objective.

We discussed the issue at length in Committee. From these Benches we proposed various amendments to try to ensure that the new health authorities would be democratically rooted in their own local communities and demonstrably appointed on an open basis. However, the Government rejected all those amendments. The present amendment would simply create a statutory, independent authority to advise on health service appointments; a system which, after all, is widely accepted in other fields and is in the best traditions of British public service.

Perhaps I may remind the House of the system which exists in Scotland. The Secretary of State for Scotland has created a committee of five chaired by the Lord Provost of Edinburgh—who, I understand, is a Labour councillor—to advise him on the appointment and reappointment of non-executive members of the health boards in Scotland. In order to broaden the selection base of candidates to posts in that field, a wide range of bodies which represent many different aspects of community life in Scotland—for example, the voluntary sector, different Church groups and members of different political parties—have been invited to put forward names and widespread public advertising is going on at the same time.

Initial interviews for people whose names come forward as a result of those processes are conducted by the chairmen of the relevant boards. They then pass on their recommendations to the national advisory committee for consideration and recommendation for appointment. That committee also considers reappointment to health boards on the basis of local reports.

When we discussed this matter in Committee the Minister said that the Scottish system could not be adopted sensibly south of the border because of the different scale of organisation of the health service in England and Wales and the much larger population in those two countries. But that would only be an argument, it seems to me, against having one national, advisory body for England and Wales. Amendment No. 1, which we are now considering, proposes that there should be an appointments body for each of the English regions and for Wales. That would enable local knowledge to be used in making recommendations for appointments in precisely the same way as has been done up until now by the regional health authorities.

During the Committee stage the Minister also said that in future candidates' appointments would be sifted locally and that the sifting panel, may include an independent member".—[Official Report, 30/3/95; col. 1725.] But the fact that the sifting panel may include an independent member is not good enough. It seems to me that that leaves too much to local discretion and to the continuing suspicion that appointments are being arranged on a cosy and friendly basis rather than in an open environment.

The Minister also said that she would re-emphasise the role of the regional chairmen in the new process. When I reread the Official Report I was not sure who precisely this would refer to under the new system. I imagine that the Minister refers to the person who will be appointed to be the regional member of the health service executive. That person will of course be appointed by the Secretary of State and will be just one of a few people who will be members of the executive board of the health service. That again seems to me—if it is to be the case that the emphasis is to be placed on the role played by that person—to continue the suspicion that all appointments are made on the basis of a cosy, internal collaboration rather than in an open and rigorous fashion.

I remind your Lordships that the Minister also said in Committee, in response to our amendments on appointments, that the, views of people who are more detached from the NHS can also be valuable".—[Official Report, 30/3/95; col. 1725.] That is exactly what the amendment seeks to formalise and to make statutory. We know that the committee chaired by the noble and learned Lord, Lord Nolan, on standards in public life has received more representations on National Health Service appointments than on any other subject. We also know that members of the noble and learned Lord's committee described the present proposals for changing the system of appointments—which were described in the February document and by the chief executive of the health service in his evidence to the Nolan Committee—as "inbred". They also said that they were disappointed that there was no compulsory independent element in the new proposals that were to be introduced.

During the Committee stage the noble Baroness, Lady Cumberlege, said that the Government would consider carefully any recommendations which came from the Nolan Committee on this subject. I would ask her to consider this amendment carefully. It seems to me that by accepting it she could well pre-empt what could be an important future recommendation from the Nolan Committee, which could be embarrassing for the Government if an independent selection procedure has not been placed on the face of this Health Authorities Bill. I beg to move.

Lord Elton

My Lords, I listened with great interest to what the noble Baroness said. Of course many of us are aware of the extent of government patronage and of the concern that it should be responsibly used. However, I am not at all sure that I see anything reassuring in this amendment because it does nothing more than require the Secretary of State to set up an advisory committee. At the moment he is allowed to take advice from whomever he will; under the Bill as it would be amended, he would merely be required to get the same people into one room with a chairman, so nothing whatever would change. I suspect that not very long after that the noble Baroness would seek an opportunity to move an amendment which would require there to be a committee of advisers on who should be appointed to that committee and thus to get it out of the Secretary of State's hands. This manifestly does not do that.

Lord Desai

My Lords, I support my noble friend in the amendment she has moved. I think the noble Lord, Lord Elton, is trying to damn it with faint praise, or perhaps faint criticism. The principle is openness. We must have an open system which is seen to be above criticism or above charges of favouritism. In many areas of life in this country over the past decade or so more and more matters have been made open. It is time National Health Service appointments for non-executive directors were made open. The kind of questions which are emerging in the business area as regards the responsibilities of non-executive directors and their liabilities will also emerge as regards the National Health Service as it becomes more and more market oriented. When that happens we may find that some of the people who fill non-executive appointments may not he up to scratch because they may not have the expertise required of non-executive directors in the business area. I believe it would be a good idea if we adopted the amendment moved by my noble friend. If the noble Lord opposite wants to makes it a statutory and completely independent body, perhaps we should move an amendment to that effect.

Lord Peyton of Yeovil

My Lords, I wish to support what my noble friend Lord Elton said. The noble Baroness opposite moved this amendment with her usual skill and made a persuasive case for it. However, I am not convinced, even by the cogent way in which she put her arguments, that we are really in need of another advisory committee. This country is not perhaps as rich as it was in the amount of advice and counselling which is made available at almost all levels, regardless of its value.

Lord Milverton

My Lords, I also do not see the point of this amendment. I am sure my noble friend the Minister will be able to give good reasons why we should dismiss it. As my noble friend Lord Peyton of Yeovil has just said, it seems to me the amendment would make things just as top heavy, or more top heavy. We want less of that. The amendment has not impressed me. I believe the National Health Service is open; it is not a closed shop.

Lord Ennals

My Lords, I was not present in the Chamber during the Committee stage and I greatly regret that. I rise to put a question. In moving the amendment my noble friend referred to the Nolan Committee. We are led to believe that its report will be brought forward fairly quickly. If the committee made a recommendation relating to the National Health Service and its structure and its appointments but the Government had decided to reject this amendment, what would they do? Would they take another stage of the Bill to find a way to respond to the Nolan Committee? I should have thought that in view of the importance of the Nolan Committee—I refer to its chairman, its membership and its role—they would want to respond in a positive way. Perhaps the Minister will deal with that point when she replies to the amendment.

Lord Carter

My Lords, before the Minister replies, I hope she will be sure to deal with the point raised by my noble friend on why the arrangement we are discussing is in place in Scotland but not in England and Wales. I noticed that she said that point was made by the National Association of Health Authorities and Trusts (NAHAT) in its evidence to the Nolan Committee, and it obviously supported that point. I hope that the Minister will deal with that point in her reply and that she will explain to the House exactly why the provision is required in Scotland but not, apparently, in England and Wales.

Lord Rea

My Lords, I should have thought that the Government would welcome the opportunity to have an advisory committee such as is suggested in order that fair play should be seen to be done. There is a certain amount of evidence that health authority and trust non-executive members have been drawn from those rather close to the Government and the Conservative Party. If there were to be such an advisory committee, that accusation would not be made so often. I should have thought that would be very much to the Government's advantage in the eyes of the electorate.

Baroness Cumberlege

My Lords, the point that has just been raised is one of which I have studiously fought shy during the course of these debates. However, the noble Lord will be aware that even in your Lordships' House there are Members who sit not on our Benches but on the Benches opposite who are closely involved in the health service. We very much value the contribution that they make. It is wrong to believe that one has to be a paid-up member of the Tory Party to get a position on a trust or health authority.

So far as concerns Scotland, I believe that this procedure is a new one and that the committee has not as yet made many appointments. We will watch with interest to see how that committee operates. There is an issue about size. What we propose is not totally unlike the Scottish system but it is relevant to our regions, each of which is roughly the size of Scotland.

We endorse the views of the noble Lord, Lord Desai, and the noble Lord, Lord Ennals—whom I am delighted to see back on your Lordships' Benches—that the NHS should be an open organisation. As the noble Baroness has said, on 14th February my right honourable friend the Secretary of State published new guidelines for the appointment of chairmen and non-executive directors of NHS authorities and trusts. The guidelines, which draw together examples of existing best practice in appointment procedures, demonstrate our commitment to a fair and open appointments system based on merit, not patronage. The new guidelines make it clear that potential candidates for non-executive appointments will be sifted by a panel of at least three people. These people will be serving chairmen and non-executive directors of local NHS authorities and trusts. We believe that people who are already working as non-executives are well placed to judge whether a candidate is suited to the demands of service as a non-executive director.

We recognise the need to avoid possible accusations of bias in the appointments system. We have said in the guidelines that the members who do the sifting must not be drawn from the same health authority or trust board and that the panel may include an independent member. We have suggested that this may he, for example, a member of a local community health council or a local justice of the peace. The new guidelines are designed to be flexible to meet local demands without compromising standards in the appointments process. This is reinforced when we look at the role of the sifting panel. The guidelines make clear that all new candidates for non-executive appointment will be sifted against agreed criteria to ensure that all those recommended for appointment possess the skills, personal qualities and experience required.

It is this use of nationally agreed criteria against which experienced NHS chairmen and non-executives will judge candidates for non-executive appointment that is the most important element of the sifting process, and will ensure that those recommended for appointment are of a uniformly high standard.

Perhaps I may clarify the position of regional chairmen in future. If the Bill is passed and regional health authorities are abolished, it is our intention to retain a non-executive who will be a member of the policy board and will have the role and title of regional chairman. That person will be the chairman of the health authority and the trust chairman within that region. It is important that that person is involved in the appointments process. Indeed, the guidelines emphasise that he should be. Ministers will look to regional chairmen to make their own assessments of candidates before making their recommendations to Ministers. This means that the suitability of any individual candidate will be double-checked to ensure that the process has been conducted objectively and fairly. Those finally appointed—your Lordships will be aware that many are called but few are chosen—will rest in the knowledge that they really are the best people for the job.

I endorse the views expressed by my noble friends. One can go on and on with further tiers of advice as to who eventually appoints these people. We believe there is no need to strengthen the arrangements that are already in hand. I hope that the noble Baroness will be reassured and will not press this amendment.

Lord Cledwyn of Penrhos

My Lords, the noble Baroness has dealt with the Scottish position with great care. I was concerned that she might tell us about the Welsh position before this debate ended. When I was at home in Wales over the Recess two or three people who were deeply concerned about the National Health Service asked me why Wales was being treated as if it was a region of England. Of course, it is not; it is a separate nation in these islands and has the right to be treated with the same respect as Scotland, which seems to be treated with respect at all times. Before we complete this Bill I hope that she can satisfy us that there is a good reason for not giving Wales the same independence in this matter as Scotland has enjoyed.

Baroness Cumberlege

My Lords, I very much concur with the noble Lord that Wales should have equal respect. However, the position is rather different under this Bill. There have never been regional health authorities in Wales, so that whole tier has been absent in Wales. A good deal of this Bill is concerned with the abolition of regions and therefore is not relevant to Wales. The parts of the Bill that are relevant to Wales are those which merge district health authorities and family health service authorities. Therefore, they come into this Bill. We shall be discussing an amendment later today that is concerned with the particular agency that covers Wales in terms of procurement.

With regards to appointments, I understand that that is a matter for my right honourable friend the Secretary of State for Wales. No doubt he will take note of what we do in this Bill. I am sure that he will wish to reflect on it and possibly follow the same system.

Baroness Jay of Paddington

My Lords, I am grateful to the Minister for her reply. There is a difficulty in regard to the position of Scotland. My noble friend Lord Cledwyn said that the Minister had spoken very carefully on that subject. I believe that that is the appropriate expression. Although she described the situation in Scotland very well, she did not explain precisely why there was such a clear difference in the Government's mind between what was happening in Scotland and what could potentially happen in England and Wales.

It is a little difficult to understand why, if one is to create what is de facto roughly the same situation in terms of openness as will exist in Scotland—the Minister has said that there are many similarities in the situation—it is not possible to go the whole way and make the advisory committee a statutory one. There remains the difficulty raised by my noble friend Lord Ennals—to which the Minister did not respond—about what will happen if the committee of the noble and learned Lord, Lord Nolan, makes a recommendation to the effect that there should be an independent advisory body similar in nature to that proposed in this amendment. Will the Government then feel the necessity to bring forward additional legislation or will they ignore that provision, which I suspect may prove to be a little politically difficult?

In view of my concerns about the answers that have been given and the fact that the health service should be seen to be entirely open, in particular that appointments should be conducted in an objective and open manner, I wish to test the opinion of the House.

3.38 p.m.

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

Their Lordships divided: Contents, 74; Not-Contents, 119.

Division No. 1
Acton, L. Desai, L. [Teller.]
Addington, L. Donaldson of Kingsbridge, L.
Ailesbury, M. Dormand of Easington, L.
Airedale, L. Ennals, L.
Archer of Sandwell, L. Ezra, L.
Ashley of Stoke, L. Falkender, B.
Avebury, L. Fitt, L.
Beaumont of Whitley, L. Freyberg, L.
Blackstone, B. Gallacher, L.
Bottomley, L. Gladwin of Clee, L.
Broadbridge, L. Graham of Edmonton, L. [Teller.]
Bruce of Donington, L.
Carmichael of Kelvingrove, L. Gregson, L.
Carter, L. Halsbury, E.
Chorley, L. Harris of Greenwich, L.
Cledwyn of Penrhos, L. Hollis of Heigham, B.
Cocks of Hartcliffe, L. Hooson, L.
David, B. Howie of Troon, L.
Dean of Thornton-le-Fylde, B. Hylton-Foster, B.
Jay of Paddington, B. Ogmore, L.
Jeger, B. Rea, L.
Jenkins of Hillhead, L. Redesdale, L.
Jenkins of Putney, L. Richard, L.
Judd, L. Sainsbury, L.
Kilbracken, L. Sefton of Garston, L.
Kinloss, Ly. Serota, B.
Lockwood, B. Shepherd, L.
Longford, E. Simon, V.
Lovell-Davis, L. Stallard, L.
Stedman, B.
McFarlane of Llandaff, B. Stoddart of Swindon, L.
McIntosh of Haringey, L. Strabolgi, L.
McNair, L. Taylor of Blackburn, L.
Milner of Leeds, L. Tordoff, L.
Monkswell, L. Wallace of Coslany, L.
Morris of Castle Morris, L. White, B.
Nicol, B. Wigoder, L.
Northfield, L. Williams of Elvel, L.
Aberdare, L. Hayhoe, L.
Addison, V. Henley, L.
Ailsa, M. Hives, L.
Aldington, L. HolmPatrick, L.
Alexander of Tunis, E. Hothfield, L.
Ampthill, L. Howe, E.
Annan, L. Inglewood, L. [Teller]
Astor, V. Ironside, L.
Astor of Hever, L. Johnston of Rockport, L.
Balfour, E. Kinnoull, E.
Belhaven and Stenton, L. Knollys, V.
Blaker, L. Lauderdale, E.
Blatch, B. Lindsay, E.
Blyth, L. Long, V.
Borthwick, L. Lucas, L.
Boyd-Carpenter, L. Lucas of Chilworth, L.
Brabazon of Tara, L. Lyell, L.
Braine of Wheatley, L. Mackay of Ardbrecknish, L.
Brougham and Vaux, L. Mackay of Clashfern, L. [L. Chancellor]
Burnham, L.
Butterworth, L. Macleod of Borve, B.
Cadman, L. Mersey, V.
Caithness, E. Miller of Hendon, B.
Campbell of Alloway, L. Milverton, L.
Campbell of Croy, L. Morris, L.
Chalker of Wallasey, B. Moyne, L.
Chesham, L. Munster, E.
Clanwilliam, E. Murton of Lindisfarne, L.
Constantine of Stanmore, L. Nelson, E.
Courtown, E. Norfolk, D.
Craig of Radley, L. Norrie, L.
Cranborne, V. [L. Privy Seal] Northesk, E.
Cullen of Ashbourne, L. Oppenheim-Barnes, B.
Cumberlege, B. Orkney, E.
Davidson, V. Orr-Ewing, L.
De Freyne, L. Pearson of Rannoch, L.
Dean of Harptree, L. Pender, L.
Denton of Wakefield, B. Peyton of Yeovil, L.
Digby, L. Pym, L.
Ellenborough, L. Rawlings, B.
Elles, B. Rennell, L.
Elton, L. Renwick, L.
Flather, B. Rodger of Earlsferry, L.
Forbes, L. St. Davids, V.
Fraser of Carmyllie, L. Saltoun of Abernethy, Ly.
Fraser of Kilmorack, L. Seccombe, B.
Gainford, L. Selborne, E.
Geddes, L. Shannon, E.
Gibson-Watt, L. Shaughnessy, L.
Goschen, V. Shaw of Northstead, L.
Gridley, L. Skelmersdale, L.
Hailsham of Saint Marylebone, L. Slim, V.
Strange, B.
Harding of Petherton, L. Strathcarron, L.
Harmsworth, L. Strathclyde, L. [Teller]
Sudeley, L. Vaux of Harrowden, L.
Swinfen, L. Vivian, L.
Tebbit, L. Walton of Detchant, L.
Thomas of Gwydir, L. Whitelaw, V.
Tollemache, L. Wynford, L.
Trumpington, B.

Resolved in the negative, and amendment disagreed to accordingly.

3.47 p.m.

Baroness Jay of Paddington moved Amendment No. 2:

Page 1, line 14, at end insert: ("() No order shall be made under subsection (1) above until the Secretary of State is satisfied that the establishment of each Health Authority proposed by that order is such as to ensure that every Health Authority includes persons who, by virtue of specialised training in health care disciplines and experience in health care work, can bring to health authorities perspectives derived from their professional training and expertise.").

The noble Baroness said: My Lords, Amendment No. 2 stands in my name and the names of my noble friend Lord Carter and the noble Baroness, Lady Robson of Kiddington.

The amendment seeks to ensure that the new health authorities include members whose professional qualifications and training gives them special expertise on those matters which will be at the centre of the health authorities' business. The House will recall that at Committee stage several amendments were proposed from different parts of the Chamber—from the Government Back-Benches and the Cross-Benches as well as from the Opposition—to make it compulsory for, for example, general practitioners, nurses and health visitors to be members of the new boards. All of those amendments were unsuccessful.

The Minister's main argument for opposing the amendments seemed to be that the Government now dislike the idea of representatives of any body being members of the new health authorities, although I remind the House that that has been the practice in the family health service authorities which now exist and will continue in existence until the new health authorities take over in April 1996.

The Minister was also anxious that prescribing any specific professional group for a reserved place was bound to create resentment from other bodies which felt that they had an equal right to a position on a health authority.

It is for those reasons that the present amendment is drawn in such general terms. As I am sure the Minister recognises, the terms are taken directly from the draft guidelines on professional involvement in the work of the health authorities which were issued by the Department of Health on 20th January this year. That detailed document, offering consultation and guidance to the new health authorities which may, if the Bill goes through, become the health authorities responsible next year, states in its opening paragraph: These changes make essential closer and more effective involvement by doctors, nurses (including midwives and health visitors) and other professional staff in the work of authorities, uniprofessionally, multi-professionally and on a multi-disciplinary basis. Careful attention therefore needs to be given to the means by which health care professionals make an input to decision making. This guidance makes clear the requirement on health authorities to ensure that the professions are involved in the full range of health authority work". The guidance defines professionals as, people who, by virtue of specialised training in health care disciplines in health care work, can bring to health authority issues perspectives derived from their professional training and experience". Those are the words of the amendment.

At Annex C of the draft guidelines, the Department of Health gives a list of examples where professional input is, in its view, essential. It is a long and detailed list, but it includes, for example, maintaining a district wide view of healthcare purchasing, clinical effectiveness—needing to ensure that health authorities work closely with hospital clinicians on strategies for improving clinical effectiveness—inspection and registration of nursing homes, planning health care services for people with disabilities, child protection, midwifery supervision, AIDS, mental health and mental health Act doctors.

The guidelines document concludes by describing methods for monitoring professional involvement and ensuring compliance because, appropriate professional involvement is fundamental to the effective working of authorities". It is fundamental, and yet the Government have so far rejected the idea of ensuring that professionals are members of the health authority. The Government prefer to rely on the professionals giving advice and being consulted. However, as the noble Baroness, Lady Gardner of Parkes, stated in Committee when her amendment to include a primary care worker was not accepted, consultation is not the same as being on the authority.

During Committee stage, the Minister referred to the fact that health authorities have every right to appoint members who come from a professional background. At col. 1531 of the Official Report of 28th March, the noble Baroness said: I am sure that many health authorities will have non-executive members with experience in primary care and, indeed, experience in the acute sector and in community care. Everyone who is suitably qualified will be welcome to apply for appointment, provided there is no conflict of interest".

However, there seems to me to be a great difference between that enabling position (perhaps I may so call it) and ensuring by statute that appropriate professionals are involved in the new health authorities at board level. Like the Minister I, too, am sure that many good authorities will include, for example, GPs, nurses and pharmacists among their members. But if such inclusion is not required, other authorities are just as likely to fill their membership with businessmen or accountants, many of whom in my personal experience have neither professional nor personal experience of the National Health Service.

It is worth reminding the House that the requirement for health authorities to secure advice and consult with professionals was inserted by the Government in Schedule 1 of the Bill only at Report stage in another place. It is interesting to note that in Committee the Minister stated at col. 1599 of the Official Report of 28th March that the provision to ensure that advice is given—it is now Schedule 1(3) to the Bill—was introduced so that, [professional] involvement in health authority decisions should not simply be left as a matter of good practice". That is precisely what the amendment seeks to re-emphasise: that we should not rely simply on good practice.

The Minister having heard the persuasive arguments from all parts of the House about the need for professional membership of the new authorities, I hope that the Government will now be able to go one step further than they did when ensuring appropriate consultation and will accept the amendment. The logic of their own position was demonstrated by the new Department of Health guidance on professional involvement in the new health authorities from which I quoted: that professional involvement with the new health authorities is essential. Surely the proper way to achieve such involvement is to make those with specialised training and experience in health—the amendment cites those people and they are cited in the new guidance—full members of the new board. I beg to move.

Lord Addington

My Lords, I wish to speak to the amendment which stands in the name of my noble friend Lady Robson. Unfortunately my noble friend is not able to be present due to ill health. I offer, too, the apologies of my noble friend Lord Tope who is unable to be present due to important business meetings.

The amendment effectively states that members of the board should have a working knowledge of their subject. In many other fields I have sought to argue that one should have expertise on a subject because one is then able to respond to information given. One may well miss the issues upon which advice is needed because one cannot spot them. The position is that simple. If one knows one's subject well, one is able to call for more advice where it is required.

The amendment does not state that we should not be able to call for advice from others outside the health authority. It merely provides that those members of the authority should know where to start looking for such advice. I fully support the amendment.

Lord Elton

My Lords, I have a certain sense of déjà vu. I have lost count over the years of the Bills on which I have assisted which create some body with statutory powers. We go into almost a ritual dance about who shall be members of that body. We start by listing all the people who should be members. We then come to the conclusion that the number of members is finite; and we remember that some desirable people will not be members of the body. We remind ourselves of the old rule, expressio unius, exclusio alterius, which means that if you name six people who ought to be members of the body, the suggestion is that the other 83 people ought not to be on it. Remembering that, we decide not to have names. We then normally go back to the original position: that the body shall be described by its functions and not by its components.

The noble Baroness has put forward an ingenious half-way house. I ask the Government to consider the amendment with a little care. Although she has done a great deal to avoid offending sensibilities such as those I have already described, she has made it justiciable. It seems to me that if her amendment were put on the face of the Bill, it would be open to anyone who wished to impede progress, or who was hostile to the general principle of the health authorities, to go to court and argue that the requirements had not been fulfilled. As to whether or not the requirements were fulfilled would take a great deal of argument. There seems merit in ensuring that such a body is composed in a way which enables it to fulfil its function properly. I should have thought that the way to achieve that is to give an undertaking from the Dispatch Box in a speech during which my noble friend courteously dismisses the amendment, and the noble Baroness opposite courteously accepts that assurance.

Baroness Cumberlege

My Lords, for my part I shall take that good advice. However, saving my noble friend's sorry sense of déjà vu, we feel that professional membership is an important issue and one on which feelings run high.

As I said during Committee stage, I agree that professionals including GPs, nurses, dentists, pharmacists, physiotherapists, occupational therapists, speech therapists, art therapists and psychotherapists, psychologists, dieticians, health visitors, midwives, optometrists, radiographers, scientists, biochemists, geneticists, researchers, paramedics, chiropodists and podiatrists, to name but a few, have a vital contribution to make to the decisions of health authorities. I am sure that many health authorities will have members with professional experience, whether in primary care, in the acute sector, or in community care. Everyone who is suitably qualified will be welcome to apply for appointment, provided there is no conflict of interest.

However, professional input and advice are much broader than the relatively narrow professional contribution which one or two members can provide. My list illustrates the point of how difficult it is when so many professionals are involved in a single service. Of course, on a personal basis, such members can bring extremely valuable qualities; but we feel that that is no substitute for broader professional involvement.

The draft guidelines, Professional Involvement in Health Authority Work, referred to by the noble Baroness, were circulated widely to the professions and the NHS. They show other ways in which health authorities will be expected to involve professionals. For example, some authorities have already established multi-disciplinary teams with responsibility for reviewing, planning and purchasing certain services. Others have commissioned reviews of priority services such as mental health from teams involving professionals from both primary and secondary care. Of course, all health authorities will employ professionals—nurses, for example, in senior positions—who will ensure that health authority work is informed by professional views, without necessarily being members of the health authority.

There are many other ways for professionals to be involved. The guidelines talk in detail of how professional involvement can be made effective without being prescriptive on the arrangements health authorities should put in place. So health authorities can adapt the suggested models to suit their individual needs.

As the noble Baroness, Lady Jay, said, the Government made clear how seriously they take the issue by tabling an amendment in another place. The amendment adds force to the draft guidelines by requiring health authorities to make arrangements to ensure that nursing and other professional advice is available to them. It leaves in no doubt the importance of professional involvement. My honourable friend the Minister for Health made clear in another place that any authority that did not seek professional advice or did not listen to it when it was volunteered would not be complying with its statutory duty.

In conclusion, we do not believe that the amendment is necessary. I am fully confident that the close monitoring of professional involvement planned by the regional offices will ensure that health authorities involve professionals across the range of their work. I hope that the noble Baroness will feel able to withdraw the amendment.

Baroness Jay of Paddington

My Lords, I thank the Minister for that reply and particularly for her emphasis once again that the Government and the National Health Service Executive appreciate the importance of professional involvement in health authorities. I am glad that they are prepared to be firm in their monitoring of that involvement, as is seen in the guidelines.

I am not sure that my Latin is quite up to translating it precisely, but I am also grateful to the noble Lord, Lord Elton, for giving me the instant phrase for the discussions which we had at such great length in Committee. I wish that he had been here to interject the phrase.

However, I am still anxious about the point. The draft guidelines from the Department of Health describe the professional involvement as seen by the department as essential, with which I agree. If it is intended to encompass the many functions of the health authorities—as I hope the brief list which I gave from the draft guidelines suggests—that cannot necessarily be accomplished simply by relying on advice. Unfortunately, the noble Baroness, Lady Gardner of Parkes, is not in her place. She said in Committee that there is a great difference between being consulted and being a member of an executive board.

For those reasons and since I, like the Minister, feel that it is absolutely essential that professional guidance be involved in health authority work in the future, I feel that I must test the opinion of the House. I commend the amendment.

4.3 p.m.

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

Their Lordships divided: Contents, 78; Not-Contents, 118.

Division No. 2
Acton, L. Jeger, B.
Addington, L. Jenkins of Hillhead, L.
Airedale, L. Jenkins of Putney, L.
Archer of Sandwell, L. Judd, L.
Ashley of Stoke, L. Kilbracken, L.
Attlee, E. Kilmarnock, L.
Beaumont of Whitley, L. Lawrence, L.
Birk, B. Lester of Herne Hill, L.
Blackstone, B. Lockwood, B.
Bottomley, L. Longford, E.
Broadbridge, L. Lovell-Davis, L.
Brooks of Tremorfa, L. McFarlane of Llandaff, B.
Bruce of Donington, L. McIntosh of Haringey, L.
Carmichael of Kelvingrove, L. McNair, L.
Carter, L. [Teller.] Milner of Leeds, L.
Cledwyn of Penrhos, L. Monkswell, L.
Cocks of Hartcliffe, L. Morris of Castle Morris, L.
David, B. Nelson, E.
Dean of Thornton-le-Fylde, B. Nicol, B.
Desai, L. Northfield, L.
Diamond, L. Ogmore, L.
Donaldson of Kingsbridge, L. Rea, L.
Dormand of Easington, L. Redesdale, L.
Dubs, L. Richard, L.
Ennals, L. Sainsbury, L.
Ezra, L. Sefton of Garston, L.
Falkender, B. Serota, B.
Falkland, V. Shepherd, L.
Fitt, L. Stallard, L.
Freyberg, L. Stoddart of Swindon, L.
Gallacher, L. Strabolgi, L.
Gladwin of Clee, L. [Teller] Taylor of Blackburn, L.
Graham of Edmonton, L. Tordoff, L.
Gregson, L. Wallace of Coslany, L.
Harris of Greenwich, L. Walton of Detchant, L.
Hollis of Heigham, B. Wharton, B.
Hughes, L. White, B.
Hylton-Foster, B. Wigoder, L.
Jay of Paddington, B. Williams of Elvel, L.
Aberdare, L. Cullen of Ashbourne, L.
Addison, V. Cumberlege, B.
Ailsa, M. Davidson, V.
Aldington, L. De Freyne, L.
Alexander of Tunis, E. Dean of Harptree, L.
Astor, V. Denton of Wakefield, B.
Astor of Hever, L. Ellenborough, L.
Balfour, E. Elles, B.
Belhaven and Stenton, L. Elliott of Morpeth, L.
Blaker, L. Elton, L.
Blatch, B. Flather, B.
Blyth, L. Forbes, L.
Borthwick, L. Fraser of Carmyllie, L.
Boyd-Carpenter, L. Fraser of Kilmorack, L.
Brabazon of Tara, L. Gainford, L.
Brougham and Vaux, L. Geddes, L.
Burnham, L. Gibson-Watt, L.
Butterworth, L. Gilmour of Craigmillar, L.
Cadman, L. Goschen, V.
Caithness, E. Gray of Contin, L.
Campbell of Alloway, L. Gridley, L.
Campbell of Croy, L. Hailsham of Saint Marylebone, L.
Chalker of Wallasey, B.
Charteris of Amisfield, L. Harding of Petherton, L.
Chesham, L. Harmsworth, L.
Clanwilliam, E. Hayhoe, L.
Constantine of Stanmore, L. Hemphill, L.
Courtown, E. Henley, L.
Craig of Radley, L. Hives, L.
Craigavon, V. Holderness, L.
Cranborne, V. [L Privy Seal] HolmPatrick, L.
Hothfield, L. Northesk, E.
Howe, E. Oppenheim-Barnes, B.
Huntly, M. Orr-Ewing, L.
Inglewood, L. [Teller] Pearson of Rannoch, L.
Johnston of Rockport, L. Pender, L.
Killearn, L. Pym, L.
Kingsland, L. Rawlings, B.
Knollys, V. Rennell, L.
Lane of Horsell, L. Renwick, L.
Lauderdale, E. Rodger of Earlsferry, L.
Lindsay, E. St. Davids, V.
Long, V. Seccombe, B.
Lucas, L. Selborne, E.
Lucas of Chilworth, L. Shaw of Northstead, L.
Lyell, L. Skelmersdale, L.
Mackay of Ardbrecknish, L. Slim, V.
Mackay of Clashfern, L. [L. Chancellor] Strange, B.
Strathcarron, L.
Macleod of Borve, B. Strathclyde, L. [Teller]
Mersey, V. Sudeley, L.
Miller of Hendon, B. Tebbit, L.
Milverton, L. Teviot, L.
Morris, L. Thomas of Gwydir, L.
Moyne, L. Tollemache, L.
Munster, E. Trumpington, B.
Murton of Lindisfarne, L. Vaux of Harrowden, L.
Noel-Buxton, L. Vivian, L.
Norfolk, D. Whitelaw, V.
Norrie, L. Wynford, L.

Resolved in the negative, and amendment disagreed to accordingly.

4.12 p.m.

Lord Rea moved Amendment No. 3:

Page 2, line 14, at end insert:

("Strategic Health Planning Authority for London.

"8A.—(1) It shall be the duty of the Secretary of State by order to establish a Strategic Health Planning Authority for London.

(2) The membership of the Authority shall be established in accordance with Part I of Schedule 5 to this Act."").

The noble Lord said: My Lords, in moving this amendment, which is very similar to Amendment No. 8, debated in Committee in this House, I make no apology. Some confusion prevailed last time. The amendment defined the region of London as, the area of the London Boroughs".—[Official Report, 28/3/95; col. 1552.] As several noble Lords pointed out, inner and outer London boroughs differ greatly in their socio-economic make-up. The inner London boroughs have much greater social and health needs due to their high levels of social deprivation. It is possible to consider a strategic authority covering entirely or mainly the health authorities which cover the inner London boroughs. That is the spirit in which I want to consider the proposal in this amendment.

The inner London boroughs have, on the whole, quite similar needs. They have quite high levels of unemployment; not very good housing; high levels of immigration; and degrees of poverty that we do not see so much in the outer London boroughs, whose make-up is rather similar to that of the Home Counties, which have a more affluent population in better housing, for example.

There is a need for close co-operation among inner London health authorities. Their populations are concentrated. As the Tomlinson Report, Making London Better and the London Implementation Group task force have pointed out, there is opportunity for the rational siting and sharing of specialist care units.

Primary care is relatively poorly developed in all the inner London boroughs. It will be best helped by co-ordinated action to raise standards. That is shown, for example, by action on the London Implementation Zone. Co-operation between health authorities and local authority social services departments is a crucial element in making care in the community efficient. In fact, the concept of a primary care led health service depends on that.

The noble Baroness Lady Miller, said in Committee that the work of the London Implementation Group was now complete. I suggest that there is still plenty of ongoing work for such a body, as there is for the London Implementation Zone, which relates to primary care. This amendment would allow the work of those two task forces to be built upon in a constructive way.

Finally, it is worth pointing out that the population of London—its size, depending on whether you take the population of the inner London boroughs or include Greater London—would be comparable to that of each of the eight existing regions, which are to be succeeded by the regional offices of the NHS Executive.

This amendment is reasonable. This is a very good opportunity, while changes are being made in the structure of the health service, seriously to consider setting up a suitable strategic authority for London as described in this amendment. I beg to move.

4.15 p.m.

Lord Addington

My Lords, very briefly, I support this amendment. The same issue was raised from these Benches in Committee. London is a very large and diverse area. Strategic planning in virtually all fields would be beneficial for so large an area. Health provision is certainly no exception.

Lord Desai

My Lords, perhaps I may be allowed to speak at this stage, even though I did not speak in Committee. I shall refer only to the concrete experience that I have. I declare an interest as chairman of a small drug intervention agency, City Roads, which deals with drug crisis problems.

Since the care in the community legislation was passed, this small group has had to deal with all the various boroughs of London separately. When it comes to issues such as drug and alcohol abuse, it is quite clear that there will need to be some sort of co-ordinating agency for different drug intervention agencies. Although these have to deal legally and contractually with individual boroughs, the problem is London-wide, if not larger. In the absence of an authority such as that proposed in the amendment before us, ad hoc co-ordinating committees are liable to be set up separately for different topics. Then there will be the problem of setting up co-ordination across those different co-ordinating bodies, be it for drugs, mental health, alcohol abuse or whatever.

It would make much more sense at present initially to set up a strategic health authority that can deal with all those problems. They will not go away. While some matters can be dealt with at individual health authority level and individual trust level, there will be cross-authority problems. The amendment deals with that issue; therefore I support it.

Baroness Jay of Paddington

My Lords, before the Minister replies, perhaps I may speak briefly in support of my noble friend Lord Rea. As we all know, the position in London moves very rapidly and changes very often. I was extremely interested to hear the remarks on London that the Secretary of State for Health made on television yesterday afternoon. Among other things, she said that London has had entrenched problems over many years. I believe that we would all concur with that point. She also said that the London health service is not good enough now, and that some health authorities have not planned well enough and not done well enough to meet the various problems with which London deals. All of that speaks to the argument for having some kind of strategic authority which can enable the Government, the Department of Health and the Secretary of State, to have some influence of a more direct kind so that future Secretaries of State will not need to say that the London authorities have not done well enough and feel that that is something that they can only remotely influence.

In introducing the amendment, my noble friend Lord Rea spoke about the London Implementation Group. He mentioned that it was a task force which the noble Baroness, Lady Miller, told us in Committee had completed its work.

Obviously the task force has completed its work, but the measures, the problems and the issues that it was set up to deal with have certainly not been solved. It would be useful to translate the London Implementation Group, with its various task force functions, into something with a longer life and a more strategic overview.

I was invited by the Minister, when we talked last week in your Lordships' House about the end of term report on the London Implementation Group, to visit with her the various projects in primary care which have been developed under that initiative and which she felt were very suitable examples of its success. But, without wishing to lend coin or credence to what is an unattractive word, I think that is what is described in the jargon as "projectitis". There is very little strategy attached to what the London Implementation Group has achieved and, in terms of the end of its life this month, a lack of evaluation.

If I look at some of the issues which have arisen during its life—and which have risen again, acutely, in the past few weeks—I can mention, among others, the pace of change in London. How quickly are we to implement the moves towards making primary care the most important method of delivering care to Londoners and weaning—if that is the appropriate word—them away from using the acute services for primary care? How quickly should we engage in more bed closures in the London area? How can we effectively improve primary care in a population which has little understanding of the necessity to register with GPs? I described in Committee how many local health authorities in London have had a reduction in numbers of the population registered with GP fund holders. How do we deal with improving primary care in a floating population, with all the great social distress and deprivation, which, as people know—the noble Lord, Lord Rea, referred to it again this afternoon—is particularly acute in the London boroughs? How do we organise the specialties which have been reviewed following Professor Tomlinson's report?

All of these are issues which need to be dealt with strategically. They are not susceptible to the task force "projectitis" approach of the London Implementation Group.

I was interested in the February report of the inner London chief executives on hospital services for London. It was obviously an informal group of people which got together, I believe, in response to the special lecture given by Professor Jarman about inner London health needs. The chief executives' report said: the broad strategic direction that has been set for London is correct, but at a number of points clear and strong management action is required by our Authorities if it is to be achieved in a manner which is clearly seen to benefit patients". It goes on to say: We also believe that action needs to he taken at Regional and/or national level in relation to a number of the findings in the studies". It cited, for example, the questions of management of admissions and discharges, of calculating bed requirements and whether or not trusts were in a position to make the appropriate calculations on the basis of their business cases, It also said that there should be an overall review of the yellow and red alert mechanisms across London, and of the role that the emergency bed service should play in the future.

Those are just some of the issues which the inner London chief executives clearly felt were appropriate for collective working and a strategic view.

Of course we can continue to have ad hoc committees working on these matters—as indeed the chief executives did on this particular subject—but it would be much more sensible if we had in place a strategic health authority with the additional authority and status necessary to achieve solutions to so many of the medium and long-term problems of London. I support my noble friend.

Baroness Cumberlege

My Lords, I have already made it clear that the Government's commitment to improving health services for London is very great. The direction has been well set out. The strategy was clearly laid out in Making London Better, which also set out the framework for action: to develop better, more accessible primary and community health services; to provide a better balanced hospital service to meet the needs of London's resident working and visiting population in the most appropriate way; to develop and enhance specialist services that continue to provide a high quality service; and to take action that will benefit and enhance London's excellence in medical teaching and research. Progress on all these fronts was announced earlier this month with proposals for change in services in north, east and south east London.

The Government established the London Implementation Group to provide a short-term boost and extra support to existing health agencies in London in the considerable task before them.

As my noble friend Lady Miller mentioned in Committee—the noble Lord, Lord Rea, mentioned it again this afternoon—the work of the London Implementation Group is now complete. A great deal has been achieved and London's health authorities and trusts are now moving forward this great agenda for change. But, as I emphasised in Committee—and as the noble Lord, Lord Rea, has said this afternoon—London cannot be treated as a single entity. It is a large and diverse city, often characterised by extremes. Areas that receive huge influxes of people by day—for example, in the city and the West End—have much smaller resident populations. As the noble Lord said, the needs of the Inner city are in contrast to those of its suburbs. Account must be taken of London's size and the character of its local populations. Collaboration must take place between a range of health and social care agencies if the needs of Londoners are to be met. I agree with the noble Lord, Lord Desai, on that point. The health service in London has made good progress in achieving major change to give Londoners access to a comprehensive range of services. Much of that work has been taken forward at a local level.

I do not agree with the noble Baroness, Lady Jay, about "projectitis" or with her philosophy in coining that phrase. It is at local level that the real difference will be made and where better services will be experienced by Londoners. There can be the most cerebral strategies, but they are worthless if they are not translated into real services of a higher quality experienced by Londoners; for instance, through better premises for GPs.

Nevertheless, I would not dismiss the fact that some strategic overview of the needs of the whole of London is still needed. A London focus has been retained at the highest level by the North and South Thames Regional Offices working with the NHS Executive, the Primary Health Care Forum and the Primary Care Support Force. That focus will ensure that a wider view is retained.

The London focus will mean that health authorities and trusts in London will be able to maintain a broader strategic vision across the capital. They will share experience and good practice in implementing and managing the pace of change in London's health care. This has already been demonstrated by the London Initiative Zone which focuses on improving primary care in those parts of London where need is greatest. Within the zone, health authorities have identified priorities for their local communities and have moved towards closer working partnerships, including local authorities and the voluntary sector, in tackling the problems of underdeveloped services in the community. These working partnerships have not required the establishment of a strategic, overarching, authority. They have emerged as part of the responsibilities of existing health authorities to work with other agencies. I urge your Lordships to reject this amendment.

Lord Rea

My Lords, I was slightly puzzled when my noble friend mentioned the word "projectitis". The way I heard it it was "project Titus"—which I thought might be a Roman monument built in anticipation of developments in the future Yugoslavia. I now understand that it is a form of disease.

All the words of the noble Baroness could easily have been taken as an argument for establishing a strategic body for London such as we suggest in the amendment. All the things that she said had been established by the London Implementation Group and were being done in the London implementation zone—how there was need for co-operation between the different health authorities and local authorities in London—seem to me to cry out for such an overall strategic body as we propose. However, it is perfectly clear that the Government are not taking our advice. I cannot count on mobilising support for the amendment today. It is possible that we may try yet again. For the moment, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4.30 p.m.

Lord Carter moved Amendment No. 4:

After Clause 2, insert the following new clause:

Annual report on activities of regional offices of NHS Executive

(".—(1) It shall be the duty of the Secretary of State to lay before both Houses of Parliament an annual report on the activities of the regional offices of the National Health Service Management Executive in respect of the discharge of all duties and functions transferred to those offices upon the abolition of Regional Health Authorities.

(2) In this section, "regional office" means any office of the National Health Service for the time being designated by the Secretary of State to have responsibility for the oversight of the finances and activities of the National Health Service purchasing authorities and trusts on a regional basis.").

The noble Lord said: My Lords, this amendment places a duty on the Secretary of State to lay before both Houses of Parliament an annual report on the activities of the new regional offices of the National Health Service Executive and to report in respect of the discharge of all duties and functions transferred to those offices upon the abolition of the RHAs. The second subsection of the new clause defines "regional office".

The purpose of the new clause is clear. It will create a mechanism by which Parliament can be informed of the outcome of this legislation and can monitor its effects in practice as opposed to its claimed intent. The enthusiasm of the Government for open government and accountability has often been asserted. If their real intention is, as they claim, to remove unnecessary bureaucracy, increase efficiency and create savings, the new clause will raise no problems for them and will present an opportunity for the Government to report back and parade their achievements.

We know that in 1991, as part of the Government's so-called reforms, regional health authorities were given greater powers because it was judged that a strategic authority at regional level was required. As we went through the Bill and began to see how this legislation might work, two matters became very clear. First, the Bill will allow much greater secrecy, and indeed concealment, in hospitals and trusts. We have tabled some amendments to deal with that matter. Secondly, in line with everything else the Government have done in a number of fields of activity, this legislation will ensure that all roads lead back to the Secretary of State.

Perhaps I may repeat a point I raised in Committee. At present, regional directors of public health have a duty to produce an annual public report on health care in their region. Historically, the role of practitioners of public health medicine as potential whistle blowers for public safety is one of the glories of British medicine and British public service. But at regional level—this point was underlined in an exchange I had with the Minister in Committee—they will become civil servants, bound by the Official Secrets Act 1911. Their duty will not be to the public but to the Secretary of State.

So what will happen to the annual public health report on health care in their region? Who will make that report? Can it be done by civil servants at the regional level? As the Minister underlined in Committee, they will be bound as civil servants under all the normal rules. In fact, will that reporting just stop?

The only remotely independent voice in the new structure that the Bill creates is that of the community health councils. Their chief executives, full time salaried public servants, are presently employed by the regional health authorities. What will happen to them?

I turn to statistics and information. At present the RHA collects statistics at regional level in the service of the public and, if requested, much of that information is made public. We shall also deal with that point in a later amendment regarding the codes of practice on openness. The only information that anyone can currently obtain about matters such as hospital closures come from the RHAs. The Department of Health, for understandable reasons, does not want to know about that. It tells us that in future the regional offices will collect only the statistics that the department wants for its own purposes in administering the system. Will that include information about hospital closures, for example? Will it include the closure of accident and emergency departments, or other such decisions, which impinge directly on the pattern of available health care across the region and which are certainly of public interest whether or not the department wishes to know them.

It was confirmed again in Committee that if the decisions deal with policy, however defined, the Minister will answer questions in Parliament but operational matters will be referred to the executives. So apart from the information that the regional health authorities will no longer collect, any request for information from Members of Parliament on operational matters will in future be referred to individual authorities or trusts. So there will not be the same responsibility for the flow of information to the public or their representatives for the use of public money.

The mechanism proposed in the new clause will allow Parliament to explore how those and other functions of existing RHAs are being carried out under the new structure; or, if they are not being carried out, to consider the effects of the change. We know that the vital responsibilities of the present RHAs are to stay at regional office level and be lifted into the power of the NHS Executive. On those grounds there remain severe doubts, including among health professionals, whether the new authorities that the Bill creates in place of the regions will have the expertise to plan and co-ordinate the existing activities of those regional health authorities. We have tabled a number of amendments to try to make sure that they do have the expertise that is required. The Government have resisted any attempt to put that on the face of the Bill.

All this shows is that whether at regional office level or away from that level there is a continuing and important role to be played by those who are charged with carrying out the duties which are currently the responsibility of the RHAs. We feel that Parliament must have the chance to scrutinise the effects of the legislation, not only by discussing the regulations when they are proposed but by exploring every year the cumulative practical changes to which the Bill will give affect. The new clause will do that. I beg to move.

Baroness Cumberlege

My Lords, the new regional offices will he an integral part of the NHS Executive and therefore part of the reporting arrangements already in place for the Department of Health through the departmental annual report. That report, which is a Command Paper, is laid before Parliament and is available to the public. It describes in detail the department's expenditure and activities across all its responsibilities. All major developments during the year are included. Further information about NHS Executive activities is made public through a wide range of publications, including the NHS annual report and a new series of quarterly reviews as well as a range of statistical bulletins and issues-based newsletters. We already publish extensive information on performance management of the NHS and will continue to do so.

The noble Lord, Lord Carter, expressed particular concern about the move from the regional health authorities to regional offices which will be part of the Civil Service. He felt that the move would mean a loss of openness. I can assure him and your Lordships that information held centrally, which is not of a confidential nature, is and will be available on request under the open government provisions. Regional offices are not the bodies which need to be independent. Their role will be different from that of the old regional health authorities. It is the new health authorities which will be taking decisions that directly affect local people. They will be independent in the same way as regional health authorities are now.

Regional health authorities are artificial entities in public health terms. There is no particular reason why public health should be dealt with in one geographical administrative area rather than another. The new health authorities will be much more appropriate places for public health work. Their areas will be smaller than the regions and they can be more sensitive to local variations in health and health care needs. They will have better links with local government which is an important public health role.

The shift in responsibilities for public health from regional health authorities to the new health authorities means that it will no longer be appropriate to produce regional health reports. But there will continue to be over 100 district directors of public health reporting annually on public health issues, who are wholly independent, as now. Those directors can also work together on issues of common interest, supported as necessary by the regional director of public health. Public health reports will continue to be a key and welcome feature of the work of health authorities. Therefore, I cannot accept that the amendment is necessary. I hope very much that the noble Lord will withdraw it.

Lord Carter

My Lords, before I decide what to do with the amendment and because the Minister was helpful in referring to the departmental annual report, may I ask her whether she can tell the House what aspects of those "appropriate" activities will be spelled out in that report as opposed to being lost in the raft of general information that will be given on the work of the whole department? I am sure that the Minister understands that there is concern about whether there will be any attempt in the departmental annual report to try to tease out and explain what has happened in terms of the responsibilities to be transferred from the RHAs to the new executives. We need to know that, at least in the early years, so that we can ensure that those responsibilities are discharged effectively.

Baroness Cumberlege

My Lords, there is in addition the Chief Medical Officer's annual report which deals specifically with the nation's health. That is produced yearly and receives wide publicity with a press conference and an explanation of it. It would also be possible to include in that report on the health of the whole nation the reports of the 100 or so health authorities which I mentioned. If the noble Lord is seeking much more managerial information, I can advise him that that is contained in the annual report of the NHS, which is produced by the chief executive, and in its quarterly reviews. There is also a range of statistical bulletins. Different types of information are available, and I can assure the noble Lord that there is no intention to be secretive.

Lord Carter

My Lords, that is extremely helpful. The purpose behind the amendment was to get on the record what the Government intend to do. In the light of the Minister's reply, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4.45 p.m.

Lord Carter moved Amendment No. 5:

After Clause 2, insert the following new clause:

Provision of information

(" . The provision of information by Health Authorities established under this Act shall be in accordance with those Codes of Practice which shall from time to time be issued by the National Health Service Management Executive or the Secretary of State.").

The noble Lord said: My Lords, in moving Amendment No. 5, I should like to speak also to Amendments Nos. 11 and 17. Amendment No. 5 deals with the new Code of Practice on Openness in the NHS which has been published by the NHS Executive. It includes not only a number of welcome provisions, but also some puzzling ones with which I shall deal. It states correctly at the start that it, reflects the Government's intention to ensure greater access by the public to information about public services and complements the Code of Access to Information which applies to the Departments … including the NHS Executive". We can all welcome that.

The introduction continues: Because the NHS is a public service, it should be open about its activities and plans. So, information about how it is run, who is in charge … should be widely available". Under the heading "Aims", the code spells out the extremely important second aim that people, are provided with explanations about proposed service changes and have an opportunity to influence decisions on such changes".

The fourth aim is that people should, know what information is available and where they can get it".

Your Lordships will remember that in Committee I referred to something that happened in my area of Wiltshire, which seemed to show that the whole of the consultation process had broken down badly. It is important to realise what is happening in a number of areas around the country. Perhaps I may again describe what happened and ask the Minister whether she feels that what happened was correct and whether it fits the code of practice that is before us. The example goes back to 1989 when a number of plans were published for reorganising the health plans in the district. There were public meetings—I attended some—and all were helpful. Everything was open. All sorts of plans were produced. New community hospitals were mentioned and there were discussions about the right sites for them. There was good local consultation and everybody was reasonably happy.

Things then went into cold storage because the plan depended to a large extent on the sale of some property. That sale did not take place because of the slump in the property market. Everything went quiet. However, everybody was still convinced that what had been promised would take place, but perhaps more slowly. Without anybody in the district knowing what was going on, a secret business plan was produced in September 1994 which completely reversed all the previous ideas and proposals. The promise of new community hospitals for several areas was removed. Hospitals were to be closed, without replacement. My area, with a catchment of about 35,000 people, was to have virtually all its services removed. That seemed to be because of the possibility of a housing development on one of the sites.

All of that was in secret, despite all the previous consultations. When the report was leaked earlier this year and people saw what was proposed, as you can imagine, all hell broke lose in the district and throughout the county. The authorities then hastily backtracked and started a consultation process.

As I have said, page 3 of the code states that people should be provided, with explanations about proposed service changes and have an opportunity to influence decisions on such changes". All of us who have been involved in business know about business plans and that you do not spend a lot of time and money making such plans and then put them on the shelf as a theoretical exercise. The health authority involved had decided what it wanted to do—and that was a complete reversal of all the earlier plans. It was only because that secret business plan was leaked that we were able to achieve the fourth aim of the code, which is that people should know what information is available and where they can get it.

That is not the only such example around the country. As I said in Committee, the business of consultation starting after the authority has made up its mind is a farce. I hope that the Minister will be able to spell out exactly how the code of practice is supposed to work.

Before I turn to Amendments Nos. 11 and 17, I should like to deal with another interesting aspect of the code. I refer to the business of charging for information. Paragraph 7(b) on page 5 states: for requests from people not listed above"— that is, press and other media; community health councils; MPs; local authorities and citizens' advice bureaux— no charge for the first hour and a charge not exceeding £20 per hour for each hour thereafter", may be charged for time expended. In the case that I have just described, a local organisation has been formed, called Save Our Local Hospital. It does not have any real money and if it is asked to pay about £20 per hour after the first hour for such information, it will find it extremely hard to do so.

We had a good debate on the provisions of Amendment No. 11 in Committee, so there is no need to repeat the argument at length. When moving his amendment, Amendment No. 23, in Committee, the noble Lord, Lord Tope, gave a full list of everything that has to happen in local government regarding the declaration of interests. About half a column of the Official Report is taken up with a list of all those things that members of local authorities are required to declare. When the Minister replied, she mentioned the implementation of the codes of conduct and accountability. The Government seemed to have to rest their case on that. However, she also said: Having introduced the codes of conduct and accountability, we have begun the process of monitoring their implementation. An initial early check will be completed next month"— that was said on 30th March, so I presume that the results are due in April— and the results will be reported to Ministers shortly afterwards".— [Official Report, 30/3/95; col. 1734.] Can the Minister tell the House when those results will be available? Indeed, will that report to Ministers be in the public domain and published? It is important that we know the way in which the code of conduct has worked in the early stages. A test of the Government's view of openness will be whether they make that information public.

The Minister's other answer which I found extremely unsatisfactory was her explanation of why health authorities are different from local authorities. She said that it is because local authorities raise taxes. She also said that the Government did not have any objection to the principle of the amendment. That is extremely important because, if they have no objection to the principle of the amendment, why not accept it or table a similar amendment themselves? Big sums of money are involved. We all know what happened at Wessex Regional Health Authority. We need not go into that again—it has been mentioned often enough. That is not the only case where a declaration of members' interests was vital.

Amendment No. 17 deals with "gagging clauses", as they are known. Again I am afraid that in Committee we had an unsatisfactory reply from the Minister, which is why we have tabled the amendment again. All sorts of examples were given in Committee about where health authority employees have been gagged, in effect, when they have tried—to use the jargon or slang—to blow the whistle, and I shall not repeat them. However, perhaps I may repeat a point I made on this amendment in Committee. The terms and conditions of service of hospital medical and dental staff used to contain a clause in paragraph 330 which stated: A practitioner shall be free, without prior consent of the employing authority, to publish books, articles, etc. and to deliver any lecture or speak, whether on matters arising out of his or her hospital services or not". That is an absolute freedom. It is a safeguard for public health, the public good, and for the professionalism of medical staff which is the cornerstone of the NHS.

Another matter to which I referred in Committee, and to which I do not believe the Minister replied, was the concern relating to the additional financial incentive for trusts, as employers, to keep quiet matters which might have a negative impact on their marketing (these are customers, not patients, we should not forget) of hospitals to purchasers such as the GP fundholders, health authorities and the rest. For all those reasons, there is now real concern about the lack of openness about information.

There is a difference in ethos and approach between working for an NHS authority and working for the Department of Health. There are practical issues regarding the freedom of speech. We have had it confirmed that civil servants are responsible to the Secretary of State and are bound by the Official Secrets Act. Will concerns about standards and procedures be aired publicly? RHA staff have a strong commitment to the NHS. They consider themselves to be health service staff. While they currently work for an RHA, most expect their employment paths to cover the various parts of the service on both the provider and purchaser side.

There is a qualitative difference in being a civil servant working directly to the Secretary of State, whose career path could lead to other parts of the Civil Service outside the health service. The NHSE wishes to see more fluidity between the department and the service, but will that happen to any significant degree?

What will be the significance of all that for the service and ultimately for patients? RHAs are often rightly criticised as being remote and not attuned to the needs of the service. Will not the regional offices, staffed by people (however efficient personally) answerable directly to the Secretary of State, be worse? Is that not another example of the Government's tendency to centralise and direct under the rhetoric of devolution and the granting of freedom?

Will the Minister comment upon the footnote to page 3 of the Code of Practice on Openness in the NHS? At the top under "Scope" it states: The Code of Practice covers the following NHS organisations". The first it quotes is the RHAs. There is then a footnote which states: Under the Health Authorities Bill at present before Parliament, Regional Health Authorities would be abolished on 1 April 1996 and District Health Authorities would combine with Family Health Service Authorities to form a single local Health Authority. When necessary, this Code will be revised accordingly". When is "necessary"? How will the code be revised? It is a NHSE publication, and so presumably the code, or parts of it, will apply to the new regional offices. It would be helpful if the Minister could tell us how the code will be amended to take account of the changes proposed in the Bill. I beg to move.

Baroness Miller of Hendon

My Lords, your Lordships will be aware of the Codes of Conduct and Accountability for NHS boards, issued by my right honourable friend the Secretary of State on 28th April 1994. Your Lordships will also be aware of the Code of Practice on Openness in the NHS which the Secretary of State issued on 5th April 1995.

The Codes of Conduct and Accountability were warmly welcomed when they were issued last year, not least by your Lordships, and by the noble Lord, Lord Carter, a few moments ago. They were also welcomed by the Audit Commission, the Public Accounts Committee and Sir Adrian Cadbury himself.

There is wide acceptance that those codes have done much to ensure that the public service values of openness, probity and accountability remain at the heart of the management and operation of the NHS. They introduced new measures to enhance the accountability to their local communities of authorities and NHS trusts. All trusts and authorities now hold publicly available registers of board members' interests and those demonstrate to the public that the pursuit of private gain plays no part in any member's service to the board and to the organisation. Health authorities now produce annual reports. All boards have audit committees. All boards have remuneration and terms of service committees. Those are real steps forward in ensuring that the board is held accountable for the stewardship of public funds.

Your Lordships have previously drawn comparisons between the requirements placed on local authority councillors and what is required of health authority members. That is not comparing like with like. Local councillors are elected. Health authority chairmen and non-executive members are direct appointees of the Secretary of State and are accountable to her. They can be more easily moved if necessary. For example, the current regulations governing membership make it clear that the Secretary of State can terminate an appointment if a member has failed to comply with the requirement to disclose financial interests. The codes arc very specific about the requirement on chairmen and board members to declare any interest that may be relevant to NHS business, and that such information should be made available to the public in a register.

The Codes of Conduct and Accountability do not need to have legislative force to achieve their objectives. Current evidence is that NHS trusts and authorities are complying with the codes and that they are proving effective. To underline the importance of the new codes, my right honourable friend the Secretary of State for Health has made compliance with them a condition of appointment for all board members. There is therefore no suggestion that the requirements of the codes are not taken seriously by NHS boards. The noble Lord, Lord Carter, asked whether the results will be published. I shall have to write to him on that, because I am afraid that I do not know the answer.

The Code of Practice on Openness in the NHS was issued on 5th April and will be implemented throughout the NHS on 1st June. That code builds on the success of the Patient's Charter in making information available to the public. It aims to ensure that the public are well informed about the health service they fund; that they know what information is available and where they can obtain it.

The Code of Practice on Openness in the NHS is the first of its kind in the NHS. It is a code for the public: to help them understand what the NHS does for them and to enable them to hold their local NHS organisations to account. It sets out statutory requirements on publishing information and describes good practice in publishing other information. To give legislative force to that code would not enhance its effectiveness. My right honourable friend the Secretary of State has said that she is introducing the code of practice in order to promote a climate of openness, to foster a culture of co-operation and confidence. We believe the code of practice, as a flexible and non-statutory code, will help to achieve that in the health service.

I note what the noble Lord, Lord Carter, said about matters that happened in his area. I should like to refer to part of Section 5 of the code of practice which states: details about important proposals on health policies or proposed changes in the way services are delivered, including the reasons for those proposals. This information will normally be made available when proposals are announced and before decisions are made; details about important decisions on health policies and decisions on changes to the delivery of services. This information and the reasons for the decisions, will normally be made available when the decisions are announced". That is, apart from exemptions later in the code, NHS trusts and authorities must publish or otherwise make available in the following information the matters that I have just discussed.

With regard to the rights of the regional office staff to speak out, the regional offices will have a different role to that of the RHAs. The new health authorities will be the operators in the new system. They will be taking the decisions that will directly affect local people. There will be no reduction in the rights of health authorities to represent publicly the needs of their populations.

The regional offices will contribute to the development of central policies for the National Health Service, monitor the health authorities and trusts in their areas and intervene managerially where this is needed. Those are responsibilities appropriate to the Civil Service and therefore it is right that the regional office staff should he civil servants.

The noble Lord, Lord Carter, was anxious about the charges for information. The code recommends that charging for information should be absolutely exceptional and that no charge should be made in the majority of cases. It also sets out where information must not be disclosed; for example, where details of other people are requested.

Clearly, the change in the rights of regional office staff to "speak out" is a change of status but it gives them more influence over central policies. As civil servants in the new order, they will have greater opportunities to shape central policies by offering advice to Ministers.

I hope that in the light of that explanation the noble Lord, Lord Carter, will feel a little more satisfied and will not believe it necessary to press the amendment.

5 p.m.

Baroness Jay of Paddington

My Lords, with the leave of the House, I was a little unclear about what the Minister said about the way in which the Code of Practice on Openness in the NHS applied to the new regional offices. It states in the introduction that this builds on: and complements the Code of Access to Information which applies to the Department of Health, including the NHS Executive". How will that apply to the regional offices?

Baroness Miller of Hendon

My Lords, as I said, the regional offices will have a different role from that of the RHAs. Under those circumstances, the regional offices will contribute to the development of central policies for the NHS and will monitor the trusts. Their responsibilities will therefore be appropriate to those of the Civil Service, so it is right that the regional office staff should be civil servants.

Perhaps I may comment on a point made by the noble Lord, Lord Carter. He asked how the codes of practice will be amended. I do not have that information but I shall write to the noble Lord.

Lord Carter

My Lords, I hope that the Minister will not object if I say that that was not a very satisfactory answer. I am glad that she has spelt out the information which must be provided under Section 5 of the code. In the example that I gave, almost everything was done in complete breach of what has been suggested and we shall want to follow that up.

The arrangements for direct appointees by the Secretary of State to the various bodies raise anxieties about the declaration of interests and we hope that the new code will help to prevent the recent bad examples. I am surprised that the department has not taken a policy decision on the publication of the results of the survey as regards the Code of Conduct and Accountability. I hope that it will not be described as an imputed motive if I suggest that perhaps the department is waiting to see what the survey says before deciding whether to publish it. That is not exactly the openness of government that we should all like to see.

Charging for information was mentioned as exceptional but presumably it will be left to the trusts and authorities to decide what is exceptional and what is not. That will be a considerable disincentive to the small local groups that are set up to try to save a hospital or to protest about a closure. They will be discouraged by the charge for information, which I believe is excessive.

We have heard about civil servants at the regional offices being able to influence central policies and so forth. I wonder what will happen to the civil servant who does not believe in the internal market and how far his or her career will progress under the change of responsibilities that we have discussed.

The answer is not satisfactory but it is the kind of answer that I expect from the Government when we are discussing openness and accountability. I do not intend to press the amendment at this stage but we may wish to return to the matter on Third Reading. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Cledwyn of Penrhos moved Amendment No. 6:

After Clause 2, insert the following new clause:

Special Authority for Wales

(" . After section 8 of the National Health Service Act 1977 there shall be inserted—

"Special Authority for Wales.

The Secretary of State shall, by order, establish a Special Authority for Wales which shall have such clinical and non-clinical duties of a specialized and all-Wales character as the Secretary of State shall in such an order determine and shall include (but not be limited to)—

  1. (a) a blood transfusion service,
  2. (b) an artificial eye and limb appliances service,
  3. (c) a breast cancer screening service,
  4. (d) a service relating to the examination, checking and pricing of prescriptions for drugs, medicines and appliances supplied by the National Health Service,
  5. (e) a health complaints administrative service,
  6. 736
  7. (f) a research, intelligence and health service management information system,
  8. (g) such functions relating to capital works, the procurement of supplies, income generation and the provision of computer services on his behalf or on behalf of the Health Authorities as the Secretary of State may direct it to perform in the interests of the Welsh National Health Service,
  9. (h) such other functions as the Secretary of State may direct it to perform on his behalf of a Health Authority."").

The noble Lord said: My Lords, as I mentioned in our exchange on Amendment No. 1, I learnt during the recent Recess that there is considerable anxiety that in many ways Wales is being overlooked and neglected in the Bill. The amendment is intended to correct that neglect and to provide Wales with a number of services which I am sure the House will agree are essential. They were mentioned by my noble friend Lord Prys-Davies when he spoke in Committee on 28th March. My noble friend made a comprehensive case and went in detail into the various services affected by the Bill. He dealt with the work and contribution of the Welsh Health Common Services Authority, which provides special services and has an excellent workforce of 1,750 experienced people.

I must pay tribute to the noble Lord, Lord Thomas of Gwydir, who set up that authority in 1974 when he was Secretary of State for Wales. Since then, every Secretary of State for Wales has built on that authority and extended it. Its contribution to Welsh health has progressively been considerable.

I regret to have to say that the present Secretary of State, Mr. John Redwood, has taken an attitude quite different from his predecessors. He proposes to detach three of the clinical services because, he said, he wanted to bring them closer to the mainstream of the National Health Service. That is totally unnecessary. The three services were already an essential and integral part of the Welsh National Health Service.

The Secretary of State has also instructed the staff to find work in the private sector. I find that extremely difficult to understand. They appear to be the actions of a ruthless operator who places his dogma before the interests of the Welsh people. The special health authority was deliberately disbanded, without adequate consultation or concern for those whom it served so well.

I would like the Minister to explain why consultation did not take place; that is, consultation with Welsh general practitioners, the Welsh committee authorities and the county councils in Wales. They all work together effectively in the Principality, as those who know Wales are aware. Perhaps I may ask the noble Baroness to tell the House what will happen to the 1,750 people whom I have mentioned because—and I must press this home—they have a very good reputation throughout Wales for the work which they are doing in their various areas. Will the Minister give an assurance that their jobs are safe?

I understand that the Secretary of State has said that they must find work in the private sector. May we he told where in the private sector in Wales those splendid people are to find work? We are entitled to an explanation about that matter. Work is not easy to find in Wales and unemployment is high. In some parts unemployment is higher than others. In Gwynedd, where I live, I know from experience how difficult it is to find work. I must ask the noble Baroness to tell the House how work will be found in the private sector for 1,750 people. I do not wish to see those people having to leave Wales and cross the Severn to find work as they did in the 1920s and 1930s.

I know that both noble Baronesses are ladies of compassion. I am quite sure that they feel as strongly as I do and they certainly would feel strongly, as I do, if they went to Wales to find out the feelings of the people there. This amendment is reasonable. The Welsh people support it. It is necessary. I hope that the noble Baroness will agree with me, I beg to move.

5.15 p.m.

Lord Prys-Davies

My Lords, I wish to support as sincerely as I can the amendment moved by my noble friend Lord Cledwyn. This is a positive amendment; it is not a destructive amendment. It is positive because it seeks to ensure the continued existence of the Welsh Health Common Services Authority—WHCSA, as we know it in Wales. This amendment is identical to that which was moved in Committee except that it does not include a new health promotion function. The simple reason for that is that we have no wish to complicate the debate by mixing up two arguments.

As my noble friend Lord Cledwyn demonstrated, the case for WHCSA stands on its own merits. It has given excellent service to the NHS in Wales since it was set up some 22 years ago. I should like to stress that the noble Baroness acknowledged in Committee the high quality and achievements of WHCSA and the dedication of its staff. Therefore, its contribution is not an issue. That was a helpful contribution by the Minister but the rest of her speech, which I have no doubt was written by someone else, was disappointing. That is why we are not content to let the matter rest.

As my noble friend Lord Cledwyn pointed out, notwithstanding its achievements in April last year the present Secretary of State decided that the authority should be disbanded, dismantled. We heard the Secretary of State's reason; namely, that that organisation should move nearer to the mainstream NHS, as though it were standing in splendid isolation from it. In Committee, the Minister sought to defend that curious position on an additional but ambiguous ground. The Minister said: Trusts need freedom now to introduce different mechanisms and services to support them". Two sentences later she added the extraordinary statement—particularly in view of the enormous growth of the Welsh Office— It is no longer tenable to have a large central organisation".— [Official Report, 28/3/95; col. 1595.] Those statements by the Minister do not absolve the Welsh Office from giving evidence in support of their decision. But I am sure that there in the Minister's own sentences we have the explanation. The reason is essentially ideological. That is the problem and that is the anxiety.

As I said, in Committee the Minister spoke of the need to give freedom to the NHS trusts. If that concept rightly claims a top priority—it has not been argued or demonstrated—why is it proposed to transfer the breast-screening service to a single authority; to transfer the artificial limb service to three authorities; and why is it that the blood transfusion service, thankfully, is to remain where it is? How can those arrangements for the breast-screening service and the artificial limb service give freedom to all the other trusts in Wales?

Have the risks, the damage and the injury which may flow from that decision been weighed properly in the Welsh Office? Has it occurred to the Welsh Office that the dismantling of WHCSA may do great damage to the health service of the future? As my noble friend Lord Cledwyn pointed out, the Welsh people speak highly of that organisation and they wish the high WHCSA standards to continue. But such standards, expertise and commitment require an abundance of WHCSA skills, dedication, efficiency and experience. If the WHCSA structure is removed, there will be a risk—I put it no higher—that the support will not exist. Therefore, we ask the Minister whether that down-side has been considered properly.

It is our understanding, which I believe was confirmed by the Minister in Committee, that some rapid studies were undertaken by officials to see how the post-WHCSA services could best be organised, subject to the proviso that, in any calculation, WHCSA was to be eliminated from the computation. In Committee I asked that a copy of those studies be placed in the Library before Report stage. I thought that that was a helpful suggestion on my part. That would at least help us to get at the facts. That information had not been provided to the Library by five o'clock today. Why is it being withheld? But, as it is being withheld, how can we have any confidence that the right decision is being made?

If a businessman wishes to change the administration or management of a business, he works out the costs of doing so stage by stage. He identifies the risks and the new problems which may arise and compares the proposed arrangements with the present arrangements and assesses the effects. But, in relation to WHCSA, we have no means of knowing whether that essential exercise has been undertaken properly by the Welsh Office. We have no means of ensuring that the Welsh Civil Service has done its homework properly.

The Minister claimed on two occasions during her short speech in Committee that the promoters of the amendment were seeking to set, one particular set of administrative arrangements … in legislative concrete". [Official Report, 28/3/95; col. 1596.] With respect to the Minister, whom the House holds in high regard, that does a disservice to the arguments that we have deployed.

My noble friend Lord Cledwyn and myself are not interested in an academic argument about the merits or demerits of primary and delegated legislation. However, I would add that neither of them is set in concrete; they can be changed. But if it pleases the Minister and her advisers, I am sure—although I have not discussed this with my noble friend—that we would be content to rely on the statutory instrument if she gave an undertaking to the House that there will be no substantial change in the role of WHCSA during the foreseeable future. Does that help the Minister?

I turn now to my final point. Sadly, the present Secretary of State declined—indeed, refused—to meet staff-side representatives to discuss such a curious decision which will affect their daily lives. Surely that is not the way to treat people. The Minister, who has to defend the decision taken by her colleague, tried to persuade us in Committee (at col. 1595 of Hansard) that, "Handling the process"— people are experiencing some difficulty in understanding that phrase— is a matter for WHCSA's own management". The fallacy of the argument is clear. It ignores the fact that WHCSA's management is not empowered to decide whether the organisation does or does not have a future. Its future is in the hands of the Secretary of State for Wales in the Welsh Office. We say, without underlining it, that in his decision not to meet the staff representatives—indeed, representatives of 1,750 people—the Secretary of State went wrong. We hope that the Secretary of State's mind is not closed, at least on this issue, and that he will listen to argument.

Baroness Cumberlege

My Lords, the noble Lord, Lord Cledwyn of Penrhos, invited me to agree with him. However, I fear that both he and the noble Lord, Lord Prys-Davies, will be disappointed with my response. I try my best to agree with the noble Lord on most things, hut we have a difference of opinion in the matter.

One of the main purposes of the Bill is to reduce bureaucracy in the NHS. It would be a pity if, through the amendment, we used the Bill to impose additional bureaucracy on the NHS in Wales. Your Lordships are aware that most of the functions listed in the amendment are currently carried out by the Welsh Health Common Services Authority; and that the various parts of that authority have been under review. During our considerations in Committee, I explained to your Lordships that the driving force behind the review was the needs of patients and of the NHS organisations which directly serve patients.

Our aim is to ensure that NHS organisations in Wales obtain the many support services that they need as cost effectively as possible. We believe that that is the best way to ensure that they, in turn, can meet patients' needs effectively. That is why my right honourable friend the Secretary of State for Wales decided to market test WHCSA's non-clinical services and explore the possibility of privatisation. That process will enable NHS trusts to provide more or better care for the same money. As my right honourable friend said in another place: In a world in which NHS trusts are doing more for themselves, we should not second guess them or double bank their activities through a central common services authority".

The noble Lord, Lord Cledwyn, asked me why there had been no consultation on the matter. There has been consultation with the service users and the market-testing process involves consultation with staff. I shall return to that aspect later.

The Welsh Office is currently considering options for market testing or privatisation of two of WHCSA's non-clinical services—estates design and maintenance and information technology. Following that consideration, in the next month or so, tenders will be invited. It is envisaged that the exercise will be completed during 1995–96. Market-testing exercises are already underway for two other functions, supplies and prescription pricing. The results should be known by early autumn. The noble Lord, Lord Elis-Thomas, raised a question in Committee about the use of the Welsh language in relation to prescription pricing services. I understand that colleagues at the Welsh Office are writing to the noble Lord on the matter.

As I made clear in Committee—and I am more than happy to reiterate it this afternoon—employees at WHCSA have made a valuable contribution and one which is much appreciated in terms of what they have done for the NHS in Wales. I well understand how unsettling such uncertainty must be for them. The process provides for consultation with staff and we hope that they will see that as an opportunity to improve the services that they provide. But handling the present process is a matter for WHCSA's own management. That is why Welsh Ministers have declined to meet staff-side representatives whose interests are best served by the proper out-working of the process itself.

I turn now to WHCSA's clinical services. I am very pleased to be able to confirm to your Lordships that my right honourable friend has now decided on the new management arrangements. His decisions were taken after full consultation with the NHS in Wales and announced to the NHS on 4th April. In the light of consultation, as the noble Lord pointed out, my right honourable friend decided that the management arrangements for the National Blood Transfusion Services (Wales) should not change for the time being; that the Artificial Limb and Appliance Services should, in general, be managed by the hospitals where they are based, but some specialist services will be centralised at a single point; and that management of the screening programme for Breast Test Wales will transfer to a single trust, while evaluation and research will be taken forward by the director with the University of Wales College of Medicine.

I believe that the noble Lord, Lord Prys-Davies, raised the question of destabilisation. During a full consultation with the NHS in Wales, many useful responses were received. The new management arrangements for Breast Test Wales and the Artificial Limb and Appliance Services will be phased in during 1995–96. The new arrangements are expected to be in place by 1st April 1996. Funds in support of those services are to be ring-fenced for the financial years 1995–96, 1996–97 and 1997–98. I believe that many of the amendments were made through the consultation process and because of it. Of course, the National Blood Transfusion Services will remain with WHCSA for the time being. Therefore, there should be no destabilisation.

The option appraisals for each of those services have been placed in the Library as the noble Lord, Lord Prys-Davies, requested. I cannot understand why the noble Lord says that they are not in fact there. I was informed that the appraisals had actually been placed in the Library. I shall certainly look into the matter. However, if they are not there now, I shall arrange for summaries of the consultation responses to be made available.

The amendment also suggests that the new authority should be responsible for administering health complaints. We do not see the need for such a centralised system which we believe would not be consistent with the proposals that the Government recently published for a new, streamlined NHS complaints system.

Both noble Lords, I believe, raised the question of redundancies, employment and, indeed, unemployment. It is hoped that any redundancies will be kept to an absolute minimum and that staff may be redeployed elsewhere in other areas of the NHS in Wales. Of course, there would have to be further consultation before any redundancies took place. I also believe that the Transfer of Undertakings (Protection of Employment) Regulations—commonly known as TUPE—are capable of application in that respect. It would mean that the rights of employees are protected at the point of transfer.

In conclusion, although I understand the issues that have been raised this afternoon, the Government do not believe that the amendment would help to improve the health service in Wales. We think it would introduce a rigidity and an unnecessary central bureaucracy which would only be changed by further primary legislation. Such an authority would frustrate our efforts to get the best for patients. I therefore hope that the noble Lords will withdraw their amendment.

5.30 p.m.

Lord Cledwyn of Penrhos

My Lords, we have listened carefully to the speech made by the noble Baroness. I am bound to say that I was impressed with some of the things which she said although, broadly, I was disappointed that she was unable to make the major concession. I think she is wrong in talking about rigidity in Wales. There is no rigidity in Wales. We do things in a rather more elastic way than that. If we do that, then we usually succeed. But having said that, my noble friends and I would wish to look at her speech carefully and to consider whether we might bring the matter back at Third Reading. With that in view, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 1 [Amendments]:

Lord Rea moved Amendment No. 7:

Page 6, line 24, after ("Authority") insert (", including administering the arrangements made in pursuance of this Act for the provision of general medical services, general dental services, general ophthalmic services and general pharmaceutical services,").

The noble Lord said: My Lords, in moving Amendment No. 7 I wish also to speak to Amendment No. 15, which covers the same ground. We looked at some of the issues referred to in this amendment when debating Amendment No. 19 in the name of the noble Baroness, Lady Gardner of Parkes, in Committee. The professions involved in primary care named in the amendment, while not opposed to the merging of FHSAs and DHAs in principle, are still concerned that nothing on the face of the Bill requires health authorities to protect and to promote the activities of primary care. They would feel more comfortable if words such as those in the amendment were included, as health authorities will have great pressure put upon them to devote increasingly large proportions of their budget to contracts for hospital services. Those pressures are still there, even if less direct, after the purchaser/provider split.

The Government have coined the phrase, "a primary healthcare led National Health Service", which of course many of us welcome. However, general practitioners are rather used to being told that, for example, they are the linchpin of the service, or the key to the success of the National Health Service, with little cash following the rhetoric. In the National Health Service Executive's Guidance on Transitional Issues to the new health authorities, the role of the new health authority, as it will be after the Act, is described in some detail. These are not transitional arrangements as such but describe what the new health authorities will do when constituted, as well as describing the steps to be taken towards achieving that.

Among other functions of the new health authorities which the document mentions are those in paragraph (b) on page 3 which states, developing primary care and forging constructive partnerships with all primary care professionals". Paragraph (c) on page 4 refers to, administering and managing arrangements with local GPs, dentists, ophthalmic practitioners and pharmacists". That is similar to the wording of the amendment, including the terms of service of family health services contractors.

In other parts of that guidance document reference is repeatedly made to primary care. I would not expect the words of a guidance document to be on the face of a Bill. However, the words in the amendment would remind health authorities of their obligation to those who work with and for the current family health services authorities. The guidance document from which I have quoted goes further in describing steps to be taken towards achieving a primary healthcare led NHS than does the amendment. I wonder whether in her reply the Minister can say whether and how the Government will ensure that the guidance is followed by health authorities. I beg to move.

Lord Carter

My Lords, my noble friend has explained the purposes of these two amendments extremely well. However, it is important to emphasise from this Front Bench that we feel there must be a clear recognition in the Bill of the role that is played in the health service by primary care. We know all about the GP being the gate-keeper and so on and we feel that wording on these lines—or indeed on the lines of Amendment No. 15 which is grouped with this amendment and concerns a report on the functions of the family health services authorities—would help to underline the crucial importance of primary care in the operation of the health service. It is often thought when one refers to the health service that it is a hospital service but I believe that the hospital budget accounts for only about 15 per cent. of the whole. The words I have referred to may not be perfect but something along those lines would at least underline and, as my noble friend said, would remind those concerned of the crucial importance of primary care in considering the functions of the new arrangements. I hope that if the Minister cannot accept the amendment she will at least be able to confirm the crucial importance of the whole of the primary care service.

Baroness Cumberlege

My Lords, while respecting greatly the distinguished medical career of the noble Lord, Lord Rea, in family doctor services, I think that he will surely recognise that the Government's aim in establishing the new health authorities is to create a single authority at local level with responsibilities across the full range of health care. This aim has been widely supported by many of your Lordships. We believe that the new authorities will deliver a better service to patients by removing artificial boundaries between primary and secondary care. Unified health authorities will be able to develop a single comprehensive health strategy for the people in their area. We expect them to secure a more sensitive balance than was possible in the past between prevention and treatment, and between primary, community and hospital-based care.

Against that background, I am not at all sure that it makes sense for the Secretary of State to report in isolation on certain functions, simply because in the past they were carried out by family health services authorities. The Secretary of State and the NHS Executive already publish a wide range of reports and, of course, health authorities, like DHAs now, will be expected to publish annual reports on their activities.

I recognise, as the noble Lord, Lord Carter, has said, that there are people who are concerned that former FHSA functions may be overshadowed in the new authorities and I am very happy to make it absolutely clear that we will not allow that to happen. The close working which already exits between some authorities has demonstrated that there need be no loss of focus on primary care in the new health authorities. Rather, the skills and knowledge of both DHAs and FHSAs are being brought together to provide a better service. I can assure your Lordships that administration of primary care will he a core function of health authorities, with many specific functions placed on them in primary legislation and supported by regulations. So any health authority which neglected these functions would be failing in its statutory duties.

As has already been said by the noble Lord, Lord Rea, the department issued guidance to the NHS recently on The Creation of the New Health Authorities. Your Lordships may be reassured by some of the statements in the guidance about the role of an effective health authority. For example, the guidance says that essential elements of their role include: developing a strategy in collaboration with GPs, providers, local people and other agencies … to meet national and local priorities … developing primary care and forging constructive partnerships with all primary care professionals … administering and managing arrangements with local GPs, dentists, ophthalmic practitioners and pharmacists". The performance of the new authorities will be measured by how well they carry out functions like these, not just by how effectively they purchase hospital care. I hope that your Lordships accept that the Government are committed to a more primary care-led NHS and that these amendments are not necessary.

Lord Rea

My Lords, perhaps I may ask the Minister how much force the guidance that she and I have quoted has on the conduct of health authorities and what sanctions the Government have if guidance is not followed.

Baroness Cumberlege

My Lords, some of the specific functions, not the actual guidance, are placed upon health authorities through primary legislation and are supported by regulation. If an authority were to fail in those it would be contravening that legislation and failing in its statutory duty. Certainly, the department and management executive would come down very heavily on that authority.

We have found guidance to be very effective. One aspect that impresses me about the National Health Service is that when it is asked to do something it does its utmost to achieve it. One sees that not only in terms of broad strategy but in the detail of the care that is provided. There is every reason to believe that conviction exists in the health service that guidance is there to be carried out.

Lord Rea

My Lords, what the noble Baroness says has pleased me greatly. It was in order to get such a statement that I put down the amendment. I believe that many workers in primary care will be very relieved to read in the pages of Hansard what she said. I thank the Minister very much for her statement. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

5.45 p.m.

Lord Rea moved Amendment No. 8:

Page 6, line 40, at end insert: ("() The Secretary of State shall give directions with respect to the exercise of responsibilities exercised prior to the passing of the Health Authorities Act 1995 by Regional Health Authorities in respect of the holding of contracts of registrars and senior registrars so as to require that those responsibilities should continue to be exercised on a regional basis.").

The noble Lord said: My Lords, this amendment allows us to continue the discussion we had in Committee. I refer to Amendment No. 15 and the proceedings at cols. 1601 to 1604. The National Health Executive document Options for the Future Management of Postgraduate Medical and Dental Education was published on the same day and briefly discussed in Committee. At that time the noble Baroness said: It is our intention that the training programmes of registrars and senior registrars, and in the future those doctors in the proposed new unified training grade, will be managed at regional level by the postgraduate medical deans. That was a relief. Later, she said: It will not be necessary for the doctors' employment contracts also to be held at regional level to safeguard the doctors' training interests. It would not be right for them to be held by the regional offices as part of the Civil Service."—[Official Report, 28/3/95: col. 1603.] That is possibly but not necessarily so. Mine is not the only voice to express doubt about that statement. The Committee of Vice-Chancellors and Principals said: The CVCP would prefer to see the management of PGMDE contracted to the universities which are well used to the strict accountability requirements placed on them through the Higher and Further Education Act. This amendment will accommodate that preference. The current contracts of junior doctors are overseen by the regional postgraduate deans who are jointly appointed by the universities and the regional health authorities. They can insist that the educational standards of junior doctors are protected. The CVCP and Royal colleges are unhappy that employment contracts will be held, as the Government suggest, at trust level, even if a lead or neutral trust continues to hold the main contract when a training programme involves rotation from one trust or health authority to another. I pointed out in Committee that it was difficult to insist on protected educational time in the face of heavy clinical demands. It would be more likely to be protected if a doctor's contract was with a body not directly concerned with service provision.

In Committee the Government put down several amendments to secure continuity of employment if junior doctors moved across trusts or health authorities during their rotation. However, those amendments were not moved. It is reasonable to ask why not. If the Government reject this amendment, the amendments, which the Government did not move, will be necessary to protect the jobs of junior doctors. If those amendments were withdrawn for a technical reason, surely it should be explained. Depending on the reply of the noble Baroness, we will have to consider whether or not those amendments, or something like them, should be introduced by this side. Of course, this will not be necessary if the noble Baroness accepts our amendment to keep the contracts of junior hospital doctors under one jurisdiction—the universities—through the current regional arrangements. I beg to move.

Baroness Cumberlege

My Lords, as I made clear when we discussed this in Committee, there are two important issues in relation to the contracts of registrars and senior registrars whose contracts are currently held by RHAs. First, their employment contracts need to be held elsewhere when RHAs go. Secondly, the continuity and quality of training programmes needs to be properly protected. It may be helpful if I deal first with the question of employment contracts. The Government tabled amendments to employment legislation in Committee which were relevant to these staff, among others. We did not move the amendments because we had not yet completed consultation on related issues set out in the department's discussion document on the future management of postgraduate medical and dental education. In particular, we are concerned to ensure that the new arrangements do not disadvantage doctors by breaking their continuity of employment so as to deprive them of rights under employment legislation. We are considering the means by which such protection can best be secured. Should further amendments prove necessary to achieve that, it would be our intention to table them at Third Reading.

It would not be right for the contracts of junior doctors to be held by the regional offices as part of the Civil Service. The Government have made clear that they would prefer junior doctors' employment contracts to be held by the employer, usually an NHS trust. This is consistent with the treatment of other NHS medical and non-medical staff. It is consistent with the principle that personnel issues are generally best managed at local employer level and with trust freedoms to determine the quality and type of resources they employ. Devolving contracts to employers is still a matter for discussion with the various professional bodies representing these staff.

This brings me to the second issue. I am aware that particular concern has been expressed that to transfer contracts to NHS trusts may cause problems in maintaining the required level and standards of training. A number of proposals arising from discussions with postgraduate deans were set out in the discussion document issued recently by Dr. Winyard, the medical director of the NHS Executive. The closing date for comments is today. In particular, the document suggests that there should be a network of training agreements between trainee doctors, deans and trusts. There would also be a system of service-level contracts between deans and trusts to ensure that the right environment was provided for a high standard of training delivered in a cost-effective way. Training agreements might cover matters such as the agreed balance between service and training; the level and type of specialist training to be provided; educational plans, inlcuding rotational arrangements and study leave; and arrangements for assement.

Service level contracts between deans and trusts have already been introduced in many parts of the NHS. They are a good way of ensuring that trusts continue to provide high quality postgraduate medical education. The safeguard they provide is reinforced by the dean's financial control over a very significant proportion of the resources involved—including 50 per cent. of the basic salary costs of full-time junior doctors. That amounts to between £300 million and £400 million nationally. I should make clear that neither training agreements nor service level contracts would require any provisions in this Bill.

We are committed to high quality medical education and training, which underpins our objective of providing high quality health care to patients. The interests of the profession, universities and postgraduate deans will be taken fully into account in developing the detailed framework for medical education and training. We will ensure that the staff concerned are treated fairly, and that continuity and quality of training is maintained.

In the light of those comments I hope that the noble Lord will withdraw his amendment.

Lord Rea

My Lords, once again I thank the noble Baroness for amplifying the Government's plans for postgraduate medical education. The Royal Colleges, the CVCP and postgraduate medical deans will want to consider carefully the statement that the noble Baroness has just made. A definite advance has been made. Without promising not to return to the matter at Third Reading, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Walton of Detchant moved Amendment No. 9:

Page 12, line 14, at end insert: ("() after that subsection insert— () For the purpose of ensuring the effective integration of clinical teaching and research within the National Health Service, the Secretary of State shall, in relation to any relevant committee, office or other body which he establishes to exercise any regional management function within the National Health Service, provide, following consultation with the relevant universities, that at least one member of that committee, office or body is a representative of the university medical or dental schools within that region.".").

The noble Lord said: My Lords, I rise to move the amendment standing in my name on the Marshalled List and in the names of the noble Lord, Lord Jenkin of Boding, the noble Baroness, Lady Robson of Kiddington, and the noble Baroness, Lady Jay of Paddington. The noble Lord, Lord Jenkin, who is unable to be present this afternoon, has given me permission to say that he supports fully the principles outlined in the amendment.

In the late 1960s I was a member of a regional health authority. At that time I held a consultant contract in the NHS coupled with a personal chair in the university. It became clear to me that the inter-relationship between the National Health Service on the one hand and the universities with medical and dental schools on the other was crucial and vital to the future of health services and to teaching and research in medicine, dentistry and the other health services.

When I became dean of the medical school in 1971 I was surprised when a senior government Minister expressed astonishment on learning that clinical academic staff employed by universities were heavily involved in providing clinical services to patients. In fact, throughout the history of the National Health Service those holding clinical contracts with universities have provided extensive services to patients. When I held the particular appointment to which I referred the clinical load that I carried was almost as great as, if not at times greater than, that of my colleagues employed wholly by the National Health Service.

Later, when I became chairman of the Education Committee of the General Medical Council, and subsequently its president, it came as a surprise to many of us in academic medicine to learn that there was no formal liaison mechanism between the then Department of Education on the one hand, responsible for the funding of the universities through the University Grants Committee, and the Department of Health on the other, responsible for providing the clinical facilities for medical and dental teaching. One of the actions that we pursued at that time, which I am glad to say was successful, was to persuade those two departments to come together. Hence a liaison committee was created under the chairmanship of the then Permanent Secretary at the Department of Health, Sir Christopher France.

That particular body has grown and its role has been extended until it is now the steering group for undergraduate medical and dental education and research. It is chaired by the current Permanent Secretary at the Department of Health.

Through that mechanism the relationships between the universities with medical and dental schools and the National Health Service have become much closer. Ten key principles outlining the basis of that relationship have been promulgated. I understand that those principles will be carried forward in the changes that result from this Health Authorities Bill.

One other factor of great importance which I learnt as the dean of a medical school was that at that time, some 25 years ago, it was regarded as inappropriate, if not illegal, for money to be transferred across the divide between the Department of Education on the one hand and the Department of Health on the other. Happily, that principle was soon breached because, as time went by, it became increasingly clear to those working in the health service that if there was an area within the health service where the standard of patient care and of research and education was not as high as it ought to be one of the best ways of improving those standards and of developing services was to create a chair or a senior academic post with supporting staff to try to raise the quality of the services in those particular medical, dental and other disciplines.

As a consequence, the Department of Health, through its regional health authorities, began a process of funding academic posts in the universities across the country, to such an extent that in some medical schools 40 per cent. of clinical academic posts are now funded by the Department of Health. That underlines the crucial importance of that inter-relationship between the NHS on the one hand and the universities with medical and dental schools on the other.

We have been given assurances that that process will continue, even when the regional structure has been changed as proposed in this Bill. We in the university sector were much reassured on reading the Hansard transcript of the Committee stage debate. I deeply regret that because of a professional commitment elsewhere in the United Kingdom I was unable to be present. I was very happy to read the words of the Minister when she said that: The Government are strongly committed to the vital partnership between the universities and the new National Health Service. We will work with them to achieve the highest standards of education and research".—[Official Report, 30/3/95; col. 1718.]

We were also much encouraged to learn, as a result of an amendment tabled at that stage, that the universities' position would be strengthened and that the Government were able to give a clear undertaking that, in regulations, they would require the health authorities whose areas include a medical or dental school to have a university representative as a non-executive member. That was a very reassuring development, and we were delighted to have that assurance.

However, that still left a serious anxiety about the position in the regions. As the Minister said: The regional offices are very different bodies from the old RHAs. They will not have boards on which different groups are represented. Therefore, it will not be appropriate to have a university representative within the regional office". We fully accept that, because the regional offices will be staffed by people who are part of the National Health Service Management Executive. It would be inappropriate to have a university appointee employed in such an office. We know that there will still be a powerful university voice at national level. But surely it is not beyond the wit of man to devise a mechanism whereby universities can play a major statutory, advisory role at regional level. It is true that many of the regional directors of research and development are at present, and are likely to be in the future, distinguished academics. But they do not necessarily speak on behalf of the universities at which they have previously worked.

I was much encouraged earlier today to learn from the Minister that the regional chairmen will in future be non-executive members of the policy boards at regional level. If we were to be reassured that the university voice would be heard through an agreement that the university would have the right to appoint, in consultation, a non-executive member of the regional policy board, I believe that most of the anxieties that we feel in relation to the future would be allayed.

The postgraduate dean will be a key link between the regional office and the university. I have had the privilege of seeing the consultative document which was recently circulated. I believe that it is absolutely right that the postgraduate dean in future should be jointly appointed by a contract held on the one hand with the regional office and on the other with the university. However, it may not be necessary for the postgraduate dean to be housed in the regional office as many postgraduate deans are already provided with satisfactory accommodation in the universities, funded under the partnership with the universities which is so crucial to the future.

Those are the major concerns we have. I trust that the Minister will be able to assure us that there is a likelihood that the regional policy boards—they are concerned with the crucial, strategic developments in relation to patient care, teaching and research in which the universities play such a vital role—will be able to have a non-executive university appointee in their membership. I beg to move.

6 p.m.

Lord Addington

My Lords, the noble Lord makes an important point. Integration between universities and the health service is far closer than in virtually any other area regarding universities. The fields of activity are directly connected. The frontier of medical knowledge affects healthcare very quickly. It is appropriate that there should be such representation.

Baroness Jay of Paddington

My Lords, I support the amendment. It is unfortunate that it is necessary for the noble Lord, Lord Walton of Detchant, to bring forward such an amendment at this stage. As we discussed at Second Reading and in Committee, we are all aware of the consultation, for example, between the chairman of the CVCP, the Department of Health and others professionally involved in this area to seek to resolve the issue before the Bill reached this stage in your Lordships' House. But still it is unclear what will happen. In introducing the amendment, the noble Lord underlined this important area. It is particularly unfortunate that arrangements are still not in place.

Noble Lords will remember that in Committee I referred to the correspondence between Dr. Edwards, chairman of the CVCP, and the Secretary of State. The chairman stated that for the Department of Health to write to regional directors asking them to remember that universities should be consulted in appropriate circumstances underlined the heart of the problem. It gave no assurances about the appropriate circumstances. It left the process of consultation to the individual decision of regional directors.

Noble Lords have made an incontrovertible statement: that a formal, clear and unambiguous mechanism needs to be in place before we start the new arrangements. The noble Lord, Lord Walton, emphasised the important role of academic medicine in the higher ranks of the medical profession. As the noble Lord, Lord Addington, said, it is equally important to patients that that extremely important connection is maintained. If we are to have an effective, knowledge-based health service, as Ministers constantly tell us that we have—it is an ambition to which we all subscribe—we must ensure that the important links between academic medicine and the health service are maintained at every level so that standards of excellence are not simply maintained but continue to be improved.

Baroness Cumberlege

My Lords, we discussed a similar amendment in Committee when the noble Lord, Lord Walton, was unable to attend. I am glad that today he has been able to contribute his considerable expertise. It is recognised nationally and internationally. I am grateful for this opportunity to emphasise again the Government's commitment to the vital partnership between the universities and the NHS. Perhaps I may reiterate my earlier comments. We intend to continue to work closely with the universities to maintain the highest standards of education and research. We agree entirely with the noble Lord, Lord Addington, and the noble Baroness, Lady Jay, that it is a crucial link.

As the noble Lord, Lord Walton, said, the new health authorities will have membership; it will be laid down in regulations. They will be required to include a medical or dental school member on their boards as a representative and as a non-executive member.

The new regional offices will be firmly part of the Department of Health. Their advisory and liaison arrangements will be much more closely linked with the national advisory framework. The regional offices will be different from the old regional health authorities and, as the noble Lord said, it would be inappropriate for their management boards to include representatives of outside bodies. However, there will be many other links between universities and the Department of Health at regional level.

As I made clear in our previous debate, regional chairmen will have a special responsibility in this area. Perhaps I may clarify a point which the noble Lord may have misunderstood in an earlier debate. There will not be eight NHS policy boards reflected in each region. There will be one national policy board, as indeed there is now, upon which the regional chairmen will sit. But there is nothing to stop regional chairmen within their regions building any mechanisms they wish in order to strengthen those links. Indeed, that was my situation when I was regional chairman at South-East Thames. We had a clear structure that incorporated the university representatives who were not members of the health authority but had a contribution to make in that they were involved in the medical schools—the deans, and so on. So there is much opportunity there.

The postgraduate medical deans also form a strong and important link since they will be fully involved in both the regional offices and the universities. We are just completing consultation on the document which my department published last month, Options for the Future of Postgraduate Medical and Dental Education. We believe that the proposals contained in that paper can be developed to provide an effective and acceptable basis for managing postgraduate education.

We also discussed in our earlier debate the "10 key principles", referred to by the noble Lord, Lord Walton. These guide effective working relationships between the universities and the NHS, in particular at regional level. The recent report of the Higher Education Funding Councils' Joint Medical Advisory Committee found that the principles were well regarded and were seen to provide an essential point of reference at a time of change. The committee recommended that the principles should be rewritten to reflect the new NHS. That is being given active consideration at present. We shall, of course, involve the universities in any changes that are made.

Your Lordships have raised concerns about research and development. On 11th April the Government published a plan to implement the Culyer Report, Supporting Research and Development in the NHS. Under the new research funding system, National Health Service research and development funds are to be raised through a levy on NHS purchasers and distributed via cost-based contracts. Contracts will be for research, research facilities and service support for research. The new system will aim to target NHS research and development funds to important work of high scientific quality.

Input from people with a university research background will be essential, especially during the development stage when we are agreeing definitions of coverage and eligibility for funding. Regional offices will, of course, work closely with universities in drawing up and managing contracts for NHS funding of research.

I can assure your Lordships that research and development will remain a top priority in the new NHS. Each of the new regional offices will have a senior post of regional director of research and development. Part of their role will be to develop extensive networks so that the views of all interested bodies, particularly universities, can influence their decisions.

We are continuing to have regular and constructive discussions with the Committee of Vice-Chancellors and Principals about the changes in the Bill. Indeed, there is to be a meeting in the next few days between the CVCP and NHS Executive directors to discuss the CVCP's concerns about liaison between universities and regional offices. I am sure that those discussions will lead to an effective framework to ensure that regional offices work closely and constructively with universities. In the light of those comments, I hope that the noble Lord will withdraw his amendment.

Lord Walton of Detchant

My Lords, I am grateful, as always, to the Minister for her comprehensive reply. She has given us a number of important reassurances about the interrelationship between the universities and the NHS. Since there is to be a meeting between the Committee of Vice-Chancellors and Principals and members of the National Health Service Executive or the Government, I trust that we can await the outcome of that meeting before deciding whether to bring back further amendments at Third Reading. Incidentally, the Minister said that that meeting was to be held in the next few days. My understanding is that it has been cancelled, or at least postponed. However, we trust that it will take place in the near future.

I, like my colleagues in the universities, will read the Minister's comments carefully. The issue of regional representation or the non-representation of the regional university voice is crucial. I had not understood that the policy board would be a purely national body. I trust that the regional chairmen may be persuaded to create mini-policy boards at regional office level because of the crucial nature of the relationship and its importance to the future. However, in the light of what the Minister said, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

6.15 p.m.

Baroness Jay of Paddington moved Amendment No. 10:

Page 19, line 34, after ("Authority") insert ("but of whom one shall be a Chair of the Social Services Committee of a local authority in the area for which the Health Authority is to act").

The noble Baroness said: My Lords, my amendment is designed to establish a formal working relationship at board level between the new health authorities and the social services of the relevant local authorities, In a sense, it does not cover the same ground as that discussed on the previous amendment introduced by the noble Lord, Lord Walton, but is designed to try to make more precise and more formal the relationships which are vital to the work of the new health service and community care arrangements.

Noble Lords will be aware that it is the Government's aim to transfer more and more health services from hospitals, from the acute sector to the community and primary care, and that the boundaries between medical treatment and social care are becoming ever more blurred. We have seen some of the difficulties that that has caused for both health and local authorities in the past one-and-a-half years. The problems of funding and managing care in the community for the mentally ill, the disabled and the elderly, have been discussed in your Lordships' House on many occasions. Like other services they are now the joint responsibility of health and social services authorities.

In the past few years we have also seen the development of The Health of the Nation programme which crucially depends on co-operation and collaboration between, among others, local environment and education agencies and health authorities. We cannot expect to have successful "healthy alliances" on issues such as air pollution and asthma and sexual health education in schools if those responsible for the programmes are working from different parts of the social and health services and perhaps working in demarcated isolated.

Noble Lords will be aware that Clause 22(1) of the National Health Service Act 1977 places a statutory duty on health and local authorities to co-operate to secure the health and welfare of their residents. But the formal mechanism for achieving that has been through the joint consultative committees which, in my many years' experience of membership of two such committees, has always been the least satisfactory and least practically effective part of health authority work. My discussions with local authority colleagues, both past and present, suggest that they feel the same.

The amendment is designed to breathe new life into inter-agency co-operation at a formal level by bringing social services into the heart of the new health authorities. I suspect that the Minister will say in response that the Government prefer to rely on good practice and guidance to achieve co-operation. I am sure that in some places that will be enough. I am impressed, for example, by the recently published Community Care Plan for Westminster 1995/96. That local authority document is signed jointly by the director of social services from the local authority and the chief executive of the local health authority. The proposals emphasise the importance of their joint planning teams. Interestingly, they measure their performance against key area targets suggested by the Department of Health. The document also says that there are longer-term issues which the Department of Health has asked them to continue to address. Those include focusing on, developing care management; making sure that continuing care responsibilities are made clear; developing the 'enabling' role of the local authority; learning to manage the market for social care and improving collaboration between agencies". That is obviously an example of good practice which has been largely driven by officers of the local authority and executive directors of the health authority. It depends on effective working relationships between individuals.

However, there is nothing in the new Bill and little in the guidance to ensure either that that kind of good practice continues or, perhaps in other places, gets started. The whole crucial system could collapse if particular individuals moved to other posts or there were bad personal relationships between the executive officers involved.

Surely, it would be more sensible if the relationship were formalised by making the chair of social services a member of the health authority board. Community care plans would then, in the current jargon, be jointly owned. If the Government or the Department of Health would prefer to make the local social services director an executive member of the new board, ex officio—which could be specified in regulations—we would find that satisfactory. But the important issue is to create an unavoidable requirement for health authorities and social services to work together.

There seems to be an inconsistency in the Bill of relying on good practice, for example, in that area and, as we discussed earlier, in professional representation on health authority boards; but not in other areas—particularly in regard to professional advice which we discussed in relation to Amendment No. 2. Paragraph 3 of Schedule 1 to the Bill requires health authorities to secure professional advice. The presence of the social services in the health authority is at least as important and, therefore, should be given the statutory force of the other type of advice by making the chair of the social services committee or the director of social services an integral part of the new health authorities. I beg to move.

Lord Rea

My Lords, I speak from a lifetime of work in primary healthcare in which collaboration with the social services has been absolutely crucial. That does not only apply to primary care; socio-economic conditions are absolutely crucial in governing the health status of whole communities. Nevertheless, that said, the co-operation between social services and the health service has not been as good as it should have been. The frustrations of the JCCs that my noble friend mentioned are only one part of this. Even at a lower level things have not always been as good as they should be—although, as I said in a debate last week, I have the highest respect for the integrity, motivation and dedication to work of individual social workers.

Enabling the director of social services, or someone who is nominated in his or her place, to sit in on the meetings of the health authorities and to take part in the discussions that lead to decisions, and to be always there to give advice from a social services point of view, would be enormously helpful in boosting the morale of the social services. It would make them feel much more as if they are true partners in integrated care, which is surely part of the new primary care led National Health Service.

Baroness Miller of Hendon

My Lords, we have made clear on a number of occasions the Government's view that membership of health authorities should primarily be decided on the basis of an individual's personal skills and qualities and not the office that they hold or the group they represent. I should first explain, however, that neither the chairmen of local authority social services committees nor any other member of a local authority is currently excluded from membership of DHAs and FHSAs. They will continue to be eligible for appointment to the new health authorities.

It is true—as the noble Baroness, Lady Jay, said—that the experience of a social services committee chairman might be valuable in many circumstances. This does not mean, however, that social services committee chairmen will necessarily possess the range of skills, qualities and experience that are necessary to serve effectively on a health authority. The duties that will fall to health authorities will be wide-ranging; many will fall outside the scope of the responsibilities of a local authority social services committee.

One of the aims of the new guidelines on the appointments process, published by the Secretary of State for Health in February, is to ensure that appointment to NHS boards is open to as wide a range of people as possible. That will enable us to continue to achieve our objective of ensuring that the NHS continues to benefit from the appointment of the best people both to health authorities and trusts.

The allocation of a non-executive appointment on health authorities to the chairmen of social services committees is in direct contradiction to the key principle of making appointments based on the merit of the individual. This principle is key to the success of the appointments process and must not be undermined.

There are other mechanisms in place to help health authorities and local authorities comply with their statutory duty of necessary co-operation. In particular, joint consultative committees of local authorities and health authorities will continue under the new NHS structure and their work will be made easier by the reduction in the number of NHS authorities at local level.

I was very sorry to hear that the noble Baroness, Lady Jay, did not have a particularly good experience of JCCs; nor indeed did the noble Lord, Lord Rea. I can say from personal experience as a former chairman of the local FHSA that we had very good experiences on our JCC and much valuable work was done on that committee, notwithstanding that the chairman of the local social services committee was not a member of the FHSA. Although it was very early days, we produced a joint community care plan then as well. I hope that the noble Baroness may feel that she can withdraw the amendment.

Baroness Jay of Paddington

My Lords, I am very grateful to the Minister for that reply. The whole issue of representative members of health authorities is one that we have discussed at length in relation to different amendments and at different stages of this Bill. My primary concern in introducing the amendment was to emphasise the concerns that have been expressed many times in the House about the most effective ways of developing community care, particularly in relation to the joint responsibilities for continuing care of the NHS and social services.

I suspect that, although we could no doubt dispute for several minutes or even hours about our relative experiences on joint consultative committees, some other form of mechanism will have to be developed if we are to be sure that effective working relationships between social services and health authorities can be dependent on something more formal than simply the good working relationships of individuals. However, the spirit of the amendment was, as I said, to explore my concerns about that particular relationship. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 11 not moved.]

Baroness Cumberlege moved Amendment No. 12:

Page 31, leave out lines 7 to 9.

The noble Baroness said: My Lords, your Lordships will recall that we debated this amendment, along with two others concerning the Local Government Finance Act, at Committee stage. As I explained during that debate, Section 28A of the Local Government Finance Act 1982 confers certain functions on the Audit Commission. The section should have been repealed by the 1990 Act. It is no longer needed because similar functions are conferred on the Audit Commission by the 1990 Act.

The set of three amendments clarified the situation by repealing Section 28A and removing a provision in the Bill which amended that section. Owing to my error, and despite the help and co-operation of the Benches opposite, the second of that group of three amendments was not moved at Committee stage. That is the amendment I have moved today. It is needed to make sense of the other two and to complete the clarification. I invite, indeed beg, your Lordships to agree this amendment. I beg to move.

Lord Carter

My Lords, this amendment gives me the chance to thank the Minister for the very helpful letter that she sent me after we discussed this amendment and the one that she failed to move. In her letter she states: The Government amendments tabled during Committee Stage clarify the situation by repealing section 28A and removing all references to that section from the Bill". But of course they did not, so she has had to move this amendment.

The Minister will remember that I was rather puzzled on reading Chapter 32 of the Local Government Finance Act 1982, having obtained a copy from the Printed Paper Office, since there was no way of telling that the Act had been amended. I have checked this with authorities. There is a difficulty for us, without the resources that the Government have, in tracking down the way in which Acts have been amended. I am told that in 18 months' time, once the computer programme is right, a system might be available. It would be helpful in instances such as this—that Act was amended twice by the Local Government Act 1989 and the National Health Service and Community Care Act 1990—if there could be a footnote or an indication in some phrase such as "as amended by Clause so-and-so of the amending Act". As I say, when one goes back to the Act itself and the chapter referred to, it is not possible to find the amendments at all because the relevant section has been amended by later Acts of Parliament. It is a lacuna in our procedures, a gap which it is hard to fill.

As the noble Baroness said, this amendment puts right a slight omission at a previous stage of the Bill.

Baroness Cumberlege

My Lords, perhaps I may take up the point that the noble Lord made. Certainly it rests with a higher authority than myself. Perhaps we could discuss that. It is a very valid point.

On Question, amendment agreed to.

Clause 3 [Preparations for reorganisation of authorities]:

Baroness Cumberlege moved Amendment No. 13:

Page 2, line 32, leave out ("prescribed").

The noble Baroness said: My Lords, in moving this amendment I should also like to speak to Amendment No. 14. They are both technical amendments. They relate to Clause 3 of the Bill which contains provisions to enable regional health authorities, district health authorities and family health service authorities to prepare for the reorganisation on 1st April 1996. In particular, Clauses 3(2) and 3(3) enable us to make regulations allowing DHAs and FHSAs to exercise functions jointly or on each other's behalf.

We will make regulations under these provisions to come into force as soon as the boundaries of the new health authorities have been agreed. So, for example, DHAs and FHSAs which are to merge will be able to form joint committees to plan for the first year's work of the new health authorities. The powers in Clause 3, and the regulations, will of course lapse on 1st April 1996 when DHAs and FHSAs are abolished.

All DHA and FHSA functions are to be brought together in a single body from 1st April 1996. We consider that a smooth transition will best be achieved if all DHA functions and all FHSA functions except a specified few, are made exercisable by the other bodies. But we have recently been advised by our lawyers that Clauses 3(2) and 3(3) as they stand would make that difficult. They state that the regulations will apply to "prescribed" functions. We are advised that the word "prescribed" indicates that we are expected to specify particular functions. To list all DHA functions without any exceptions or omissions could be considered outside the powers of the clause. We therefore wish to remove the word "prescribed" from the two subsections. I should make it clear that the regulations under this clause will not affect the legal status of DHAs and FHSAs. They will remain separate entities, each accountable for its own decisions and actions until 1st April 1996. I invite your Lordships to accept this simple amendment. I beg to move.

6.30 p.m.

Lord Carter

My Lords, I am grateful to the Minister for her explanation, because we wondered about the purpose of these amendments when they were put down.

Although the word "prescribed" is to be removed from Clause 3(2) and 3(3), it remains in Clause 3(4), which states: Regulations made under this section in respect of any function shall not, except in prescribed cases … Is there some contradiction here? Perhaps the Minister will look at it to ensure that there is no overlapping.

It is interesting that the report of the Delegated Powers Scrutiny Committee draws attention, as has the Minister, to the provision in Clause 3(10) limiting the life of the power, which ceases to have effect on 1st April 1996. It is what the Australians call a "sunset clause". It is appropriate to have a sunset clause for a sunset government.

Baroness Cumberlege

My Lords, I think I shall ignore that last comment. I understand the issue that the noble Lord has raised. Perhaps I can take it up and come back to him on that.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 14:

Page 2, line 40, leave out ("prescribed").

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

On Question, amendment agreed to.

[Amendment No. 15 not moved.]

Schedule 2 [Transitional provisions and savings]:

Baroness Jay of Paddington moved Amendment No. 16:

Page 43, leave out line 3.

The noble Baroness said: My Lords, I apologise to the House if the amendment seems to be somewhat cryptic. It is designed to achieve the rather important result of preventing employees of existing regional health authorities being automatically transferred to the Civil Service and, therefore, into the direct employment of the Secretary of State.

We are particularly concerned about the future employment of the chief officers of community health councils, whose contracts of employment are at the moment held by the regional health authorities. The community health councils have a very important role as independent watchdogs in the NHS. Ministers have acknowledged that role. Many people who work in the NHS—and those who use it—feel that that role may become rather more important after the reorganisation and the establishment of the new health authorities, and following some of the moves towards a more centralised structure of the health service.

My concern about the employment of community health council officers was increased by the remarks of the noble Baroness, Lady Miller, in response to the earlier amendments of my noble friend Lord Carter about the gagging clauses and the new codes of openness as they apply to the health service. In reply to my noble friend's amendment, the noble Baroness, Lady Miller, said that it was appropriate that employees in the new regional offices—who will be members of the Civil Service—should be subject to the regulations which limit their ability to speak out. That was in relation to the so-called gagging clauses.

We can argue about that, but it is not relevant to the amendment. It may indeed be relevant to some of the people employed in the regional offices in a Civil Service capacity, but it is completely inappropriate to chief executives and chief officers of community health councils, whose very function is to speak out about matters in the health service.

The noble Baroness also said that employees of the regional offices would be in the Civil Service because that would bring them closer to the strategic planning and policy decisions of the Secretary of State. Although I have no doubt that many of those decisions and discussions would be of great interest to chief officers of community health councils, it really is not appropriate, either to their role or to their function, to see that as an advantage to them if they are to be employed by the new regional offices.

As they are recipients of public complaints, the community health councils are often seen by the public as independent bodies. It is very important that that should be reinforced, particularly at the moment when, as we have discussed on many occasions, there is considerable public disquiet about some of the measures being undertaken by the health service.

The relationship between the chief officers who service the community health councils, their chairmen and members, is perhaps not unlike the relationship between local authority committees and the officers who service them. The officers' advice is obviously crucial. Their particular work is important because those who sit on a CHC do so on a part-time, voluntary basis, whereas chief officers are employed full-time. They are the people who have the expertise, who disseminate information and prepare agendas, and so on, to enable their committees of volunteers to function properly.

What will happen to those officers who are employed by a regional health authority when that authority is abolished? We have sought answers to this question at several earlier stages during the passage of the Bill but we have yet to receive a precise response. If it is intended to transfer them to the new regional offices—where they might be described as "outreach workers" of the regional offices—it would be entirely inappropriate and would seriously compromise them.

It is often to a community health council that members of individual health authorities and the local public users of the health service go as a first point of reference for information or confirmation about an issue, particularly a complaint. If chief officers are to become outreach officers of regional offices, that will necessarily compromise their position. Certainly it will be seen as undermining their role as independent commentators, advisers and general watchdogs of the local services.

If, on the other hand, it is intended that chief executives and chief officers of CHCs will be employed by the health authority in which they are situated, or perhaps by a commissioning agency or a consortium of local trusts, that, too, would be inappropriate. It is bound to lead to allegations of collusion. It would not, for example, be possible for an officer of a community health council to be seen by members of the public as entirely independent if it was known that he was an employee of a local trust or local commissioning agency.

It would be helpful if the Minister would be a little more precise than she has been and explain what exactly has happened in terms of discussions with the community health council national bodies and other organisations representing patients' interests in the health service. Precisely how does she see this absolutely vital function continuing? There is no clear indication in the Bill of what will happen.

The purpose of the amendment is to achieve some clarity and, as I said at the beginning of my remarks, to ensure that these very independent officers—these very vital people in the structure of the new NHS—are not automatically transferred to the employment of the regional offices and, therefore, automatically become civil servants. I beg to move.

Baroness Cumberlege

My Lords, the objective of this amendment has already been debated at Committee stage under Clause 1 of the Bill. We agreed then that regional health authorities will be abolished to cut unnecessary bureaucracy and reduce waste at the centre of the NHS.

We also agreed that some functions, such as co-ordination of education and training, and supporting consortia of health authorities in purchasing specialised services, should still be performed at regional level. This means that a streamlined regional system of NHS management is still needed.

To abolish RHAs and replace them with a new set of statutorily independent bodies would simply mean the recreation of the bureaucracy we are committed to removing. Only by replacing RHAs with regional offices which are part of the Department of Health can we be sure that bureaucracy will be kept permanently under control and that the new streamlined management will work effectively. The tasks which regional offices will perform, such as monitoring the new health authorities and contributing to the development of central policies for the NHS, mean that it is appropriate that they will form part of the Civil Service. We agreed all that in the debate on Clause 1.

This amendment, which prevents the transfer of staff to the Secretary of State—that is, to the regional offices—on 1st April 1996, contradicts the agreements reached on Clause 1 in that debate. But, as the noble Baroness said—I understand now, having heard her speak—her amendment is confined to the future of the secretaries of community health councils. I am sure we all agree that they do a valuable job. They perform a most important task representing the interests of the public in their dealings with local National Health Service bodies. They have a well-deserved reputation for independence, authority and insight.

CHCs have a statutory responsibility to represent the interests of the community in the National Health Service. Indeed, they have the right to be consulted on any substantial changes in services to local patients. These are important safeguards which ensure that CHCs have a voice in the management of the NHS. In addition, CHCs have observer status on health authorities and the right to meet them annually.

As I made clear during our earlier debate, there will be no change in the requirements of health authorities to consult community health councils.

It is essential that community health councils speak with an independent voice. They act wholly on behalf of the local community. The Government are fully committed to maintaining that independence.

In the new system, the establishing authorities for CHCs will be the regional offices of the Department of Health. They will be responsible for providing important support and training for CHCs. But clearly, as the noble Baroness said, it would not be appropriate for officers of CHCs to be employed by the regional offices. That would mean that they would become civil servants. It could be seen as compromising their independence. So the employment contracts of staff will be held in the NHS.

The details of who will make appointments of CHC members and how those appointments will be made are still under discussion. I can assure your Lordships that the vital independence of CHCs will be protected.

Having listened to those remarks, the noble Baroness will, I hope, not press the amendment.

Baroness Jay of Paddington

My Lords, I am grateful to the Minister for those remarks. Obviously, I understand that we agreed the principle of RHA abolition at an earlier stage. As I said at the beginning of my remarks, I feared that the amendment was somewhat cryptic. I am grateful for what she said about the continuing independence of the community health councils and particularly their staff. The words she used—she said that their employment contracts will be held within the NHS —are frankly not as specific as I should have liked. I am encouraged by what she said about it not being appropriate for them to be held by the regional offices of the new health service. I understand—and we agreed—the reasons for that.

However, the Minister did not say that they would not be held by consortia of trusts or indeed of local purchasing authorities. In my view—I hope I made it clear in my remarks when proposing the amendment—that would be equally as compromising as their being employed by regional offices. I shall want to look at precisely what she said and perhaps consult outside with community health councils about the terms that the Minister has now expressed in her reply. At this stage I shall withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 17 not moved.]