Health Authorities Bill

HL Deb 28 March 1995 vol 562 cc1504-72

3.19 p.m.

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

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

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

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Clause I [Abolition of RHAs, DHAs and FHSAs and duty to establish Has]:

Baroness Jay of Paddingtonmoved Amendment No. 1:

Page t, line 11, at end insert

("(1A) Before making any order under subsection (1) above, the Secretary of State shall consult such persons as he considers appropriate about the desirability of making the order and shall lay before each House of Parliament a report of the consultation.

(1B) If either House of Parliament resolves, in the light of the report made under subsection (1A) above, that the Secretary of State shall not make any order to establish a new health authority, the Secretary of State shall by order instead establish—

1. (a) authorities for such regions in England as he may by order determine, and
2. (b) authorities for such areas in Wales or those regions in England established under paragraph (a) above as he may by order determine;

and orders determining regions or areas in pursuance of this subsection shall be separate from orders establishing authorities for the regions or areas.

(1C) The authorities established by order under subsection (1B) above shall be named as follows—

1. (a) an authority established for a region shall be called a Regional Health Authority;
2. (b) an authority established for an area shall be called a Health Authority and in addition by a special name signifying the connection of the Health Authority with the area for which It is to act.").

The noble Baroness said: The purpose of this amendment is to give the Government the opportunity to reconsider some of the very radical proposals for yet again reorganising the National Health Service which are contained in this Bill. It aims to persuade them to consult more generally and more widely, particularly among those who work in the NHS and those of us who use it, about whether or not the abolition of the regional health authorities—one of the structural changes proposed in the Bill—will enhance the National Health Service or detract from its services to all of us.

Noble Lords who took part in debates on the earlier reorganisation of the health service about four years ago, at the beginning of the so-called reforms, will remember that there were constant requests from all sides of this Chamber that the proposals should be introduced gradually; that there might be opportunities for testing, for perhaps piloting, some of the schemes that were introduced; and that the internal market should, as it were, be a gradual revolution. All noble Lords who took part in those debates and made those points were disappointed. As we all know, the whole reorganisation was introduced on one day and a nationwide revolution went ahead, and many noble Lords are aware of the results. In particular, those noble Lords who are members of health authorities or of trust bodies know that there has been a large degree of uncertainty and concern about those changes as they have been brought about. It is instructive to notice from the poll published at the end of last week that public concern about the NHS is at its highest for three years—that is, since the so-called reforms were introduced. This amendment is designed to try to learn the lessons of the past and to think again, steadily and clearly, about the way in which these new proposals are to be introduced.

It is interesting that the noble Baroness the Minister, in winding up the debate at Second Reading, herself drew the attention of the House to the fact that only four out of the 19 Members who spoke in that debate had given the proposals wholehearted support. A great deal of the specific concern that was raised in various different ways at Second Reading was about the abolition of the regions.

One of the problems about this particular Bill is that it is enabling legislation. A great deal of the detail is not contained on the face of the Bill and will be subject to later regulations. But, in general, my criticism of the regional abolition is perhaps best expressed by the Minister in her winding-up speech at Second Reading. She said: The role of the regional offices will be quite different from that of the old regional health authorities. In the old NHS structure it was appropriate for RHAs to be separated from the Department of Health, but in the new system health authorities will be the main operators. They will take most of the decisions which directly affect local people".—[Official Report, 6/3/95; col. 68.]

That expresses my concern about the basic principle of abolishing the regional health structure within the health service: we achieve fragmentation of the national structure and centralisation through the regional offices at the same time.

At Second Reading I proposed a number of tests against which we should judge whether or not we felt that the changes to the NHS were ones that we should support. They included tests about the effectiveness of the service, its efficiency, its equity and its accountability. All of those points are addressed in separate amendments later on the Marshalled List; but if I could summarise them as they are on the principle of the abolition of the regions they would include these major points.

In abolishing the regions we shall lose some of the crucial functions of the strategic overview of the health service which the regional authorities were independently providing in the structure. We shall particularly lose the strategic overview of some of those so-called Cinderella services which are very important to the people who receive them but are not necessarily attractive in the internal market where, as we know, individual trusts and small local health authorities will be competing with each other for business, as it is now called.

I include in those strategic functions that we shall lose when the statutory regional authorities go, concern about mental health, and particularly about the programmes for looking after people with mental illness in the community; concerns about HIV and AIDS, which, again, have been issues addressed by regional bodies; and concerns about the areas of drugs and alcohol abuse. As noble Lords will see, none of those is the kind of subject that is necessarily attractive to small local health authorities which are competing with other small local authorities for business within the internal market. Nonetheless, they are extremely important. They are crucial elements of the National Health Service and in the delivery of services which are best looked at in the context of a regional overview and a regional provision of services.

The noble Lord, Lord Walton, who, sadly, cannot be with us this afternoon, was very eloquent at Second Reading about the importance of maintaining the tertiary services which are offered, and have been offered, by the regional services of the NHS. He spoke about the planning of expensive tertiary services, such as neurology and cardiology, which have previously been overtaken at the regional health authority level and on which there seemed to be very little guidance about how and where they will be effectively planned and organised in the future. As the noble Lord said, these were regional specialities which could be "glamour" specialities for individual trusts rather than the services that I mentioned before, in the sense that each trust might well want to compete to offer a neurology and cardiology service, for example, but that that might not be a very economic or effective way of offering those services, and was the kind of thing that had been handled best at the regional level.

The noble Lords, Lord Walton and Lord Dainton, and several other noble Lords with considerable experience in the field of academic medicine, were also concerned at Second Reading about the links with universities which had been maintained in the previous arrangements at the regional level. They queried the problem that there no longer seemed to be formal representation for academic medicine at the university level with the regions. I understand that there has been a suggestion that there will obviously be informal links. However, noble Lords who spoke at Second Reading were most concerned about the fact that there was no statutory provision for that level of input into the new regional offices of the Department of Health; and that meant that it would be unlikely that they would be involved in the management and strategic planning of the work of the NHS in the way that they had been before, which would indeed be a loss to the health service in general.

In that area, too, is the whole question of research and development. Noble Lords will be aware, because it was the result of an initiative by this House, that the research and development programme of the NHS was established some few years ago. Research and development has become a very important part of maintaining standards of excellence within the NHS. Up to now it has been largely directed and planned by the regional directors of research and development, who have themselves been attached to the regional health authorities.

These matters will perhaps be the concern of the regional offices—the regional outposts of the Department of Health. But one of the matters that is of concern, and was mentioned often at Second Reading, relates to independence and the separate arrangements for the input of academic medicine—the regional postgraduate deans, the regional directors of research and development—which has been so important in the past few years. There was concern that if those people were to become civil servants—that is, direct employees of the Department of Health through the regional outposts rather than being part of an independent statutory body as they had been as members of the regional health authority—then in a sense their academic and intellectual independence was to some extent under threat.

That brings me to the other major point of concern about the abolition of the regional health authorities; namely, accountability. As regards the regional health authorities with their independent chairmen, many points were raised at Second Reading about whether or not they were truly independent or were political placemen of the Government. Membership of the authorities will he addressed in later amendments. But the statutory independence of the regional health authority provided a very important step in the relationship between the Department of Health and the management executive of the health service and the very local concerns of independent health authorities and trusts.

The Government have often spoken of how this new Bill will reduce bureaucracy and levels of management in the health service. As we know, there has been much criticism from this side of the Chamber about the explosion in management in the health service over the past few years. But it is worth remembering that that explosion has not taken place at the regional level. In fact, at the regional level the number of managers and administrators has been reduced. It is at the lower health authority and trust level that the numbers of managers have increased so greatly; it is there that the operations of the internal market—the contracting system—have meant that more and more people have had to be involved.

In a sense, the notions of bureaucracy and accountability have to some extent been confused by the Government. It seems to me that accountability can be achieved through the lean structure of the RHAs as that has now developed. As I said, the number of bureaucrats and administrators at that level has been reduced. But one does not automatically achieve something good simply by sweeping away a number of officers. What is lost in terms of public accountability, which, as we know, has been under question within the health service, through abolishing that regional tier is much more than what is gained by reducing the number of officers.

Perhaps I may quote again from another expert in the field of health care, Professor David Hunter, who is director of the Nuffield Institute for Health at the University of Leeds. He recently wrote that the essential functions of the regional health authorities which seem to have no firm place in the new structure included, arbitrating in local disputes; providing a challenge to local myopia in service development and commissioning …encouraging innovation and new ways of doing things; promoting health strategy development, community care and priority services, and research and development".

All those suggest a very good reason for thinking again about the abolition of the regional health authorities and indeed for consulting further and explaining more about where those functions will reside under the Bill.

I was interested to note that yesterday, in answer to a question in this Chamber, the Minister said that she had learnt not to say "never, ever" in the health service. I hope that she will apply that judgment to this amendment. I beg to move.

3.30 p.m.

Baroness Robson of Kiddington

On behalf of these Benches I support very much the amendment moved by the noble Baroness, Lady Jay. She explained it in great detail. There is not much that I can add. I like the thought that it gives us the opportunity to think again.

In my view, the regions have served the NHS very well. We removed the area health authority at one point and that was perfectly correct because it should never have been there in the first place. But the region is a completely different animal. If we are to have a National Health Service which has some kind of uniformity, in the sense that everybody receives the same services wherever they happen to live in the country, it cannot be left completely to health authorities which just cover a small district. The regional health authorities have served us very well.

I wonder whether the noble Baroness the Minister will think back and consider how we would have dealt with the establishment of regional specialties and regional centres if there had not been the regional health authorities in the past. It certainly would not have been done by the district health authorities, as there is always a desire to have the maximum amount of services within one's own district, particularly under the present purchaser and provider system which is an encouragement to have the high-tech and expensive services with which more money can be earned.

The noble Baroness, Lady Jay, was perfectly right to say that there is another function for which the regions have been responsible and which would be lost if they were abolished; namely, the strategic overview they have taken of services which she called the Cinderella services. That role is of tremendous importance. It has become even more important since the new health reforms were introduced because they are not the glamorous services which attract a large amount of cash. I agree that the regions have also acted as a stopgap for arbitration in disputes.

Additionally, the regions have been responsible for medical training, strategic planning of nurse education, various health programmes, such as screening for cancer, and research and development. According to the new plans, some of those duties will be undertaken by the regional outposts. I agree with the noble Baroness, Lady Jay. I much prefer those responsibilities to be undertaken by people who are not civil servants but who represent us, the general public and the patients in the community. Other responsibilities will be taken over by the new health authorities which may not have the necessary expertise. They will frequently look at problems from a parochial point of view. If the responsibility for nurse training is spread to the health authorities, they will consider what is needed within each little area. They will not think about the matter from a national point of view. That could be very detrimental to the future of the health service. After all, we rely on the nurses and on producing enough nurses for the future. I feel that there is a great danger under the proposed alterations that that will not happen.

I sincerely hope that the Government will think again about the abolition of the regional health authorities. If they do not accept our proposal that they should remain, will they accept that the regional outposts must have a much bigger input from ordinary, independent people?

Lord Elton

I was very surprised when the noble Baroness sat down, because I thought that after her summary of our debate at Second Reading she would address the intentions within her amendment and tell us how they would work. In the absence of such an explanation, I assume that the principal intention is the one she briefly outlined and upon which the noble Baroness, Lady Robson, elaborated; namely, the substitution of a two-tier system for the one-tier system proposed in the Bill.

The Bill passed Second Reading. Its sole purpose is to introduce a single-tier system. It seems to me that we should not waste too long discussing overturning the whole principle of the Bill by an amendment which the Opposition have not even taken the trouble to explain.

Lord Rea

One of the questions unanswered by the Bill concerning the proposed abolition of the regions is: what is to become of the organisation of postgraduate medical education? The regional postgraduate deans and the regional advisers in general practice have played, and do play, a major role in the organisation of postgraduate education for general practitioners, general practitioner trainees and junior doctors. I am familiar with the work of the regional advisers in general practice, who are responsible not only for postgraduate education, but also for the training, selection and supervision of the general practitioners who are to become trainers involved in the vocational training scheme in general practice. Without them the success story of raising the status and academic standards of British general practice over the past 25 years could not have occurred.

It was suggested that the contracts of junior hospital doctors, which are now held by the regions, should be held by the regional postgraduate deans. But where will they be based? Where will they obtain the infrastructure to carry out the job efficiently? If the regional postgraduate structure is to be maintained as it should be, the new health authorities individually, even if they undertake postgraduate eduction, will need to be co-ordinated nationally. Where will the offices of the postgraduate dean and advisers be situated? To whom will they be accountable?

I assume that universities will continue to play a major part. But that needs to be in the Bill. Surely it will be easier to continue this vital part of the National Health Service—that is, the system for postgraduate education—if the regional structure of the National Health Service remains, as the amendment allows.

Baroness Gardner of Parks

I take the technical point made by my noble friend Lord Elton and find it interesting that we are developing arguments on this amendment. I was amazed to hear the noble Baroness, Lady Jay, say that this was a case of the National Health Service being reformed "yet again"—that was her expression—when that is not at all the case. This is just the next stage in the present reform. I shall be opposed to any further reform. This is the end of the reform and in the Second Reading debate many of us said that it was time to allow the health service to settle down and start working because it has been reformed too often. This is not a new reform; it is a further stage in the reform about which everyone has known for a long time.

The noble Baroness went on to say that there was a large degree of uncertainty in regard to the changes. That may be true. But the staff in the regions are aware of what is happening and of what they expect to happen. Nothing could be worse than deferring any kind of decision on this matter in such a way that those people are thrown into a greater state of uncertainty. Many are already looking into what their position will be. The whole system is geared to the fact that staff come high on the list of concerns and are being carefully considered in the arrangements that are being made at the moment.

The noble Baroness said that health authorities make most of the decisions. She seemed to think that that was bad. I believe it is good. It makes the situation more localised and closer to those people receiving the service. The Cinderella services were referred to by the noble Baroness, Lady Robson. We are overlooking the role of the CHCs in this. The community health councils are aware of the Cinderella services and are active and efficient in drawing attention to any gap they see in the provision of services under the National Health Service.

When the noble Baroness, Lady Robson, was chairman of a regional health authority, nursing education was quite different from what it is now. Project 2000, which is the present system of training, meets her anxieties in that regard. I should perhaps say that I was vice-chairman of a regional health authority until a year ago when I became chairman of one of the large acute hospital trusts. But I am well aware of the Culyer Report on research. People do not need to worry. Everyone working within the National Health Service is aware of the emphasis that will be placed on research and on further postgraduate education. There is already a federation of teaching hospital trusts which meets regularly. The chairman of that body is based in Liverpool and I am convinced that there will be no problem as regards the future. The academic world of medicine is most concerned and interested to see that postgraduate education continues, as well as undergraduate education. The amendment is simply obstructive and I shall oppose it.

3.45 p.m.

Lord Stoddart of Swindon

Perhaps I should declare an interest in that I act as a consultant to Unison. I confess that I do not agree with the points of view just expressed from the other side of the Chamber. After all, the amendment seeks to ensure that further consultation takes place before a final decision is made. The noble Baroness, Lady Gardner, and the noble Lord, Lord Elton, believe that that is unreasonable. But in my view this amendment was tabled following the anxiety expressed by many people and organisations.

Why is it that we all receive briefings from such places as the Royal College of Nursing, from the BMA and all kinds of other organisations which are concerned that the measures at present dealt with by the regional health authorities should continue to be exercised in a proper manner, worthy of the service and suitable for the patient'? I accept that it is entirely reasonable for the Opposition to seek to ensure that those people's views are taken into account, and that is exactly what the amendment seeks to do. Quite frankly, to try to abolish a tier which has worked extremely well over decades requires extra special attention and therefore, for myself, I believe that the amendment is reasonable and should be considered.

There is something else that I want to know. We are abolishing the regional tier and will have other regions of civil servants. How are they to be answerable to the patient? How are they to be answerable to the public'? And how are they to be answerable to Parliament? At present the regional health authorities are answerable to the public and therefore they are not constrained in any way by any oath they take in relation to the Official Secrets Act. Will we find, because of that oath of secrecy taken by civil servants, that information we have hitherto received will not be given to the public and to Parliament? We want to know—certainly I do; I do not know about my noble friends—to whom the new bodies will be answerable and how they will exercise the power being given to them.

That is another good reason for accepting the amendment and why my noble friend should not be criticised for tabling it. It is important. We need to be sure that the people involved in the reorganisation are satisfied that it will be to the advantage of the National Health Service and that the reorganisation is not being done in a way that will injure the patient. That is entirely reasonable and I am surprised that there should be any criticism from the other side.

The other point which concerns me, and I shall make it my last, relates to staff. As the noble Baroness, Lady Gardner, said, the staff are important. They will lose 1,500 jobs within the regional authorities. They have already lost 1,300 jobs, so 2,800 jobs have had to be accommodated as a result of this reorganisation. It is entirely reasonable that we should ask that the staff receive proper treatment. They need to be reassured about their pensions for the future. They need to be reassured that they can be accommodated elsewhere within the National Health Service. They need to be given some assurance that those who remain in the service will have a career progression available to them. Those are all legitimate concerns.

Consultations with the trade unions in the National Health Service have taken place in a reasonable and friendly manner, and progress has been made. But Members of the Committee are entitled to raise these issues and to be given some reassurance that staff who have given their expertise and their service to the regional authorities will be treated well and will receive assurances about their pensions, their conditions of service and, if redundancy is involved, good redundancy terms. I hope that redundancy will not be involved. I hope that all the staff will be accommodated within the new arrangements. I trust that the Committee will agree that my noble friend has done a great service in putting down this amendment as it has enabled us to discuss these very important matters in detail.

Lord Carr of Hadley

It may be that all the subjects which the noble Lord and other noble Lords have mentioned should be discussed if they have not already been discussed. However, we have surely to look at the amendment on the Marshalled List. It seeks to insert into the Bill, to which your Lordships gave a Second Reading two weeks or so ago, an amendment which in another place we would undoubtedly have described as a wrecking amendment because it seeks to go back to the principle we decided against when we gave the Bill a Second Reading.

Baroness Jay of Paddington

I apologise for interrupting but I wish to correct the impression about what happened in another place. An amendment very similar to this was discussed in Committee. It did not even include the words "to take back and consult on this issue". It simply did what the noble Lord is now suggesting constitutes a wrecking amendment. It asked for the paragraphs which come under subsection (1B) in my amendment to be reconsidered. I do not think that the noble Lord can draw on that analogy as a way of describing the impossibility of today's amendment.

Lord Carr of Hadley

I confess to being 20 years out of date with regard to what happens and to what is thought and felt in another place. It evidently has a more humane and tolerant attitude to these matters than it would have had 20 or 30 years ago.

What we have to do is not just discuss the matters which have been mentioned but look at what the amendment would do. It would insert into the Bill very complicated procedures which would take a great deal of time to bring to fruition. If they led to changes in the structure we would produce a health service which was an extraordinary pattern of different systems of organisation in different parts of the country. I cannot believe that that would be good for the development of better health services for the patients of this country.

It so happens that purely by chance I had to lunch today someone who was my personal assistant in industry during the latter part of the 1950s and much of the 1960s. She is now a widow living alone, of my kind of age. I shall not be more specific. We did not talk about the health service but at the end of lunch I suddenly looked at the clock and said, "I must hurry you away because I have to go to the House to talk about health". She said, "Before I go, may I just say to Parliament, 'Well done' about the health service. I now come under a budget holding practice and when I need to go to hospital I go to a trust hospital. I cannot tell you how much the health service has improved in my part of Kent since reorganisation." I believe that that is increasingly the feeling of many people in this country.

It is certainly the feeling in my part of Gloucestershire where more and more people are satisfied with the improvements they experience in the way the health service is working. I should be astonished if any government of any party substantially reversed the changes. They might trim them around the edges but the changes have come to stay. If they have pot come to stay there will be a great revolt among the 'patients of this country who are seeing improvements month by month. If we were to insert into the Bill an amendment of this kind we would greatly reduce the speed with which our health services, both in general practice and in hospitals, are being improved.

Of course, not all is perfect. Of course, there are things wrong. But there always will be. And, of course, all the changes do not go right immediately; they go better in some areas than in others. But if one is looking, as we are in the case of the National Health Service, at an enormous organisation which employs about 1 million people and spends more money than any other organisation one can think of, one has to face the very difficult balance between what has to be centralised and what has to be decentralised. Anyone with practical experience of working in, let alone running, managing and directing a large organisation, has over the past 10 or 20 years come increasingly to understand that in order to make an organisation work humanely and efficiently some things have to be centralised. They need to be centralised effectively and they should be kept as few in number as possible. But other things have to be decentralised. They must be decentralised thoroughly. One must take some risks. If one puts in different layers of authority at the top and at the bottom, one gets delay, democracy, lack of speed in action and fuddled decisions.

No organisation as large as the National Health Service is perfect. It will always have faults which will need to be looked at. But I genuinely believe that results are beginning to show and that we are now on the right lines. Let us concentrate on getting those lines more right where they are not always straight at the moment rather than on trying to hold everything back and go backwards.

In moving the amendment the noble Baroness mentioned mental health, HIV and AIDS, drugs and alcohol abuse and so on, which she said would not be of attraction and interest to competing suppliers. But, with respect to the noble Baroness, that is standing everything on its head. She is not appreciating the crucial change that this service of ours is now becoming customer-driven rather than producer-driven. These things may not be of natural interest to specialised suppliers. But, my goodness, they are of prime interest to the purchasing authorities whose job it is to ensure that there are supplied in their districts the kind of services, including services for mental health, HIV and AIDS, drugs and alcohol abuse, and further education and training for all branches of the medical profession, which the patients in their areas will need. It is the purchasing authorities which increasingly have the power: they are the ones which represent the patients. That is a move in the right direction. It is because that is beginning to be felt by patients that my friend who had lunch with me a couple of hours ago said what she did on leaving.

4 p.m.

Lord Carter

Perhaps we may return to the interesting point made by the noble Baroness, Lady Gardner of Parkes. She said that this matter is not yet another reform of the health service but part of the seamless robe of reform which started in 1990. I was on the Front Bench team with my noble friend Lord Ennals during the passage of the Bill. I have looked through the Act and there is no reference in it to the abolition of the regions. In fact, all through that legislation the regions are built into the whole structure, including their functions. The idea that the abolition of the regions is part of the original reforms thought of at the time is plainly wrong. In fact, that is the reason why we have this Bill: to do away with them and their functions. It is reasonable to have a discussion on their functions and authority and the arguments which we shall produce for retaining them. But to imply that it is all part of the reforms that were thought of in 1990 is not correct.

Lord Peyton of Yeovil

My noble friend Lord Carr, like the pioneer that he is, broke absolutely new ground in actually referring to the amendment. I want to follow his very distinguished example. I differ from my noble friends who describe the measure as a wrecking amendment. I believe that the first half of the amendment is just quaint and I wonder what it will achieve. In a moment I shall invite the attention of the Committee to the amendment in some detail. The second half of the amendment is undoubtedly calculated to do damage to the Government's proposals and with that I would not agree.

I invite the Committee's attention briefly to the first four lines of the amendment which states, Before making any order under subsection (1) above, the Secretary of State shall consult such persons as he considers appropriate".

I do not believe that one would be assuming too much if one took it for granted that the Secretary of State has already consulted those persons whom she considers to be appropriate. I believe that that would go without saying. When she was consulting about the desirability of making the order under this section, I do not believe that she could have been in any doubt as to the advice she would receive from those persons whom she considered it appropriate to consult.

Then there is the proposal that the Secretary of State shall lay before Parliament a report on the consultation which has taken place. I wonder whether any of your Lordships would be so bold as to rise in his or her place this afternoon and assert that a detailed report on those consultations would be of any interest at all. I believe that it would be a great waste of time save to those who suffer from insomnia.

As I have already said, it must be apparent that the next part of the amendment is designed to make nonsense of the Government's proposals and to render them meaningless. The amendment continues: If either House of Parliament resolves, in the light of the report made …that the Secretary of State shall not make any order

then certain things will follow. The report received would not put any fetter on the right of either House of Parliament to reject the Government's decision. Therefore, one must assume, as I have said, that the first part of this amendment is quaint, and the second merely wrecking.

Perhaps I may trouble the Committee for it 'moment or so with a recollection from my own past, a very long time ago—not all that long, it seems, after Noah landed in the Ark—when I found myself a member of a regional hospital board. I say nothing which reflects any disrespect whatever on the membership of the board—I would be taking great risks if I did—or on the quality of its officers. To put the matter very politely, it seemed to be yet another layer of administration. Its product was very large indeed when measured in terms of paper. It was a real paper mill.

I would just like to weary the Committee for a moment with one particular recollection. One day, having gone through a huge mass of paper, I inquired of one of the officers as to what value my opinion would be on whether Dr. So-and-So of Tewkesbury should have six months' sabbatical leave or on what a needle sharpener in Bodmin should be paid. I said that the knowledge and quality of my advice on both those subjects would be absolutely nil. The answer came clearly: "Sir, officials must be protected".

One needs to be very careful before one perpetuates the bureaucratic machines which spread paper and which ask people to pass opinions on matters as regards which they do not have any detailed knowledge.

My noble friend, Lady Cumberlege, is a most gracious lady and I am sure that she would be the first to acknowledge the generosity of the Opposition in offering her this opportunity to reconsider. But I suspect that, like so many gifts on offer today, this is not one that she will particularly value. It would not altogether surprise me if she triumphed over her habitual graciousness and actually turned it down flat. In fact, I shall go further and say that I very much hope that she will.

There is one further point that I should like to make. I recall in my distant days long past in the other place that the only weapons of Oppositions were time and delay. One of the ways to take up a little time when some particularly tiresome Bill was in the offing, was to propose a little more consultation: somebody else ought to be consulted for no very good reason, but they ought to be consulted because it would be a friendly thing to do. As a result we have the most elaborate machinery of consultation laid on us in this country which is time wasting and costly in terms of cash.

I was talking just now to my noble friend Lady Faithfull who has a very great knowledge of the social services. She was assuring me of how the social services would be relieved of an extremely tiresome duty if they had to consult only one level of administration instead of two. I am not always very friendly towards the Government's legislation, but on this occasion I find it a joy. I particularly admire my noble friend Lady Cumberlege. I find it a great joy also to support what I regard as a thoroughly sensible measure. I have no doubt that my noble friend will wish to throw out an amendment which, as I have said, is quaint in the first half and in the second just damaging.

Lord Skelmersdale

Before my noble friend the Minister pours what I hope will be very icy water indeed on this amendment, I would like to respond to something which the noble Lord, Lord Carter, said. As he knows very well, the reforms have been discussed in the health service since about 1985. The year 1990 was the tip of a particular iceberg in that discussion. The moment the 1990 Bill was published the discussion within the health service immediately turned to how much longer shall we keep the regional authorities.

Lord Carter

Perhaps I may respond to that. I believe that the noble Lord is wrong. The reforms started on a "Panorama" programme when the previous Prime Minister, Mrs. Thatcher, was asked what the Government were going to do about the health service. She said that they were going to reform it. That was a surprise to her Ministers and, I believe, in particular to the Minister, Mr. Kenneth Clarke, who took over the job and found, I am told, a blank sheet of paper. The idea that these measures are a seamless robe that started in 1985 and proceeded smoothly along the way, is not so.

The only point that I was making, in response to the noble Baroness, Lady Gardner, was that it is not correct to say that this was thought of in 1990. If that had been the case, the provisions would have been included in the Act which we spent a great deal of time discussing.

Lord Skelmersdale

I do not like having to defend myself in this way; but I mentioned the date of 1985—

Lord Carter

It was 1988.

Lord Skelmersdale

—and it was my then right honourable friend, who is now the noble Lord, Lord Moore, who instigated the reforms. My right honourable friend the current Chancellor certainly did not come into office with a blank sheet of paper.

Baroness Cumberlege

I am very tempted to enter the debate on correcting the history of this matter because I was party to many of the discussions that took place at that time; but I do not think that this is quite the moment to go into that. I take on board the views of my noble friend Lord Peyton that we need to get on with the job. Perhaps we should think of the phrase, "God make speed to save us".

My noble friends Lord Elton, Lord Carr, Lord Peyton and Lord Skelmersdale were right to remind the Committee that we have already agreed the principle of the Bill at Second Reading. I made clear during that debate that one of the two purposes of the Bill is the abolition of regional health authorities. Indeed, the Long Title of the Bill makes that clear. This is a Bill to abolish regional health authorities, district health authorities and family health services authorities, and require the setting up of new health authorities. As my noble friends Lord Carr and Lord Peyton have said, that leaves many details for us to discuss; but whether to abolish RHAs is not one of them.

Perhaps I may remind your Lordships why the Government have proposed the abolition of RHAs. We do not deny that RHAs played a necessary and important role in the NHS before the 1990 reforms. Their management skills were vital, not least in hands-on management of hospitals and in directing DHAs, and they carried out useful operation and co-ordinating tasks.

The regional health authorities were crucial in the first stages of the reforms. Their valuable experience and support were needed to ensure the successful development of NHS trusts, of GP fundholders and of purchasing district health authorities. Systems of management had to be built up at a local level, and RHA expertise was needed here. But as my noble friend Lady Gardner said, responsibility has now been successfully devolved from RHAs closer to patients. I am grateful to my noble friend Lord Can for highlighting the success of GP fundholders and NHS trusts. The development of stronger local purchasing authorities has changed the way the NHS should be managed in the future. There are fewer purchasing authorities than there once were because of authority mergers. After this Bill there will be fewer still—only around 100 in total—so large organisations will not be needed at regional level to manage them.

I do not deny that regional co-ordination will still be vital after the reorganisation. We are not proposing to move all RHA functions to health authorities—that is why the regional offices have been established. The NHS executive headquarters and the regional offices will contribute to health policy across the country and to developing the overall strategic direction of the NHS: for example, they will develop and evaluate the overall NHS research and development strategy, which has been mentioned this afternoon. Perhaps I may reassure the noble Baronesses, Lady Jay and Lady Robson, and the noble Lord, Lord Walton,in absentia, that strategic planning for specialised services such as neurosurgery must of course still be performed at regional level. Health authority areas will be too small for planning such services—so they will be achieved through consortia of health authorities. These will be supported, particularly in the early stages, by the regional offices. They will not be expected to devolve functions to purchasers if they do not have confidence that they are capable of maintaining high standards.

But the need for a regional management structure does not mean that the size and bureaucratic complexity of the RHAs is still needed. Regional strategic management must be administered with a light touch, respecting the freedoms of both purchasers and providers. The effectiveness of the National Health Service Management Executive regional outposts, which had only 10 to 15 staff each to manage all the NHS trusts in the region, has shown that this new approach can be successful in the NHS.

Your Lordships have expressed doubts about the accountability of the regional offices. Perhaps I can try to reassure the noble Lord, Lord Stoddart of Swindon, and other Members of the Committee that the move from RHAs to regional offices, which are part of the Civil Service, is a logical step. The role of the regional offices is best carried out as part of the department, in direct line to the Secretary of state. They will not be taking the key decisions which will directly affect local people. The new, stronger health authorities will be taking those decisions, and they will be "independent" and "accountable" in the same way as RHAs. Regional offices will have new opportunities to influence policy by offering advice to Ministers. It is entirely appropriate this should be the province of members of the Civil Service, and the regional offices will of course be accountable to Parliament through the Secretary of State, just like the rest of the department.

Because regional offices will be part of the department, it will be easier to ensure that they remain small and streamlined. Had we replaced RHAs with separate statutory authorities, there would be a risk of building up again the bureaucracy we are committed to removing. With regional offices firmly part of the department, we can reduce duplication of work between the NHS executive and regions. In the past, there has been overlap in areas like performance management, guidance and interpretation of policy, checking of statistics, and so on. Most things will be done in the future either by regional offices or by the executive headquarters as part of the same organisation. There will be no need for them to double-check each other. This will lead to savings.

The noble Lord, Lord Stoddart, asked about redundancies in the National Health Service due to the changes. Perhaps I can refer to the efforts that have already been made by the regional health authorities. Of course, there will inevitably be costs associated with redundancies. We accept that; but we shall try to minimise the numbers as much as possible. The regional health authorities are making every effort to minimise the disruption to staff, using measures such as voluntary redundancies, clearing house arrangements, out-placements and retraining schemes. Where it is necessary to make staff redundant, they will receive the full financial benefits to which they are entitled. I pick up the points made by my noble friends Lord Carr and Lord Peyton that we need to get on with the business. That is particularly true in the context of staff because nothing is more demoralising than not knowing where one's future lies.

The new health authorities will be well placed to take on functions currently discharged by RHAs. Functions can be delegated to the lowest sensible level—closer to patients, so that decisions can be taken quickly in response to changes in need.

The noble Baroness, Lady Jay, expressed concern about the move of the regional directors of public health from RHAs to regional offices. But the role of the regional directors of public health will be different in the new system. Most public health functions will be carried out by the new health authorities. They will be a much more appropriate place for public health issues than the RHAs, which are artificial entities in public health terms. District directors of public health will report on the health of their local populations and will be free to comment on the factors affecting health care in their area. The role of the regional director will be to ensure that health authorities carry out their public health role effectively. Those responsibilities will be entirely appropriate to their status as civil servants.

The noble Baroness, Lady Robson, mentioned nurse education. I should like to address that issue on Amendment No. 11.

The noble Lord, Lord Rea, asked about post-graduate deans and regional GP advisers. I am pleased to tell the noble Lord that we have today published a full consultation document which will be placed in the Library tomorrow. I believe that that will answer many of the noble Lord's misgivings and concerns.

To conclude: it is the new health authorities which will take responsibility for the public health of their populations, for planning services, for assessing health needs. They will develop an effective, primary care-led NHS. The retention of regional health authorities is not necessary for this and could well get in the way. Their abolition will save money to be reinvested in patient care. There will be savings of around £150 million per year when the Bill is fully implemented, and the bulk of this will come from the abolition of RHAs, the cutting of bureaucracy and the reduction in duplicating work. I invite your Lordships to reject the amendment.

Lord Rea

Before the Minister sits down will she amplify—ever so slightly—the news that she gave that there is now a document in the Library about the future of the postgraduate deans and postgraduate medical education? Will she give us an inkling of what it says?

Baroness Cumberlege

It will be placed in the Library tomorrow. It is a document which has been drawn up after a great deal of consultation with the postgraduate medical deans. It looks at the contracts of junior doctors and other issues that we shall be addressing in later amendments. Basically, it says that contracts for education should be placed with the postgraduate medical deans and contracts for their terms and conditions of service with the trusts.

Lord Stoddart of Swindon

Before my noble friend replies, perhaps I may ask a question about the £150 million which will be saved. As parliamentarians, we are often told that we will save money, but later we never know how it has been saved. Is it the Government's intention to make reports to Parliament as to how much of the £150 million has been saved and where it has gone?

Baroness Cumberlege

We have given an undertaking that all the money that is saved will go back into patient care. Many of us rejoice at that. Clearly when it comes to the annual public expenditure survey round a great deal of detail is available to Members of this place.

Baroness Jay of Paddington

I thank the Minister for giving that detailed reply to the points raised by me, the noble Baroness, Lady Robson, and my noble friends. The degree to which the Minister was able to give us the detail to some of the points that we raised was a clear indication that she saw that some of the points we made were serious and worthy of such a response. As she said, many of those points will be returned to in subsequent amendments. The issues, especially relating to public health and nurse education, which the Minister herself raised, will be ones which we shall discuss in detail. She may not be surprised to hear that I am not reassured totally at the moment by what she said in general about those and other specific points.

I should like to pick up the point made by the noble Lord, Lord Peyton, about the quaintness of consultation. What the Minister has just said in her response, especially to my noble friend Lord Rea, about the position the Government are now taking on postgraduate education and the role of the postgraduate deans at the regional level of health organisation is an exact and good example of the way in which consultation after the event—after a Bill is published—is achieved. We all know that when the Bill was first published grave concern was felt, especially by the Committee of Vice-Chancellors and Principals of universities. The Government consulted, with the results that the Minister has been able to announce today.

Lord Peyton of Yeovil

I am much obliged to the noble Baroness for giving way. The point I was seeking to make was not that consultation in general was ridiculous, but that it could be, and it was, particularly ridiculous in the context in which she proposed it.

Baroness Jay of Paddington

All I can say to the noble Lords is that the Minister has demonstrated, in particular in relation to a complicated measure such as this, that consultation after the event—after a Bill has been published, and after it has been considered, as it has in this case, by one House of Parliament—can result in an interesting and useful amendment which is not put on the face of the Bill but which is achieved by consultation outside and leads to a greater understanding and approval of the regulations by those involved. That is the simple point that I was making and the simple point that is contained in the first part of my amendment.

However, I also make the point, as Members of the Committee who were present on Second Reading will know, that we on these Benches firmly opposed the principle of the Bill, which was included in the terms of the abolition of the regional health authorities. I, as a relatively junior Member of this place do not need to remind the Committee that it is not the convention of this place to divide on Second Reading. But if speakers from the Government Benches are now suggesting that it would be appropriate for us to divide on Second Reading when we oppose the principle of a Bill, that is something which I am sure will be of great interest to many Members other than those taking part in the Committee this afternoon.

What has been demonstrated generally this afternoon in our discussion on the substance of the amendment, which of course is the substance of the principle of the Bill, is that there is—if I may call it such a thing—a philosophical divide in the Committee between those on these Benches and those on the Government Benches about the nature of the NHS. We see the abolition of the RHAs as a way of reducing standards of excellence in the NHS and of reducing the public accountability of what is one of our most important public services. For those reasons, I should like to test the opinion of the Committee.

4.25 p.m.

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

Their Lordships divided: Contents, 95; Not-Contents, 160.

Division No. 1
CONTENTS
Addington, L.	Dormand of Easington, L.
Archer of Sandwell, L.	Dubs, L
Ashley of Stoke, L.	Eatwell, L.
Avebury, L	Falkland, V..
Banks, L.	Farrington of Ribbleton, B.
Blackstone, B.	Fitt, L.
Bottomley, L.	Freyberg, L.
Brooks of Tremorfa, L.	Gallacher, L.
Bruce of Donington, L	Gladwyn, L.
Callaghan of Cardiff, L.	Graham of Edmonton, L.
Carmichael of Kelvingrove, L	Gregson, L.
Carter, L.	Grey, E.
Castle of Blackburn, B.	Hamwee, B
Chapple, L.	Harris of Greenwich, L.
Clinton-Davis, L.	Haskel, L.[Teller.]
David, B.	Hollis of Heigham, B.
Dean of Thornton-le-Fylde, B	Holme of Cheltenham, L.
Desai, L.	Hooson, L.
Diamond, L.	Houghton of Sowerby, L.
Donaldson of Kingsbridge, L.	Howie of Troon, L.
Donoughue, L.	Hoghes, L.

Irvine of Lairg, L.	Rea, L
Jay of Paddington, B.	Redesdale, L.
Jeger, B.	Richard, L.
Jenkins of Hillhead, L.	Robson of Kiddington, B.
Jenkins of Putney, L.	Rochester, L
Judd, L.	Rodgers of Quarry Bank, L.
Kilbracken, L.	Russell, E.
Kirkhill, L.	Sainsbury, L.
Lester of Herne Hill, L	Scanlon, L.
Lovell-Davis, L.	Seear, B.
Mallalieu, B.	Sefton of Garston, L.
Mar and Kellie, E.	Serota, B.
Mason of Barnsley, L.	Shepherd, L.
Mayhew, L.	Simon, V.
McIntosh of Haringey, L.	Stallard, L.
McNair, L.	Stoddart of Swindon, L.
Merlyn-Rees, L.	Strabolgi, L.
Milner of Leeds, L.	Taylor of Gryfe, L.
Mishcon, L.	Thurso, V.
Monkswell, L.	Tope, L.[Teller.]
Morris of Castle Moms, L.	Turner of Camden, B.
Nicol, B.	Varley, L.
Wallace of Coslany, L.	Ogmore, L.
Wedderburn of Charlton, L.	Peston, L.
Wigoder, L.	Plant of Highfield, L.
Williams of Elvel, L.	Prys-Davies, L.
	Williams of Mostyn, L.

NOT-CONTENTS
Acton, L.	Downshire, M.
Addison, V.	Dundonald, E.
Ailsa, M.	Eccles of Moulton, B.
Aldington, L.	Ellenborough, L.
Alexander of Weedon, L.	Elles, B.
Ampthill, L.	Elliott of Morpeth, L.
Annaly, L.	Elton, L.
Archer of Weston-Super-Mare, L.	Faithfull, B.
	Ferrets, E.
Ashbourne, L.	Fraser of Carmyllie, L.
Astor of Hever, L.	Fraser of Kilmorack, L.
Balfour, E.	Gage, V.
Belhaven and Stenton, L.	Gainford, L.
Beloff, L	Gainsborough, E.
Bethell, L.	Gardner of Parkes, B.
Birdwood, L.	Geddes, L.
Blaker, L.	Gilmour of Craigmillar, L.
Blatch, B.	Gisborough, L.
Blyth, L.	Glenarthur, L
Boardman, L.	Goschen, V.
Boyd-Carpenter, L.	Gray of Contin, L.
Brabazon of Tara, L.	Gray, L.
Brain of Wheatley, L.	Gridley, L.
Brigstocke, B.	Grimston of Westbury, L.
Broadbridge, L.	Hailsham of Saint Marylebone, L.
Brougham and Vaux, L.
Bruntisfield, L.	Halsbury, E.
Cadman, L.	Harding of Petherton, L.
Caithness, E.	Harmsworth, L.
Campbell of Croy, L.	Hayhoe, L.
Carnegy of Lour, B.	Hayter, L.
Carnock, L.	Hemphill, L.
Carr of Hadley, L.	Henley, L.
Chalker of Wallasey, B.	Hives, L.
Charteris of Amisfield, L.	Hogg, B.
Chesham, L.	Holderness, L.
Clanwilliam, E.	HolmPatrick, L.
Clark of Kempston, L.	Howe, E.
Cockfield, L.	Hylton-Foster, B.
Colnbrook, L.	Inglewood, L.[Teller.]
Cornwallis, L.	Johnston of Rockport, L.
Courtown, E.	Killearn, L.
Cranborne, V.[Lord Privy Seal.]	Kimberley, E.
	Kinnoull, E.
Cumberlege, B.	Kintore, E.
Davidson, V.	Knollys, V.
Dean of Harptree, L.	Lauderdale, E.

Liverpool, Bp.	Renfrew of Kaimsthorn, L.
Long, V.	Richardson, L.
Lucas, L.	Rodger of Earlsferry, L.
Lyell, L.	Saltoun of Abernethy, Ly.
Mackay of Ardbrecknish, L.	Sandford, L.
Mackay of Clashfern, L. [Lord Chancellor.]	Savile, L.
	Seccombe, B.
Marlesford, L	Shannon, E.
Marsh, L.	Sharples, B.
McColl of Dulwich, L.	Shaughnessy, L.
McConnell, L.	Shaw of Northstead, L.
McFarllane of Llandaff, B.	Simon of Glaisdale, L.
Merrivale, L.	Skelmersdale, L.
Mersey, V.	Slim, V.
Miller of Hendon, B.	St. Davids, V.
Milverton, L.	Stewartby, L.
Mottistone, L.	Stodart of Leaston, L.
Mountevans, L.	Strange, B.
Mowbray and Stourton, L.	Strathclyde, L.[Teller.]
Moyne, L.	Sudeley, L.
Munster, E.	Swansea, L.
Nelson, E.	Swinfen, L.
Newall, L.	Telviot, L.
Noel-Buxton, L.	Thomas of Gwydir, L.
Norrie, L.	Trefgarne, L.
Northesk, E.	Trumpington, B.
Oppenheim-Barnes, B.	Tugendhat, L.
Orkney, E.	Ullswater, V.
Orr-Ewing, L.	Vaux of Harrowden, L.
Oxfuird, V.	Wade of Cholrlton, L.
Perry of Southwark, B.	Wakeham, L.
Peyton of Yeovil, L.	Warnock, B.
Pike, B.	Weatherill, L.
Rankeillour, L.	Wilson of Tillyorn, L.
Rees, L.	Winchester, Bp.

Resolved in the Negative, and amendment disagreed to accordingly.

4.34 p.m.

Baroness Jay of Paddingtonmoved Amendment No. 2:

Page 1, line 11, at end insert:

("() The Secretary of State may by order establish a Health Authority's membership to include representatives of—

1. (a) medical practitioners, registered nurses and registered midwives; and
2. (b) other persons with professional expertise in and experience of health care.").

The noble Baroness said: I hope that I shall be able to explain the amendment as clearly as possible to the Committee. It concerns the ability of the Secretary of State to prescribe the types of people who should be members of health authorities. That should not be an exclusive power but he should have the ability to prescribe who should be included on the new health authority boards.

It is an attempt to have written on the face of the Bill the necessity for professional involvement in the decision-making process of the new health service. The words relating to the people to be included are taken from Schedule 1 to the Bill. In Schedule 1 it is suggested that those are the people to whom health authorities should look for professional advice. That was as a result of an amendment proposed by the Government in another place on Report after argument on the subject in Committee. Therefore, the schedules make specific provision in relation to the advice of those people. My amendment is designed to ensure that there is a statutory duty on the new health authorities to obtain that advice by making that kind of professional expertise part of the authority.

Noble Lords who spoke on Second Reading will remember that several noble Lords wished, for example, to include nurses as members of health authority boards. This amendment seeks to provide a broader application of professional expertise involved at board level on the new health authorities. At present, such professional membership exists in family health authorities which will become, effectively, part of the new merged health authorities.

It is interesting to note that the draft guidelines which the Department of Health issued in January of this year on professional involvement in the work of the new health authorities refers to the: need for closer and more effective involvement by doctors, nurses and other professional staff in the full range of the work of the authorities".

The guidance goes on to state: Health authorities will need to demonstrate that their mechanisms are effective in terms of planning and decision making, good communication and professional understanding of local policies and strategies".

There are many examples in the draft guidance of areas in which it is intended that there will be professional input. Some of those areas appear in Annex C of the draft issued for consultation; for example, maintaining a district-wide view of healthcare purchasing; establishing ways of judging clinical effectiveness; planning health care services for people with disabilities; working on midwifery supervision and child protection measures; and looking at the whole area of mental health.

Those are obviously areas in which it is extremely important to have the right and appropriate level of input into decision-making from professionals of the type who are mentioned in the amendment. It seems to me that the simple way to achieve that is by making sure that the new health authorities are advised appropriately by precisely the people who the draft guidelines say will be extremely important to the work of the new health authorities. That can be achieved by making them members of the boards.

The amendment would not mean prescribing numbers. It may mean that the number of non-executive members may have to be increased slightly but I do not see why that is necessarily a problem. However, it slows down the process of the health authority boards being dominated, as many have been in the past few years, by people with very little practical involvement or interest in the health service.

I can speak to that from my own experience. The work of the district health authority with which I have been involved for many years has been slowed down by the involvement of people who have come in from outside with very little practical knowledge of the way in which the health service works and who show very little understanding of its mechanisms. At one stage, I asked people—I hope not in a sense of hostility—whether or not they were health service patients. It was surprising that several were not. It was surprising also that several were not involved in the local community which they were supposed to represent.

This is an attempt to try to redress the balance in that way. It is also my experience that one member of my local authority always referred to the fact that the papers and minutes were addressed in what she described as "NHS-speak"; that is, they were written in words which were often referred to and explained by the technical, medical and professional health-related issues which they were intended to cover rather than being written, as it were, for the local newspaper.

The proposal would not in any way affect the fact that the bodies which will run the local health authorities can have a broad concept of experience. It would not mean that there would need to be a prescribed number. When the Minister spoke on Second Reading in response to various noble Lords who raised the question of having people from individual professions represented on the authorities, she said that she did not like the concept of representation. I suspect that that may well be included in the Minister's reply this afternoon.

In the amendment, we are not suggesting representation of particular professional bodies; we are suggesting the inclusion of the voices of those from a professional background who can lend their expertise and experience to health authorities and who in any event, as the Bill stands, must statutorily be consulted for their advice. That is why I commend the amendment to the Committee. I beg to move.

Lord Boyd-Carpenter

Will the noble Baroness explain what she believes the legal effect of her amendment would be if it were accepted? As I understand it, it merely says: The Secretary of State may by order establish a Health Authority's membership to include representatives

of various professions. But surely the Secretary of State already has complete power to do so; indeed, he has power to include all those representatives in the membership of the health authority. As the amendment only purports to give the Secretary of State such authority if he so desires —"may" being the word used—surely it would have absolutely no effect if carried.

Baroness Jay of Paddington

I am sorry if I did not make myself clear in explaining the purpose of the amendment. The point behind the amendment is to put on the face of the Bill the necessity to include people who are already included in Schedule I as being appropriate advisers. If the noble Lord looks at line 23 of Clause 1 of the Bill, he will see that it says: The Secretary of State may by order", and then various indications are given as to the way in which the Secretary of State may behave in relation to the health authorities. The amendment is simply an attempt to add to those possibilities.

Lord Boyd-Carpenter

But does that not amount to a statement in that all the amendment is doing is saying that the Secretary of State "may" do what in fact he can already do?

Baroness Gardner of Parkes

I oppose the amendment. In fact, it is rather in conflict with Amendment No. 13 which is tabled in my name. As the noble Baroness said, she has taken the wording from the schedule. Amendment No. 13 would alter that schedule and, consequently, the wording of the noble Baroness's amendment. I am not opposed to any of those people serving on such an authority. However, I have been approached by pharmacists who are very upset that "medical practitioners", "registered nurses" and "registered midwives" have been named in Schedule 1, whereas they are not. Therefore, I was asked to put forward an amendment which would add the word "pharmacists". I immediately declined and said that I could not do so, the reason being that the moment I did so I knew that dentists would approach me and make the same request. It seemed to me that we would then go on through all the health professions, including chiropractitioners and so on. Thus we would have ended up with a whole list of people.

Therefore, I have tabled Amendment No. 13 to Schedule 1 which would delete the whole of paragraph 3(a) as set out in the noble Baroness's amendment and the word "other" at the beginning of paragraph 3(b), so as to make representation on such boards open to any health professional. The pharmacists—and I know that the dentists would feel exactly the same—feel very much second-class citizens because doctors, nurses and midwives have been named, while they have not been. Even though, according to the terminology, they know that they would be able to participate under paragraph (b) of the schedule, they feel that preference would be given to those who are specifically named in paragraph (a) and that those people would believe that they had the right to be on the board whereas the others were just another option. For that reason, I cannot support the amendment.

I should like to see persons of professional expertise being included, but I believe that they will be appointed in any case. The noble Baroness said that many of those in trusts and in health authorities have no direct health experience. However, I heard just that question today from Charter 88, regarding today's "Quango Day" meeting. A quick calculation was made. On my trust, there is a direct national health experience of over 80 years in the non-executive members of the board. Therefore, it is certainly not general practice for those on trusts to have no health background.

4.45 p.m.

Baroness Robson of Kiddington

I support the amendment moved by the noble Baroness, Lady Jay. I have a certain amount of sympathy for the other professions. However, we could not possibly have an amendment that named all the different professions. The reason for "medical practitioners", "registered nurses" and "registered midwives" being specifically mentioned is, in my view, due to their close involvement with patients in hospitals and in the community. They are in a special class compared with other expertise that relates to the health service.

During her response to the first amendment, the Minister said that the purchasing authorities, in themselves, represent the patients in the community. One cannot imagine a health authority that did not include a member of the medical profession, especially a general practitioner. In the new pattern of health care that we now have with the emphasis being on community care, the general practitioner is most important. Moreover, the nurses are the people who give 80 per cent. of the care in hospitals. They know more about what patients feel; indeed, they know more about what patients need. They are perfectly capable of contributing enormously to the purchasing question of a health authority. I would very much welcome it if the Government were to accept the amendment.

I heard from the Royal College of Nursing that there could be a problem with having a nurse representative on the board of a health authority. The reason is that it is not really permitted for a member of a board of one authority to be working for another authority. It would be very difficult for nurses to be represented on such boards because most of them are working in hospitals. I hope that the Government will consider that point and make a special allowance to ensure that nurses can be represented on the boards.

Baroness Gardner of Parkes

Before the noble Baroness sits down, perhaps I may refer back to the matter of the pharmacists. The noble Baroness said that the three groups mentioned in the amendment are those most closely connected with the community. However, I met a number of pharmacists today. They assured me that the role of the pharmacist in the community is greatly increasing. Indeed, the aim is for many patients to go first to the pharmacists before they visit their GP. That would lighten the load for general practitioners. In fact, the pharmacists ask why the regulations cannot be such that eventually the GP, through information technology, can input prescriptions directly from the practice to the pharmacy. All those measures would save time for GPs.

We have had debates in this Chamber on the increasing role in the community of pharmacists. Therefore, we must accept that they are very much a group which is directly involved with the community and, indeed, are probably more readily available to patients as regards their hours of working than is the case with most surgeries.

Baroness McFarlane of Llandaff

I have a personal interest in supporting this amendment as a registered nurse and midwife. If I have a criticism, and if I must be pedantic about words, it is the words "representatives of because the schedule states, Every Health Authority shall make arrangements for securing that they receive from

the stated professions. I think that is rather different. My contention is that this matter of health authority membership is not a matter of narrow sectional interests or professional sectional interests. In the discussion in the Committee today we have heard that many different health professions have a claim as regards their interests in the work of a health authority. Nonetheless, I think that there is a strong case to be made for the professions mentioned here, and a strength in their being written onto the face of the Bill. It is not sufficient to say as regards these particular professions, which have such a large contribution to make to the disposal of resources of a health authority, that we shall take advice and receive representations from them. Those professions need to be present where the cut and thrust of decision-making takes place in the authority. Secondhand information is not sufficient. However, I hope that we shall be able to deal with this in greater detail when we discuss the schedule.

Baroness Eccles of Moulton

It is important to remember—as my noble friend Lord Boyd-Carpenter has said—that the Secretary of State is of course presently empowered to appoint any health professional to a health authority. It would be interesting to know how many are serving on health authorities at the present time. However, the difficulty we have here is the representative aspect of this proposal. It is important that health authorities are made up of people from as wide a range of experience as possible, and also that they are tailored to suit the needs of the particular area that the health authority serves. In my view, I do not think that it would be at all helpful to be prescriptive in this matter.

Before 1991, health authorities had a number of representatives. These comprised doctors, nurses and trade union representatives and it was difficult for them, having been appointed, to leave their professional hats outside and not to allow their special interests to influence the policies that were being debated. Under the present arrangements we have a health professional on our authority; but they are not there as a representative and in no sense do they feel under any obligation to promote the interests of their own sector because they are appointed in their own individual right, and of course the professional knowledge and expertise that they bring is valuable. But as they are not a representative, they do not feel they are under any obligation.

At present, as regards advice, we take advice from a wide range of professionals, and this is extremely helpful. But that is quite a different matter to selecting an individual to sit on a health authority representing a particular profession. Incidentally, as regards the size of authorities, if a body is to be able to take decisions in an effective way, I believe that it should not comprise more than about a dozen persons as above that number the body's effectiveness immediately becomes restricted. I fully support the inclusion of health professionals on health authorities. They are of great value in an independent capacity and if they are appointed where appropriate. However, I do not support the proposal that such a requirement should be specified in the Bill.

Lord Skelmersdale

Reference has already been made to the words inserted into Schedule 1 in another place. However, there is of course another part of Schedule 1—namely, paragraph 59 on page 19—which is germane to this amendment. The paragraph states, A Health Authority shall consist of (a) a chairman appointed by the Secretary of State; (b) not more than a prescribed number of persons (not being officers of the Health Authority) appointed by the Secretary of State: and (c) a prescribed number of officers of the Health Authority".

Clearly a health authority will have a chairman. However, in any health authority with which I have come in contact, the officers of the health authority to a large extent include the professionals which are described in this amendment. Therefore I believe that to a great extent this amendment would duplicate what is already in the Bill in paragraph 59.

Lord Rea

I hesitate to engage in discourse with the noble Lord, Lord Boyd-Carpenter, on terminology in a Bill because he has such vast experience; but I should like to see the word "may" replaced by "shall". As the noble Lord knows full well, "may" is frequently used in legislation and allows a certain amount of leeway. I see it as a flagging up of the fact that the Minister may appoint these categories of people, so that if he does not appoint them, it can be pointed out that he was entitled to do so. If it is not on the face of the Bill, he might be able to smooth that over and it would appear that it is not within the range of possibilities that he can appoint those categories of people.

Lord Boyd-Carpenter

I was just pointing out that the amendment as it stands would have no legal effect whatever.

Lord Carr of Hadley

We must never lose sight of our main objective in discussing these matters, and that, surely, is to produce the smoothest working, most effective, health service that we can from the point of view of the patients—all our fellow citizens of this country—and to use every penny we possibly can on patient care out of the £30 billion-odd we devote to it, and to save every penny we can on administration, provided we get an efficient, smooth service.

As regards the functions of any board of directors or authority of this kind, there are two limiting factors. One is the size of the membership. If a body is too large, it is not a good policy-making body. I do not think I need enlarge on that. People have different ideas as regards ideal numbers. However, a figure any higher than 15 is getting dangerously high. I think anything over 10 is probably getting dangerously high. However, one must decide on a number.

As regards implicating professionals in this matter, if we are to appoint them as representatives, as my noble friend Lady Gardner of Parkes and others have already pointed out, there is no end to the number of people whom we could appoint as representatives. There are different aspects to the profession and people involved in these aspects all have a great role to play in this matter, not least the pharmacists. I live in a country area and I know of the role played by pharmacists in advising people who live in a country district with a dispersed population. In my area there is a most excellent group practice but it is spread over a widely dispersed population.

Secondly, there is also the matter of whether it is right—in my view it is not right in principle—to have any board or committee packed with too many experts. I am not saying for one moment that we should exclude from membership a doctor, a nurse or a pharmacist. It would be mad not to include people with that sort of background. However, I submit that they should not be representatives. Many years ago now I had some years' experience as a member of a board of governors of one of our large London teaching hospitals. It was an admirable body but its membership was so large and so diverse that from a management point of view the body was useless. It served other purposes but it was a poor directional body. The governing body's main committees were also large and had all sorts of representatives on it. There were also some small sub-committees.

I remember very well serving on a small sub-committee which was charged with looking at rough specifications for the new St. Mary's which we hoped might be built some time in the next few decades, if not sooner. That small committee of eight people included two doctors. They were distinguished members of our staff, but because they were so busy they were seldom able to attend meetings every month. One or other might attend, but rarely both. They were highly dedicated men—both now, sadly, long since dead—who had different views. We reached the ridiculous position where we listened to one doctor one month, and the next month the other doctor attended and proposed the exact opposite of what his colleague had proposed. When we finally produced a report for the main sub-committee of the board the doctors and nurses argued about it because they could not accept that those members of our committee had the power to represent the medical view or the nurses' view.

Therefore, we must have people with relevant experience, but above all we must be free to ask such people to give evidence and to talk to us. If one has official representatives of doctors and nurses others are shy of coming. However, they must be free to come and give evidence. Once one has an official representative one is going down a very dangerous path leading to long delay and uncertainty of decision.

5 p.m.

The Lord Bishop of Liverpool

I have not been in this Chamber for a while because I have been in the hands of the National Health Service. I am enormously and wonderfully grateful to it.

As I understand it, the purpose of the amendment is to ensure that there is a balance. I understand that the drafters of the amendment want to see that a balance is maintained between primary and secondary healthcare. With my longstanding interest in urban priority areas, I have taken a special interest in the health divide, ever since the Black Report and much else. I am clear that if we want to remove that health divide then primary healthcare is the place where principally that has to be done. When large-scale spending is at stake, as people who work in hospitals have told me, the balance of power frequently slips from primary healthcare, however much lip service is paid to its importance.

In a city like Liverpool one can draw health on the map very easily and predictably, showing dramatic differences. Better take up of healthcare, better education, better diet and better hygiene—the issues which primary healthcare addresses—will shift the ground infinitely more than what happens in hospitals.

It is very important that the membership of the boards should be balanced and should include sufficient interest in primary healthcare in order to fight that corner.

Baroness Gardner of Parkes

I should like to take up the point made by the right reverend Prelate. I have put down an amendment to amend Schedule 1 to include a representative who is involved in primary care. However. Amendment No. 2 does not make clear that the people concerned should be involved in primary care. I do not believe that the amendment covers that point.

Baroness Cumberlege

I am grateful for this opportunity to debate how best we can ensure that professional healthcare experts are fully involved in the work of health authorities.

The Committee will be aware that the Government have recently published new guidelines on appointments to health authorities. My right honourable friend the Secretary of State made clear our approach when she said that: Membership of a trust or health authority is a demanding and responsible task. I want the best people for the job: people who are unswervingly committed to the NHS and its values and who can bring the energy and skill which an evolving, dynamic health service needs.

Both professional and non-professional people can offer that skill and commitment. Those working in primary care have a particularly important contribution to make as we move towards a more primary care led NHS, and I agree with the comments of the right reverend Prelate. 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.

There are, however, many other groups with a contribution to make. I make no apology for emphasising the value of members with financial and business skills with voluntary sector experience and with experience of representing consumers from a lay perspective.

My noble friend Lord Carr is right that it is important that the new authorities are effective decision-making bodies. For that, they must be compact and streamlined. It would not be possible, or desirable to include on every health authority a representative of all the different groups and organisations with an interest in health services. Not only would that make health authorities less effective as decision-making bodies, but it would go against our aim of ensuring that health authority members are chosen for their personal skills and abilities.

No health authority can do its job properly without involving doctors, nurses, midwives, health visitors and the many other skilled professionals working in the NHS—and I include pharmacists and dentists. I fully accept the valuable personal contribution that they can make, as executive or non-executive members of authorities.

I can reassure the right reverend Prelate the Bishop of Liverpool that GPs and other primary care practitioners, will be free to apply for appointment to health authorities. That will include GP fundholders—who cannot currently be members of district health authorities, so we are widening the scope. However, it would not be appropriate for employees of trusts—including nurses—also to work for purchasers as members. We therefore agree with the Royal College of Nursing that as members nurses are more likely to make their contribution as executive members of health authorities. But of course, we welcome suitably qualified nurses as non-executives where there is no conflict of interest.

Membership is far from being the only way for professionals to be involved. That is why—in paragraph 3 of Schedule 1 —referred to by the noble Baroness, Lady Jay—the Bill now places an absolute, clear statutory duty on health authorities to secure advice from medical practitioners, registered nurses and registered midwives and other people with professional expertise in and experience of healthcare.

The noble Baroness, Lady Robson, and the noble Baroness, Lady McFarlane, quite rightly highlighted the contribution of nursing. They will agree that the Government have demonstrated in many ways their commitment to nurses, midwives and health visitors. It is relatively easy to praise the nursing profession, but we have given nurses added responsibilities and shown our trust in their professional skills. One example that I should like to highlight is nurse prescribing, an area in which I have taken a personal interest. As my noble friend Lady Gardner said when we debated the first amendment, we have made an enormous investment in nurse education and training through the introduction of Project 2000. MyChanging Childbirthreport acknowledged the central role played by midwives in the routine care of women during labour.

Purchasing healthcare requires innovation, understanding of health needs, sensitivity in relationships with patients and the wider public. We believe that there are many people who can bring those skills to purchasing.

My noble friends Lord Boyd-Carpenter and Lady Eccles quite rightly pointed out that the amendment before us has no practical effect. The Secretary of State is already free to appoint healthcare professionals to health authorities. She already has the power to appoint members of health authorities in general. We believe that by inserting a pointless provision there is a risk that a court might doubt the generality of the existing power.

We are committed to involving a whole range of healthcare professionals in the decisions of the new health authorities. However, I do not believe that the amendment is the best way to achieve that. Therefore, I hope that the movers of the amendment will be willing to withdraw it.

Baroness Jay of Paddington

I am grateful to the Minister for that reply. In some ways there is only a small distance between us. We both agree that it is vital that members of the various professions are involved, but I agree with the noble Baroness, Lady Gardner of Parkes, that there would be difficulty in having an all-embracing list of everybody who would wish to be involved and who would feel that they should rightly be involved.

The distance between us is that I want to see this representation on the face of the Bill. I take the point that it has been argued that this might create a position which was nonsensical. However, having taken advice, we are seeking—in the Minister's words—to achieve the "absolute, clear statutory duty" of the health authorities to receive the advice of these people as members of those authorities. I refer Members of the Committee again to the guidance issued by the Department of Health regarding examples where professional input will be "essential"—I cite the department's word—in the new authorities. If that input is to be essential, covering such a wide range of policy and strategic decisions, how can it be achieved simply through the mechanism of advice?

Unlike other noble Lords who spoke from the other side of the Chamber, I am not shy of the concept of representation. There is a difference between us on that issue. I was interested that the noble Lord, Lord Can, referred to a size of authority or a decision-making body which was considerably less large than the present Cabinet as being the only effective body to take decisions.

There are some issues between us, in particular on the clear and statutory duty that we should like to see placed on the Secretary of State to achieve professional representation on the health authorities. We want to achieve such representation where decisions are taken and not simply in an advisory capacity. On that basis, I wish to take the opinion of the Committee.

5.11 p.m.

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

Their Lordships divided: Contents, 94; Not-Contents, 139.

Division No. 2
CONTENTS
Addington, L	Bruce of Donington, L.
Archer of Sandwell, L	Callaghan of Cardiff, L.
Ashley of Stoke, L.	Carmichael of Kelvingrove, L.
Avebury, L.	Carter, L.
Banks, L.	Castle of Blackburn, B.
Blackstone, B.	Clinton-Davis, L.
Bottomley, L.	Cocks of Hartcliffe, L.
Brooks of Tremorfa, L	David, B.

Dean of Thornton-le-Fylde, B.	McIntosh of Haringey, L.
Desai, L.	McNair, L
Diamond, L.	Merlyn-Rees, L.
Donaldson of Kingsbridge, L.	Meston, L.
Donoughue, L	Milner of Leeds, L.
Dormand of Easington, L.	Mishcon, L.
Dubs, L.	Monkswell, L.
Eatwell, L	Morris of Castle Morris, L.
Falkland, V.	Nicol, B.
Farrington of Ribbleton, B.	Ogmore, L.
Fitt, L.	Peston, L.
Gallacher, L.	Plant of Highfield, L.
Geraint, L.	Prys-Davies, L
Graham of Edmonton, L.	Rea, L.
Gregson, L.	Redesdale, L.
Grey, E.	Richard, L.
Hamwee, B	Robson of Kiddington, B
Harris of Greenwich, L.	Rochester, L.
Haskel, L.[Teller.]	Russell, E..
Hollis of Heigham, B	Seen, B.
Hooson, L	Sefton of Garston, L.
Houghton of Sowerby, L.	Serota, B.
Howie of Troon, L.	Shepherd, L.
Hughes, L.	Simon, V.
Irvine of Lairg, L.	Stedman, B.
Stoddart of Swindon, L.	Jay of Paddington, B.
Strabolgi. L.	Jeger, B.
Taylor of Gryfe, L.	Jenkins of Putney, L.
Thomas of Walliswood, B.	Kilbracken, L.
Thomson of Monifieth, L	Kinloss, Ly.
Thurso, V.	Kirkhill, L.
Lester of Herne Hill, L.	Tope, L.[Teller.]
Liverpool, Bp.	Tordoff, L.
Longford, E.	Varley, L.
Lovell-Davis, L.	Wallace of Coslany, L
Mallalieu, B.	Wedderbum of Charlton, L.
Mar and Kellie, E.	White, B.
Masham of Ilton, B.	Williams of Elvel, L.
Mason of Barnsley, L.	Williams of Mostyn, L.

NOT-CONTENTS
Aberdare, L.	Cross, V.
Addison, V	Cumberlege, B.
Ailsa, M.	Davidson, V.
Aldington, L.	Dean of Harptree, L.
Archer of Weston-Super-Mare, L.	Denham, L.
	Dilhorne, V.
Astor of Hever, L.	Downshire, M.
Balfour, E.	Dundonald, E
Bethell, L.	Eccles of Moulton, B
Birdwood, L.	Eden of Winton, L.
Blaker, L.	Elles, B.
Blatch, B.	Elliott of Morpeth, L.
Blyth, L.	Elton, L.
Boardman L.	Faithfull, B.
Boyd-Carpenter, L.	Ferrers, E.
Brabazon of Tara, L.	Fraser of Carmyllie, L.
Braine of Wheatley, L.	Gage, V.
Bridgeman, V.	Gainsborough, E.
Broadbridge, L	Gardner of Parkes, B.
Brougham and Vaux, L.	Geddes, L.
Cadman, L.	Gisborough, L.
Caldecote, V.	Glenarthur, L.
Carnegy of Lour B.	Goschen, V.
Carnock, L	Gray, L.
Cam of Hadley, L.	Greenway, L.
Chalker of Wallasey, B.	Gridley, L.
Charteris of Amisfield, L.	Grimston of Westbury, L
Chesham, L.	Hailsham of Saint
Clanwilliam, E.	Marylebone, L.
Clark of Kempston, L	Halsbury, E
Courtown, E	Harding of Petherton, L.
Craigavon, V.	Harmar-Nicholls, L.
Cranborne, V.[Lord Privy Seal.]	Harmsworth, L.
	Hayhoe, L.
Cranbrook, E.	Hemphill, L.

Henley, L	Orr-Ewing, L
Hives, L	Oxfuird, V.
Hogg, B	Perry of Southwark, B.
Holderness, L	Peyton of Yeovil, L
HolmPatrick, L	Pike, B.
Howe, E	Porter of Luddenham, L.
Hylton-Foster, B	Rankeillour, L.
Inglewood, L.[Teller.]	Rees, L.
Johnston of Rockport, L.	Renfrew of Kaimsthorn, L
Kimberley, E.	Rodger of Earlsferry, L.
Kinnoull, E.	Savile, L..
Kintore, E.	Seccombe, B.
Knollys, V.	Sharpies, B.
Lauderdale, E	Shaw of Northstead, L
Layton, L.	Simon of Glaisdale, L.
Liverpool, E.	Skelmersdale, L.
Long, V.	Slim, V.
Lucas of Chilworth, L.	St. Davids, V.
Lucas, L.	Stewartby, L.
Lyell, L.	Stodart of Leaston, L.
Mackay of Ardbrecknish, L	Strange, B.
Mackay of Clashfern, L.[Lord Chancellor.]	Strathcarron, L.
Marlesford, L.	Strathclyde, L.[Teller.]
Merrivale, L.	Sudeley, L.
Mersey, V.	Swansea, L.
Miller of Hendon, B.	Swinfen, L.
Milverton, L.	Thomas of Gwydir, L.
Mottistone, L.	Thurlow, L.
Mountevans, L.	Trefgarne, L.
Munster, E.	Trumpington, B.
Nelson, E.	Tugendhat, L.
Newall, L.	Ullswater, V.
Nickson, L.	Vaux of Harrowden, L.
Norrie, L.	Wade of Chorlton, L.
Northesk, E.	Weatherill, L.
Oppenheim-Barnes, B.	Wilson of Tillyorn, L.

Resolved in the negative, and amendment disagreed to accordingly

5.19 p.m.

Baroness Jay of Paddingtonmoved Amendment No. 3:

Page 1 line 14, at end insert ("and those areas shall, so far as is practicable, be of equivalent population size and coterminous with local authority boundaries").

The noble Baroness said: This amendment stands in the names of the noble Lord, Lord Tope, and myself. It addresses the issue of the size of the new health authorities and is designed primarily to try to obtain information from the Government about how they see the organisation of the health authorities, particularly in relation to their coterminosity with local authorities and councils.

As we know, the mood within the health service is to achieve what is becoming known as primary care-led purchasing. It will obviously include a great deal of community care which involves local social service bodies and other organisations, particularly in the voluntary sector. Previously, they often related more to local authorities than to local health authorities.

The amendment is also an attempt to address the issue raised by the right reverend Prelate the Bishop of Liverpool on the previous amendment about the so-called health divide. The question is whether it will no longer be the case—if we can achieve relative coterminosity both in relationship to local councils and local population sizes—that what you obtain in terms of some services, particularly community care, can sometimes depend on where you live and not on what you need.

Members of the Committee will remember that at Second Reading many of us were concerned with the issues which relate inequality of wealth to inequality of health. Difficulties occur when health authorities are simply related to a particular type of population; they may have problems in addressing the broad spectrum of healthcare. At the moment there are 111 district health authorities and 90 family health service authorities. As I understand it, in the end, when reorganisation has gone through, there will probably be 80 or 90 health authorities—the new HAs. These will have no regional responsibilities, only responsibility for the local area.

It is of great importance that the health authority areas should be roughly of the same geographic and population size. As the amendment says, that can only be done, so far as is practicable".

I hope that that will be more practicable, particularly in some wider urban areas, than in the past.

It is easier to arrange the kind of community care we all hope to see if there is a close relationship between the areas which are organising social care and those which organise healthcare. Later, under a further amendment, we shall discuss the National Health Service responsibility for continuing care. Noble Lords who took part in our earlier debates on the subject will know the clear necessity for close co-operation between social services and health authorities if community care is to be successful. That is particularly important in dealing with problems which reflect the health divide in terms of population income and population health.

When we discussed the matter on earlier occasions, there was general agreement around the House that the so-called healthy alliances, very much underlined in the policy inThe Health of the Nation, are much easier to organise if they are carried out at a local level with health, social services, voluntary sector bodies, charities and education bodies all working towards the same end. We see that clearly when we consider the issues which relate to questions of poverty and health. But they also relate clearly to issues related to health education and health promotion.

If we end up with health authorities which are variable, both in the size of their population and their relationship to local authorities, it seems that the objectives of achieving equity and effectiveness, particularly in the areas of primary and community care, will not be achieved. I hope that the Minister will be able to tell us that it is an aim of the detailed reorganisation that there should be an attempt to achieve both a sense of coterminosity with local authorities and relative equality in terms of population. I beg to move.

Lord Donaldson of Kingsbridge

Before the noble Baroness sits down, can she tell me exactly what "coterminosity" means? Does it mean that the two areas end at the same point? If not, what does it mean?

Baroness Jay of Paddington

I suspect from the expression on the noble Lord's face that, like me, he regards "coterminosity" as a rather ugly term. If that is the case, I agree with him. As I understand it, "coterminosity" in terms of this amendment and local government means that two authorities are responsible for social policy for different parts under the same umbrella of care—for example, healthcare in its broadest sense and, as I emphasised, community care and primary care. They are organised by bodies which have a responsibility for the same geographic area. I give an example from my experience in west London. For many years I was a member of a health authority which had the entirely arbitrary name of Parkside. The name did not relate in any sense to the local authorities who organised social services. Since the reorganisation in the past few years, the health authority is now known as Kensington, Chelsea and Westminster Health Authority. It directly relates to those local councils who have responsibility for local social services in the same area as the health authority.

Lord Tope

The noble Baroness has explained "coterminosity" very well. It means the same authorities having the same boundaries. I intervene at this stage with my experience of local government rather than of the health service. That is why I wish to support the amendment. Increasingly, local authorities have to work and wish to work in partnership with many other agencies in the context of the Bill, particularly in the field of community care. It has been the bane of the lives of local authorities that other authorities such as health authorities not only have names which are meaningless to most of the public and to many of their members but also have quite different boundaries. We still find that in a number of areas different authorities working in the community who need to work together have different boundaries. It is confusing for the public and often also for the authorities themselves to know who is responsible for what.

This is a simple and straightforward amendment. It is so obviously right that I share the wish of the noble Baroness that the Minister should tell us that the Government accept the amendment or, at the very least, its spirit. I fear that if the proposal does not apply when the further reforms come into effect, it will be a recipe for further confusion which need not arise. I support the amendment.

Baroness Eccles of Moulton

My impression, ever since the reforms began, has been that the Government's aim is to achieve coterminosity wherever possible. A great deal has happened in that direction. I have had experiences similar to those of the noble Baroness, Lady Jay, where my district has become coterminous and our work has become a great deal easier.

However, we must remember that England is not made up of neat and tidy parcels either of population or territory. Therefore, to make it prescriptive that health authorities should in future be coterminous with local authorities would be a pity. I know that the words, so far as is practicable", are included in the amendment, but it would be a pity because it seems to me that there is no need for it.

5.30 p.m.

Baroness Cumberlege

We do not intend to be prescriptive in any way about the population size of the new health authorities in this Bill. As with district health authorities, the size of an authority will be dictated by what is required for it to discharge its responsibilities effectively, and this may vary according to local circumstances.

However desirable, it would not be practical to prescribe that each health authority is coterminous with a local authority. The size considered best for the performance of local government functions in one area may well be rather smaller than that which my right honourable friend the Secretary of State for Health decides is the optimum for the new health authority as a strategic purchaser of health care.

As the noble Baroness, Lady Jay, said, bothCare in the Community and The Health of the Nationrequire health and local authorities to work closely together, and, as we move towards a primary care led NHS, there will be even more opportunities for joint working. An important part of assessing and meeting the health care needs of a population will be the effectiveness with which a health authority relates to other local bodies, particularly local authorities. However, although common boundaries with local authorities can contribute to successful joint working, it does not guarantee success—the key is a commitment to working together to share objectives, information and plans. As my noble friend Lady Eccles said, England is not neat and tidy, and therefore we do not consider it appropriate to include in the Bill a provision on the size of health authorities in relation to local authorities. We must allow regional offices the flexibility to meet differing local circumstances. Regions have been charged with developing a clear view about the desirable size for the new health authorities to ensure effective collaboration with other agencies, and to be responsive to local people and their health needs. The views of the local population and interested organisations will be sought through public consultation on the boundaries of the new health authority. My right honourable friend the Secretary of State for Health will then decide on the boundaries of the new health authorities.

The size and shape of health authorities must be determined by what is best for the purchasing of health care. Having the same population base as local authorities is not necessarily always the answer. On this basis, I am therefore unable to accept an amendment which might jeopardise the ability of a health authority to carry out its functions effectively. I hope that the noble Baroness will withdraw her amendment.

Lord Carr of Hadley

Before my noble friend sits down, can she expand a little further her comments on boundaries? I understand very clearly why it would not be practicable or desirable to go for equality or near-equality in population sizes. I can also understand quite clearly why it would not be possible to have one health authority for one local authority. However, I do find it difficult to understand why a health authority's boundaries would have to cut across and through a number of local authority boundaries.

Baroness Cumberlege

It would certainly be our intention to avoid that problem. But I know, for example, an area in Surrey very well where there is an anomaly that we believe will be very hard to put right immediately. All that we suggest is that there should be more flexibility and more room for judgment than this amendment allows, which suggests that each health authority ought to have a population of similar size and always be coterminous, where practical, with a local authority.

Baroness Jay of Paddington

I am rather disappointed by the Minister's reply. Given the terms in which the amendment is couched, stating as it does, so far as is practicable, be of equivalent population size and coterminous with local authority boundaries", I would not have described it as necessarily prescriptive. The illustrations that have been given suggest that there is a need for (I hesitate to use this word again) some degree of coterminosity, particularly, as the Minister said, in the further development of primary care and local purchasing. If we have anomalies whereby there is such a disjunction between a local social services authority responsible for one part of care and a local health authority responsible for-another, we shall simply continue the argument that is going on at the moment, much to the detriment of patients and those who use the health service, about who is responsible for looking after them at different stages.

However, I take the points that were raised about the difficulties of laying down the particular areas of England in small and neat boundaries. That was not intended to be the point of the amendment. As I say, it was intended to convey the hope that by achieving, where practicable, equivalent population size and coterminosity, we could achieve greater equity of services, and greater equity particularly between local and health authorities. Having heard what the Minister said, I will think about the matter further. At this stage I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Cartermoved Amendment No. 4:

Page1 line 23, after ("may") insert ("following consultation with the appropriate local authorities, Community Health Councils and other relevant bodies").

The noble Lord said: With this amendment we return to the subject that we discussed in relation to Amendment No. 1; namely, the importance of consultation. It is a pity that the noble Lord, Lord Peyton, is not in his place. Noble Lords will remember that, when we discussed consultation previously, the noble Lord described the idea as "quaint". I was minded to look up the definition of quaint in the Oxford Dictionary. One definition is, "daintily odd". I did wonder whether there was anything faintly subliminal in the choice of that specific word, meaning as it does "daintily odd", by that particular noble Lord.

In moving this amendment I should like to present the general argument in favour of consultation as described in the amendment, and then give two particular examples which are known to me and which show why, in the area in which I live, consultation on the health service is, I am afraid, regarded as a farce.

This is yet another major change. I return to the point that was made when we discussed the first amendment. This is not just a planned development that was foreseen when the 1990 Act was passed. It is another major change, and should be treated as such. That is, of course, why we have a Bill before Parliament in which to deal with it. Any noble Lords who were involved in the 1990 Act will remember how we tabled amendments asking the Government to consult and to try out the various ideas, which were supported at the time by all the Royal Colleges. But at the time they were rejected and the whole thing was done in one fell swoop overnight. And we know the result.

There are a number of ways in which the Government go through the motions of consultation. One is to request consultation and then give very short deadlines for reply. If my memory serves me right, when consultation was begun on the community care part of the 1990 Act, the consultees were given only a very few weeks in which to reply.

The amendment mentions the local authorities, the community health councils, and so on. It is important, because of the danger of overlap (or duplication) between health authorities and the local social services on such matters as community care, that where such a danger exists, there should be the form of consultation for which we ask.

In Section 5 of the 1990 Act there is a duty that the community health councils and the local authorities should be consulted about trusts. It would be interesting to know from the Minister why such consultation was thought to be important in 1990 in relation to National Health Service trusts but is apparently not required under the terms of this Bill. We also have to bear in mind the likely effect on local authorities of the proposed boundary changes. Consultation is required to ensure that there is no overlap or duplication.

The report of the House of Commons Health Select Committee on priority setting in the NHS, published in January, also stressed the importance of consultation. The report contained some useful recommendations; namely, that the statutory requirements for consultation over health plans should be brought into line with those for community care plans at the earliest opportunity; that purchasers should seek the views of community health councils during the formulation of protocols; that health authorities should demonstrate that they have a systematic approach to consultation relating to strategic development, specific health issues, service shifts, purchasing plans and promoting healthy lifestyles; and evidence of communication and consultation with different local groups to take account of their needs. I think we all agree that health authorities should be as open as possible in consulting citizens and consumers about the service that they provide. We also think that they should publish plans about how they have consulted consumers and their representatives in identifying the health needs of their area. For all those reasons we feel that the Bill should include the requirement for consultation specified in the amendment, and as indeed was laid down by the 1990 Act.

I now move from the general to the particular. I do not apologise for this. Often in this Chamber we deal with the wider issues which concern the principles of a Bill, but it helps occasionally to look at specific local issues to see how they effect the patients (not the "consumers") on the ground. Let me give two examples that concern hospital and ancillary services in my home locality, which has a medical catchment area of some 35,000 people. When the replanning started six years ago in 1989, it was declared that there would be a new community hospital to replace the old district hospital. Plans were deposited in March 1993 and the planning authority was shown the community hospital. Further plans were deposited earlier this year in 1995 but any mention of a community hospital was omitted. Instead, for the first time, a link road was shown with the possibility of building over 200 houses on what had been planned as the hospital site. That was a health trust which was working to commercial imperatives and could see the chance of using development land to provide the money for other developments in the area in the health service at the expense of the promise of a local community hospital. I shall not go into the detail but the local community feels that consultation is a farce.

We know that in September 1994 a business plan was produced. It was kept secret. It went into some detail and showed the favoured option which was to close a number of community hospitals and to build one new hospital on another site. The plan was kept completely under wraps. There was an attempt to send it for a full costing analysis. When, earlier this year, it became clear that that was likely to happen and that all the promises that had been made were about to be broken, the health authority decided to set up a consultation exercise with local groups in the area. As can be imagined, that was met with contempt. Although it was denied, the decision had obviously been taken internally for commercial and not for health reasons. In fact, Devizes Town Council (where I live) wrote to the Prime Minister and asked for his help with this matter. It was pointed out that before any of the consultations started: The Regional Office of the NHS Executive has been asked to approve the preferred option … which … will mean the loss of our Community hospital of 49 beds and all supporting services. This is to be replaced by a 15 bed hospital building providing only respite care and accommodation for terminally ill patients … In six years we shall have lost all our Health Services in a town with a catchment area of 35,000".

I have deliberately given an example to show that if we are going to have consultation, it should actually mean something. The health authorities should not now start to go through the motions of a consultation without revealing that their minds have already been made up, however much they might say the opposite.

In the same area, and the same health district, there was another example of the disastrous effect of ignoring the wishes of the local people. A highly effective hospital laundry operated in the area. It had won the tender for the work in the future. The tendering process was then rigged to ensure that, although it was the lowest tender, the work would in fact go to Swindon. I shall not go into great detail into what happened. A number of people were made unemployed as a result of the closure of the local laundry. There is now a situation in that health district in which the patients in Bath are requested to bring their own sheets to the hospital; patients have to go outside to purchase baby linen; there has almost been the closure of a number of catering departments, as there are no clean aprons; and the contract has been lost from a private nursing home. There were photographs in the local press of a three to four week pile-up of hospital dirty laundry which eventually had to be discarded because it was ruined and there were complaints from Oxford hospital about the level of service. Finally, a spokesman from the health trust appeared on HTV on Thursday 9th March. He stated that the only way that the hospital could continue with operations was by going out and buying new linen.

Those examples are local and particular but they can be repeated around the country. They show that it is important not just to have the consultation requested by this amendment, but to ensure that it means something and that the wishes of the local people are listened to. I beg to move.

Lord Tope

I rise briefly to support this amendment, which in many ways speaks for itself. In the previous debate we were talking about the extent to which local and health authorities now work together, particularly in the field of community care. To me it seems inconceivable that the Minister or the Government would seek to vary, change or even abolish a health authority without consulting the relevant local authorities in that area who have been or would be working with that health authority.

But there is another reason why this amendment deserves to be supported. In part perhaps that is what the noble Lord who has just spoken was referring to. For better or worse, local authorities are now the only democratically elected bodies in the areas concerned. That is not to say that that is the sole and only way of consulting the public; nor should it be. Nevertheless, they are the only bodies that can claim legitimately to represent the whole of public opinion. That is another reason why they deserve to be consulted and indeed should be consulted before any such changes go ahead.

Similarly, the community health councils work closely with the health authorities and scrutinise them. It is hard to conceive that changes as envisaged in this clause of the Bill would go ahead without consultation with community health councils. If that is the Government's intention—I wish to believe that it is—I can see that it would do no harm. They would certainly give reassurance to those of us who need it by accepting this amendment.

Let me add a word about the nature of the consultation. Too often when local authorities are consulted, the time allowed for a response is ludicrously short. For matters of such importance, local authorities need time to be able to consult their communities, to get a proper response and not least to go through the inevitable committee cycle. The same is possibly even more true of community health councils, whose members are in every sense voluntary and where time is more limited. So, rather than simply pay lip service to this amendment if, as I hope, it is accepted, I urge the Government, in their consultation both on this measure and generally, to allow proper time for meaningful consultation and meaningful responses. If they do, I am sure that at the end the decisions will be very much better for it.

Lord Peyton of Yeovil

I welcome any opportunity that I have to agree cordially with the noble Lord, Lord Carter. I wrote down his exact words: if we are going to have consultation, it should actually mean something".

I agree totally; but I should like to add a rider and ask whether he will co-operate with me in reaching agreement: the more consultation you have, the less it is likely to mean.

People become extremely bored with consultation. I wish that those who are constantly advocating more and more consultation would ask themselves this question: what would those who are taking part in the exercise be doing if they were not consulting? It is just possible that they might be doing something much more useful. Because I believe that to be very likely, I hope very much that my noble friend, despite the eloquence of the noble Lord opposite, will reject the amendment.

Baroness Gardner of Parkes

I find this a strange amendment in that it asks the Secretary of State to do all the consulting. A lot of consultation takes place now but it is not direct consultation by the Secretary of State. It is done by other people—tiers further down—who are in much more direct contact with groups.

Our trust has a "learning from patients" system, which we find immensely useful. The patients say what they find good and bad in the service that is being given and they say what they want to see. There are several meetings every year with community health councils. There are now consultations going on at all levels.

The noble Lord, Lord Peyton, mentioned that there was, perhaps, too much consultation. I usually agree with the National Consumer Council, but recently it wrote to me suggesting that we have a consultation about the form that consultation should take, which should be published in the newspaper. The extra layers that are being added and the times and delays are excessive. I cannot support the amendment.

Baroness Cumberlege

In the debate on the Second Reading of the Bill in another place my honourable friend the Minister for Health made it clear that the NHS will carry out consultation on the boundaries of the new health authorities. We believe that the public must be kept informed and given the opportunity to comment on any major changes that will affect the delivery of health services. My honourable friend also gave an undertaking that there would be no change in the requirement for health authorities to consult community health councils. Regulations will continue to require authorities to consult CHCs on proposals which would involve substantial changes in the provision of health services.

We—and the NHS—recognise that key local bodies such as CHCs and local authorities may have practical and constructive comments to make which will affect decisions on boundaries. I do not consider that it is essential for the duty to consult to be enshrined in legislation. We have already demonstrated our commitment to consultation by consulting on every boundary change since 1990 even though the 1990 Act removed the statutory duty to consult. It is our intention to continue to consult on boundary changes in most circumstances. That is sensible management practice.

I refute the suggestion made by the noble Lord, Lord Carter, that consultation is an empty process—I believe he described it as a "farce". I do not believe it is. I can reassure my noble friend Lord Peyton that plans have been changed as a result of consultation. The noble Lord, Lord Tope, was absolutely right in bringing us back to the purpose of the amendment, which is not so much about health services, but that, The Secretary of State may, by order, vary a Health Authority's area, abolish a Health Authority or establish a new Health Authority". It is looking at health authorities as an administrative entity.

We have made changes; for example, the consultation that we carried out when we were reducing the number of regional health authorities from 14 to eight and when the boundaries were changed in Cumbria before the orders were laid before Parliament. It is not therefore the Government's intention to ignore consultation.

My main objection to the amendments is not that they oblige us to consult; it is that they make no distinction between large and small changes. I take the point made by my noble friend Lord Peyton that it is important for consultation to concern serious issues and changes that really matter to people. There must be a distinction between those and others that make no difference at all.

I am fearful that we will lose flexibility if health authorities have to waste time consulting on every little change. They should be spending their time on more important things, like consulting the public on their purchasing plans and on proposals for service development. There is a real danger of overburdening people with consultation documents instead of focusing on what matters most.

Parliament agreed in the 1990 Act to remove the requirement to consult on health authority boundary changes. It did that to streamline procedures and to give us flexibility if we needed it. To give one example, a health authority may want to make a small change to its boundary to keep in line with its local authority. That is a sensible thing to do which avoids confusion. Very few people will be interested in that though the health authority will want to make sure that the handful of people affected—the local authority, the community health council, perhaps a couple of local GPs —know what is happening. A public consultation on such a change would be completely over the top and it would probably put the health authority off proposing the change at all.

On that basis I am not able to accept these amendments which would remove necessary flexibility for no good purpose.

Baroness Gardner of Parkes

On a point of information, perhaps I can say to the Committee that I referred to the National Consumer Council. It may be that it was the Consumers' Association; I would not want to attribute the information to the wrong source.

Lord Carter

I am grateful to all those who have taken part in this short debate and particularly to the noble Lord, Lord Tope. As he emphasised, local authorities are now the only link with democratic election to show what people want to happen in the health service.

I was interested by the intervention of the noble Lord, Lord Peyton. He seemed to face both ways when he both accepted and rejected the amendment in the same sentence, which was very quaint.

Lord Peyton of Yeovil

I dislike the idea that I left the noble Lord in any doubt because that would be an extremely uncomfortable state for him to be in. In my most friendly desire to agree with him as far as I could, I said that I accepted what he said—that if we are to have consultation it must be meaningful. But I asked him to agree with me in certain other respects. In case the noble Lord is in any doubt, I reject totally his amendment and I hope that my noble friend will do the same.

Lord Carter

The support that the noble Lord gave me was similar to the support that he often gives to his own Front Bench. To be serious on this point for a moment, consultation goes badly wrong—I deliberately used the examples from my own locality—when people refuse to attend the consultation process because they feel that it is a waste of time. It was very badly handled in my area.

The amendment is worded in the way that it is because of the wording in the Bill, which says that, The Secretary of State may by order (a) vary a Health Authority's area; (b) abolish a Health Authority; or (c) establish a new Health Authority". That is a wide-ranging power and we felt that it was important that the organisations specified in the amendment should at least be given the chance to consult.

The Minister mentioned the undertaking in regard to boundaries, which is the least the Government can do, and also that it would be the Minister's intention to consult the community health councils where substantial changes are involved. But who decides what is substantial? Obviously it would be the Minister.

I did not say that consultation was a farce; I said that the people in my area now regarded it as a farce on account of what happened in the examples that I gave. The Minister made a fair point that the amendment makes no distinction between a small and a large change. But if she is prepared to accept the principle, we can easily come back with a reworded amendment. However, we have heard the words "streamlined" and "flexibility" before; they mean centralisation and quangos.

I do not think that I shall be able to change the Government's mind. I do not propose to divide the Committee on this amendment, but we shall return to the important point of consultation at a later stage of the Bill. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddingtonmoved Amendment No. 5:

Page 2, line 7, at end insert: ("() that no area for which a Health Authority acts extends into the area of two or more Regional Health Authorities in existence immediately before the passing of this Act").

The noble Baroness said: Amendment No. 5 stands in my name and that of the noble Lord, Lord Tope. The noble Lord, Lord Peyton, will be delighted to know that it does not involve consultation, whether of a quaint kind or any other.

The amendment is designed to elicit information on the types of area the Government intend to prescribe for the new health authorities. As when we debated Amendment No. 3, we are concerned to establish at an early stage, before this becomes something about which we may have to struggle to consult, that information is available about the size and nature of the new health authorities. It will clearly be of enormous importance to local communities, particularly in the areas of the divide between social and health care, to which I referred on an earlier amendment.

We should like to know precisely what will be the defining limits of the purchasing authorities which are to come into existence? How wide will their purchasing power be? The Secretary of State for Health said in an earlier debate on the Bill that we obviously want smaller and more effective decision-making working bodies. Yet there is a suggestion that some of the health authorities—the new purchasing organisations—will cover considerably larger areas than those of the present commissioning agencies.

How will they be able to combine? As the Minister suggested in her answer to the previous amendment, if they are not coterminous with local borough or district authorities, how broad will the combination be allowed to go? Could the possibility arise that it would not simply cross the boundaries of local authorities and those of previously existing commissioning agencies, but would also cover the area which embraces the boundary between the previously existing regional health authorities? That would obviously lead to an even greater dislocation of services than we have discussed before on earlier amendments.

One of the problems which the Government must acknowledge about the existence of these larger commissioning agencies is that in a sense they are looking for someone to fulfil the strategic function which, as we argued earlier on the first amendment, was most satisfactorily fulfilled by the old RHAs. If we are to have what are in a sense reorganised regional health authorities under another name—I realise that they will not have the same powers—and if they are to extend over large areas and to be able to commission services on a very wide basis for a very large number of people, are the Government in fact seeking to achieve some of that strategic overview, which we feel was more satisfactorily fulfilled by the old regional health authorities, in these new health authorities with their very unclearly defined boundaries? How will the existence of these much larger commissioning agencies sit with the Secretary of State's welcome assertion that she wants smaller, more effective decision-making working bodies?

Perhaps I may, without trespassing too far beyond the precise bounds of this amendment, also ask the Minister to comment about the precise area which the regional offices of the new bodies will include. As she will know, there is considerable concern in the Yorkshire and Northern region that this area will be as large as Scotland and also in the south and west that the merger of the South West and Wessex RHA will create for a regional office an area which will stretch from Portsmouth to Penzance.

The idea behind proposing the amendment is to invite the Government to explain slightly more clearly than they have done before how broad these areas for local health authorities will be, how wide their powers of commissioning will become and how they will be able to combine. As we say in the amendment, we hope to establish that they will not be so broad as to cover an area which extends beyond the bounds of an old regional health authority. I beg to move.

6 p.m.

Baroness Cumberlege

We do not intend to be prescriptive about the configuration, size or boundaries of the new health authorities in the Bill. As with the district health authorities, the size of the new authorities will be dictated by what is required for them to discharge their responsibilities effectively, and this may vary according to local circumstances. For instance, what suits a largely rural authority such as Norfolk may not suit inner city Newcastle. I do not consider it appropriate to include a comment on the size or shape of health authorities in the Bill. We must allow regional offices the flexibility to meet differing local circumstances.

As the Committee is aware, regional health authorities will be replaced by regional offices of the NHS Executive in April 1996. The regional offices will be responsible for the health authorities within their area and that area will be formed from the boundaries of the health authorities. We envisage that regional offices will be responsible for a similar area to RHAs. The actual area will, of course, be subject to consultation and the decision of my right honourable friend the Secretary of State for Health. We cannot bind that process by stipulating that boundaries must be within extant regional health authority boundaries.

Regions have been charged with developing a clear view about the desirable size and shape of the new health authorities to ensure effective collaboration with other agencies. They will be responsive to local people and their health needs. The views of the local population and interested organisations will be sought through public consultation on the boundaries of the new health authorities. My right honourable friend the Secretary of State for Health will then make a decision on the boundaries themselves.

I am unable to accept the amendment which we feel might jeopardise the ability of a health authority to carry out its functions effectively. I hope that the noble Baroness and the noble Lord will agree to withdraw the amendment.

Baroness Jay of Paddington

I thank the Minister for that reply. I am disappointed by the sense I am getting from her responses that she regards the word "prescription" as being something which is an anathema to her. What we are suggesting in several of these amendments is not some form of prescription in a totalitarian sense but simply a clarity of purpose on the face of the Bill rather than leaving so much in the hands of the Secretary of State or indeed in the regulations which, as we know, are couched in very general terms. We shall return to the subject of how those regulations are couched when we come to a later amendment.

It is obvious that one cannot prescribe the way in which the health authorities will be ordered in terms of their individual boundaries. That is not what we are asking for. We are asking for clarity about the size and the overall perspective for commissioning of each individual health authority. However, I understand that the Minister is reluctant to accept the amendment and so I shall not pursue it at this stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddingtonmoved Amendment No. 6:

Page 2, line 12, at end insert: ("() No order shall be made under subsection (1) above until the Secretary of State is satisfied that the establishment of Health Authorities proposed by that order is such as to ensure that the provision of long term health care will meet the needs of the population of each local area.").

The noble Baroness said: This amendment raises an important subject which we have debated in the House on several occasions. It is designed to make explicit the responsibility for purchasing long-term care from health authorities and not local authorities, where, as your Lordships will know, it would be means tested. We bring forward the amendment partly because of the considerable importance that attaches to the responsibility for health authorities in this area and also because we would like to debate with the Minister the new guidelines on this subject which have been published in the past few weeks and which, like so much of health service organisation and administration, have not been brought before Parliament.

The Committee will remember the interesting and important debate introduced by my noble friend Lord Ashley of Stoke on this subject before Christmas when we were looking at the draft guidelines on continuing care and where we identified —this was identified all round the House—considerable confusion about the nature of responsibility for this particularly important area. As I said at the beginning, what we are attempting to do by this amendment is to make that responsibility explicit.

The background to the subject is that as regards continuing care, health service beds for this important service have fallen in the past three years from 73,000 to 59,000. That is happening at a time when people are living longer and where there is even greater need for the proper kind of long-term care, particularly for the frail elderly but also for the young and disabled. The fall in the number of beds has been called by authoritative people a stealthy withdrawal of free healthcare. As noble Lords who have taken part in previous debates and Questions on this subject will know, it has led to very bitter controversy between many local authorities, which feel that they are inadequately funded to deal with the social aspects of what they would think of as being healthcare. It has led to what is called cost shunting and there have been particular concerns about early discharge from NHS acute care hospitals into the community and into primary care situations where there is little back-up and very little concern for the social care which would be offered, it is to be hoped, by a local authority.

The new regulations have now been published and they have been distributed widely in the NHS. I must say that they are a very great improvement on the previous draft document. I particularly welcome the words in the document that until explicit criteria are established between local health authorities and local authorities no health authority should reduce its services any further or alter its hospital discharge procedures. Noble Lords will remember that when we debated this subject there was considerable concern about the lack of clarity with regard to hospital discharge and particularly the criteria for qualifying under the regulations for free healthcare.

As I say, the new regulations are much clearer. The rule of thumb (if one can call it that) for qualifying for National Health Service care seems to be now that a patient who needs that kind of care must need consultant supervision from a doctor who is at senior level—in other words, once a week. At least that establishes a line of medical responsibility which is much more helpful than before.

However, there are still considerable queries about it. The considerable queries revolve particularly around nursing care and whether or not, for example, a 24-hour nursing care requirement for somebody who is in their home or somebody who might be regarded as in a convalescent home of any kind, is in or out of the qualifying criteria. That is of particular importance in areas like big cities, particularly in London, where it is very difficult to find placements for nursing in what one used to call convalescent care situations.

There is also the problem about the clear criteria which, according to the new document, must be agreed between local authorities and health authorities. But there is not the sense in which there is national guidance on this which many noble Lords who took part in the earlier debates were very concerned to achieve. What I fear that this will continue to lead to, unless we have the kind of explicit assurances which this amendment addresses, is that there will be grave inequities between different local authorities and local health authorities. Where one has a good working relationship between a local health authority and a local social services department and there is a certain amount of flexibility in the local budget, one will get one kind of service and in another area where there is no appropriate consultation or a good working relationship between the local health authority and the local social services department, the situation may break down in the way which has been highlighted rather dramatically and appallingly in many cases recently, and which have been shown by the media.

The other issue which is another improvement in the new regulations is the establishment of independent panels to decide the kind of disputes which may arise when there is not a good working relationship between social services and health authorities. Although the independent panel will exist, if there are no touchstones of national eligibility criteria which seem to be the necessary framework for making this kind of decision-making work in a National Health Service, it is very difficult to see what touchstone the independent panel will use to decide whether a case is legitimate or otherwise.

That is the basic point about the whole issue of continuing care; namely, that if we are to retain the necessary characteristics of a National Health Service with equity of medical care and social care across the wide variety of different populations and different kinds of communities which the National Health Service services, we must ask that there are national criteria to establish what a patient and his or her family can expect from the health services.

The Royal College of Nursing has reinforced that by saying that nationally determined criteria should be set down rather than local standards. It has also drawn attention to the problems where one gets one set of services in one authority which appear to be means-tested, and in another they appear to be legitimately free.

The amendment would clearly identify the new health authorities as having the responsibility for purchasing continuing care for their local population. It would clarify the current confusion faced by many patients and their carers, and potential patients, who still believe that the NHS is withdrawing from its responsibility to provide a free and comprehensive health service. The Government would do a great deal to advance the change that they have made in publishing these new guidelines which, as I say, are a considerable improvement—indeed, it is difficult to imagine they came from the same authors as the previous guidelines—if they accept this amendment and agree to establish a very clear responsibility on the new health authorities for this particularly difficult and yet very crucial part of the National Health Service. I beg to move.

6.15 p.m.

Baroness Cumberlege

It is our belief that this amendment is unnecessary as health authorities are already responsible for setting local priorities in response to local needs and circumstances, and there is a clear obligation on them to secure a full range of services to meet the needs of their population.

We are determined that all health authorities should properly discharge their responsibilities in this area. That is why we took extremely seriously the report which the Health Service Commissioner published last year which criticised the failure of one health authority in this respect. As a result we issued guidance to health authorities in February of this year making clear their responsibilities in this area. I am grateful to the noble Baroness for her gracious comments on their improvement over the draft guidance.

The key objectives of the present guidance are, first, it unambiguously reminds health authorities that it is a fundamental responsibility of the NHS to arrange and fund services to meet people's needs for continuing healthcare from the cradle to the grave. Secondly, it requires all health authorities to review their current arrangements. They should draw up policies and eligibility criteria for continuing healthcare and where significant gaps in provision exist they should take action to fill these. The guidance offers a further opportunity to strengthen collaboration between health and local authorities. Thirdly, it sets out a detailed national framework which all health authorities must reflect in their local arrangements. This should lead to much greater consistency across the country in how these issues are handled while preserving an appropriate level of local flexibility to respond to local needs. Fourthly, it reinforces the special care which is required in making decisions about hospital discharge for frail and vulnerable people who are likely to need continuing intensive support, whether on a long-term basis or on a short-term basis, to aid rehabilitation and recovery.

Finally, it encourages greater openness in how decisions about continuing healthcare are taken. Local policies and eligibility criteria will be subject to public consultation. They will be published with details included in community care charters. From April 1996 patients who consider eligibility criteria have not been correctly applied in their case will have the right to ask the health authority to review their case.

This guidance is a key priority for the NHS. The NHS executive will monitor implementation of the guidance to ensure that all health authorities do arrange and fund a full range of services to meet continuing healthcare needs for their local population although some of the public coverage of this issue has perhaps been clouded in that the NHS has never been responsible for meeting all needs for continuing care. Ever since the beginning of the welfare state in 1948, there has been a division of responsibility between the NHS and local authority social services.

Our concern, similar to that of other governments in the past, has been to ensure that health and local authorities work together across the boundary to provide an integrated and effective response to people's needs. That has been one of the driving forces of the new community care arrangements and in particular of the agreements which we have required local authorities and health authorities to reach on their respective responsibilities for continuing care and on hospital discharge. The guidance on continuing care builds on this further.

In conclusion, we believe that this amendment is unnecessary. Health authorities are already responsible for securing a range of services to meet the continuing healthcare needs of their local population. The Government are taking significant steps to ensure that health authorities do adequately discharge their responsibilities and that they work together effectively in meeting the needs of people who need continuing support. I urge the noble Baroness to withdraw the amendment.

Baroness Jay of Paddington

I thank the Minister for that reply. As I said in my opening remarks, I am encouraged by the new guidance which is going out to local health authorities and the new health authorities. I suspect that the basis of my concern is the one which I have raised quite often in discussion with the noble Baroness. It is the question of how one achieves the sort of equity and kind of standards which I am sure that she and her right honourable friend want to see achieved, without any kind of national standards or national criteria for local health authorities to work to.

It is difficult from a ministerial perspective to imagine the difficulties which may be faced by local people working in this very complicated field, and often dealing with very difficult and sometimes rather tragic cases, to be able to rationalise and perhaps even justify to themselves decisions which may seem rather harsh or difficult whether on a medical or a social care basis. It would be helpful if they could have some national criteria and national standards. They could then take comfort from the fact that decisions had been made on the basis of a national policy as a way of establishing continuing standards for the National Health Service.

As I said, I am encouraged by the fact that the Minister is relying on the new guidelines. We shall have to monitor them closely and hope that they work. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 7 not moved.]

Baroness Robson of Kiddingtonmoved Amendment No. 8:

Page 2, line 12, at end insert:

("Strategic Health Planning Authority for London

8A.—(1) It is the duty of the Secretary of State to establish a Strategic Health Planning Authority for the region of London.

(2) It shall be the duty of the Authority established under subsection (1) above to direct activities of the London regional offices of the National Health Service.

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

(4) In this section "the region of London" means the area of the London Boroughs.".").

The noble Baroness said: I have pleasure in moving Amendment No. 8, which stands in my name. When introducing the Bill on Second Reading, the Minister said that it put the finishing touches on the present reforms of the National Health Service. Therefore, this is probably our last opportunity to consider the problems facing London. I hope that we shall not have any more health service Bills, given that this is supposed to be applying the finishing touches to the present reforms.

I believe that we must look at the problems of London specifically. As Members of the Committee know, I was chairman of one of the metropolitan regions covering London in 1974 when the four metropolitan regions were established. Each region covered an enormous outlying area. Indeed, the whole of south-east England was divided between those four regions. We grew up in the period when the effects of the Resource Allocation Working Party (RAWP) began to be applied. That was when the metropolitan regions lost out in terms of resources to regions in other parts of the country which had been doing badly before. That happened because the metropolitan regions were considered to be rich—although they are not really. The outlying areas may be rich, but London is certainly not one of the well endowed regions when it comes to the provision of National Health Service services for its population.

I remember that only a year or two after the introduction of the regional health authorities many of us in those authorities discussed the problems of trying to make sense of health provision in London. We wondered why we could not have one regional health authority to cover greater London. Therefore, what I am proposing now is not a new idea. However, it seems a perfect opportunity to do something about the problem.

None of the various co-ordinating committees in which I participated managed to achieve complete co-ordination of health provision in London. There was always too much sectional interest for success to be achieved. Since then, there have been many reports about the problems of health provision in London, particularly the Tomlinson Report. It is true that London has enormously special problems. It has a great number of teaching hospitals, many postgraduate special health authorities and, along with that, probably some of the poorest and most neglected community services of any region.

If we are to have a coherent health plan for greater London, it is important that we establish an authority which will carry out the proper strategic health planning that is required. I do not believe that that can be done by different authorities. Although we have now abolished the four regions—there are now the two regions of North and South Thames—it is my contention that the only way in which we shall be able to make sense of the health services in London is to have a planning authority for the whole of London. I beg to move.

Lord Rea

I support the noble Baroness, Lady Robson, in her amendment. With her experience as chair of one of the regions which contained both deprived inner, and leafy outer, London boroughs, as well as the affluent communities of Surrey, the noble Baroness is well placed to draw attention to the difficulties of catering for the wide range of needs of such a population. The noble Baroness, Lady Cumberlege, who is to answer for the Government, has precisely the same experience of looking after that region.

If a map is made of the United Kingdom in which health authorities—or electoral districts—are shaded from light to dark according to their degree of relative deprivation or poverty, as we all know, the south, especially the south-east, appears white or a very pale shade of grey compared with the north or north-west. The exception however, is inner London. As the noble Baroness pointed out, it stands out as a sizeable dark blot on the map, a blot covering the inner core of the former four Thames regions, now reduced to two.

The concentration of teaching hospitals in inner London, and thus the allocation of National Health Service funds, has historically directed attention away from providing the community services which are needed for relatively deprived people while outer London's hospital services were being built up to decrease the dependence of outer London's population on the relatively expensive teaching hospitals. We know that the Government are now aware of the need to build up primary and community health care in inner London. The squeezing and merging of the teaching hospitals a la Tomlinson has revealed and accentuated the deficiencies, particularly for those with mental illness which is, of course, far more prevalent in deprived areas, and particularly in inner-city communities.

As the noble Baroness pointed out, how much better it would have been if historically the needs of the whole of inner London could have been considered as a unit. In the future, the skeleton of the regions which remain will function better under the overall aegis of the strategic health planning authority which is proposed by the noble Baroness. The London Implementation Zone (LIZ) and the London Implementation Group (LIG) are a precedent. They already straddle the two remaining regions. I suggest that there is need for a continuing, overall co-ordinating body, such as the noble Baroness suggested. I fully support the amendment.

Baroness Gardner of Parkes

I am interested that the noble Baroness, Lady Robson, referred to RAWP because that was when resources started to move out of London under a Labour government who said that London had too much. I do not know whether that was on a financial basis. It is not clear to me whether that was what the noble Baroness was saying. But as the noble Lord, Lord Rea, pointed out, historically there were too many teaching hospitals in the centre of London and, by comparison, other areas were deprived of services—

Baroness Robson of Kiddington

I referred to RAWP because under RAWP all the London metropolitan regions lost money to the regions further out in the north.

Baroness Gardner of Parkes

Exactly. The same has been happening under the London Implementation Group and as a result of the Tomlinson Report. They have continued what started under RAWP. RAWP was the beginning of the change to move funds out of London.

The noble Lord, Lord Rea, talked about inner London whereas, in her amendment, the noble Baroness refers to, the area of the London Boroughs", which means both inner and outer London. There is a marked difference between the old LCC inner London area and the GLC greater London area. To tie the authority to London would be complicated and not necessarily beneficial at this stage. The North Thames and South Thames regions, as the noble Baroness said, encompass much greater areas. To bring back an authority to cover just London—as I say we have discussed whether it would be inner or outer London—would not make it coterminous with anything.

We had a debate earlier about health authorities being coterminous. There is no greater London council, so there is no one authority with which the proposed authority could be coterminous. I do not see the case for allocating an authority just for London. The present mix of the areas outside London with London is right. When I was vice-chairman of my region I found it beneficial to contrast what was happening in the North East Thames Region (inner London) with what was happening in Essex. Of course North Thames now takes in the whole of Hertfordshire as well.

Patients do not recognise boundaries. London also attracts patients from outside London. I do not believe that this is a practical amendment and I oppose it.

6.30 p.m.

Baroness Miller of Hendon

The Government are committed to improving health care in London. That is why we set up the London Implementation Group which has provided the impetus for initiating long overdue changes.Making London Better, which was the Government's response to the Tomlinson Report, sets out clearly the framework for action. It has four main strands: first, to develop better, more accessible primary and community health care services through GPs and other professionals working in the community. I am sure that the noble Baroness, Lady Robson, and the noble Lord, Lord Rea, will be pleased about that because they commented upon primary health care.

The second strand is to provide a better balanced hospital service, meeting the needs of London's resident, working and visiting populations more appropriately; thirdly, to concentrate, develop and enhance specialist healthcare services; and, lastly, to take action for the benefit of teaching and research. But the work of the London Implementation Group is now complete. It was established to take on responsibility for the reorganisation of the city's primary and acute services and its medical education and research. It had a temporary role.

The King's Fund Commission produced an authoritative report on the issue of health care in London in 1992—before the publication of the Tomlinson recommendations. The King's Fund report—London Health Care 2010, changing the future of services in the capital—recommended that a task force like the London Implementation Group should be established. But, it did not recommend establishing a single health authority for London. That possibility was considered and rejected.

London is made up primarily of individual communities, often with a diverse cultural and social make-up. The needs of those communities also vary considerably within local areas. A single strategic health planning authority for the whole of London would not take account of that variation. The emphasis must continue to be on local health needs met by local health authorities. I agree with my noble friend Lady Gardner that it would not be helpful to confine "the region of London" to the "area of the London Boroughs". That does not take account of natural population flows, particularly on the margins of greater London. The Thames regions include Kent, Sussex, Essex and Surrey. Those areas need to be considered alongside London.

Individual health authorities will be the key strategic bodies in the new system, acting at local level in London as elsewhere. Where issues affect more than one HA, they will be expected to work together in consortia or by identifying a lead HA. In that way, we can ensure that the needs of local communities will be taken into account. Of course, some oversight at a wider level than that of HAs will be needed. The regional offices of the NHS Executive will oversee the work of the health authorities. They will make sure that HAs work together where appropriate. And there will be only two regional offices for London, replacing the four Thames RHAs which previously shared responsibility for London. The regional offices will be well placed to co-ordinate where necessary.

A strategic health planning authority would serve only to impose another administrative tier, It would mean more bureaucracy, administrators and managers. There would be a real risk of London dominating the rest of the country instead of having a proper balance between the regions. The Bill puts in place the necessary structures for NHS management. There is no reason to treat the capital in a totally different way from the rest of the country. I hope that the noble Baroness, Lady Robson, will withdraw the amendment.

Baroness Jay of Paddington

I am sorry to speak after the noble Baroness, Lady Miller. I am afraid that I was not quick enough to realise she was speaking on behalf of the Minister. With the permission of the Committee, I should like add a few points in support of the amendment. I was interested to hear the noble Baroness, Lady Miller, mention the King's Fund because, as I am sure she is aware, its latest contribution to the discussion about London advances the argument for the establishment of a strategic health authority rather than the reverse.

As the Committee will remember, in its original report the King's Fund gave one view of London's health services. From reading its more recent appraisal of the situation, as I understand it, much of that has been reversed. It claims that newly emerging evidence suggests that the capital's health care needs have been underestimated, and rather than call, as it did in its original document, for a reduction in funding, it now suggests that purchasing should be increased by £200 million.

I cite that finding because it suggests that there are strategic problems in London that need to be addressed, and probably need to be addressed in the long term in a rather more detailed and consistent way than was possible under LIG, which, as the noble Baroness, Lady Miller, said, was set up for a specific purpose and a specific time-limited project only.

I agree with the noble Baroness, Lady Robson, and, I am afraid, disagree with the noble Baroness, Lady Gardner. The London boroughs area has several specific problems which are worthy of the attention of a strategic policy body of the kind for which we have argued in general terms in relation to regional health authorities. Perhaps I may mention a couple of points which were not mentioned. There is considerable concern about the lack of take-up of GP services in London. There are a number of people among the floating population who are not registered with GPs and so are not available for the kind of primary care which, as we know, it is intended will become the more formal basis of the health service. The floating population ranges from the affluent young, who just happen to live in bed-sit accommodation and never register with GPs, to the huge numbers of homeless and rootless.

Perhaps I may illustrate again from my own local health authority. The number of people registered with GPs decreased between 1990 and 1993. Those who are not registered with GPs are still using the acute sector A&E departments and the minor injuries units for their primary care services. In the past, Ministers have referred to that use of the A&E departments for primary care services as inappropriate. Obviously, in an ideal world, that is the right word, but the fact remains that we have not yet sorted out London to make it possible to establish primary care services which are acceptable to that peculiar population of floating people who are not registered with GPs and in a way which enables one to be confident about the reduction in acute sector beds.

That leads me to the 64,000 dollar question about London: is it under-bedded or over-bedded? That is what I might refer to in shorthand as the "Professor Jarman" debate. That is another issue which is best addressed on a strategic level by a broad approach which cannot be dealt with usefully at the local health authority level. It is something which must be agreed upon, considered and referred to in a way which takes account of the broader areas both in inner and outer London, and it must achieve the right balance.

The other areas of concern to local health authorities in London relate to such issues as the discussion on whether a hub and spoke approach is taken to the arrangement of services. Again, that should be decided strategically by taking an overview. It cannot be achieved by looking only at local health authority needs and resources.

In its latest document to which I referred at the beginning of my remarks, the King's Fund said that there are three issues which need to be addressed: first, what is the capital's fair share of national resources; secondly, what is the appropriate way to respond to the healthcare needs of Londoners—that is, how to achieve a balance between primary and acute care in a rather peculiar population; and thirdly, how any necessary changes in the balance between health and social care can best be implemented. Those seem to be strategic questions which can be best addressed by a strategic body. Those issues cannot be covered by the regional outposts which, as the noble Baroness, Lady Miller, said, will be overseeing the work of the local authorities. Positive, directed and advocate-based arguments are required in order to carry out an analysis of those very difficult issues relating to the particularly difficult situation of the population in inner London. I support the amendment.

Baroness Robson of Kiddington

I thank the noble Baroness, Lady Jay, for her strong support of my amendment. In answering for the Government and in refusing to accept the amendment, the noble Baroness, Lady Miller, went into some detail describing what was happening in London and how the London Implementation Group had finished its work and that it had worked for some time. Without mentioning their names, she referred to task forces which have been set up to cover various aspects of the London health and social services problem. Is not the fact that those bodies have been set up an admission that London needs an overall strategic planning authority?

The membership of that authority needs to be established in accordance with Part I of Schedule 5 of the 1977 Act and not on the basis ofad hoccommittees which look piecemeal at the various problems.

I am desperately sad that the noble Baroness cannot see her way to accept my amendment. I shall not press it now; but I shall certainly return to the matter at a later stage.

Amendment, by leave, withdrawn.

Clause 1 agreed to.

6.45 p.m.

Lord Reamoved Amendment No. 9:

Insert the following new clause:

("Independent health complaints authority

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

"Independent Health Complaints Authority.

10.—(l) It shall be the duty of the Secretary of State to establish a Health Authority to be known as the NHS Complaints Authority.

(2) The Secretary of State shall, before 1st April 1997, by regulations made under any of sections 13 to 17 (as appropriate) of this Act, provide for the Authority established under subsection (1) above to exercise all the duties and responsibilities of Health Authorities under the Hospitals Complaints Procedure Act 1985 ("the 1985 Act").

(3) It shall also be the duty of the Secretary of State to require, by directions made under section 1(1A) of the 1985 Act, each NHS trust to make provision for its complaints system to be supervised by the Authority established under subsection (1) of this section.

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

The noble Lord said: In moving this amendment, I shall speak also to Amendment No. 31 which refers to Schedule 1 of the 1977 Act.

I should say at the outset that the creation of an independent complaints authority as suggested by the amendment is not the only way in which to achieve a uniform, National Health Service-wide fair and independent complaints procedure. But in the context of the Bill, it seems the most suitable way to respond to the need for overdue improvements in the present inadequate systems for processing complaints.

Complaints need to be dealt with as speedily, fairly and independently as possible in order to give as much satisfaction as is reasonable to the complainant. But it should also lead to changes in the National Health Service which minimise the chances of the problem recurring.

I am well aware that the Government have published recently the documentActing on Complaints, which is their reply to Professor Alan Wilson's report dated May 1994,Being heard. That response is to be welcomed; but we should like the Government to go further.

ThePatient's Charterhas very laudable objectives, but it needs teeth to be effective. There must be a good mechanism enabling patients to point out where they feel that the National Health Service has failed to live up to those high standards or has been responsible for unnecessary suffering or expense for them or their relatives.

At this stage I do not intend to make any political points about the reasons why there has been such a recent increase in complaints. There will always be complaints against the National Health Service where sick people are undergoing operations involving questions of life or death.

In its critique ofActing on Complaints, the National Consumer Council states: We urge the Government to keep up the momentum towards a common complaints system".

This amendment is offered in that spirit. Paragraph 176 of Professor Wilson's report,Being heard, states: All unnecessary differences between NHS complaints procedures should be avoided to establish maximum commonality between them",

not coterminousity. He refers to 29 other paragraphs in the report to back up that central recommendation.

In particular, the report draws attention to the difference in procedures between complaints against family health service practitioners and those against hospital staff. InActing on Complaints, it is suggested that there should be three separate groups of panels to hear complaints: first, non-clinical hospital complaints; secondly, primary healthcare complaints; and thirdly, clinical complaints. That is completely against the recommendations at paragraphs 177 and 178 of the Wilson report, which states that the division between hospital and FHSA complaints procedures, is confusing to the public…and wrong in principle".

Again, there is no need for a separate system for complaints about clinical judgments. Common principles and features must apply to the handling of all complaints. That is the principle underlying the amendment.

There is also an uneasy feeling that complaints procedures are administered by people who are too close to the providers. That has increased since almost all provider units are run by trusts which also have to provide the structure for dealing with complaints against themselves.Acting on Complaintsprovides that a convener, who is a non-executive director of a trust or a member of the health authority in the case of primary care complaints, will decide, with an independent chairman, whether to convene a panel on any complaint. The independent chairman of the panel will be chosen from a list held by the regional office of the National Health Service Executive. I accept that in most cases, such a chairman will be of high integrity and wisdom.

However, the fact that the list is held by the National Health Service Executive may itself raise a few eyebrows. We believe that by putting the complaints procedure outside the trust or health authority concerned, there will be a greater feeling that justice will be seen to he done.

The role of the health commissioner—that is, the ombudsman—will remain important and should remain outside whatever complaints procedures are in place. It may be tempting to place the whole complaints mechanism under the ombudsman, thus increasing the role of his department, but that would be wrong as it is very important to maintain an appeal mechanism which is clearly separate from the National Health Service. Moreover, there are complaints about complaints, and how the latter are handled, which have recently increased. In the report of the Select Committee on the health ombudsman for last year, which has just been published, the ombudsman, Mr. William Reid, is quoted as saying: I was getting rather fed up of seeing the same mistakes made again and again and the trend of handling local complaints getting worse".

Mr. Reid is also quoted in the same report as saying: When people find they are treated discourteously … that one question is answered but four are not … that it takes a very long time to get a reply [which is] couched in terms [that] a lay person would not [understand], it is hardly surprising that they want to complain to someone independent".

But the wait of 45 weeks before a complaint is heard by the ombudsman suggests that his office and staff need to be expanded.

However, if complaints were handled better locally, such an expansion of the ombudsman's office would become unnecessary. If properly implemented, a complaints authority with local supervision in all health authorities should improve procedures and reduce the number of appeals to the health ombudsman which are now at a record level. Although it is not on the face of the amendment, the new complaints authority should recognise the role of community health councils in supporting complainants. But I would hope that the authority would take a conciliatory rather than an adversarial position in the majority of cases.

I have spoken now for eight minutes and I believe that I have said enough. Nevertheless, I shall be most interested to hear the Minister's opinion and that of other Members of the Committee. I beg to move.

Baroness Gardner of Parkes

I believe that the complaints procedure in the health service is now working very well. I further believe that it is no longer carried out on a confrontational basis. When I was in general practice as a dentist, we were asked to put leaflets in our waiting rooms advising patients on how to complain. However, every dentist threw them into the rubbish bin because they did not want patients to do so. However, since that time, there has been more of a consultation between patients and dentists; indeed, there is an encouragement to say the good things and to make suggestions as well as making complaints. I believe that that has been very effective in general practice.

So far as concerns hospitals, I believe that every complaint is taken seriously and that also applies to health authorities. Indeed, I know of no complaints that fail to receive an answer. Of course, it sometimes takes quite a long time to investigate a matter and, therefore, a temporary answer has to be sent. Moreover, on occasions, full inquiries into matters have to take place which can involve a considerable amount of time and effort on behalf of the staff. I do not believe that adding the proposed extra layer of authority just to deal with complaints would bring any improvement to a system which I believe is working very well at present.

Lord Stoddart of Swindon

I shall not take very long over what I have to say. First, I do not know whether or not to support the amendment. I, too, do not want another layer of authority to be added. But, nevertheless, I understand why the suggestion has been made. Further, having heard my noble friend's opening remarks, I must say that I would now be inclined to support the amendment despite the fact that, when I first saw it, I had doubts about it.

My concern as regards complaints within the health service is that too little account is taken of the vulnerability of patients and their ability and wish to complain. I see that the noble Baroness, Lady Gardner, shakes her head. However, I have received a good deal of correspondence recently about the National Health Service. It is quite clear to me that patients do feel vulnerable, but that they are loath to complain in case their complaints are seen as being a criticism against operatives in the NHS. There are things about which patients want to complain, but they feel that if they make a complaint about, for example, the facilities, it would be taken as a complaint against their nurse, their doctor, their nursing assistant or some ancillary worker. That problem must be solved. I simply do not know whether the existing health service or the proposed arrangements will be able to do so.

Members of the Committee will know that I successfully moved the National Health Patient Accommodation Bill through this Chamber. The aim of the Bill was to provide patients with the right to be treated in single-sex wards. No doubt the noble Baroness will remember it. I have been amazed at the public reaction. It is quite clear that it was not realised within the health service that that was a problem. However, my postbag indicates that it is an enormous problem and that people, especially women, feel extremely bad because they will be treated in mixed-sex wards. It frightens and worries them; and, indeed, retards their progress. Yet, until quite recently, we had not really known about the problem because the complaints procedure was not available to reveal it.

I must tell the Minister that I am extremely sorry to say—indeed, I regret it very much—that my Bill was blocked in another place a week ago last Friday. After the noble Baroness has had sight of the 1,000 letters that I have received and which I intend to send to her, I hope that she will persuade her colleagues in government to change their minds. Even if they want to amend the Bill slightly, I hope that they will allow it to progress through the other place and that they will give it time.

We are discussing a serious problem. I believe that the amendment which has been moved is a real attempt to address a great problem within the health service and one which needs to be treated with great seriousness because those involved are, as I said, at their most vulnerable stage.

Baroness Jay of Paddington

As my noble friend Lord Stoddart of Swindon has mentioned the fact that he is unsure whether or not to support the amendment—although, in his concluding remarks, I believe he indicated that he would—perhaps I may just add two points that I hope the Minister will address which emerged from my noble friend's contribution. The first is the sense that patients have of the independence of the body to which they complain within the health service. My noble friend made a most important point about the degree of sensitivity which people feel when they are making complaints, especially as regards some of the subjects that he mentioned; for example, single-sex wards.

Patients feel that their complaints—about something which they regard as being a question of comfort, human rights or however they may wish to express it—will be seen as criticism of members of the medical profession. They are especially sensitive about any complaints which may be seen as criticism of the nursing profession.

We must be absolutely sure—and this is very much the thinking behind the amendment—that any complaints procedure which is acceptable and successful within the NHS is understood to be completely independent and neutral and not involved with the management of the NHS or, more importantly, seen in any way as a means of channelling criticism of the professions which most patients would not wish to do.

Secondly, can the Minister say how quickly she believes the new system will be able to work and what speed is intended to be asked of the new mechanisms in response? Again, following my noble friends Lord Rea and Lord Stoddart of Swindon, I believe that there is some concern in that there is no mention in the new proposals about how quickly a patient may expect to receive a response to any complaint. This, of course, would indeed apply to the kind of situation which my noble friend has described when someone might find himself or herself confronted with the possibility of either going into a mixed-sex ward or having an important operation delayed, or whatever it might be. I hope that the Minister will address those points, and I hope that my noble friend Lord Stoddart will support the amendment.

Baroness Gardner of Parkes

I hope that my noble friend will cover the role of the health ombudsman when replying to this amendment.

7 p.m.

Baroness Cumberlege

I shall do my very best also to win over the support of the noble Lord, Lord Stoddart. I think that would be a victory indeed. I have to say I admire his ingenuity in making yet another passionate plea on the issue of mixed sex wards. Although that is not part of this amendment, it is an issue that we take seriously, albeit that his Bill was not successful.

As I understand the noble Lord, Lord Rea, these amendments were tabled in the light of the recommendations of the Wilson Committee's Report on NHS complaints procedures. That committee was set up by my right honourable friend the Secretary of State in June 1993, following increasing concern within the NHS, the professions and patient representatives about the shortcomings of the existing complaints procedures. As the noble Lord said, the Government's response to Professor Wilson's report was published last week in a document entitledActing on Complaints. This sets out detailed plans for a new NHS complaints system for England. Similar systems will operate in Scotland, Wales and Northern Ireland.

I am sure the noble Lord, Lord Carter, will be pleased to hear that before we publishedActing on Complaintswe consulted widely and had a very impressive response—over 620 responses were received. We are most grateful to all the individuals and organisations who gave us their views. The Wilson Committee recommended that the current confusing array of different complaints procedures should be replaced. Instead, there should be a simpler system which would put matters right more quickly for patients and use their experience to improve the quality of service for everyone. The Government have accepted this recommendation and the NHS will, from April 1996, have a simpler, speedier and more effective complaints system. I think that responds to the request, of the noble Baroness about when things were going to happen., The emphasis in the new system is on quick responses to complaints at local level with an investigation or conciliation where necessary.

I wish to add a personal note. When I was a health authority chairman we used to say that a bunch of flowers was worth £40,000. As the noble Lord said, the independent panels will be set up to consider complaints which cannot be resolved using the local procedures. Finally, if a patient remains dissatisfied, the complaint can be referred to the Health Service Commissioner. I am sure the noble Lord and also the noble Baroness, Lady Gardner, will welcome the Government's intention that as soon as parliamentary time allows we will bring forward legislation to extend the commissioner's remit so that he can investigate all complaints by NHS patients.

We agree with my noble friend Lady Gardner that an effective new complaints system can be achieved without the need for a centralised complaints authority such as this amendment proposes. The Wilson Report did look at the possibility of a complaints commission, not unlike the authority proposed in this amendment. However, it was offered as only one of four possible homes for the organisation of the second stage, the independent panels. The other three options were: chief executives of the trust or family health services authority dealing with the complaint; purchasers; and regional offices of the NHS Executive. The emphasis of the recommendations was on a rapid and effective response from front line staff and a speedy method of resolving more difficult complaints by a designated complaints officer or the chief executive. If all complaints handling in the NHS was administered by a central bureaucracy, we believe we would not achieve the required responsiveness, speed and simplicity.

I can assure the noble Baroness, Lady Jay, that we have considered all the options in this report. Our proposal for stage two is that the review panels will have a majority of lay members, completely independent of the service provider. The panels, therefore, will have access to independent professional advice on issues of clinical judgment. The decision as to whether a panel will be set up will be taken by a convener. For complaints about hospital services the convener will be a non-executive member of the trust concerned; for family health services, a non-executive of the relevant health authority. Before deciding whether or not a panel is needed, the convener will always consult the independent chairman who would chair the panel if one were to be set up. The panels themselves will consist of an independent lay chair and the panel convener. For complaints against trusts, the third member will be a purchaser representative—in most cases a health authority non-executive, or, if appropriate, a GP fundholder. In the case of family health services, the third member would be another independent member.

I am very glad to have had the opportunity to outline the Government's plans for a simpler, speedier NHS complaints procedure. I hope I have made clear that there is no need for these amendments which would simply set up a whole new complaints bureaucracy. I hope the noble Lord will withdraw the amendment.

Lord Rea

I wish to thank the noble Baroness for her remarks. In fact, these amendments, as she realises, were 'exploratory in intent and followed the suggestions that were in the Wilson Report and also the suggestions by the National Consumer Council that perhaps there should be a national complaints commission. Of course, the noble Baroness is right. For that commission to administer all the complaints procedures throughout the country would be a bureaucratic and an impossible task. We were suggesting that there should be an independent authority—possibly a commission, to use another term—to oversee the complaints panels of the different health authorities and trusts throughout the country in order to keep standards up.

As the noble Baroness intimated, complaints need not necessarily be bad, although if more bunches of flowers were offered quickly enough perhaps there would be fewer complaints. However, a well handled complaint can be beneficial in that it can lead to adjustments of local practices and to improvements in the future. However, that is not to say that I do not think that many of the complaints now coming before panels are due to the delays and frustrations that people are experiencing directly as a result of the fact that the money does not follow the patient. There is not so much patient choice as there used to be and, inevitably, disappointments and inconveniences occur.

However, it is not my intention to press this amendment. I wish to thank all Members of the Committee who have spoken. We will read what the Minister said because I believe it is the first time that the Government's intentions, outlined inActing on Complaints, have been announced on the Floor of the Chamber. While thanking everyone for their contributions I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddingtonmoved Amendment No. 10:

Insert the following new clause:

("Health Authorities: public meetings

A Health Authority established in accordance with the provisions of this Act shall each year hold at least the same number of public meetings as was held by an authority which it replaces.").

The noble Baroness said: In moving this amendment I wish to speak also to Amendment No. 26. The purpose of these amendments is to ensure that the new health authorities hold open public meetings at least as frequently as do the existing district health authorities and family health services authorities. It seems to us that this Bill provides an ideal opportunity to ensure that the new purchasing bodies are at least as open and accountable as their predecessors, if indeed not more so.

Throughout debates on this Bill, both here and in another place, Ministers and others who have spoken on all sides of the Chamber have emphasised the need for openness in the health service. Again, that was referred to in the previous amendment. People believe that an independent and open organisation is very important in establishing public confidence.

I understand that the National Health Service Executive code of practice consultation—that word again—on the holding of meetings has been concluded but not yet released. Therefore, this is a good opportunity to explore the necessity for putting this minimal amendment on the face of the Bill to guarantee in practice that matters will not get worse under the new arrangements for health authorities.

There is considerable evidence, much of it anecdotal but also some that is authoritative from community health councils and organisations such as the research body Community Rights, that health authorities are not as open and public in their meetings as they were previously and that this has become a closed area of government. I know from my own experience of matters which could well be discussed in open session being discussed in closed session, often for no better reason than that there might be embarrassment to executive directors required to answer rather tricky questions.

There is also a tendency among health authorities to use the so-called seminar procedure to debate many important policy issues which can then be brought to the public meeting almost for rubber stamping. The real discussion and exchange of opinion goes on behind closed doors at the seminar and the debate on the subject matter in the open meeting is almost rehearsed. That is partly due to the fact that health authorities operate under the Public Bodies (Admission to Meetings) Act which, I was fascinated to discover, had been a Private Member's Bill introduced by the noble Baroness, Lady Thatcher, in 1960. In it there is a catch-all phrase which allows for the health authority to go into private session on any pretext which it determines.

One hopes therefore that the Government will accept the provisions of the amendment. Dare one hope that they will go even further and, if they are to issue new guidance and codes of practice, incorporate some of the provisions of the local government access to information legislation, under which local authorities act, to give the new health authorities the responsibility to publish reports, produced for the consumption of their members, more widely and allow the background papers to be seen?

As I said, this is an exploratory amendment designed to establish the Government's intentions in terms of their guidance to health authorities under the new regulations. However, I hope that they will at least accept this very minimal amendment, which does no more than ensure that in future matters will not get any worse than they are now. I beg to move.

Baroness Robson of Kiddington

I wish to speak to Amendment No. 26 which is linked to the amendment moved by the noble Baroness, Lady Jay. It is essential that meetings of health authorities should be held in public. That does not apply only to one annual meeting. All meetings of health authorities should be held in public so far as possible. There will be times when that is not appropriate. I remember from my own experience that delicate subjects arise which involve personalities. In such cases meetings would have to be held in private session. However, those should be kept to a minimum.

It is desperately important that members of the community health council should have the right to attend and take part in such meetings. They provide the best communication between health authorities and the general public. They have served us very well over the years. They have progressively been deprived of their rights under the health reforms. I should like those rights to be reinstated so that the voice of the community health councils can again be heard.

7.15 p.m.

Baroness Miller of Hendon

Amendment No. 10 is not necessary. Existing health authorities are covered by the Public Bodies (Admission to Meetings) Act 1960, to which the noble Baroness, Lady Jay, referred, under which, subject to certain conditions, any meeting of an authority must be open to the public. The necessary amendment to that legislation to cover the new health authorities is included at paragraph 91 of Part III of Schedule 1 to the Bill.

Having established in general terms that all meetings of a health authority will be open to the public, what is not addressed in the Bill is how many such meetings should be held. However, there has never been any provision in legislation to dictate to a health authority how many meetings it must hold. The Committee will know that it is not the policy of this Government to interfere unnecessarily in the administrative arrangements of National Health Service boards. Health authorities hold as many meetings as are needed to transact their business. That arrangement will continue under the new system. It is for the chairman and members of such boards to make the arrangements that meet the needs of that body.

Those Members of the Committee who hold or have held positions on management boards will particularly appreciate the need for flexibility in these matters. There will be times when a board, having a great deal of business to conduct, needs to meet frequently. There will be other times when board meetings can be kept to a minimum. It would be inappropriate to interfere in such a local management matter in the way suggested by the amendment. Health authorities must be free to conduct business in the way that best fits their needs rather than having unnecessary restrictions placed upon them.

On a more general point, the Committee will be aware that we are committed to ensuring that the public have access to as much information as possible, not only through access to meetings of health authorities. Consultation on a draft code of openness for the National Health Service has now been completed. The code will set out the public's right to information, except in clearly defined circumstances, and it will be published soon.

Also, under the codes of conduct and accountability introduced in April 1994, health authorities are for the first time expected to publish an annual report. The steps we have taken and the plans we have for future improvements demonstrate our commitment to openness in the National Health Service. Amendment No. 10 at best achieves nothing and at worst interferes with the smooth management of the National Health Service.

As regards Amendment No. 26, all health authority meetings will be open to the public because the Public Bodies (Admission to Meetings) Act will apply to health authorities, as I stated earlier.

The amendment also raises the issue of the role of community health councils. The councils perform a very important function in representing the interests of the community in the National Health Service. On a personal level, when I was chairman of the Barnet Family Health Services Authority, we regarded highly the way in which the community health council performed its function on behalf of the local community.

Community health councils already have observer status on health authorities and the right to meet them annually. As my honourable friend the Minister for Health made clear in another place, there will be no change in the requirement on health authorities to consult community health councils as a result of the Bill. We do not wish to do anything which undermines effective working relationships between community health councils and their local health authorities. However, it would not be right for them to take an active part in health authority meetings.

It is important that CHCs retain their independence. Their members act wholly on behalf of local patients. There must be no risk of a conflict of interest that might cause them to take other obligations into consideration when dealing with local health authorities or trusts on behalf of patients.

Health authorities and community health councils perform two completely different functions. The health authority is responsible for ensuring that the health needs of the local communities are met. The community health council is there to provide a voice for the local community. It is important that those two functions remain distinct if they are to be performed effectively.

Health authority meetings will be open to the public. The right of CHCs to observe at health authority meetings and to meet health authorities annually will be retained. Their role as an independent voice in the National Health Service will not be changed by the Bill. I very much hope that the noble Baroness, Lady Jay, and the noble Baroness, Lady Robson, will not feel it necessary to press their amendments.

Baroness Jay of Paddington

I am grateful to the noble Baroness for her reply. She has not addressed one of the points with which I am concerned. I refer to the difference between the technical ability of health authorities to hold all their meetings in public and the reality. In reality, progressively much business is discussed in seminar form (or whatever it may be called). There is discussion between members with the matter brought to the public view only at a time when decisions have been taken.

I understand the noble Baroness's almost ideological (if I may use that word) dislike of interfering in the local management of health authorities. However, there is the question of a slippage of public awareness. As I said in my opening remarks, there is the sense that sometimes public meetings are almost rehearsed because so many decisions have been taken earlier. One cannot be reassured unless there is a firmer understanding about how many of the authorities' meetings are to be held in public.

I understand the noble Baroness's points about flexibility as regards local business, and so on. But I am anxious about the way in which so many local authorities now use the opportunities afforded under the catch-all phrase to which I referred in the 1960 legislation to move into closed session in seminar format.

Therefore, although I shall not press the amendment at this stage, I hope that the Government will take the matter seriously. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Cartermoved Amendment No. 11:

Insert the following new clause:

("Nurse Education Authority

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

"Nurse Education Authority.

.—(1) It shall be the duty of the Secretary of State to establish a Health Authority to be known as the Nurse Education Authority.

(2) The Secretary of State shall, by regulations made under any of sections 13 to 17 as appropriate, provide for the Authority established under subsection (1) above to have the duty of commissioning nurse education in England.

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

The noble Lord said: The purpose of the amendment is clear from the wording. It deals with a problem which may arise: the important question of nurse education after reorganisation. As is clear, the amendment establishes a new authority responsible for the commissioning of nurse education at a national level. It is based on the argument that a national overview is needed to prevent nurse shortages which would be to the detriment of patients. It is clear that the abolition of the RHAs will have profound implications for the of nurse education. In the past the RHAs were responsible for determining the demands of employers for nurses and for purchasing education and training places to meet that demand. Indeed, the national balance sheet exercise was set up in 1991 to determine the future supply and demand within regions, and in England as a whole.

It would be helpful if the Minister would confirm that that will be the case. We understand that with the abolition of RHAs, the strategic overview or planning function will be devolved. It seems that the Government have devised a fairly complicated way of doing that. Initially, the regional offices of the NHS Executive will commission education programmes on the basis of proposals by healthcare purchasers and employers.

In the longer term—it has not been defined; it would be helpful if the Minister could do so—local consortia of health authorities and trusts will take on that role. Their plans should be overseen by a regional education development group in the new regional offices. That seems to us to be a recipe for muddle, confusion and overlap in particular as it appears—again I ask the Minister to confirm this—that there is no intention to continue with the national overview for nursing in England. Unless the business is carefully planned in the way in which I have described, it could end up in a fearsome muddle.

We are all aware of the implications for patient care if there is a shortage of qualified nurses. There has been a 33 per cent. reduction in training places for nurses between 1987 and 1994. The wastage rates have ceased to fall, and the turnover rates have risen. That indicates the greater mobility of the current nursing workforce. However, casualisation—the increasing use of short-term contracts, agencies, bank nurses and the like—is an increasing feature of the system. It is certainly very different from the nursing profession which we have all been used to and the way in which nurses were employed.

There is also concern that the need for nurses beyond the health service should be planned for and recognised. There is concern that when deciding on the future need for nursing, the local consortia of authorities and trusts, overseen by the regional educational development, the groups of the NHS Executive and the civil servants, will focus solely on the needs of the health service, and, in the health service, perhaps on the needs of the hospital service. The need for nurses in local authorities, prisons, the growing nursing home sector, and in the workplace—the industrial nurses—may not have sufficient attention paid to it.

What will happen to colleges of nursing and to nurse teachers? If predictions underestimate future demand for nurses, that will have an impact on education establishments which provide nurse training. It is clear that if health authorities in their new role fail to place a contract with an education establishment for a specific branch of nursing —the RCN gives an example of learning disability nursing —then the nurse tutors at the establishment are likely to be made redundant. If at a future date the demand prediction changes, then the infrastructure for education in the specialist sector has been lost.

We can all agree that planning the future of the nursing workforce is a highly complex exercise. It needs to be based on figures which have been closely researched and which include the analysis of the need for nursing outside the NHS, but, above all, which give a national overview of the demand for nurse education to ensure that the correct number of nurses with the necessary mix of skills are available to meet the future needs of patients. I beg to move.

Baroness McFarlane of Llandaff

The noble Lord has spoken comprehensively about the fears for nursing education in the future. Indeed, we are in the midst of some of those fears now. I was apprehensive to hear, for instance, that a region had budgeted for 10 training places for community nurses for the coming year. With all the developments in primary healthcare and community nursing that figure seemed to me to be completely inadequate.

While I am fully convinced that there needs to be a national overview of the commissioning for nursing education, I remain to be convinced that the creation of a special health authority for that purpose is the answer to those problems.

However, I am sure that we must not trespass on the statutory duties of the UKCC and the associated boards.

Baroness Cumberlege

I am sure that the Committee will agree that patients should have the highest quality care from nurses. That is why those closest to the delivery of that care should have a major influence on the volume and type of education commissioned. Our policy is to place patients' needs firmly at the centre of education and training.

We believe that the amendment would diminish this crucial influence and do so to the detriment of patient care. It would unnecessarily create a costly central bureaucracy, diverting funds from patient care.

We recognise the need to ensure an adequate national supply of appropriately trained nurses. I take the points made by the noble Baroness, Lady McFarlane: we need to keep the issue under close scrutiny. However, that is why we are putting in place arrangements to commission education and training which will take place within a policy framework and guidelines set by the NHS Executive Headquarters.

I hope that the noble Lord, Lord Carter, will be reassured that we have recently published guidance setting out the criteria for devolving purchasing to consortia. Local purchasing will begin when health authorities meet those criteria. That is why we said that it will happen in the longer term rather than immediately on 1st April 1996.

The NHS Executive will maintain a national overview of demand and supply, taking account of the needs of the NHS and other providers of healthcare. Most importantly, we are ensuring professional input at every level of the new arrangements. We will be supporting the development of workforce planning and education commissioning skills at local level.

As the noble Baroness said, Parliament has already established, the statutory bodies to set and maintain standards of education in nursing—the United Kingdom Central Council and the English National Board—with which we work closely. A nurse education authority would undermine the responsibility that Parliament has vested in those bodies.

More flexible working arrangements and better use of professional skills means that nurses and midwives are remaining in their posts longer and more people are returning to the profession after career breaks. Those factors are reflected in the reduced number of students. But, of course, the longer-term supply of nurses has to be kept constantly under review, which is what the policy framework and guidelines set by the NHS executive will do.

The noble Lord, Lord Carter, raised the issue of supply. I can reassure him that recruitment to nurse education is healthy. The number of qualified nursing and midwifery staff employed by the NHS has increased by 14 per cent.; that is 30,000 more nurses since 1981. There are more qualified nurses for every unqualified nurse now than there were in 1981. Practice nurse numbers in the family health service have grown by 674 per cent. over the past 12 years. I believe that this nation's nurses are educated and trained to the highest standards and that they are the best in the world. Thus, we believe that a nurse education authority will add nothing to what we are already doing. Therefore, I urge that the amendment be withdrawn.

Lord Carter

I am grateful to the Minister. She said that what was proposed in the amendment would be a costly exercise in bureaucracy. However, one may compare it with what the Government intend to do. That is, first, regional offices of the NHS executive, then the local consortia, the regional education development group and all the rest of it, without the national overview for nursing.

I think that the Government are being extremely optimistic if they believe that they will reduce bureaucracy. Obviously, the information which the Minister gave about the policy guidelines and the criteria is welcome. She has not said how long is the longer term about which I asked. I understand that the Government wish to see how matters turn out before they can reach a decision on when the switch to the local consortia takes place.

There is some reassurance in what the Minister said, but I am not sure that we will not have to return to the problem. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Miller of Hendon

I beg to move that the House be now resumed. In moving the Motion, may I suggest that the Committee stage begin again not before 8.30 p.m.

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

House resumed.