§ House again in Committee.
§ Clause 2 [Related amendments]:
§ Lord Prys-Daviesmoved Amendment No. 12:
§ Page 2, line 19, at end insert ("; and—
§ (c) the Special Health Authority for Wales.").
§ The noble Lord said: In moving Amendment No. 12, I should like to speak also to Amendment No. 32. Both amendments stand in my name and in those of my noble friends Lady Jay and Lord Carter. The aim of the two amendments is to guarantee the continued existence of the Welsh Health Common Services Authority, as we know it. That is the authority which provides specialist services, often of considerable complexity, and requiring specialised equipment, highly qualified staff and economic operation throughout Wales.
§ The authority currently employs about 1,750 people. It has been tested in the hot fires of experience and it has passed the test with flying colours. Perhaps I may mention some of its successes. In 1992–93, 93 per cent. of artificial limbs were delivered early or on time. Indeed, the Artificial Limbs and Appliances Service was recently awarded a Chartermark by John Major. The authority checks about 33.7 million prescriptions per annum, with a value of £244 million per annum, and has achieved a high level of accuracy. Then there is Breast Test Screening, a service nearly of life and death significance. That is on course to achieve a 25 per cent. reduction in mortality by the year 2000. The authority's Estate Care Group has received many awards. Its design group is recognised as the leading hospital design unit in the UK. Furthermore, its procurement group, which was formed only recently on the reorganisation of supply functions in Wales, is doing well.
§ Therefore, it is fair to say that by common consent the authority's record has been good. However, I am sorry to say that the present Secretary of State for Wales, without the benefit of any independent investigation of the facts, is now intent on "untying"—that is the Welsh Office's word for the old word "destruction"—the services and that bank of skills, practical knowledge and experience which the authority has in abundance. The Secretary of State is intent on "untying" the organisation by April 1997. That radical departure in policy is the cause of worry in Wales as the potential damage is enormous.
§ I would not dream of wearying the Committee this evening by going through Amendment No. 32 line by line although my colleagues and I would be delighted to deal with each provision with the Minister if the Welsh Office were to say in reply to the debate that it is prepared to reconsider its decision. I must acknowledge that paragraph (d) implies the merger of the organisation with Health Promotion Wales.1589
§ The Welsh Health Common Services Authority owes its genesis to the NHS reforms of 1974. In fact, it was the creation of the noble Lord, Lord Thomas of Gwydir, when he was Secretary of State for Wales. Since then, there have been five Secretaries of State for Wales, four of whom have been Conservatives. From time to time since 1974, each Secretary of State has enhanced the role of that special authority. However, as I said earlier, the present Secretary of State has taken up a very different position.
In April of last year, the Secretary of State announced that three clinical services managed by the authority; namely, Artificial Limb Service, Breast Test Wales and National Blood Transfusion, would be moved (in his words)
closer to the mainstream NHS
as if the authority was far removed from the NHS. In fact, it is an integral part of the NHS in Wales. As for the remaining services, in a speech in the other place in June of last year, the Secretary of State announced—pretty arrogantly, many of us thought—that the staff were to take themselves into the private sector where they can compete against others. Since then he has imposed a recruitment freeze on the authority's administrative and clerical services. The Secretary of State can do that without the authority of Parliament.
§ There are at least three substantial grounds for concern about the Secretary of State's decision. The first is the fact that the special health authority is to be virtually disbanded without any evidence that that is necessary or that better standards of provision will be achieved. Surely a change of that order of magnitude ought to be soundly justified. We have been looking in vain for a justification.
The second ground for concern is the speed with which the decision has been taken and is being implemented when there is no need for urgency. There is no need for it to be given priority. In a letter from the Welsh Office dated 24th January this year, which is signed by a senior civil servant, Mr. R. C. Williams, the head of the Health Services Division of the Welsh Office, there is clear evidence that the decision has been rushed. In paragraph 2 of his letter, Mr. Williams states that the implications of the transfer of those major services from the special authority have been evaluated:
So far as was practicable in the time available, the options, criteria and weightings were tested with relevant interests in the field".
§ We are disturbed by that sentence. What is suggested is that there has been a model, or an hypothesis, which has been tested properly by known methods for undertaking that process, but nowhere in that letter, or in any other letter, are we told what were the criteria and the weightings.
§ Moreover, the pattern and context of the consultation have not been disclosed. Thus, we do not know whether the "relevant interests" include the people who are dependent upon the services or donors to the blood transfusion service. Indeed, I have been told that the testing amounted to little more than that certain ideas about how the services might be organised were put to a selected few who went along with the ideas.1590
§ The fact remains that the so-called testing was limited "so far as was practicable in the time available". I want to pay tribute to Mr. Williams the author of that letter, for his integrity. He has at least brought his reservation to the surface. I wonder whether I might ask the Minister to place in the Library, before Report, full particulars of the options that were tested; the criteria which were applied; and the weightings that were calculated. May we have the names of the parties who were consulted? In what capacity they were consulted? Over what period of time were they consulted? With that information to hand, we can ask more questions and be satisfied whether justice has been done or denied. Or are we in Parliament asking too much of a department in requesting that that information be deposited in the Library?
§ Paragraphs 5, 6 and 7 of the letter of 24th January deal inadequately with the funding and management of these essential services which are to be transferred to the private sector or which are to be decentralised. The first sentence of paragraph 5 refers to the funds that are "being repatriated". That is a pretty novel use of the word "repatriated" in this context, because those services have not been performed at a local level; they have been centralised at the Welsh level.
The implicit risks emerge in the second sentence. There may be a flaw in the English here but I have checked it and it reads:
The intention is to maintain steady state and avoid destabilisation of these services as new management arrangements come into force".
§ Then in the third sentence we are told that the funding is to be ring-fenced for 1995–96 and 1996–97. We stress that if the continuity of those services is considered by the Welsh Office to be important—it is important—then expenditure on them should not be liable to local discretion at the end of 1996–97. Surely the ring-fencing should stretch far beyond 1996–97.
§ Finally, Mr. Williams speaks of the need for authorities to adopt consortium or lead purchaser arrangements for the artificial limb service as it is, in Mr. Williams's words, "a complex operation".
§ I come to the third point of our serious disquiet. Just as one feels that inadequate attention has been paid to patients and potential patients, so one feels also that the staff of the special authority are being treated as if they were objects to be moved about like puppets on a string at the whim of the Secretary of State for Wales. I can assure the Committee that there is immense uncertainty among the 1,750 people employed by the special authority. There will be redundancies. There may be early retirements. For married staff, there is concern also about the position of their families: 12 months from now will they be in work or unemployed? Will they be able to live in or about Cardiff or will they have to move elsewhere in Wales? If they have to move elsewhere in Wales, will they be able to sell their homes? Will that upset the children's education? Do those considerations matter to the Secretary of State?
§ In our view, it is inexcusable for the Secretary of State to have refused to meet a deputation from UNISON, whose members will be directly affected by the Minister's decision. Can that decision be 1591 reconsidered? It appears to us that the present Welsh Secretary's prime objective in his dealings with the Welsh health service is merely to encourage competition. It is our submission that his goals are much too narrow, and prohibit us from thinking in a creative way towards a better health system for Wales. I beg to move.
§ 8.45 p.m.
§ Lord Elis-Thomas
I support the noble Lord, Lord Prys-Davies. He did not spell out his credentials for speaking on the amendment. I remember him, of course, as a leading member of the old Welsh Hospital Board before reorganisation in 1974. I instanced that because it is important to emphasise that the need for an all-Wales structure in health service provision dates back to those days. A regional health authority was not created for Wales; the Welsh Office carried out that function and in order to do so it had to establish specialist agencies which delivered those services on an all-Wales basis.
That is what our debate tonight is really all about: whether we should have a special health authority covering those specialist services, which were mentioned in detail by the noble Lord, or whether we should entrust the delivery of those services to patients and the users of health services in Wales to the market testing proposals announced by the Secretary of State, to the transfer of clinical services to the so-called mainstream NHS services, and to the market testing of non-clinical services.
It seems that the Government are not clear about the health service objectives of their proposals. In Committee in another place the Minister, Mr. Rod Richards, emphasised that when the market testing exercise had been completed the department would be able to form a view on the functions that still needed to be carried out at the all-Wales level.
That is a complete reversal of how one should approach the whole question of the delivery of services. If we have a way of operating the specialist services which are already functioning effectively on an all-Wales level, to market test, and then, as it were, look for residual services that need to be provided at that level demonstrates a failure to understand the complexity of health service delivery, particularly in an area such as Wales.
I am concerned also about two other aspects of the proposals. A detail has been drawn to my attention by the trade union (UNISON) which is involved with the authority and by certain GPs; namely, the linguistic implications of the changes. At the moment, it is possible for a family practitioner to write a prescription in the Welsh language if the local pharmacist can take that prescription, and to know that there are arrangements within the present prescription pricing mechanism which enable that to be dealt with. If that service were to be contractorised, it is not clear whether that would still be the case. Within the terms of the Welsh Language Act, with which I have a certain affiliation, it seems clear that if the policy is to be fulfilled it is essential that that should still be the case. If contractorisation removes that service outside Wales, 1592 it may well be difficult for that need to be met. That is a specific service which is currently available. I should like the department's view, either directly from the Minister or later from the Welsh Office.
There is another aspect which concerns me; namely, the role of the Health Promotion Authority for Wales. The authority has had a long record of partial success in tackling very difficult issues of national ill-health within the Principality. I speak as someone who was an admirer of the earlier initiatives of Sir John Catford, who is obviously no longer in favour with the Government. Heartbeat Wales and other initiatives affected the lifestyles of people within Wales and certainly affected the high level of heart disease risk as a result of diet, lack of exercise and lifestyle which was unfortunately part of our historical baggage.
My concern is that although health promotion is being transferred to DHAs which have a health promotion role, that role will reduce the national profile of health promotion. I believe that Heartbeat Wales and the Health Promotion Authority for Wales initiatives were able to provide an all-Wales profile as regards lifestyle issues relating to preventive health care. For all those reasons, together with those set out by the noble Lord, Lord Prys-Davies, I believe that the present proposals of the Welsh Office are a step backwards. I do not see the healthcare justification for the proposals and, as the noble Lord said, the communications from the department indicate an internal tension among the department's officials who care about the delivery of services and who have a long record of delivering the services under different governments and Secretaries of State, which may be more relevant in this discussion. In the official communications, one can detect an ambiguity and a tension.
Therefore, I hope that the Government and the Welsh Office will take a further look at the matter. If they cannot meet our request for special treatment for the national agencies which already exist, at least they should ensure that there will be no reduction in the level either of health promotion for health protection or the delivery of those services which have been made available previously on a national level for all parts of Wales.
§ Lord Stoddart of Swindon
Although I cannot speak with the same authority and expertise as my noble friend Lord Prys-Davies or the noble Lord, Lord Elis-Thomas, I give them my support as, I suppose, an exiled Welshman. It is shocking that an authority which, as my noble friend pointed out, has given such outstanding service over such a long period of time should be now under threat of destruction within two short years. Surely that cannot be right.
My noble friend mentioned the services which have been administered by that body. There is no need for me to elaborate because he dealt with it so well. However, I know that it is dangerous to interfere with something which has worked so well and so smoothly over such a long period of time. The problem with this Government, not only in relation to the health service but in every other aspect of public life, is that they are market-testing mad. We never really know whether their market-testing 1593 madness is doing well or doing badly. My guess is that in very many cases it is doing extremely badly indeed. But, with services like these, we really cannot afford to take the risk of market-testing when we know that the present administration has been doing the job well over a period of time.
The present Secretary of State, who represents Wokingham—I live very near there—is an intelligent man. Let us make no mistake about it; he is an extremely intelligent gentleman. I cannot understand why he has embarked on this particular route and why he is ignoring Welsh opinion, particularly bearing in mind the sensitivity of the Welsh people regarding his occupation of the post of Welsh Secretary without having any background in the Principality. One would have thought that he would tread very, very carefully indeed. But no, so far as I can see he is riding roughshod over local opinion. I believe that he will regret that.
As my noble friend pointed out, there has been a lack of consultation in a country where people become very involved and are very concerned about their public services. They do not see them at arm's length. They like to involve themselves in their services because they know, through bitter experience, that it is those services which keep them afloat when times are bad. I lived in the Rhondda Valley when times were very bad indeed. It was the protection of the public services and the Co-op, I might say, which kept us going through those very bad times.
That fact was brought home to me last year when I had the honour to be the chief guest of the mayor at the Rhondda centenary celebrations. The people have not changed since I was there. They still value their public services and still believe that they should be carried out, not in some sort of competitive way, but by people who are dedicated to the task. Now they see that the authority which has been doing the job so well for so long is to be wound up.
As my noble friend pointed out, the staff of the authority must be very unsettled and concerned about their future. I believe that there are about 1,700 of them. In Wales, which is a comparatively small country, that is a significant number of people. They are entitled to receive assurances about their future. One of the reasons they are worried about their future is the failure of the Government to agree to consult them about what is going on in spite of the fact that my noble friend and I have requested that such consultation should go ahead. It is little wonder that they have very little confidence in what is being done. I should like the assurances for which my noble friend has asked this evening. If they are not given this evening, they should be given at some time in the future. The staff will expect to be consulted and to be given assurances about their future within any organisation which may replace the present authority. When she replies, I hope that the Minister will show that she understands and appreciates the strength of feeling that there is over the issue and that she will perhaps help us by giving us some decent information.
§ 9 p.m.
§ Baroness Cumberlege
I should say, with trepidation, that I recognise the fact that I am now entering into foreign territory. However, I should tell Members of the Committee that I spent a very happy day on Friday in the Brecon Beacons. As a former chairman of the national association, I remember conversations that I used to have with my Welsh colleagues and how much I used to marvel at their luxury of not having a regional tier. Of course, they have not had a regional tier since 1974, but the amendments would go a long way to reintroducing one and imposing additional bureaucracy.
Members of the Committee will also be aware that the Welsh Health Common Services Authority and the Health Promotion Authority for Wales are both established by secondary legislation. Nothing presently in the Bill would prevent their continuance for as long as they are needed. The common services authority was the subject of a review last year, following which my right honourable friend the Secretary of State for Wales announced that clinical services would be returned to the mainstream NHS and non-clinical services would be market tested.
The noble Lord, Lord Stoddart, asked for the criteria as regards whether market testing had been successful. There are a number of criteria that one could use but perhaps one of them might be the savings. We know that savings have been made through market testing now reaching £1 billion. That money has been reinvested directly into patient services. I see that the noble Lord wishes to intervene. I give way.
§ Lord Stoddart of Swindon
I am much obliged. The Minister mentioned a figure of £1 billion. Does that refer to Wales or to the whole of the National Health Service?
§ Baroness Cumberlege
I believe that that applies to England and Wales.
Whatever the eventual outcomes of the present exercise for the many different parts of the Welsh Health Common Services Authority—the achievements of which, I have to say, I happily acknowledge—it is the needs of the organisations, and the patients who rely upon them, that will be the driving force for the change. The very processes being followed will ensure that. I cannot believe that they will necessarily have to remain part of one single organisation.
The noble Lord, Lord Prys-Davies, was very concerned that decisions are being rushed through at present. However, there has been very careful discussion with service users and consultation with the NHS. Those responses are being considered at the moment. As regards the details of the options previously considered, perhaps I may ask my Welsh colleagues to write to the noble Lord. I shall do the same in respect of the detailed issues raised by the noble Lord, Lord Elis-Thomas.
Several noble Lords mentioned the need for a central services authority which dates back to the 1970 reforms. I recognise that the common services authority was expanded over the years. Again, I should like to pay tribute to its many successes. However, I should also 1595 like Members of the Committee to recognise that the NHS reforms fundamentally changed its position. Trusts need freedom now to introduce different mechanisms and services to support them.
Our aim is that the NHS in Wales should be able to assess the many support services it needs by the most cost-effective means. Our overriding interest is that NHS trusts should provide more and better patient care for the same money. It is no longer tenable to have a large central organisation. When the current exercise is completed, we shall be able to form a view as to which functions will still need to be carried out at the all-Wales level.
I turn now to the employees of the WHCSA. I do not speak Welsh, but I believe that that acronym is pronounced "Weksa". The employees have made a valuable and much appreciated contribution to the NHS in Wales. I well understand that the uncertainty they face is very difficult for them. However, the process itself provides for consultation with staff. I hope that they will come to see it as an opportunity to improve the services that they provide. Handling the process is a matter for WHCSA's own management. That is why Welsh Ministers have declined to meet staff-side representatives whose interests are best served by the proper working through of the process itself.
The role of the Health Promotion Authority for Wales has changed in recent years, as the health promotion role of district health authorities and family health services authorities has grown in importance. The Parliamentary Under-Secretary of State for Wales, Mr. Richards, is currently reviewing the delivery of health promotion in Wales, including the future role of the authority. The results of his review are expected shortly.
In both reviews, the focus should be on responding flexibly to the evolving needs of the health service and, more importantly, to its patients. However, the proposed new clause would require all flexibility to be forfeited. It prejudges how all those services should be provided and allows no means, short of new primary legislation, for revising that judgment. It also asks us to take a leap of faith in abolishing both WHCSA and the Health Promotion Authority for Wales, transferring their functions to a new body with a new management. It would also make the new body responsible for processing health complaints.
As I said earlier, the Government have published their proposals on the subject in the past few days. They constitute a welcome streamlining of present arrangements, and are far superior to the proposal implicit in the suggested new clause for a new, centralised, bureaucratic and wholly rigid management in Wales.
The Artificial Limb and Appliance Service, Breast Test Wales, and the National Blood Transfusion Service, Wales, have recently reviewed the options for the future management of the services that they provide. Having considered their conclusions, my right honourable friend the Secretary of State for Wales has recently consulted on the propositions that management arrangements for the National Blood Transfusion Service, Wales, should not change for the time being; that management of the screening programme of Breast 1596 Test Wales should transfer to a single trust; and that the Artificial Limb and Appliance Service should, in general, be managed by the hospitals where they are based but some specialist services might best be provided from a single point.
I do not wish to prejudge my right honourable friend's consideration of the responses to his consultation. However, I should like to point out that the proposed amendments would not only anticipate a reasoned judgment of the best way forward in the light of those responses, but would also require that one particular set of administrative arrangements should be set in legislative concrete. In the light of what I have said, I ask the noble Lord to consider withdrawing the amendment.
§ Lord Prys-Davies
I wish to thank my noble friends Lord Stoddart and Lord Elis-Thomas for their staunch support of the amendment. In view of one remark of the noble Lord, Lord Elis-Thomas, I should make clear that I was chairman of a Welsh hospital board from 1968 to 1974. That was many years ago; it was an unpaid office. However, I have not moved the amendment out of some nostalgic loyalty for the integrity of the excellent staff of that old Welsh hospital board. My basic reason for moving the amendment is our profound belief that the Secretary of State is making a huge mistake.
The Minister, with her usual courtesy, has disagreed with the amendment, as I feared she would. But she really has not disagreed in detail with a number of the basic points we advanced. With deepest respect to the Minister I must say that I, for my part, am wholly dissatisfied with her general comments. The Minister has not given specific confirmation that she will place the information that we have requested in the Library before Report stage. In our submission we are entitled to know what options were considered. The Minister said that the three clinical services were asked to consider the options and to produce their schemes. However, they were under instructions to do so from the Secretary of State for Wales. I ask the Minister to ensure, if she can, that the options, the criteria and the weightings are set out in a document in the Library. May we also have full particulars of the parties who were consulted? The Minister used a general phrase. We are asking for further and better particulars of that statement.
I also trust that we can soon have a satisfactory reply to the question posed by my noble friend Lord Elis-Thomas. We want assurances that the use of the Welsh language will not be prejudiced in any respect by whatever decisions the Secretary of State, in his wisdom, decides to impose. We are entitled to that confirmation. If we do not get it, it appears to me that he is flying in the face of the principles of the Government's policy as set out in the Welsh Language Act 1993.
It may be our fault that the Minister has not fully understood our case, but we will have to consider carefully what has been said. The Chamber this evening can hardly be described as full. Nevertheless, we will consider what has been said. It is clearly inappropriate 1597 to test the feelings of the Committee this evening and therefore I do not propose to press the amendment. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Clause 2 agreed to.
§ Schedule 1 [Amendments]:
§ The Deputy Chairman of Committees (Lord Lyell)
I must advise the Committee that if Amendment No. 13 is agreed to, I will not be able to call Amendment No. 14. I now call Amendment No. 13.
§ Baroness Gardner of Parkesmoved Amendment No. 13:
§ Page 5, line 18, leave out from beginning to ("persons") in line 20.
The noble Baroness said: The patients are the most important group in the health service. I think we would all agree with that. But, after the patients, no one is more important than the medical practitioners, the registered nurses and the registered midwives. Therefore my amendment in no way seeks to denigrate them or to reduce their importance. Paragraph 3 of Schedule 1 states,
Every Health Authority shall make arrangements for securing that they receive
appropriate advice. I consider that to remove the reference to,
medical practitioners, registered nurses and registered midwives
would not in any way damage the paragraph because the advice would then come from,
persons with professional expertise in and experience of health care".
§ Medical practitioners, registered nurses and registered midwives are all included in that phrase. Throughout today it has been said again and again that the Government do not wish to be prescriptive in the legislation. The three groups designated in the schedule seem to me an example of being prescriptive. Their inclusion in the Bill therefore seems contrary to the line taken on every other amendment moved today. If we are to retain the reference to those three groups of personnel, I believe there is every justification for the case put to me by pharmacists who have asked why they are not included. I notice that the following amendment seeks to include registered health visitors in the schedule. What about dentists, osteopaths and chiropractors? We could mention a great many groups of people who would like to be included in the schedule. They all feel that they are equally important as the three groups which are named.
§ Earlier this afternoon the noble Baroness, Lady Robson, suggested that those groups are closest to patients. That is arguable, and it is also variable depending on the individuals involved and the areas in which they work. We heard from my noble friend Lord Carr that in his area community pharmacists are very close to patients. Therefore, one cannot say that those groups are named because they are the only professionals who are close to patients.
§ I believe that either we should not refer to any category but limit the reference in the Bill to people with professional expertise in and experience of healthcare or 1598 we should enlarge the list of those named to cover each and every one of the health professions to make clear that we believe that they should all be included.
§ I do not believe that any further presentation on the amendment is required. The position is perfectly clear, particularly in the light of comments made earlier this afternoon. I beg to move.
§ 9.15 p.m.
§ Lord Carter
This is a very ingenious approach to the problem, which the noble Baroness explained extremely well. It appears that the intention is to exclude some in order to please all. I should be interested to know what criteria the health authority would use to choose the persons with professional expertise in and experience of healthcare if subparagraph (a) is omitted. The noble Baroness has ingeniously used a very wide definition. I entirely understand and support the anxiety of pharmacists, and all the other professions which are not mentioned, because—to use a football analogy—they seem to have been relegated to the second division as the Bill is worded.
The Minister has a very interesting choice to make when responding to the amendment. Either she accepts the amendment and infuriates everyone referred to in subparagraph (a), or she rejects it and infuriates all those encompassed in subparagraph (b). I shall be extremely interested to learn how she deals with the amendment.
§ Lord Rea
I shall say the same as my noble friend, but in different words. In contrast to Amendment No. 20 which the noble Baroness will move later, I oppose this amendment. I have to declare an interest as a general practitioner. However, I feel that the amendment would weaken the influence of the main professionals working in the National Health Service, particularly those named in the Bill, who would be deleted by the amendment. However, I do not feel that the amendment strengthens the case of the other professionals to be consulted or to act as advisers since instead of having a subparagraph in the Bill to themselves, they would have to share the same line with doctors, nurses and midwives, who are more numerous.
§ Baroness Gardner of Parkes
I am grateful to the noble Lord for giving way. He has misunderstood the amendment. They would not share the same line; the line would be replaced.
§ Lord Rea
But they would be included in the same line in the end. I suggest that, being included in the same line as the nurses and doctors, there would be more chance of their being forgotten than if they had a line to themselves as they do now. I very much hope that the noble Baroness will withdraw the amendment or that, if she does not, the Minister will gently oppose it.
§ Baroness Eccles of Moulton
I should like to say a word about the amendment. The purpose of the amendment to the National Health Service Act is to ensure that health authorities take advice. When one considers the enormous range of duties of the health authorities it is clear that they have to take advice from a wide range of health professionals. I shall be interested 1599 if my noble friend the Minister can explain why the three categories of health professionals mentioned in the Schedule have been selected so that special attention is drawn to them on the face of the Bill.
§ Baroness Cumberlege
To respond to the noble Lord, Lord Carter, he will know that the training for every Minister takes place on a high wire and one has to perform a balancing act.
§ Baroness Cumberlege
That is undisputed.
I understand my noble friend's anxiety. The provision she seeks to amend was added to the Bill in another place because of the concern felt across the professions that their involvement in health authority decisions should not simply be left as a matter of good practice. We had already made clear in draft guidelines which were circulated widely to the professions and the NHS that involving healthcare professionals was not an optional extra. The amendment which the Government tabled in another place added weight to the guidelines which outlined the areas where professional involvement will be needed. These include strategic development of services, developing primary care services and contracting decisions.
The Government's provision makes particular mention of doctors and nurses, including midwives, as do the draft guidelines. There is no implication here that health authorities will have fulfilled their statutory duty by consulting doctors and nurses. They must involve a whole range of professions. This point is stressed in the draft guidelines—they list 20 or so different groups—and is made clear in the provision itself which covers everyone with,professional expertise in and experience of health care".
Doctors and nurses are the largest groups of healthcare professionals. They are involved in virtually every aspect of patient care in hospital, community and primary care settings. It is appropriate to give them special mention in this amendment but I repeat that other groups have an equally important contribution to make in their areas of special expertise. I urge my noble friend to reconsider and withdraw the amendment.
§ Baroness Gardner of Parkes
I thank the Minister for her reply and the other participants for their exchange of views. I note that the noble Lord, Lord Rea, referred to the main professionals. I did not like the word "main". It seems to confirm exactly what I said: that those three groups were more important than anyone else in the health service.
§ Baroness Gardner of Parkes
I did not understand the noble Lord to say that. I note that the Minister said that. I had intended to ask the noble Lord whether he referred to numbers when he used the word "main". His intervention cheers me greatly. The important point is— 1600 it is the point that I seek to make in proposing the amendment—that all health professionals are equally important in the overall pattern of team care for patients.
The Minister stated that consultation must involve the whole range of professionals. She referred to about 20 groups. That statement inHansardwill give considerable reassurance to people who have been worried that they are being overlooked or, as the noble Lord, Lord Carter, said, put into the second team.
I shall read what has been said, as I am sure will others. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness Dean of Thornton-le-Fyldemoved Amendment No. 14:
§ Page 5, line 18, at end insert ("and registered Health Visitors").
§ The noble Baroness said: The amendment adds health visitors to Schedule 1(3) (a). However, I certainly take to heart the points made by the noble Baroness, Lady Gardner of Parkes. Clearly a whole range of professionals is absolutely crucial in delivering health services to patients. Patients, of course, must be the first criterion that we address when dealing with the Bill and its effects.
§ We assessed that Amendment No. 13 probably would not be agreed and decided to leave Amendment No. 14 on the Marshalled List. The logic underlying the amendment derives from the 1979 Act which specifies nurses, midwives and health visitors. We believe that the provision adds to the Bill.
§ Health visitors play a crucial role in the delivery of healthcare. They visit families in their homes—something that many nurses and doctors do not have the opportunity or the need to do on a regular basis. They play a key role, too, in child protection matters. It is not as though the patient comes to them in the health environment. Health visitors go into the home and see the family and children. They see the family in the round, whether it is a single parent or two-parent family. They see the circumstances in which the family live and the way in which that affects the family's health matters.
§ The provision is particularly important as health visitors increasingly play a bigger role because of the drawdown in social service support in the community. It is equally important, as much health care is now being delivered in the home; and quite rightly so. More health care takes place outside the hospital, which is right and good for the community and the family. Since that is the case, I hope that the Minister will be able to accept the amendment. I do not venture to suggest that she does not recognise the valued service that health visitors give and their crucial role within the community. I therefore hope that the amendment finds favour and is accepted. I beg to move.
§ Baroness Cumberlege
I am grateful to the noble Baroness for giving me this opportunity to emphasise the importance of the role of health visitors and the part they will play in the new health authorities. She is right in supposing that I have long been an admirer of that section of the nursing profession. I have a little 1601 understanding of the difficult work they undertake and the impact they can have in strengthening parents' confidence and abilities in bringing up their families.
Let me make it clear that the new duty in the Bill requiring health authorities to secure professional advice certainly includes health visitors. There should be no doubt about this. Health authorities will be under a statutory obligation to involve health visitors in their work where their special skills and experience are relevant.
Health visitors are, of course, registered nurses who have gone on to take an additional specialist qualification. They are therefore already within the provision. The definition "registered nurse" also covers many other specially qualified nurses such as district nurses, mental health nurses and so on. I know, though, that health visitors have a particularly distinct professional role.
The draft guidelines on professional involvement, on which the Government have just finished consulting, reflect that. The guidelines highlight the vital role of health visitors in child protection, mentioned by the noble Baroness. Of course, they have a much broader contribution to make in health needs assessment, prevention of illness and health promotion because of their close involvement with families and children and the local communities in which they live. My department's good practice document,Targeting Practice, provides many examples of the contribution that health visitors make toThe Health of the Nationtargets.
I hope that the Committee will accept that the amendment is not required and that health visitors will be firmly involved in the new health authorities. I hope that the noble Baroness will see fit to withdraw it.
§ Baroness Dean of Thornton-le-Fylde
I thank the Minister for that reply, particularly the reference to the guidelines on which consultation has just concluded. That is helpful, but it does not answer the point about having "health visitors" on the face of the Bill as a requirement. However, I take encouragement from what the Minister said. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Lord Reamoved Amendment No. 15:
Page 6, line 45, at end insert:
(" "(1A) The Secretary of State shall give directions with respect to the exercise of the responsibilities exercised prior to the passing of the Health Authorities Act 1995 by Regional Health Authorities in respect of—
§ The noble Lord said: In moving the amendment, I wish to thank the officials in the Box for supplying me with a draft of the memorandum on options for the future management of postgraduate medical education 1602 which is to be placed in the Library tomorrow. I shall refer later to the document which I have had only a brief chance to read.
§ The amendment seeks to retain the current arrangement whereby the contracts of junior doctors above senior house officer level are held on a regional basis. There are several reasons for wanting to retain the arrangement. Registrars and senior registrars are in training to become consultants. They have special requirements as part of that training. The requirements are facilities for consultants to give them tutorials and time for study. The junior doctors should be regarded as a national and not a local resource since from their ranks will come the next generation of specialists. They often need to move during training rotation from one hospital or community trust to another to obtain the relevant experience—sometimes crossing borders of health authorities.
§ At present junior doctors are employed on national terms and conditions of service so as to maintain high standards throughout the National Health Service. Devolution of their contracts to trusts would, we feel, jeopardise these arrangements. These training posts need to be overseen by someone independent of the trust for which they are working at a particular time to ensure, for example, as I mentioned earlier, that time is set aside during the course of a week in which consultants can teach juniors. If it is left entirely to the trust, pressure of work might well seem to be a higher priority. This amendment would ensure that these important concerns are addressed.
§ I turn briefly, after a very cursory reading, to the new memorandum. I have to say that I find it quite confusing. Instead of coming down firmly for one solution, it offers several choices. I feel almost certainly that the authors of this memorandum were fully aware that the issues were contentious. It seems to be another example of making up legislation as you are going along. There are options in the memorandum which it seems will be given out for consultation.
Employment contracts for junior doctors—which is the topic of the amendment—could, according to the memorandum, be organised in three different ways. I refer to the document itself:
all contracts to be held by the Trust responsible for the hospital in which the doctor is working…contracts to be held by a nominated 'lead Trust' for the training programme in that specialty, with junior doctors working on secondment for the other Trusts participating in the rotation",
all contracts held by a single 'lead Trust' for the region, either the Trust with the most training posts overall…or a 'neutral" Trust"'—
whatever that is.
Again junior doctors would be seconded to the other Trusts providing training on a rotational basis".
A fourth alternative is also offered; namely,
the possibility of the contracts being held by a purchasing health authority".
§ I do not honestly feel that any of those options answers the problems that I outlined would occur if the current satisfactory arrangements are interfered with. The document turns down altogether the option of a contract being held by the health commissioning 1603 (purchasing) authority; and it does not mention at all, so far as I have read, the possibility of the contract being held by either the postgraduate dean or the regional health commissioner.
§ While, of course, we have to study this document with greater care, it does not offer an answer which would allow me to withdraw this amendment. It is quite important that the principles enunciated in the amendment should be adhered to. I beg to move.
§ 9.30 p.m.
§ Baroness Cumberlege
I appreciate that the noble Lord, Lord Rea, has not really had time to read this document. But if he had just read the next sentence he would have noted that,The NHS Executive's preferred option is for all contracts of NHS employees",
and so on. But I am sure that we shall return to the subject on Thursday when we discuss the other amendments.
Perhaps I may put this matter into some context. There are two distinct issues in relation to the contracts of registrars and senior registrars—whose contracts are currently held by regional health authorities. First, employment contracts need to be held elsewhere when RHAs go. Secondly, the continuity and quality of training programmes need to be properly protected under any new arrangements. It is our intention that the training programmes of registrars and senior registrars, and in the future those doctors in the proposed new unified training grade, will be managed at regional level by the postgraduate medical deans.
We are currently discussing the detail with the deans but we envisage the negotiation by the deans with NHS trusts of educational contracts. The doctors themselves might also be party to those contracts. Such contracts would ensure that the quality and continuity of training is protected while also recognising trusts' responsibilities for the effective delivery of services to patients.
It will not be necessary for the doctors' employment contracts also to be held at regional level to safeguard the doctors' training interests. It would not be right for them to be held by the regional offices as part of the Civil Service.
As we made clear in the report published in the summer,Managing the new NHS, our preferred option is for contracts to go to trusts. That is consistent with the treatment of other medical staff, with the principle that personnel issues are generally best managed at local employer level and with trust freedoms to determine the quantity and type of resources that they employ.
The Government have tabled amendments which we shall debate at a later stage in Committee. When we come to debate those amendments, I shall be able to explain more fully the safeguards that we propose to enable contracts to be held by trusts.
We are committed to high quality medical education and training, which underpins our objective of providing high quality healthcare to patients. The interests of the profession, universities and postgraduate deans will be taken fully into account in developing the detailed 1604 framework for medical education and training. We shall ensure that the staff concerned are treated fairly and that continuity and quality of training is maintained. Therefore I sincerely hope that the noble Lord will withdraw his amendment.
§ Baroness Jay of Paddington
Perhaps I may ask the noble Baroness a logistics question. Is she saying that the Government will bring forward amendments which encompass the proposals in the document published today on the second day of Committee stage of this Bill or will they be left to a later stage?
§ Baroness Cumberlege
When we come to the amendments, I shall be able to explain more fully the safeguards that we propose to enable these contracts to be held by trusts. At the moment, the proposal is that the contracts should be split: educational contracts to be held with the postgraduate medical deans and the normal employment contracts to be held with the trusts. I shall go into this matter much more fully. I appreciate that the Committee has not had a chance to see the consultation document, which is the key to much of this debate.
§ Baroness Jay of Paddington
I am sorry to pursue this matter, but does it therefore mean that this will be discussed in detail on Report?
§ Lord Rea
What the noble Baroness said is extremely interesting. I am sure that her words will be read with great care by all the Royal colleges, the British Medical Association, many universities and all those practitioners in the field concerned with postgraduate medical education. As I said, we shall also study this document in greater detail. I am sorry if I misinterpreted some of its recommendations, but we shall come back, having digested the document more fully. I also hope to discuss the matter with the colleges and the British Medical Association before we debate it again in Committee. At this time, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness Dean of Thornton-le-Fyldemoved Amendment No. 16:
Page 7, line 17, at end insert:
("(c) of responsibilities exercised prior to the passing of the Health Authorities Act 1995 by Regional Health Authorities in respect of public health initiatives requiring that those responsibilities should continue to be provided on a regional basis.").
§ The noble Baroness said: The issue of the present structure of regional health authorities, the duties and responsibilities that they carry and how they will be transferred to the new health authorities form a theme that has run through the whole of our debates on the Health Authorities Bill. It came up at Second Reading and has come up today as well.
§ There is a lot of concern that many of the regional features of the present regional health authorities will go by the board. In fact, they will no longer be carried out at a regional level. This amendment will have the effect 1605 of ensuring that the best key features which are currently carried out at regional level will continue to be carried out.
§ At the moment regional health areas, and particularly the regional director of health, has a standing in the community on a whole range of issues. For instance, if there was a factory being built that was going to create a lot of pollution, the regional director of public health could be brought in and express a view on behalf of the people in the community. He could be consulted on new developments and general health issues in the region. The regional director of public health is currently required also to commission an independent report for the regional health authority on the population in the region. That report is drawn together from the districts. It assesses the need for regional specialist services—an area about which we have expressed concern during the discussions on the Bill—the development of teaching facilities and links with universities.
§ A question that we raise in relation to the provisions of the Health Authorities Bill is that, when one sees the transfer of regional staff, including the executive person, into the national health executive as an employee, thus becoming a civil servant, it is difficult to understand how that person can be accepted in the eyes of the local community as a person of independence; someone whose voice speaks purely from the health point of view and not necessarily from the fiscal point of view with all its usual constraints. It is not simply a matter of implementation therefore; it is also anxieties about the enactment of the responsibilities of the regional public health director.
§ Perhaps the Minister will address a number of questions when she responds to the amendment. Will the regional director, while a civil servant, continue to publish the annual reports? Will he have independence or be required to conduct himself as a civil servant with the obvious understandable constraints on him as an individual that that implies when carrying out the job? Will constraints be placed upon him in carrying out how he sees what is a wide-ranging remit?
§ At first glance it may appear that there will not be a great deal of difference; it will still be the same people. But in fact the functioning of this responsible area of work may be considerably different. It is that, linked with the specialist services, linked with what is needed in the region in relation to teaching facilities, technology and links with universities, that need to come from regional level and which themselves will feed into a national policy directorate. How will the Bill address those concerns? We do not believe that the Bill as it stands addresses them. I beg to move.
§ Baroness Cumberlege
Today and earlier in our Second Reading debate we heard a great deal about the crucial role played by regional health authorities in public health, leading the way in new policies, taking the strategic overview of the so-called Cinderella services, spearheading specific health of the nation projects, supporting health promotion, creating health alliances, leading local purchasers in creating a knowledge-based, effectiveness-led NHS. It has been a record of highly creditable achievement.
1606 The public health role of the new regional offices will continue to be crucial, but it will be different in character. The role was spelt out last summer in the NHS executive document,Public Health in England: Roles and Responsibilities of the Department of Health and the NHS. That report emphasised that, subject to our deliberations on the Bill, regional directors of public health and the new regional offices of the NHS executive will be responsible for ensuring that public health considerations drive the work of the new regional offices and ensure that public health functions are discharged effectively in each of the regions.
Some public health functions previously undertaken by regional health authorities can safely be devolved to the new health authorities with their larger resident populations. An important example is the purchase of breast cancer screening services. However, we recognise that a number of the present regional public health functions are more efficiently organised for populations larger than even the biggest of the new authorities.
An executive letter issued to the NHS on 10th March of this year identified four such functions. Those are: work associated with a confidential inquiry into stillbirths and deaths in infancy; the purchase of cancer registry services; the purchase of quality assurance services for breast and cervical cancer screening; and the appointment of doctors under Section 12 of the Mental Health Act 1983. Subject to the passage of this legislation, responsibility for these four functions will pass to a lead health authority which will undertake the work on behalf of all health authorities in the region, supported and monitored by the regional office. We believe that this approach allows decisions to be taken, as far as possible, at the local level where they can be influenced by the professional staff with most knowledge of the relevant health needs and healthcare services. It allows the necessary strategic view to be taken and permits more effective monitoring. Public health staff in the regional offices will have an important responsibility to ensure, through close liaison with a range of healthcare professionals in primary and secondary care, that health needs are properly assessed, outcomes reviewed and appropriate responses put in place.
The noble Baroness asked me whether the regional director in future will publish annual reports. I would expect them to contribute very heavily to the chief medical officer's annual report which covers all England and Wales. But in the future we would expect local health authorities to publish their own annual reports, part of which would, of course, take into account the public health aspects. It would be inconceivable for a health authority to publish a report without that important underpinning of expertise and knowledge. In the light of what I have said, I hope that the noble Baroness will withdraw her amendment.
§ 9.45 p.m.
§ Baroness Dean of Thornton-le-Fylde
I regret the fact that the Minister's answer does not give me much comfort. It goes no way towards meeting the questions 1607 and points that I raised. However, I recognise that it would not be very constructive to divide the Committee at this stage. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness Robson of Kiddingtonmoved Amendment No. 17:
§ Page 7, line 44, after ("area") insert ("provided that no such council shall be a council for an area larger than the area of the council for the area of the Area or District Health Authority which that Health Authority has replaced").
§ The noble Baroness said: This amendment seeks to ensure that community health councils are not overburdened under the reorganisation. Where two district health authorities are replaced by one new health authority it is essential that both those community health councils are preserved. One cannot demand of a community health council that it should cover an area twice the size that it has previously covered. The members are all volunteers. They give an enormous amount of their time. As the Minister agreed, they have given invaluable service, advice and help to the health service. They are the main statutory bodies representing the general public. It is important that they should not be given too much to do where they cannot possibly fulfil the demands which the general public will make on them. Where two district health authorities are put together, I ask the Minister to agree that there should be_ two community health councils serving that health authority or that the number of people on the community health council should be doubled. I beg to move.
§ Baroness Jay of Paddington
I support the noble Baroness, Lady Robson, in this amendment. It is a very good opportunity to emphasise that the new arrangements for health authorities should in no way diminish the contribution which community health councils can and should make to the operations of the National Health Service, particularly given the abolition of the regions and the enlargement of some of the purchasing authorities to bring the concerns of the health service down to the level of the users and the patients.
As the noble Baroness, Lady Robson, said, it is very important that these purely volunteer bodies should not be given excessive burdens to administer. As I understand it —perhaps the noble Baroness the Minister will correct me if I am wrong—it is not yet clear from the regulations or schedules who will employ the one executive director of the community health councils now employed from the regional health authority.
I believe that all this is sending a message to community health councils who are extremely hard pressed and who do an enormous amount of good work. As the noble Baroness, Lady Robson, said, and as I have just mentioned myself, they are entirely staffed by volunteers with the exception of the one staff person. They should not be asked to extend their responsibilities beyond the areas which they now embrace which sometimes are quite large, given the few people involved.
1608 The other side of the coin is that if the CHCs have to extend to a larger area than that embraced by their present responsibilities they will become more invisible to the very people who want help in gaining access to the organisation of the health service. I know, particularly in large cities, that the community health council often tends to be slightly anonymous. It is not so apparent as the council located in the main high street of smaller towns and villages. It is very important that the CHC should remain close to the local population it seeks to serve. I hope very much that the Government will be able to accept the amendment which I support.
§ Baroness Cumberlege
The Government recognise that community health councils must be accessible to their local community and be able adequately to represent that community. There is nothing in this Bill to reduce the number of CHCs. It is a matter for discussion between the CHCs and their establishing body how many CHCs there are in an area.
The establishing body for England at the moment is the regional health authority. From the 1st April 1996 it will be the Secretary of State, acting through the regional offices of the NHS executive. In considering how many CHCs there should be we shall be seeking to ensure that the CHC can represent the community within its boundary.
We shall take account of factors such as the geographical size of the area and the diversity of the population. Guidance issued by the NHS executive in January 1994 made that clear. The provisions in Schedule 1 make clear that a CHC can he established to cover the whole area of the health authority or any part of it. The establishing authority, in consultation with health authorities and the CHC themselves, will review CHC boundaries to see whether the CHC can be more effective if its boundaries are changed. That may mean reducing or even increasing the number of CHCs. In some places it will mean changing the areas of some CHCs so that they have only to relate to a single health authority or to part of a single authority. With those words I hope that the noble Baroness will be reassured and that she will choose to withdraw the amendment.
§ Baroness Jay of Paddington
Perhaps I may briefly intervene again. I may have rather foolishly not followed exactly what the noble Baroness said. Did she say that the CHC paid official will now be employed by the regional office of the Department of Health? Is that the way it will work?
§ Baroness Cumberlege
No, the contract will be held at health authority level. The terms and conditions and the monitoring of it will be dealt with at the regional office. We believe it inappropriate that CHC secretaries should become civil servants.
§ Baroness Robson of Kiddington
I thank the Minister for her reply. I am not very much clearer in my mind having listened to what she said. It seems that in some cases there will be community health 1609 councils for one health authority area even if it is enlarged while in other areas there may be two. However, there are no clear guidelines on what should happen.
As the community health councils have worked well under the district health authorities, with each community health council serving one district health authority, I wanted an assurance that, if they are to be amalgamated, there will be two community health councils and that nobody else could interfere with that decision—whether the Secretary of State or the regional outposts of the Department of Health.
1610 I shall have to return to this issue, having read carefully what the Minister told us. I could not quite follow the basis of the decision-making as to how many community health councils there will be. 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 do now resume.
Moved accordingly, and, on Question, Motion agreed to.
House adjourned at four minutes before ten o'clock.