§ 3.33 p.m.
§ Read a third time.
§ Lord Carter moved Amendment No. 1:
§ After Clause 2, insert the following new clause:
§ ("Report on implementation of Codes of Practice
§ —(1) The Secretary of State shall annually lay before both Houses of Parliament a report on the monitoring of the implementation of the Codes of Practice set out in subsection (2) as they relate to any function carried out before 1st April 1996 by a Regional Health Authority, District Health Authority or a Family Health Services Authority.
§ (2) The Codes of Practice referred on in subsection (1) are—
- (a) the Code of Practice on Openness in the NHS;
- (b) the Code of Practice on Access to Government Information; and
- (c) any other Code of Conduct or Accountability.").
§ The noble Lord said: My Lords, the first amendment stands in my name and that of my noble friend Lady Jay of Paddington. It is a further and last attempt—this being Third Reading—to try to stiffen the Government's resolve regarding openness and accountability.
As the Bill proceeded through both Houses we heard a great deal about openness and accountability. Amendment No. 1 seeks to put on the face of the Bill a mechanism which will allow Parliament to review annually the performance of the National Health Service in terms of the three codes listed in the amendment:
the Code of Practice on Openness in the NHS; the Code of Practice on Access to Government Information; and any other Code of Conduct or Accountability".
It applies to the officials who will be taking over in large measure the responsibilities that were formerly the function of the regional health authorities.
§ In the course of the passage of the Bill the issue of complaints was discussed. For instance, we know that complaints in regard to hospitals have risen by 133 per cent. since the year before the reforms. In 1990–91 hospital complaints numbered 37,350; by 1993–94 they had more than doubled to 87,184—according to government figures. I mention that because although machinery has been devised to deal with complaints—we discussed this in the course of our debates—there is still a problem. It is not clear how the new machinery will work in practice. An annual report on compliance with the three codes would help to show how the NHS in all its forms is dealing with complaints and other matters of concern to patients, particularly as it is the NHS Executive which will be responsible for monitoring the procedure.
§ I am sure that the Minister will not agree with me but anyone who spends any time around the health service knows that to a large degree public confidence in the service has been undermined and staff morale is very low. That is because it is market mechanisms rather than public scrutiny which is used within the service. That has removed accountability from the process. The RHAs, which are to be abolished from April 1996, though they are not perfect, allowed for a degree of accountability. A number of their vital functions have been transferred to central government.
I was struck by a recent article in a magazine called the Health Director, a journal for directors of NHS boards produced by the National Association of Health Authorities and Trusts. I shall paraphrase some of the remarks in the article to show why the machinery of accountability needs to be redrafted in the form we suggest. I remind your Lordships that this is an article written from within the health service and intended for directors of trust boards. It points out that the entire NHS reforms quickly ran into a communication mire. It continues,
a new language of 'purchasers', 'providers', 'contracts' and 'extra-contractual referrals', which came across as meaningless bureaucratic twaddle … Yet inescapably throughout, there has been the imperative of the internal market, requiring trusts to compete with each other for patients; and health authorities and GP fundholders to shop around for the best deal. Encouraged to communicate with local communities, each part of the NHS has developed and honed its public relations skills and used them to establish its own position in the market".
The article is referring to hospitals, health services and the family doctor, not Tescos or Sainsburys. It continues:
'Negotiation by press release' has become an essential addition to the skills of the modern NHS chief executive. Newspapers and airwaves buzz with NHS people, ever-available, buying, selling, criticising and marketing health services. And the public gets more and more confused by the messages and more and more dispirited as they listen to NHS people squabbling among themselves".
When one considers that those remarks come from within the health service and are written for a magazine aimed at directors of health service boards, one can see
why openness and accountability are largely missing. Apparently a simulation exercise took place for officials regarding communication and,
it becomes clear that 'the public', although in this case made up of NHS people, actually don't understand much of what is said, and much of what they do, they don't believe. They feel patronised and ignored, and quickly become genuinely angry and confused".
At Report stage I asked the Minister—and she was kind enough to reply to me—what would happen after the Government conducted their initial monitoring of the implementation of the codes of conduct and accountability in relation to public service officials. I asked when the exercise would be completed and whether the results of the monitoring would be made public. I said that I hoped that the Government would not wait to see the outcome of the exercise before deciding whether or not to publish the results. I am grateful to the Minister for replying to me. In her letter she said,
I can confirm that this monitoring is almost complete and that the outcomes will be reported to the Secretary of State for Health in mid-May".
It has not yet been decided how the results will be reported to a wider audience",
which rather confirms my suspicion that the Government are waiting to see what the monitoring exercise says before they decide whether or not to make the results public.
§ In Committee and on Report I gave a local example concerning hospital plans which I shall not repeat to your Lordships. I shall merely say that it is a classic example where the preparation of a secret business plan which was not made available to the people concerned has led to bitterness, distrust and disbelief in the whole operation in the area where I live.
I turn to the code of openness. I referred to this matter on Report but I think it is worth pressing the Minister again regarding the business of charging for information. The code says, entirely fairly:
It is recommended that charging [for information] should be exceptional".
§ It says that the trusts and authorities may make a charge for providing information but are not required to do so. It is recommended that charging should be exceptional. It also suggests in the ground rules that there should be no charge for the first hour and a charge not exceeding £20 per hour for each hour thereafter. One can well understand how, with a small community that is trying to put together a scheme to save its local hospital, this could be a very useful weapon in the hands of the trust or authority concerned if it wished to stifle that group just by charging excessively for the information that is being asked for.
Finally, I wish to turn to the question of communication with the public and the media and the guidelines produced by the NHS Management Executive entitled Guidance for staff on relations with the public and the media. With regard to whistle blowing and the gagging of employees, the document states that,
any employee contemplating making a disclosure to the media is advised to first seek further specialist guidance from professional or other representative bodies and to discuss matters further with his or her colleagues and, where appropriate, line and professional managers".
One can see how that could be used to stifle employees.
§ For all the reasons I have given it is clear that there must be some means of monitoring these codes. I give credit to the Government for issuing the codes, but it is not just a case of having them available. We must see how they are actually working, how the health service is reacting to the codes and how it is performing against them. Although the Government are monitoring the code of practice on openness, is that information to be made available to the wider public? What we are asking for is an annual report to Parliament on how the three codes are working out in practice and what is happening with regard to openness and accountability. We want to see how this vast organisation is conducting itself in terms of the openness and the accountability which we all want to see. A report to Parliament would provide a mechanism to enable that to be done. I beg to move.
§ Lord Peyton of Yeovil
My Lords, the noble Lord has shown himself to be an avid reader of reports, in which case—I take that to be the case—he must be a very busy man indeed. I am glad to see him looking in comparatively good health compared with what one would expect.
It seems to me rather strange that the noble Lord should be so keen a reader of the reports when he is such a sharp critic of the contents of much of the literature, if that is the right terms, which is published on these subjects. However, there is one point on which I do rather warmly agree with him. I refer to the appalling jargon which is used in the health service today. They have gone into this proverbial market place and grabbed every epithet they could find and transferred them to the health service whether or not they fitted. Mostly, they do not seem to fit at all.
The noble Lord commented on the PR skills in the health service. The number of questions which are asked about the health service today and the number of people who go round scavenging for something that is amiss mean that the health service has every need of PR skills. Whether those skills are adequate, I do not know, but I would hazard a guess that they consume a great deal of time which might be better used in other ways.
If I may turn to the amendment, I wonder who will write these reports and who will read them. The noble Lord, Lord Carter, is a glutton for punishment. He indicates himself as the first victim of this shower. I hope he will have some pity on himself. Who will be available to write these reports and how much of their time will they take? Who will monitor the information? It seems that we have a passion in this country for looking over everyone's shoulders to see what they are doing. This constant desire to interfere and to question and to have a report must be one of the most foolish activities. It seems to be based on the idea that everyone is either incompetent or dishonest. I think that that is stretching things a little far.
1486 I am reasonably confident that anyone with my noble friend's intelligence and perception will wish the House to reject the amendment but I hope that she will pause in doing so to say a word about the time which would be taken if these activities were to be encouraged.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)
My Lords, with the advice of a Sir Ernest Gowers in Plain Words, I shall try to speak in a simple and straightforward way. The codes of conduct and accountability published in April 1994 by my right honourable friend the Secretary of State make clear the expectation that all those who serve the NHS will maintain high standards of corporate and personal probity. All members of health authorities and trusts are required to confirm their acceptance of the codes which include, among other things, a requirement to declare interests which may be relevant to NHS business.
We introduced these codes so that there would be no doubt about what is expected of NHS members; and having introduced them, of course we intend to monitor how they have been implemented until we are certain that the codes are being followed. It may also reassure your Lordships to know that there is already within the codes a requirement for every health authority and trust to present at least an annual report, a practice that is very often followed by industry and commerce. In that way its performance may be assessed by the NHS Executive on behalf of the Secretary of State, by the Audit Commission and its appointed auditors and also by the local community.
The code of openness in the NHS was published in April this year and will be implemented from 1st June. We shall also monitor the way in which this code is implemented in its early years until we are confident that we have achieved the culture of openness that we are seeking to encourage. Furthermore, there is already an important safeguard in the system since the Health Service Commissioner may investigate any complaints referred to him by the public about the withholding of information. He will publish his own reports on his findings.
The code of practice on open government applies to the Department of Health and will apply to the regional offices of the NHS Executive when, subject to this legislation, regional health authorities are abolished in April 1996. The code does not apply to the NHS and it is not therefore appropriate to consider its monitoring or reporting arrangements under this legislation.
The noble Lord, Lord Carter, raised the issue of complaints. I am sure he will be aware that the complaints procedure has recently been reviewed in line with the Wilson Report. It is because people are aware now that if they make a complaint some action will be taken that they are more encouraged to do so. That partly accounts for the increase in the number of complaints that are received. Indeed, we encourage people to tell local management what needs to be put right and what we can do better within the National Health Service. We tell them the routes open to them in order to make complaints.
1487 From my experience in the direct running of health services, we should always remember that the tributes always far outweigh the complaints. The noble Lord asked about charging under the code of openness. The code makes quite clear that charging should be exceptional. It also states in paragraph 10 that people may complain about the level of charges, which is of course also a safeguard. My noble friend mentioned bureaucracy. He is quite right in that it can grow surreptitiously. It needs to be constantly checked. The whole purpose of the Bill is to reduce bureaucracy by abolishing regional health authorities and a whole tier of administration.
We are committed to ensuring that the codes of openness, conduct and accountability become an established part of the NHS. That is best done through appropriate management actions guided, as necessary, by Ministers and not through the statutory mechanism that has been proposed in this amendment. Therefore, I ask your Lordships to reject it.
§ Lord Carter
My Lords, I am very grateful to the noble Lord, Lord Peyton, for his kind remarks about my ability to read government reports. I can assure him that I get some light relief from reading them. I also read the speeches of the noble Lord in Hansard. They soon send me to sleep.
I referred to the magazine called Health Director produced by the National Association of Health Authorities & Trusts. It refers to the PR skills of executives who negotiate by press release. I remind noble Lords of what happened in the Wessex and West Midlands areas. There were criticisms about national health procedures from the Public Accounts Committee. There was a great deal wrong. We hope that these codes will help to put these matters right. It will take some time, but if it saves the Government the sums of money which were lost in Wessex and the West Midlands, it will be time well spent.
I heard what the Minister said about monitoring, but it is the publication of that monitoring which is so important. I am willing to give way if the noble Baroness can tell the House what in fact the Government intend to do after they have monitored the performance against the codes. Do they intend to publish in full the results of the monitoring?
§ Baroness Cumberlege
My Lords, with the leave of the House, perhaps I may say that the Government have not yet decided on that matter. The first reports are coming through, but we would in no way want to be secretive. Local government is closely monitored and councillors do or do not declare their interests. The same principle will apply to the National Health Service.
§ Lord Carter
My Lords, I am surprised that the Government are unable to take a decision in principle before they have seen the results of the monitoring. However, they intend to make them public and that is significant. Of course the health authorities, the trusts and the department produce annual reports as regards their performance. But it is what is left out of the reports which is so important. How can one criticise an 1488 omission if it cannot be found? For all those reasons it is important to have a much firmer machinery to see that the codes are monitored and the results reported to Parliament.
The Minister mentioned complaints. Perhaps I may remind her of the things which have been left out of the recommendations of the Wilson Committee and the Acting on Complaints document:Publication of complaints statistics by trusts, health authorities and health boards; development of a system for recording and classifying complaints on a UK basis; that all the GP practices and trusts review their complaints handling on at least a quarterly basis and make an annual published report on these reviews to the relevant health authority or board or main purchasers; that organisations regularly find out what their users think about their handling of complaints; and that each Health Department publishes an annual complaints bulletin".Those are the recommendations of the Wilson Committee to which the noble Baroness referred, but they were not included in Acting on Complaints. The answer which the Minister gave was unsatisfactory and I wish to ask the opinion of the House.
§ 3.54 p.m.
§ On Question, Whether the said amendment (No. 1) shall be agreed to?
§ Their Lordships divided: Contents, 74; Not-Contents, 156.1490
|Division No. 1|
|Acton, L.||Jeger, B.|
|Addington, L.||Jenkins of Putney, L.|
|Airedale, L.||Judd, L.|
|Allen of Abbeydale, L.||Listowel, E.|
|Archer of Sandwell, L.||Lockwood, B.|
|Ashley of Stoke, L.||Longford, E.|
|Avebury, L.||Lovell-Davis, L.|
|Birk, B.||McFarlane of Llandaff, B.|
|Blackstone, B.||McIntosh of Haringey, L.|
|Broadbridge, L.||McNair, L.|
|Bruce of Donington, L.||Mayhew, L.|
|Callaghan of Cardiff, L.||Milner of Leeds, L.|
|Carter, L. [Teller.]||Molloy, L.|
|Castle of Blackburn, B.||Monkswell, L.|
|Clinton-Davis, L.||Morris of Castle Morris, L. [Teller]|
|Diamond, L.||Nicol, B.|
|Donaldson of Kingsbridge, L.||Northfield, L.|
|Donoughue, L.||Perry of Walton, L.|
|Dormand of Easington, L.||Peston, L.|
|Elis-Thomas, L.||Rea, L.|
|Exeter, Bp.||Richard, L.|
|Falkender, B.||Rodgers of Quarry Bank, L.|
|Falkland, V.||Sainsbury, L.|
|Farrington of Ribbleton, B.||Serota, B.|
|Gallacher, L.||Shepherd, L.|
|Gould of Potternewton, B.||Smith of Gilmorehill, B.|
|Graham of Edmonton, L.||Stallard, L.|
|Harris of Greenwich, L.||Stedman, B.|
|Haskel, L.||Strabolgi, L.|
|Hayter, L.||Taylor of Blackburn, L.|
|Hilton of Eggardon, B.||Tordoff, L.|
|Hollis of Heigham, B.||Turner of Camden, B.|
|Howell, L.||Wallace of Coslany, L.|
|Howie of Troon, L.||Williams of Crosby, B.|
|Hughes, L.||Williams of Elvel, L.|
|Jay of Paddington, B.||Williams of Mostyn, L.|
|Aberdare, L.||Harlech, L.|
|Addison, V.||Harmsworth, L.|
|Ailsa, M.||Harrowby, E.|
|Aldington, L.||Henderson of Brompton, L.|
|Alexander of Tunis. E.||Hives, L.|
|Allenby of Megiddo, V.||Hogg, B.|
|Alport, L.||Hood, V.|
|Ampthill, L.||Hooper, B.|
|Archer of Weston-Super-Mare, L.||Howe, E.|
|Astor, V.||Iddesleigh, E.|
|Astor of Hever, L.||Inglewood, L. [Teller.]|
|Belhaven and Stenton. L.||Jenkin of Roding, L.|
|Bellwin, L.||Kinnoull, E.|
|Beloff, L.||Lauderdale, E.|
|Blake, L.||Lindsay, E.|
|Blaker, L.||Long, V.|
|Blatch, B.||Lucas, L.|
|Blyth, L.||Lucas of Chilworth, L.|
|Boardman, L.||Lyell, L.|
|Borthwick, L.||McColl of Dulwich, L.|
|Boyd-Carpenter, L.||McConnell, L.|
|Brabazon of Tara, L.||Mackay of Clashfern, L. [Lord Chancellor.]|
|Brougham and Vaux, L.|
|Bruntisfield, L.||Malmesbury, E.|
|Burnham, L.||Manchester, D.|
|Butterworth. L.||Marlesford, L.|
|Cadman, L.||Merrivale, L.|
|Caldecote, V.||Mersey, V.|
|Campbell of Alloway, L.||Milverton, L.|
|Campbell of Croy, L.||Monteagle of Brandon, L.|
|Carnegy of Lour, B.||Mottistone, L.|
|Carnock, L.||Mountevans, L.|
|Chalker of Wallasey, B.||Mowbray and Stourton, L.|
|Charteris of Amisfield, L.||Moyne, L.|
|Chelmsford, V.||Munster, E.|
|Chesham, L.||Murton of Lindisfarne, L.|
|Clark of Kempston, L.||Nelson, E.|
|Clifford of Chudleigh, L.||Noel-Buxton, L.|
|Cochrane of Cults, L.||Norrie, L.|
|Coleridge, L.||Northesk, E.|
|Constantine of Stanmore, L.||O'Cathain, B.|
|Courtown, E.||Oppenheim-Barnes, B.|
|Craigavon. V.||Orkney, E.|
|Cranborne, V. [Lord Privy Seal.]||Orr-Ewing, L.|
|Cullen of Ashbourne, L.||Palmer, L.|
|Cumberlege, B.||Pearson of Rannoch, L.|
|Dacre of Glanton, L.||Pender, L.|
|De Freyne, L.||Perry of Southwark, B.|
|De L'Isle, V.||Peyton of Yeovil, L.|
|Dean of Harptree, L.||Pike, B.|
|Denham, L.||Plummer of St. Marylebone, L.|
|Digby, L.||Pym, L.|
|Dixon-Smith, L.||Rawlings, B.|
|Downshire, M.||Rennell, L.|
|Dudley, E.||Renton, L.|
|Eccles of Moulton, B.||Richardson, L.|
|Elles, B.||Seccombe, B.|
|Elton, L.||Shannon, E.|
|Faithfull, B.||Sharples, B.|
|Ferrers, E.||Shaw of Northstead, L.|
|Finsberg, L.||Shrewsbury, E.|
|Foley, L.||Skelmersdale, L.|
|Fraser of Kilmorack, L.||Stewartby, L.|
|Gainford, L.||Strange, B.|
|Gardner of Parkes, B.||Strathcarron, L.|
|Geddes, L.||Strathclyde, L. [Teller.]|
|Goschen, V.||Sudeley, L.|
|Gray, L.||Suffield, L.|
|Haig, E.||Swansea, L.|
|Hailsham of Saint Marylebone, L.||Terrington, L.|
|Halsbury, E.||Thomas of Gwydir, L.|
|Trefgarne, L.||Westbury, L.|
|Trumpington, B.||Wharton, B.|
|Ullswater, V.||Whitelaw, V.|
|Vaux of Harrowden, L.||Wise, L.|
|Vivian, L.||Wynford, L.|
|Wade of Chorlton, L.||Young, B.|
§ Resolved in the negative, and amendment disagreed to accordingly.
§ 4.2 p.m.
§ Schedule 1 [Amendments]:
§ Baroness Jay of Paddington moved Amendment No. 2:
Page 5, line 21, at end insert:
(" "(c) other persons with professional expertise in and experience of social care," ").
§ The noble Baroness said: My Lords, this amendment seeks to ensure that the new health authorities must secure advice from people with social services expertise and experience in the same way as they will be required to take advice from healthcare workers.
§ On Report, I moved an amendment to make the chairman of the relevant social services committee a full member of each health authority board. In reply, the noble Baroness, Lady Miller, said that that would not accord with the Government's wish that non-executive members of health authority boards should all be generalists (col. 755 of the Official Report of 24th April). The noble Baroness restated that the Government are opposed to representatives of any outside bodies serving on health authorities. Although we do not agree with that position, I acknowledge that the Government will not at this stage be moved from it.
§ However, throughout our debates on the Bill and at other opportunities in your Lordships' House, great emphasis has been placed on the need for co-operation and collaboration between local health and social services agencies. Ministers have often spoken of their ambition to move more and more health services out of hospitals and into the community, and to improve health education and promotion through the so-called "healthy alliances" between different types of agency. Those goals will be smoothly and properly achieved only by formally establishing strong working links between health and social services authorities.
§ I expect that in reply the Minister may repeat what the noble Baroness, Lady Miller, said on Report: that mechanisms such as joint consultative councils already exist and that, in general, it is best to rely on good practice and the local development of good personal relations. However, as we discussed on Report, joint consultative committees have a very limited power and agenda. The noble Baroness, Lady Miller, and I discussed our relative experiences of serving on such committees—hers was happier and more fulfilling than mine. Whatever the relative personal experiences, I am not sanguine about leaving very important matters, such as continuing and community care for the elderly, the mentally ill and the young disabled solely to the insubstantial hope of good practice in every health authority or to the rather frail mechanisms of organisations such as joint consultative committees.1491
§ The boundaries of health and social care are becoming increasingly blurred. The confusion about financial responsibility for different services is creating tensions and difficulties in many areas across the country, and in many areas local authorities often resent what they see as an additional burden on their tight budgets. If health and social service agencies are arguing about their relative responsibilities, the people who are suffering are their clients, their patients. I was talking this week to an executive director of a London health authority who was pleased by the development of good informal relations with social services colleagues in her borough, but she cautioned me at the same time that that was by no means universal. In her graphic phrase, "There's war out there".
§ We have a duty in framing the legislation to try to do everything that we can to ensure that the services that are often needed by the most vulnerable members of our society are delivered to a high standard throughout the country. If every health authority is required, as it would be by the amendment, by statute to take advice from social services, that would go some way towards establishing national standards of care.
§ The Government clearly think that it is essential that health authorities receive advice from people with experience and expertise in healthcare—from general practitioners, nurses and midwives among others. That is contained in the provisions of Schedule 1(3) as it now stands. Amendment No. 2 would strengthen the pool of professional advice available to health authorities by including those with the kind of social services experience and expertise that will be essential for the development of the National Health Service. I beg to move.
§ Baroness Cumberlege
My Lords, I welcome this opportunity to debate an important aspect of health authority responsibilities: that of working with statutory, voluntary and private social care organisations to secure effective and co-ordinated provision for a range of needs.
I have made clear in previous debates that the Government are committed to close working between the new health authorities and local authorities on many issues, but especially on community care. There are mechanisms already in place to help health authorities and local authorities to comply with their statutory duty of co-operation. In particular, there are the joint consultative committees. I appreciate, however, that the noble Baroness has highlighted that there are mixed views on this, but joint consultative committees will continue after the reorganisation and we expect that their work will be made considerably easier by the streamlining of local NHS authorities in this Bill.
The high priority that the Government give to co-operation on community care issues is reflected in a great deal of guidance issued in recent years. The guidance issued in February onNHS responsibilities for meeting continuing care needsreinforces the need for effective local and health authority collaboration. Specific guidance on joint commissioning is being issued to local authorities and health authorities shortly. The guidance has sought to clarify the responsibilities of the different agencies and to ensure that they evolve effective means of working together.
1492 This amendment deals with a particular aspect of that co-operation: securing professional advice. Your Lordships will be aware that we have been consulting on draft health service guidelines on the importance of health authorities involving professionals in their work and some ways in which they might do that. The draft guidelines carefully distinguished between involvement of staff working in the NHS (who would often be directly approached for advice) and involvement of staff working for other agencies, such as local authorities, where the normal protocol would be for the approach to be made more formally and as part of an inter-agency agreement.
We fear that the amendment might have the effect of clouding the respective role of health care and social care authorities. The Bill currently makes clear that health authorities must make arrangements to take advice from health care professionals. I think that there would be a danger of undermining the role of, for example, social services departments, if health authorities were also required to take advice from social care professionals. The correct route for that advice, in so far as it affected health care, would be through inter-agency working. We must maintain parity of roles to avoid placing obligations on health authorities, which might result in their second guessing the social care agencies. I therefore invite the noble Baroness to withdraw the amendment.
§ Baroness Jay of Paddington
My Lords, I am grateful to the Minister for that reply. The only phrase which surprised me slightly was the one about clouding the boundaries between social and health care, because it seems to me that in the development of health and social services, particularly in the fields of continuing and community care, we are seeing the clouding of those boundaries with what I had thought were intended to be positive results.
I am aware, as I said when moving the amendment, that there have been considerable difficulties about financial responsibilities between local authorities and health authorities. To describe the merging, as it were, of social and health care as clouding the boundaries in a pejorative sense is surprising. There will obviously be some further development of inter-agency working. The purpose of the amendment is to give that structure a formal mechanism and to ensure that all health authorities, both good and bad, would be forced to take the appropriate advice to help them through their new responsibilities for community care on both sides of the fence.
However, it is something upon which, in a sense, we shall never agree, because it concerns the formality of mechanisms and the understandings that we on this side of the House would like to see in regard to representation on health authorities of people with additional responsibilities which affect health care. As I say, this reflects a fundamental difference, but at this stage of the Bill I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.1493
§ Baroness Jay of Paddington moved Amendment No. 3:
Page 5, line 24, at end insert:
("(1 A) Every Regional Chairman shall make arrangements for securing that they receive from universities with undergraduate medical and dental schools advice appropriate for enabling the Health Authorities in their region effectively to exercise the functions conferred or imposed on them under or by virtue of this or any other Act." ").
§ The noble Baroness said: My Lords, this amendment too is concerned with professional advice. In earlier debates, we on these Benches, the noble Lord, Lord Walton of Detchant, and others, expressed concerns about the possibility that links between academic medicine and the health service will be seriously weakened by the new arrangements proposed in the Bill. Potentially, the weakest link in the chain is at the regional level, and yet that is the crucially important level at which the academic world of medicine should be concerned with the health service.
§ That is where, until now, postgraduate medical deans have been full members of the RHAs, and where the complicated, but nonetheless essential, joint funding arrangements between the university medical schools and the NHS have been managed. The Department of Health now funds directly a large number of academic posts across the country. In some medical schools, I understand as many as 40 per cent. of clinical academic posts are funded through the health service. That is obviously of great mutual benefit to all the institutions involved and it is of great benefit to the patients and users of the health service. The link contributes greatly to this country's tradition of excellence in academic medicine and NHS care.
§ The universities have been given undertakings that that form of funding (support for those clinical posts) will continue, but precisely how the systems will be managed is still in doubt. There are no clear provisions in the Bill to create statutory mechanisms to organise joint funding nor to create joint working arrangements to ensure that the views and ideas of the medical and dental schools are available automatically to the NHS.
As so often in the Bill, the Government seem to be relying upon the development of good practice to solve everything. In Committee, I drew attention to correspondence earlier this year between the Secretary of State for Health and the chairman of the CVCP. The Secretary of State said that the regions had been reminded to take account of the views of university's inappropriate circumstances, but Dr. Edwards, chairman of the CVCP, writing in March replied that that was not good enough and,
given the very great uncertainties ahead, it is our view that a formal mechanism which is clear and unambiguous needs to be in place from the start".
The Minister has told your Lordships that since then informal discussions have taken place to try to resolve that issue, but, so far as we know, nothing has yet been agreed about regional arrangements—certainly nothing appears on the face of the Bill. On Report, the noble Lord, Lord Walton, said:
Surely it is not beyond the wit of man to devise a mechanism whereby universities can play a major statutory, advisory role at regional level"—[Official Report, 24/4/95; col. 749.]
I can only echo those words. Amendment No. 3 is designed to assist the wit of man to achieve precisely that purpose.
§ We know that the Government will not accept outside representation on the management boards of the new regional offices, but, as the Minister said on Report, regional chairmen will have a special responsibility even in that area. Amendment No. 3 seeks merely to bind those regional chairmen to securing advice from the universities in the same way that the local health authorities will be statutorily bound to involve local health professionals under Schedule I. In that way, the regional chairmen will have a formal stimulus to establish the kind of mechanisms the Minister commended on Report, to include the vital contribution of university representatives. I beg to move.
§ 4.15 p.m.
§ Lord Addington
My Lords, I support the amendment which has to it the name of my noble friend Lady Robson. To suggest that the new health authorities receive advice from the academic medical establishment is not unreasonable or radical. As the noble Baroness said, to rely on good practice taking place in the future is chancy, because it may not take place. By having on the face of the Bill, "you shall consult" overcomes that problem, and will result in that necessary contact. I support the amendment strongly.
§ Baroness Cumberlege
My Lords, the amendment seeks to place a formal requirement on regional offices to set up liaison arrangements with universities. It would not be workable in its present form, and, more importantly, it is entirely unnecessary. I fully understand the reasons why the noble Baroness has tabled the amendment. I know it reflects the more widespread concern that the relevant interests of universities and their medical and dental schools might somehow be overlooked after RHAs have been abolished.
I can reassure the noble Baroness that there is no need for a new statutory provision to ensure that that does not happen. Effective liaison arrangements, both formal and informal, are currently in place, even though most of them are not required by legislation. Indeed, the recent report from the Joint Medical Advisory Committee of the Higher Education Funding Councils presents a very favourable picture of the effectiveness of liaison between NHS trusts and medical schools. There is no reason why that should be undermined once RHAs are abolished, nor will we allow it to be.
I have previously referred to the 10 key principles in your Lordships' House, during debates on the Bill. They provide a very clear and firm statement of the need for effective liaison. The Joint Medical Advisory Committee's report says that they are working well. The amendment proposes a statutory provision which is so vague that I believe it might well undermine the effectiveness of the 10 key principles. People might say, "We meet our statutory requirement, why should we comply with the 10 key principles as well?" We would not want that to happen.
1495 My right honourable friend the Secretary of State has also made it clear to the regional chairmen, who are all members of the NHS Policy Board, that she expects them to take a particular interest in ensuring that there is good liaison between the NHS in their region and universities. Any problems will then come swiftly to our attention and can be dealt with quickly and effectively.
Finally, I should also report that a meeting has been arranged between senior people in the Committee of Vice-Chancellors and Principals and senior officials of the NHS Executive (including the chief executive) on 9th May. They will discuss the question of appropriate arrangements for effective liaison between regional offices and universities. I am sure that that meeting will be constructive and productive.
I hope that I have made it clear that the amendment would not be workable and is in any case entirely unnecessary. I invite the noble Baroness to withdraw it.
§ Baroness Jay of Paddington
My Lords, I thank the Minister for that reply, in particular for the information about the further meeting between the CVCP and the Department of Health on 9th May. We have had lengthy discussions about the subject during the various stages of the Bill. It is unfortunate that the final meeting to resolve the matter will take place after the Bill has passed all its stages in another place and in this House.
The arrangements are of great concern to the academic medical community and, as I have stressed several times in this House, to those of us who are anxious about the excellence of patient care. It is unfortunate that such important matters have been left until the last minute before being resolved and that they will be resolved when we will be unable to discuss them in the course of dealing with this legislation.
However, on the understanding that progress is being made towards an agreement with the Committee of Vice-Chancellors and Principals, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness McFarlane of Llandaff moved Amendment No. 4:
§ Page 19, line 32, at end insert ("including at least one officer who is a registered nurse and who has had, in the twelve months immediately preceding his or her appointment, experience of managing services to patients.").
§ The noble Baroness said: My Lords, I rise to move the amendment standing in my name on the Marshalled List. To do so may appear to he tedious in the light of the lengthy consideration given to the principle of professional representation and related amendments at each stage of the Bill. However, I have looked at the Minister's replies to the amendments, pleading not for professional representation but for a representation of the expertise that nurses bring to health authorities. In every case, the replies were in terms of professional representation.
§ I am the first to agree—as we did after the Second Reading and the Committee stage—that to plead for professional representation of every profession in the health service would be impossible. But it is the expertise which nurses bring to a health authority for which I plead.1496
§ If no obligation is laid on the authorities to include within their membership a registered nurse who has experience of managing services to patients that would create a notable departure from historical precedents. Your Lordships' House will know that since the days of Miss Nightingale the history of the health services of this country has been punctuated by a succession of redoubtable ladies—and in some cases gentlemen—who have managed those services with great expertise. They achieved national eminence as a result.
§ Since the first National Health Service reorganisation in 1974 each district health authority has had an executive nurse director. To manage the service without a lead nurse at each level would be departing from historical precedent. The chief nurse has not been in lead positions on health authorities as a professional representative. She has been there as an indispensable contributor to the work of the health authorities at every level. The reasons for that were well rehearsed during previous stages of the Bill. They include the size of the nursing service; its sophistication and complexity; its specialist roles; its intimate impact on patient care and on all other services; and the intricacies of skill mix.
§ Nurses provide 80 per cent. of the direct patient care and the cost of the nursing service is 40 per cent. of current National Health Service expenditure. It is unthinkable to leave the policy decisions of that great resource to the vagaries of personnel or lay managers, or even to the directors of public health who have no special knowledge of the manpower and legal requirements of the service. At district health authority level I have witnessed attempts at that and I have been appalled at the outcomes and failures in patient care that have resulted.
§ The Minister herself has endorsed the crucial contribution of nursing to the purchasing function. On Second Reading she expressed the view that she would be very surprised if the majority of health authorities did not appoint executive members with nursing experience. I refer your Lordships to col. 70 of the Official Report of 6th March.
§ Current evidence appears to be to the contrary. At the beginning of the year the Royal College of Nursing conducted a survey which revealed that only half of the district health authorities and the family health service authorities currently have nurses in executive positions on their boards. More significant is the Government's own research, Creative Career Paths in the NHS. A study by consultants for the NHS women's unit reported in March this year and showed that only 58 per cent. of the purchasing organisations surveyed had a nurse at director level.
§ For the purposes of our argument today, these trends can only impoverish the health service further as it diminishes the number of those who are available to take executive roles on purchasing authorities. I believe that the real argument for an executive member with experience of managing services to patients lies in the necessary expertise that they bring to the work of the authority. That was amply illustrated by the study commissioned by the nursing directorate of the NHS Executive. It took the form of structured interviews with chief executives and nurses working in purchaser organisations. It listed the contribution that nurses can 1497 make to purchasing. To summarise: they can challenge clinical practice because they are clinically credible; they can challenge the basis of prices because they have a breadth of practical experience across clinical areas, understand how nursing costs are calculated and have experience of managing budgets; they can evaluate alternatives because they have worked at the sharp end of "care"; they can interpret users' needs; and they can contribute to quality because they have working experience of setting up quality standards in processes and procedures and see quality from the users' point of view.
§ I spoke to an executive nurse on a health authority and I asked her what contribution she makes to the work of her authority in purchasing. She stated that she is able to give advice on nursing skill mix changes being proposed by a provider unit. She is able to provide a nursing focus on complaints and untoward incidents. She leads the quality standards programme for the health authority. She facilitates the involvement of users in commissioning and contributes to health needs assessment work. She advises on value for money in contracts. She contributes specialist knowledge and expertise in contracting for different care groups, and so forth. It is difficult to conceive how a health authority can function adequately without such expertise at its immediate disposal and not just at an advisory level.
I conclude by quoting the secretary to the Welsh Board of the Royal College of Nursing. She states:
There is no doubt that the proper exercise of those statutory functions of the Authority which relate to nursing or midwifery practice or to the protection of the public will continue to require the expertise and vigilance of the most senior of nurses and for which that nurse will be accountable to the United Kingdom Central Council which endorses, strongly, the claim now being made".
I beg to move.
§ 4.30 p.m.
§ Lord Addington
My Lords, this is a reasonable amendment which provides that representatives of the nursing profession shall be included on all health authority boards. As the noble Baroness has just told us, nurses provide over three-quarters of the actual contact with patients and are involved at virtually every level of treatment. However, a survey conducted at the beginning of the year showed that half of the boards currently do not have a member of the nursing profession in an executive position.
It just does not seem to make sense that there is no representative of the nursing profession, which has most of the direct contact with patients. I suggest that the Government should look again at this matter because it is not sufficient to say that they would expect there to be some form of representation for the profession which provides the majority of contact with patients.
§ Lord Carter
My Lords, on these Benches, we are pleased to support this amendment. In moving the amendment, the noble Baroness, Lady McFarlane, set out the arguments extremely clearly. Perhaps I may repeat the crucial statistic which she mentioned. Nurses are the largest professional group in the health service, providing 1498 80 per cent. of direct patient care. The noble Baroness explained why the profession should be involved in the way which the amendment proposes.
Like the noble Baroness, I noticed the remark which the Minister made on Second Reading to the effect that she would be very surprised if the majority of health authorities did not appoint executive members with nursing experience. We need something rather stronger than ministerial surprise in this instance.
On a previous amendment I quoted from an excellent article in Health Director, which is produced by the National Association of Health Authorities and Trusts, by Mr. Ian Wylie who is head of communications at the King's Fund. He gives a very good summary of the operation of the health service. He says:The present operation of health services involves a constant and complex interaction of six elements: professionals. purchasers, providers, patients, public and politicians".I notice that it is also rather alliterative. He goes on to say:Each of these six parts must work with and influence each of the others to reach a balance which is the best solution for healthcare. As health services cannot function without an effective interplay of the six partners so the communication processes for health services must also involve all partners".It would seem to me that if it is to involve all those partners, the paragraph sums up the situation extremely well. If there is to be an effective interaction and interplay between all parties, there should be a means of ensuring that nurses are represented.
I do not believe that other professionals would be offended if the nurses were represented because of the very vital role which they play in terms of their skill and expertise and the sheer weight of their involvement—80 per cent. of direct patient care. I hope that the Minister will feel able to accept the amendment.
§ Baroness Cumberlege
My Lords, first, I thank the noble Baroness for giving me notice of this amendment. I should like to take this opportunity to apologise to her for stating at an earlier stage in the passage of the Bill that she was a vice-president of the Royal College of Nursing. In fact, she is a fellow of the Royal College which, in my view, is a much more exalted position because it must be earned professionally.
Perhaps I may also thank the noble Lord, Lord Addington, for filling in for the noble Baroness, Lady Robson, at very short notice.
We have debated the question of nurse membership at each stage of the Bill's passage. I recognise that the continuing debate is not just special pleading for a particular group. It reflects the very real conviction that the involvement of nurses in purchasing will lead to better services for patients.
It is easy for me to talk about the essential contribution which nurses make to the work of health authorities—and I strongly believe that nurses have distinctive experience to bring to bear on purchasing. But words need to be backed up with actions. The Government have demonstrated in many material ways that they value nurses, and trust their professional skills; for example: our nurse prescribing initiative extends the role and influence of nurses. We believe it will be shown to bring genuine benefits both to patients and staff.
1499 Over £400 million has been made available to support the introduction of Project 2000, which is achieving higher standards of education and training for nurses. Project 2000 students are educated to become flexible, innovative and accountable practitioners in both hospital and community settings. Better trained nurses means better care for patients, and, as the Royal College of Nursing reminds us, as did the noble Baroness today, nurses have 80 per cent. of direct patient care. Practice nurse numbers have grown significantly over the past 12 years. They have significantly enhanced the skills of primary care teams.
The Changing Childbirth initiative is helping midwives to strengthen their position in the routine care of women during labour. The Government have provided significant funding for the initiative, including support for a full-time implementation team; for 14 development projects last year; and £1 million for further investment this year. NHS trusts have created new opportunities for nurse leaders with the establishment of executive director posts.
Those initiatives, more than anything I can say today, speak of our commitment to the nursing contribution. I believe that they should reassure nurses that we mean what we say in the draft guidelines on professional involvement which we issued earlier in the year. The guidelines call for nurses to be involved in planning and purchasing of health services, in clinical effectiveness strategies, in the inspection of nursing homes, child protection, midwifery supervision, Mental Health Act responsibilities and many other areas. They point out that nurses are playing a key role as health authority employees. The new statutory duty to involve professionals, introduced in another place, will enhance that role. Perhaps I may quote briefly from the draft guidelines:The skills and knowledge which nurses bring include an appreciation and clear understanding of health care drawn from practical experience across all clinical areas, an ability to challenge clininal practice and an understanding of … how staffing and skill mix can be fine-tuned to achieve optimum use of resources.The guidelines make clear that the regional offices will he monitoring the arrangements made by health authorities to ensure that they command the confidence of the professions locally. If the new arrangements do not command the confidence of the nursing profession, I can assure your Lordships that the regional offices will take action.
The noble Baroness, Lady McFarlane, mentioned the IHSM survey. We are not complacent about the findings of that report, but I should like to point out that the figures are moving in the right direction. The 58 per cent. of purchasers with a nurse at director level compares with only 40 per cent. in the 1992 survey.
We recognise that the noble Baroness is proposing an amendment which she feels will guarantee a full nursing contribution to the work of the new health authorities. Although I fear that we shall not reach full agreement on this issue, I hope that I have been able to convince her that our disagreement is about the appropriate means, not about the desirable end. I have emphasised in previous debates that membership is not the only or, we believe, the most important way to achieve a nursing input. I have 1500 spoken before about the role of nurses as health authority employees, as expert advisers, as members of review teams, and so on.
We agree with the noble Lord, Lord Carter, that a broad and integrated involvement is what we will be looking for and we believe that it is more effective than relying on a single nurse member. Three of the five executive posts are already filled—by the chief executive, director of finance and director of public health. We believe that we must leave it to the judgment of the chairman and the non-executives to fill the remaining two executive posts with the officers whose skills best match local needs. I regret, therefore, that I cannot support the amendment.
§ Baroness McFarlane of Llandaff
My Lords, I thank the noble Baroness for her personal generosity and also for the many things which she has done personally for the profession and the contribution which she continues to make in that direction.
However, I do not believe that the catalogue of measures to which she has referred, such as Project 2000, dear as that is to my heart and, I know, to hers, really answers the question about having a nurse with expertise on every health authority. But I take the point that she has made and am reassured to a certain extent.
I shall watch developments with interest because, at present, I do not think that I can put a vote of confidence in the membership of the health authorities. But, at this stage of the proceedings, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Baroness Cumberlege moved Amendment No. 5:
§ Page 30, leave out line 13 and insert:
§ (2) In section 29").
§ The noble Baroness said: My Lords, in moving the above amendment I shall speak also to Amendments Nos. 6 and 7. We discussed at Report stage the future arrangements for the contracts of registrars and senior registrars. As I explained then, the employment contracts of these staff are currently held by regional health authorities and need to be held elsewhere when RHAs are abolished.
§ There are in fact a number of staff whose contracts of employment are at present held by regional health authorities and who are undertaking rotational training programmes which require them to move regularly between different NHS employers. Clearly, when RHAs go, new arrangements need to be made for these staff.
§ Junior doctors and dentists in the registrar and senior registrar grades are the largest group affected. Others affected include clinical psychology trainees, finance and general management trainees and some pharmacy and scientist training grades.
§ While the contracts of these staff are held by regional health authorities, they can move between different NHS bodies as part of their training without losing the employment rights which depend upon serving a period of continuous employment. The most obvious place for contracts to be held in future is with the NHS trust or other NHS employer. The provisions in Schedule 2 to the Bill 1501 ensure that there is protection of continuity for staff who move from RHAs to other NHS bodies on 1st April 1996. However, without the amendment, the continuity of employment of those trainees would be broken on any subsequent moves between NHS employers.
§ It is an important matter. The Government recognise that the way the contracts are handled in future could affect those employment rights which depend upon serving a minimum period of continuous employment. For example, both protection against unfair dismissal and the right to return to work after maternity leave depend upon having served two years with one employer.
§ Staff in these training grades must move regularly between employers in order to gain a high standard of professional training. We need to ensure that there are no obstacles to discourage them from moving. That is what the government amendments are designed to achieve.
§ The Government have made clear that their preferred option for these staff is for their employment contracts to be held by their employer—usually an NHS trust. That is consistent with the treatment of other staff. It is consistent with the principle that personnel issues are generally best managed at local employer level; and with trust freedoms to determine the quantity and type of resources that they employ.
§ Devolving contracts to employers is still a matter for discussion with the various professional bodies representing such staff. I hope that the amendment will offer them a significant reassurance. It enables the Secretary of State, by order, to specify particular groups of staff undergoing professional training which involves moving between NHS employers. For these staff, employment with successive employers as part of their training programme will be treated as continuous employment for employment protection purposes. In other words, the employment rights of these staff will be exactly the same as if their contracts had continued to be held by the RHA.
§ I am aware that particular concern has been expressed that transferring junior doctors' contracts to NHS trusts might cause problems for maintaining the required level or standards of training. We have just completed consultation on a discussion document which sets out the various options and possibilities for the employment arrangements of junior doctors, including their contracts. That is set in the context of an overall strategy for the organisation and management of postgraduate medical education. The document was issued widely to representatives of the medical and dental professions, to the education bodies and to employers' representatives. We will take careful account of the comments received before final decisions are taken. The amendments do not in any way pre-empt that consultation, or the various discussions going on with professional bodies. They simply ensure that, where trainees are employed by more than one NHS body during their training, continuity of employment can be safeguarded.
§ Your Lordships may wish to know why we thought it appropriate to specify in subordinate legislation the categories of staff to whom the new paragraph is to apply. It is to enable us to ensure that the necessary protection is provided not only to the grades currently employed by RHAs but to any equivalent successor grades which may 1502 in future replace them. I should, however, make clear that the intention is not to extend further the employment rights of these staff but to preserve their existing rights. We have no plans to use the power to provide for categories of staff not currently employed by RHAs.
§ I will now turn to the amendment tabled in the name of the noble Baroness, Lady Jay. That amendment seeks to provide for postgraduate deans to be health service employers for the purposes of the government amendments. I can assure your Lordships that NHS authorities listed as employers in the government amendment encompass the full range of potential employers for the staff concerned after 1st April 1996.
§ I would be entirely inappropriate for deans to be added to the list of employers. They are not health service bodies. No other individuals are statutorily designated as employers within the NHS; nor are any other NHS staff employed by individuals in the way that the amendment would suggest. The postgraduate deans will themselves be employees of one or more other bodies. Decisions are yet to be made about the various options in our discussion document, but there is even a possibility that the deans might in future be employed outside the NHS.
§ I hope that I have made clear that the amendment would not be workable and that, therefore, the noble Baroness will consider withdrawing it. I invite your Lordships to agree to the government amendments which, we believe, provide a helpful and necessary safeguard. I beg to move.
§ 4.45 p.m.
§ Lord Rea
My Lords, I should like to take the opportunity to speak to Amendment No. 7 which is included in the current group of amendments. We tabled the amendment in order to allow us to continue the discussion on postgraduate and continuing medical education. In fact, at each stage of the Bill in this House the matter has been discussed. We need to continue to discuss the matter because, despite what the Minister said, we are still not quite certain about how the Government intend to safeguard the training component of the contracts of junior hospital doctors, notwithstanding the issue of a document during the Committee stage giving options for postgraduate, medical and dental education.
As the Minister said, even while the Bill has been going through the House, consultations and discussions are still taking place with universities, the British Medical Association, postgraduate deans and Royal Colleges. We do not yet know the Government's intentions. It would he useful to us if the Minister could, perhaps, expand a little on how far those deliberations have gone and tell us about the Government's current thinking on the matter.
To allow the contracts of junior hospital doctors in training posts—that is, registrars and senior registrars, as they will be in a unified grade in future—to be held by a regional "post-graduate Dean", as suggested in the amendment, would ensure that contracts were drawn up so as to allow adequate time and facilities for post-graduate studies to be made available, as is the case at present. I understand that it is the Government's intention that regional postgraduate deans will remain in post, possibly partly university funded and partly NHS 1503 funded, and that they will work in conjunction with the regional offices of the National Health Service Executive, which will be the successors to the regions.
I also understand that postgraduate deans will continue to have a supervisory role in the educational part of junior doctors' contracts. However, a drawback to that arrangement is that the postgraduate deans will, at least in part, become civil servants if they are employed through those offices and that they will, therefore, lose some of their independent status.
However, we feel that by relinquishing overall administration of the junior doctors' contracts to a trust—as the noble Baroness has said—or possibly a group of trusts, as the Government amendments would allow, the postgraduate deans will lose their bargaining power on behalf of junior doctors. For example, if a trust is hard pressed financially or it has an increased workload, it will be tempted to cut down on the time allowed for training activities and to increase pressure on junior doctors to carry out purely service activities. That is likely to occur partly because of the move—it was a welcome move—to reduce the hours of junior doctors, especially for house officer and senior house officer grade. This will increase the pressure on registrars to perform faster and to see more patients. That tendency is already occurring because of the increasing use of technology and more rapid turnover through hospitals.
There is a real need for a powerful independent voice from postgraduate deans to ensure that these pressures do not squeeze postgraduate medical education out of junior doctors' timetables. It would be some comfort if the noble Baroness could state that the contracts for junior doctors in training could be uniform nationally so that individual trusts could not modify them to suit their own needs, with adverse consequences for training. The British Medical Association is keen that contracts should be established on a national basis. It states:The reason that national terms and conditions of service for junior doctors was agreed at the time of the NHS and Community Care Act was because it was feared that juniors would be particularly vulnerable to exploitation by trusts. It is essential that all junior doctors continue to be employed on national pay and terms of service, and there must be no question of any local deviation".That, unfortunately, would appear to be possible under the arrangements that are being developed. The amendment allows contracts to be held by a postgraduate dean. I agree with the criticism that the noble Baroness has put forward about employment by a single person. That was suggested simply in order to stimulate discussion at this stage of the Bill. But in order for that to function a supportive administrative apparatus would have to be in place. That should not be difficult because the structure is there in the regional health authority set-up. That structure could be transferred to a special health authority. In fact a special health authority is one of the bodies mentioned in the noble Baroness's amendments. That is the British Medical Association's preferred approach.
The BMA proposes,a special health authority arrangement for holding contracts of postgraduate deans which could assume responsibility for all doctors in training within the region. It would have the benefit of establishing 1504 a clearly identifiable purchaser of medical education and training within the existing NHS system of management, with clear lines of accountability".This would preserve the strategic planning function of the present regional structure with regard to manpower planning and training needs for future numbers of consultants, as well as preserving the degree of independence for postgraduate deans which they need in order to protect the interests of junior hospital doctors.
§ Baroness Cumberlege
My Lords, perhaps I could reassure the noble Lord, Lord Rea, that it really would not be proper for individual deans to be employers. Nor would it be appropriate for the contracts of junior doctors, or indeed other trainees, to be held in the same place as the deans' contracts. Deans may be employed in the regional offices as part of the Civil Service. It would not really make sense for the junior doctors, for whom the deans are responsible, also to be civil servants. Alternatively, the deans may be employed—as I have said already—outside the NHS. It would not be proper or sensible for staff providing essential NHS services to be employed outside the service.
I think the noble Lord also asked about safeguards for training. These will be achieved through educational contracts between the deans, trusts and junior doctors. The deans, of course, will also continue to fund 50 per cent. of the basic salary costs, as they do now. With regard to the consultation document, it was drawn up in close collaboration with the deans. We have had 100 responses to the document. We have not yet had a full opportunity to consider them all. I have listened carefully to the points made by the noble Lord, but of course those points do not affect the government amendments which are before your Lordships this afternoon.
§ On Question, amendment agreed to.
§ Baroness Cumberlege moved Amendment No. 6:
Page 30, line 21, at end insert:
("(3) In Schedule 13 (computation of period of employment)—
"18B.—(1) If a person employed in relevant employment by a health service employer is taken into relevant employment by another such employer, his period of employment at the time of the change of employer shall count as a period of employment with the second employer and the change shall not break the continuity of the period of employment.
§ (2) For the purposes of sub-paragraph (1) employment is relevant employment if it is employment of a description—
- (a) in which persons are engaged while undergoing professional training which involves their being employed successively by a number of different health service employers, and
- (b) which is specified in an order made by the Secretary of State.
§ (3) The following are health service employers for the purposes of this paragraph—
- (a) Health Authorities established under section 8 of the National Health Service Act 1977,
- (b) Special Health Authorities established under section 11 of that Act,
- (c) National Health Service trusts established under Part 1 of the National Health Service and Community Care Act 1990,
- (d) the Dental Practice Board, and
- (e) the Public Health Laboratory Service Board."").
§ [Amendment No. 7, as an amendment to Amendment No. 6, not moved.]
§ On Question, Amendment No. 6 agreed to.
§ Baroness Cumberlege
My Lords, I beg to move that this Bill do now pass. I am glad to sum up at the end of your Lordships' consideration of this Bill. I will say just a few words, following the model of concise debate which has characterised the Bill's progress. Though concise, the debate has also been constructive and well-informed and we have benefited again from the great depth of experience and commitment to the NHS which exists in your Lordships' House.
This has also been, by and large, a most good-humoured debate. Perhaps that reflects the measure of agreement between us on one of the central measures, the replacement of district health authorities and family health services authorities by the new health authorities. The noble Baroness, Lady Jay, and the noble Baroness, Lady Robson—who I am disappointed is not able to be here this afternoon for very good reasons—together with their teams have pressed the Government vigorously on many points of important detail. I am glad that they have, nevertheless, been able to welcome the new authorities, since they are also welcomed throughout the National Health Service. I should particularly mention the noble Lord, Lord Carter, whose detailed knowledge has been so necessary in showing us all how to move amendments, and whose inquiring mind was so impressive when we discussed the details of the Local Government Finance Act.
The new health authorities will have real influence and a vital role. They will be responsible for ensuring that the entire health needs of their population are met. For the first time, responsibility for primary and secondary care will be brought together within one authority—and planned together in a coherent and co-ordinated way. The noble Lord, Lord Rea, has been probing throughout on the subject of primary care and education. I have, I hope, been able to reassure him that health authorities will pay great attention to developing primary care teams in their areas and forging partnerships with professionals, including both fundholding and non-fundholding GPs. My noble friend Lady Gardner also made an important contribution on this subject, ensuring through her amendment that we remembered the importance of all the primary health care professions.
The abolition of RHAs has caused more debate in your Lordships' House. But the reasons for removing RHAs are clear and compelling. Such large, bureaucratic organisations are no longer needed at regional level. Many of their functions can now be transferred to the new health authorities, closer to patients. Their removal will streamline central management, reducing waste at the centre —and the NHS Executive regional offices will provide a strategic overview where that is still needed.
1506 This Bill will lead to substantial savings and there will be re-investment directly in patient care. There has, perhaps, been a certain amount of confusion about the amount of these savings, particularly during the debate in another place. So let me confirm the good news again: we estimate that savings of £150 million will be achieved every year once the Bill has been fully implemented in 1997–98. The majority of the savings—some £100 million per year—will come from RHA abolition.
The noble Lord, Lord Walton, and my noble friend Lord Jenkin have ensured that we did not overlook the essential partnership between the universities and the NHS. The highest standards of education and research must be maintained and I am glad to have been able, today, to set out clearly our plans for junior doctors' contracts. As always the membership of the new health authorities has been a matter of particular concern. We have debated that issue again today. My noble friend Lady Cox and the noble Baroness, Lady McFarlane, have, as ever, been powerful advocates for the nursing profession's contribution and we have noted with care the points they have made.
My noble friend Lord Elton broadened our debate by adding a second language during our discussions on membership when he reminded us that expressio unius, exclusio alterius—a point with which we agree.
We are committed to appointing the best people to serve on each health authority. The new appointments procedures introduced by the Government will help to ensure that. I should particularly like to put on record today my appreciation of all existing members of regional health authorities, DHAs and FHSAs who have served the NHS with such commitment and dedication. It is they who often have to take the most difficult decisions, and I am aware that they seldom receive sufficient recognition for all the work that they do.
Finally, I have stressed today and on several other occasions the need to ensure that the new authorities are open and accountable. I can assure your Lordships that the core values of openness, probity and accountability remain at the heart of the management and operation of the NHS. This Bill will move decisions closer than ever to patients, ensuring that as much of the work as possible takes place at local level, It will streamline central management so that as much money as possible is spent at local level on patient care. The NHS Executive, both centrally and in the regional offices, will oversee health authorities and provide leadership and a strategic overview to the whole NHS.
I should like to conclude by expressing my gratitude to all noble Lords who have taken part in our consideration of the Bill over the past few weeks. Your Lordships' scrutiny of the Bill has been genuine and courteous as well as thorough. I wish to thank especially my noble friend Lady Miller, who unfortunately is unable to be with us today due to a prior commitment, for easing my burden during the past few weeks. Her contributions have been many and valuable.
I have not been able to mention all noble Lords who have taken part in the debates on the Bill, but I would not wish to end without mentioning the contribution of 1507 my noble friend Lord Lyell, who ensured that even the finest details of the Dartford-Thurrock Crossing Act did not pass unscrutinised.
We have discussed the Bill thoroughly. It marks a logical and positive step for the NHS. I commend it to your Lordships' House.
§ Moved, That the Bill do now pass.—(Baroness Cumberlege.)
§ 5 p.m.
§ Lord Rea
My Lords, with the permission of the House, perhaps I may ask the noble Baroness a question, about which I have given her notice, concerning the future of the research and development programmes that are at present managed by the regions under the regional directors of research and development. Those directorates have grown in importance since Professor Michael Peckham was appointed Director of Research and Development, largely as a result of your Lordships' Select Committee report.
When the regions are replaced by the regional offices of the National Health Service Executive, how will the regional directors of research and development be affected? If they are to be part of the regional offices they will technically become civil servants, as will the regional directors of public health. That will have the drawback that they could come under pressure only to commission or fund research which is acceptable to the government of the day. During the deliberations of the Select Committee the importance of independent, and sometimes uncomfortably targeted, research was made clear. Such research is often critical of certain established practices and therefore positively unpopular.
The Select Committee recommended that National Health Service research and development should be administered through a special health authority. That was not accepted and the directorate of research and development was created instead.
I should like to suggest that the idea of a special health authority should be re-examined. Such a body could act as the administrative base for all regional directors of research and development to allow them a degree of independence from the National Health Service Executive.
I do not expect the noble Baroness necessarily to agree with that suggestion, but I hope that what I have said will allow her to say what the Government's plans are for this important but so far little discussed activity of the regional health authorities which are to be abolished by this Bill.
§ Baroness Jay of Paddington
My Lords, I am speaking to the Motion that the Bill do now pass.
When we discussed the Bill at Second Reading I suggested five basic tests for any change in the National Health Service: does it improve the effectiveness of the service? Does it improve efficiency? Will the change lead to greater equity? Will it lead to greater accountability? And will it improve the overall health of the nation's population?
1508 At Second Reading I argued that this Bill failed all those tests. Nothing which has happened in our subsequent debates on the detail of the legislation has changed my mind. Although the Government see this as a measure which is primarily designed to dismantle bureaucracy in the NHS, we on these Benches remain convinced that the Bill is a threat both to public accountability and to standards of excellence in the health service.
From these Benches we voiced particular concern about the abolition of the regional health authorities. The Government have insisted that that is simply the removal of an unnecessary tier of administration. However, as your Lordships know, the extraordinary growth in NHS management has not been at that level but further down the line in individual trusts and purchasing authorities. Staff numbers in the regions have actually gone down since the so-called reforms.
From these Benches we have moved amendments to try to protect the special strategic functions of the regional health authorities, particularly those of public health, and to maintain the links between the universities and the NHS. The noble Lord, Lord Walton, has been particularly concerned about the future connection between the university medical schools and the health service. But none of the amendments —neither those which the noble Lord proposed nor those that we proposed from these Benches—was accepted.
Equally unsuccessful were the attempts from all parts of the House to establish professional membership of the health authorities. At Committee stage the noble Baroness Lady Gardner of Parkes sought to include health professionals working in primary care. My noble friend Lady Dean of Thornton-le-Fylde wished to include health visitors. The noble Baroness, Lady McFarlane of Llandaff, who rightly tried again this afternoon, moved amendments to include the invaluable contribution of nurses at board level in the new health authority.
From these Benches we have tried to improve the general openness and public accountability of the health authorities. We moved amendments to make selection procedures for members more rigorous and objective. Again, all were rejected, despite the fact that during the passage of the Bill the committee on standards in public life chaired by the noble and learned Lord, Lord Nolan, has already been critical of the new arrangements proposed in February by the Secretary of State for Health.
I should like to thank my noble friends Lord Cledwyn of Penrhos and Lord Prys-Davies for diligently keeping the red dragon flying and eloquently trying to pursue the special concerns of Wales, They, too, have been disappointed, as was the noble Baroness, Lady Robson, who sought a strategic health authority for London to try to sort out the continuing agonising problems of health services in the capital.
The noble Baroness, Lady Robson, was very helpful in supporting many of the amendments from these Benches, despite her ill health during the proceedings of this Bill. I should like to thank her and her noble friends Lord Addington and Lord Tope for their contributions.
Above all, I must thank my noble friends Lord Rea and Lord Carter for everything they have done to advance our arguments so powerfully and, to my mind, so 1509 persuasively. My noble friend Lord Rea has brought all his practical experience of working in the NHS for many years to our debates. His particular knowledge of primary care and the issues which confront general practitioners working in the inner city has been vital.
My noble friend Lord Carter has been my essential coach on the Bench. His encyclopaedic understanding of the health service and of previous legislation, as well as of the procedures of your Lordships' House, has been invaluable. He has guided me patiently through the legislative jungle and saved me from many transgressions.
I should like to express the thanks of all of us to the Minister and her noble friend Lady Miller. They have been helpful and detailed in all their replies to our debates. The Minister has been particularly kind in writing fully to me and my noble friends about matters which could not immediately be resolved on the Floor of the House. We are very grateful to her.
In conclusion, I wish it were possible to send the Bill on its way with our best wishes. However, I am afraid that I still think this is a very political Bill, driven more by ideology about developing the health market than real concern about the state of our greatest public service.
As we are finishing our deliberations on a political day—I only assume that the absence of other noble Lords from the Chamber is because they are all actively involved in the local elections—I feel justified today in repeating the words of my right honourable friend the Leader of the Labour Party:We must wait for a general election to renationalise the National Health Service".
§ Lord Addington
My Lords, on the Motion that Bill do now pass, first I thank the Minister for her kind words about my noble friend Lady Robson, who is unable to be here. I also thank the noble Baroness, Lady Jay, for her kind comments about my noble friend and myself.
What we object to most about the Bill comes in its first line:An Act to abolish Regional Health Authorities".We do not believe that they should go because we need co-ordination and planning for health authorities, as, indeed, for all other public services. On strategic planning, the planning authority for London should have been put into the Bill. As the noble Baroness, Lady Jay, mentioned, my noble friend Lady Robson tried to have it included. As it was not seen fit to do that, this must go down as an opportunity lost.
One final point should be raised. With this legislation, it has been suggested that community health councils should not be expanded to an unmanageable size. At Committee stage my noble friend Lady Robson made inquiries about the matter but the Minister said that she did not believe that that would happen. However, we have no guarantee that it will not.
Bearing those points in mind, I hope that the Bill is considerably more successful than I suspect it will be, taking into account the gaps and certainly the lack of an 1510 overview and strategic planning. I hope that those shortcomings will not severely damage the National Health Service.
§ Baroness Cumberlege
My Lords, perhaps I may start by responding to the noble Lord, Lord Rea, and his anxieties about the regional directors of research and development.
In the new system, the regional directors will be members of the top management team in the new smaller regional offices. That means that they will become civil servants, but it also means that their influence and their profile are likely to increase. The NHS research and development programme has formally committed itself to openness in its operation and the reporting of all its findings. That will remain the case. The content of the research carried out will, as now, be determined on the advice of the central research and development committee and the regional research and development committees. Bringing all of them together within the NHS executive will, we believe, improve the efficiency and cost effectiveness of the programme. The directors work as part of the national research and development strategy. We believe that this arrangement is a good one and, of course, it will continue. I think that the noble Lord, Lord Rea, has nothing to fear.
I was interested in what the noble Baroness, Lady Jay, said about her template of five important key areas: effectiveness, efficiency, equity, accountability and the improvement of the health of the population. We believe that the Bill will go some way towards improving all those five counts, but, of course, only time will eventually tell.
As I understood it, the policy of the party opposite is that we should reduce bureaucracy. Indeed, there has been a suggestion that something like 800 administrators could go. I find it surprising that with that policy the same party should so champion the regional health authorities. I chaired a regional health authority and enjoyed doing so, but I recognised that the whole system had a stultifying effect on innovation, new ideas and imagination. It lengthened what could be quite quick decisions because of the red tape involved. The measures in the Bill before your Lordships will free up a great many people within the health service. I am convinced that it will result in a far better National Health Service for the people of this country.
§ I commend the Bill to the House.
§ On Question, Bill passed and returned to the Commons with amendments.