Lords Sitting of 29 April 2002

Preamble
The House met at half-past two of the clock: The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Southwark.

Proof of Age Scheme
Baroness Gardner of Parkesasked Her Majesty's Government:
Whether they support the British Retail Consortium's efforts to introduce a nationally recognisable PASS (Proof of Age Standards Scheme) for use by those aged 12 and over.
The Minister of State, Home Office (Lord Rooker): My Lords, the Government welcome the British Retail Consortium's proposals and congratulate it on the steps it is taking to help retailers to comply with the law. We have held very positive discussions with the British Retail Consortium about how its scheme would work in practice. In giving our full endorsement we would need to be satisfied that acceptable standards were in place to check the age of an applicant and that the British Retail Consortium would put in place procedures to ensure that those standards would be applied to all cards in the scheme. Any scheme would also need to be self-financing. The British Retail Consortium is aware of our views and I am confident that it will be able to satisfy them.
Baroness Gardner of Parkes: My Lords, I thank the Minister for that satisfactory reply. It would be marvellous to have a national scheme. Does the Minister agree that in the past one of the difficulties has been that although a number of card schemes existed for proof of age they were not recognised in various parts of the country? A scheme produced in Essex might not be acceptable in Northamptonshire. I mention that as an example. I know nothing of the practice in those counties. Do the Government believe that it is important to have a hologram or a photograph on the cards? The British Retail Consortium considers that to be necessary.
Lord Rooker: My Lords, as regards the latter part of the noble Baroness's supplementary question, I understand that the proof of age industry steering group will meet tomorrow, 30th April, to finalise he details of the scheme. We shall then have a better idea of the scheme. However, I understand that the cards will conform to all the normal criteria as regards date of birth and will probably include a photograph and a hologram. As to the first part of the supplementary question, it is crucial to have a national standard and a national logo on all cards. Such a measure would be beneficial. At present some local authorities produce cards which are not acceptable in other parts of the country. There are many age-related limits regarding
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what young people can or cannot do. I refer to age-related limits applying at the ages of five, 10, 12, 13, 14, 15, 16, 17, 18 and 21. Therefore, there is a need for a proof of age card that can be used nationally. The BRC is going in the right direction.
Lord Campbell-Savours: My Lords, why do we not just go the whole hog and introduce the national identity card scheme which a majority of the people of this country actually want?
Lord Rooker: My Lords, there are two reasons why we cannot do that. The first concerns time. The BRC initiative could be up and running quickly once it is accepted as an accredited system. As regards an identity card system, these days the Home Office calls that the entitlement card. As I said, the Government will produce a large consultation paper before the Summer Recess with a long consultation period to follow. I cannot be precise about that period but it will be rather longer than normal. If legislation were to follow, it would take one or two years or longer. The delay involved would be a factor to be taken into account. A stand-alone proof of age card would be useful for young people who may not always want to carry an entitlement card, particularly if it is part and parcel of a passport or a driving licence. A stand-alone proof of age card would have many uses.
The Earl of Onslow: My Lords, is the noble Lord aware that under no circumstances would I carry or even apply for a proof of age card? Is this not a case of the bossy boots nanny state with a card stating that one is five, 12, 14, 18 or 21? Cannot we get on with our lives without holograms and dates of birth? It is Nineteen Eighty-Four gone mad.
Lord Rooker: My Lords, the noble Earl's question proves that he belongs to a bygone age.
Lord Dixon-Smith: My Lords, does the Minister agree that, welcome though the British Retail Consortium's proposals are, and reassuring though it is that the measure, once agreed, could be introduced quickly, to refer to the Minister's qualification, is it not somewhat humiliating that the British Retail Consortium can act quicker than the Government, given all the powers and authority that the Government possess?
Lord Rooker: My Lords, the noble Lord confuses the position. The British Retail Consortium seeks to accredit on a national basis all the cards that exist at the present time. I refer, for example, to the successful operation of the cards of the Portman Group on behalf of the alcohol and brewing industry and other cards that already exist. The British Retail Consortium wishes to have a nationally accepted logo on cards to enable a retailer or service provider in one part of the country to accept a card produced by a local authority elsewhere as the BRC PASSlogo is implanted in it. That would make compliance with the law much easier. It is not a matter of introducing a new card, rather it is a national accreditation system for existing cards.
Lord Dholakia: My Lords, does the Minister accept that a substantial number of the shops we are discussing are owned by people from ethnic minorities? Will he consider discussing with the British Retail Consortium the need to have the relevant information in various languages to ensure that the staff who serve in those retail outlets understand their obligations under the law?
Lord Rooker: My Lords, I never experienced any difficulty in my former constituency as regards proof of age cards among corner shop licensees and newsagents who sold tobacco. Those shops are the bedrock of this country and many of them are owned and managed by members of the Asian community. I saw notices regarding providing proof of age pinned to the backs of tills. It is clear that such a system must take account of all shades of opinion and language issues. However, by and large, we are talking about proof of age. That matter should be fairly easy to accommodate.
Lord Graham of Edmonton: My Lords, does the Minister accept that the statement he made will be warmly welcomed by all those involved in any form of retailing? Will he confirm that at the moment it is illegal to purchase fireworks under the age of 18, airguns and pellets under the age of 17, petrol under the age of 16 and video and computer games under the age of 12? Does the Minister accept that retailers in general have done a great job in the difficult area of policing and monitoring the law and that a measure such as that proposed by the BRC would not only help the country but would also be of considerable assistance in enabling those involved in retailing to keep within the law?
Lord Rooker: My Lords, my noble friend is quite right. This is a matter of serious proportions. However, if I were to read out some of the requirements involving age-related limits about what one can and cannot do—they appear on a website—it would show that the situation has grown like Topsy over the years. Some of the requirements appear to be quite preposterous. They are nevertheless the law. Such a card and a national accreditation system would help retailers to comply with the law. The issue of consolidation is for another time and, I suspect, another piece of legislation.

Young Offenders: Arrest and Sentencing
2.43 p.m.
Lord Corbett of Castle Valeasked Her Majesty's Government:
What progress has been made on reducing the time taken between the arrest and sentencing of young offenders.
The Parliamentary Secretary, Lord Chancellor's Department (Baroness Scotland of Asthal): My Lords, for all youth offenders in the youth court, we have reduced the time from arrest to resolution from 87 days in 1997 to 57 in 2001. Persistent young offenders are more troublesome to deal with and in that regard the figures are encouraging.
The Government's target to halve the time taken to deal with persistent young offenders was achieved by August 2001. By January 2002, the time from arrest to sentence had been reduced from 142 days to 69.
Lord Corbett of Castle Vale: My Lords, I thank the Minister for that reply and ask that she congratulates all those in the criminal justice system who have worked so effectively to achieve that welcome improvement. Can she comment on reports that the £319 million Libra IT system, which was meant to enable magistrates' courts, the police and the probation service to exchange information at the touch of a button, is on the brink of being abandoned? If that were to happen, what impact would it have on reducing delays in the criminal justice system?
Baroness Scotland of Asthal: My Lords, the question relating to Libra is perhaps a little off the point. However, everything is being done to ensure that the system that is involved in delivering these results continues. It will not he adversely affected by any delay or difficulty caused by the Libra project.
Lord Goodhart: My Lords, does the Minister agree that there is a serious problem with persistent young offenders who commit other offences between the dates of arrest and conviction? Does she further agree that it is essential to provide more local authority secure accommodation so that those exceptional young offenders are not simply left on the streets to commit offences over and over again?
Baroness Scotland of Asthal: My Lords, I certainly agree that persistent young offenders are a real concern. It is absolutely essential that appropriate accommodation is made available to them. The noble Lord will know that the Government have taken many initiatives to try to ensure that the issue of persistent offenders is addressed effectively.
Lord Mackenzie of Framwellgate: My Lords, while congratulating the Minister on reducing the time between arrest and trial, I recall when people were arrested one evening and the following day were brought before the courts and dealt with, particularly if there was a guilty plea. Lawyers, of course, were not involved. Does she think that there may be an advantage in dealing with people without the involvement of lawyers?
Baroness Scotland of Asthal: My Lords, I know that many are tempted to return to the days when there was no legal representation and people could not give voice

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to their rights. But, thankfully, those days are gone. Now, the individuals who come before our courts can be assured that they will receive proper representation from proper, qualified lawyers, who are able to assist them—as is their right.
Baroness Buscombe: My Lords, while we are very encouraged by the figures that the Minister has given us in relation to the time between arrest and sentencing, will the Minister comment on the figures for detection rates? In London alone, the detection of crime has fallen from 25 per cent to just 17 per cent of all known crime.
Baroness Scotland of Asthal: My Lords, I am not able to comment on the noble Baroness's figures but they do not directly relate to the Question, which was about persistent young offenders. In relation to persistent young offenders, it is right that we have done much to reduce the amount of activity that those young people have engaged in, not least by reducing the rate of recidivism—or at least by attempting so to do.
Lord Acton: My Lords, can the Minister say whether there is any appreciable difference, in terms of the time involved, between girl persistent offenders and boy persistent offenders?
Baroness Scotland of Asthal: My Lords, I am not able to help my noble friend but I am more than happy to look at the figures to see whether there is any such difference. I shall write to my noble friend if any such indication is found.
Baroness Dean of Thornton-le-Fylde: My Lords, will the Minister comment on the fact that there appears to be a culture of adjournment in youth courts? That will obviously considerably delay matters.
Baroness Scotland of Asthal: My Lords, I take this opportunity to wish my noble friend a very happy birthday.
Noble Lords: Hear, hear!
Baroness Scotland of Asthal: My Lords, I am very much aware that in the past there was an issue in relation to delay. That is why, on 21st May 1997, my noble and learned friend the Lord Chancellor wrote personally to the chairmen of all youth panels emphasising that speed was essential in terms of confronting young people with the consequences of their wrongdoing. Speed is essential in terms of bearing clown on the easy habit of re-offending. The youth courts, as we have seen, have responded very well. I emphasise that when any particular adjournment is necessary in the interests of justice, that is determined by the magistrates through the exercise of their own independent judicial discretion.

Young Offenders: Community Sentences
2.49 p.m.
Lord Campbell of Croyasked Her Majesty's Government:
Whether they propose to offer to young offenders, as an alternative to community service, playing parts in special performances of Shakespeare's plays.
Lord Rooker: My Lords, we have introduced a range of community sentences for juveniles which provide individual programmes to tackle their offending behaviour and its causes. The arts can, and indeed do, play a valuable part. Youth offending teams across the country have successfully used music and drama, including Shakespeare, and other art forms. But we believe that these activities should remain available as part of an offending behaviour programme where appropriate and not become alternatives to them.
Lord Campbell of Croy: My Lords, I thank the noble Lord for his reply. Is he aware that schemes involving Shakespeare are already proving themselves in the United States? But would the Government approve of such a project here while not, of course, supporting any idea that the quality of mercy blesses him that takes as well as him that gives, or that "Once more unto the breach" might refer to prison walls?
Lord Rooker: My Lords, being only a simple engineer, and at the risk of upsetting people, I have to say that The Merchant of Venicei was the only piece of Shakespeare penance that I ever did at my old school, Handsworth Technical College. Therefore, there is a big gap in my cultural life, and I mean that.
However, I fully accept what the noble Lord said. This morning I asked my officials where they believed the noble Lord, Lord Campbell, was coming from. They told me that there had been a most interesting article in The Times of 15th April, which I read, giving information about what is happening in America. The article was incredibly positive and informative, and we shall certainly consider the issues that it raised. We are using art and sport, and not only in relation to those who have offended. It is very important that those who do not offend do not believe that they are being kept out of these programmes. That would send the wrong signals. The Youth Justice Board has a large programme, and youth offending teams across the country are making good use of such material.
This morning, I also discovered that there is such a thing as a Henry V leadership programme, which I understand is run by someone by the name of "Olivier". Indeed, Home Office officials have been sent on it.
Lord Clinton-Davis: My Lords, is there not one common theme in both the Question and the Answer: much ado about nothing?
Lord Addington: My Lords, if we are to use any form of art therapy or artistic or cultural activity in relation

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to young offenders, does the Minister agree that it is important to remember that good playwrights have existed in this country since the 17th century?
Lord Rooker: My Lords, indeed, they have. However, the nature of Shakespeare's language and the way in which people are able to describe events and convey violence through language rather than physically have proved to be beneficial both here and in the United States. Again, I refer noble Lords to the important piece in The Times. I believe it is important that people use both modern and what one might call "less modern" initiatives in both sport and art.
Baroness Buscombe: My Lords, is the Minister aware that a number of such initiatives are already taking place in prisons? For example, last summer Winchester Prison put on a most brilliant opera—"The Threepenny Opera".
Lord Rooker: My Lords, yes, indeed. One arts-based initiative—the London Shakespeare Workout—uses the language and themes of Shakespeare with professional theatrical performers to engage inmates, education staff and prison officers. Therefore, an enormous amount of such work is taking place now. It is not new. I believe that the noble Lord, Lord Campbell, has raised an important issue. It is not all about clamping people down; it is about opening people up and encouraging them to be positive, whether they have offended or not. This is an important issue to have been raised in the House.
Baroness Sharp of Guildford: My Lords, I am delighted that the Minister mentioned those who have not offended. Does he believe that enough is being done to promote youth services in this country? It is most important that young people partake in positive activities, but there has been a considerable run-down of youth activities, largely by local authorities.
Lord Rooker: My Lords, the noble Baroness is right. I highlight, for example, the Youth Justice Board. Its Splash schemes have been run in the school holidays since the summer of 2000. They have included more than 200 projects and have provided sports and arts activities for 20,000 13 to 17 year-olds in deprived areas of the country over a five-week period. In the scheme's first year, 2000, the total crime rate fell by 6 per cent in those areas compared with a national rise of 3.8 per cent. Therefore, an enormous amount of work is being done, and I do not believe that one should use such Questions simply to take a knock at local government.
Lord Carlisle of Bucklow: My Lords, does the Minister agree that the introduction of the community service order, which, I am happy to say, was introduced by a Conservative government in 1972, was one of the most imaginative and important changes to take place in penal policy? Faced today with a situation, such as we were faced with in 1971, of
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overcrowding in prisons, will the Minister say what steps this Government are taking to consider alternatives to prison?
Lord Rooker: My Lords, the noble Lord, Lord Carlisle, is absolutely right. The total number of sentences received by juveniles—that is, young people between the ages of 10 and 17—in the year 2000 in England and Wales was 91,000. Community sentences accounted for 39 per cent of that number. There were probation orders and supervision orders, and community service orders made up 5·3 per cent of the grand total, which is very high. With attendance centre orders, combination orders, curfew orders, reparation orders, action plan orders, and drug treatment and testing orders, community sentencing forms 40 per cent. That is a considerable improvement on what went on in the past. We are always looking at other systems, and I believe that the work carried out by the Youth Justice Board during the short time that it has been in existence has made a considerable contribution.
Baroness Howells of St Davids: My Lords, is the Minister aware that Her Royal Highness the Princess Royal takes an active part in an organisation called Crime Concern, which works in the most deprived parts of Britain? Some of its resources come from the Youth Justice Board, but at present it is trying to increase its funding. Does my noble friend believe that he will be able to get the Home Office involved far more in such funding? Crime Concern works not only with young people who have not committed crimes; it also works with families in the most deprived areas. I am pleased to tell noble Lords that it is also getting young people to write their own plays about their lives and to act them out with others. They are highly supervised.
Lord Rooker: My Lords, I want to answer my noble friend's question about funding. It is a very sensitive matter at present. If I say that the Home Office does not have enough funds, that will be construed as an attack on the Treasury, which it is not. If I say that we have all that we need, we shall be told, "Well, you don't need any more", and our funding will be cut back. Therefore, I shall have to take away for consideration the suggestion about funding.
My noble friend is right about the amount of work that is taking place. Of course, the Home Office is also part of the regional government machinery. Together with the Home Office agencies, it works with people in the regions so as to be more in touch with what is going on on the ground. I believe that in that way it will also make an important contribution.
Lord Lucas: My Lords, will the noble Lord join me in celebrating the success of drama in prison and, in particular, that of Shakespeare in prison, which engages the most resistant learners? It brings them out of themselves and starts them on the path to learning. It has a long and successful history. Will he also

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celebrate the success of Shakespeare rather early in his time in writing in rap rhythm, which is extraordinarily helpful when one is trying to work in prisons?
Lord Rooker: My Lords, I am happy to support and agree with what the noble Lord said, but I shall certainly not get into Shakespeare and rap.

Tobacco Advertising and Promotion Bill
2.59 p.m.
Lord Skelmersdaleasked Her Majesty's Government:
Whether they have referred the Tobacco Advertising and Promotion Bill to the European Commission under Directive 98/34 EC as amended by Directive 98/48 EC.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, we notified the Bill on 28th March. The notification is without prejudice to the Government's view that the Bill does not contain any technical regulations.
Lord Skelmersdale: My Lords, I am grateful to the Minister for confirming what was slipped out by Written Questions in both Houses of Parliament. Does the noble Lord agree that this is an extraordinary situation as the Government have made a complete U-turn, having resisted such a proposition on no less than five different occasions?
Lord Hunt of Kings Heath: No, my Lords. We have always taken the view that this is not notifiable. We have listened carefully to the arguments put forward by many noble Lords during the passage of the Tobacco Advertising and Promotion Bill through your Lordships House. As a result of the points that were raised, we decided, as a precaution, that it would be sensible to notify, as we have done. We remain of the view that it is not notifiable, but as a result of the discussions in your Lordships' House, I believe that we are justified in notifying as a precautionary measure.
Lord Clement-Jones: My Lords, I congratulate the Minister and his colleagues on adopting the Bill in the other place, where today it has its Second Reading. Will he join with me in deploring the decision of the Conservative Front Bench in the other place, which is in stark contrast to the decision of the Conservative Front Bench in this House, to oppose a Second Reading for the Bill on the spurious ground that there is a lack of evidence that the Bill will be effective and on the ground that the stand-still provisions under the technical services directive will apply?
Lord Hunt of Kings Heath: My Lords, I pay tribute to the noble Lord, Lord Clement-Jones, for his initiative in bringing forward a Bill in this place. I pay tribute to the skills of his draftsmanship in so doing. On the position of the party opposite, I must express
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my great disappointment that it does not seek to support the intent of the Bill. If the Bill passes in another place, I have no doubt whatever that it will have an enormous impact in terms of reducing smoking among the people of this country.
Lord Bruce of Donington: My Lords, is the Minister aware that the two directives cited in the Question have little other than general relevance to the Question? At the moment the matter is in the hands of the Conciliation Committee of the European Parliament and the Council. Once the Council reveals its decision, it has to be laid before the Scrutiny Committee of both Houses before it can become effective.
Lord Hunt of Kings Heath: My Lords, I doubt that anyone knows more than my noble friend of the intricacies of European legislation. I believe that he refers to the European advertising directive. In 1998 we supported a directive that provided for a comprehensive tobacco advertising ban in Europe. That was challenged in the courts and in October 2000 it was struck down by the European Court of Justice. As a result, the Government decided to deliver its commitment by way of UK legislation, which, if the current Bill passes in another place, we will have done. However, my noble friend is right. Since then the European Commission has brought forward further proposals for a directive on tobacco advertising and sponsorship. That is still subject to discussion within Europe.
Lord Naseby: My Lords, as the Minister has indicated that notification of the Bill was in response to the protestations made from noble Lords on this side of the House, will he tell the House whether in the interim he has also considered the situation of treating all sports equally, or is Formula 1 motor racing the only sport to be allowed a long period in which to comply whereas every other sport is to be treated on a short timeframe?
Lord Hunt of Kings Heath: My Lords, I had thought that the issue of notification had been raised by noble Lords from various parts of your Lordships' House, including the Cross Benches. On sponsorship, the noble Lord knows that our intent is that sponsorship events with a view to promoting tobacco advertisements need to stop, but we do not want the ban to harm sports. When the original Bill was debated, we made it clear that we believe that it is right, subject to consultation, to expect most tobacco sponsorship of sporting events to end as soon as possible, but that global sporting events which receive considerable income from tobacco interests should be given a certain period of time to phase out the use of tobacco sponsorship. That remains the position of the Government.
Lord Faulkner of Worcester: My Lords, is it the case that there are no European Union or WTO free trade rules that prevent governments from making

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exemptions in order to protect health? As the Bill when enacted will have the effect of saving at least 3,000 lives a year, it falls into that category.
Lord Hunt of Kings Heath: My Lords, my noble friend puts the matter correctly. From the evidence that I have seen, both from the World Bank and from Clive Smee, the economist commissioned by the previous government to look at the impact of a ban on tobacco advertising, there is no doubt that the effects of the Bill, if passed by another place, will have a positive impact on our overall strategy to reduce smoking in this country.

Business
Lord Carter: My Lords, at a convenient moment after 4.30 p.m., my noble friend Lady Amos will, with the leave of the House, repeat a Statement that is being made in another place on Israel and the Occupied Territories.

The Queen's Golden Jubilee
3.6 p.m.
The Lord Privy Seal (Lord Williams of Mostyn)rose to move, That an humble Address be presented to Her Majesty to congratulate Her Majesty on the occasion of the Fiftieth Anniversary of Her Accession to the Throne.
The noble and learned Lord said: My Lords, this is an historic occasion. The whole House will agree with me when I say that, as the fifth longest serving monarch, Her Majesty Queen Elizabeth II has had an exceptional reign.
Over the past 50 years she has met more people in the United Kingdom, the Commonwealth and overseas than any other monarch. She has been advised by 10 Prime Ministers, including Lord Home of the Hirsel, the last Prime Minister to sit, even if briefly, in this House. She has given Royal Assent to no fewer than 3,135 Acts of Parliament and has opened Parliament on 49 occasions. Those statistics bear witness to the quantity of work that Her Majesty has performed, but they do not describe to us the grace and dignity with which Her Majesty has reigned. It is those qualities that we celebrate today.
The past months have not been exclusively happy. We hope that tomorrow's ceremonies will mark the beginning of a brighter period for Her Majesty. We can look forward to a great season of celebrations over the coming months. We shall see country and Commonwealth join together to celebrate 50 years of Her Majesty's reign. There will be street parties, concerts, parades and tributes as all join together, with the Royal Family, to mark this splendid anniversary.
I know that your Lordships will wish to join together to thank Her Majesty for half a century of service, to offer her our affection and support. In
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agreeing this humble Address, we express our hopes that the years ahead will be rich in joy and fulfilment for her and for the nation. I beg to move.
Moved, That an humble Address be presented to Her Majesty to congratulate Her Majesty on the occasion of the Fiftieth Anniversary of Her Accession to the Throne.—(Lord Williams of Mostyn.)
Lord Strathclyde: My Lords, it is a pleasure and a delight to follow the noble and learned Lord the Leader of the House in the sentiments that he has expressed. I shall be brief for I know that the noble and learned Lord the Lord Chancellor will speak eloquently tomorrow of the deep sense of admiration and loyalty that this House bears Her Majesty the Queen.
Few in all the long generations of our monarchy have reached a Golden Jubilee: four in England and one in Scotland. This rare event is a just cause for national celebration. It should not be a "low-key" jubilee. Her Majesty deserves the fullest expression of the gratitude and affection of the nation and it is right that tomorrow this House and another place should lead in that.
Some no doubt will stress the changes that have taken place during Her Majesty's reign. I would like to stress something that has not changed since February 1952—Her Majesty's unswerving dedication to her high sense of duty to our nation and to all its people.
As others reminded us, 55 years ago as a young princess Her Majesty gave a memorable and moving pledge of service to this country and to the Commonwealth. With the constant support of Prince Philip at her side, she has never for one moment failed in that promise. Indeed, has any monarch ever given such unstinting and varied service to Britain or the Commonwealth?
This jubilee year began under the dark clouds of personal sorrow for Her Majesty. But even in those sad days, which touched so many millions of people, she was, I hope, able to see in a striking and remarkable way the deep well of affection in this country for Her Majesty and for the Crown.
Over 50 years, people in all walks of life and in all parts of the world have felt their lives enhanced by the presence of the Queen. She literally embodies the union of our kingdom. Let us hope that in her jubilee year, Her Majesty will feel ever more deeply the warmth of the respect and affection of her people which, by her service and unrivalled sense of duty, she so justly deserves.
Baroness Williams of Crosby: My Lords, we on the Liberal Democrat Benches have great pleasure in associating ourselves with the remarks of the Leader of the House and the Leader of the Opposition. We too look forward with great anticipation to the undoubtedly eloquent phrases we shall hear tomorrow from the Lord Chancellor.
I believe we all recognise that the vow taken by Her Majesty the Queen in her Cape Town speech on 21st April 1947—her 21st birthday—has been fulfilled

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in every possible sense. Most of us when we are young have good intentions. Most of us, over the years, fall away from those good intentions. The Queen has, in every possible way, fulfilled the intentions she expressed on that occasion. I believe that the people of this country recognise that perhaps more generously and full-heartedly than sometimes do the media, as exemplified by their response to the deaths of Her Majesty the Queen Mother and Princess Margaret, and their strong fellow feeling with the Queen in her bereavement.
I remind the House also that the Queen has been deeply respected and much admired by all those who have served as Prime Minister, another extremely lonely post. In this House we have the benefit of one former Prime Minister, the noble Lord, Lord Callaghan, who himself has served for 50 years and whose golden jubilee is celebrated this year. He, I know, would give full attribution to the experience and wisdom of Her Majesty in her discussions with her Prime Ministers.
Finally, as well as being Queen of the United Kingdom, the Queen is also the Head of the Commonwealth. It is important to say that 25 years ago, at her Silver Jubilee, many people would not have predicted that the Commonwealth would still be here. Not only is it still enduring; it is also expanding in size because other countries wish to join it. With her usual extraordinary felicity, when the Queen returned to South Africa in 1993, after the installation of a new democratic regime under President Mandela, it was in the townships that the signs said, "Thank you for coming back". It could hardly have been put more eloquently. Since that time both Mozambique and Cameroon have joined the Commonwealth, something we often value insufficiently.
We on these Benches are delighted to be associated with the words of respect and admiration for Her Majesty. We wish her a very happy tour of her kingdom with the support of her family and of course of her long-standing and devoted husband, the Duke of Edinburgh.
Lord Craig of Radley: My Lords, I thank the Lord Privy Seal for introducing this Motion. It is a great privilege to be able to congratulate Her Majesty the Queen from these Benches in the year of her Golden Jubilee. On behalf of all the Cross-Benchers I humbly express to Her Majesty our profound loyal greetings and good wishes.
Fifty years is a long time to have been always active and so utterly dedicated to duty at the heart of this nation and the Commonwealth. In no other role in life does the individual have to start off and hit the road running, as it were; and then continue to travel that road years after others who, reaching an age of honourable retirement, settle back to enjoy their grandchildren, to indulge their hobbies and other interests, to unwind and to become free of the thousand-and-one pressures that once used to crowd in upon them in their working lives.
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Her Majesty has many fine attributes and qualities. Grace and dignity have already been mentioned and many others can be identified. If, I hope without presumption, I single out one of the many characteristics of being our Queen, it is because it is so unique and has been fulfilled in such an exemplary way.
Modern information technology, to say nothing of the methods of today's media in covering every aspect, real and imagined, of a story line makes for a permanent, or near permanent, public parade and coverage of all that is said or done. No moment of private grief, of joy, of concern about family or nation, escapes today's paparazzi attention. The telephoto lens and eavesdropping devices abound. They can never be safely ignored. To have been blessed with Her Majesty's constant, long and total dedication to her duty and to her subjects against a background of coverage unique in its intrusiveness is without any parallel in previous generations.
I pay tribute also to the fine supporting role that His Royal Highness the Duke of Edinburgh has played as consort throughout the Queen's years of commitment and service to the nation. Unalloyed admiration, genuine warmth of feeling and heartfelt congratulations from all her subjects on her Golden Jubilee are richly deserved by Her Majesty. Long may she reign over us.
3.15 p.m.
The Archbishop of Canterbury: My Lords, from the Lords Spiritual I rise to support the Motion. The politicians among us have rightly remarked on the wisdom and knowledge which Her Majesty brought to the government of her kingdom, and the diligence with which she attends to the affairs of state. I want to pay tribute to a different kind of wisdom.
The noble Baroness, Lady Williams, mentioned that on her 21st birthday the Queen committed herself to our nation. The actual words were to invite us to go forward together with an unwavering faith, high courage and a quiet heart, promising to dedicate her whole life to the national service. Just five years later, looking ahead to her Coronation, Her Majesty asked all her people around the world to pray for her; that God would give her the wisdom and strength to fulfil those awesome coronation promises to rule lawfully, to judge mercifully and to uphold His Church. How magnificently those prayers have been answered.
Through 50 years of profound change and upheaval, Her Majesty the Queen has been the steadfast heart of a worldwide family of nations and peoples setting the finest examples of faithful Christian service; of duty born with courage and joy; of loyalty, dignity and sacrifice. As we look forward to a summer of jubilee celebrations I want simply to say this. We have been richly blessed to have had such a person as our gracious sovereign. We thank God for her and for her husband Prince Philip, whose magnificent support has contributed so much to a remarkable reign. Today we pay grateful tribute for all that they have given and continue to give to our nation, our Commonwealth and our world.

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On Question, Motion agreed to nemine dissentiente; and it was ordered that the said Address be presented to Her Majesty by the whole House in Westminster Hall tomorrow at eleven o'clock.

Communications
Lord Williams of Mostyn: My Lords, I beg to move the Motion standing in my name on the Order Paper.
Moved, That it is expedient that a Joint Committee of Lords and Commons be appointed to consider and report on any draft communications Bill presented to both Houses by a Minister of the Crown, and that the committee should report not later than three months after any such Bill has been presented to both Houses.—(Lord Williams of Mostyn.)
On Question, Motion agreed to; and a message was ordered to be sent to the Commons to acquaint them therewith.

National Health Service Reform and Health Care Professions Bill
3.19 p.m.
Report received.
Clause 1 [English Health Authorities: change of name]:
Lord Hunt of Kings Heathmoved Amendment No. 1:
Page 2, leave out lines 26 to 31 and insert—
"(5) No order shall be made under this section relating to a Strategic Health Authority until after the completion of such consultation as may be prescribed."
The noble Lord said: My Lords, I am grateful to the noble Baroness, Lady Thomas of Walliswood, for helpfully recommending in Committee on 14th March that the Government could usefully reconsider the wording proposed by new Section 8(5) of the 1977 Act as inserted by Clause 1(2). I promised to look at the wording again. I am pleased to say that on reflection we are able to bring a revised and shortened version before your Lordships' House.
The wording as now drafted follows closely the precedent set for NHS trusts in Section 5(2) of the National Health Service and Community Care Act 1990—as substituted by the Health Authorities Act 1995 (Section 2(1), Schedule 1, paragraph 69(B). The term "prescribed" has the same meaning as in Section 128 of the 1977 Act; for example, prescribed in regulations made by the Secretary of State. I beg to move.
Baroness Northover: My Lords, we are very grateful that the Government have accepted that wording.
On Question, amendment agreed to.
Earl Howemoved Amendment No. 2:
Leave out Clause 1.
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The noble Earl said: My Lords, I have tabled the amendment because I want to explore the functions of strategic health authorities. In Committee, we debated them quite extensively. In particular, I want to explore what the term "performance management" means in the context of strategic health authorities. We are told by the Government that by 2004 primary care trusts will control 75 per cent of the entire NHS budget and will thereby acquire a great deal more autonomy than hitherto—"shifting the balance of power" to the front line.
There are many of us who cannot help being somewhat sceptical about this shift in the balance of power. The reason for that is that the powers of the Secretary of State to intervene in the affairs of the health service and to micro-manage remain unaltered. Indeed, by virtue of the Bill those powers are considerably augmented. The Government say that in order to preserve proper accountability to Parliament it is necessary to retain such reserve powers. I wonder how "reserve-like" the Secretary of State's powers feel to those in the NHS who battle daily with the welter of targets, directions and instructions that descend on them from health authorities and from Whitehall. Last week I heard from a doctor that there is an instruction relating to the degree of lustre which must be achieved on polished surfaces in NHS buildings.
However, let us look at the mechanisms being established in the Bill and their functions. We are told that strategic health authorities will be there to set the strategic framework, to knock heads together, to broker solutions, to performance-manage, to lead policy development and so on. As the Minister emphasised in Committee, they will he there,
"accounting to the Secretary of State for the performance of the NHS in their areas".—[Official Report, 14/3/02; col. 1039.]
One bets they will.
How will that work in practice? It might be illustrative if I cited one example of the heavy-handed way in which strategic health authorities are already making their presence felt on the ground.
At a recent trust board meeting—I shall not say which one for obvious reasons—the directors found themselves unable to present a finance plan for the year we are just entering because of last-minute restrictions imposed by the strategic health authority. The relevant PCT was told that it will begin the year underfunded by some £500,000. As a result, earmarked funds allocated last year for the various national service framework programmes on cancer, mental health and the NICE agenda have gone out of the window. The money has to be used instead to plug shortfalls in the budget. Any additional shortfalls have to be plugged by what is termed "repayable brokerage"—in other words, short-term loans.
The language used by the board to describe the actions and attitudes of the strategic health authority is revealing. The strategic health authority, said one board member, was being "excessively prescriptive and restrictive". Another said that the strategic health authority was behaving like "control freaks".

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That is the kind of decentralisation and operational freedom which we are going to see rolling out across the National Health Service. It is the tone of things to come. As my noble friend Lady Noakes said in Committee, what all this amounts to is an illusion of decentralisation in which true decision-making takes place at the level of the SHA.
The noble Lord, Lord Clement-Jones, has expressed his concern that strategic health authorities will not be strong enough to withstand micro-management from the centre. I think that I would put the argument slightly differently: they have been created expressly as vehicles to implement and enforce centrally driven directives.
Ironically, this brings us back full circle to some of the conundrums that we were wrestling with in Committee: what to do about those activities and services for which a single PCT is not equipped individually to perform, but which can only be delivered across a wider area—teaching and research, specialist services and public health. The Government's answer is that in many cases of this kind there should be a PCT with lead responsibility within an informal grouping of PCTs. But that sounds extraordinarily cumbersome. How many informal groupings will a PCT find itself in simply because the Government are determined that no higher tier of management in the health service should take responsibility for these broader strategic matters? Why not recognise the operational leverage vested in strategic health authorities, rather than labour under the illusion that PCTs will be the drivers of decision-making?
I do not intend to anticipate our later debates on these matters. However, it seems to me that in these areas of broader relevance for the health service we should acknowledge that here is a way in which strategic health authorities can sensibly play a lead role.
Finally, I turn to a question that I asked the Minister in Committee, but which he did not answer. If there is a conflict or divergence of opinion between one strategic health authority and another, what mechanisms are there in place to resolve such disagreements? That is not such a simple question as it may sound. If one imagines a strategic health authority brokering sometimes difficult solutions across several primary care trusts for the benefit of the population in an area, how will it be capable of compromising such a brokered solution, merely because there are objections from the strategic health authority down the road? If there are two opposing and conflicting views of what is strategically best for an area, who decides which way to go? I beg to move.
Lord Clement-Jones: My Lords, I agree with a great deal of what the noble Earl, Lord Howe, has just said. One of the key debates in Committee was over the setting up of these strategic health authorities. In Committee, the Minister claimed that the key roles of these strategic health authorities would be performance management, capital investment strategy, workforce development and information management, but not
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other functions such as public health and specialised commissioning. We shall have the debates later on those particular topics, but it is still not clear to us on these Benches why not?
Furthermore, why should it be at this level of 28 strategic health authorities and not at regional level? What makes the planning of capital investment more apposite to the level of strategic health authorities rather than at regional level, whereas public health is handled at regional level? Why are strategic health authorities being set up that bear no relationship to local government boundaries or the Government's own regions?
As I mentioned in Committee, over the years there have been a massive number of changes to the structure of health services. In 1974, area health authorities were established; then came district health authorities; and then health authorities. Now we are to have strategic health authorities. One constant has been the NHS region, although there have been boundary changes and some consolidation. There will be nine regional directors of public health, who could well fit into a regional structure—certainly more comfortably than could the four regional directors of health and social care, whose areas will bear no relationship to any regional or local government boundaries.
In any reorganisation, it is vital to ensure proper accountability for health strategy. That could be secured by a regional organisation but is unlikely to be secured through strategic health authorities. In Committee, the Minister said that he saw a key role for strategic health authorities in performance management and banging heads together. Yet the Government's most recent document about delivering the NHS Plan states that although in effect they will be the local headquarters of the NHS and will hold to account the local health service, build capacity and support performance improvement, three-year franchises to run strategic health authorities will be let, with performance judged against a published annual delivery contract with the Department of Health.
That is Burger King come to Richmond House. Strategic health authorities will clearly be an integral part of the NHS administration, yet they are to be franchised. The Secretary of State has a well known infatuation with the private sector, but that is a love affair too far. Despite our debates in Committee, the new announcements only make the department's plans appear more half-baked. I urge the Government to think again. Why do they not at least consolidate the reforms in the Bill and the recent White Paper and return in a few months' time?
3.30 p.m.
Lord Peyton of Yeovil: My Lords, I support every word so far spoken about the amendment. As I have a great respect for the noble Lord, Lord Hunt of Kings Heath, I offer him my genuine and profound sympathy for the heavy burden that he now has to carry in justifying this rubbishy clause.
The clause deserves to be known as a large slice of Milburn. I hope that it will be strung around his neck. It has his fingerprints and foot-marks on it to the full:

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first, in all the importance that he attaches to names; and secondly, in his almost unlimited appetite for powers.
I remind your Lordships of subsection (4), which states:
"The Secretary of State may by order …. vary the area of a Strategic Health Authority".
He may abolish one, establish a new one or change one's name. I wonder why he bothers to come to Parliament at all. If anything, your Lordships are too obliging in giving Ministers immense powers, for which they ask taking for granted that they will be given. Almost invariably, they misuse those powers in such a way as to cause themselves and everyone else a lot of difficulty. I can only venture to suggest that the scrutiny exercise that we undertake is insufficient. It does not remove sufficient of the powers that unthinking Ministers grab to themselves just in case they may be necessary, in case they get into trouble and would otherwise have to return to Parliament.
I should like your Lordships to vote against the clause and remove it altogether. It is a rubbishy and tiresome provision. The only vice from which it is free, but from which the rest of the Bill suffers—I am pleased to see the noble and learned Lord, Lord Brightman, in his place—is the sin of legislation by reference. However, later in the Bill there are plenty of examples of that, to which I shall endeavour to call your Lordships' attention.
I cherish the hope that the noble Lord, Lord Hunt, will remember that he gave undertakings to try to remedy the horrors of the Bill by making the Government's purpose clearer. I have looked hopefully for an amendment containing a Keeling schedule, or something like that, but I have so far failed to find one. If the noble Lord has by any chance fulfilled his undertaking, I hope that he will immediately call my attention to that and I shall give him a humble apology. I hope that the amendment will be carried.
Baroness Carnegy of Lour: My Lords, reading the clause, it struck me that something rather strange may happen. Paragraph (4)(b) states that the Secretary of State may by order,
"abolish a Strategic Health Authority".
Could he abolish them all at once by order, thus altering the whole scheme of things?
Lord Hunt of Kings Heath: My Lords, I warmly welcome the positive remarks that noble Lords have made about the clause, which I find most encouraging.
First, the noble Earl, Lord Howe, was arguing two points. In the first stage of his argument, he suggested that strategic health authorities would be control freaks. We shall come to later amendments proposed by him and by other noble Lords, the overall thrust of which is to give strategic health authorities more power and to take it away from primary care trusts. That would be a great pity. We are not dealing with a
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proposal to micro-manage the health service. We are at the start of a process of massive decentralisation to the primary care level within the health service.
I turn to the Statement made by my right honourable friend the Secretary of State for Health in another place on the day after the Budget. He said that our intent is to,
"go further in extending devolution in the NHS, building on what has been achieved … The health service should not and cannot be run from Whitehall".—[Official Report, Commons, 18/4/02; col. 715.]
He announced various measures consistent with the Bill's provisions to ensure that power is indeed devolved to the local level. That is our whole purpose for primary care trusts. By 2004, we will devolve 75 per cent of the entire budget of the NHS to the primary care level, where key decisions can be made about both provision of primary care services and commissioning of secondary and tertiary care services. That is the most visible possible signal of our intent to devolve to the front line.
Later, we shall discuss the role of organisations such as the Commission for Health Improvement. The whole point is that the structure that we are setting up will establish clear national standards and an independent inspectorate—the context within which we can then devolve decision-making to the local level far more than has ever happened before. If we have a foundation of national standards and an independent inspectorate, we will be able to devolve in the way that we seek.
Several questions were raised about the role of strategic health authorities. It is tempting to go through the list of their functions, as we did in Committee, but it would be better for me to resist that temptation. I am satisfied that the size of each strategic health authority is about right. It is pitched at a population of about one and a half million for each. I say to the noble Lord, Lord Clement-Jones, that that is small enough for them to retain a local connection but large enough to allow them to cover the kind of areas that we want for our care networks.
The noble Lord will recall the example of cancer networks in which the planning of services—primary, secondary and tertiary care—goes beyond existing NHS organisational boundaries. The boundaries of strategic health authorities will, in the main, cover those care networks. That is a persuasive argument for the type of boundaries that exist for the 28 health authorities that we have established, which will become strategic health authorities.
The people who have been appointed as chief executives of the strategic health authorities are of a high calibre. To the noble Earl, Lord Howe, I say that they know as well as we do that the importance of their role lies not in being heavy-handed or behaving like control freaks; it lies in being sensitive to the need to give as much room as possible to NHS trusts within their boundary to work as flexibly as possible while being able 'to intervene when things go wrong and cooperation is not working as required.

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The existence of such reserved powers is not evidence of control-freakery; it is a sensible way of ensuring that there is a performance management system that allows the strategic health authorities to intervene in the kind of issues about which the noble Earl is concerned. His examples of teaching, research and specialist services are ones with which I agree. The success of the proposals will be in ensuring that such intervention is minimal.
The noble Earl, Lord Howe, also asked about potential disagreement among strategic health authorities about priorities and about the future development of services. The people running the authorities are grown-ups. They are paid quite well for what they do, and they include some of our most senior people. I would expect that, by and large, they will be able to reach sensible agreement. Of course, there may be occasions on which that will not be possible. On such occasions, I would expect that the directors of health and social care—we have one director of health and social care for each quarter of the country, four in all—will be on hand as trouble-shooters to broker a sensible resolution of disagreements, although I do not expect that they will happen frequently.
The noble Earl, Lord Howe, raised the question of the SaFF process, the customary round of agreement between health authorities and NHS trusts about the money to be spent in the forthcoming financial year. My experience of the process is that there will always be tensions between those who commission services and have the money and those who provide the services and want the money. We should not worry too much about noises emanating from the health service at the moment. In my time working in the NHS or observing it, I cannot recall a year in which there were no tensions in the SaFF process. Inevitably, under the new arrangements, there will continue to be such tensions between primary care trusts, which will hold most of the budget, and other trusts. However, those tensions detract from the overall structure that we have put in place.
Our purpose is to devolve to the primary care level. That is why I shall resist some of the amendments to be proposed later today that would wrest power and control from primary care trusts and place them with strategic health authorities.
I understand the general points made by the noble Lord, Lord Peyton of Yeovil, about the structure of the Bill and the way in which some of the clauses have been written. He will know that I have some sympathy with his view. I wrote to the noble Lord informing him of the Government's intention to endeavour to consolidate NHS legislation in due course. There is, in the House of Lords Library, an amended version of a working version of the National Health Service .Act 1977, as amended by legislation up to the Health and Social Care Act 2001. I understand that that does not entirely answer the point raised by the noble Lord.
3.45 p.m.
Lord Peyton of Yeovil: My Lords, I am obliged to the Minister, if only for his courtesy. I inquired about
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this in the Library and the Printed Paper Office. My description of what I required may have been inadequate, but the document was not recognised in either place. I do not recall receiving the Minister's letter.
Lord Hunt of Kings Heath: My Lords, I shall make sure that we send the noble Lord another copy of the letter double-quick. I shall also ensure that the amended working copy of the 1977 Act is made available.
Lord Peyton of Yeovil: My Lords, I would appreciate it very much if the Minister could send me a copy of the letter, if only as an aid to memory. Presumably, it will arrive long after the horse has bolted and the stable door locked.
Lord Hunt of Kings Heath: My Lords, it is not beyond the bounds of possibility for us to get a copy to the noble Lord very quickly.
The history of the health service over many years includes many efforts by different govemrnents to restructure the health service. The format of Clause 1 follows previous legislation and previous reorganisations. It is good to see on the Benches opposite several Ministers who, in their time, were responsible for restructuring the health service and proposing to Parliament clauses that were similar to that before the House today. All of us who have been involved in the health service will accept that it requires a period of stability during which we devolve more responsibility to local level. That is the intended effect of the Bill. It is extremely significant that 75 per cent of the budget for the NHS is to be devolved to the most local level possible.
Lord Peyton of Yeovil: My Lords, I accept what the noble Lord says; it is the intention that it should be so. However, why on earth does subsection (4) of Clause 1, to which I have already drawn the attention of the House, allow the Government—once having devolved—smartly to go into reverse and either abolish, modify or change in one way or another the authority which has now been established? If these changes were meant to be permanent, one could acknowledge them with some respect, but to make the changes and then say, "I will take them back tomorrow if I want to", is a rather strange way of going about the matter.
Lord Hunt of Kings Heath: My Lords, I do not think that the proposal departs from any principle that has been adopted in health service legislation enabling sensible changes to be made to the boundaries or names of health authorities. I believe that it is sensible to put this power on to the face of the Bill because in a few years' time, who knows whether, as a result of other changes, it might be necessary either to reduce the number of strategic health authorities, or to increase it. There may be reasons why the name might need to be changed. For example, a local authority may change its name. One might then want to change the name of the strategic health authority in order to reflect that.

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I can assure noble Lords that, once having established 28 strategic health authorities, the Government do not intend suddenly to decide that we want to make changes. It is intended that the legislation in relation to strategic health authorities should last for a considerable period of time. This provision seeks purely to offer flexibility in the future for any organic changes that may take place in health service provision.
Lord Clement-Jones: My Lords, the Minister is seeking the flexibility to make changes to the boundaries of strategic health authorities and so forth. But are not the Government asking for total flexibility in terms of the arrangements to which I referred earlier; namely, to deliver the NHS Plan by way almost of outsourcing the management and administration of strategic health authorities, which form an absolutely essential part of the NHS—or at least they seem to, as the Minister has described them—through this process of franchising?
Lord Hunt of Kings Heath: My Lords, I think that the noble Lord may have missed the point in relation to franchising. One of the problems encountered over many years by the NHS has been the assumption that every organisation in the NHS is the same and performs to the same extent. We have failed to recognise that, within a national system, it is possible to have very successful organisations, but also some which are not so successful. The emphasis here, as it is in other announcements made by the Government, is to recognise that there are some very successful people in the health service and that in the future we want to be able to extend their ability to manage and lead services.
Through franchising we can, first, enable successful managers to take on a wider range of responsibilities—which is surely a sensible approach—and, secondly, if in the fullness of time there are people from outside the NHS who it is considered could do a good job within the NHS, then again, why not use the franchising facility to enable that?
Lord Clement-Jones: My Lords, I am sure that the Minister is convinced of the case but, in effect, this will sub-contract the mainstream management of the NHS—not a facility of the NHS, an acute trust, a mental health facility or any other area in which subcontracting, private or independent provision is desirable. This provision will allow for the subcontracting of performance management of the NHS. What other examples could the Minister cite of successful sub-contracting of performance management in the public services?
Lord Hunt of Kings Heath: My Lords, I am sorry that the noble Lord has taken such an inflexible approach to this matter. Corporate responsibility lies with the board of the strategic health authority, but if such a board were to decide that bringing in external
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management would help that authority to achieve its goals, why should it not do so? What could be the objection to that?
Are we saying that the current appointment arrangements are exclusively the only arrangements that are desirable with regard to appointing senior people to the NHS? Surely we want to introduce a degree of flexibility so that we see a range of people coming forward to work in the National Health Service. I think that franchising is an excellent idea which will enable us to reach out far more widely than is the case at the moment. If, as a result, better services are provided to the public, then surely that is to be supported.
Lord Filkin: My Lords, perhaps I may remind the House that we are debating this legislation on Report. Rather than opening up a new topic for debate, interventions made after the Minister has begun his response should be limited only to short questions for clarification.
Lord Clement-Jones: My Lords, I fully accept those words, but further clarification is needed on this matter. The words covering the delivery of the NHS Plan were not available when we considered the Bill in Committee. Certain elucidations need to be gained from the Minister.
The franchises appear on the one hand to be a form of outsourcing, while on the other hand they appear to be contracts of employment. Can the Minister clarify that?
Lord Hunt of Kings Heath: My Lords, I think that we are probably moving outside the rules for debate on Report. Perhaps I may conclude my remarks by saying this. In developing and delivering the NHS Plan, it is our intention to provide high quality services to the public. I am sure we all agree that we need high-quality leadership to undertake that. We depend on high-quality management.
If, through franchising, we can—in the first case that I mentioned—ensure that those managers who are outstandingly successful can be given wider responsibilities, then surely that should be supported. If there are people in other areas of either the public or the private sectors who could bring to bear new skills which would be of help to the NHS, then again I believe that it is right for us to be keen to adopt those skills.
However, as we have seen from the appointments that have been made in the first round, the great majority of the people who will be leading the strategic health authorities are those who are currently serving within the NHS. I believe that they are of a high calibre and they understand the balance that needs to be struck between effective accountability to Ministers and Parliament on the one hand, while on the other hand allowing primary care and other trusts as much freedom at the local level as possible. They must ensure that throughout a proper balance is maintained. I am

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confident that those who have been appointed will keep to that balance and that the fears expressed by the noble Earl will prove, ultimately, to be groundless.
Earl Howe: My Lords, I thank the Minister for his very full reply. I am also grateful to all noble Lords who have taken part in this debate for their expressions of agreement on a number of the points that I have sought to make.
My message can be summed up quite simply: why not recognise the reality? Strategic health authorities are already showing every sign of being capable of taking the lead in driving through centrally-driven programmes. Let us recognise that they are doing that. In some contexts, that kind of prescriptive line management attitude is regrettable, but in others I would contend that it has something to recommend it. Prescriptiveness is regrettable in the day-to-day operational contexts which ought genuinely to be devolved to PCTs.
The Minister spoke of the prospect of intervention being minimal. I shall cite only one example which perhaps throws doubt on that. Dr Julian Neal, an executive committee member of East Hampshire PCT, was recently quoted in the BMA News Review. He spoke about the way in which strategic health authorities were instructing PCTs on how to allocate their budgets so that centrally-driven initiatives were funded before anything else and money channelled into secondary care. He said:
"When you hear the rhetoric it is good. They are talking about autonomy and decentralisation. But the reality is getting worse. It has never felt so micromanaged and centralised as it does now … We have very little control and that's demoralising for those working in PCTs".
That is a pretty depressing set of statements on a number of levels. What many PCTs want to do is to look for ways of taking the pressure off secondary care by investing more in primary care, but they are so hedged in by diktats from above that they are simply unable to do that.
We can see, of course, what is actually happening; it is what I mentioned a little earlier. Steve Gillam, who is director of primary care at the King's Fund and a GP, recently said:
"The money is being diverted into secondary care. It's going to pay off overspends. Even key areas such as clinical governance are being pushed down the priority lists by all the other must-do's".
The Minister spoke of the SaFF process and tensions. It is more than only tensions. In any structural reform of the health service the first thing that we need is clarity. With that in view, do not let us pretend that there is radical decentralisation and autonomy across the board when there is no such thing. I agree that 75 per cent of the budget being devolved is a significant departure as long as PCTs have real operational freedom, but do not let us use expressions such as "performance-manage" and "setting the structural framework" when what we mean in some important circumstances is "direction from the centre".
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I shall not labour the point further. I note the wish of my noble friend Lord Peyton for me to press the amendment. I hope that he will forgive me if do not. It was wholly and exclusively designed as a probing amendment and it has been extremely useful to that end. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
4 p.m.
Earl Howemoved Amendment No. 3:
After Clause 1, insert the following new clause—
"STRATEGIC HEALTH AUTHORITIES: PUBLIC HEALTH
(1) Each Strategic Health Authority shall have a duty to—

(a) improve the health of members of the public within its area; and

(b) ensure the delivery of such public health services as may be appropriate by Primary Care Trusts within its area.

(2) Each Strategic Health Authority shall appoint a Director of Public Health who shall be a member of the Authority."
The noble Earl said: My Lords, we move on now to an issue which, since we debated it in Committee, has caused me and many others a good deal of concern—that is, how the new structures established by the Bill will deliver a coherent public health service. The Minister took the trouble, for which I thank him, to organise a briefing session for Peers on this subject last week. I found it helpful—as I am sure did all those present—but some of the concerns that I had prior to that session persist.
The Government have decided that the delivery of the public health agenda should rest primarily with primary care trusts. Each PCT will have a team dedicated to public health and a director of public health on its board. The Minister said in Committee that:
"The new directors of public health … will be the engines of public health delivery".—[Official Report, 18/3/02; col. 1156.]
Their focus will be on local neighbourhoods and communities. Specialist expertise in public health will be pooled through the medium of the proposed public health networks, which will be flexible in character and include, among others, NGOs.
Sitting above the 300 or so PCTs will be the regional directors of public health based in the offices of the nine government regions. It is the regional directors who will exercise the departmental public health function on behalf of the Chief Medical Officer and to whom the PCTs will be accountable. Their role will be one of planning and co-ordination; they will set up and service the public health networks; they will plan for emergencies; and they will tackle the wider issues associated with health inequalities within the regions.
Set apart from the line of accountability between the regional directors and the PCTs will be the strategic health authorities. The role of the SHAs will be to performance-manage PCTs in their public health functions. Each strategic health authority will have a public health doctor on its top team.
The first thing that strikes you when you look at this tree of accountability is how odd it is. There are two separate and distinct reporting lines: 303 PCTs

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reporting to nine regions—a very flat structure, incidentally—and, simultaneously, those same PCTs reporting to 28 strategic health authorities for their performance management. The strategic health authorities—the role of which is, above all, meant to be strategic—will not, so far as concerns public health, act strategically at all. They will have a purely operational function. The strategic function will be performed by the nine regional directors. The nine regions will be distinct and separate from the four regions represented by the regional directors of health and social care.
While the nine regional directors will have responsibility for maintaining the public health networks, it is far from clear how accountability to, from and within those networks will be defined. Trying to apply the concept of accountability to informal and flexible networks seems fairly impossible. Within a network, accountability acquires an in-built fuzziness. I, for one, find that disturbing.
So odd does the system look that it is as if the Government, having invented a decentralised structure for delivering the bulk of primary and secondary healthcare, suddenly found themselves having to shoehorn public health into that same structure. Having decided that PCTs—and only PCTs—should be the engines of primary care, it is as if Ministers had little alternative but to decide that somehow or other PCTs would need to be responsible for the delivery of public health as well.
I am the first to agree with the Government that effective primary care is integral to improving public health. There is no argument about that. But health protection, health improvement, surveillance and reducing health inequalities—and the specialised skills that go with all of those—are issues that run much wider than an area or population typically served by a single PCT. Of course, the Government recognise this, which is why we have the concept of these so-called networks.
But the obvious question that arises is: why do it this way? Why in particular leave strategic health authorities out of the loop? Instead of these loosely defined networks and instead of vesting responsibilities in PCTs, which they are individually ill-equipped to handle, instead of having two parallel lines of accountability, why not acknowledge that there is a much readier and less complicated route that could be taken? That, as my amendment suggests, is to make strategic health authorities the initiators and drivers of public health programmes across an area and allow SHAs to performance-manage PCTs for the functions devolved to them. Would it not make more sense to allow the strategic direction of public health to rest with the strategic health authorities, each of which would have a dozen or so PCTs underneath it, rather than with the nine regions, each of which would have to direct and co-ordinate between 30 and 40 PCTS?
The extraordinary feature of the Government's model is the proliferation of public health directors and teams in PCTs—more than 300 of them—more people than can possibly exist at the moment with the
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appropriate qualifications. Obviously not every public health director can be a doctor—nor would I regard it as necessary across the board—but it may well be the case that in a particular area neither the public health director nor his line manager at regional level was a doctor qualified in public health. That would run some big risks, both direct and indirect.
A consultant recently told the BMA News that,
"The process has made a mockery of professional qualifications because you don't seem to need them. It has destroyed and demoralised the profession".
Yet, despite that, we are told that all is well. The supreme irony is that individuals who have the relevant specialist qualifications are being given what I can only describe as the elbow. Twelve public health consultants received letters earlier in the year telling them that their jobs were at risk of redundancy, although I believe that the BMA has now intervened on that. I have heard of 20 senior public health consultants who have been parked at strategic health authorities for the coming year. I am told that that number is likely to increase. Of all the daft consequences of this enormous upheaval in the NHS, that has to be the daftest. We cannot afford to lose such people.
The delivery of the public health agenda is about coordinating a broad spectrum of discrete but associated activities. It requires firm and clear leadership from people who are capable of identifying what is needed and how to meet that need. Every participant has to be fully aware of how the key public health responsibilities have been allocated and how the services can be accessed. For PCTs to take the lead in this far from simple matrix of function is, I fear, a recipe for fragmentation and dissipation of effort. It is a forced and ill-thought-out answer to a very important set of questions. Those questions, about how exactly the arrangements will work and who will be tasked with doing what, are still being asked throughout the health service.
I am not suggesting that the Government have remained silent or inactive on these issues, but out there—and, indeed, in here—the details are still lacking. Why is that? Why, even now, does the BMA, among others, state that it is practically in the dark about what is intended? The Secretary of State is on record as admitting that the structural changes now under way in the health service present "huge risks". That was a refreshing admission, but if it is true that there are huge risks, why are those risks being magnified by a failure to articulate the strategy for public health in a way that commands the confidence of everyone?
I very much hope that the Minister can be a little more forthcoming and precise on these matters when he replies, because we badly need reassurance. I beg to move.
4.15 p.m.
Lord Clement-Jones: My Lords, I strongly support Amendment No. 3, which was cogently introduced by the noble Earl, Lord Howe. I shall also speak to Amendment No. 4.

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There is no doubt about the importance of the debate on the future of public health services. If we are genuinely to switch emphasis towards prevention and make an impact on health inequalities, we need to develop our public health service, not to mention all the issues of health improvement and surveillance mentioned by the noble Earl, Lord Howe.
However, despite the Minister's worthy attempt in Committee to allay worries and the helpful meeting that he arranged to discuss the implications of the new organisation for public health, there are still considerable concerns and many outstanding questions on the issue, as the noble Earl, Lord Howe, has made clear.
Changes have already been made in anticipation of the Bill passing through this House. I understand that public health directors moved from area health authorities to PCTs on 1st April. Those shadow strategic health authorities, which we were debating under the earlier amendment, are already in place.
We have had some reassurance from the Minister on the filling of director of public health roles. That appears by and large to have taken place. However, there are key questions relating to organisational capacity and continuity, how PCTs will deal with public health specialisms, the way in which new management systems will operate and the issue of resources.
As your Lordships have heard from the noble Earl, Lord Howe, despite the need for capacity, the new system is already operating in a bizarre fashion, with consultants having been made redundant and then unmade redundant. It seems extraordinary that public health consultants have been parked at strategic health authorities for the corning year. Many of them have strong specialisms, including epidemiology, health information, statistics, preventive medicine, health promotion, communicable diseases, environmental health, development and evaluation of health services, teaching and research. Those are all valuable areas of specialism that we must not lose to the public health service. It is probable that these public health professionals will be tasked with short projects until their future is determined, but that is hardly a motivational way of dealing with valuable people. What an extraordinary state of affairs, when there is a great need for capacity in the public health service.
There are particular concerns about specialisms being lost. We have heard much in Committee and subsequently about the new public health networks, but there is no obligation on PCTs to ensure that particular specialisms are covered. The relationships will clearly be all about brokering within networks and between agencies to get things done, but there is little obligation on the PCTs as regards particular specialisms.
Furthermore, as the Minister admitted in Committee, if action by a network in a particular area is all about PCTs chipping into the resource pot, we will see a permanent game of NHS budget poker being played between PCTs up and down the NHS structure.
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By their nature, networks will require a phenomenal amount of energy and organization—more than would be present if strategic health authorities had that responsibility. As regards management and accountability, as the noble Earl, Lord Howe, pointed out, the responsibilities for different aspects of public health as between different parts of the health service risk being blurred.
Having heard the Minister and his officials, our concern is that the management structure is overcomplicated. It appears that performance management will be carried out by strategic health authorities, but actual management will be carried out by regional public health directors. As the noble Earl, Lord Howe, said, how will those networks be held accountable? In Committee, the Minister talked about headbanging by the strategic health authorities, but what sanctions will they have? Would it not be preferable to give accountability to the strategic health authority, which is then line managed by the regional health director? We seem to have a topsy-turvy set of organisational proposals.
The Minister did not clarify in Committee what resources PCTs will have for public health. Nor do we know whether they will be ring-fenced. Yet here we are with PCTs already taking over public health services. Will they have a ring-fenced budget? Will they have adequate resources to fulfil the Government's agenda? All those difficulties need to be overcome if PCTs are effectively to discharge their public health functions.
The one bright spot relates to the new national agency, explained in Getting Ahead of the Curve. This is along the right lines, even though the way in which it is to be implemented, through the regulatory reform order procedure, is not satisfactory.
We on these Benches are very nervous about the new proposals. The Government risk getting so far ahead of the curve that they will fall off. I hope that the Minister can reassure us.
Baroness Cumberlege: My Lords, I am reluctant to enter the debate, particularly as it concerns structure, because, in his reply to my noble friend Lord Peyton, I felt the Minister's finger on my collar. In previous times, when I was in government, we also reorganised. I hope that the Minister 'will remember our debates in Committee, when I sought strongly to get politicians out of meddling with the National Health Service. Although I had a lot of support from the Cross Benches and from the Labour Benches, I did not. get much support from the Minister on that issue.
I want to speak about public health, because I remember that before the Minister and I were in this House, he was a very strong advocate of public health. He sought strongly to promulgate, disseminate and follow the findings of the report produced by Sir Donald Acheson, a former Chief Medical Officer.
However, the person who has made the most difference in public health throughout the ages is my noble friend Lord Waldegrave. My noble friend was the architect of a most coherent plan entitled, The Health of the Nation, which concentrated on five key

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areas; namely, coronary heart disease/strokes, cancer, mental health, HIV and AIDS, and accidents. Each of those areas had very specific targets—27 in all. The plan was concise, it was achievable, and it was targeted. When I became a junior Minister, it was my responsibility to implement the plan. It was one of the best parts of my job.
The plan was cited by the WHO—the World Health Organisation—to other nations as an example to follow. I remember attending conferences where the plan was extolled, which did not surprise me. It was so clear, well defined and strategic; it placed a huge emphasis on local involvement. That is my worry as regards the proposals now being put forward.
Having listened to my noble friend and the noble Lord, Lord Clement-Jones, there seems to me to be a great lack of clarity in the way that the structures have been established. We shall lose a great deal without clarity. Public health is one of the areas that are squeezed out when the pressure greatly increases. As we know, in the health service the immediate always pushes out the important. Therefore, above all others, this area needs to be most carefully defined.
We also need a good deal of involvement in the area. It can be described as a "nannying" area, because it can be quite irritating. Much of the process is very negative; for example, "Don't do this", or, "Don't do that". The skill is to make it fun—to inject some pizzazz into it and to ensure that people really want to go with the grain of it. The proposed new teams are most important, but I agree with my noble friend Lord Howe that a public health specialist should be involved. When I mentioned that possibility in Committee, the Minister responded by saying that he thought I was being too purist, and pointed out that perhaps I was ignoring the work of health visitors, nurses and others, who could take on that role. I understand that. Those people do have a part to play in the process. However, I believe that leadership in this area is most crucial. But it must be leadership that is very well respected by other health professionals, especially the medical profession.
We achieved a good deal through The Health of the Nation. Of the 27 targets, only three showed no improvement; namely, HIV/AIDS, teenage pregnancies, and obesity, which are still very challenging. I have to stress that, in two years, we did not have one case of measles that was not imported. It makes one sad to consider the current MMR debacle, because I thought that we had almost eliminated the disease. One of the engines for change was the health education authority, which has been abolished. When we reach Amendment No. 27, I hope that we shall be able to discuss its replacement.
Finally, I should like to address the issue of the directors of public health. In Committee, my noble friend Lord Howe asked about these specialists and their independence. Traditionally, directors of public health in this country have had a special responsibility over and above that of management. We have expected them to use their integrity and their professionalism to say how it really is in the health
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service. Those reports have been a touchstone, a marker in our social history. Their findings have made successive administrations feel both uncomfortable and embarrassed. However, such reports are hugely valuable because they are independent.
My noble friend mentioned the fact that the strategic health authorities will have performance management responsibilities in terms of public health. I should like to be clear in my own mind on how the Minister sees those people at the strategic level. Will they be medical managers, or will they be public health specialists? When one reads through their proposed duties, much of their work seems to be managerial. I believe that we need something beyond and above that level: we need people of much courage, who will be really passionate about their subject as they drive it forward. I hope that the Minister will pick up some of these points. The amendment before us nails down most clearly a duty on the SHAs and primary care trusts to improve the health of the nation, which is very important. I hope that the noble Lord will see merit in the amendment.
Baroness Masham of Ilton: My Lords, within the umbrella of public health there are many different subjects that are specialties of their own; for example, tuberculosis, HIV/AIDS, the different sexually-transmitted diseases, and the hepatitis diseases, all of which are on the increase. Healthy eating, smoking, education, alcohol and drug abuse, and vaccinations are other areas to consider. It is a huge umbrella. When there is change, there is insecurity. It takes about two years to bed down new health authorities. The Minister's meeting was most helpful, but we need to know that adequate funding and resourcing will be available, as well as co-operation between health and local authorities. I support the amendments.
Lord Peyton of Yeovil: My Lords, perhaps I may take this opportunity to thank the Minister for the way that he has succeeded in moving his department so quickly. I have now received a copy of his letter of 20th April, a very brief reading of which makes me almost tearful that I did not receive it earlier. However, this is a time—I hope—to be mildly useful and not, perhaps, a source of trouble to him before the end of this stage of the Bill.
As one of those people who has long attributed some of the problems and difficulties of the NHS to political meddling, it was a breath of fresh air to hear my noble friend Lady Cumberlege, who has experience of the health department, make exactly that point. I thank her warmly for doing so. There is one point that puzzles me. The amendment tabled in the name of my noble friend states:
"Each Strategic Health Authority shall have a duty to … improve the health of members of the public within its area".
Similarly, Amendment No. 4, to which the noble Lord, Lord Clement-Jones, has attached his name, uses almost the same words with regard to primary care trusts. Perhaps the Minister—or, indeed, my noble

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friend—can say whether there is anything in the current duties of the SHAs, and those of the PCTs, that would exclude their seeking,
"to improve the health of members of the public within [their] area"?
Indeed, it seems to me that it follows almost from the name that such bodies would have no reason to exist unless it was their duty to do precisely that. I should be most grateful for some enlightenment.
Lord Turnberg: My Lords, I, too, was privileged to he present when my noble friend the Minister gave a briefing last week. However, I came away with a different impression from that gained by the noble Earl, Lord Howe. If one looks most carefully at what is currently lacking in the delivery of public health in its broadest terms, it is really concentrated at the primary care level. We have regional directors of public health and directors of public health at health authority level, but something is missing at the primary care level where much of the public's health needs to be addressed.
It seems to me that this proposal of a heavy investment of personnel with responsibilities for public health in primary care trusts is just what we need. Of course, they would need to work in networks and collaborate and co-operate across their "patch" and that is intended. It would be an impressive and worthwhile investment on the part of the Government. Those personnel would need to be monitored to make sure that they delivered. That would be done at strategic health authority level. As I say, the proposal would constitute a worthwhile involvement and investment on the part of the Government. We should support it.
4.30 p.m.
Baroness Pitkeathley: My Lords, there is much anxiety about the new system with regard to public health as has been evident in our debate. That is a natural anxiety. All of us who have an interest in this issue know that the way to bring about real improvements in the National Health Service is by improving the way we tackle public health; that is, by making people more aware of the effect of lifestyle on their health, enabling them to change their lifestyle if necessary and, above all, encouraging them to take more responsibility for their own health.
It must surely he clear that for such a range of public health functions to he effective they must be carried out as near to the patient and his or her family or carers as possible. It seems to me that only at primary care level can the needs of local populations, which will naturally vary, be understood and responded to. Only at that local level can needs be analysed and causes of ill health and health inequalities be responded to. Only at primary care level can leadership be exercised to ensure co-operation and co-ordination between services and to promote innovative solutions which are responsive to local needs. Of course, strategic health authorities will have an overseeing and a support role and that is right, but the main responsibility must lie with primary care trusts.
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Amendment No. 4 seems to me to be unnecessary as the responsibilities of primary care trusts in relation to public health are clearly set out. Many directors of public health are already in post and developing wide-ranging networks and relationships which will enable them to draw directly on the experience of patients and, indeed, of their whole populations. As chair of the New Opportunities Fund I pay tribute to some of those directors of public health in primary care trusts for the excellent support they have offered the New Opportunities Fund in getting some of our public health programmes off the ground. The knowledge they have of their local communities and their commitment to meeting their needs is truly impressive. The duties placed on them already are more than adequate. The best thing we can do now is to support them in carrying out those duties and to help them to deliver on the commitment the Government have shown to public health.
Lord Hunt of Kings Heath: My Lords, one point on which we are all agreed is that public health is important to the way forward and to ensuring that the health of the nation overall improves. The key issue is at what level the principal public health authority should be based. The noble Earl, Lord Howe, clearly expressed the view that it should be based at the strategic health authority level. The Government disagree. We think that that is too remote a level. It would be remote from local government and from the local community.
Looking back over the past 20 or 30 years I am sure that no one could say with confidence that public health has been sufficiently integrated into the NHS decision-making structure for the pursuit of public health goals to receive the support and vigour that is required. One of the reasons for that is that public health has often been divorced from the critical primary care level. I am convinced that to give public health the dynamism, leadership and success that it needs, we need to make the essential link between the public health specialist and primary care.
One of the most successful ways of developing public health programmes is in the GP's surgery. One of the most successful interventions in relation to reducing smoking is the advice GPs and their staff give to members of the public. There are persuasive arguments for saying that the principal public health authority ought to be the primary care trust. That potential is surely to be found in local neighbourhoods and communities in the programmes being developed to lead, drive and improve health and reduce inequalities and in forging relationships with local authorities as much of the effort involved in public health concerns getting local agencies to work, together.
I suggest that it is at the primary care trust level that one is likely to get the important links between the health service and local government. I believe that the strategic health authorities, which will have an average population of 1·5 million, would be too large for this purpose and would have to engage with too many different local authorities to be successful. At primary

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care trust level one has much more chance of getting successful partnerships to work together across agency boundaries.
The noble Baroness, Lady Cumberlege, raised two issues. First, she referred—as she did in Committee—to the King's Fund report. I do not disagree with her comments on the need for devolution and the need for politicians to step back from micro-managing the health service. However, I disagree with her suggestion that we should set up a national public corporation, as it were, to do that. I have grave doubts as to whether in reality that would divorce the health service from political influence. I believe that the devolution model that we are adopting is likely in the end to be much more effective. Surely no better indication of that is our desire to ensure that public health is placed at the lowest possible level of decision-making.
I agree with the noble Baroness, Lady Cumberlege, that the calibre of the directors of public health will be very important. I have already said in Committee—that has been confirmed—that the post of director of public health in primary care trusts is open to specialists in public health from a range of backgrounds as well as to consultants in public health medicine. To enable them to carry comparable responsibility across the 10 core areas of public health practice those specialists will need to have training, experience and qualifications comparable to those of consultants trained in public health medicine who will be on the GMC specialist register. Our ability to extend to another group of professionals the opportunity to be appointed directors of public health at the primary care trust level constitutes a great advance in the public health movement.
I agree with the noble Baroness that these are high calibre appointments. We need them to be robustly independent. We need them to provide leadership in public health. We need them to be public figures whom the public can rely upon in terms of their pronouncements and reports on public health. That is what we expect to happen. That role is much better conducted at the primary care trust level than at the strategic health authority level. I do not believe that simply having 28 directors of public health would give the strength, viability and public visibility that we will realise from appointing a director of public health in all primary care trusts.
On the parking of people, the explanation is simple. As we wish to ensure continuity of service, we decided that all staff who are currently employed in such situations would be assured of a further 12 months of employment, from 1st April this year to 30th March next year, in order to give time for the arrangements to bed down and for primary care trusts to appoint full public health teams. I accept that among public health professionals, this is a time of uncertainty. However, that is surely the best way to ensure that they are kept on the payroll and that primary care trusts are given the time that is needed to establish their full public health teams.
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I was asked why we seek to retain performance management at the strategic health authority level while giving a strong role to directors of public health at the regional level. On performance management, that is consistent with the whole structure and relationship between strategic health authorities and primary care trusts. I have already said that I expect that performance management to be "light touch". However, it is appropriate that the performance management role is conducted at the strategic health authority level.
On public health networks, whichever way one cuts the cake, there will always have to be flexible arrangements to ensure that one has the right level of expertise. That would be the case even if one decided to follow the noble Earl, Lord Howe, and make strategic health authorities the principal public health body—there would still be a need to share specialties and to have flexible arrangements. As we have gone down the route of giving primary care trusts a public health lead, we have suggested—and will propose and develop—public health networks that take on board the point that was raised by the noble Baroness, Lady Masham. I refer to the point about ensuring that primary care trusts work together and that specialisms within public health are effectively covered. That brings us to the role of regional directors of public health. As a result of their professional competence and knowledge, they are best placed to enable public health networks to work effectively.
On the proposal that those bodies will he based in the nine government offices of the regions, surely that is a way of pulling together the work within central government and local government in relation to public health. Much of the work of the regional offices of government relating to local authorities can have an important influence on public health policies generally. In addition, those regional directors will be accountable to the Chief Medical Officer and will work closely with the four directors of health and social care within the Department of Health. We will secure co-ordination between the work of government as a whole in public health and in relation to health and social care at that critical regional level.
At the end of the day, there is a clear decision to be made: where should major public health responsibility be? The Government believe that that is best placed at the most local level possible—that is, with the primary care trust—where the impact of working with general practice and other primary healthcare practitioners will be a very powerful tool in relation to securing effective public health practice. However, that will have the safeguard of networks that pull together the work of primary care trusts and the performance management by those primary care trusts from strategic health authorities. It will also involve the professional mentoring role of regional directors of public health. That is a coherent set of arrangements and, crucially, it rests the key public health responsibility at the lowest possible level within the health service.
4.45 p.m.
Earl Howe: My Lords, once again, I am grateful to all noble Lords who took part in this important debate and in particular to the Minister for his reply.
Restructuring the NHS involves inevitable upheaval. Part of the Government's problem is that they are starting this upheaval from a rather shaky base. They began their period of office in 1997, so far as public health is concerned, very well. The White Paper, Saving Lives: Our Healthier Nation, contained much that was laudable. It followed the agenda set by the White Paper, The Health of the Nation, about which my noble friend Lady Cumberlege spoke with her usual authority.
To be fair, the Government have notched up some signal successes, such as the flu vaccination programme and the introduction of vaccinations for meningitis. However, when we look elsewhere—to the mushrooming of sexually transmitted diseases, the rise in HIV, the failure to maintain MMR vaccination rates, the rise in TB infections and the rise in malnutrition—their record is, frankly, pretty poor. Much of that failure, I am bound to say, rests at the centre. We need to realise what may ensue from upheaval to the health service. What we have had up to now, underpinning the delivery of public health, are functioning networks of key individuals. Those important relationships are now being disrupted and unpicked. Such disruption carries dangers of its own.
The King's Fund report, Public Health in the Balance, which was published recently, underlined the shortage of staff with public health skills in London. However, many of the messages in that report apply more widely. It states that fragmenting the teams that are based on health authorities and splitting them up into primary care trusts involves the risk of losing key specialist skills. The report found that there is a wealth of public health experience in London but also a high turnover of staff and a lack of appropriate qualifications. Strategic planning, including workforce planning, is vital if local needs are to be met.
Picking up those concerns, I heard what the Government said about why they had chosen to put in place a dual line of accountability for primary care trusts. I shall reflect carefully on the position that the Minister set out. I do not disagree that the performance management role should be performed by strategic health authorities. My suggestion merely was that strategic health authorities are well placed to do rather more—in other words, to take a strategic role. The overarching point that I was trying to make was that if one wants to upgrade public health, as we all do, one starts—surely to goodness—by defining one's objectives and the functions that need to be performed, and one then builds one's service around that. One does not do things in reverse—one does not start with a structure and then try to make public health fit into it.
I take some comfort from what the Minister said. I do not disagree with him that the public health agenda has not always been pursued at the level of primary care with the vigour that we could have
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wished. There is much to be achieved through primary care trusts. There is a good case for centring much of the delivery effort at that level. However, issues such as the function of the surveillance of health promotion and health protection run much wider than primary care trusts and they need direction.
The Minister and the noble Lord, Lord Turnberg, spoke about public health networks and commended the notion of flexibility. I say that flexibility is fine but that networks are inherently loose and vague. I agree with the noble Lord, Lord Clement-Jones, that they involve a great deal of energy and organisation. I still maintain that the accountabilities in the Government's model are not ideal. That aspect of these proposals, on its own, is one that we may live to regret. However, I believe that this has been a helpful debate. It is time to move on, and I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 4 not moved.]

Israel and the Occupied Territories
4.50 p.m.
The Parliamentary Under-Secretary of State, Foreign and Commonwealth Office (Baroness Amos): My Lords, with the leave of the House, I shall repeat a Statement being made in another place by my right honourable friend the Foreign Secretary. The Statement is as follows:
"With permission, I would like to make a Statement on recent developments in Israel and the Occupied Territories, specifically in relation to Hebron, Bethlehem and Jenin, and in respect of the better news involving a UK contribution to ending the siege of President Arafat's headquarters in Ramallah.
"Since the House last debated this subject on 16th April, the situation in Israel and the Occupied Territories has remained very tense. On Saturday, after four Israelis, including a five year-old child, were killed in the West Bank settlement of Adora, the Israel defence forces moved into the nearby town of Hebron. There have been reports that at least seven Palestinians have been killed and 20 injured in the fighting which followed.
"At the same time, the stand-off continues at the Church of the Holy Nativity in Bethlehem, where 200 Palestinians, some of them armed, have taken refuge from the Israeli forces for the last three weeks. Three of the Palestinians inside the church compound have been shot dead by Israeli forces, including one last night.
"The most reverend Primate the Archbishop of Canterbury has raised his concerns at the situation with my right honourable friend the Prime Minister and myself, as have leaders of many other denominations and faiths.
"However, talks between Israeli and Palestinian negotiators are under way in an attempt to resolve the situation. Nine Palestinians have already left the

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church compound. I understand that several dozen more Palestinian civilians may shortly leave, and that there will be deliveries of food to those who remain inside.
"During the debate on 16th April, many right honourable and honourable Members on both sides of the House expressed their concerns at reports alleging that the Israeli military had used disproportionate force during their action in the refugee camp in Jenin which began on 3rd April. At the UK's instigation, the United Nations Security Council on 19th April agreed Resolution 1405, which welcomed the initiative of the Secretary-General, Kofi Annan, to send a fact-finding team to Jenin to establish what had happened.
"Following this resolution, the Secretary-General appointed a team led by Martti Ahtisaari, the former president of Finland, and including Sadako Ogata, the former UN High Commissioner for Refugees, Cornelio Sommaruga, the former president of the International Committee of the Red Cross, Bill Nash, a retired American Major-General, and Peter Fitzgerald, a senior Irish police officer. At General Nash's request, LieutentantColonel Miles Wade, a serving officer in the British Army, has been added to the team.
"However, I am sure I speak for the whole House in expressing my serious concern that, 10 days after Israel first agreed to this fact-finding mission, it has yet to be admitted to Jenin. During the meeting of the Israeli Cabinet yesterday, further objections were raised to the arrangements for the team's visit.
"Let me repeat what I said to Israeli Foreign Minister Shimon Peres: Israel must co-operate without delay with the UN team in order to establish the facts. The Israeli Government themselves have claimed that their action was necessary and proportionate. If that is so, they have nothing to fear and much to gain from a fact-finding mission composed of such distinguished and internationally respected individuals.
"Potentially the most positive development over the weekend was the acceptance in principle by Israel and the Palestinian Authority of a United States-United Kingdom initiative to allow the Palestinian leader, Yasser Arafat, to leave his compound in Ramallah, which has been under siege continuously since 29th March.
"Under the terms of this initiative, Israeli forces would pull back from President Arafat's compound and from Ramallah itself and leave President Arafat free to travel both within the Occupied Territories and elsewhere and free to return.
"At the same time, six Palestinian men would be removed from the compound to a Palestinian facility in a secluded location in the Occupied Territories. Of those six, four have been convicted by the Palestinian Authority for involvement in the murder last October of Israeli Cabinet Minister Rehavam Ze'evi, one is the Secretary General of the Popular Front for the Liberation of Palestine, the
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group which claimed responsibility for Minister Ze'evi's killing, and one has been detained because of alleged involvement in the Karine A arms shipment affair in January.
"Under the initiative, Britain and the United States have agreed to provide a small number of supervisory wardens to oversee the men's detention. The wardens themselves will be unarmed. Let me make this clear: it is the Palestinian Authority's prime responsibility to ensure the physical security of the facility and the personal security of the US and UK wardens.
"A month ago we sent out a scoping mission. An advance party of experts from the UK will arrive in the region this afternoon to begin to set arrangements in place and to satisfy themselves as to the personal protection of the wardens themselves. The UK wardens all have experience of working in similar situations with the OSCE.
"This proposal was first put to Israeli Prime Minister Sharon by my right honourable friend the Prime Minister in early November last year. I drew it to the House's attention again in our last debate 13 days ago.
"At this point, I would like to place on record my appreciation of the work of US Secretary of State Colin Powell, of others in the Bush Administration, and of American and British diplomats in Israel and the Occupied Territories who have helped to make the progress we have.
"But there is still much work to be done to bring this initiative into effect. I am sure the whole House will join me in expressing the hope that no last-minute hitches occur and that these arrangements can be put into place with all dispatch.
"This is a significant step forward. But on its own it is not enough. It is now imperative that the two sides build on this modest measure of agreement, stop the violence and start talking to one another. The Security Council itself, in a series of resolutions in recent months, has laid down clear imperatives on both parties. Both parties are obliged to move to a meaningful cease-fire and to resume security co-operation.
"Israel should withdraw from Palestinian-controlled areas and must heed Security Council demands. Once he has been released from the siege, President Arafat will plainly be able to exercise much enhanced political leadership of the Palestinian Authority. He must take that opportunity and do all in his power to stop the violence and work for peace.
"Ministers and officials have been in constant touch with both sides to the conflict to stress the need for a constructive approach. This Government's commitment to helping to re-start a peace process is absolute. The same unity of purpose exists throughout the international community. But the hopes and expectations of a generation of Israelis and Palestinians rest above all on the shoulders of two men: Prime Minister Sharon and President Arafat.

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"Now is the time for them to grasp the opportunity which international efforts have created and to demonstrate that they are truly committed to peace".
My Lords, that concludes the Statement.
4.59 p.m.
Lord Howell of Guildford: My Lords, I am sure that the whole House will be grateful to the noble Baroness for repeating the Statement. I thank her for doing so and I am sure that many of your Lordships will welcome the positive element contained in the Statement, as well as the very important references to other less positive aspects. Personally, I welcome very warmly the evidence of the direct role which the skills of British diplomacy are being allowed to play in relation to the deal which releases Chairman Arafat. Indeed, it is to that third aspect of the noble Baroness's Statement that I want to turn first.
As the Minister said, in theory, this deal should ensure that Chairman Arafat is much better placed than he has been while holed up in Ramallah to begin to reassert some control over his more extremist elements and to gain back some of the authority which has been lacking. It is a very small bridge that we have come to and crossed, and it is positive that the deal has been done—one hopes that that will be the case—but I should like to know a little more about how the supervisory wardens are going to work. Where are they going to be located? How long do they expect to be in this role? It is quite a novel involvement and we should like to have as much information as we can from the Minister on it.
Although Arafat may be better placed in theory, one wonders whether that is going to be the case in practice. Is it not the position that the Palestine Authority has really been destroyed, both physically and in terms of leaders, in the incursions by Israel into the Occupied Territories in recent weeks? Is it not very hard to see how the means of controlling extreme elements, and the reassertion of some kind of law and order by the Palestinian Authority, can really begin until the Palestinians again have the infrastructure, leaders and authority to play a solid part both in ruling their own area and in moving back to negotiations? What proposals are being considered for trying to rebuild the physical infrastructure and for channelling in funds that will not simply be diverted into terrorism and weapons? How can one begin to repair some of the physical damage?
As for the leadership question, can the Government share with us any thoughts on who is going to work alongside Chairman Arafat, who is no longer young? Vast energies are going to be needed. Is not the need for leaders on the Palestinian side who are not so connected with violence? Is not the need for leaders who do not only condemn the Israeli excesses, which have been clear enough, but who are prepared to condemn utterly the suicide bombers and the sickening martyr culture? One would look to the Palestinian side for that condemnation if the hopes for a return to negotiation are to open out.
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That deals with the third part of the Statement. I shall, if I may, return to the first part—on the Church of the Nativity, which we discussed in your Lordships' House the other day. Surely the position remains that those who are holed up in the Church of the Nativity should let the non-combatants out. I gather that some have come out, but it must be right that all should now be released. If the Palestinian gunmen and the hardcore of Hamas and Al Fatah terrorists who are in there want sanctuary, that is one thing, I suppose, but if they want to carry their weapons in there and use the Church of the Nativity as a defensive position or as a device for hostage taking, surely that is not acceptable at all. Bearing in mind those facts, can something be done to bring the realties home to people before there are worse tragedies and more killing of more innocent people as well as the destruction of a very holy place?
Finally, Jenin is a very serious matter indeed. I agree totally with the Government that it must be in the interests of the state of Israel to hold an inquiry and bring into the open what happened. There are perhaps four very varied versions of what actually did happen. We have seen with our eyes the evidence of massive physical destruction, but we really do not know who caused it, who died in it, how much booby-trapping there was, or what kind of terrorist activity had to be destroyed within the camp. I totally agree with the Government that an inquiry should certainly produce answers to those questions.
Overall, it must be the aim—slowly, by these small moves, one of which we have heard about today—to move forward towards negotiation again, and towards settling the matters, deep and historical as they are, not by endless bloodshed and killing but by sensible and civilised dialogue and discussion.
5.5 p.m.
Lord Wallace of Saltaire: My Lords, we on these Benches also welcome the Government's Statement on this extremely grave international problem. It is good news on Ramallah, and we congratulate the Government on the contribution that they have made to progress in that area. We also thank the Government for their continuing efforts in Bethlehem. Is not a similar agreement for the removal of the terrorists from the Church of the Nativity also possible there? I am very happy to hear that food has now been taken in. We know that there are wounded within the church and gather that some of the wounds are gangrenous. It would seem possible to allow a greater degree of flexibility in letting people out.
We note the British contribution to what is proposed. It would be interesting to know a little more about Colonel Wade's background and experience. We note that there will be further British contributions in terms of the proposed wardens. We also note, in the various discussions going on in the media, suggestions that, if there were to be substantial moves towards a settlement between Israel and Palestine, there might well be further calls on British and other European forces to police a settlement. Are contingency discussions going on not only with overstretched British forces, but, as we now know, with

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overstretched German and French forces as to how contributions will be found for such a force if progress is made?
We agree strongly with the Government's remark that the United Nations inquiry team should by now have been accepted into Jenin. I understand that, yesterday, having been to Jenin, the noble Lord, Lord Janner, was on television and said that he did not find evidence of allegations of disproportionate force. I look forward to hearing his support for the proposition that the Israeli Government should by now have accepted that that team should be allowed into Jenin. If there is nothing to hide, then they do not need to hide anything.
We cannot have a situation in which the international community, led by the United States, is claiming the right for a pre-emptive attack on Iraq, as is currently being discussed in Washington, justified on the grounds that Iraq refuses to accept inspectors except on very restrictive terms and that Iraq is in defiance of a number of UN resolutions, when we accept that the Israeli Government, on whatever grounds, are behaving in a relatively similar way.
I welcome also the news that those who are charged with the murder of the tourism minister are now to be dealt with in what appears to be a satisfactory manner that is acceptable to both sides. I think that we are entitled to ask for the Israeli Government, and for Mr Sharon as prime minister, explicitly to disclaim the views expressed by the tourism minister and others within the government that Israel is entitled to the whole of Judea and Sumeria and entitled to expel the Palestinians from that territory. That is, after all, part of the problem.
On Saturday, I read in an American newspaper that, so far, Mr Sharon has refused to accept that any settlements should be withdrawn. Clearly, a great many of the settlements will have to be withdrawn if there is to be a resolution. The basis for a settlement, as the Saudis have now proposed, is that there must be two states—one Israeli, the other Palestinian—on this territory. I think that we are entitled to ask both Mr Sharon and Mr Arafat explicitly to accept that that is the principle on which we should go forward.
Our support for Israel has rested on the quality of its government, its respect for law, and the restraint of its behaviour in the use of force even when at war with its neighbours. It seems to many of us that the destruction of the Palestinian economy, its infrastructure, even its government records and the entire apparatus of authority and of daily life has been disproportionate in its impact. Much of that has, after all, been paid for by European assistance over the past 10 years. Moreover, if we are to rebuild, European governments will undoubtedly be asked to pay again.
Israel's behaviour undermines the case for intervention in Iraq which is currently being presented in Washington. We must ask the American Government—and I hope the Minister can reassure us that the British Government are making this point to our American allies—to bring pressure to bear on the
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Israeli Government to accept this basis for a settlement, as well as on what remains of the Palestinian Authority.
5.10 p.m.
Baroness Amos: My Lords, I thank the noble Lord, Lord Howell, for his contribution, and in particular for the welcome he gave to the role played by the United Kingdom.
The noble Lord asked a number of specific questions about the work of the supervisory wardens, where they would be located, and how long their role would continue. I am unable to answer all those questions. As the Statement indicated, the supervisory wardens would be unarmed. The physical security of the facility would be the responsibility of the Palestinian Authority. The location would be remote, and it is not clear at this point how long the process would take. We undertake to keep the House informed of progress on this. It is important to state that the supervisory wardens from the United Kingdom have worked with the OSCE and have experience in the Balkans, in Bosnia and in Kosovo, so they are well experienced in working in difficult and sensitive circumstances.
The noble Lord asked about the destruction of infrastructure in the Palestinian Authority. The European Union has played a key role, and has expressed concern about the destruction of infrastructure. We recognise that it is important that the infrastructure is restored. I am aware that there are discussions within the European Union on the matter.
The noble Lord asked also about leadership. This is an issue on which it would be wrong for me to speculate in terms of next stages in the leadership with respect to the Palestinian Authority.
The noble Lord asked about the importance of condemnation coming from the Palestinian side of the continuation of violence, and in particular of the suicide bombing. President Arafat has made that condemnation. We have called for it to be made in both English and Arabic because it is important that it is understood.
With regard to Jenin—raised by both the noble Lord, Lord Howell, and the noble Lord, Lord Wallace of Saltaire—there are various versions of what happened. That is why we believe that the fact-finding mission needs to go in, to give us the information. My right honourable friend the Prime Minister said last week during Prime Minister's Questions, for example, that it would help Israel's reputation, given that Israel has said that the force that was used in Jenin was proportionate. Therefore, we continue to call for the UN fact-finding mission to go in, and to do so as quickly as possible. I entirely agree with the noble Lord, Lord Howell, that it is important that sensible dialogue and discussion continue to take place. It is absolutely clear that there will be no military solution to the conflict.
On the issue of what is happening in Bethlehem, we believe that both sides have to compromise. The situation remains extremely serious. Since noble Lords

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discussed this matter., there have been a couple of positive events. Two bodies have been taken away, and nine teenagers were let out before the weekend. As was indicated in the Statement, we understand that food is going in. Talks must continue to secure a reasonable outcome for the release of those who want to leave the church. We have made that clear to both the Israeli Government and the Palestinian Authority, and we shall continue to do so.
The noble Lord, Lord Wallace, asked about possible discussions with regard to a contingency situation: if we needed to find contributions not only from ourselves but from our European partners in terms of finding resources for some kind of peacekeeping force. There are continuing discussions on the matter. Noble Lords will be aware that there was a discussion within the UN, and we continue to keep in touch with our European Union partners on the matter. When there is more to say, we shall make that clear to the House.
With regard to UN Security Council resolutions, it is important to remember that UN Security Council resolutions on the Middle East place different responsibilities on both sides. They call on the Palestinian Authority not to engage in terrorism, and there have been calls on the Israelis to make a number of movements. It is important for us to remember that. The comparison with the situation in Iraq is not one that I agree with. The situation in Iraq has gone on for 12 years. It is substantially different from the situation that we are discussing today.
Our policy is clear. We want to see a secure State of Israel; we want to see a viable Palestinian state; we want an end to physical settlements; and we want the issue of the refugees to be resolved. We continue to work with the United States Government and others, including Saudi Arabia, and we shall continue to work in a positive way with our partners. The noble Lord, Lord Wallace, suggested that we put pressure on the United States Government. The work that we have been doing and the outcomes that we have seen today are a good example of the way in which we have worked together.
5.17 p.m.
Lord King of Bridgwater: My Lords, is it the intention that the UK/US initiative should subsequently be endorsed by the UN? Is this initiative taking place under the authority of the UN?
I have two specific questions. The term "supervisory wardens" is used. I take it that those undertaking this responsibility are not members of the Royal Military Police but that they are civilians. Is it intended that this will be a permanent UK/US responsibility; or will other nations subsequently take over this responsibility in what may well be quite a protracted assignment?
Baroness Amos: My Lords, the initiative does not come under the UN. This was suggested by the United Kingdom some time ago. It was re-discussed recently and agreed by ourselves and by the United States. We
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needed to move very quickly, which is why the United Kingdom and the United States have agreed to take this forward. It is not intended as a permanent UK/US initiative. We see it very much as a first step in terms of taking matters forward and as a bridge, as it were—a term used by the noble Lord, Lord Howell. As I said, the wardens will not be armed; they will not come under the umbrella of the Royal Military Police.
Lord Janner of Braunstone: My Lords, I thank Her Majesty's Government for their involvement in efforts to find a way to help to achieve peace so that both sides and their families and their children will not walk in fear, as they do today.
The noble Lord, Lord Wallace, is correct. I was in Jenin on Saturday. Perhaps I may ask my noble friend two or three questions arising from that visit. First, is she aware that the Israeli Government are concerned about the terms of reference of the committee and its membership, as various leaders of that government told me, but that if that is settled, as they hope it will be, they indeed welcome the inquiry. They all say, without exception—they and the soldiers who were there, whom I met, and their leaders whom I met—that they have absolutely nothing to hide, and that it is a very complex situation.
Finally, has my noble friend been told by the United Nations and UNRWA, who were my hosts, what they told me, namely: that they have interviewed some 1,500 people from the camp; that they are satisfied that the number of deaths is 54 with some 18 people missing—most of them are probably either in hospitals or in prisons; and that 23 Israelis were killed in what was a fierce battle in Jenin? Jenin is regarded by the Israelis as a terrorist centre and a base for the suicide bombers, the results of whose operations I also saw. In view of that and of what the United Nations has said, does the Minister accept that the alleged massacre is a total myth, propagated by Palestinians and their allies and by the media, and that it certainly is untrue?
Baroness Amos: My Lords, I am aware that the Israeli Government have expressed concerns about the terms of reference of the committee and its membership. As I understand it, they are engaged in discussions with the UN Secretary-General. Our view remains that a fact-finding mission in Jenin is the best way of dealing with the differing reports coming out of the town. My noble friend mentioned figures that he was given when in Jenin. We have been given a number of different facts and figures from different people, and that is why we want the fact-finding mission to go in as quickly as possible. We continue to believe that the membership that has been announced for that mission represents a distinguished group of internationally recognised and well-respected individuals, as I said in the Statement.
Lord Richard: My Lords—
Lord Chalfont: My Lords, I thank the Minister for repeating the Statement. I found it not only a positive Statement, as the noble Lord, Lord Howell, said, but

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also a balanced one. I am afraid that balance as a commodity is in short supply in many of the debates on the Middle East, especially in some quarters of our media.
I speak as someone who has spent a great part of his professional life fighting terrorism. I confess to a prejudice: I loathe terrorism in any form. I loathe it in the form that it is taking in the Israeli/Palestinian conflict at the moment, in which innocent civilians, including five year-old children, are the subject of targeted violence and murder. It seems to me that those who speak of the brutality of the Israelis—as one noble Lord spoke the other day in your Lordships' House—have to answer why they use that kind of expression. Do they believe that Israel has the right to exist within secure borders? If they do, surely Israel has the right to mount operations in its self-defence.
We all know—I will be the first to admit—that there have been excesses in the Israeli response. Of course, as noble Lords have said, there have been such policies as the settlement policy, which clearly is unacceptable and provocative and must be reversed as soon as possible. If people believe that Israel has a right to self-defence, the kind of unbalanced attitude that many people have expressed to the conflict must be reconsidered.
Lord Grocott: My Lords, perhaps I can respectfully remind the noble Lord that many noble Lords want to ask questions and only 20 minutes is allowed for Back-Benchers' questions.
Lord Chalfont: My Lords, I am aware of the 20-minute rule and I shall be as brief as I can. I shall bring my remarks to a close. Israel perceives that it is under threat. This House has a deserved reputation for reasoned debate, objective judgments and analysis of international problems. Although this may sound like the worst of all clichés, there are two sides to this terrible conflict. No service is done to truth or to peace to pretend that there is only one.
Baroness Amos: My Lords, I agree with the noble Lord, Lord Chalfont, in that a balanced approach is absolutely critical. We all know that discussions and debate about what is happening in the Middle East brings out deep emotions on both sides. There are differences that are deep-rooted and historical. That is why we believe that it is so important to find the means and mechanisms to continue dialogue and discussion. As I said earlier, it is the only way in which we can reach any kind of peaceful solution. A military solution is not the way, so we shall continue to listen to both sides. We shall continue to work with both sides and to bring pressure to bear on them and we shall tell each side when we believe that it is acting in a way that is disproportionate and excessive.
Lord Clinton-Davis: My Lords, does my noble friend accept that it is vitally important to recognise that time is of the essence in starting meaningful talks? There is a great temptation to allocate blame in the interests of
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achieving a meaningful dialogue. I believe it is absurd to talk about achieving a solution to the issue of settlements now. It should be discussed but not as a precondition for the dialogue that my noble friend and the Government have initiated. Would my noble friend also accept that it is important to avoid the temptation that exists of allocating blame straightaway, whether to Israeli or Arab? The dialogue should be started from a clear basis.
Baroness Amos: My Lords, I agree with my noble friend. Time is of the essence. We have been careful not to allocate blame when there has not been the evidence to support it. We have sought to be robust in our engagement with both sides and to try to ensure that UN Security Council resolutions that have been passed are adhered to. But I recognise that there is also frustration on both sides because we shall not start with a blank sheet of paper. We are dealing with a complex set of issues about which there has been dialogue and discussion over many years. Part of the reason that frustration is felt by many is because there are times when we seem to come extremely close to an agreement, and then it fades. Therefore, I agree with my noble friend that it is important not to allocate blame, but to seek to work together in a way which is meaningful and positive.
Lord Hannay of Chiswick: My Lords, I thank the noble Baroness for the Statement and support the decision taken by the Government. However, will the noble Baroness redouble the efforts of our Government to persuade the Israeli Government that this unseemly haggling over the fact-finding mission to Jenin is doing nobody damage but themselves? Will she also remind them that Israel's reputation never sank lower than in 1990 when it declined to admit a fact-finding mission after the killing of a number of unarmed Palestinians on the Temple Mount?
I hope that the efforts of persuasion can be successful because I am afraid that the Government of Israel are doing nobody harm but themselves. Does the noble Baroness agree that it is a priority to get an overall peace negotiation under way and that it will be necessary, if that process is to be sustainable, that it is not interrupted every time a terrorist atrocity is committed; otherwise we are simply handing the agenda over to the men of violence? That is what has happened for the past year. They will not desist if they think that each time they create an atrocity they can stop the peace process in its tracks, and they believe that worst is best.
Baroness Amos: My Lords, I agree with the noble Lord, Lord Hannay, that the fact-finding mission must go in, and go in quickly. That point was made by my right honourable friends the Prime Minister, the Foreign Secretary and others to the Israeli Government.
I agree with the noble Lord also that it is important not only to get the peace negotiations under way, but also to ensure that they are sustained over a period of time and not interrupted. It is a matter of both sides

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being brave in taking that step. We know from our experience in Northern Ireland that taking that step and being brave is probably the single most important factor in terms of obtaining a longer-term peace. We all hope that that will happen in the Middle East.
The Lord Bishop of Southwark: My Lords, I too welcome the Government's Statement. The most reverend Primate the Archbishop of Canterbury has taken a personal interest in the situation. Indeed, he met regional faith leaders earlier in the year. His personal envoy, Canon Andrew White, has been extremely active in trying to find a solution to the Church of the Nativity siege. We continue to be willing to play a constructive part if we can be helpful.
We in the Church receive many painful stories, as do others; in our case, from Palestinian Christians. We urge the Government and our Jewish friends in this country to encourage the Israeli Government to allow the UN fact-finding team to be admitted swiftly to Jenin. It is difficult to see how there can be progress until that takes place.
Baroness Amos: My Lords, I welcome that statement from the right reverend Prelate. It is important that a constructive role is played by all faiths in this conflict. A number of different initiatives are being taken behind the scenes in that respect. I commend those and thank the right reverend Prelate for his comments.
Lord Richard: My Lords, I begin by apologising to the House for rising straight after my noble friend Lord Janner sat down. It was because, not perhaps for the first time in our 40 or 50 years' acquaintance, what he said provoked me to the extent that I wished to respond immediately.
Is my noble friend aware that the last two sentences of the remarks of my noble friend Lord Janner prove beyond peradventure the need for an objective assessment of what actually went on in Jenin? For my noble friend to say that the Palestinian story is a myth is, with respect, not helpful. I do not know whether it is—and he does not know whether it is, although he thinks that he has more evidence than I have.
Perhaps I may ask one question which I hope is practical. If the Israeli Government continue to deny access to the UN fact-finding team, what are the Government proposing that the UN should do, that the US should do and that we should do?
Baroness Amos: My Lords, I agree with my noble friend Lord Richard that we need an objective assessment. We have all agreed that the fact-finding mission would be a way to deliver that, and we need that regardless of the comments made by my noble friend Lord Janner. This House and the Government are of the view that that fact-finding mission is necessary.
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In terms of "What next?", we need to keep talking. In addition, the UN Secretary-General, Kai Annan, will make recommendations to the UN Security Council if the fact-finding mission continues to be refused entry.
Lord Wright of Richmond: My Lords, last week I asked the noble Baroness what representations we were making to remove the restrictions on the movement of President Arafat. I warmly congratulate the Government on the steps that they have taken which we hope will end those restrictions.
Unlike most Members of this House, I listened to the debate in the other place this afternoon. I commend to the noble Lord, Lord Janner, two horrific accounts from his honourable friends who recently visited Jenin. Does the Minister agree that it will be extremely difficult to find a more objective and distinguished team than Mr Sommaruga, Mrs Ogata and Mr Ahtisaari?
Baroness Amos: My Lords, I thank the noble Lord for recognising that we worked hard to end the restrictions on President Arafat. I am aware that at times in this House the noble Lord did not feel that we were working hard enough or fast enough.
We realise that there are conflicting accounts. I am aware, for example, that my honourable friend Ann Clwyd returned from her visit to Jenin with her own view of what had happened. That is why we are supporting the UN fact-finding mission. We need an objective assessment as quickly as possible to enable the whole international community to take a view.

National Health Service Reform and Health Care Professions Bill
5.38 p.m.
Consideration of amendments on Report resumed.
Baroness Northovermoved Amendment No. 5:
After Clause 2, insert the following new clause—
"DUTY OF PRIMARY CARE TRUSTS AND STRATEGIC HEALTH AUTHORITIES REGARDING EDUCATION, TRAINING AND RESEARCH
Primary Care Trusts and Strategic Health Authorities shall have a duty to safeguard and promote education, training and research."
The noble Baroness said: My Lords, various themes emerge in this Bill. As the Government seek to devolve—a laudable enough aim—there is a real danger that certain responsibilities that currently exist within the NHS will not be delivered as PCTs look to the immediate needs of the majority of their immediate population. Those are areas of service which even now are delivered on a patchy basis, often dropping to the bottom of the list of priorities. We have already seen that happen with public health and have debated how best to ensure that strategic health author ties and PCTs have a duty and responsibility to deliver on that, and how fragmented teams in different PCTs may well find it a challenge to bring their concerns to the fore.

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In much the same way, education, training and research are long-term needs within the service, which the Government must have a duty to foster, but which with the pressure of immediate events at local level may not seem the highest of priorities. It is rather like using money for long-term capital projects: it is down the line that the benefits are seen, yet it is today's budget and time that must be devoted to ensuring this future.
In Committee, we moved an amendment which spoke of the need for it to be a duty for PCTs to foster and safeguard teaching and research. We have now broadened that out. The amendment places a responsibility on strategic health authorities and PCTs to safeguard and promote education, training and research.
In Committee it was pointed out that some PCTs will have a duty concerning teaching, but the point here is to ensure that this runs throughout the health service and not just a part of it.
Presently, there is no obligation on managers to encourage teaching and research in these new PCTs. They have not been around for very long. Yet here they are with vastly increased budgets and therefore the power to make things happen—or not. This is a matter of national importance which must be carried right through to the local level.
I was glad that in Committee the Minister said that it is in the interests of the NHS and the Government to ensure that we address these areas. I was also glad to hear that he was sympathetic to the aims of my amendment. But he then argued that the Secretary of State retained the power to ensure that this was happening and that therefore my amendment was not necessary. I ask him to think again.
Let us look at the situation now without such devolution. We had the debate back in November introduced by the noble Lord, Lord Walton of Detchant, which highlighted the problem of insufficient people undertaking research and teaching and the enormous pressures on those who are carrying this out. But this is a problem that is already becoming more and more acute. If one looks at today's Evening Standard its headline is, "Promise of extra doctors". That is hopeless. The article makes the point that the Government's pledge to provide 15,000 extra doctors for the NHS cannot be met if severe shortages in teaching staff get even worse.
We hear in this article that at Guy's, King's and St Thomas' about 50 staff are at imminent risk—about 20 per cent of the workforce. The BMA anticipates that following consultation, 10 to 12 will go voluntarily, but there will be roughly 40 who are judged as "surplus to requirements". Of course we hear the usual tale that Guy's, St Thomas' and King's are looking to save money to reduce their debts. We all know that it is unlikely that other trusts in London will absorb those made redundant into full-time NHS contracts. So how, if the Government are to meet their
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target for new doctors, will they do so if they are losing the clinical academics needed to teach the new students?
As a senior lecturer at Guy's, King's and St Thomas's, Dr Wierztichi puts the matter today in this way:
"It is crazy. The number of medical students is increasing but the number of medical academics is falling because of the redundancies. If the Government does not start seeing medical academics as a priority, it will be impossible to achieve the Government's targets".
That is what is happening now, today, before devolution, when the Secretary of State theoretically has more control over matters. What happens when matters are devolved? It does not reassure me to hear, as the Minister put the matter in Committee, that PCTs are empowered to conduct, commission or assist the conduct of research. Empowered does not ensure. That means that they can, but it does not say that they have to.
The Minister also stated that an NHS trust may provide training. Again "may", not "must". But the noble Lord also said that research and teaching must be undertaken because the NHS must support teaching and research. But who will undertake the responsibility to carry through such a laudable aim? When a manager decides at a meeting between competing priorities, how do we ensure that research and teaching—or any such long-term aims—are anywhere near the top of the agenda?
I am certain that the Minister shares with all of us the desire to see teaching and research flourish in the NHS. However, that desire must be carried through into obligations on those who are in a position to decide whether or not it is carried out. Otherwise, with the best will in the world, and all the resources at the Chancellor's disposal, the NHS simply will not have the long-term future that I am sure the Minister and certainly we wish to see. I beg to move.
5.45 p.m.
Baroness Noakes: My Lords, I rise to speak to Amendment No. 8 which is grouped with Amendment No. 5. I support Amendment No. 5 and agree with the points made by the noble Baroness, Lady Northover. Amendment No. 8 goes a little further. There are two main differences between the two amendments. Amendment No. 8 extends the duty in relation to teaching and research beyond PCTs and strategic health authorities to include NHS trusts.
It is clearly important that there is a duty in relation to teaching and research and that that covers those who commission the services. Without that the funding will not be secure and teaching and research could easily be squeezed out by other priorities. But we must not forget the provider side of the equation. While trusts have powers under the 1990 Act in relation to teaching and research I believe that they do not have corresponding duties.
Secondly, Amendment No. 8 expands on what is meant by teaching and research. We typically think of that as covering medical teaching and research. The

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noble Baroness, Lady Northover, spoke about that matter. The noble Baroness, Lady Emerton, reminded us in Committee that all primary care professionals and multi-professional teams operating in the community are also dependent on high-quality research. The definition in subsection (2) of Amendment No. 8 is designed to widen the net.
There are other differences in wording between the two amendments. I do not want to debate semantic points. The amendments are at one in wishing to ensure that teaching and research thrive and prosper. I believe that creating a duty would have a positive effect. It will strengthen the hand of those seeking budgets to cover teaching and research and ensure that that is kept high on the agenda for all who plan, commission and deliver services within the NHS.
Lord Roberts of Conwy: My Lords, I speak to Amendment No. 11 which is also in this group. It seeks to empower the National Assembly of Wales to direct local health boards in Wales to support and promote teaching and research. Of course it may be argued that the Assembly already has such power under Clause 6 and subsection (2) of new Section 16BB and that my amendment is unnecessary. But at least it serves the purpose of drawing attention to the need to promote teaching and research in the NHS in Wales as elsewhere. Indeed, I would have attached the substance of this amendment to the duties of health authorities in Wales, but there has not been much talk about health authorities, although of course they are to be created under Clause 1.
The noble Baroness, Lady Northover, and my noble friend Lady Noakes have already advanced the general case in relation to England. I shall not repeat those arguments, which are just as applicable, if not more so, to Wales.
I am especially concerned about the University of Wales, College of Medicine in Cardiff, which is the only medical college in the Principality, and not just because I am its honorary president. It requires the support not only of its local health authorities but of others, because the college places many of its graduates in hospitals and practices throughout Wales. It is clearly important that the 22 proposed local health boards and 15 trusts in Wales should support those placements, because they involve our future doctors and consultants.
The College of Medicine and some of the other colleges of the University of Wales provide other courses for health professionals and, again, the support of local health boards and trusts is essential—and likely to increase in the years ahead as the Government's modernisation plans develop and NHS staff require retraining to fulfil them.
Of course, the Minister's Statement after the publication of the White Paper referred not only to 15,000 extra doctors but to 35,000 more nurses. They must all he trained, and others will also require training. The College of Medicine in Wales trains dentists, nurses and other health professionals.
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Indeed, it is the college of the NHS in Wales. It is vital that it is fully supported in its teaching and research at all levels of the organisation that it serves.
Baroness Finlay of Llandaff: My Lords, I shall speak to Amendments Nos. 5 and 11, to both of which my name is attached, and in support of Amendment No. 8. It may initially appear that there is a discrepancy between the wording of Amendments Nos. 5 and 11, but I shall explain that the spirit behind them is identical.
In his Statement on the NHS Plan, the Minister told the House that the investment would provide 35,000 more nurses, 15,000 more doctors, 40 new hospitals and 500 primary care centres. Of course, a new hospital requires many professionals other than doctors and nurses. The noble Baroness, Lady Northover, highlighted the severe shortage of clinical academics—I must declare an interest as a clinical academic and vice-dean of the University of Wales College of Medicine.
Investment in the NHS requires training of new staff and their clinical placement. As the noble Lord, Lord Roberts of Conwy, outlined, those placements are made throughout the NHS in Wales and are also for medical students and other healthcare students from England, Scotland and Northern Ireland. The placements are crucially important and provide the clinical exposure that is the strength of the United Kingdom training system. They are where students learn to integrate science and clinical care.
I have recently completed a visit to an NHS trust that takes students from the University of Wales College of Medicine. Chief executives of all trusts value the importance of an affiliation with a teaching institution. They recognise that that is how they recruit high-calibre staff and maintain clinical standards in their current staff, who are involved in teaching and are challenged by students.
I turn from teaching to education and training. Teaching is an activity from a teacher towards others, but much learning is now self-directed, so training may be a more appropriate word for the broader range of activity that goes beyond undergraduate or postgraduate education. Training requires facilities for continued professional development—library facilities, seminar rooms for teaching, tutorials and discussion groups—as well as protected time. All of that costs money.
The document, Delivering the NHS Plan, alludes to the development of the NHS university, which will allow individually tailored professional development. That is to be applauded, but it will also require resources.
Another area that has not yet been touched on is the importance of training and retraining of senior staff to maintain staff in the NHS, rather than lose them through early retirement. In June 2000, a BMA survey found that 62 per cent of consultant surgeons—419 out of 676—planned to retire early. That represents an enormous loss of expertise to the NHS. An Answer to a Question in the other House about early retirements

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from hospitals stated that approximately one third of all retirements of hospital doctors was premature, through either early retirement or ill-health. Premature retirement was defined as prior to the normal retirement age of the NHS pension scheme—60. Of course, it is to be hoped that many people stay on beyond 60. I think that 60 is young to be retiring— I am sure that many noble Lords would agree.
I turn again to the document, Delivering the NHS Plan. It states:
"Foundation trusts will … abide by the NHS principles",
although it does not define those in detail, and that the new foundation trusts will,
"promote diversity and encourage innovation".
With innovation must come research, to which I now briefly turn. There must be research into models of care and the quality of care in each setting, to evaluate outcomes and to monitor care delivery through audit. But many outcome measures are yet to be developed.
In many areas, outcome measures are remarkably crude—for example, death rates, infection rates, failed discharge and so on—and do not capture the quality of life change for the individual patient. Patients must wherever possible leave the episode of care feeling better than when they entered it. Where that is not biologically possible, they should certainly feel that their distress has been lessened and that they and their families are supported. We should now be measuring those sorts of subtle outcomes.
There is also a need for quantitative and epidemiological studies, which all need funding. The research councils have inadequate funding, which does not meet the research cost to answer the current urgent questions in healthcare. There are costs in entering patients in trials, so even where an NHS unit, wherever it is, is a collaborator, a hidden cost is involved. But there is good evidence that patients in trials do better.
There is no better example of that than the management of childhood leukaemia. The coordination of trials meant that all children with leukaemia were entered in them. In my working lifetime, the picture has changed from a very high mortality rate when I first qualified to an expectation of successful treatment of the primary disease today. That is a real compliment to co-ordinated research. It is only with collaborative research across the board that such a thing can happen. For such collaborative research to be promoted in all sectors requires investment from the health service that must cross all boundaries, from primary to secondary and tertiary care across to the voluntary sector and into private partnerships.
I therefore seek reassurance from the Minister that the duty of education, training and research will be safeguarded, and that each strategic health authority in England and organisation in Wales will have a university representative on its board. That would ensure rigorous quality control of education, training and research to inform the strategic health authority and other planning bodies and that services falling
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within the body's remit are evaluated. That also applies to primary care trust boards and all NHS trust boards.
The primary care sector will carry increasing responsibility. It will be more involved in teaching of all disciplines as more education and training occur in the community and with the increased budget for primary care and its increased workload and delivery of care. It is there that research questions must be asked, to allow cost efficacy to be assessed and ensure that needs are met. All those in healthcare, whatever their role, must have that duty explicitly laid out in the Bill, to ensure that the important safeguards of the quality of the service are not lost.
6 p.m.
Lord Thomas of Gresford: My Lords, Clause 6 sets out in legislative form the policy of the National Assembly for Wales. I read the Assembly debates—in Committee and plenary session—and I found that it did not turn its attention to the substance of the matter referred to in Amendment No. 11.
It is not for me to add anything to the arguments that have been so fully and ably expressed by those who have spoken. I support the amendment.
Baroness Cumberlege: My Lords, I support Amendments Nos. 5, 8 and 11. I have examined some of the consultation documents that were generated by PCGs when they sought PCT status. Many of them are excellent and are full of hope and commitment. However, I could find little mention of a serious intent to include teaching and research, save for specifically financed pilot projects. If the NHS Plan is to be successfully implemented, PCTs must contribute to the academic life of the NHS. For PCTs that cover a medical school or university, that is not just important: it is essential.
I shall not go into great detail about the number of placements necessary, but, as chairman of St George's Hospital Medical School Council, I know that it is already a struggle to find enough placements, not only for medical students, nurses and the professions allied to medicine, but also for social workers. That is important for the future of the health service. We shall have to work more closely in teams, and those who are part of the teams must understand clearly how the NHS works and how care—social care and healthcare—is given.
In Committee, the Minister said:
"1 also accept that there are concerns about the recruitment of clinical academics and more generally about the pressures on clinicians within our teaching hospitals in terms of the amount of time that they have for teaching and hard clinical practice".— [Official Report, 18/3/02; col. 1117.]
The Minister was right to be concerned. At the moment, 73 professorial chairs are unfilled, 36 of which have been empty for over six months, and there are 118 unfilled senior lecturer posts, 64 of which have been empty for six months. Those are appalling facts for those of us who are serious about teaching and research.

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Medical schools have also sustained devastating financial knocks delivered through the research assessment exercise. The new formula has had unintended consequences, and the medical schools' research budgets have suffered greatly. In London, there has been a reduction of 20 per cent in the funding for five-star clinical research, and GR funding, which used to be weighted in favour of medicine, has been removed. There really is a crisis.
If we are to attract high quality academic staff, it is essential that they have the time and space to carry out their teaching and research duties. I appreciate that the workforce confederations will commission teaching, but it IA ill be up to the PCTs to make provision for an environment that is conducive to teaching. I am concerned that PCTs will be so anxious to hit the Government's delivery targets and avoid another visit from CHI or prevent a run-in with the local authority's overview and scrutiny committee that they will avoid the added costs of teaching and research. I can understand that PCTs will be pressurised and will seek every ounce of energy and commitment from those working on the wards and in the surgeries. There will be no capacity to fulfil the academic duties that are so necessary to the future of the NHS.
In their monitoring, strategic health authorities must be generous towards academic clinicians and give them the permission to do what their academic posts demand in addition to their service requirements. I hope t hat that monitoring will take that into account. PCTs and strategic health authorities would welcome such a duty, to give them cover in relation not only to the commissioning of work but also to the day-to-day running of services.
I shall digress for a moment. I remember when my son took to motorbikes. That was in the days before helmets were compulsory. I was extremely concerned for his safety, and, once the law had been introduced, I was able to say to him, "I am sorry, but you must wear your helmet. It is the law". My noble friend Lady Noakes drew a clear distinction between powers and duties. I n this case, a power would be welcomed by the PCTs and the strategic health authorities.
In Committee, the Minister said:
"As part of the strategic role of each strategic health authority, I see a particular responsibility for ensuring that the conditions are right for enhancing teaching and research".—[Official Report, 18/3/02, col. 1118]
A sensible workload is part of the right conditions, and so is space. Already, we see that one of the dangers associated with designing new hospitals and health centres is that no margins are built in to provide the extra tutorial accommodation, library facilities, IT and general circulation space needed for adequate teaching. Experience of public/private partnerships shows that such facilities are the first things to be axed from building plans, so that budgets can be met.
In Committee, the Minister was sympathetic to our concerns. He said:
"I assure noble Lords that it is in the interests of the National Health Service and the Government to ensure that we address some of the problems that noble Lords have raised in the debate".— [Official Report, 18/3/02; col. 1117.]
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Like the noble Baroness, Lady Northover, I was filled with hope. I thought that we really would make some progress. However, the Minister resorted to Section 5(2)(d) of the 1977 Act, which he felt would suffice. With 73 empty professorial chairs, the NHS in serious turmoil and an ambitious programme vastly to expand the number of students—we all welcome that—does not the Minister think that putting a clear duty in the Bill would be of huge benefit in promoting and safeguarding the quality of education and training in the NHS?
Baroness Masham of Ilton: My Lords, I shall give an example. My cousin, who is a microbiologist, was attached to a teaching hospital and the university in Leeds. He found that he just did not have enough time to do clinical research, and he went to teach in Malaysia. He loved working there and is now settled in Australia with his wife and children. The world is small, when people have written interesting medical papers.
We must try to keep young, keen medical people who are research-minded in this country. I support the call for the promotion of teaching and research to be written into the Bill, as proposed in Amendment No. 8.
Baroness Gibson of Market Rasen: My Lords., I too am aware of the concern that has been expressed in the House and elsewhere about the future of academic medicine. I shall explain to the House why I chose to intervene in the debate.
Before I came to your Lordships' House, I worked for Amicus, the trade union, many of whose members are healthcare professionals. When I went to Amicus, I was made aware of the need for research and training. Indeed, I have worked with our members over the years in pressing that need.
It is vital to recognise the importance of education, training and research. Not only should they be furthered but, as was pointed out so eloquently by the noble Baroness, Lady Finlay of Llandaff, it is essential that the necessary funding is provided to support such activities.
I certainly support the idea behind the amendments but, having looked into the proposals and listened to the debates both today and in Committee, I wonder whether they are really needed. I take the points that have been raised by a number of speakers about the difference between a power and a duty, but I understand that we already have in place statutory powers in other legislation which ensure that education, training and research are not forgotten. Perhaps those powers should be looked at in more detail before we decide to put something more into the Bill, otherwise we may find that we err towards repetition.
For example, the Secretary of State has powers to ensure that research is undertaken. I am sure that both the current and future Secretaries of State will take those responsibilities very seriously. Health authorities and primary care trusts have such powers delegated by regulations. I know that some noble Lords do not

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think that they are strong enough, but perhaps we should seek to express them more forcefully rather than adding anything further to the Bill.
The noble Baroness, Lady Northover, stated that medical academics must be recognised as being of vital importance. Of course she was absolutely right to make that point, but perhaps I am a little more optimistic than are other noble Baronesses who have spoken so far. I believe that PCT and SHA members will ensure that they concentrate positively and constructively on training and research. I agree that expertise has to be retained and that research into models and quality of care is extremely important. However, I return to my main point: by introducing these amendments we shall err towards repetition. There are already in place in legislation powers that should be exercised.
Baroness McFarlane of Llandaff: My Lords, I rise to speak in support of the amendments. I am often asked a number of questions about the quality of nursing education today and whether it has deteriorated. The usual attitude is that, "things are not what they were". My view of the current position is that nursing education is lacking in high quality clinical supervision from registered nurses in practice situations. I believe that that has developed as a result of a shortage of nursing staff. Perhaps education in the clinical setting is the last thing that a busy registered nurse will consider taking on.
Similarly, academics in nursing find themselves short of time to devote to clinical supervision. For that reason, I believe that rather than allow nursing education, and education for the other health professions, to fall to the bottom of the pile, we should look to placing a duty on the authorities to provide for the education of the professions.
The noble Baroness, Lady Northover, has already referred to the very informative debate recently initiated by my noble friend Lord Walton of Detchant. I know that he was distressed to have to leave the House this afternoon before we came to these amendments. He fully supports them.
I believe that the need to ensure that adequate research facilities for all the health professions are in place is of absolutely paramount importance. When we consider the duty of "quality", we refer frequently to the need for evidence-based practice. Unless adequate research is undertaken across all the health professions, so that we can say with some assurance that the care being given is based on sound evidence, then the quality of care will suffer every time. I, too, wish to add my support for these amendments.
6.15 p.m.
Lord Turnberg: My Lords, I have enormous sympathy with the principle underlying the amendments. As a superannuated clinical academic, how could I not have sympathy for them? However, I am not sure whether they would necessarily achieve what is desired.
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Undoubtedly there are major problems with regard to academic medicine. We have heard about many of them from noble Lords this afternoon. We have nowhere near enough clinical academics, in particular at a time when the need for more teachers in medicine has never been greater. We are increasing by 50 per cent our medical student numbers, so that from around three years hence we shall produce some 6,000 doctors a year rather than the current figure of 4,000 a year. Someone has to be in place to teach all those students.
The problems faced by academics are numerous. Of course they have to deliver clinical services as well as fulfilling their teaching and research roles. All these points are outlined in a publication from the Academy of Medical Sciences on threats to academic medicine, which I recommend to noble Lords. I should express an interest in that I am vice-president of the Academy of Medical Sciences.
All that is made worse by problems with regard to the university funding formula. The research assessment exercise seemed to have been disproportionately biased against those disciplines relevant to medicine. Furthermore, all kinds of other difficulties are now arising, in particular in the London teaching hospitals, about which we heard earlier. However, this is largely a matter for the Department for Education and Skills and the Higher Education Funding Council. Of course the Department of Health has a major interest, but we cannot lay all these problems at the doors of the primary care trusts and the strategic health authorities, although they will have to be supportive.
Most of the funding for teaching and research comes through other routes: through the universities, the research charities and the research councils, while the Research and Development Division at the Department of Health provides infrastructure support for such research and teaching. Thus while I believe that the PCTs and SHAs will need to play a role, we cannot expect them to deliver on all the deficiencies that can be identified in academic medicine; many of them lie at the feet of many other bodies.
Lord Hunt of Kings Heath: My Lords, this has been an interesting debate. As I said in Committee, it is very important that the NHS maintains high quality teaching and research, not only for the NHS as a service but also, I suggest, on behalf of the wider interests of this country. We have always enjoyed a high reputation as regards the quality of our teaching and research. That is why, for example, the research-based pharmaceutical industry invests so heavily in research into new drugs and medicines in this country. Clearly the Government have a responsibility for ensuring that we maintain overall our pre-eminent position in this area.
With regard to the argument over the amendments, I think it is clear that the relevant statutory powers already exist. Noble Lords have already referred to Section 5(2)(d) of the National Health Service Act 1977 which gives a power to the Secretary of State to,
"conduct, or assist [others]…to conduct, research".

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Those powers are delegated to health authorities and subsequently to primary care trusts. Under paragraphs 14 and 15 of Part III of Schedule 5A to the 1977 Act, primary care trusts are empowered to,
"conduct, commission or assist in the conduct of research",
and to,
"make officers and facilities available in connection with training by a university or any other body providing training in connection with the health service".
Paragraph 11 of Schedule 2 to the National Health Service and Community Care Act 1990 states that:
"An NHS trust may undertake and commission research and make available staff and facilities for research by other persons".
Under Section 51 of the 1977 Act, the Secretary of State has a duty to exercise his functions so as to secure that there are made available,
"such facilities as he considers are reasonably required by any university which has a medical or dental school in connection with clinical teaching and with research connected with clinical medicine or, as the case may be, clinical dentistry".
I accept that in relation to some of those powers there is an issue in regard to power and duty, but surely my noble friend put her finger on it when she said that, given the powers which are clearly already there, the question is how to make sure that it happens effectively. That is the challenge. It will not be helped by placing a duty on the face of the Bill; it will be helped by the Department of Health and the Department for Education and Skills taking their responsibilities seriously and ensuring that there is a coherent approach throughout the educational and health sectors.
I understand the point raised by the noble Baroness, Lady Northover, and her concern that funding for teaching and research should not be squeezed out by other more pressing and immediate priorities of primary care trusts. But, as my noble friend Lord Turnberg pointed out, it is precisely to ensure its protection that NHS funding for supporting research and development, and learning and personal development, is managed as central budgets allocated directly to NHS providers, including primary care organisations. These funding streams are accounted for separately. Other dedicated funding streams for teaching and learning, such as PGEA and study leave for general practitioners, are also managed separately to ensure their proper protection. I do not believe that primary care trusts will be under pressure to spend that money for other purposes.
But it is not only a question of funding; primary care trusts have a positive role to play in engaging in teaching and research issues and in providing the right environment. That is why we are supporting the development of health and education sector partnerships at the strategic health authority level and below. This recognises the need to engage whole health and education communities and to consider the interplay between education, training and research and development issues and local health services. We see that partnership embracing not only acute teaching trusts and partners in schools and further education but also links between NHS employers and education
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providers, on which the workforce development confederations that we have established are currently focusing.
I have suggested that the amendments cover areas and powers which the Secretary of State has been given already to support such teaching and research activities. However, I fully understand that particular arguments have been made on the recruitment and retention of medical teachers. As I suggested in Committee, the Government are giving a great deal of consideration to this matter. Much of the responsibility for dealing with the issue rests within higher education rather than with the Department of Health.
Universities employ clinical academics, with funds for research infrastructure, and the direct costs of teaching medical, dental, pharmacy and optometry students allocated to universities by the Higher Education Funding Council for England. The NHS responsibility is for supporting the service costs of hosting research and development and clinical teaching.
I accept that there are pressures in this area: there is no doubt about that. It is because of that that the Department of Health and HEFCE have recently agreed a strategic alliance which covers education as well as research issues. The intention is to enable better joint working on these issues of mutual concern.
It is worth noting that, despite the concerns expressed about the availability of clinical academics, the majority of existing medical schools have considerably expanded their intakes since 1999 and most have plans for future growth. At the same time, four new medical schools, three new centres of medical education and a satellite graduate entry medical school are currently in the process of being created. I should say to those universities which took part in the application process that one of the issues they addressed in their bids to become new medical schools or to have expansion take place was that of having sufficient clinical academic staff.
In view of the concerns expressed about this issue, the department and HEFCE have agreed to set up a joint monitoring group to take an overview of the expansion of medical student numbers. The General Medical Council's education committee will also he involved. Although medical student education is not the direct responsibility of the Department of Health, our officials have been discussing with HEFCE what further action needs to be undertaken to respond to the perceived problem.
Ultimately, action at national level between the various government departments and HEFCE is the right way forward. I do not accept that writing duties on the face of the Bill, particularly in respect of primary care trusts, would have an influential impact on issues relating to the recruitment of academics in universities.
As to Amendment No. 11, the noble Lord, Lord Roberts, referred to the role of the College of Medicine at the University of Wales in Cardiff. I acknowledge the quality of that university's medical education

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department. I accept that for Wales its links to teaching, research and the clinical activities of NHS trusts are vitally important. However, ultimately, those are matters for the Welsh Assembly. If it has not yet had full discussions on those matters, I have no doubt that it will do so in the future. It is inappropriate to include specific limited examples in a general permissive power. That would frustrate the intentions behind the establishment of the Welsh Assembly.
I hope that I have indicated that the concern of noble Lords to ensure that teaching and research is given its proper place in the NHS is accepted and supported by the Government. I do not believe that PCTs will be the prime movers in dealing with issues such as the shortage of clinical academics, but they do have a role to play in ensuring that we have the right kind of environment in which teaching and research activities take place.
The substantive argument surrounding teaching and research is that they are matters for the department, other government departments and HEFCE to deal with. PCTs can support the process, but the argument is not advanced by seeking to add powers and duties on the face of the Bill.
Baroness Finlay of Llandaff: My Lords, before the Minister sits down, I thank him for informing us about the joint monitoring group on medical student expansion. As part of this, will there be a university representative on the boards of strategic health authorities?
Lord Hunt of Kings Heath: Yes, my Lords.
6.30 p.m.
Baroness Northover: My Lords, I thank the Minister for his reply and noble Lords for their participation in the debate and support for the amendments. Much of what the Minister said today, as opposed to in Committee, is welcome news. Nevertheless, I and many others remain concerned about this area. I do not feel as optimistic as the noble Baroness, Lady Gibson, about how things are going. The status quo is not good enough at the moment. This is an opportunity to try to improve on matters and certainly not to let them go back.
I can think of one current example of an endowment that is supposed to be used for teaching and research, but is being fought for by clinical academics against the understandable desire of administrators to fill a black hole. A duty on the administrators in question would make that situation easier for the clinical academics. There are clever ways of getting round that. Increasing service costs, which the Minister mentioned earlier, is one way in which that money can be tapped into. I see no reason for optimism about the current arrangements.
There is still time for the issue to be addressed. I hope that further thought will be given to it, because there is a shared concern across the House to ensure that education, training and research are promoted in
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the NHS at every level. I hope that we can find a way to move forward that would command the support of your Lordships. In the meantime, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 3 [Directions: distribution of functions]:
[Amendment No. 6 not moved.]
Baroness Noakesmoved Amendment No. 7:
After Clause 3, insert the following new clause—
"READINESS OF PRIMARY CARE TRUSTS
(1) The Audit Commission shall investigate every Primary Care Trust with a view to establishing whether that Primary Care Trust is ready to carry out functions which the Secretary of State may transfer to it by way of a direction under section 16D of the 1977 Act.
(2) In carrying out an investigation under subsection (1), the Audit Commission shall consider in particular—

(a) whether the Primary Care Trust has staff of the right number, quality and experience to deal with the functions which may be transferred; and

(b) whether the finances of the Primary Care Trust are sufficient to meet the functions which may be transferred and any deficits which are to be transferred to it.

(3) If the Audit Commission considers that a Primary Care Trust is ready to carry out the functions referred to in subsection (1), it shall publish a report to that effect and shall send a copy of the report to the Secretary of State.
(4) If the Audit Commission considers that a Primary Care Trust is not ready to carry out the functions referred to in subsection (1), it shall not publish a report under subsection (3) but shall publish a notice setting out the matters that would need to be dealt with before a report under subsection (3) could be issued, and shall send a copy of the notice to the Secretary of State.
(5) If the Audit Commission has published a notice under subsection (4), the Secretary of State may request the Audit Commission to carry out a further investigation with a view to publishing a report under subsection (3).
(6) The Secretary of State may not make a direction under section 16D of the 1977 Act unless the Audit Commission has published a report under subsection (3).
(7) The Secretary of State shall pay the Audit Commission an amount equal to the full costs incurred by the Audit Commission in acting under this section."
The noble Baroness said: My Lords, the amendment would insert a new clause after Clause 3. It deals with the readiness of primary care trusts to take on the additional responsibilities that the Government plan to place on them. We had a useful discussion in Committee on the readiness of PCTs. However, that discussion did little to assuage the doubts that I and other noble Lords had raised. That is why I am returning to the subject.
This amendment is different from that tabled in Committee, which would have deferred the requirement for 100 per cent conversion to PCT status for a year. In the event, we learnt from the Minister that the vast majority of PCGs were scheduled to be converted to PCTs by 1st April. While we had considerable doubts about the conviction of local health professionals to those conversions, the plain fact was that it had happened. The moving finger writes and, having writ, moves on. We have to accept that PCTs are now a fact of life.

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However, conversion to PCT status is only the beginning of the story, not the end of it. Conversion to PCT status allows health authorities to delegate some of their functions to PCTs. However, we know that the Secretary of State's aims, as set out in Shifting the Balance of Power, are for PCTs to be responsible for planning and securing the totality of care and services that their population needs. To that end, at least 75 per cent of NHS funds will be in the hands of PCTs in due course.
In practice, PCTs will be expected to carry out virtually all the functions of current health authorities. We have 300 or so PCTs, many of which have been in existence for only a matter of weeks. They are taking over the functions of what used to be 90-odd health authorities, until the other part of the health service restructuring forced that number down to 28.
The key issue addressed by the amendment is whether PCTs will be ready to take over the new responsibilities. The Government have said that they will delegate those responsibilities directly to PCTs from October this year. When we asked the Minister about the Department of Health's process for testing whether PCTs would be ready, we received answers that I found disconcerting. The Minister told us that the decision to allow PCTs to be formed was made on the basis of a number of criteria and that, provided those were satisfied, a PCT would get the go ahead. If the PCT then took on more responsibilities, that was a matter for the board. The strategic health authority also has a role in ensuring effective leadership.
I was grateful for the details about the initial criteria, which the Minister supplied last week, but they have not put my mind at rest. The criteria have a lot of abstracts, such as vision. Even the criterion of fitness for purpose focuses on processes to get adequate staff.
In Committee, I asked the Minister a number of detailed questions about the availability of properly qualified and experienced staff, including chief executives, finance directors, directors of public health and commission staff. I referred to many of the informed studies that identified weaknesses ranging from information management to governance. Remedying those defects is not a requirement of the approval criteria. As long as a PCT has a process, it will pass muster. It is clear that the Secretary of State will be happy to delegate functions to PCTs once the Act is passed without inquiry as to their readiness.
The amendment would provide for a detailed examination of each of the PCTs by the Audit Commission. Noble Lords may recall that when we discussed a similar amendment in Committee, the requirement was for an examination by the Commission for Health Improvement. The Audit Commission is more independent than CHI, although we shall return to that question later. The assumption in the amendment is that the Audit Commission would carry out readiness investigations.
The scheme of investigation is simple. The Audit Commission would investigate the readiness of every PCT to carry out the functions that were to be
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delegated to it. If the Audit Commission was happy, it would publish a report saying so and send a copy to the Secretary of State, who could go ahead and issue his directions delegating functions. If the Audit Commission was not happy, it would issue a notice setting out what needed to be dealt with. The Secretary of State would then be able to ask the Audit Commission to go back, have another look and, if it was then happy, issue the report.
There are two aspects of that procedure that I should like to note. First, the Audit Commission should publish its findings so that they are available not just to the Secretary of State, but to the strategic health authority, the patients forums, local authorities and others. Transparent processes are healthy processes. Secondly, subsection (2) deals specifically with two aspects of readiness. The first is
"whether the Primary Care Trust has staff of the right number, quality and experience".
That is crucial. It will not be enough to say, as the Minister said in Committee, that there is a PCT development programme in process, or it is up to the chief executives to acquire the right staff.
In that connection, perhaps the Minister will comment on the fact that it has now been decided that the annual development programme for PCT leaders is regarded as "neither appropriate nor helpful", according to a letter from the Modernisation Agency on 15th April. It is up to PCTs to decide whether to take part. Do the Government now believe that PCT people do not need a development programme, or is this a recognition that PCTs are struggling so much that time out for so-called development would be a straw that broke the camel's back?
The second aspect of subsection (2) is finance. If it is not clear that the PCTs have adequate finance to meet their responsibilities, as well as any inherited deficits, they should not go ahead. Financial stability must be an important prerequisite. In Committee, I spoke to a separate amendment dealing with the transfer of deficits to PCTs. I was disappointed that the Minister told us that the Government were set on saddling PCTs with the deficits of their forebears. It is important to see whether the PCTs can cope with the deficits that they will inherit.
I acknowledge that the criteria for PCT formation include detailed financial management questions, but they are not being considered immediately before PCTs are burdened with extra responsibilities. Finance is tight. There is plenty of anecdotal evidence that PCTs will be struggling with the deficits that they have inherited—deficits in the strict accounting sense and the much more important hidden or underlying deficits. The amendment would test, on a PCT-specific basis, whether those pressures can be coped with and whether there is sufficient money in the system overall, on an NHS-wide analysis.
I hope that the Minister will welcome this revised amendment and see the need for a detailed examination of PCT readiness before going ahead. I beg to move.
Baroness Carnegy of Lour: My Lords, during our discussions on Report, no reference has so far been made to the fact that the Chancellor of the Exchequer will put enormous sums of money into the health service. I am wondering to what extent primary care trusts are being told that they can anticipate increased funds for the future. If they are to receive 75 per cent of the health spend, which is so much bigger, it seems strange for them not to take that into account when making appointments. If they are experiencing difficulty in attracting adequately qualified people to fill key posts for the future, are PCTs being told that they can upgrade somewhat as regards qualifications and salaries? Are they being told that the Chancellor's infusion of cash can affect their attitude to the debts that they inherit; and, indeed, to their general spending plans?
It seems strange to be engaged in this and previous discussions without reference being made to the fact that the spending of PCTs will be enormously increased. If account is not now taken of future funding, it will be very difficult for those bodies properly to use such money. Indeed, it should affect the thinking from this moment. When he replies, can the Minister enlighten the House in this respect?
Baroness Pitkeathley: My Lords, like many noble Lords, I used to have anxieties about the state of readiness of primary care trusts. However, I recently had the opportunity to meet quite a few chief executives, chairmen, and non-executive directors. I was extremely impressed by their level of readiness, and especially by their confidence and eagerness to get on with the job. They are not envisaging taking on their considerable responsibilities without support; nor, indeed, should they be expected to do so. Adequate support is available and will be provided in terms of both training and information.
Primary care trusts are already becoming a resource for each other as regards shared learning, examples of good practice, and so on. Once again, we must return to the purpose of this reorganisation; namely, to shift the balance of power and the decision-making to primary care level. We must resist anything that detracts from that aim. In my view, the proposal to ask the Audit Commission to investigate the state of readiness would be both cumbersome and expensive. Therefore, I oppose it.
6.45 p.m.
Lord Hunt of Kings Heath: My Lords, my noble friend is absolutely right with regard to her experience when meeting members of primary care trusts throughout the country. In all our debates—on Second Reading, in Committee, and now on Report—many doubts have been expressed about the capability and capacity of primary care trusts to take on the responsibilities that they have been given. However, I have not come across the degree of doubt expressed in this Chamber when talking to those working in primary care trusts, and those in the health service generally. There is very genuine enthusiasm at the
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primary care level for those responsibilities, and for the potential of primary care to have such a dynamic influence on the rest of the NHS.
Although I accept that we must do everything that we can to ensure that PCTs are able to take forward the major responsibilities that they have now been given, we should not talk ourselves into the rather doom-and-gloom scenario outlined by some noble Lords. Judging from my meetings with members of PCTs throughout the country, I believe that they are well able to take on such responsibilities.
The noble Baroness, Lady Carnegy, is surely right to ask us to consider the funding context in which PCTs address their future strategies. The noble Baroness will know that the Budget announcement in terms of NHS allocation does not kick in this financial year. Specific allocations to the health service will need to be made in due course for the next financial year. However, she is right to point out that that gives PCTs an ability to look ahead over a five-year period so as to get an idea of the scale of likely funding. That will enable them to plan forward with a much greater degree of certainty than has often been the case with the NHS where annual allocations were often not notified to authorities until a very late stage.
The amendment specifically suggests that the Audit Commission should publish a report when a PCT is ready to carry out its functions. I am the first person to acknowledge the role of the Audit Commission, which has a very good track record in ensuring economy, efficiency, and effectiveness in the delivery of health services. However, I do not believe that it would be appropriate for the commission to make the kind of decisions envisaged under the proposed new clause. Ultimately, the decision as to whether a PCG should become a PCT, or whether a PCT should take on certain functions, is surely a matter for the Secretary of State to decide in the light of all the information to which he has access.
I was grateful to the noble Baroness, Lady Noakes, for identifying the four key areas about which the Secretary of State must be satisfied: the benefits of what will be achieved; the degree of support for the proposals; the fitness of the proposed organisation to deliver; and the impact on other organisations. However, it is the responsibility of the Secretary of State to make that decision. I can tell the noble Baroness that Ministers have been extensively involved in reaching considered judgments as to the readiness of primary care groups to take on primary care trust status. We have not hesitated to refer proposals back for further work and consideration. Indeed, we have rejected proposals on a number of occasions over the past year, or so. It is in our interests, as much as in anyone else's, to ensure that PCTs have the necessary capability.
We want to support PCTs in their development. In Committee, I mentioned a number of initiatives that we have taken in order to help PCTs reach the necessary position in terms of capability and skills. I agree with the noble Baroness in relation to the issue of management capacity. We are talking about new

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organisations, which will need time to develop their management capacity. However, I have been encouraged by the calibre of people who have applied to become PCT chief executives. With the available programme of support, we shall be able to ensure that leadership in PCTs is of a very high order.
I should also point out to the noble Baroness that it is not just a matter of executive directors. The chairmen and the non-executive directors will also have a significant role to play in ensuring that boards reach sensible decisions. Again, the calibre of chair appointed to lead primary care trusts has been of a high order. At the end of the day, it is a question—really, a judgment—of whether we believe that PCTs are capable of performing this very responsible task. I believe that they have the ability to do so. The support that they will receive through the modernisation agency, and through other mechanisms, will assist them in their task. However, it is a matter for Ministers to make such judgments. It would not be right to ask the Audit Commission to carry out a role in relation to that function.
Baroness Carnegy of Lour: My Lords, with the leave of the House, perhaps I may ask the Minister to clarify his answer to my question. Can he say whether or not primary care trusts are being told that they can upgrade salaries and qualifications in anticipation of receiving more money?
Lord Hunt of Kings Heath: My Lords, on the question of staff salaries, primary care trusts will be bound, as are other NHS organisations, by national terms and conditions agreed between the department and staff organisations. However, there is a great deal of flexibility in the health service now in relation to what staff can be paid for particular job responsibilities. At the moment we are in discussion with relevant staff interests to introduce much greater flexibility in the future. Certainly I hope that in the future primary care trusts will be able to take part in those enhanced flexibilities.
Baroness Noakes: My Lords, I thank all noble Lords who have taken part in the debate. I also thank the Minister for responding. I do not doubt the enthusiasm that he has reported today and on previous occasions. That is wholly consistent with my knowledge of managers in the NHS. However, enthusiasm does not make them ready to assume managerial responsibilities and that is the direction in which the amendment takes us.
I believe that there are significant risks. The Minister talked about issues of managerial capacity. My solution was to ask the Audit Commission to look at that. I accept that it is the Secretary of State's decision at the end of the day. However, I genuinely would have been more reassured if I had heard that the department had some robust process that could inform the Secretary of State after approval of a PCT.
Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Baroness for giving way. I tried to describe
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the process that led to the approval of primary care trusts. Although I do not claim that the amount of paperwork involved is always a symbol of a rigorous process, the reports that Ministers received in relation to applications from PCGs to become PCTs were extensive. They covered issues of management capacity as well as other considerations.
Baroness Noakes: My Lords, I thank the Minister for those comments. I was not trying to suggest that the process of becoming a PCT was handled on a less than rigorous basis. My point was that the decision to approve a PCT occurred some time before the PCT assumed the significant additional responsibilities that are implicit in the provisions of the Bill that is before your Lordships' House. I refer to a gap as between considering a process sufficient in terms of acquiring PCT status but not considering whether that process achieves the quality of result that is desired. It is that gap that I focused on.
I issue the gypsy's warning; namely, that I hope that I do not have the opportunity to say from this Dispatch Box, "I told you so". In the meantime, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 8 not moved.]
Baroness Noakesmoved Amendment No. 9:
After Clause 3, insert the following new clause—
"SPECIALISED SERVICES
(1) The Secretary of State shall not direct Primary Care Trusts under section 16D of the 1977 Act as to his functions in relation to specialised services as defined in subsection (3) but may so direct Strategic Health Authorities.
(2) The Secretary of State shall not direct Primary Care Trusts or Strategic Health Authorities under section 16D of the 1977 Act in relation to national specialist services as defined in subsection (4).
(3) Specialised services for the purposes of this section arc the services covered by the National Specialised Services Definition Set issued by the Department of Health from time to time.
(4) National specialist services for the purposes of this section are the services which are the responsibility of the National Specialist Commissioning Advisory Group from time to time."
The noble Baroness said: My Lords, this amendment returns to the topic of specialised services which we debated in Committee. The amendment is an improved version of the one we debated in Committee. It has two objectives: first, that the Secretary of State cannot devolve commissioning of specialised services covered by the National Specialised Services Definition Set to primary care trusts but may devolve to strategic health authorities; and, secondly, that the Secretary of State cannot devolve the commissioning of national specialist services covered by the National Specialist Commissioning Advisory Group to either PCTs or strategic health authorities.
I do not think that there is any controversy with regard to the second of those propositions as I do not believe that the Government have suggested anything else. Indeed, even the Minister with his unbounded enthusiasm for PCT capabilities has not, I believe, suggested that they take over commissioning from the National Specialist Commissioning Advisory Group.

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The real issue concerns specialised services. I think that it is common ground that it is unlikely that individual PCTs will consider commissioning specialised services on their own. These are services which are currently covered by regional specialised commissioning groups. They cover 37 services, some of which are still in draft.
The arrangement that Shifting the Balance of Power envisaged, and was urged on us by the Minister in Committee, is that PCTs should commission collaboratively. But that assumes that all PCTs will want to work collaboratively, with one PCT leading and others providing the funds. It is by no means clear that they will. Indeed, the noble Lord, Lord Turnberg, told the Committee that he had spoken to some non-executive directors of PCTs who said that they did not want to work in that way. And there are real concerns that the primary care focus of PCTs will lead them away from acute commissioning in general and away from commissioning low volume, high cost specialised services in particular. The prevailing primary care orientation in PCTs is unlikely to make successful specialised services commissioning through collaborative mechanisms a racing certainty.
The Minister had an answer in Committee for the possible reluctance of PCTs to buy into local collaborative commissioning. He said that if a PCT was,
"not prepared to play ball…the strategic health authority would have the opportunity to intervene and bang heads together".—[Official Report, 14/3/02; col. 1025.]
Noble Lords who have followed the passage of the Bill thus far will know that "head banging" is the colloquial term for performance management. The Minister said that he did not expect many PCTs to refuse to form consortia. But the mere fact that purchasing consortia are required is an indication that commissioning for specialised services has been delegated to the wrong level. The most natural level is the strategic health authority. The Minister said in Committee that commissioning consortia,
"might cover the population size of the strategic health authority or involve going across one strategic health authority boundary to another".—[Official Report, 18/3/02; col. 1170.]
Shifting the Balance of Power specifically states that strategic health authorities will sit on the specialised services consortia of PCTs.
What is all of this telling us? It is as clear as daylight that the natural level for specialised services commissioning, given the structure of the NHS that the Government have forged, is the strategic health authority. Many of us here may think that 28 is too many for that tier in the NHS. Indeed, I should be prepared to lay money that that number will come down through mergers. But that is the structure that we have and within that it is more logical to devolve specialised service commissioning to strategic health authorities as they most naturally represent the population for whom services will be commissioned.
The Minister told us in Committee how he envisaged PCTs working in networks, not just for specialised services but also for public health and other
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areas that go beyond the relatively small populations covered by each PCT. If those networks do not function well enough, the strategic health authority would have to step in and, to use the euphemism, "performance manage" them. That rests on networks being a natural way of operating. The Government's concept of health service management is through a lot of ever more complex networks and partnerships. That is simply too complex and ignores the fundamental principle of organisation design, which is maximum simplicity.
I do not doubt that managing the health service is a complex matter but I do doubt that creating complexity for the sake of it is a sensible approach. I should stress that we on these Benches do not oppose the devolution of functions. It was we and not the current Government who started the firm push towards decentralisation in our 1990 reforms. But we do not agree with decentralisation to unnatural levels or with over-complex management structures.
As I said in Committee and will say again now, specialised services are vital services and must be protected. It is in our view wholly wrong to use the infant PCT structures in some kind of experimental re-engineering of networks to undertake this essential commissioning task. I beg to move.
7 p.m.
Lord Clement-Jones: My Lords, as the noble Baroness, Lady Noakes, said, the Minister discussed in some detail on the second day of our debate in Committee the question of specialised services and the way in which they would be commissioned. As we have heard, the Government's proposals involve the dismantling of the current regional specialised commissioning groups and the creation of commissioning consortia. The reason for that, as the Minister said in Committee, involved the interrelationship between primary, secondary and tertiary care, rather than treating specialised services as an isolated service to be resourced and dealt with in a completely different way from that applied to other services that will be commissioned by PCTs in the future. Despite those words of attempted reassurance, many of us believe that the Government's current proposals to devolve NHS specialised commissioning responsibilities to primary care trusts in that way could lead to a deterioration in the national provision of specialised services.
Clearly, different primary care trusts will have different commissioning expertise. Who will be responsible for poor commissioning in, for example, specialised heart surgery? Who will monitor performance, and so on? Who will even guarantee that there will be the necessary expertise within a particular consortium? That could, we believe, lead to a new postcode lottery for specialised services, in which the availability of treatment for those serious illnesses was decided not on clinical need but on geographical location.
The Minister mentioned the interim role of the regional specialised commissioning groups (RSCGs) in handing over capacity and skills to primary care

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trusts. That is extremely welcome, but why cannot those bodies be kept in place as a permanent repository of expertise and information? Much of the Bill is already so virtual as to give rise to real concerns. We have public health networks, patients forums coordination and now the consortia. All of that seems to stem from the Secretary of State's unwillingness to have any clear lines of accountability whatever.
Although the primary care trusts that join the consortia will be bound by existing financial commitments, they will have complete discretion about whether or not they wish to prioritise spending on particular specialised areas and join an individual consortium in the first place.
The RSCGs will have no power to compel primary care trusts to join consortia. Will the strategic health authorities be able to do so, other than by banging heads, as the noble Baroness, Lady Noakes, suggested?
The proposed system of PCT consortia could lead to a substantial disruption in the provision of specialised services. The Minister's words in Committee were helpful as regards the transitional process to cover circumstances in which LHA service agreements run out and existing consortia do not effectively cover specialised commissioning needs. However, the fear on these Benches—and, clearly, on other Benches—is about the longer term. We believe that the arrangements in the Bill are not satisfactory and we have considerable doubts about the future of specialised commissioning.
Earl Howe: My Lords, like other noble Lords, I am very concerned about the risk that we are running in relation to specialised services—that of destabilising the commissioning mechanisms that have been built up over the past few years. It seems that there are huge dangers in dismantling the regional system of specialised commissioning for services such as paediatric and neonatal intensive care, cleft lip and palate, burns and plastic surgery and haemophilia. Much careful work has been done at the regional level in terms of developing coherent plans for vital services such as those. That work must be safeguarded; it must not be jettisoned.
My noble friend Lady Noakes mentioned the work of the National Specialist Commissioning Advisory Group, which deals with highly specialised services such as rare cancers and liver, heart and lung transplants. The work done by the NSCAG has created coherence and consistency across the country. I hope that the Minister will reassure us in his reply that there is no threat to the work of that group.
My concern as regards any commissioning that takes place above the level of the primary care trust—I suppose that this anticipates a later provision in the Bill—is that there is a lack of clarity about the arrangements for patient and public involvement in the commissioning process for services of that kind. A rule of thumb should be followed: wherever commissioning takes place—whether at national level, or lower down in the structure—that is the place at
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which the consultation must be conducted. Consultation cannot be ignored in that context because it is a key part of the quality agenda. I believe that that makes it essential for there to be a specific duty to consult at the right level. We shall deal with that point later. Having a hotchpotch of primary care trusts consulting their local communities in different ways would be unacceptable because it would not be possible to determine whether consultation on a particular change covering a specialist service, for example, had or had not been effective; nor would it be clear who could be held to account for it.
If the Government are wedded to their plans—I take it that they are—I commend to them the idea of a joint commissioning committee in a group of primary care trusts, with clear responsibilities for consultation and patient and public involvement as well as clear accountability and audit arrangements. For that, it may be necessary for PCTs to pool their budgets and to delegate their legal duty to commission. Perhaps the Minister could comment on those ideas when he replies.
Baroness Masham of Ilton: My Lords, the Minister knows full well my interest in specialised services. Perhaps I should declare an interest: I broke my back and had my life saved at a spinal injury unit. Those units are spread across the country; there are seven in England. They go far beyond strategic regions; many of them are super-regional.
Primary care trusts can be parochial. Through the self-help group that I founded with the Spinal Injuries Association, I have come across many people who were not sent to spinal injuries units. My noble friend Lady McFarlane is well aware of the problems and costs of dealing with pressure sores, which can be prevented with good nursing. That involves not merely specialised medical people but also nurses, physiotherapists and occupational therapists. It is vital that those patients go quickly to a specialised unit; otherwise, the whole process becomes very expensive. They can spend up to an additional year getting the problems treated and solved through plastic surgery and all sorts of other measures. Urinary tract infections and the treatment of the bowels may be involved. I have previously discussed such issues in the House. I am aware of the case of a young man who went to Charing Cross Hospital with a broken neck. There was no free spinal unit. No nurse would evacuate his bowels. Noble Lords can imagine the distress that that caused a young man in his twenties. However, that is the sort of situation that arises.
The Minister visited a spinal unit, and we are grateful to him for that. He knows what I am talking about. There are many other highly specialised conditions, including neurological conditions. Some GPs may not have even heard of some of those conditions. Sometimes the training of medical students does not include specialised services; for example, in relation to haemophiliacs, HIV patients and, of course, cancer patients. One could go on. It is a disaster if such patients do not go to a specialised unit quickly.

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Therefore, I want to ask the Government why they do not include this issue in the Bill in order to place some emphasis on its importance. I know perfectly well that many specialists want to hold on to interesting patients and then disaster happens.
7.15 p.m.
Lord Filkin: My Lords, if it is necessary, it may be worth returning to the central thrust of the Bill; that is, our commitment to establishing one body which is as close as possible to the public that it serves with a comprehensive responsibility for the health needs of the public in a particular area. For that reason, we see it as essential that the responsibility for commissioning specialist services rests with primary care trusts rather than being placed somewhere else in the system.
Whenever devolution or delegation is proposed, understandably there are always anxieties about whether one should devolve this or that function. I know that the Liberal Democrat Benches will join with us generally in resisting those arguments because frequently the benefits outweigh the risks that are advanced.
The general thrust is that jointly commissioning specialist services by agreement or through a lead PCT is very different from, and we believe vastly better than, having no power at primary care trust level for making judgments about the form of specialist services that are required best to meet the needs of the public.
Having said that, noble Lords have raised a number of concerns about specialised services. We know that in such services patient numbers are small and quality can be achieved only by bringing together a critical mass of patients in each centre. That means that relatively few centres will offer treatment and there will not be a specialist centre in every locality and every local hospital.
As has been mentioned, specialised services are defined by reference to the National Specialised Services Definitions Set, the first version of which was published in December last year. It was a major piece of work commissioned by the Government involving contributions from clinicians, managers, commissioners and patients. It has been published on the department's web site.
Under shifting the balance of power, primary care trusts are responsible for commissioning health services for their local populations. As I indicated, we believe that rightly that should include specialist services. Why do we believe that the anxieties that have perhaps properly been expressed in this debate will not be realised? First, PCTs will be expected to work together on a consortium basis to secure specialised services. That will be an expectation from the department and, more specifically, from the strategic health authority. If, against any bounds of common sense or argument, they are resisted, then ultimately the strategic health authority has the power of direction, although one does not expect or believe that that will be necessary.
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However, there is no clarity in that respect. The strategic health authority has a duty to ensure that effective consortia arrangements are in place.
Secondly, PCTs are expected to work together in order to maintain continuity and ensure stability. In the short term, clearly PCTs will be extremely busy in the next 12 months or so but they will be expected to honour existing agreements—financial and otherwise—that have, in the past, been negotiated by regional specialised commissioning groups.
Therefore, the existing systems will continue for at least the next year, allowing people to settle in and then, through discussion within a locality or strategic health authority, to hold discussions and make decisions about whether or not any changes in the past practice of commissioning might be desirable.
In order to support that process, regional specialised commissioning groups will continue for at least a further year, with PCTs replacing the former health authority members. RSCGs will have a specific role in developing PCT capacity to commission specialised services as part of a planned transition to successor arrangements. As part of that, in the context of specialised services it will be particularly important to ensure that enough people with the right skills continue in their role.
A number of encouraging reports—I believe that a survey was carried out in January this year—show that PCTs are already beginning to engage very successfully in discussions about taking on commissioning roles for specialised services. But it is not possible to come up with a single geographic model for specialised functions. In some cases, the only sensible commissioning unit will be at national level. In response to the question raised by the noble Earl, Lord Howe, the national level commissioning body will continue with its role, although, in time, the functions with which it deals will evolve because that is the nature of medical service and medical science.
However, it is not possible to say that the strategic health authority is the right body to take on responsibility in certain areas. I have given the principal reasons why we believe that PCTs should have the comprehensive responsibility for services for their public, including commissioning services. Functionally, the strategic health authority might be appropriate in relation to some functions but not in relation to others. There will be a whole pattern of service needs and service distribution which will vary from that. Therefore, there is no single "Holy Grail" answer in response to where all such specialised commissioning should take place.
As I indicated, the role of the strategic health authority will be to oversee the consortia arrangements, with regional directors of health and social care ensuring that the specialised services that go beyond strategic health authorities are also delivered properly within that region.
The Government are adopting a pragmatic approach to commissioning arrangements for specialised services. As I have signalled, current

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commissioning arrangements will be continued for at least the next year. Local experience will then inform how they should evolve in the future.
However, the Government have given serious consideration to the valid points raised by noble Lords during the Committee stage of the Bill. I am pleased to be able to inform the House that my right honourable friend John Hutton announced at a joint meeting of the all-party parliamentary group on 21st March that over the next six months he would head a review into commissioning arrangements for specialised services, in particular, for the regional-type services covering several strategic health authorities, with a view to issuing guidance in the autumn on arrangements beyond 2002–03.
The review will canvass views on how best to integrate the current RSCG arrangements with the new health and social care regional boundaries so as to ensure that highly specialised services covering large geographical areas are properly planned, funded and monitored.
Finally, I turn to a number of the questions raised by noble Lords during the debate. I have marked that the national commissioning body will continue. In answer to the question raised by the noble Lord, Lord Clement-Jones, as to who would be responsible for commissioning, for ensuring that the commissioning is carried out expertly or for monitoring the commissioning quality at PCT or at consortia level, the answer is clearly that it will be the strategic health authority or, if it is at the supra-SHA level, the regional director.
As to why regional directors should not continue, I believe that that was covered in the previous points that I made. The answer was that that was the case for two reasons: the first was devolution; and the second was that there is nothing perfect about a regional level.
The noble Earl, Lord Howe, indicated his concern about the risks of dismantling, as he saw it, well-developed and coherent plans for specialist services at regional level. But, of course, such structures may well not be dismantled. They will certainly continue for at least another year. One would then expect to see a process of evolution, as people felt that improvements could be made to them, rather than starting with a blank sheet of paper.
With regard to the question of patient and public involvement, I should have thought that that would need to take place at a number of levels. Clearly, the question of whether or not a patient considered that he was being properly served would always need to be dealt with at PCT level. I believe that the noble Baroness, Lady Masham of Ilton, gave a very human example of where one would expect a challenge to take place if a certain practice persisted. However, one would also expect there to be the potential to scrutinise a consortium arrangement and a specialised service arrangement. The nature of scrutiny will of course differ in each of those three places according to the functions they are pursuing.
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The noble Earl, Lord Howe, also asked about pooled budgets. It is perfectly possible as part of a commissioning agreement for PCTs not only to commission jointly but to pool and share risk by putting funding into a pooled budget. One can well see circumstances in which that would be both sensible and desirable.
I am grateful for the many points raised in this debate and in Committee. We recognise that these are substantial changes. However, we fundamentally believe that they will in time lead to a better service for the public. That is why we resist the amendments.
Baroness Noakes: My Lords, I thank all noble Lords who have taken part in the debate, and I thank the Minister for that comprehensive response. The concerns which have been raised are fundamentally about accountability and the strength of the accountability relationships. There is deep scepticism about the efficacy of networks as proper accountability arrangements for something as important as specialised services.
I was heartened, however, to hear that the regional specialised commissioning groups will stay in position for "at least another year". The "at least" was significant as the Minister seemed to be saying that subsequent events will be determined by how the arrangements progress. I should hope that the arrangements will not be dismantled if there is any significant doubt that PCTs can handle them on their own. I was also interested to hear what Mr Hutton has announced in another place about a review. I shall read with interest the comments of both the Minister and Mr Hutton on the matter.
Therefore, I do not think that it would he appropriate to press this amendment today. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Baroness Northovermoved Amendment No. 10:
After Clause 5, insert the following new clause—
"THE HEALTH INSPECTORATE
(1) There shall be a body corporate known as the Health Inspectorate, which shall take effect from 1st April 2004.
(2) The Health Inspectorate shall assume at that date the functions undertaken prior to that date by—

(a) The Commission for Health Improvement, and

(b) The National Care Standards Commission.

(3) The Secretary of State may by order make such amendments to the legislation relating to the health service in England and Wales as in his opinion facilitate, or are otherwise desirable in connection with, subsections (1) and (2)."
The noble Baroness said: My Lords, Amendment No. 10 seeks to establish a health inspectorate incorporating CHI and the National Care Standards Commission. The noble Earl, Lord Howe, moved the provision in Committee and we supported him. 'We had a particular and longstanding concern—which has been supported in your Lordship's House but overturned in another place—that independent hospitals should come within the same inspection system as NHS hospitals. That point is the subject of our Amendment No. 23.

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The case for Amendment No. 23 also was argued in Committee. As we seem to have prevailed in the matter, perhaps I do not need to rehearse the arguments. However, we are seeking to probe the position in the light of the Chancellor's Budget Statement on 17th April; the resultant statement by Alan Milburn in another place on 18th April, which was repeated to your Lordships by the Minister; and the document Delivering the NHS Plan. In the section on "Strengthening Accountability", that document states that there will be an,
"independent, single new Commission for Healthcare Audit and Inspection which will bring together the health value for money work of the Audit Commission, the work of CHI and the private healthcare role of the National Care Standards Commission. The new single Commission will have responsibility for inspecting both the public and private health care sectors".
Given that we have been calling for just such integration for a number of years and in various health Bills, we welcome the fact that we have finally persuaded the Government of our case. Although it may seem slightly churlish of me, I find it irresistible to refer to the Minister's reply in Committee—on 18th March; not so long ago—that such a merger was "somewhat premature". One has to wonder how a matter of a few weeks and the Easter holiday has given him sufficient pause for thought to decide that a merger is no longer premature.
Indeed, the Government have adopted our proposals with such enthusiasm that even more organisations are to be merged. Welcome though that conversion is, however, I feel some sympathy for the Minister. One consequence of this Bill's passage is that we shall soon have to unpick other arrangements. Should not the Government stop right now—as my noble friend Lord Clement-Jones suggested when we first considered the Bill—collect their thoughts and work out what they really need to do? Perhaps my amendment should not simply have sought the merger of CHI and the National Care Standards Commission but sought to merge this Bill and its successor. Meanwhile, I recognise that there seems to be agreement on merging some of the current inspection organisations and strengthening their independence from government. In the spirit of wishing to know exactly what the Government have in mind, I beg to move.
Baroness Noakes: My Lords, I shall speak to Amendment No. 22, which is grouped with Amendment No. 10.
Although Amendment No. 22 is similar to Amendment No. 10, Amendment No. 10 proposes the setting up of a new body—the health inspectorate—to take over all of the functions. Amendment No. 22 takes the different and more targeted approach of combining only the independent health sector functions of the National Care Standards Commission and the relevant functions of CHI. In that respect it is like Amendment No. 23.
In Committee, we proposed an amendment in the terms of Amendment No. 10. However, we recognise that the Government's policy has moved on, and we
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are confident that the Minister will welcome Amendment No. 22 as it more closely reflects government policy. The White Paper Delivering the NHS Plan sets out the Government's own aims, which include the merger of the private health functions of the National Care Standards Commission with those of CHI.
This group of amendments concentrates on merging the inspection functions of CHI with those of the National Care Standards Commission relating to independent hospitals. These amendments will not transfer the Audit Commission's value for money functions which are part of the Government's White Paper proposals. We believe that audit issues are separate from inspection issues. When the Government choose to present legislative proposals to address those issues, we shall of course consider them carefully. Nevertheless, it is not yet abundantly clear that the transfer of the Audit Commission's functions is a good thing. However, it clearly would be a good thing to merge the relevant inspection functions of CHI and the National Care Standards Commission. Like the Liberal Democrats, we on these Benches have been arguing for such a merger ever since we debated the Care Standards Act 2000.
Timing is another difference between Amendment No. 10 and Amendment No. 22. Amendment No. 10 sets up a new body and allows until April 2004 for the provision to take effect. However, the National Care Standards Commission has been in existence for only a few weeks and it would make sense to transfer its functions now. Although it would be complex and take some months to establish a new body, using CHI as the vehicle for merger would allow much faster implementation.
I recently had the opportunity to talk to the chief executive of the National Care Standards Commission, which is very much an embryonic organisation. The chief executive is trying to create a coherent whole out of 2,000 or so staff who have been drawn largely from local authorities across the country. Inevitably, the organisation does not yet have a clear ethos and corporate style. Although it is being structured and developed for the agenda which was first set for it, that is not happening in a manner that matches the Government's latest statement of intent.
I am quite clear that the chief executive, whom I have known for a number of years, will be energetic in his desire to forge a fully functioning National Care Standards Commission and that he will work towards whatever structure will facilitate the ultimate transfer of its functions. However, I am also clear that it is not a good use of his time, or that of his management team, to concentrate on bringing the private healthcare functions fully within the National Care Standards Commission. It would be much better if they could concentrate on transferring those functions to CHI so that the style, ethos and structure can be determined from the outset in a new home. It is also not fair to the independent hospital sector to have them exposed to different regimes over time.

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The Government have announced that the inspection of independent hospitals will be carried out by CHI on behalf of the National Care Standards Commission. But that still leaves significant functions in the hands of the commission. It seems that the only sensible course is to let CHI forge the managerial identity of all of the independent hospital functions. It does not make sense to keep them in separate bodies, however much co-ordination and co-operation takes place.
I look forward to the Minister's comments. I fully expect him to welcome the move towards government policy exhibited by these Benches and by the Liberal Democrat Benches.
7.30 p.m.
Lord Clement-Jones: My Lords, I shall speak briefly, as the dinner hour approaches. I could not resist twisting the Minister's tail a little further than my noble friend Lady Northover has done, and indeed the noble Baroness, Lady Noakes. Words such as "water under the bridge" and "blinding lights" spring to mind in respect of the Secretary of State's—and indeed the Minister's —conversion.
Perhaps I may remind the Minister of his words in Committee to the noble Earl, Lord Howe. He said:
"There is nothing between us on this matter, therefore. Our intention is that there will be a convergence between the activities of these four bodies, including CHI and the National Care Standards Commission, drawing together their expertise in joint work where appropriate, and sharing best practice".—[Official Report, 18/3/02; col. 1202.]
The reference at the time was to health and to social care. It is interesting, therefore, that between March, when the Minister uttered those words, and the publication in April of Delivering the NHS Plan, the Government changed their mind about how many audit and inspection bodies they wanted.
I appreciate that it is difficult for the Minister to keep up with the pace of reform ideas within his department and indeed outside it. I wonder whether all this is the result of having policy-makers at No. 10, at the Treasury and at the department itself, all vying for influence, so that it is not known finally what a policy outcome will be until the protagonists have worn themselves out in argument. I assume that that took place some time in early April.
Further questions arise in connection with the new body. As my noble friend indicated, these amendments have been superseded and could well have been substituted with a much grander amendment. But whatever the structure, the quality of information generated by trusts which will be subject to inspection and audit is of great importance. I ask the Minister to comment on the recent Audit Commission paper, Data Remember, which highlighted the need for much better management and production of data, particularly non-clinical data. I am sure that the Minister has the facts discovered by the Audit Commission, which in many respects were quite depressing in terms of the quality of data, particularly non-clinical data, that are available to inspection and
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audit. It does not matter whether that is the Audit Commission or the new body. The new body will have to have that data available to it.
I share much of the agnosticism of the noble Baroness, Lady Noakes, as to whether the value-for-money inspection aspect of the Audit Commission needs to be merged into the new body. Clearly, we shall await the proposals. However, I ask the Minister to comment on an interesting statement made last week by Sir Andrew Foster, the controller of the Audit Commission. He said that the Government are taking a "risk" in launching the commission for healthcare audit inspection while radically reforming the structure of the NHS. He is very close to the audit and inspection process.
There is a further situation. On the same page of the Health Service Journal—which I know the Minister reads when it is hot off the press—there is an article relating to Dame Deirdre Hine, who it appears will not be carrying on in the same function with the new audit body. The issue is to some degree about whether the new body will have a developmental agenda or whether it will be purely audit and inspection. Many people feel that CHI has been successful in its developmental approach. It has not been a purely punitive, performance and target based body. There has been quite a degree of mentoring, coaching and so on about its activities. Many people and many managers in particular have welcomed that approach. It would be unfortunate if some of those elements were lost in creating the new body.
Baroness Gale: My Lords, I want to speak against the amendment. The Secretary of State has already announced the need for organisational integration of CHI, the National Care Standards Commission, the SSI and the Audit Commission to create the commission for healthcare, audit and inspection, and to integrate the health work of CHI with the private healthcare function of the NCSC and the work of the Audit Commission. I understand that this has been welcomed by those who work in that field.
It should be remembered that the work of the National Care Standards Commission has only just been established. A major reorganisation and shake-up such as is set out in Amendment No. 10 is not feasible or desirable at this stage.
Of course, all existing bodies should work in the closest co-operation and they have already expressed their intention to do so. A single new body for inspecting healthcare in both the NHS and the private sector is already planned. This merger needs time and sensitivity to settle down, and we should not seek to complicate the situation further as would happen if the amendment were to be accepted.
Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Baroness, Lady Northover, for her probing amendment, which I have great pleasure in responding to. All I can say is that I believe that there is complete consistency in all that I have said on these

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matters in this House, going back over the years of pleasure that I have had in bringing NHS Bills before the House.
So far as concerns my remarks in Committee and where we are now, what the Budget Statement and the Statement by my right honourable friend the Secretary of State for Health took forward was the consideration in the Kennedy report, which argued for a review of the regulatory bodies to ensure greater clarity and greater consistency. That is what has happened, and the announcement took place two weeks ago.
The noble Lord, Lord Clement-Jones, raised an interesting question as to whether we should have put together a health and social care inspectorate rather than two single inspectorates. We considered carefully whether we should go down the route of establishing a single health and social care inspectorate—to which the amendment moved by his noble friend would lead, although the title "health inspectorate" would not be very appropriate if we went down that route. An assessment took place and a number of criteria were considered. They included the impact on the burden of service providers, the effect on organisational stability, the effect on the cost of inspections and a number of other matters.
In the end, we came to the conclusion, particularly given the nature of the organisational change that would have to take place, that it would be better to keep to a health inspectorate and social care inspectorate, but making it clear to the new organisations—and primary legislation will be required—that they would have a duty to co-operate together. As I have said, legislation to establish the new inspectorial bodies will be introduced as soon as we have worked through the practical details and as soon as parliamentary time allows. As to whether I introduced a new definition of what "somewhat premature" means, the six-week gap between my saying that and now should not be taken as a general precedent for a definition by government as to what "somewhat premature" means.
Life moves on, and the question now is how to ensure that in the interim we continue arrangements with the National Care Standards Commission and with CHI to ensure that their current functions are managed effectively, while setting up as soon as we can the interim arrangements for taking forward our new proposals. As noble Lords will know, CHI is currently able to review arrangements for clinical governance in NHS services provided by the independent sector, including those provided by independent hospitals. We are examining how we may take forward that work.
The Bill gives CHI a new function of inspection against published standards and that responsibility will be extended to services for NHS patients wherever they are treated. We have deliberately made provision in the Care Standards Act 2000 for CHI to be able to exercise the functions of the National Care Standards Commission and vice versa. Of course, in answer to the noble Baroness, Lady Noakes, we shall seek to ensure that those arrangements and agreements are
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completed as quickly as possible. I have no argument with her in terms of wanting to ensure that that is put in place as quickly as possible.
I noted with interest what the noble Baroness had to say about her discussions with the chief executive of the National Care Standards Commission. He made a statement when we announced the decision for two inspectorates, and said that he welcomed the proposed legal requirement for the new commissions to co-operate with one another. He also said that we must ensure that the interests of service users are at the heart of the reform. In our project plan for taking this work forward we shall work closely with the commission, with CHI and with the Audit Commission to ensure that there are smooth transition arrangements.
It is worth making the point that the new health inspectorate will be staffed largely by current employees of CHI, the commission and the Audit Commission. Of course, they will continue their existing important work until the new body comes into being. We appreciate that the transfer of staff needs careful thought and we shall ensure that that takes on a seamless transition to minimise the impact on current staff. On the issue of working together in the interim, we shall meet with CHI, the National Care Standards Commission and the Audit Commission to ensure that that happens as effectively as possible.
The noble Lord, Lord Clement-Jones, referred to the decision of Dame Deirdre Hine not to seek re-appointment to CHI when her term of office comes to an end. I take this opportunity to place on record my and the Government's appreciation of the tremendous work that she has undertaken.
On whether the inspectorate will be an inspectorate or a developmental agency, one needs to be abundantly clear that it will be an inspectorate. That is our intention. We have always seen the modernisation agency as the main developmental arm of the National Health Service, but we expect the new inspectorate—
Lord Clement-Jones: My Lords, can the noble Lord kill the rumour that the Secretary of State would rather like the inspectorate to be like Ofsted with Mr Chris Woodhead?
Lord Hunt of Kings Heath: My Lords, that is the first time I have heard the suggestion that Mr Woodhead may be appointed to the health inspectorate. It would be wrong of me to engage in speculation about who would be appointed because that will follow from the process of legislation. That sounds rather unlikely.
7.45 p.m.
Lord Clement-Jones: My Lords, I meant "like Mr Woodhead" and not actually Mr Woodhead. That would be a fate that I had not contemplated for the new Audit Commission.
Lord Hunt of Kings Heath: My Lords, as far as I know there is no one like Mr Woodhead! I pay tribute to Dame Deirdre Hine and I say quite clearly that the body is to be an inspectorate. Of course, we would

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expect the inspectorate to build on the achievements of the commission, CHI and the Audit Commission. We are building up a great deal of expertise as to how effective inspections work. I certainly agree with him when he implies that inspection is not just about sticks, but also about carrots and about acknowledging successes. If one reads the reports by CHI, one will see that while, quite rightly, they pinpoint problems and concerns, they also highlight successes within individual organisations.
On the Audit Commission, I note what the noble Baroness, Lady Noakes, says, which was echoed by the noble Lord, Lord Clement-Jones. I make it clear that we are talking about the value-for-money studies and not the more general responsibilities of the Audit Commission that will remain with that commission in relation to the NHS. On data quality issues, the Audit Commission report did not paint an altogether wholly depressing picture. Beware of Audit Commission press releases that sometimes do not always reflect the degree of comment within the Audit Commission's report itself. Yes, it pinpointed problems but it also showed areas where the NHS has improved. We have made clear to the NHS that boards of NHS organisations are responsible for their own quality data. There are distinct signs of improvement in quality, but we shall urge the NHS to do even better in the future.
Baroness Northover: My Lords, I thank the Minister for his reply. I beg to differ with the noble Baroness, Lady Noakes. It is not noble Lords on the Liberal Democrat Benches, or those on her Benches who have drawn closer to the Government, but the other way around. Amendment No. 10, which was formerly a Tory amendment, is a probing amendment, a vehicle and not a detailed prescription. It was tabled in order to explore exactly what the Government have in mind. I am not sure how far we have achieved that. It is certainly very welcome when a Minister, in his consistency, moves from opposing us to supporting where we stand. I would welcome such consistency any time. We look forward to seeing the Government's detailed plans as soon as possible. In relation to private hospitals they cannot come too soon. Meanwhile, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Lord Fillkin: My Lords, I beg to move that consideration on Report be now adjourned. In moving the Motion I suggest that the Report stage begin again not before 8.48 p.m.
Moved accordingly, and, on Question, Motion agreed to.

Disabled People in the Performing Arts
7.47 p.m.
Baroness Anelay of St Johnsrose to ask Her Majesty's Government whether they consider that cultural attitudes towards the employment of disabled people in the performing arts are a barrier to their successful employment in this area.
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The noble Baroness said: My Lords, I thank those noble Lords who have put down their names to speak in this debate. I also thank Equity, the London Arts Board and the Arts Council for their helpful briefings.
I tabled this debate to put the spotlight on issues relevant to disabled people who want to work in the performing arts. I want to ask Government what role they believe that they have to play in ensuring that disabled people have an equal opportunity to obtain work and how much action they believe is best left to the world of the performing arts itself and more widely to all of us who go to the theatre, enjoy music, watch films and TV and listen to the radio.
I have planned this short debate for some time, but the catalyst was seeing Eric Sykes perform on stage. His star quality was not dimmed by age or his hearing and sight difficulties. Not a bit of it. His sense of comic timing and delivery enchanted the whole audience.
It is axiomatic that the performing arts should reflect all of society and therefore that they should harness the ability of disabled people to play a full part. It is the right thing to do and it can make good business sense too. Star quality is not confined to performers who have no disability.
Why is it that disabled performers today face a similar situation to that of black and Asian performers 30 years ago—that is, few are given the opportunity to perform at all and are likely to be confined in the main to stereotypical and limiting roles?
I was intrigued to read the Eclipse report published last week by the Arts Council in partnership with the Theatrical Management Association. It plans to combat what it perceives as institutional racism in the theatre sector. It sets a target of March 2003 for every publicly funded theatre organisation in England to have reviewed its equal opportunities policy and ascertained whether its set targets are being achieved and, if not, to draw up a positive action plan to develop opportunities for African, Caribbean and Asian practitioners. And does the Minister endorse that report tonight? Does he believe that that may be a way forward to tackle the barriers faced by disabled people?
Who should take action? What could or should they do to change cultural attitudes which inhibit the employment of disabled people in the performing arts? The Government have a crucial role to play in the way in which they direct employment and social security policy. The last Conservative government put the Disability Discrimination Act on the statute book and that will reach its final stage of implementation in 2004.
Much has been done to improve physical access to arts venues. But there is still a severe lack of access to backstage areas. Particularly for the small arts venues, there are huge financial barriers to the implementation of access policy. Arts venues are often housed in elderly buildings, many of them historic, where the modifications required to improve access facilities require major building works. What resources and support are the Government making available to assist venues to achieve full physical access?

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It is also vital that disabled people should have access to the same professional training opportunities as their non-disabled colleagues. Most accessible training opportunities are still provided by under-resourced organisations such as Heart 'n Soul. That is an arts organisation which offers creative opportunities to people with learning disabilities. Though in receipt of some public funding, such organisations are registered charities and rely heavily on support from trusts and foundations.
Can the Minister tell the House whether there are any higher education courses in the performing arts accessible to people with learning disabilities in particular? I am told that the Razor Edge Theatre Company, in association with the Rose Bruford College, is currently trying to set up such a course but that financial support for it has not yet been confirmed. I note of course that the Special Educational Needs and Disability Act 2001 extends the scope of the DDA to cover education. By 2005 all bodies responsible for the provision of education and other related services will have a legal duty not to discriminate against disabled students and other disabled people. What measures are the Government taking now to assist educational bodies to adjust their recruitment policies, their courses and their buildings so that they can comply with the new Act?
The Government could also assist by increasing the flexibility of the benefits system still further. The performing arts are staffed to a significant extent by people undertaking short-term, temporary and part-time contracts. After all, that is a way of working that often suits disabled people who cannot always work full-time for indefinite periods. However, people need to be able to return easily and immediately to benefits following a period of work. Due to the inflexibility in the benefits system, many disabled people working in the performing arts draw a salary way below their worth or indeed do not accept any remuneration at all.
While I appreciate that the threshold of therapeutic earnings recently increased to £20 a week, that still gives disabled people little income allowance before their benefits are affected. Does the Minister believe that disabled people should be able to enjoy pay parity with their colleagues without the fear of it leaving them exposed in other areas of their lives? Is the Minister aware that the Access to Work scheme has great potential but in its current form is failing to meet the needs of disabled people who are seeking work in the arts?
I am advised by the London Arts Board that specific problems are as follows. First, many arts contracts are part-time or short-term. But the ATW application process can be extremely slow and complex and therefore in some cases it is simply not an option. Freelance work is very common in the arts sector, yet it can be very difficult for freelance workers to gain access to ATW.
Secondly, working in the performing arts often means that one is travelling to work in non-office environments. That can generate needs which ATW
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does not meet. For example, it is very difficult to get personal assistance covered by ATW. Finally, ATW is not available to disabled people in work experience or placements in training. How do the Government plan to address those three problems?
So far in my speech I have concentrated on the responsibility of government, since it is the raison d'être of any Unstarred Question that one asks the Minister to answer questions. Ministers in your Lordships' House are required to give very much a virtuoso performance. They are required to respond to questions concerning all departments and not just on those for which they have primary responsibility. Indeed, the noble Lord, Lord Davies, tried to say last Thursday that he did not have to answer for the DTI. But I am afraid he does—that department and all the others. However, in sympathy with him because some of my questions require a detailed knowledge of benefits and educational matters, I gave advance notice of those questions to the DCMS.
Beyond the responsibility of the Minister, I am aware that there are responsibilities vested in the world of the performing arts and in all of us, the audiences, which are just as, if not more, important. I hope that other noble Lords will have time to touch upon them. Perhaps I may give brief examples. First, lottery distributors need to ensure that there is a fair distribution of funds. The Arts Council of England has done valuable work. For example, in 1993 it set up the apprenticeship scheme which works with arts organisations to create opportunities for people with disabilities to get access to employment with arts organisations. It is currently working on an arts and benefits guidance booklet to enable disabled people to make informed choices about work and benefits and hopes that that will be published this summer.
In the arts world, producers, writers and casting directors all need to take a positive approach to the employment of disabled people. Does the Minister agree that they should be aiming at inclusive casting? Is the Minister aware of the valuable work done by Equity to highlight the ability of disabled performers in its publication Spotlight?
Perhaps above all else we the audience have the main role to play. We can take a constructive attitude. We can have an open mind and a willingness to engage with the issues and challenge our own perceptions of what constitutes an entertaining and successful performance. So are we stuck with a vicious circle or can we break free? The vicious circle is that the arts can play a vital role in changing attitudes, but the general invisibility of disabled people, particularly in the performing arts, and to a woeful extent in television, will not change until all the issues I have mentioned today are addressed. The problem is that the issues will not be fully addressed until the arts help to change our attitude towards disabled people.
Next year is the European Year of Disabled People. Let us be ambitious. Let us set that as our deadline for breaking free of the vicious circle.
7.58 p.m.
Baroness McIntosh of Hudnall: My Lords, I am sure noble Lords are grateful to the noble Baroness, Lady Anelay, for introducing this debate on this important but, it has to be said, frequently overlooked topic. I agree with much of what the noble Baroness said, which is perhaps not a position in which I would ordinarily find myself.
I start by declaring an interest in that I am the now outgoing executive director of the National Theatre and the principal designate of the Guildhall School of Music and Drama, both organisations which have a part to play, and indeed are working to play their part, in addressing the issues raised by this Unstarred Question.
The Question seems to address two separate although obviously related matters; first, whether there are in fact impediments to the employment of people with disabilities in the performing arts; secondly, whether those impediments are the result of a cultural bias against such people, whether in society at large or specifically within the performing arts. The probability, based on the available evidence—of which the noble Baroness put a great deal before us—is that the answer to both questions is yes. That could be a very short debate. But that simple answer conceals a complex reality, as the noble Baroness has pointed out. The following are quotations from Promoting Change, which is a handbook produced by the Employers' Forum on Disability.
"Many people react to disability in ways that are rooted in unfamiliarity coupled with lack of information.
People may find it difficult to change their way of looking at disability because the term covers a wide range of very different people and they simply do not know who 'disabled people' really are. Only wheelchair users or perhaps blind or deaf people may come to mind.
Many people are deeply uneasy or even frightened by their level of discomfort or lack of experience".
We should not forget that that is the context in which issues of this kind are discussed, whether in relation to the arts or any other aspects of employment.
Historically, I am sorry to say, the arts have not always been in the vanguard in ensuring employment opportunities are available for disabled people, although over the past 20 years some important steps have been taken to improve matters. I am not just referring to opportunities for performers. There are many other jobs to be done, from stage management to payroll management, and from lighting technician to press officer. The people who fulfil those functions are as vital to the success of any production as the actors, dancers or musicians who appear on the stage. The Arts Council's apprenticeship scheme which the noble Baroness has already mentioned, in which I am glad to say that the National Theatre participated, has helped to ensure that some disabled practitioners in these areas have been able to gain experience through secondments.
However, the most visible way to improve the profile and status of disabled people in the performing arts is through the wider and more integrated employment of performers. There is some way to go
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before we can say that that has been achieved. In relation also to what the noble Baroness, Lady Anelay, said in connection with the employment of performers from ethnic minorities, it has taken a long time for these issues to be pushed up the agenda, both of the performing arts and of the funding organisations. The issue has always been there, but it has taken a long time for us to be able to say with any degree of confidence that we have made progress. I fear that these issues do take a long time.
However, companies such as the Graeae Theatre Company and the CanDoCo dance company have been working for years producing excellent work using disabled performers and performing for large and mixed audiences. These companies have done a huge amount to break down the barriers and to show just how extraordinary can be the impact of seeing performers whose ability to communicate is in no way limited, and indeed is sometimes actually enhanced, by their disabilities, as the noble Baroness said. But the big challenge remains that of getting more mainstream training organisations and mainstream performing companies to see the possibilities, rather than the difficulties, of including performers with disabilities routinely in their plans.
One of Graeae's founding members is the actor Nabil Shaban. Nabil has had a distinguished career in theatre, film and television. He has also been a forceful advocate for the right of disabled performers to be considered on equal terms with their non-disabled colleagues. I am sure that he would not mind my saying that over the years I have spent a few uncomfortable hours listening to him point out the shortcomings of my own, and other, organisations as far as concerns our record of employment. I hope that he will also not mind my saying that in order to employ him, which we were delighted and privileged to do at the National Theatre, we had to make quite a few adaptations to facilities backstage, and to review our health and safety policies and procedures, to ensure that he could work in a dignified and independent way within a building built with absolutely no concession to the possibility that any performer might be less than fully mobile, fully sighted or with full hearing.
These days, theatres, like all other places of public resort and entertainment, generally try to provide a decent service to their disabled paying customers. The DDA has made sure that if they do not, sanctions can be brought to bear. The National Theatre provides a range of services for its disabled patrons, including proper wheelchair access, signed performances and audio description. In 1996 it received a substantial award from the National Lottery, mainly to refurbish the public areas of the theatre. Many of the improvements were directed towards making it easier and more comfortable for disabled audience members to visit. I regret to say that less attention was paid to the rearrangement of the backstage areas. I venture to suggest—indeed, the noble Baroness has already suggested this—that one of the biggest disincentives

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for arts organisations, particularly smaller, less well-funded ones, to the employment of performers with disabilities is the challenge—mainly financial—of providing appropriate facilities.
Speaking at the launch of the London Arts Disability Action Plan last November, Jenny Sealey, who is the current artistic director of Graeae, asked:
"Are people not employing disabled actors because of lack of accessible rehearsal spaces? … This is a very real issue in London … Where there is good rehearsal space the owner of the space has to hire it out for commercial gain and small companies get priced out".
She certainly has a point.
There is also the question of education and training. I learnt a couple of days ago that the Guildhall School of Music and Drama has selected a severely physically disabled student to join its three-year acting course from next autumn. The fact that this was being reported to me as a matter of some note tells us something about how rare it is. Integrating disabled students into the kind of training that Guildhall and other similar colleges deliver requires thought, imagination, change and a willingness to concede that there is more than one way of being an actor. Body and mind must be trained certainly, but talent comes in many different shapes. As educators we must be open to our responsibility to identify and encourage it, however it presents itself and whatever obstacles may be in the way—although I ask my noble friend the Minister to recognise that there are additional costs involved in such inclusivity, which training organisations find hard to bear from currently available resources.
As the noble Baroness, Lady Anelay, said, as audiences we must learn to set aside our preconceptions. In a world unhealthily preoccupied with narrow models of physical perfection, this can be a challenge.
A couple of years ago, during the National Theatre's Connections Festival of youth theatre, we presented the work of a group of young people from Scotland. All the performers had disabilities—mostly learning, but some physical. It was a very big thing for them to be performing at the National Theatre, but it was also a very big thing for us to be working with them. They were doing a play of their own devising about falling in love and the difficulties that the well-meaning world of caring parents and anxious teachers put in the way of disabled people making relationships. It was a powerful piece.
Within the group was a young man with severe cerebral palsy. He was confined to a wheelchair and unable to speak or control his movements. As far as possible he was completely integrated into the action of the play. He was wheeled about the stage either by a carer or by one of his fellow performers. At a key point in the action there was a silence. Out of it slowly emerged a series of strange and unfamiliar sounds. We looked for the source and gradually realised that he was. Someone was holding a microphone in front of him and he was speaking. The sounds he made had
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astonishing, unexpected and almost shocking beauty. It was an extraordinary contribution to the whole event.
Of course it was intensely moving. It could not fail to be. But more than that it was revelatory. I learnt something about my own prejudices that evening; as I have on so many other occasions when I have seen performers harness and overcome their disabilities to show me something that I could not have learnt in any other way. The reason it is important that all performing arts should be inclusive is not just that performers with disabilities deserve opportunities to practise their art—they certainly do—but because we the audience can learn so much from seeing them do so.
The Government have, I recognise, a firm ongoing commitment to improve employment prospects for all disabled people. I am sure that my noble friend the Minister, when he comes to reply, will refer to the initiatives which the Arts Council and other bodies are currently progressing to address issues specific to the arts. These include the apprenticeship scheme, which I have already mentioned, and a handbook of good practice on employing disabled people which the Arts Council is also preparing.
I wonder whether my noble friend would also look with his colleagues in other departments at the issue which the noble Baroness, Lady Anelay, has mentioned, of whether the current benefit system could helpfully be reviewed to minimise the likelihood of barriers to employment being created in this area.
I should like to end by quoting again from the words of Jenny Sealey of Graeae Theatre. At the conclusion of her speech at the launch of the London Arts Disability Action Plan, she said:
"I believe that attitudes as well as physical barriers are stopping disabled representation on the stage. Surely there are only two possible reasons for this state of affairs: either disabled actors are no good or there is institutional discrimination at work. I believe that Graeae and others have proved that the talent is there, albeit somewhat raw, of course, as training opportunities have been scarce … And in many ways some of the … advances in access for audiences—signed performances (never the night you want to go), captions, wheelchair access, audio description and the rest compound the crime as disabled people are finally given the privilege to spectate as the able-bodied world parades itself for their entertainment".
These are powerful, angry words. We have a lot of work to do before they will cease to resonate.
8.10 p.m.
Baroness Wilkins: My Lords, I congratulate the noble Baroness, Lady Anelay of St Johns, who has once again introduced a most interesting debate of concern to disabled people. I thank her for raising the issue so thoroughly and for probing the Government on what action they may take. I am also grateful to the noble Baroness, Lady McIntosh of Hudnall, for her excellent speech. I hope not to be too repetitive.
We have all laughed at the Peter Cook and Dudley Moore "Tarzan" sketch. Peter Cook, playing the casting agent, tells a one-legged Dudley Moore,

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"You are applying for a role more usually associated with a two-legged artiste. I have nothing against your left leg. The trouble is, neither have you". That is classic comedy but it also raises some fundamental questions about the employment of disabled people in the performing arts. Can people with a discernible impairment be cast in roles where that is not specified in the script? The joke rests on the perception that the answer to that is, "No, they cannot". The result is that there is a major reluctance to employ disabled people in the performing arts.
As other noble Lords have said, the other main barrier to disabled people being employed is the paucity of training for disabled would-be actors. Drama colleges traditionally refuse places to disabled people on the grounds of the self-fulfilling prophecy that they could not possibly get work.
The obvious barriers faced by disabled people in the arts led to a reaction that has come to be known as the disability arts movement. One of its main spokespeople is Sian Vasey, to whom I am grateful for her advice on the subject of this debate. From its beginnings in the 1980s, the disability arts movement wanted to combat more than the purely physical and attitudinal barriers to disabled people's participation in the arts. It also aimed to deal with the cultural barrier of absence—disabled people did not exist. Rarely in mainstream art is the experience of disability depicted and disabled people are seldom to be seen in cultural output of any type. The prime objective of the disability arts movement is to achieve visibility for disabled people. It is committed to creating a world where disability genuinely has a place and to ensuring that the issues that disability raises are given a cultural platform.
Performance was one of the first sectors of the movement to flourish. Other speakers have mentioned the Graeae Theatre Company of disabled actors, which was formed in 1981 and now runs a continuous programme of challenging and exciting work under its outstanding director, Jenny Sealey. I declare an interest as a former trustee. There is also the Strathcona Theatre Company and the Heart 'n Soul musical theatre company, both of which focus on the talents of people with learning difficulties. Those groups all perform work of the highest standard and are now well established.
The work of Candoco, a dance company formed by spinally injured ballet dancer Celeste Daneker, is outstanding, as the noble Baroness, Lady McIntosh, mentioned. Anyone who sees the beauty of David Toole's dance using solely his arms—he has no legs—becomes aware of the limitations that we have traditionally imposed on that art form by our insistence on physical perfection.
A handful of individual performers who gained their experience from those companies are now staging their own work and achieving recognition. For example, Nabil Shaban, Caroline Parker and Mat Fraser have all recently put on shows in Edinburgh that have transferred to fringe venues in London. Among other
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individual performers are a number of successful stand-up comedians who have created powerful routines entirely from disability related material.
Turning to the issue of the lack of training for disabled performers, disability theatre companies have to date been almost the sole source of training, but that is clearly a huge role to take on and one that would be better done by training establishments. A small number of drama colleges are now dealing with the chicken-and-egg situation of no training, therefore no job; no job, therefore no training, and are taking disability seriously. The Liverpool Institute for Performing Arts runs a course called Solid Foundations, which awards a certificate of higher education in the performing arts specifically for disabled people. Others taking specific initiatives are the Arden in Manchester and the New Vic in Newham.
The Royal Academy of Dance has given time and thought to the issues and developed a policy that is careful not to exclude disabled people from its programme of classical ballet exams. Its policy document states:
"The RAD will make every effort to accommodate applicants and students with special needs. All applicants must meet the programme entry requirements and must demonstrate their ability to an acceptable level within the programme specific Selection Criteria … Over and above this, the needs of each applicant with disabilities will be investigated and negotiated with the individual on a case by case basis to ensure that s/he will not be disadvantaged. If, after every effort has been made, it is not possible to accommodate an applicant's needy then it may be that the applicant cannot be offered a place".
As Candoco has shown, certain kinds of impairment would not be a barrier to a career in classical dance and a positive approach will enable a start on this career path.
Little statistical information is available in the field. The Arts Council of England ran an initiative to increase the employment of disabled people in the arts back in 1997. According to its chair, Paddy Masefield, at that time 650,000 people were employed in the arts and cultural industries, of whom one in 1,000 was a disabled person. More recently, the Arts Council of England annual survey of the whole arts workforce in the year 2000 reports that only 2 per cent are disabled people.
Equity compiles a directory of disabled performers that it publishes jointly with Spotlight. That is available free of charge and offers a free listing for performers. Equity, too, has no statistics but gets regular calls from people looking to cast characters who are disabled. It therefore feels that there is progress in such casting. However, according to Equity, there is far less interest in employing disabled actors to play characters who are not specifically disabled.
That brings us right back to the problems faced by the one-legged artiste who wants to play Tarzan—or perhaps not Tarzan, but plenty of roles need not be played by able-bodied actors. There is massive unexplored potential that would benefit not only disabled actors but the whole world of drama, allowing it to break barriers and find fresh talent. Some examples of successful integrated casting include

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Nabil Shaban playing Hamlet and the Tottering Bipeds theatre company production of Waiting for Godot with two Graeae-trained disabled actors playing Vladimir and Estragon. Graeae itself has staged imaginative productions of Ubu, The Changeling and other standard texts written with an able-bodied cast in mind.
The issues involved in such integrated casting are perhaps more complicated than those involved in the integrated casting of black people and others from ethnic minorities, but inroads are being made. I therefore suggest that the time is right for a concerted employment and training initiative, hosted by a range of relevant bodies, to build on the foundations that have largely been laid by disabled people's own efforts. We need to cut through the negative assumptions and the lack of imaginative casting.
Disabled people have cause to be grateful to the noble Baroness, Lady Anelay of St Johns, for raising the issue in such a timely and constructive way.
8.18 p.m.
Lord Addington: My Lords, the noble Baroness, Lady Anelay of St Johns, has once again scored a hit from a nice sideways angle. The three noble Baronesses who have spoken have used virtually every point that I had thought of—I had thought that I would be able to cite the Peter Cook and Dudley Moore sketch myself.
The main thing that occurs to me about government action on this matter is that they now—but only recently—have most of the necessary legislation in place. When the Disability Discrimination Act 1995 comes into force—I believe that that will be next autumn—the artificial cut-off for organisations employing fewer than 15 people will end. That will probably serve as a wake-up call to the entire arts industry with rather far more force than it at present imagines.
What usually happens in sectors that have to deal with disability legislation is panic. They say, "Oh my God, we can't do anything. What will happen? It will be the end of us". Then there is a period of calm reflection, followed by some action. That will probably go on throughout the arts movement. Much subsidised theatre will have to do some deal with government to tackle the problems. There is always the excuse of the ancient building that has something or other backstage that cannot be moved. Usually something is done on such occasions, and I suspect that, with a little will—inspired by the knowledge that it will be illegal not to do something—much will be done. The same process is about to affect the training and education institutions that provide our performers.
The removal of the exceptions made under the DDA by the Special Educational Needs and Disability Act 2001 will ensure that anyone who receives public money for training and education will be drawn into the matter. If I started to draw on examples I would, I am sure, mix them up, but that is the situation as I
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understand it. Thus, the Government are in a situation to make sure that there is training. If we accept that education is a good thing in itself—we are talking here about education and training, and I do not know where the cut-off point is between the two—it should not be the case that someone may find it less or more difficult to get work in a certain field. That argument should carry only limited weight. The Government will fund many such courses directly or indirectly, and they must apply pressure. That is how I see the Government's role. It is a rather narrow channel, but they can ultimately cause things to happen; they will be the catalyst for change.
As has been said, there are many examples of disabled theatre companies which have said, "We can perform and entertain. We can create something meaningful". That should not come as a surprise. The arts world has embraced one large group of disabled people for a long time—dyslexics. There are few occasions on which one would refer to the late Oliver Reed and Susan Hampshire in the same breath—both successful actors, both dyslexic. Dyslexic people find theatre a convenient art form. They are not restricted to using bits of paper in front of them; they can express themselves in other ways that suit very well. It is such flexibility that has created the tradition that theatre is—small "1"—liberal. The theatre has generally been slightly ahead of most parts of society in bringing people in. It is worth remembering that Shakespeare did not write for women, for instance. Ethnic minorities and people of different sexual orientation have also found a home in the theatre before other places.
We are asking people to do no more than take a slightly sideways look at what has been done. Often, we talk about disabilities that are visible and can he perceived. We will have achieved full integration when it is perfectly normal to find someone in a wheelchair playing a part normally taken by someone who can walk. That is the real test, as it would be with any form of discrimination. Someone said to me that we would be able to tell when women had reached the same status in society as men when a woman did not need to be slightly better than the men to get to a certain level but only as bad as they were. The same would be true of any form of disability integration. When it becomes normal to see parts being filled by disabled people, we will have achieved it.
The noble Baroness, Lady Wilkins, spoke of a chicken-and-egg situation. If people are trained, they will eventually be used; if they are not trained, nothing will happen. If the Government are prepared to make sure that the organisations that they fund do train people, something will happen.
The noble Baroness, Lady Anelay of St Johns, raised a practical point about the benefits system and the idea that the benefit might be used to cover costs additional to basic living costs. The Government must tackle that issue, which does not apply only to those in the performing arts sector. The benefit trap for people with disabilities is well recognised. Pressure from here may help, although the Department for Culture, Media and Sport versus the Department for Work and

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Pensions might be a David-and-Goliath situation. However, every little helps. We must apply more pressure to make the transition from benefits to work—or work with benefits, as it must be in certain situations. If that does not happen, there will be no continuous throughput of people.
The theatre should open itself up to a new way of looking at a large number of people. It will have to do that, and it is capable of doing it, provided we point it in the right direction. The Government are in a position to apply considerable leverage by making sure that anything that is dependent on government help for its workforce or to keep itself running starts to address such issues.
We are asking for equal rights for the disabled; we are not asking for tokenism. We are not asking on behalf of people who cannot bring anything to their field. They must have an equal opportunity. That is what is required. All that we can expect the Government to do is to make sure that the door is open; it will be up to society as a whole to see that people go through that door.
8.27 p.m.
Lord Davies of Oldham: My Lords, like all noble Lords who have spoken, I express my gratitude to the noble Baroness, Lady Anelay of St Johns, for raising this important issue and the way in which she did so. She struck a positive chord when she quoted Eric Sykes as an exemplar. She recognised that that most famous of Oldhamers would be of particular interest to me, as I represented the town in the other place for many years and met Eric when the town celebrated its 150th anniversary. He is one of our outstanding examples of achievement and talent. As the noble Baroness said, he is a wonderful example of someone who triumphed over an interesting and difficult disability to reach the high regard in which he is held by the nation.
The noble Baroness will forgive me for saying that I understand the emphasis that she put on the Eclipse report. There is no doubt that the report is of great importance, but it is only a week or so old, so it is difficult for me to give a definitive government response. Suffice it to say that we recognise that the report emphasises how important it is that there should be an end, in so far as it exists, to any form of institutional racism in the theatre. We know that there have been one or two cases of late in which it has been contended that the theatre has not always lived up to the highest standards.
Without in any way prejudicing our response to the report, I can make it clear that the Government believe that there is no place in society for institutional racism in any quarter. The Macpherson report made that clear. Noble Lords know that in due course we shall be producing our own response to the report. I recognise the salience and immediacy of that report to the issue we are debating this evening.
Several noble Lords have mentioned that new legislation, the Disability Rights Commission and new benefits have already gone some considerable way
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towards improving the position of disabled people in society. However, noble Lords have also indicated that there is absolutely no room for complacency. I am grateful to all those who identified areas in which much still needs to be done. It is important that the Government play their proper role in ensuring that effective improvements are made.
There is no doubt that disabled people are under-represented in audiences, on the boards and in the publicity materials of arts organisations. We are working in close partnership with arts sectors to build a clearer picture of the employment of disabled people at all levels in the arts. That vital knowledge will enable us to build appropriate and meaningful pathways to take the sectors forward. All areas of the arts must be supported and encouraged actively to recognise that everyone has the right not only to act, sing and dance, but also to manage, innovate and direct.
Too often when one considers the performing arts, one thinks only of that which takes place on stage and, to a certain extent, at the front of house. We consider less the crucial roles which can and ought to be taken on by all sectors of our society in support of a performance. A successful approach must be holistic, built on specific expertise and sustainable in the long term.
The noble Baroness also mentioned the problems which obtain with regard to physical access for disabled people to theatres and other venues. We recognise the nature of this problem. On occasion even our more modern theatres can give rise to difficulties so far as concerns audiences, and even more so for those who wish to play their part in working to support and contribute to artistic productions. But our Victorian theatres obviously present particular difficulties in this respect. Suffice it to say that we welcome initiatives such as the Civic Trust Access Award sponsored by English Heritage. It celebrates the provision of successful access to historic buildings and sites. The winner this year—an entirely appropriate choice as regards our debate this evening—was the Royal Court Theatre. It has achieved a successful reconciliation of meeting the access needs of disabled people within the conservation requirements of a very historic building.
It can be done, although a great deal still needs to be done to ensure access for those who wish to attend our great and exciting productions. However, the noble Baroness also pointed out that access must also be provided for those who wish to earn their living in support of theatres. At the present time, the restrictions and limitations of the backstage, to say nothing of the problems for audiences, all serve to inhibit the proper participation of certain categories of disabled people. They cannot play their full part in, our performing arts.
In his contribution, the noble Lord, Lord Addington, pointed out that the development of legislation is conducive to our making signal improvements over the forthcoming months and years. The full implementation of the Disability Discrimination Act 1995 will support our approach in

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the arts. The legislation will establish comprehensive and enforceable civil rights for disabled people which would necessarily include access to the arts. We support a requirement of the interpretation of the law that it should not be seen as the bare minimum, but rather a provision that is generous and made in the best spirit. Contributions to the debate from all sides have indicated how important it is to establish "best spirit" in terms of the will to achieve improvements in this area.
Noble Lords also made it clear that disabled people participating in the arts should achieve full equality in pay. That ought to go without saying. We all know that it is possible for people to discriminate unfairly and that challenges have to he made through tribunals of all kinds and even in the courts. However, let us make no bones about the fact that the whole thrust of the Government's position with regard to employment law seeks to ensure that pay inequalities which are unjustified in terms of people's competence to fulfil their role must be rooted out.
I very much appreciated the references made by the noble Baroness, Lady Wilkins, to those theatre companies which have made special contributions to the advance of the cause of the disabled in the arts. I refer to the CandoCo theatre company, the Graeae Company and the Heart'n Soul company. All are immensely talented and innovative companies being led by disabled people. They clearly demonstrate that excellence need not be compromised. As the noble Baroness pointed out, they are not concerned with the issue of condescension; indeed, they show how past expectations are now being dismantled, thus helping to ensure that disabled people can play their full part.
However, the performing arts are notoriously competitive and provide a precarious profession. That does not alter our aim to equalise opportunity for all, but education and professional training are key factors in achieving that. The Special Educational Needs and Disability Act 2001 significantly amends the Disability Discrimination Act—a point identified by the noble Lord, Lord Addington—and places new duties on providers of post-16 education. Some £172 million has been allocated for the years 2002–04 to support the implementation of new post-16 educational duties, although no doubt it will take some time for the funding to work its way through.
Perhaps I may make the obvious point that access to higher education requires people to meet certain standards for all courses. People must prove themselves competent before they engage upon a course. However, the thrust on all sides during our debate suggested that there should be no arbitrary and unfair discrimination against the disabled; far from it. It should be recognised how much disabled people can benefit from courses which perhaps may need to be tailored to their specific needs, but which still meet the requirements of the HE institution. I was grateful to the noble Baroness, Lady Wilkins, for identifying those courses which are at the forefront of increasing
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opportunities for disabled people to be trained in areas in which their capacity for playing their part in the performing arts will be enhanced.
In their broader objectives, the Government are seeking to place 50 per cent of young people on higher educational courses beyond the age of 18. It would ill fit that objective if we failed to ensure that those who suffer from disabilities were not given the structures and proper consideration that enabled them to participate as much as possible. So we look forward to educational opportunities expanding in those terms.
I turn to the issue alluded to by my noble friend Lady McIntosh and also by the noble Baroness, Lady Wilkins; that is, the way in which disabled people are portrayed in the media. It is another factor in improving the involvement of disabled people at all levels across the arts, but it is not a question of gestures and tokenism. What is required is the sustainable and meaningful involvement of professional disabled people. That needs to be encouraged and we ought to take advantage of those who triumph over considerable difficulties and go on to establish themselves as role models, serving as an enormous encouragement to the next generation coming along.
A fine example of creative and innovative means of raising issues of disability awareness and representation is the disability rights campaign, Actions Speak Louder Than Words. It has at its centre the film "Talk", which portrays a society where non-disabled people are a pitied minority and disabled people live full and active lives. The film moves away from the traditional approach to disability awareness with excellent results. It won the best short film award at the Third Rushes Soho Shorts Film Festival and will be used as part of the national curriculum as of 2002. It is already being used as part of the disability awareness programme of companies such as British Airways, the BBC, the Halifax and many others.
It is important that we get through the performing arts positive role models and a representation of disablement and the way in which difficulties can be overcome, a point alluded to by my noble friend Lady McIntosh.
The noble Baroness, Lady Anelay, referred to the European Year of Disabled People. While the picture in the United Kingdom is not perfect—as has been amply identified in the debate—we do have a lot of good news. It is important that we share these achievements both within this country and beyond—for instance, the Royal Court's achievements in reconciling access to historic buildings; the Graeae Theatre Company's successful collaboration with the English National Opera Baylis on educational outreach projects. The significant initiatives we have taken show that this country intends to be at the forefront of achievement in the European Year of Disabled People in 2003. We want to be in a position to indicate how much progress has been made in the United Kingdom so far as concerns disabled people and their employment in the performing arts.
Proper concerns have been raised about the way in which disabled people are treated in our society at the present time. On previous occasions the noble

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Baroness has chided me for my inability to appear as a renaissance man covering a wide range of departments and I am going to let her down today. I am not sure that I can deliberate with her in great detail in regard to benefits and the disabled. She will recognise the Government's commitment to providing to our disabled fellow citizens sufficient resources to enable them to play as full a part in society as possible. This is against a background of public will for recording an increase in achievements in this area.
I do not underestimate the breadth of the problem or the complexity of the issues which confront us. We have talked today about a very important but very limited area of employment. We all recognise that the performing arts can play a symbolic and significant role in communicating to the wider nation the need for improvement and change—and how that change could be effected to the benefit of disabled people—but, nevertheless, we as a society have a very long road to tread. We may congratulate ourselves—as I believe the noble Lord, Lord Addington, was prepared to concede—on having certain crucial aspects of the legislative programme in place, but that is still some way from the effective discharge of the functions required under the law and the improvements flowing from it.
Lord Addington: My Lords. I tried to indicate that the easy part will be the passing of legislation. The difficult part will be chasing it up and making sure that it is used.
Lord Davies of Oldham: My Lords, the noble Lord is right—although most of us do not find passing legislation particularly easy, certainly not from the Dispatch Box on this side of the House. But the noble Lord is right, implementation of the legislation will present extra challenges.
Barriers to the employment of disabled people are not acceptable to the Government, in this field or in any other field. We are working to break down barriers and to promote opportunities for everyone in society, including in the arts. I am grateful for the opportunity to engage in the debate on this issue, which was so successfully introduced by the noble Baroness, Lady Anelay. The Government acknowledge the part that they have to play in advancing the issues we have discussed today.
Lord Filkin: My Lords, I beg to move that the House do now adjourn for three minutes until 8.48 p.m.
Moved accordingly, and, on Question, Motion agreed to.
[The Sitting was suspended from 8.45 to 8.48 p.m.]

National Health Service Reform and Health Care Professions Bill
8.48 p.m.
Consideration of amendments on Report resumed.
Clause 6 [Local Health Boards]:
[Amendment No. 11 not moved.]
Clause 8 [Funding of Primary Care Trusts]:
[Amendments Nos. 12 to 14 not moved.]
Clause 9 [Funding of Local Health Boards]:
[Amendment No. 15 not moved.]
Clause 10 [Expenditure of NHS bodies]:
[Amendments Nos. 16 and 17 not moved.]
Clause 11 [Duty of quality]:
[Amendments Nos. 18 to 23 not moved.]
Clause 12 [Further functions of the Commission for Health Improvement]:
[Amendments Nos. 24 to 26 not moved.]
Baroness Finlay of Llandaffmoved Amendment No. 26A:
Page 18, line 17, at end insert—
"( ) The Commission for Health Improvement shall present annually its report to the health joint select committee."
The noble Baroness said: My Lords, I understand that Amendment No. 30 has been grouped with Amendment No. 26A.
This is a probing amendment to ask the Government how they propose to monitor the inspection bodies and how that monitoring might be conducted. When the issue was previously debated, on 21st March, the Minister helpfully explained that a Select Committee of both Houses must be established by Parliament and it is not appropriate to seek in a Bill to suggest to Parliament how it should operate. I am most grateful to the Minister for that helpful clarification.
However, time has moved on rather rapidly, as we have already heard tonight. The document Delivering the NHS Plan has been published. As others have already said, it suggests that discussion on the Commission for Health Improvement may by now be obsolete as, to quote the Minister, time moves on. The Commission for Health Improvement is to be brought into the proposed independent single new commission for healthcare audit and inspection, or CHAI, with a longer pronunciation on the vowel sound. This new single commission is to publish an annual report to Parliament on national progress on healthcare and how resources have been used. A similar new single inspectorate for social services is also to be formed from a merger of the Social Services Inspectorate and the National Care Standards Commission. This commission for social care inspection, or CSCI, will also publish an annual report to Parliament on national progress on social care and an analysis of where resources have been used.
Given that the two bodies to be incorporated into those two new inspection commissions currently cover England and Wales, it is very important that there should be a capability to question those bodies in detail. As devolved arrangements will structure NHS services differently, it seems essential that the bodies can be quizzed in detail about their findings. It is also important that they can be questioned as to evidence

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of their cost-effectiveness, to be sure that they are not imposing an ongoing burden on the health service without proven value for money in their functioning. They should be able to demonstrate clearly that it is they who are driving up standards, as opposed to research findings and other developments that occur in healthcare, which may independently be driving up standards—to return to a phrase that I have used previously on research, confounding variables that may give the same result.
Apparently, legislation will be needed to establish those new commissions. So, no sooner will this Bill pass from us than it will be amended by further legislation hot on its heels. Under that proposed legislation, both CHAI and CSCI are to be more independent of the Government than their constituent bodies have been. The aim of Amendment No. 26A is to explore whether a committee of both Houses might be established in the interim. Such a committee would need to have representation from all four parts of the United Kingdom to consider issues that are partly or fully reserved functions.
The purpose of the amendment is to probe the exact mechanisms whereby debate may be had to establish such a committee that could examine the reports delivered to Parliament from the inspectorate bodies. I beg to move.
Baroness Noakes: My Lords, it appears to be for the convenience of the House that I speak at this point to Amendment No. 30, although, as noble Lords will find out, it addresses slightly different issues from those that the noble Baroness has just addressed. I shall continue nevertheless.
Amendment No. 30 deals with the independence of CHI, which we debated briefly in Committee. Since then, we have had the Government's White Paper, Delivering the NHS Plan, in which they set out their proposals for the new commission for health audit and inspection. One aspect of that new commission is that it will be more independent of government than the Audit Commission, CHI or the National Care Standards Commission. Commissioners will be appointed by the independent appointments commission rather than by Ministers. We were delighted that the Government are moving towards recognising that greater independence for such bodies is desirable. The Minister resisted the idea when we discussed a previous amendment.
I shall not go through the details of the amendment, which would make changes designed to create greater independence for CHI. I shall highlight just two of them. The amendment would amend Schedule 2 of the Health Act 1999, which set up CHI, taking away the Secretary of State's powers of direction. If we are trying to devise a genuinely independent body, giving the Secretary of State massive powers to tell it what to do will negate that independence.
In Committee, the Minister made much of the effectiveness of CHI's work. We have no wish to criticise its work. Nor do I claim that there are
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instances of CHI's work not appearing to be independent. However, we know how insidious powers of direction in the public sector are. Everyone in the relationship—CHI, its chairman, its chief executive, the Department of Health, its staff, the Secretary of State and others—knows that the directions are there. The powers colour the relationship even if they are not used. In effect, they undermine independence.
I could not say that I was truly independent if someone else had the power to tell me what to do. Much of the way in which relationships are conducted between bodies such as CHI and departments is about subtle inflections. We can be sure that the relationship recognises who ultimately pulls the strings.
Financial independence is another aspect of independence. That is why subsection (2)(e) of the proposed new clause would take away the Secretary of State's discretion as to how much he pays CHI. If someone else determines how much money I get each year, that person determines what I can do and, more importantly, what I cannot do and I am not independent. The same is true of CHI. The 1999 Act simply says that the Secretary of State will give CHI what he thinks is appropriate. It is important that CHI should be given what it needs to carry out its functions. There should be an open and transparent discussion about the amounts needed. CHI should not have to come with a begging bowl to see what scraps the Secretary of State chooses to throw in. There should be a more equal relationship, based on what CHI needs to do.
The Government have announced their additional independence proposals for the new inspection and audit body. The amendment would accelerate that process of independence for one important component of the new body—CHI. I hope that it commends itself to the Minister, as it is now fully in line with government policy.
9 p.m.
Baroness Northover: My Lords, I shall speak to Amendments Nos. 26A and 30, which relate to two key principles: the first is to ensure that the NHS, and its inspection systems, are as independent of government as possible; and, secondly, that the NHS, and those working within it, must ultimately be answerable to Parliament. Amendment No. 26A talks of CHI answering to the health Select Committee of both Houses of Parliament. We are also putting forward this idea in relation to the regulation of health professionals, and shall return to it later.
If the Minister responds by saying that he believes this proposal to be impossible—or even premature—I shall point out that his newest document speaks of reporting annually to Parliament,
"on national progress, on healthcare and how resources have been used".
Something tells me that his line in consistency is, once again, bringing him closer to us, which I welcome. Similarly, we have argued for the greater independence

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of CHI and—lo and behold!—we see in his document that his new merged creation that will incorporate CHI is to be,
"more independent of government than the Audit Commission, CHI or the NCSC".
My feeling is that it is time to go home, while we await the Minister's new proposals that will shortly supersede all that he has been arguing for here.
Lord Clement-Jones: My Lords, I welcome the fact that the Secretary of State appears to have accepted that accountability for clinical governance and performance standards should be separated from the management of the delivery of healthcare. Currently, when it comes to inspection and bodies like the Commission for Health Improvement, the Secretary of State still calls the shots on the criteria by which hospital trusts are to be judged. But the regulatory system must be publicly accountable and transparent. For that reason, as mentioned by my noble friend Lady Northover, the professional regulatory bodies and the proposed new commission for healthcare, audit and inspection—and, indeed, the commission for social care inspection—should be subject to direct overview by Parliament through a Select Committee, not by the Secretary of State.
From the recent White Paper, to which some noble Lords have referred, Delivering the NHS Plan, it is unclear exactly what the proposed accountability of the new commission for healthcare, audit and inspection will be. As has already been mentioned, the paper states that the new commission will be more independent of government than the Audit Commission. I am sure that many of us will use that as a stick with which to beat the Minister during the progress of forthcoming Bills in an effort to ascertain whether or not that yardstick is being fully applied.
In his current state of grace or knowledge, can the Minister enlighten us as to whether or not the commission will determine the standards and targets to be met without the intervention of the Secretary of State? There are some crucial questions to be answered. I very much hope that the Minister will be able to enlighten us at this stage.
Lord Hunt of Kings Heath: My Lords, I am gratified that the noble Lord, Lord Clement-Jones, believes me to be currently in a state of grace; indeed, that is rather more encouraging than his usual remarks about my position.
The amendments before us are most interesting. They bring us back to one of the essential components of the The Way Forward for the NHS; namely, the Commission for Health Improvement and the health inspectorate, for which we shall bring forward legislation in due course.
I should tell the noble Baroness, Lady Finlay, that it seems to me that we must distinguish between the annual report to Parliament, which forms part of a provision under the Bill, and the separate question as to how Parliament deals with such a report and the work of the commission. It is right to distinguish
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between those two facets because it is not for the Government to dictate to Parliament on how it discharges its functions. That is my essential difficulty with an amendment that proposes the establishment of a Select Committee.
If I am asked how Parliament discharges its own responsibilities, I should point out that it is abundantly clear: through Questions, through debates, and through the work of Select Committees, Parliament is able to question and call in witnesses from the Commission for Health Improvement, and other bodies, and thereby discharge its own responsibilities. However, that is a matter for Parliament to decide.
Having been responsible for some of the organisations about which we are debating—such as the National Institute for Clinical Excellence—my experience is that Select Committees are most interested in the affairs of such bodies; indeed, they have no hesitation in undertaking reviews through which they call in witnesses, including the bodies and those affected by what they do, as well as Ministers. I have no sense of Parliament not being able effectively to scrutinise the work of CHI, and its successor body. My difficulty is that I could not support an amendment that sought to dictate to Parliament the establishment of a specific Select Committee. At this stage of the Bill, I do not believe it is appropriate to take such a move. However, if it were decided, by Parliament to establish such a committee, it would be the duty of NHS bodies to co-operate with it. I have no hesitation in saying that the Government would encourage that process.
I turn to Amendment No. 30. I should point out to noble Lords that one example of the effect of accepting such amendments would be to give the commission the power to deal with matters like remuneration and allowances. I wonder whether the noble Baroness, Lady Noakes, really considers it appropriate simply to hand over that kind of power, lock stock and barrel, to the Commission for Health Improvement. Surely, public accountability and the discharge of the Secretary of State's accountability to Parliament suggest that that matter should rightly fall to the Secretary of State.
We have already made clear—and shall certainly do so when it comes to the health inspectorate—that we expect the commission to continue to operate at arm's length from Ministers, as is the case with other non-executive public bodies. Indeed, it is a key feature of executive non-departmental public bodies that the Secretary of State remains accountable to Parliament for the performance of the body in question. As a vital part of the constitutional arrangements to ensure public accountability, so far the Secretary of State has appointed the chairman and other members of the commission. Clearly, the debate has moved on and, as the noble Baroness, Lady Noakes, suggested, when we announced plans to establish an independent single new health and social care inspectorate, we made it clear that the commissioners of the new inspectorate would not be appointed by Ministers but by the NHS

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Appointments Commission. That seems to me to constitute an acceptance that the new body will have more independence. It is an important step forward.
I now turn to the general direction-making powers which the amendment would remove. We debated that matter in Committee. At that time I made it clear that they were reserve powers. There is no question that they should be used as a matter of routine; but one has to accept that there is always a possibility, I hope remote, that a serious problem could arise in relation to the commission's activity or governance which, for whatever reason, the commission failed to address. Surely it would be right that the Secretary of State, who is accountable to Parliament for how that body acts, should be able to take whatever action is necessary at the time. If an executive non-departmental public body receives funds from the Secretary of State, as is the case with a commission, surely it is appropriate and necessary for there to be some control to guard against financial impropriety and to ensure that funds are applied for proper purposes as set out in the Bill.
However, as I said in Committee, one would expect that kind of intervention to be rare indeed. The whole case behind the Government's proposals and programmes for the National Health Service is to put in place a rigorous inspectorate which is fully independent in the way it conducts its reviews and inspections. There can be no advantage whatsoever in the Government seeking to influence such an organisation in the conduct of those inspections. The whole strategy of the Government depends on having a robust independent organisation undertaking those inspections. It must make sense that, as with all non-departmental public bodies, there are safeguards that allow intervention to take place in what one hopes would be wholly exceptional circumstances where the public interest would demand that that takes place. Having said that, I hope that noble Lords will recognise that we have listened carefully to the arguments; that we are moving the agenda on with the announcement made by my right honourable friend two weeks ago; and that we are committed to a robust independent body to undertake the inspections.
Baroness Finlay of Llandaff: My Lords, I thank the Minister for his reply. I am glad to hear that he found the amendment interesting. He clarified the matter by distinguishing between the annual report to Parliament and how Parliament would deal with such a report and monitor it. He clearly outlined that, under the Select Committee structure, Ministers can be questioned and called to account. I understand from that that he is implying that the questioning on the reports as laid before Parliament would come within the remit of the current Select Committee structure.
Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Baroness for giving way. I was trying to say that it is for Parliament to decide how arrangements will be set in place. I described some of the ways in which currently bodies can be called before
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parliamentary committees. If Parliament decided to set up a separate Select Committee, it would be the responsibility of NHS bodies to co-operate with it.
Baroness Finlay of Llandaff: My Lords, I am grateful to the Minister for that clarification. It would be helpful for the public to be assured of the mechanisms whereby Parliament will rigorously evaluate the inspection processes. The inspection processes will be more distanced from government than was previously the case, as has been set out in the document to which we alluded and which has been quoted.
The question of reserve powers becomes very important as the process of devolution gets further under way. It is particularly important for areas of health services that develop differently to be sure that the inspection bodies are functioning appropriately, independently and at a level of equity in their judgment of services which may be fundamentally different in different parts of the United Kingdom. Certainly, the Secretary of State funds the bodies as they stand, but if there is irregularity or misappropriation of money, I should have thought that the ultimate sanction was to withdraw the funds. That would have to be justified.
The question of influencing an inspectorate has been raised. That is a concern because an inspectorate may find and report on occurrences in the NHS as it devolves that are not favourable to the government of the day and it may also find that the investment of moneys—even new moneys—has not achieved the required outcome. It is for those reasons that this has been an important debate which has emphasised the need to maintain the independence of the inspectorate and the way in which its members will be questioned. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
9.15 p.m.
Baroness Noakesmoved Amendment No. 27:
After Clause 12, insert the following new clause—
"PUBLIC HEALTH FUNCTIONS OF THE COMMISSION FOR HEALTH IMPROVEMENT
The Commission for Health Improvement shall have such further functions as may be prescribed relating to the management, co-ordination, provision or quality of public health services for which prescribed NHS bodies, service providers, local authorities or other bodies have responsibility."
The noble Baroness said: My Lords, the amendment would give the Commission for Health Improvement responsibility for public health services that are operated by NHS bodies and it would allow CHI to investigate a report on how well public health responsibilities were carried out by the NHS.
We have already had a significant debate today on public health—we did so in the context of primary care strategic health authorities and regional directors of public health. Those debates were led by my noble friend Lord Howe and the noble Lord, Lord Clement-Jones. There is one clear message from those debates—that there is considerable anxiety about how well the

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bodies populating the Government's new NHS universe will respond to the challenges of public health.
I have two questions for the Minister. First, will the Government say whether public health is important? I know that that is a "motherhood" question; the Government will of course say that public health is important. However, if that is true, will the Minister say why the White Paper that was issued a couple of weeks ago, Delivering the NHS Plan, made no reference to public health? Some of us found that an astonishing omission.
My second question is harder. How do the Government show that they think that public health is important? My noble friend Lord Howe and the noble Lord, Lord. Clement-Jones, displayed the confusions that lie at the heart of the Government's approach to public health—much rests on untried and untested public health networks which are run by primary care trusts. They are struggling to get the right quality and quantity of staff to handle those responsibilities. Above those bodies are strategic health authorities and regional directors of public health, with overlapping, and to some extent indistinct, roles. Many of us are sceptical about the efficacy of all of that and raise questions about how serious the Government are about public health if they are subjecting it to such a bizarre structure.
The amendment is designed to put some degree of oversight into public health, using CHI as the agent. If public health services are not working under those new structures, we can rely on CHI to say so.
When we discussed a similar amendment in Committee, the Minister said that the term "public health" was not statutorily defined and could be very wide indeed. My response is to say that a wide definition is exactly what the amendment would require. I have no problem whatever with the term bearing its natural meaning and not being artificially restricted. If the Minister has a specific definition in mind, I am sure that noble Lords will be prepared to consider it.
In Committee the Minister gave us some comfort by saying that the Government recognised that there was an issue in this regard. He said:
"the Government are giving serious consideration to how the issues can best be taken forward and to the extent that CHI's remit needs to be revisited in these areas".—[Official Report, 21/3/02; col. 1581.]
Since then. I have not heard or seen anything to diminish our concerns about public health. If anything, the lack of a reference in the White Paper increased our concerns. I hope that the Minister will say that the Government have considered the matter further and that they are minded to agree to the amendment. I beg to move.
Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Baroness for again raising the issue of public health. She asked whether public health was important to the Government. As she would expect, it is very important indeed.
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She also asked how the Government showed their commitment in that area. If we look back to 1997, we can see a long series of actions that reinforce the critical importance of public health to the health of our nation. The list includes the development of area strategies in relation to inequalities in health; the work around sexual health; the issues that have been raised in a number of national service frameworks, many of which, as part of their overall strategy, focus on public health elements; the various targets that have been set; and the development of health action zones. That is a long and impressive list which we shall continue to develop in future. Indeed, I would argue that the Chief Medical Officer's announcement earlier this year of a plan for a health protection agency, which we discussed briefly in our earlier debate about public health, provides another example of how we wish to bring together some of the current national public health functions and co-ordinate them rather more effectively with what is happening at local level.
There can be no question about it: public health is important to the Government. We are confident—we debated this matter at some length earlier this afternoon—that from the arrangements that we are putting in place will come a far more powerful public health function because we have made the essential connection between public health and primary care. As noble Lords will know, I am confident that this is the right area on which to place much of our emphasis.
That said, I understand that the noble Baroness has raised a substantial question which, as I said in Committee, certainly needs to be given careful consideration, particularly in favour of giving recognition to the importance of public health services. As the noble Baroness knows, in Delivering the NHS Plan, we stated that a new commission for healthcare audit and inspection would be established. In the light of our discussions in Committee, we have decided—I am happy to assure noble Lords that this is the case—that we shall give careful consideration to the role that that new commission might have in relation to public health services, particularly where the public health responsibilities of primary care trusts are concerned.
However, the issues are complex in terms of clarifying the range of public health services that might appropriately be brought within the new body's remit, the relationships with both the bodies responsible for those services and those currently responsible for their inspection or regulation, and the legislative consequences arising.
The Bill before the House today gives CHI several important roles. At this stage, I should be reluctant to add to those roles in the way suggested by the noble Baroness without full consideration of the implications. However, I hope that she will accept my assurance that we are giving serious consideration to how these issues can be best taken forward, in particular in the light of our announcement about the new health inspectorate.
Baroness Noakes: My Lords, I thank the Minister for that response. I was pleased to hear that the issue of public health in the context of CHI or of a new commission is still live; that is, it has not been closed down. It is perhaps a matter of regret that the Minister will not accept the amendment now as the PCTs get under way with the new public health functions. As several noble Lords have said today, there must be considerable doubts about how they will work in practice.
Despite the optimism that the Minister has expressed, there are considerable doubts about how the system will work in practice. The ability to inspect the public health functions now would be a good arrow in the armoury of CHI. Nevertheless, I am at least pleased that the Government are still considering the matter, and I suppose that I can only say, "Roll on the next NHS reform Bill". I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 14 [Commission for Health Improvement constitution]:
[Amendments Nos. 28 and 29 not moved.]
[Amendment No. 30 not moved.]
Baroness Noakesmoved Amendment No. 31:
After Clause 14, insert the following new clause—
"PATIENT CHOICE
It shall be the duty of the Secretary of State in carrying out his functions under the 1977 Act to ensure that, so far as it is reasonable for him to do so, persons who receive services under that Act are given a choice as to the time, manner and location of those services."
The noble Baroness said: My Lords, I rise to move Amendment No. 31, which seeks to create a new duty on the Secretary of State to give effect to patient choice. I should not like the Minister to think that my favourite bedside reading at present is Delivering the NHS Plan. However, I shall quote from it again. A whole chapter of Delivering the NHS Plan is dedicated to choice for patients. Paragraph 5.4 of chapter 5 states:
"For the first time patients in the NHS will have a choice over when they are treated and where they are treated. The reforms we are making will mark an irreversible shift from the 1940s "take it or leave it" top down service. Hospitals will no longer choose patients. Patients will choose hospitals".
Amen to that. However, I cannot resist pointing out that the roots of the policy lie in our reforms of more than a decade ago—reforms largely reversed by the Government after 1997. We rejoice that the Government have had a Damascene conversion to putting patient choice at the heart of their policies.
I should like to be able to take more time to explore the mechanisms—especially the financial mechanisms, which seem to be extremely complex—for giving effect to policies such as money following patients. I should also like to be able to explore the technology implications, especially given the Government's failure to date to progress the information
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management and technology agenda within the NHS. However, the key issue is to get the principle of patient choice firmly embedded in the NHS.
When we discussed this amendment in Committee, I had expected a warm welcome from the Minister. Now that the White Paper has been published, I expect a welcome that is considerably warmer than the one I received in Committee. What the Minister said then was,
"I do not think that it would be appropriate to put the matter on a statutory basis. It is much more a question of policy to be decided by the Secretary of State."—[Official Report, 21/03/02; col. 1582.]
The Minister was effectively saying that patient choice might have been the Government's policy, but they wanted to be able to change it at will without the inconvenience of legislation. That seemed to suggest that patient choice was not a wholehearted policy of the Government. However, we now have the White Paper, and it suggests that patient choice is indeed a government policy which should supersede the Secretary of State's whims or transitory will. I therefore invite the Minister to put the issue beyond doubt by accepting the amendment. I beg to move.
Lord Hunt of Kings Heath: I am sorry to disappoint the noble Baroness but, after reflecting on our discussions in Committee, I believe that this is ultimately a matter for Ministers and government policy, rather than an issue to be addressed in the Bill.
It is tempting to have a wide-ranging discussion on the internal market. However, I shall desist from talking about the grossly unequal effect of that market, in which patients of fundholders got a lot whereas the rest of the patients got very little. I shall also desist from talking about the incredibly bureaucratic structure that was put in place. All I shall say is that this is a real commitment to patient choice by the Government. I think that the noble Baroness herself made it clear from her commendable reading of our Delivering the NHS Plan that this is a very important matter on which we wish to make progress.
Essentially, the aim is that, by 2005, all patients will be able to choose the date, time and place of their treatment. Indeed, one of the "must do" targets set out in the NHS Plan is that, by the end of 2005, all patients will be able to receive treatment at a place and time that suits them. This is a clear and public commitment and—through the additional resources that we are making available to the NHS—we are demonstrating that commitment by piloting patient choice from July.
Patients with coronary heart disease will be able to benefit from patient choice. Where a patient has been on an in-patient waiting list for coronary heart disease treatment for more than six months, he will be offered swifter treatment in a different NHS hospital, in the private sector or indeed in another EU country. We are looking to extend the pilots across other specialities

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and in different areas. That is the importance of what we are proposing. We are not simply picking out a few GP practices where the arrangements will be on offer. The intent is that all GPs and all patients will have greater choice.
In view of the record of the previous government, I am surprised that the noble Baroness raised the issue of IT. When one thinks of those IT disasters, it is no surprise that, by the mid-1990s, there was a wholesale loss of confidence within the NHS about major IT projects.
I accept that the NHS has a long way to go in order to get the IT up to scratch in the way we all want. However, I am impressed by the commitment of people in the NHS to make IT happen, and by the success of some recent national projects. There is no doubt that we need to give this matter further attention. There is no doubt that it has to become a priority for the Government and for the NHS. IT systems will be part of the essential infrastructure which will enable us to ensure that patient choice will be a reality.
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I repeat what I said in Committee. I do not consider that this matter should be on the face of the Bill. It is a matter of policy for the Government. We have unequivocally stated our intent in this area and we are committed to making sure that it will happen.
Baroness Noakes: My Lords, I thank the Minister for that reply. I am left with a puzzle. This is a matter for government policy but not a matter for legislation. I am not sure that I know when government policy should or should not be a matter for legislation. The White Paper contains many government policies, some of which are for legislation and some of which are not. I shall have to consult wiser heads than my own and reflect further on the matter. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Lord Filkin: My Lords, I beg to move that consideration on Report be now adjourned.
Moved accordingly, and, on Question. Motion agreed to.
House adjourned at twenty-seven minutes before ten o'clock.