HL Deb 29 April 2002 vol 634 cc461-84

3.19 p.m.

Report received.

Clause 1 [English Health Authorities: change of name]:

Lord Hunt of Kings Heath

moved 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 Howe

moved Amendment No. 2: Leave out Clause 1. 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".

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 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: 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 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.

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 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.

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 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 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".

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 Howe

moved 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—

  1. (a) improve the health of members of the public within its area; and
  2. (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 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 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.

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.

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 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 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 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.

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 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.

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 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.]