HL Deb 29 April 2002 vol 634 cc496-531

5.38 p.m.

Consideration of amendments on Report resumed.

Baroness Northover

moved 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.

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 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 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. 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 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 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.

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.] 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 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.

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". 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 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 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 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 Noakes

moved 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—

  1. (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
  2. (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.

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 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 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 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 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 Noakes

moved 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.

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 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 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 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.

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. 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 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.

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 Northover

moved 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—

  1. (a) The Commission for Health Improvement, and
  2. (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.

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 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.

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 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 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 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 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.