NATIONAL HEALTH SERVICE AGENCY FOR ENGLAND

HL Deb 14 March 2002 vol 632 cc974-1010

(1) There shall be a body corporate to be known as the National Health Service Agency for England (referred to in this Act as "the English Agency") for the purpose of carrying out the functions transferred or assigned to it by or under this Act.

(2) The functions of the English Agency are performed on behalf of the Crown."

The noble Baroness said: Before I speak to my amendments, I declare an interest as a board director of Huntsworth plc, as an associate of Quo Health, as an unpaid chair of St George's Medical School, and I am involved in a number of charities, also unpaid.

In moving Amendment No. 1, I shall speak also to Amendments Nos. 2 to 6. I do so with great optimism. I have no doubt whatever that the Minister will embrace them with the fondness of a familiar friend. In his former life as chief executive of the NHS Confederation, the Minister promoted a similar model. I am not looking backwards; I am looking forwards and seek to modernise. The purpose of the proposed new clauses is to remove politicians from the direct management of the NHS and to set up an agency for that task.

Let me begin with a quote: The public want accountability but are not very keen on the fact that the responsibility for it lies with the elected politicians, whom they don't altogether trust". The words are not mine but those of Mr Paul Corrigan, written only last summer, in regard to a new model for the NHS. Members of the Committee who are Whitehall watchers will know that Mr Paul Corrigan is now the special adviser to the Secretary of State—and all noble Lords will surely be aware of how special a special adviser is.

So, with a bit of luck, I could have the support of the Minister and the Secretary of State's special adviser. Better still, I know that I have the support of the noble Lord, Lord Desai, who is an internationally distinguished economist and sits on the Government Benches. He is launching a special and important hook tonight. His book contains well over 300 pages, and I am sure that it will be read in academic circles and beyond. I am grateful to him for being here today and supporting these amendments.

I also have the support of the twin Baronesses of Llandaff, if I may call them that. Llandaff is clearly a place of great resource and sagacity. They also have put their names to these amendments. That is very important to me because the noble Baroness, Lady McFarlane, was the first professor of nursing in the UK and has been an outstanding leader of nurses, and the noble Baroness, Lady Finlay, is a medic with an international reputation in the field of cancer care. In tabling these amendments, I was anxious to obtain the support of health professionals because I believe that health professionals really know the consequences of political interference, and, of course, there is nothing more compelling than personal experience.

It is true that politics and politicians have never been able to sustain the reputation for goodness. But political input into the NHS is, of course, necessary, since the wise men from the Treasury bring the great and essential gift of money. Therefore, political accountability is a major issue. However, politicians are handicapped. They have to run the NHS in four or five year races between elections. That in itself is incompatible with managing a huge and complex organisation. The dash to do something when targets are not met or when things seem to go awry is irresistible. As the press cuttings mount, the panic increases and another ill-thought-through initiative is directed through the system, another reorganisation of the management, as if that will solve the problem.

As the noble Lord, Lord Clement-Jones, said at Second Reading, health Ministers have gone into initiative overdrive, and the right reverend Prelate the Bishop of Birmingham pleaded for the NHS to be left alone. That view was echoed by the former Secretary of State, the right honourable Mr Frank Dobson, who recently wrote in the February edition of the Nursing Standard: Most people in the NHS don't want another round of management reorganisation. They want to be left alone … By the time I ceased to be Health Secretary, I realised that NHS management and staff needed more discretion to be able to respond to the varying needs of local patients, make best use of new methods of working and new equipment and play to the strengths of local clinical teams". I think it is sad that he did not stay a little longer.

Effective managers know that successful change is brought about not by endless tinkering with the systems but by inspiring leadership and well-motivated staff. Real change has to be effected from the bottom up. What really matters is what doctors, nurses and managers do, how they are trained, how they are motivated, what they feel about the world; and at the moment it is not good.

I suspect that the Minister will know from his many travels around the country that NHS managers have had to re-apply for their own jobs sometimes five or six times in 10 years. As a result, too many of the best find something better to do and leave. We are losing a whole cohort of experience, knowledge and wisdom from the NHS.

When the NHS trusts were introduced they were an innovation; they devolved power. I remember that as a former regional chairman I considered that my most important role was to seek out the best people to chair those new trust boards and to ensure that the non-executives would make a significant input, bringing wisdom, knowledge and a wider perspective to the management of those boards. We were successful, too. We appointed the noble Baroness, Lady Hayman, to chair a trust, the noble Baroness, Lady Dean, to be a non-executive, and the noble Baroness, Lady Jay, to be a member of a health authority, to name but a few. It was very important for us to get the best people, because the chairs and the trust boards appointed the chief executive and the management team. The boards made the strategic decisions, and when things went wrong the chairs fell on their swords.

That has now changed. Today the word "trust" is a misnomer. Trusts are not to be trusted. The trust boards do not appoint chief executives—Ministers do. When things go wrong, Richmond House sacks the chief executive by e-mail. Even the department is not trusted. Decisions are taken by the Cabinet Office special advisers, unseen people known only to the most high.

The clauses that I move today do not further disrupt the delivery of services to patients. They do not give birth to another quango. Rather, they are there to build a new relationship between patients, politicians and NHS staff. They are about transferring one part of the organisation into a different position, transferring those powers and responsibilities.

The amendments that I propose are mirrored in the clauses to be moved by the noble Baroness, Lady Finlay, reflecting the Welsh dimension. My first amendment inserts a new clause before Clause I of the Bill. That clause establishes a new corporate body, to be known as the National Health Service Agency for England, whose functions are performed on behalf of the Crown.

The second proposed new clause sets out the composition of the agency, with 12 members, a chairman, a deputy chairman, five non-executive members and five executive members. The chairman of the agency will appoint a chief executive, the appointment to be approved by the Secretary of State. That follows the pattern of other agencies and seeks to get the commitment of both the board and the Secretary of State. Without the confidence of both those parties, the chief executive could have no hope of success. Since this body will be pivotal in managing the NHS, I have given the Secretary of State the power to prescribe its constitution by regulation.

The third proposed new clause describes the functions of the English agency and gives power to the Secretary of State to amend the functions through affirmative regulations and to give directions on strategic matters relating to its functions. The fourth new clause concerns the transfer of property, rights and liabilities necessary for the discharge of its functions. The fifth concerns the financing of the agency and its accountability for the spending of public money. The sixth and final clause ensures that the agency is accountable to Parliament. It will be open to the committees of both Houses to scrutinise the agency's activities.

In drawing up these clauses, I have taken a great deal of advice, and I am grateful to all those who have helped me—not least the King's Fund. However, I am under no illusion that they are probably imperfect and could be improved. Therefore, my purpose today is not to produce a blueprint but to keep the King's Fund initiative going and to instil in people's minds the fact that there is another way, a third way, a better way to run the NHS.

This is not new territory. There are a number of models, such as the Higher Education Funding Council for England, the Medical Research Council, the Food Standards Agency, the Audit Commission, the BBC and so on, which could be adapted. Every one is unique and tailored to its purpose, but that should not prevent Ministers and the department from using their immense skills and imagination to do the same for the NHS. As the Chancellor of the Exchequer showed the nation when he gave away Treasury powers to the independent Bank of England, the political will is necessary.

When the King's Fund produced its report, the response in the national media was amazing. The headline in the Independent, above an editorial by Donald Macintyre, was: If only politicians could keep their hands off the NHS"; in the Evening Standard, Politicians are crippling NHS, warns Lord Haskins"; and on the BBC website, Ministers should stay out of the NHS". I could quote many more examples. This is a very popular initiative among the public. It is even more popular among those who work in the NHS.

In summing up, I want to be fair to politicians but governments have a pretty disastrous record of managing organisations. They are poor at it because the majority of them have no experience. I exclude the Minister, who has very successfully run an organisation with a commercial element to it, but that is an exception and he is exceptional. Politicians have to work within an impossible electoral cycle, and they are nomadic. Ministers and Secretaries of State do not last, so there is no continuity. On Second Reading, my noble and learned friend Lord Howe of Aberavon told the story of a civil servant who had worked for 17 different departments for 43 Ministers, but always in the same room.

The speed of change in medicine is a huge challenge, and change needs a robust organisation to manage it. My amendments are a first step to a separation between politics and health, to take the day-to-day management of the NHS seriously. I am not advocating a private NHS run for profit, but a competent, effective hoard of directors to appoint the best managers—a board that will be accountable to the Secretary of State and to Parliament; a board that will establish and run, on a day-to-day basis, an organisation that suits the needs of the health service, not the imperatives of a manifesto.

The organisation that I am advocating is not one further to disrupt the delivery of service to patients. I ask all noble Lords, and Members of another place, to look deeply at the performance of politicians, and at the political system, as to its suitability and effectiveness in running the NHS; and to ask the following questions. Do we have a health service that befits the fourth largest economy on earth? Is the taxpayer getting value for money? Is each person getting what he or she needs from the National Health Service? After a period of introspection, perhaps we the politicians ought to have the courage to fall on our swords and leave the detailed management of healthcare to others. I beg to move.

Lord Desai

It gives me great pleasure to support the amendment moved by the noble Baroness, Lady Cumberlege, to which I have attached my name. I thank the noble Baroness for the free publicity that she gave to my book. As I explained to my noble friend the Minister, if the debate continues for a certain length of time, I may have to leave the Chamber. I am slightly more liable to be blamed there than here for what I have done—so I had better own up now.

It is also a pleasure to participate in this debate because my political career reached its height when I was shadowing the noble Baroness in this place. Since that time I have occupied positions further and further away from the Front Bench on this side of the Chamber. That serves me right! I should add that I was present at the creation of this proposal. The noble Baroness put forward the idea at a dinner organised by the noble Lord, Lord Patel, at the Adam Smith Institute, where we freely and openly discussed the sort of problems faced by the National Health Service and what we could do about them.

One of the better aspects of the second term of the Labour Government is that we are now engaged in a very open debate about the problems of the NHS. That is very healthy. After all this debate, we may decide to make lots, or very few, changes but we are in the process of examining it very critically. At the dinner to which I referred, the noble Baroness suggested that perhaps we should set up an independent agency to run the NHS, but—lo and behold!—the King's Fund put forward the same idea soon afterwards. That is very impressive, because my noble friend Lord Haskins, who knows a good deal about red tape, regulations and running businesses was chairing that committee at the time.

I remember Nye Bevan saying with some pride that a clattering bedpan in any hospital should shake the Secretary of State for Health. That is the most absurd model of running a corporation that I can think of, although no doubt it was said with the best intentions. Perhaps we thought in those days that a totally centralised and totally politicised institution was the best way to run the NHS. You certainly cannot sustain that model today. That was illustrated rather tragically when we had this bit of a to-do in another place about Mrs Rose Addis, whose problems were discussed at Prime Minister's Questions and featured on national television in a manner whereby all sides seemed to be guilty. That should never have happened.

It is, indeed, a puzzle. Food is perhaps as important as health, if not more so. If I manage to pick up half a dozen rotten eggs at a Tesco store, my MP does not have to ask the Prime Minister what he will do about it with immediate effect. Those problems are not seen to be ministerial problems; they are seen as problems that have to be sorted out in some other way. We must have reached the stage by now when we ought set up a model of the NHS, without giving up any of its fundamental core principles. As the noble Baroness emphasised, this is not a scheme to privatise or to change in any way the nature of the NHS: the object is to improve its management.

Therefore, we need to ask ourselves whether it is now time to depoliticise the running of the health service. Obviously, politics will be in command. There would be a Secretary of State for Health to take care of the strategic thinking and the Treasury would have to provide the money, but we still need a new model. Of the new models that are available to us, I should like to commend the example of the Higher Education Funding Council. I presume that I should declare an interest at this point because, as an academic, I am a victim of the HEFC. Nevertheless, it is a good model because it receives money from the Treasury and then allocates it to higher education institutions under various clearly transparent criteria. The advantage of having such a model would be the depoliticisation of the NHS. To that extent, it would preserve the morale not only of the people who work within the health service but also—I refer back to the case of Mrs Addis—that of the patients who use the service. We should never again find ourselves in the situation where, for whatever reason, patients become political footballs.

For me, the crucial amendments are Amendments Nos. 2 and 3. I very much admire the precision with which the noble Baroness has laid down the functions of the proposed agency. However, I should like to make one further point as regards a further function that the agency might be able to carry out—one that it would be difficult to perform under the present system. One of the major problems with the present system relates to a sense of ownership. We must give patients a sense of ownership of their National Health Service in two senses: first, they are taxpayers who provide the money for the service; and, secondly, they must take responsibility for their own health. People should take care of their health, with the help of the NHS; but, at all times, they should feel that this is something that they own.

One of the problems with the present over-centralised and over-politicised system is that it is difficult to cultivate that sense of ownership because party politics ultimately interfere in the way in which the NHS is seen to be run. I commend the amendments to the Committee. I very much hope that my noble friend the Minister will make a very short speech and say, "Agreed".

5.30 p.m.

Baroness McFarlane of Llandaff

I rise to speak to Amendments Nos. 1 to 6 standing also in the names of the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Desai. I was delighted to be able to add my name to theirs.

At Second Reading, I listened with great interest to the speech of the noble Baroness, Lady Cumberlege. It seemed to me that she was giving expression to the kind of reforms that I had been longing to hear raised throughout my experience in the National Health Service from 1948 onwards—since its inception. I then read the King's Fund report, The Future of the NHS—A framework for debate, which has previously been mentioned by the noble and learned Lord, Lord Howe of Aberavon, as it has by the last two speakers in this debate.

Following the publication of the Government's NHS Plan, the King's Fund brought together a group of considerable expertise and wide experience—senior commentators, academics and practitioners from health and other sectors—to consider the future of the National Health Service. This diverse and experienced group worked under the chairmanship of the noble Lord, Lord Haskins. Their analysis of the problems of the National Health Service reflects my own experience in the service over the years, and I respond positively to many of their recommendations. The amendments that we have tabled would go some way to fulfilling the changes that they suggest.

The King's Fund group identified three inter-related problems: over-politicisation of the National Health Service; excessive centralisation; and a lack of responsiveness to individuals and local communities. That confirms my experience. The report suggests that the key to these problems is enabling front-line staff, patients and the public to assert greater influence over how healthcare is managed and delivered.

I have no doubt that, in the early clauses of the Bill, the Government seek to empower front-line staff and place their expertise at the centre of care delivery. The Bill also seeks greater public and patient involvement. I know that nurses welcome these aspirations. However, I believe that the reforms as set out in the Bill still leave the National Health Service with a political stranglehold on its day-to-day management.

It is, of course naïve to suggest that health could be taken out of politics. While healthcare is provided out of general taxation, there has to be a political will to allocate a budget and to set the broad strategy outlines for the health policies which express the democratic values of the day. The question is not whether the state should or should not be involved, but the nature and extent of that involvement.

The problem with the present system is that successive governments have increasingly been drawn into the operational detail and day-to-day running of the service. The intense political pressure to achieve certain targets has resulted in anomalies such as that recently reported by the National Audit Office when it identified "inappropriate adjustments to waiting lists". I know that nursing staff, for instance, become frustrated and disillusioned when the "star rating" of their trust is reduced and they feel impotent to alter it by their own efforts. The King's Fund report states with some eloquence: The dynamics of the current system draws the Government into taking responsibility for every 'dropped bedpan"! In previous reforms, too much attention has been focused on reforming the structure of the NHS. We have lurched from the tripartite system of the early NHS to the many-layered district, area and regional layers of governance; to hospital trusts and primary care trusts, and the introduction of the internal market. All have been implemented without much analysis of the impact on patients and staff.

I was a member of an area health authority prior to 1976, when I resigned to join the Royal Commission on the National Health Service. I spent three years serving on the commission examining the structure of the NHS, and every layer of staff and the way in which the service worked. More recently, I have been a member of an area health authority and chairman of its complaints committee. I am left with the feeling that we are often busy rearranging the deckchairs while the "Titanic" sinks. The emphasis on structure and adapting to successive new structures saps a great deal of the professional energy that we prize so highly in our National Health Service. The structure does little to liberate professionals to give high-quality care.

This experience, and talking to nurses and many other health professionals, convinces me of the need to create distance between the Government and the NHS, and the need for an organisation working at arm's length from the Government. We have some notable examples of how this can work in organisations such as the Higher Education Funding Council, the Environment Agency, and the Food Standards Agency. Our amendments seek to establish a National Health Service agency for England, and—in the amendment tabled by the noble Baroness, Lady Finlay—an NHS agency for Wales. They seek also to delineate the respective functions of the agency and the Secretary of State. I commend the amendments.

Lord Clement-Jones

I congratulate the noble Baroness, Lady Cumberlege, on introducing this subject. We have already heard three notable speeches. My congratulations are not purely because the noble Baroness quoted from my Second Reading speech—although that is always very welcome.

One of the points on which many of us agree is that the Government's scheme of devolution as set out in the Bill is inadequate. That has been pointed up in the speeches so far. The inexorable centralisation that has taken place in the NHS over the past 10 years will not be reversed by the terms of the Bill as it stands.

We have only to look at the position of the chief executive of the NHS over the years. We had Sir Andrew Foster, followed by Sir Alan Langland, followed by Mr Nigel Crisp. If we look at the way in which each of those individuals carried out their job and the constraints to which they were subject, it is extraordinary how much more centralised the NHS became in that period and how more power has gone to the Secretary of State. The Secretary of State has progressively taken more power over the NHS, mostly in the name of performance management but also in terms of funding. That has been the case in every single area of the NHS. Discretion at local level has been reduced inexorably over time.

A number of previous speakers have referred to the plethora of targets. The taunt which the Government like least is being accused of micro-management. But micro-management is what this Government do. As the noble Baroness, Lady McFarlane, made clear, it leads to a loss of morale. If professionals do not have a discretion to operate and are constantly subject to intervention, that leads to a loss of morale. I agree entirely that the structures proposed in the Bill will not lead to the liberation of the health professions. They will lead to more constraints. In that respect, the Bill is entirely flawed. One has only to ask the question: what will the Bill do to boost the morale of those who work in the health service? The answer is: very little, if anything. Therefore, the grounds on which the amendment is based are extremely strong.

Clearly, any scheme of devolution of responsibility for the NHS must be genuine. The current scheme proposed by the Government actually gives more power to Ministers rather than less. On those grounds, I do not believe that it is a genuine attempt at devolution. For devolution to be effective and genuine, there need to be one or more strong, accountable bodies responsible for health service strategy, supervening between government and local delivery. There also need to be geographical entities with clear and common boundaries, which would enable joined-up strategy with a range of other public services, such as housing, education, transport, environment and social services.

In the view of the Liberal Democrats, those conditions are clearly met by regions. When regional assemblies are created, a further benefit of accountability would be met. Regional health authorities or regional assemblies would have the critical mass to ensure sufficient expertise in specialist commissioning and public health, where the new structures in the Bill give rise to particular concern.

That is one model. There is clearly a need for further debate. I have a great deal of regard for the work of the King's Fund and its recent report, which has been mentioned by all the previous speakers. It is a very thought-provoking piece of work, which does not necessarily exclude other regional models of organisation. In particular, its emphasis on the need for decentralisation of real power to acute trusts and PCTs is important, as is its perception that the NHS is over-politicised, too centralised and lacking in responsiveness.

I am not yet convinced that a single, monolithic, quasi-government body is a great deal better at the top level than the one we have at present. We need to think of a more varied and diverse model. That is why I believe that we should go for the regional model. Directionally, the King's Fund report and the amendments are right. However, in addition to the structure of devolution, there needs to be a clear commitment at the same time to simplification of our structures and of our clinical governance procedures. That would help morale enormously. A great difference would be made not just by the structures, but by their quality and simplicity. On Second Reading I quoted 21 different methods of clinical governance by which health professionals are governed. We have to simplify that to make a difference.

There is a great deal more to debate. The Liberal Democrats have made no bones about our belief that the Bill is premature in the way in which it tries to tackle current NHS structures, introducing a half-baked solution to the issue of devolution and the need to increase the morale and autonomy of professionals and managers. There is a whole debate to carry on. As I said on Second Reading, the Government should take away their structural proposals and allow that debate to continue.

5.45 p.m.

Baroness Carnegy of Lour

It is not clear whether the Liberal Democrats are in favour of the amendment or of the Government's idea. The noble Lord seemed to speak in favour of both sides. Perhaps we should not be too surprised by that—I am not sure.

I was not able to speak on Second Reading, but I listened to a lot of the debate, including the speech of my noble friend Lady Cumberlege, and I read the rest with enormous interest. There is a great deal to discuss on the Bill. My noble friend Lady Cumberlege, who moved the amendment, together with the noble Lord, Lord Desai, and the noble Baroness, Lady McFarlane, who amplified what my noble friend said so ably, have done a great service to Parliament by highlighting the root cause of the mess that the National Health Service is now in. There are many problems, but the root cause is undoubtedly that there is too much involvement of Ministers in the running of the National Health Service.

I am told by people who work in the National Health Service—including some in Scotland, although we are not discussing Scotland—that, as one would expect, the points made by the noble Baroness, Lady McFarlane, are accurate. There is a widespread view among professionals in the National Health Service that that is the problem. People do not talk about the problem out loud because they do not know the answer and they do not want to upset Ministers, naturally. They cannot suggest anything positive, so they do not express that view.

The King's Fund has done a great service in analysing the situation and coming up with a similar idea. I was involved in the universities during the period when they were adjusting to the fact that the Government were not dealing with them directly, but doing so through the funding council. I was also involved with further education colleges when they stopped working directly with local authorities and their funding moved to a funding council. It took a bit of time, but the effect was not far from miraculous. I am sure that the noble Lord, Lord Desai, will confirm that people at all levels began talking realistically, sensibly and responsibly about how they were spending their money and, in the case of universities, how they could preserve academic freedom within that process.

The Scottish funding council is on such good terms with the universities that there are no complaints. Having said that, I suspect that I shall immediately get a shoal of letters, but I have noticed that the universities are really rather pleased with how the system is working. Imagine what a similar system would be like in the health service.

The National Health Service is an enormous organisation, with 1 million employees. It is ridiculous to think that it can be run centrally. It would of course be ridiculous if an agency such as that proposed by my noble friend tried to do that. However, the agency would not have the imperative to do that. The criterion for its success would be that the National Health Service operated gradually better for patients and professionals and that everybody felt freer to run the thing in the right way. The agency would not have to be doing things every day, along the lines of Mr Blunkett's philosophy of "An initiative a day or a day wasted". That is what currently happens in the National Health Service. The system would not depend on new initiatives; it would depend on the ability of the agency to show that it had arranged things in such a way that everybody was taking responsibility better. Then it really would be possible to devolve, because there would he no pressures not to do so. The Government would have no need to be frightened, because under my noble friend's proposals the Secretary of State would be able to place constraints on the agency if he felt that he had to do so.

The proposal should be taken very seriously as a possible way forward. The Government should not find it too difficult. Although they have not come up with the suggestion, it has clearly been rumbling around as an idea in the health service for some time. If the Minister has "Reject" written on his briefing notes, I hope that he will not follow that line, but will stand up like a very experienced man and accept that a lot of wise things have been said—not by me, but by people who know much better than I do what they are talking about—and that the idea should be followed up. I support the amendment.

Baroness Pitkeathley

I am a great admirer of the noble Baroness, Lady Cumberlege, and of the King's Fund, but I am afraid that I am not able to support the amendment. My view, which sounds heretical in the context of this debate, is that there is no getting away from the fact that the provision of healthcare is a political issue. As long as the noble Baroness and others ask questions such as, "Is the taxpayer getting value for money?"; as long as we have a health service that is funded out of general taxation, to which we are all committed; and as long as patients are represented by the political process, we cannot take politics out of the NHS. At least we cannot depoliticise the strategy of the NHS. We can, however, depoliticise the running of the NHS.

The Bill offers us the opportunity to do that because of its emphasis on primary care and putting most of the power at primary care level. We have been saying for years that power in the NHS should be as near as possible to the patient and his or her family. I think that the Bill will do that. Primary care trusts will make it much more possible than ever before to achieve the sense of ownership that the noble Lord, Lord Desai, described, and to help patients become more responsible for their own health. The "inexorable centralisation of the NHS" described by the noble Lord, Lord Clement-Jones, also can be dealt with by devolving power to primary care trusts, where patients will have much greater access and much greater control. That is also what the NHS professionals want. Nowadays, whenever one speaks to NHS professionals, almost all of them—with the exception of one or two old pockets of resistance—say that the real emphasis must be on what patients want. As that is what the professionals want, I think that the proposals will deliver both improved morale and improved delivery.

I have one other concern about the amendment. I hope that, as we make progress on the Bill, because it is an NHS reform Bill, we shall not forget that the NHS is inextricably intertwined with the provision of social care by local authorities and others at local level. Although the point is made explicitly in the unfortunate term "bed blocking", it obviously also arises before the patient is admitted to hospital. In addition to health care provision, social care provision is enormously important. I do not know how the amendment would address that issue, which remains a concern for me. I oppose the amendment.

Earl Howe

My noble friend Lady Cumberlege is to he congratulated on presenting us with such a well-argued set of proposals at the start of our Committee proceedings. I venture to say that few former health Ministers on these Benches command greater respect in the House than she does, and I have no doubt that that respect will extend in full measure to her speech today. For my part, I thank her for steering us towards some extremely interesting and fruitful debating territory.

It seems to me that we can best approach that territory by looking back at recent NHS history. In my lifetime, a succession of structural changes has been imposed on the NHS by governments of both parties. In the 1960s, we had Labour's grand design to rationalise the structure of the NHS under single administrative authorities. We then had the Crossman White Paper of 1970 which proposed an entirely new plan for integrated health services under fewer, larger health authorities. Under the Heath government, we had Keith Joseph's White Paper which proposed 15 regional health authorities above the 90 area health authorities proposed by Crossman. In 1982, the 90 area health authorities were replaced by 200 district health authorities to facilitate better planning and provision of health services at a local level. And so it went on. The aim of all those reforms was the same: to improve the delivery of healthcare to the patient, and to make the system as a whole more co-ordinated and cost-effective.

The language used nowadays may be slightly different from that of the 1960s and 1970s, but in essence the aim of the new reforms set out in this Bill is absolutely identical. I think that the Government would do well to learn a lesson or two from the past. When it comes to health service reform within the existing Bevanite model, there is really nothing new under the sun. We have been here before. Consequently, we have to ask ourselves a rather obvious question. If past reorganisations of the model have not been entirely successful, why should this latest reorganisation fare any better? We are told that—as the noble Baroness, Lady Pitkeathley, has reminded us—the difference this time is the devolution of 75 per cent of the NHS budget to local level. I have serious doubts about the credibility of that claim. However, because I do not want to anticipate our later debates on PCTs, I shall simply say for now that, after so many reorganisations, over decades, it is at least open to question whether the problem facing us in the NHS is not so much the balance of power within the system as the very nature of the system itself.

It is of course the pursuit of that line of thought that has prompted my noble friend Lady Cumberlege to table her amendment. Within a nationalised monopoly, we can shift the balance of power all we like, but at the end of the day it is still a nationalised monopoly. Genuine devolution of power would take politicians out of the driving seat and put patients and doctors in their place. I agree entirely with the noble Lord, Lord Clement-Jones, that, for all the Government's claims to the contrary, this Bill does not do that. Ministers will retain as much power, if not more, to influence the delivery of healthcare as they have ever had in the past.

The Government, understandably perhaps, are sensitive to the suggestion that they have micro-managed the health service. But how else are we to describe the multitude of politically inspired targets imposed on the NHS since 1997? I readily admit that that has happened not just since 1997, but the practice has been put into much sharper focus in recent years. I have no doubt that these targets are, in their own way, well meant. The trouble is that they tend to distort strict clinical priorities. The sickest patients find that they are waiting longer than they should because of the need to treat fewer sick patients within an imposed deadline. Wheels are taken off trolleys so that they are no longer trolleys but beds. The BMA has described the situation as follows: Artificial targets imposed on an overstretched service cannot be met without resorting to ingenious massaging of the figures. It does not fool, nor does it help patients".

Perhaps the most damning recent criticism has come from the former chief executive of the NHS Confederation, Stephen Thornton, who told his annual conference last year that, Labour has embarked on measures to tighten the grip of central control of the service, motivated by a desire to end unacceptable local variations, which has had the unintended consequence of disempowering many at the front line". Of course, as a number of noble Lords have said, that affects morale—which is a point not so far removed from that very well made by the noble Lord, Lord Desai, about the need for a sense of ownership in the health service. In October 2001, the NHS Confederation went on to complain that "target fatigue" was setting in, so numerous were the targets that the Government were setting.

I would be the first to applaud if I felt that the Bill was going to change that situation. I would he the first to welcome a set of proposals that offered the prospect of genuine empowerment of patients and of doctors as patients' advocates. However, the essential structure of the health service will remain unaltered— based, as it always has been, on centralised, top-down control, with extensive powers residing with the Secretary of State. Political appointments will continue. This type of centralised management, although motivated by a worthy desire for uniformity and fairness, costs a very great deal of money. The highest percentage growth in NHS staff in the past five years has not been in doctors or nurses, but in managers. There is a price to be paid for the NHS in terms of bureaucracy and, therefore, of efficiency. The system wastes money. In a service that, throughout its life, has been under-funded, that is a heavy price to pay.

My noble friend's proposition that we should set the health service free from politicians is not new, as she acknowledged. Nor is it free from intellectual hurdles: principally the need to ensure that ministerial accountability to Parliament is preserved to an extent that is balanced and meaningful and, if an NHS agency existed, it would need to avoid the very centralisation and bureaucracy that the present system tends to embody.

The scale of the difficulties in the NHS makes this an opportune moment to revisit the ideas that my noble friend has set out so well and to examine their implications; not least as a backdrop to this important Bill. I hope that in introducing her amendment, my noble friend will have started a debate that will continue to run in and outside this Chamber among politicians of all parties. It deserves our full attention and engagement.

6 p.m.

Lord Hunt of Kings Heath

This has been an interesting and high quality debate. I am sure that we are all grateful to the noble Baroness, Lady Cumberlege, for introducing a subject which, in terms of the balance between local and central, will permeate throughout the debates on the Bill. She has had a distinguished career in the National Health Service and as a health service Minister. From my own experience in the NHS and in the Department of Health for nearly three years, I certainly accept that micro-management of the health service from Whitehall is not sensible or feasible.

I read the King's Fund report with great interest, and there is much in it that I support and commend to the Committee. However, there are some serious issues that need to be put before your Lordships in relation to the specific proposal that the noble Baroness has put before the Committee. I understand the desire to prevent the NHS from becoming what is often termed "a political football". Over many years, several ideas have been put forward of ways in which to organise the NHS to lessen the degree of political influence in the running of the health service. The noble Baroness, Lady Cumberlege, even referred to a paper that I wrote some years ago on this subject. However, that was before I had had the benefit of the extensive re-education provided for me by my officials at the Department of Health. The idea has always been the same: to improve the quality of NHS management by removing it from over-extensive political control. My noble friend Lord Desai, who attached his name to the amendment, is shortly to launch his book entitled Marx's Revenge!

As ever in such matters, I prefer to turn to Bevan and Morrison for encouragement and advice on the balance between the centre, the department, Parliament and the local National Health Service. If one refers back to the extensive debates of the post-war Labour government, one sees the arguments of Morrison, who championed the cause of local government and wanted the NHS to be a local authority service, and Bevan, who rejected that by saying that he thought that such a service would be patchy, and that there would be great inequalities. In a sense, a compromise emerged of a national service run through locally appointed boards. However, as the noble Earl, Lord Howe, pointed out, many changes are taking place to the structure, but essentially that is the model with which we are still running the National Health Service. It is certainly true that over the years there have been many debates as to whether that is appropriate.

As early as 1956, the Guillebaud committee considered this issue. That was a very good report into the financing of the health service. It came to the conclusion that creating a special corporation to run the NHS was flawed. The committee said that, The exact relation of this proposed body … to its minister has never been defined, and it is here that the crux lies. If, in matters both of principle and detail, decision normally rested in the last resort with the minister, the body would in effect be a new department of government … if, on the other hand, certain decisions were removed from the jurisdiction of the Minister (and consequently from direct parliamentary control) there would be need to define with the utmost precision what these decisions were. Clearly they could not include major questions of finance. Nor could any local government authorities responsible for local planning or administration reasonably be asked to submit to being over-ruled by a body not answerable to Parliament".

The noble Baroness, Lady McFarlane, was a distinguished member of the 1979 Royal Commission. Again, the matter raised by the noble Baroness, Lady Cumberlege, was discussed. It said: The establishment of an independent health commission or board to manage the NHS was one of the solutions most frequently advocated in evidence. There are a number of possible models including the British Broadcasting Corporation, the Post Office, the University Grants Committee and the Manpower Services Commission". The commission's conclusion echoed that of Guillebaud. It said: The very large sums of public money required by the NHS would … make some continued parliamentary supervision inevitable. Parliament would, as now, be involved in legislation, the provision of funds and securing financial accountability. The Secretaries of State and the health departments would continue to have major functions, for example in appointing the commission's chairman and members, negotiating the appropriate level of funding and setting priorities and objectives. A commission might act as a buffer between the NHS and Parliament but the NHS would remain dependent on the willingness of Parliament to vote funds. The effect, therefore, might be to duplicate functions that at present are carried out, however unsatisfactorily, by the health departments and the top tier of health authorities". In 1983, Sir Roy Griffiths, in his writings, came to a similar conclusion: A case could be made for an independent corporation … This has a variety of defects, not least that one would have to formalise unnecessarily the role of the corporation vis-à-vis the Secretary of State, which would be extremely difficult in such an intensely politically sensitive operation". The Griffiths report was highly significant in reaching that conclusion because the logic of all that Griffiths wrote in relation to general management was that there should be a separation between the NHS and the Department of Health. None the less, Roy Griffiths, whose expertise I believe has been unequalled in terms of analysing the issues of management in the health service, came to the conclusion that the kind of independent corporation proposed by the noble Baroness was, in the end, untenable.

My understanding is that the final review that took place was an internal review by Terry Banks in 1994 a functions and manpower review. As a result of that the then Secretary of State in the previous government reached a similar decision. I say that not to dismiss out of hand the proposals put forward by the noble Baroness, Lady Cumberlege, because I fully understand and sympathise with where she is going. It is of great interest that all those notable reviews and committees started out sympathetic to the notion, but in the end came to the conclusion that it is not practical to go down that route.

One problem is that those who advocate the removal of the NHS from the political arena have never satisfactorily explained how proper political accountability would be maintained.

There is another reason why one should view this proposal with a great deal of caution. Both the noble Earl, Lord. Howe, and the noble Lord, Lord Clement-Jones, have hinted at it. There is no guarantee that removing the NHS from the purview of ministerial control would remove the risk of over-centralisation. Given that what is proposed is essentially a public corporation, experience over the past 50 years suggests that they tend to be highly centralist. That is not the route down which the Government wish to go.

The noble Baroness, Lady McFarlane, spoke eloquently of the need to take the NHS out of politics. The noble Lord, Lord Clement-Jones, spoke about the risks of centralisation. He did not speak about the impact of parliamentary scrutiny on the oversight and management of the National Health Service. The noble Lord, in his distinguished career as the Liberal Democrat spokesman on health, has asked many questions. He has made many suggestions of decisive firm action that the Government should take in managing the health service. I have yet to hear him ask a question seeking to remove a target or suggest that the department does not set a policy in a particular area. That applies to many noble Lords who speak in our debates on health. The emphasis of scrutiny in your Lordships' House is to press the Government to take further action, to set further targets—

Lord Clement-Jones

Is not the fact that more and more powers are taken by Ministers in this Government precisely the reason why many Members of this Chamber, including myself, are keen to question the Minister?

Lord Hunt of Kings Heath

No, I do not think that that follows. My point is that the inevitable impact of parliamentary scrutiny, given public concern about the National Health Service, is a tendency of Members of both Houses to ask the Government to take further action in relation to the health service, whatever its structure at any one time.

Baroness Carnegy of Lour

The Minister mentioned the Manpower Services Commission. I was a commissioner of that body when I came to this House. The government of the day was scrutinised the whole time concerning what the Manpower Services Commission was doing. I was not always very happy about what the Minister said because I thought that he sometimes knew what the commission was doing and sometimes he did not. But the Government's actions could be scrutinised totally. I would suggest that there is nothing here to prevent that.

6.15 p.m.

Lord Hunt of Kings Heath

The reference to the Manpower Services Commission was in relation to the report by the Royal Commission in 1979. The Royal Commission looked at the model of the Manpower Services Commission and asked whether that would be a suitable one for the National Health Service. It felt that because of the large sums of public money voted by Parliament for the NHS, intense parliamentary scrutiny would be inevitable. Therefore, it felt that that kind of model was not appropriate for the National Health Service.

I do not believe that a national agency, as proposed by the noble Baroness, Lady Cumberlege, is an appropriate way forward. The challenge for me and for the Bill is to identify a structure to enable parliamentary accountability to be discharged, which sets national standards, allows for effective performance management of the NHS—as it must be because the NHS spends money voted by Parliament—while allowing considerable freedom of action at a local level. My contention is that that is what the Government have done.

The emphasis in our first term in office was to set up a national framework in which standards were set through the National Institute for Clinical Excellence, through national service frameworks, and inspected by the Commission for Health Improvement. Therefore, there is a strong set of national standards with an independent inspectorate. The NHS Modernisation Agency can help improve performance at local levels. Within that context, by setting that national framework, one can then allow much more freedom at a local level. That is what the Bill proposes by the establishment of strategic health authorities and principally by ensuring that primary care trusts, which are close to the frontline, have the bulk of NHS resources.

I say to the noble Earl, Lord Howe—and we shall debate primary care trusts in due course—that my view is that, given that primary care is the crucial influence on activity in the National Health Service, devolving the budget to the primary care level makes a great deal of sense. It matches clinical responsibility with financial responsibility. I am convinced that, given the structure at national level, the commissioning of services at primary care level, we have the foundations to produce the right balance between the centre and locality.

My right honourable friend the Secretary of State has made it clear that we are keen to look at current responsibilities and freedoms of NHS trusts. In the future, he wants those trusts that are performing well to have much less intervention from the centre. We are currently developing plans for foundation hospitals, independent not-for-profit institutions with just an annual cash for performance contract and no further form of performance management from the centre, and mutuals or public interest companies within rather than outside the public services and, particularly, the NHS.

The foundation that is set in the Bill will allow that structure to flow. It will, rightly, keep accountability to Parliament for the running of the NHS but will allow much greater devolvement to the local level. That is a better response than a national corporation which—however much I sympathise with the reasons put forward by the noble Baroness—risks more centralisation and tensions between such an agency and Ministers. In the end it would not serve the purpose desired by the noble Baroness.

Baroness Pitkeathley

I offer an apology to the Chamber. It has been pointed out to me that I should have my registered an interest. I work as a very part-time consultant to a company providing nursing and residential care. I should have declared that. I meant no discourtesy to the Committee. I apologise if any was shown.

Baroness Cumberlege

I thank all Members of the Committee who have taken part in the debate. It has been an interesting debate, especially in its historical context. I particularly thank those who attached their names to the amendments.

One of the points made by the noble Lord, Lord Desai—who unfortunately has had to leave—is particularly worth mentioning. It really is fairly disgraceful that the cases of individual are dragged across the Floor of the House, discussed in great detail and then blown up in the national press. No one felt proud of the Rose Alice case. Of course there are others.

That is one of the penalties that we pay when we have politicians so much involved in running the NHS. The noble Baroness, Lady MacFarlane, was absolutely right that it was not a case of whether Parliament was involved, but the nature and the extent to which it is involved and how it should be involved. There should be a greater distance between the Government and the NHS.

I am not trying to negate any accountability, but perhaps I may address the point made by the noble Baroness, Lady Pitkeathley. She said that she felt that one could not take politics out of health. No country's parliament does not get involved in health care but it is a question of degree and how it is done. The noble Lord, Lord Clement-Jones, explained how confusion between the political and the executive has increased over the years. He made a plea for clear and common boundaries. I agree. There are many models that we can explore. The King's Fund, on which I have built much of my work, is the first to say that it must go further and that there is much more work to be done.

My noble friend Lady Carnegy of Lour drew extremely interesting parallels with the way that the further and higher education funding councils and their predecessor, the university grants committee, evolved over the years. We now see universities set free. My noble friend used the word "miraculous". I want to achieve the same for the National Health Service—a miraculous change in its effectiveness, morale and the way it is run.

I thank my noble friend Lord Howe for his thoughtful exposition of the history of the NHS and the lessons to be learnt. He was so right to draw attention to morale and the waste of resources. He was absolutely on stream but we need a strong political and intellectual debate—not just in both Houses but outside.

The Minister said that micro management is neither sensible nor feasible. We agree. But past legislation has intensified it. That is the impression within the NHS. Ministerial teams have consistently bypassed chairs and boards to take direct action in sacking chief executives. If that is not micro management, I do not know what is.

I was grateful to the Minister for referring to past reports. The reports from Guillebaud, the Royal Commission, the Manpower Services Commission and Sir Roy Griffiths were all important but from another age. The Guillebaud report was produced at a time when we still had the vestiges of post-war rationing. That was a very different world. We have to move on.

I worked closely with Sir Roy. I was the only person who sat through all the years of the NHS policy board that Sir Roy established. That board was supposed to serve as an umbrella, to protect the NHS from politicians. It was meant to be an intervening mechanism. At that time Sir Roy felt that there could not be a separate corporation or agency of the kind that I am promoting, but he was a realist. He understood not only the health service but industry, commerce and the wider world. He knew that one could not do everything at once but had to take a step-by-step approach.

The time has come for my proposal to take off. It is an idea of its time. We have many robust intellects within this nation in the King's Fund and far beyond. I do not believe that we lack the wit to devise something that will improve the NHS enormously, help the people who work within it and give patients a much better deal.

Lord Hunt of Kings Heath

The kind of national corporation that the noble Baroness espouses might turn out as centralist as any other feature of the health service's structure through the years. Does she not think that the foundation trusts proposed by my right honourable friend the Secretary of State, which are about creating new types of local organisation, would be given considerably more freedom than current organisations provided they met performance criteria? Does not the noble Baroness accept that that could be a highly successful way of achieving sensible management of the NHS at local level?

Baroness Cumberlege

However the agency or corporation worked would depend entirely on its rules of engagement. The amendment gives power to the Secretary of State to draw up an agreed constitution. Foundation trusts could be set free but for how long? When will there be intervention? When will the Secretary of State decide that a trust's performance is not up to scratch? What will be the criteria? Many of us are concerned that decisions will be made but not according to clear and concise criteria, so that one will not know exactly when the Secretary of State will intervene.

I thank noble Lords for an interesting debate. I shall read Hansard carefully but at this time I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 2 to 6 not moved.]

Baroness Finlay of Llandaff

moved Amendment No. 7: Before Clause 1, insert the following new clause—

"NATIONAL HEALTH SERVICE AGENCY FOR WALES

(1) There shall be a body corporate to be known as the National Health Service Agency for Wales (referred to in this Act as "the Welsh Agency") for the purpose of carrying out the functions transferred or assigned to it by or under this Act,

(2) The functions of the Welsh Agency are performed on behalf of the Crown."

The noble Baroness said: I shall speak also to Amendments Nos. 8 to 12. I declare an interest as an NHS clinician in Wales.

We had an interesting and informed debate on the proposals for England. As the Bill applies to England and Wales, Amendments Nos. 7 to 12 reflect Amendment No. 1.

The border between England and Wales can be considered to be a semi-permeable membrane, with a flow of patients in both directions. So arrangements must allow a reciprocity of provision. The philosophy behind the amendments is summed up in a statement by Tim Rogerson of the University of Wales College of Medicine, who is president of medicine, nursing, physiotherapy, dentistry, occupational therapy, radiography and operating department professionals. He said: I do not want to spend the next 40 years of my career within an NHS that is used as a political football. We need a level of independence comparable to that of the Bank of England. That would allow leadership by the people who actually know where it should go. Without this independence, then our deep-seated loyalty to the NHS will be drastically weakened". Such a sentiment was separately and independently expressed and endorsed at the conference of Welsh LMCs last night. The various short-term, simplistic, political headline targets that we have all seen set for the NHS have failed. Delivery of health care is complex, rapidly changing and subject to global as well as local influences.

There is much that is good in Wales. As the noble Lord, Lord Clement-Jones, suggested, there is much benefit from local consultation, and that occurs. Twenty two local health boards are proposed and, fortunately, they will be coterminous with local authorities—which will provide an excellent opportunity for preventive medicine and long-term care support.

Amendment No. 7 names the body that should oversee health service reorganisation in Wales, functioning on behalf of the Crown to depoliticise day-to-day running of the NHS. Amendment No. 8 outlines the board for the Welsh agency and Amendment No. 9 outlines the fund ions—principally in relation to local health boards. The local health groups have been in existence for two years and are functioning well in what they do but are still learning their role and evolving. They cannot take on the huge number of functions about to be devolved to them and have themselves declared that they are under enormous time pressure to take on those functions.

General practitioners have wanted a primary care directorate in Wales, but agreement to it is now in doubt. The directorates proposed through the Assembly are directorates for renewal, policy, finance, quality, human resources and facilities. The fear is that without a single agency that will result in fragmentation and duplication of work and duplication of decision-making processes. In fact, there will be loss of expertise and of the collective memory. It is the collective memory that safeguards patients. The reorganisation is also resulting in the loss of senior, experienced personnel.

Last night, a motion was passed unanimously at the conference of Welsh LMCs stating the need for a, significant body to handle contractor services in Wales to protect both professional interests and those of patients". An example is the Exeter computer system, which administers patient registration, cervical cytology recall, breast test Wales recall and other items of patient monitoring. The GPC Wales and directors of contractor services are concerned that fragmentation constitutes considerable risk to patient care and loss of continuity in registration of patients and patient records. That is just one system at risk under fragmentation of the system. Several hundred statutory functions currently undertaken by health authorities in Wales will he devolved or taken in centrally—although that remains undecided.

I turn briefly to secondary and tertiary care. The Bill contains enabling clauses. The Minister for Health and Social Services, Jane Hutt, proposed that the National Assembly for Wales confirm key proposals that included strengthening the Specialised Health Services Commission for Wales as the basis for an all-Wales, arm's length commissioning body, commissioning tertiary services and with enhanced capacity to advise, guide and facilitate the commissioning of secondary care. For such a commission to work with local health boards, there is a need for Wales-wide co-ordination, rather than 22 local health boards individually negotiating for secondary care, and to strengthen the Specialised Health Services Commission for Wales for commissioning tertiary and specialist services. Specialist services are provided in secondary care organisations.

The remit for the proposed all-Wales body, and indeed for an enhanced Specialised Health Services Commission for Wales, is still being worked out. It will be essential to ensure high standard, highly specialised services without unnecessary duplication, delivered as cost-effectively as possible. The organisation should then be brought under the Welsh health agency, which as I understand it is possible under the Bill's enabling provisions.

Amendment No. 10 deals with transfer of functions and responsibilities, further to define the role of the Welsh agency. Amendment No. 11 ensures that finance is transferred, with open accounting for the way funding is spent, and that it remains within the strategic framework directed by the Assembly. Amendment No. 12 ensures that the agency reports on its functions and is fully accountable. It will he up to the health committee in the National Assembly for Wales to question how the agency administers its function and ensure that it has evaluated the system of delivery, with outcomes data collected systematically and consistently to expand the evidence base.

Overall, such a Welsh agency would have clearer accountability and protect the service from "reorganisation fever" and resultant "reorganisation fatigue". Seven is a mystical number, deemed to be lucky. There are seven days in the week, seven ages of man and seven deadly sins. The intention behind the amendment is to protect the service from management reorganisation for at least seven years and allow evolution of delivery systems. Meaningful comparisons of outcomes can then be evaluated between the regions of England and Wales. I beg to move.

6.30 p.m.

Lord Thomas of Gresford

I feel rather like Professor Tom Rogerson, who, from what the noble Baroness said, appears to be the professor of almost every speciality. This is the third Bill on which I have spoken this week. We have dealt with education and the police and are now dealing with health from a Welsh perspective. In each case, the English provisions seemed to be trying to give the Secretary of State more and more power and remove a degree of accountability.

In education and health, we in Wales have a far more transparent and accountable body in which decisions can be discussed; in which there is a subject committee on health, for example, that discusses health issues and questions the Minister; where matters can be considered in full plenary session; and so on. My suggestion that the Home Office might like to devolve some powers to Wales was greeted as if it were the end of civilisation by a Minister. That bastion is yet to fall.

In Wales, I am happy to say that in the Bill we have achieved a structure different from that in England and far more satisfactory. I regret that I must oppose the amendment. It was in fact our policy and written into the partnership agreement with Labour in Wales that there should be no further organisational change to the National Health Service, so that we could concentrate on delivering services. To use the expression of the noble Baroness, we were fed up with moving the deck chairs and thought that we ought to do something about the engine and get the ship moving in the right direction.

As the Labour government in Wales in partnership with us wanted to abolish health authorities, we considered those proposals with two principles in mind. The first was a desire to strengthen local decision-making and the second to strengthen an all-Wales strategic approach to commissioning health services, especially secondary and tertiary care. After discussion with the Minister in Wales, the Specialised Health Services Commission for Wales seemed to be a body that could deal with the problems of commissioning specialised health services on an all-Wales basis. We thought that it should have a rather wider remit, providing technical advice and support to the local health boards on commissioning of services, and further independent and impartial advice.

The Specialised Health Services Commission for Wales having been set up and running, it seems unnecessary to put in place between it and the National Assembly, with its open accountability to which I have already referred, a further body—such as that proposed in the amendments—mirroring the English system where the constitutional structure is now so different. Consequently, our view is that the structures in Wales, whereby decisions have been devolved and power placed in the hands of GPs, community nurses and health workers through the local boards, mean that the Specialised Health Services Commission for Wales can deal with the overall, strategic role for which the LMC resolution passed last night seemed to be calling. On these Benches, given the proliferation of acronyms, we have discussed what an LMC is, but I am sure that we shall be told in due course.

While appreciating the spirit in which the noble Baroness moves the amendment—namely, to check the accumulation of powers in the hands of the Secretary of State in England—we consider it inappropriate in Wales and we on these Benches cannot support the amendment.

Baroness Finlay of Llandaff

I apologise for having used an acronym without first defining it. LMC stands for local medical committee. It is the committee made up of general practitioners across Wales.

6.45 p.m.

Lord Roberts of Conwy

First, I congratulate the noble Baroness, Lady Finlay of Llandaff, on bringing forward these proposed clauses. They are similar to those put down by my noble friend Lady Cumberlege. However, there are significant differences. The thrust of the debate has been slightly different. The noble Baroness, Lady Finlay, talked of the need for Wales-wide co-ordination. We have to consider the deliberations of the LMC. There is a need to address the needs of the national dimension of the NHS in Wales. That is why I have some sympathy with the thrust of the new clauses.

There is nothing in the Bill about the Welsh national dimension. The National Assembly and the relevant Minister are symbolic of it but we know little of the detailed arrangements. We know something of the machinery set up to implement the Bill and change the present structure of the NHS in Wales. There is the Minister's own implementation group and a subsidiary group within the NHS directorate. Then there are task forces charged with recommending the shaping of transition in specific areas. All were described well by the right honourable Member for Llanelli, Mr Denzil Davies, at Second Reading in another place.

At col. 251 of the Official Report of 20th November in another place, he said: I have a splendid paper which sets out the structure and the steps necessary for implementation … The paper describes the implementation plan, and 12 bodies will be created to carry it out. We start with something called a 'national steering group' which 'oversees the process of implementation'. That is fair enough, but we then have an implementation group that 'oversees the management of the implementation'. I am not sure what the difference between management and 'the process of implementation' entails". He then talks about his lack of understanding of the jargon and says: In addition to the implementation group, there will be nine task and finish groups. Apparently, they will 'scope' the implementation". Mr Davies complains that he has not heard of the verb "to scope" before. It is all very amusing. His last comment bears repeating. He says: So we start with a process that is followed by the management and then the scoping of the implementation. At the end of the day, when the 12 groups have sat down and done their work, we have 52 bodies plus the Committees of the National Assembly and its bureaucracy to control and administer the health service for a small nation of 3 million people". Assuming that the structural changes go according to plan, what will be the final controlling body at the top which will perform the functions described in the new clauses and possibly others that the Assembly may find necessary? We have not been enlightened on that point. There is nothing much about it in the Bill. Will those nine task groups, the implementation group and the scoping groups stay on and run the NHS in Wales from day to day? All we know is what we heard from the Minister for Health in Wales, Jane Hutt. She said that there was a complex web—I was struck by her description—of bodies at the top of t he NHS in Wales. That was her vision of the future.

It has always been recognised that there are certain aspects of the NHS that are best planned and provided nationally. At the time of the reorganisation in the early 1970s a central body, the common services agency, was set up to provide hospital buildings and technical services. The case for such a national organisation as the most economic and effective provider of certain services remains strong. Many other activities demand uniformity and standardisation which only a national body can supply. There is the purchasing of drugs. The noble Baroness, Lady Finlay, referred to IT. Health and well-being strategies referred to in the Bill will be evolved by local partnerships between the 22 local health boards, local authorities and trusts. Someone has to give direction to those bodies so that there is some identity between the different strategies in different areas.

Devolution of power and responsibility is all very well but it is generally accepted that it has to be supervised, guided and regulated; otherwise there will be an excessive, confusing patchwork. There will be alarming gaps in provision and other defects.

The only further piece of enlightenment that we have had is from the Parliamentary Under-Secretary at the Wales Office, Mr Touhig, in the fourth sitting of Standing Committee A on this Bill on 29th November. He made great play of the fact that, the Assembly views the strengthened directorate as part of the new relationship that will be developed with the NHS. It will ensure that a concerted effort is made at national and local level to deliver local services that provide national standards of care".— [Official Report, Standing Committee A, Commons, 29/11/01; col. 85.] So there is recognition at least that there is a national dimension to the NHS in Wales as well as the local, devolved level. But we have nothing about that national dimension within this Bill.

The biggest hurdle facing the new clauses is that they involve creating another quango, albeit an assembly quango. Some of us will know that the Assembly has a heritage of antipathy against quangos even though the Labour Party has created quite a few in its time—and very good quangos they have been. The Welsh Development Agency and the Development Board for Rural Wales have been greatly valued. The local health boards will be quangos of a kind. However, some form of national agency—perhaps not so much a corporate body, as suggested in the amendments, but on the lines of the agencies with which we are more familiar in Wales—would be preferable to control by politically driven committees. As Members will know, there have already been complaints that Assembly Ministers bypass their official bodies—quangos such as the Arts Council—and exercise personal power and patronage. Furthermore, as Assembly Ministers, they have the right to do so, I understand.

I suspect that the Minister will say that we are all being impatient when we want to see the national dimension of the NHS represented by the Assembly and the Minister and that we should await the draft NHS Bill for Wales, promised in the Queen's Speech, to see the final shape of the NHS. Surely, however, the Minister can give us some idea of the thinking of the Assembly government on such issues and say a little more about that complex web, as Jane Hutt described the arrangements at national level.

Baroness Farrington of Ribbleton

I feel that I have made this point on many occasions when speaking for the Government on policy in Wales. The noble Lord, Lord Roberts of Conwy, asked whose role it was to supervise the Assembly. The position, under the devolution settlement, is that supervising, guiding, monitoring, criticising, complaining and holding to account the Members of the Assembly is the task of those who are fortunate enough to live in the Principality. The Assembly serves them.

I accept the freedom and pleasure that people take from living and working on either side of Offa's Dyke. Those who live on one side do not, at the moment, have the benefit of regional devolution; those who live on the more democratically accountable side of Offa's Dyke do. In that sense, I accept that, for the purposes of social life, work and healthcare, it may be a semi-permeable membrane, as the noble Baroness, Lady Finlay of Llandaff, said. Politically, however, one side is far stronger than the other.

The new clauses would place responsibility for the management of the NHS in Wales in the hands of a new agency set up for that purpose. As noble Lords have recognised, the proposal is similar to those contained in Amendments Nos. 1 to 6. My noble friend Lord Hunt of Kings Heath has just provided admirable evidence and argument as to why an agency for England should not be established. Many of the arguments are similar for Wales, and Members of the Committee will be grateful to hear that I do not intend to repeat them all. I shall concentrate instead on the additional defects in the principle of the arrangement proposed in the amendment moved by the noble Baroness, Lady Finlay of Llandaff, and the other amendments to which she spoke.

The Wales-only clauses in the Bill involve a new assertion of the National Assembly's direct democratic control of its health responsibilities. That point was made by the noble Lord, Lord Thomas of Gresford. The establishment of local health boards in Wales will enable the Assembly to take a major step forward to renewing the NHS in Wales. It will develop the local health group model and will pave the way to achieving the aims of the NHS Plan in Wales, Improving Health in Wales, published by the Assembly on 2nd February, 2001. The proposals for structural change have been the subject of full and open consultation in Wales. The strengthening of local health groups, allied with a new sense of leadership, direction and oversight of the NHS on the part of the National Assembly for Wales, will deliver a key part of the NHS Plan in Wales, namely, an organisation that is strengthened locally and nationally. That will follow the abolition of health authorities in Wales by 31st March, 2003.

Creating an additional health service agency for Wales would pose a serious risk of over-centralisation and would impose a centralised model of control over the whole system. That begins to answer some of the points made by the noble Baroness, Lady Finlay of Llandaff. It is the opposite of what we are trying to create in Wales. The national and local accountabilities and functions are clear. The Assembly will provide strategic direction and leadership on health policies, standards, resourcing and so on. Local health boards, in partnership with local authorities and other key stakeholders, will secure and deliver healthcare in their localities.

To the noble Baroness, Lady Finlay of Llandaff, I say that the Specialised Health Services Commission for Wales will provide specialist advice and guidance, and the Assembly regional offices will maintain a visible local presence and act as a source of information and advice. The noble Lord, Lord Roberts of Conwy, in describing the complex web, was describing a range of groups that were asked to help implement the NHS Plan in Wales. They are completing their tasks and are being wound up. The implementation of the structural reform is now a management-led exercise, run in partnership by the Assembly, the NHS and the authorities. I hope that that clarifies what the Minister, Jane Hutt, meant when she spoke to Peers from all parties.

The role of the Specialised Health Services Commission for Wales is to be strengthened to provide an all-Wales, arms-length commissioning body to deal with tertiary and other highly specialised acute services. The commission's activities will be based on the needs expressed by local health boards and will work for local health boards and the Assembly. Technical advice and guidance for NHS Wales will also be available from the commission. As in England, the real power and resources in the NHS in Wales will move to the front line. From next April, local health boards, involving professionals and patients, will be up and running in all parts of Wales.

The Bill demonstrates the Government's commitment to the principle of devolution. The National Assembly for Wales continues to develop policies that are distinctive to Wales, reflecting different local and national conditions and perspectives. I recommend that the House do not accept the amendment moved by the noble Baroness, Lady Finlay of Llandaff. Were she to feel that she could withdraw the amendment, I should hope that, if she had any further detailed questions, she would not hesitate to seek clarification between Committee stage and Report.

7 p.m.

Baroness Finlay of Llandaff

I thank all those who contributed to this debate and addressed the issues I raised. Perhaps I might briefly respond to some of the comments.

The noble Lord, Lord Thomas of Gresford, pointed out that we have open debate in Wales and have benefited greatly from the National Assembly for Wales. The partnership arrangement opposed further reorganisation and that brought a sigh of relief from within the profession. The Specialised Health Service Commission for Wales should certainly have a greater remit, which is needed to ensure tertiary highly specialised services and secondary care. However, it does not ensure consistency of standards across primary healthcare and the delivery of the statutory functions around Wales with a degree of equity.

The reassurance of a single primary care directorate may solve the anxieties of the local medical committees. The noble Lord, Lord Roberts of Conwy, appreciated the thrust of the debate in Wales; that it is different and that there is a need to ensure national consistency and equity of primary care delivery across Wales.

There is a deep-seated concern that the changes are too far and too fast, and with that uncertainty goes demoralisation. Purchasing drugs and IT systems should be standardised. In a nation of 3 million people we surely could have a single computerised system to ensure laboratory results are available as they emerge from the autoanalyser and as a patient moves between different sectors of the service. We have an information system for clinical oncology developed and run by my trust which is an example of good practice. Unfortunately, it deals only with cancer patients.

I am not proposing a further quango for the sake of it. The corporate body may not be the best solution. But I hope that the debate will inform the NHS Bill for Wales. The noble Baroness, Lady Farrington, kindly replied in detail to the points I raised. The Assembly will be held to account by the people of Wales. The Assembly acts on behalf of the people of Wales. That is why there needs to be clear blue water between the people and the service's daily organisation.

The intentions behind the NHS Plan are to be welcomed and can be achieved by evolution, not revolution. We have severe shortages in primary care among professionals in Wales, and there is concern that primary care professionals cannot take on too much too quickly. I am grateful for the debate and therefore beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 8 to 12 not moved.]

Lord Clement-Jones

moved Amendment No. 13: Before Clause 1, insert the following new clause—

"DUTY TO PREVENT AGE DISCRIMINATION

(1) It shall be the duty of any person or body exercising functions or otherwise providing services within the National Health Service to prevent discrimination by reason of age against any class of persons receiving services from the National Health Service except where clinically justified.

(2) It shall be the duty of any prescribed NHS body to publish an annual statement of the measures they have taken to prevent discrimination on the grounds of age against any class of persons receiving services from the National Health Service."

The noble Lord said: Aficionados of health Bills—that word is not out of place; we have had a health Bill every year since this Government came to office—will recognise that Amendment No. 13 is similar to amendments tabled to each of the previous health Bills. I make no apology for that. One in five of us is aged 55 or over and 42 per cent of NHS resources is devoted to older people. If we do not get our health service right in relation to older people, we are failing horribly not only in human terms but also in the waste of resources.

In the recent past the Secretary of States was quoted as saying, I will not tolerate anything which smacks of age discrimination in the NHS". But the fact is that this Government, to date, have not done nearly enough to prevent it. Before they came into power in 1997 they promised an investigation into age discrimination in the NHS. The grounds for such an investigation were obvious. It was clear that there had been restrictions on heart bypass operations, heart transplants and cardiac rehabilitation for older people. Kidney dialysis and transplants had been refused to patients over the age of 70 and there are no public health fitness targets for those over the age of 65 in Our Healthier Nation.

That is just a snapshot of some of the problems that could have been investigated at the time. But that inquiry never took place. A succession of reports from voluntary organisations and official bodies since 1997 have shown the presence of age discrimination in the health service. The national confidential inquiry into perioptic deaths in 1999 referred to staff shortages and lack of experience leading directly to the deaths of older people.

An Age Concern survey of 1,000 patients at the end of 1999 found that health was a key concern of older people. But its survey of GPs at the same time found that 77 per cent said that rationing on the basis of age was taking place in the NHS. Another report by Age Concern, Speaking Out, which was published in November 2000, showed that ill-treatment and discrimination against the elderly was still rife at that time.

A report published in 2000 by the Association of Community Health Councils on accident and emergency departments demonstrated horrendous discrimination against older people. Elderly patients are rushed to hospital but are then left to wait on average far longer than younger patients to die on trolleys.

The King's Fund report, Old Habits Die Hard: Tackling Age Discrimination in Health and Social Care, was published earlier this year. So it is not just reports of 1999 and 2000 which illustrate age discrimination; the King's Fund report was published earlier this year. It illustrates the belief of senior managers that age discrimination is endemic in the health service. Three out of four senior health and social care managers believe that age discrimination exists in their local services. Help the Aged's recent report, Age Discrimination in Public Policy, is a review of evidence of discrimination and was published this month.

The National Service Framework for Older People by itself is not enough. It is welcome and of course the Government are relying on it as an alternative to legislation. But we need to create a positive legal duty and a positive culture of care. It is not only a matter of resources; above all, it is a matter of respect. That should be enshrined in legislation.

As I have said, we on these Benches have argued on previous occasions, both in respect of the Health and Social Care Act and the Care Standards Act, that such a duty should be on the face of legislation. This Bill presents another opportunity for the Government to accept the need for a clear duty not to discriminate. It is clear that the voluntary approach is not working. Older people are still receiving second rate care. We need to ensure, as a matter of legislation, that training takes place and staff in the NHS recognise the need to comply. I beg to move.

Lord Turnberg

I am sorry that I am unable to support the amendment of the noble Lord, Lord Clement-Jones. I say I am sorry because, in my advancing years, I am second to none in my wish to see age discrimination banished from all walks of life, not least in the health service. So I am right behind, indeed somewhat ahead, of the noble Lord in the principle behind the amendment.

My problem is in working out whether this principle should be on the face of the Bill. I fear that it should not, otherwise we would have to include discrimination on all sorts of grounds—colour, creed, race, religion, all of which are vitally important. Discrimination on any of those grounds is equally abhorrent.

We would have to be clear, therefore, that discrimination of any type is not approved. So, much as I should like to see this provision on the face of the Bill, I regret that I cannot support it.

Baroness Pitkeathley

I too must speak against this amendment, not because I am in any way opposed to age discrimination but for the reasons put forward by my noble friend.

Discrimination of any kind is utterly unacceptable in the NHS. However, amendments to a Bill is probably not the way to ensure that we tackle age or any other kind of discrimination. A framework already exists for tackling this problem in the National Service Framework for Older People. There is already evidence that that is working well for the benefit of older people.

In my prolonged stay in hospital last year, I saw no evidence at all of any kind of discrimination against older people because each patient—at least in my ward in the Middlesex hospital—was treated with dignity, respect and courtesy as well as with clinical expertise, based not on the patient's age but on their clinical needs. How that operates in the ward is not by legislation, but by the training, experience and attitude of all staff. Attitudes are set and changed by committed leadership and example and by staff working in a climate which is so respectful of individual patients that discrimination on any ground is simply unacceptable.

Earl Howe

I have a great deal of sympathy with this amendment. The Government's national service framework for older people, published a year ago, was filled to the brim with sound principles and good, sensible practice. It was widely and deservedly welcomed among managers in the health arena, and indeed in social care. Nevertheless, when one speaks to many people in the health service there is a perception that the legacy of ageist attitudes from the past continues to cling on, if only in odd corners.

I admit that evidence of ageism is elusive and anecdotal. But the feeling emerged very strongly from the recent King's Fund study that unless there are the proper resources and support available for managers trying to implement the national service framework, it would be very difficult to promote and foster what is quite a complex policy on as wide and as thorough a basis as is necessary. Rates of progress in implementing the national service framework vary considerably around the country. The King's Fund argued that motivation to tackle age discrimination would be a great deal strengthened by the creation of a legal requirement to promote age equality. One has at least to stop and listen to that view coming from that source.

Against that backdrop it has to be said that there is even the odd Cassandra taking part in this wider debate. Recently, Malcolm Johnson, who is director of the International Institute on Health and Ageing at Bristol University, expressed the view that the Government's pledge to stamp out ageism in the NHS is doomed to failure because of a lack of staff and resources. For example, he has spoken about the low priority generally given to chronic illnesses and the lack of checks and screenings for older people as evidence that ageism in health care is endemic. He was also quoted as saying that the training of most practitioners contains very little about older people and that in the minds of healthcare professionals there is an inbuilt hierarchy of priorities which is hard to shift. Those are the things which he said stand in the way of rooting out ageism.

I do not believe that I would classify myself as quite such a pessimist because I believe that clinicians and managers are much more alive to the issues of discrimination than they perhaps were a few years ago. But I believe that there is still work to do. We need to involve older people themselves in looking at the various policies which have a disproportionate effect on older people and hear what they think about them. We need to examine those specialist services which are aimed mainly at older people and make sure that there are no unacceptable disparities around the country in terms of access to treatment and support. Incidentally, I wonder how the new NHS structures will facilitate that process of comparison.

I turn to a particular hobbyhorse of mine. We need to look at hospices and specialist palliative care services, where the degree of public funding has been allowed to slip in recent years to levels that make it very difficult for many hospices to continue functioning. I hope that the Minister will be able to give his own insight into these very important issues.

7.15 p.m.

Baroness Thomas of Walliswood

Perhaps I may make a small additional point. The noble Baroness, Lady Pitkeathley, and other speakers, have referred to the need for equal treatment in the sense of equal respect given to patients of different ages. But that is not necessarily what we are talking about here. On a number of occasions we have discussed in this House the problem of ensuring that older people get the right food when in hospital. It is to that kind of thing as well as to those matters raised by the noble Earl, Lord Howe, that those responsible should direct their attention when spending 75 per cent of the funds directed at NHS secondary care. Their influence could be very strong in ensuring that hospital trusts in particular pay attention to the special needs of older people and not so much to the need for respect.

Baroness Finlay of Llandaff

I wish to speak very briefly to this amendment because it highlights an extremely important issue, which is that discrimination against any group cannot be condoned in any way. Sadly, with limited resources, there is always some form of rationing. But it really must not be at the expense of any single group.

Perhaps may take up the point made by the noble Earl, Lord Howe. The hospice service is now providing a core service to patients, which relieves the NHS of some statutory functions, yet it does not even receive 50 per cent funding for the core service delivery of specialist palliative care. It is not frills in the service, but core care for people in need. It is worth remembering that money spent on small items—such as ensuring that patients have the dentures they need, as these are rapidly realigned if they do not fit; that they have the mobility aids that they require installed in their own homes to allow them to get home—could result in cost savings at the end of the day rather than increased expenditure.

Therefore, I suggest that the spirit of the amendment is excellent but, sadly, it addresses age only. There are many other groups within our population who have disabilities of different kinds and who also experience a degree of discrimination or who believe that they are discriminated against. Possibly, the proposed patients' fora and the community health councils, which I am delighted to say we are retaining in Wales, should be charged with ensuring specifically that this type of discrimination does not occur.

Baroness Carnegy of Lour

When the Minister replies can he answer one question for me? In a number of GP practices I know, when one telephones for an appointment one is asked for one's date of birth. Is that usual and what is the reason for it?

Lord Hunt of Kings Heath

From nodding heads around the Chamber, apparently it is quite usual for some practices to ask for that information. I do not know the reason for it. It may be sought as part of the identification. Quite often one is asked for a date of birth, along with the postcode, for identification purposes. I cannot supply any more information on that.

This is a very important debate. Noble Lords have debated the issue of discrimination against older people in the health service on a number of occasions. However, I say to the noble Lord, Lord Clement-Jones, who a few minutes ago was an arch decentraliser, now in a very centralist directional mode—

Lord Clement-Jones

But the noble Lord realises that on devolution of any kind national standards are of great importance.

Lord Hunt of Kings Heath

I am glad for that support of government policy. This is a very important matter. I believe that the government's approach, which is essentially through the national service framework which many speakers have mentioned, is the right way forward. That framework sets out a number of standards for older people. The first states, NHS services will be provided, regardless of age, on the basis of clinical need alone. Social care services will not use age in their eligibility criteria or policies to restrict access to available services". It seems to me that that sets the philosophy under which we expect services to be provided for older people, either in the National Health Service or in social care. It is one thing to say that but it is another to ensure that it happens in practice. The national service framework contains a positive action strategy to ensure that older people are never unfairly discriminated against in accessing National Health Service or social care services. We shall be monitoring compliance with that strategy. In our view, delivering on the national service framework for older people makes the duty to prevent age discrimination in healthcare unnecessary, although of course, I am sympathetic to the overall aim that the noble Lord, Lord Clement-Jones, is trying to achieve.

We have recently completed an analysis of the audits of age-related policies required by the framework. That has shown that age-related policies are normally based on clinical evidence. In nearly all other cases reviews of the policies are being undertaken or action has already been taken.

Noble Lords have referred to the excellent King's Fund report on age discrimination, and as was recognised in that report, there is little consensus or clarity on the meaning and consequences of age discrimination. I have no doubt that more work needs to be done as the NSF programme develops. Guidance was issued to inform the age-related audits of written policy in the National Health Service. Additional tools need to be developed to assist in the auditing of policies on implicit age discrimination and on the national benchmark of access to the services and treatment that are important for older people.

Age discrimination is complex and cannot be addressed overnight. It may manifest itself in a number of different ways—I agree with the noble Lord, Lord Clement-Jones on this. Those ways might include low overall rates of provision of those interventions that are relatively more important for older people, such as hip and knee replacement, cataract surgery, occupational therapy, chiropody, community equipment, assistive technology, hearing aids and National Health Service dentistry, to acknowledge the comments made by the noble Baroness, Lady Finlay. Age discrimination may show itself in low relative rates of access of older people to specialist services compared with younger people or refusal of particular treatments, such as revascularisation or expensive drugs. There may be low referral rates to particular services or, indeed, unthinking or insensitive treatment from individual members of staff. We would all have to acknowledge that there are examples of that within the National Health Service. I should make it clear that the aim of the national service framework is not to favour older people over other age groups but to ensure that they are treated as individuals. Some progress has been made.

The noble Baroness, Lady Thomas, talked about the issue of food in hospitals. I well recognise that that has been an issue both in terms of the nutritional value and whether older people actually eat enough. Past evidence has shown that they do not. There is also the matter of how meals are organised on the ward and whether nursing staff monitor that individual patients are either feeding themselves or are given assistance if necessary. We are making progress. The chief nursing officer has written to individual nurses to remind them of their duties in that respect. The work that we are doing on a national menu will improve the overall substance and nutrition of the food provided in the National Health Service.

The work on phasing out mixed-sex wards again is an example of responding to issues raised by older people. We published new guidance on resuscitation policy and we have said that decisions not to resuscitate should be made on a case-by-case basis. A blanket do-not-resuscitate policy based on a specific patient group such as older patients is unacceptable. The health service recognises that surgery is becoming safer and new techniques and treatments mean that more people can receive treatment, including older people for whom surgery may not previously have been an option.

When breast-screening programmes were first set up in 1988 evidence suggested that older women would not accept screening invitations, so they were not included in the routine recall programme. Government-funded pilot studies have now shown that extending routine invitations for breast screening to women aged 65 to 69 is both feasible and cost-effective. Noble Lords will know that we are extending the programme as a result.

More generally, the noble Earl, Lord Howe, raised the question of how to involve older people in decisions about their treatment and, more generally, in ensuring that the National Health Service is fully aware of their needs. Patient forums are one way of ensuring that, close to where services are provided, there is input from older people and others to ensure that some of these issues are raised.

On the matter of hospices and special palliative care, I acknowledge their vital role and the partnership required between the National Health Service and the independent care sector. Noble Lords will know that we have made various announcements in the past few months concerning the provision of extra resources and by encouraging the health authorities locally to develop palliative care policies in which independent care provision becomes fully part of the overall strategy and policy of that area.

To answer the question asked by the noble Baroness, Lady Carnegy, it has been confirmed that date of birth is always requested for identification only and not for any other reason.

In conclusion, I echo the points made by my noble friends, Lord Turnberg and Lady Pitkeathley that there is all-round support for the intention behind the amendment, but I do not believe that legislation is the right route. We are making progress; there is a lot to do, but the national service framework provides the best vehicle for doing so.

Lord Clement-Jones

I am grateful for the support—at least for the intention behind the amendment, as the Minister put it—and for the fullness of the Minister's reply.

I confess to being slightly disappointed at the response of the noble Lord, Lord Turnberg, to the amendment. It is one of those tuppence coloured, penny plain issues. If I offer penny plain, which is the age discrimination issue, that is far too narrow; so it is not comprehensive enough in its anti-discrimination provisions. If I offer the tuppence coloured, which is a general duty of equity within the health service, that is far too blanket in its nature and could be shot down for being too vague and covering far too wide a group of patients. I do not think that one would win in that kind of argument, so I shall not base too much credence on the fact that a legal duty is an inappropriate way of proceeding.

I ask those who are not in favour of a legal duty to say what they would do if I were to come back in a year's time, when I am sure we will have yet another Government health Bill, and say that the national service framework has not been working. Will the Minister say when he believes evidence of compliance will be made available under the NSF? He said that the health service would be monitoring compliance and it is therefore incumbent on Ministers to produce that evidence regularly and say when it will be available.

I take as my model—a campaigning model to some degree—the noble Lord, Lord Morris of Manchester. He has no hesitation in bringing forward a proposition time and time again—in fact, every six months. I am being moderate in introducing mine only once a year. The noble Lord, Lord Morris proposes compensation for haemophilia patients who contract hepatitis C—and quite rightly. I am confident that noble Lords who are sceptical of imposing a legal duty will eventually realise that the national service framework is not enough. Let us see how the national service framework will work in practice and monitor compliance.

The Minister himself does not appear to be too confident. Fie referred to "some progress", which is not a resounding accolade for progress on the national service framework.

Lord Hunt of Kings Heath

I am grateful to the noble Lord for allowing me to intervene. I was seeking to give a realistic assessment of where the NHS had got to. I said that there were considerable challenges—all noble Lords will agree with that—but that we had made good progress in some areas, and I gave a number of examples.

The national service framework provides the right vehicle for ensuring that appropriate action is taken, but we should not under-estimate the challenges facing the health service. That is not being complacent; that is being realistic about the real challenges.

The noble Lord, Lord Clement-Jones, asked about progress and programmes. By April of this year, the agreements that need to be reached between NHS trusts and health authorities will include initial action to address any age discrimination identified and any strategic policies needed to reflect the health improvement programmes agreed for the next financial year. By October of this year, in order to facilitate comparisons across health authorities and to establish best practice benchmarks based on health outcomes and needs, an analysis of the level and patterns of services for older people will be completed. That means that local health systems from 2003–04 onwards will be able to demonstrate year-on-year improvements in moving towards those benchmarks. So, in terms of measurement, we have the right structure to enable the establishment of benchmarks and the measurement of improvement.

Lord Clement-Jones

I am grateful to the Minister for that clarification. Ultimately, this matter boils down to patient experience. It will not be very edifying if I come back in a year's time and say that voluntary organisations such as Age Concern and Help the Aged have reported that patient experience is still poor, and the Minister retorts to me, "No, no. All our benchmarks are in place and are being developed". Will there be tracking of patient experience and will we find out whether matters are improving?

Lord Hunt of Kings Heath

I am glad that the noble Lord has raised the question. He will probably have forgotten our intention to have national surveys of patient opinion, which will be published over the next few months. They will include national questions which will enable the comparison of trust with trust, together with local questions which individual organisations can add to the survey. That is one way in which we can pick up on some of the issues. Patient forums—which will enable us not only to pick up on the results of surveys but to reflect on the evidence that patient advisory and liaison services have provided within individual trusts—will also be a way in which progress can be monitored and the attention of the boards of NHS trusts drawn to particular concerns in this area.

I reject the noble Lord's charge that we do not have a vigorous process for ensuring that this happens.

Lord Clement-Jones

I am grateful to the Minister. That is much more satisfactory. As long as the surveys are directed specifically, among other matters, to the experience of older patients, of older people in acute hospitals, that will be entirely satisfactory. We would all welcome that. To have consistent data of that kind tracked through the years will help establish a much better basis for ensuring that we take account of patient experience.

It has become clear in the course of the debate that the Committee does not believe that we are quite ready for legislation. However, it should be borne in mind—the noble Earl, Lord Howe, referred to this—that it is significant that the King's Fund, having carried out its survey of health service managers, came to the conclusion that the only way to eliminate age discrimination in the health service was through legislation. That statement was not made lightly in the course of its report.

No doubt we shall return to this matter at a future date. At this stage my amendment was designed to test the Government's resolve on the question of age discrimination. It has done so successfully and elicited a fairly full statement on the Government's current policy on eliminating age discrimination in the health service. I am grateful to the Minister. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Filkin

My Lords, this may be an convenient moment to break for dinner. I suggest that we return to this business not before twenty-five minutes to nine. I therefore beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.