HL Deb 14 March 2002 vol 632 cc1020-42

House again in Committee.

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

Earl Howe

moved Amendment No. 14: Page 1, line 5, leave out from beginning to "Health" and insert "From 1st April 2003, The noble Earl said: In moving this amendment, my principal purpose is to provide the Minister with an opportunity to flesh out in more detail than we currently have the thinking behind the far-reaching structural changes that the Bill proposes for the NHS. In the process, however, I should like to raise some major question marks over the wisdom of these changes.

The restructuring of the NHS that the Government are proposing was foreshadowed in the document Shifting the Balance of Power, published just over 18 months ago. I am the first to acknowledge the significance of these changes for the internal management of the health service. They will entail considerable upheaval for those who administer and run the service—the biggest upheaval for more than 25 years. Their ostensible purpose, if we take our cue from what Ministers have told us, is to devolve power and decision-making downwards from Whitehall, to create shorter chains of command, to introduce greater local responsiveness within the service and to cut bureaucracy. All those objectives are entirely laudable. The question we need to pose as we go through Committee is whether and to what extent the Bill will achieve them.

The Bill places a duty on the Secretary of State to create strategic health authorities for the whole of England. Our understanding is that there will be 28 SHAs, whose function will be to guide and oversee the development of local health services and to performance manage PCTs and NHS trusts under individual performance agreements. At the same time, as we know, the creation of primary care trusts is to be accelerated, and it is PCTs, not strategic health authorities, which will be made responsible for the commissioning of healthcare services. Above the SHAs will remain the regional directors, whose remit will extend over a very much wider area than that of each SHA.

The obvious point to note about this structure is that, far from reducing the tiers of authority within the NHS, it is actually increasing them. Instead of two tiers, we shall have three. Furthermore, because there are going to be a great many more PCTs than there currently are health authorities, the actual number of health service bodies is going to increase as well. I am rather worried about the implications of that structure in terms both of the numbers of managers and administrators that it will require and the associated costs of that management. The costs, of course, are not simply financial; they can also be measured in terms of the time of trained doctors and clinicians that will be taken up in performing non-clinical duties. However, given that we accept that that is a price to be paid for the PCTs, which do have much to recommend them, where does it leave strategic health authorities? We are told that each SHA will be responsible for a population of roughly 1.5 million people, equivalent to perhaps three or four existing health authorities now. What is the rationale for that size of purview?

The BMA, among others, has expressed the worry that all this structural change—which we were promised by Frank Dobson would not happen when the Government first came to office—is going through too rapidly.

There is a strong feeling that, if more time can be taken to agree the planned configuration of strategic health authorities and regions, the end result would be a good deal better. A meeting last October of senior representatives from health, local government, and business in the West Midlands concluded that the planned configuration will be too large and too diffuse to engage effectively with trusts, with PCTs and with local authorities. Why should there be 28 strategic health authorities and not 40 or 50? I suspect that there is no fully coherent answer to that. The answer depends on what SHAs are to do. It would be helpful to hear from the Minister a little more about the role that they will play and what the word "strategic" means?

One of the BMA's concerns, which I share, is that there does not appear to be anyone within the new structure tasked with safeguarding and fostering academic activity. A later amendment deals with this matter in more detail. A debate, last year, introduced by the noble Lord, Lord Walton, most recently brought home to us how vital it is for the good of the health service and for the good of the patients that recruitment and retention in academic medicine should be encouraged. No individual PCT will be capable of performing that function, nor can it be left to Richmond House. If anything is strategic in nature, clinical academic medicine certainly is. What role, if any, is envisaged for strategic health authorities in that regard?

Perhaps the Minister will tell the Committee what mechanisms are to be put in place to ensure that conflict or divergences of opinion between individual strategic health authorities can be resolved. Given that each SHA is to he tasked with brokering solutions across organisational boundaries of PCTs and must, by definition, do the best that it can for the local population that it serves, what degree of latitude can there be for a strategic health authority to compromise on what it sees as an optimum solution, merely because there are objections from the strategic health authority next door? The statutory duty for NHS bodies to cooperate does not appear to be enough in those circumstances because, under the situation that I have described, we would be dealing with two opposing and conflicting views of what is strategically best for an area.

The amendment makes a serious proposal, but it carries with it a great number of questions about the role that strategic health authorities will play in practice. I beg to move.

8.45 p.m.

Lord Hunt of Kings Heath

I am grateful to the noble Earl, Lord Howe, for introducing the debate on strategic health authorities and, more generally, on the new arrangements that we are putting in place. I need to refer back to the speech made by my right honourable friend the Secretary of State for Health, the shifting of the balance of power speech on 25th April 2001, as mentioned by the noble Earl. That set the broad intent of our direction. There is the reduction in the number of health authorities by about two-thirds by 2002. Some 28 new health authorities are to provide a strategic overview and to take forward some of the functions, including performance management, previously fulfilled by regional offices, with much of the planning and commissioning work previously carried out by health authorities passing to primary care trusts. As we have already commented, by 2004, the intention is that they will be controlling over 75 per cent of NHS funding.

There is also the disappearance of NHS regional offices, and the introduction of four directors of health and social care, who together with small groups of staff will work closely with the Government Offices for the Regions, focusing on managing health and social care through regulation, arbitration and resolution. I do not see the four directors of health and social care, alongside the small groups of staff who will work with them, as being an additional tier of management in the health service. Essentially they will be a part of headquarters, part of a central department of health, but, if you like, with a desk responsibility for one part of the country.

On that basis, I argue that we are not, as the noble Earl has suggested, continuing with three tiers. We are reducing to two tiers; the central tier being the strategic health authorities and beneath them the NHS trusts and the primary care trusts. Within that context I believe that strategic health authorities will have an important role to play. They will have responsibility for the strategic framework and the delivery of services across all NHS organisations. They are to ensure strong, coherent, professional leadership and the involvement of all professional groups. I believe that issues concerned with academic medicine in universities fit well within that remit in terms of the relationship between strategic health authorities, professional groups, universities and academic disciplines.

Importantly, strategic health authorities will be responsible for performance, managing NHS trusts and primary care trusts. They will account to the Secretary of State for performance of the NHS in their areas, so they will be the leaders of the NHS within the strategic health authority boundaries. They will deliver agreed progress on the NHS plan through performance agreements with individual trusts and primary care trusts. They will manage performance across organisational boundaries and networks to secure the best possible improvements for patients. They will intervene to broker solutions where problems arise between local NHS bodies.

I believe that that answers the point raised by the noble Earl, Lord Howe. Clearly, in decentralising two primary care trusts, we expect them to take a major leadership role. In some cases they will work on behalf of other primary care trusts. Later we shall debate the commissioning of specialist services. It is likely that within one strategic health authority area, one primary care trust will take on the lead role of commissioning specialist services.

It is possible to envisage that there may be an individual primary care trust that is not prepared to buy-in to the cost and the agreed programme for the commissioning of specialist services. In that case the strategic health authority would have a role to bang heads and ultimately to performance-manage primary care trusts to ensure that everything worked together. There may be many other examples where an individual primary care trust has taken a leadership role. The strategic health authority will be there as a backstop to intervene if matters do not go well or if there is a problem in agreeing an overall solution across the strategic health authority boundary.

There are two other important roles for strategic health authorities. First is the preparation and delivery of strategies for capital investment. The second is workforce development. It is important that the local health economy, covered by the strategic health authority, is exercised about its future workforce requirements and ensures that it plans the right numbers, commissioning the right number of training places. Information management is another area where we shall expect strategic health authorities to take a strong leadership role.

I believe that there is a clear differentiation between the kind of role envisaged for primary care trusts and NHS trusts and strategic health authorities. I have no doubt that the strategic health authority role will be invigorating. We know that we have attracted people of the highest calibre as chief executives designate to lead those strategic health authorities.

Having said that I fully accept that there are those in the service who worry about the pace of change and about the management load that will be placed on the new strategic health authorities and on primary care trusts.

We are setting a challenging programme and timetable. But if one looks at practice in the health service, one of the complaints often raised is that it takes a long time for structural change to take place; certainly much longer than in the private sector.

Once the Government have set out their strategic direction, the best possible course of action is to move as quickly as possible to the new arrangements. I am absolutely confident that the people we have appointed are ready to accept that challenge.

The noble Lord has not as yet raised the issue of primary care trust capacity. I suspect that we shall come on to that. But I repeat—although I know that the noble Earl, Lord Howe, has some concerns about this—that all my experience suggests that the health service will rise to what I believe will be a very invigorating challenge.

Baroness Masham of Ilton

The Minister has just said that it is possible that strategic health authorities will organise specialist services such as supra-regional services. The word "possible" is worrying because it means that it is not yet organised. Therefore, the amendment of the noble Earl, Lord Howe, to delay the matter for a year may be a good idea.

Lord Hunt of Kings Heath

I will need to read Hansard. But I think that I raised the possibility of a problem with a specialist commissioning of services. If one primary care trust in a health network is not prepared to play ball with the general thrust of the agreement within a locality, the strategic health authority would have the opportunity to intervene and bang heads together.

So far as concerns specialist commissioning, we intend to continue with national specialist commissioning arrangements. The regional commissioning arrangements would be undertaken at local level. It will be a primary care trust responsibility. We would expect them to work together. They would he performance managed by strategic health authorities. I know that we shall come to a later amendment on that issue.

Earl Howe

I thank the Minister for that helpful reply. It has certainly considerably enlarged my understanding of the role of strategic health authorities.

It was good of the Minister to acknowledge that there is concern in some quarters of the health service about the speed of change. That applies in larger measure, perhaps, to the creation of primary care trusts than to strategic health authorities, although I think that it is true there also.

The Minister did not really address my point about the size of the remit that strategic health authorities will have in terms of population and why that particular size had been chosen.

Lord Hunt of Kings Heath

I apologise to the noble Earl for not responding to that question. Clearly, a number of factors must be taken into account in relation to the size of a strategic health authority boundary—for example, geography and population. There is a variation in population size between the largest and the smallest strategic health authority. But one of the most important considerations has been to try to build them as much as possible around care networks.

We recognise that, for example with cancer, for a largish population there is a requirement for an integrated service where primary, secondary and tertiary care elements all have a role to play. It is appropriate that the strategic health authority boundary, by and large, covers the kind of area required for a fully-fledged care network. That means that for a strategic health authority working for a primary care trust one could plan an integrated approach for services. Of course other factors, such as geography, population and size, also come into play.

Earl Howe

Again that was very helpful. I am particularly glad to hear that a flexible approach is being adopted in the department. That is surely right.

My noble friend Lady Noakes will have a number of other questions to ask on the subject of strategic health authorities later on. For now, I thank the Minister once again for what he has said I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

Lord Clement-Jones

moved Amendment No. 15: Page 1, line 6, leave out "areas" and innert "regions'.

The noble Lord said: In moving Amendment No. 15 I shall speak also to Amendments Nos. 16 to 28, 30, 32 and 33, 37 to 40, 44, 46 to 48 and 50.

I was interested to hear what the Minister had to say when speaking to the last amendment, but the key question with regard to Clause 1 still remains: why are strategic health authorities being set up that bear little or no relationship to local government boundaries or the government's own regions for other government departments?

His rather circular argument about care networks was also interesting: the strategic health authorities being set up in an area where it is possible to build a care network. I thought that that was almost a self-fulfilling prophesy: if one decides that that is an area where one can build a care network, one builds one. I do not think that I am being unduly sceptical about that particular choice of words by the Minister, but it would be helpful to have a little more rationale about precisely why 32 strategic health authorities are being chosen.

As we heard earlier in the debate, over the years there have been a massive number of changes to the structure of health services. I do not have the pedigree of the noble Earl, Lord Howe, to go right back to the 1948 era. I start only at 1974. We started with area health authorities. Then there were district health authorities. Then in the early 1990s we moved back into area health authorities. Now, we are going to have strategic health authorities which will cure all known organisational ills. The one constant—that is why I go back to 1974 rather than to an earlier period—has been the NHS region. Although there have been some changing of boundaries and consolidation, there is no doubt—this is something which is very familiar to health professionals—that we need critical mass at regional level, and in particular there is the need for specialist commissioning at regional level.

Many professionals have concluded that the Government's current legislative proposals to devolve NHS commissioning responsibility to PCTs in particular could lead to a deterioration in the national provision of specialised services. Their proposals to create a series of PCT consortiums to commission these services is seriously flawed because of their failure to guarantee that these consortiums will have a sufficient number of local PCT members to provide for viable services. That is part of the reason for the proposals by my noble friends on these Benches for a regional, as opposed to a strategic health authority, basis for re-organisation.

In January 2002, the Department of Health published its revised proposals on specialist commissioning in Shifting the Balance of Power: The Next Steps. The document sets out how PCTs are expected to commission local services, both primary and secondary. Despite being billed as the definitive expression of government policy, it does not contain any mechanism for guaranteeing that local commissioning consortiums will have a sufficiently large membership to be viable. That is another reason for regional commissioning.

The proposed system of PCT consortiums could lead to a substantial disruption in the provision of specialised services, as PCT boards decide that local relatively low cost, high volume services are a greater priority for investment than membership of consortiums with high cost, low volume treatments—precisely those specialised tertiary care areas of commissioning which are so important. That confused picture is of concern because the new system hinges on the good will of the new PCTs. The existing consortiums have had mixed success in attracting health authorities to their membership—even though LHAs have a tradition of strategic planning for specialised services. The problem is likely to be exacerbated by devolution to PCTs, which will undoubtedly have a steep learning curve.

That illustrates the problems of not having a clear regional basis for organisation. Another key benefit of regional organisation is that it would cover enough territory to take a strategic view of regional health services in general. Under the new strategic health authorities, there would be problems with coterminosity that would not exist regionally.

It is important also that public health strategy is dealt with at an appropriate level—such as regionally. In the Act that established the Greater London Authority, health promotion and public health-were specifically mentioned—showing that the region is considered an appropriate level.

There will be nine regional directors of public health but they will not be bolted on to any regional structure. They will be without regional health authorities to which they can relate—though they will be better placed in terms of having an individual economic region used by other government departments than the four regional directors of health and social care, who will not bear a relationship with any natural or local government boundary.

Somewhat perversely, the Government have chosen anything but a logical and sensible boundary for the reorganisation of health services. Despite the Minister's comments, if the four regional directors are not another layer of management—the noble Lord mentioned performance management—what are they? If they do not have a function, should they exist in the first place? Either they are a layer of management, have a purpose and a set of objectives or not—in which case, they should not be there. They will each be paid a salary for an inadequate job.

Above all, it is vital to ensure proper accountability for a health strategy that ties in with a known and familiar structure. That could be secured through a regional organisation. In a strategic sense, that accountability is unlikely to be secured any other way. The current scheme of reorganisation, as with so much in the Bill, is half baked. I urge the Government to think again. I beg to move.

9 p.m.

Baroness Finlay of Llandaff

I am unclear where current statutory functions, such as the inspection of nursing homes and duties in relation to the protection children, will lie if there is no coterminosity with local authority boundaries. Who will carry responsibility where the boundaries are blurred?

Lord Clement-Jones

There would be far greater coterminosity under the regional proposals than there could be with any strategic health authority boundaries. To that extent, I hope that the noble Baroness is entirely satisfied with the scheme from these Benches.

Baroness Masham of Ilton

I am rather suspicious about the four care authorities. Does that arrangement mean that people might have to pay for their needs? At present, under the health authority, they do not have to pay. Under social care, there is a means test. Some individuals desperately need certain aids—particularly severely disabled and elderly people. Otherwise, they will get into real difficulties.

I asked "Why strategic?" on Second Reading. The word "strategic" may not be as well understood by the local population as the word "region".

Lord Hunt of Kings Heath

I did not think that I would ever hear a speech in which the idea of bringing regional health authorities back into existence would be met with such enthusiasm. I well remember a debate in another place in the late 1980s in which RHAs survived by two votes. It almost brings tears to my eyes to know of the enthusiasm with which some of your Lordships regard regional health authorities.

My experience is that RHAs were uncomfortably placed—too far from the coal face and too large, given the areas and populations that they covered, to be particularly effective. The great advantage of strategic authorities is that they are large enough to deal with some of the strategic issues that I mentioned in the previous debate but not so large as to be removed from the public that SHAs exist to serve.

Strategic health authorities do follow local government boundaries, and the consultation process supported that; and SHA boundaries are consistent with those of the government offices in the regions. Trying, as ever, to pull together the needs of the NHS with the requirement for consistency across governmental boundaries, we have got as close as we can to a sensible arrangement.

The noble Lord felt that the directors of health and social care would have little work to do. I fear that he has misunderstood my point. I was answering a point made by the noble Earl, Lord Howe, when he suggested that with the new arrangements we would end up with three tiers of management. I said that the four directors of health and social care and the staff to work to them should not be seen as another tier—an intermediate tier, as it were—between the Department of Health and the strategic health authorities.

The directors of health and social care will be senior officials of the department and should be seen as occupying a headquarters function. They will be on the board of directors. It is simply that, as part of their major responsibility, they will have oversight or one part of the country's National Health Service. They will have a vital role to play. For example, as part of a national programme they will be managing the appointment, development and succession planning of all senior NHS management staff; they will support Ministers through case work visits and local intelligence; and they will be trouble-shooting. Importantly, they will bring the NHS and social care together. There is great advantage in bringing the two together under one person. To take an issue that we know well, the interrelationship between the NHS and local government, the new structure is likely to encourage a much more integrated approach to performance management.

I assure the noble Baroness, Lady Masham, that creating directors of health and social care will have no impact on the question of means-tested payments, or whatever, for personal social care. The NHS is free at the point of delivery. There will be no impact on those traditional arrangements.

The answer to the question of the noble Baroness, Lady Finlay, about regulation of the institution that she mentioned is that that will become the responsibility of the National Care Standards Commission. It will be the responsibility of that authority, which will take over the present responsibilities of health and local authorities.

The noble Lord, Lord Clement-Jones, mentioned commissioning of specialist services as an example of the need for a region. We shall debate that later, but I assure him that national specialty commissioning will continue to be undertaken at national level. I am confident that the kind of specialty commissioning that needs to take place at more local level will be undertaken effectively by primary care trusts, with the back-stop that if there are problems the strategic health authority will have a role in intervening and performance managing those trusts.

We do not need regional authorities in the new structure. Strategic health authorities provide the right balance between strategy and closeness to the population and will serve us well in taking forward NHS reform.

Lord Clement-Jones

I thank the Minister for that reply. I am delighted to note his enormous confidence in the new structure, which, as will become increasingly apparent in our debates, is not shared by many others. The Minister's point was that regions are too large to be effective. It is somewhat perverse that, alone among government departments, the Department of Health has decided that the region is not an appropriate unit of management or strategy. Every other department has chosen the region as its unit; government offices are testimony to that.

Lord Hunt of Kings Heath

The noble Lord has reminded me that I did not respond to his earlier point about public health. Clearly in public health it is important that there is a strong relationship between the NHS and the regional offices of government. That is why there will be a public health specialist who will work both to the directors of health and social care and to regional government offices. That is a good illustration of the flexibility of the arrangements which, while preserving the integrity of the NHS boundaries to serve NHS purposes, 'will none the less allow for integration and joint process with regional government offices.

Lord Clement-Jones

I am delighted that at least in one respect the Government accept that argument. I wish that they accepted it for the other 80 per cent of the health service. These public health directors will be rather lonely creatures. They will have no other health professionals to whom to talk. No doubt they will talk to their fellow officers in other disciplines in government offices, but it will be rather peculiar that there will be no other health professionals to advise them or to whom they can relate.

However, without elaborating too far, it seems somewhat strange that the Minister regards the suggestion for regions as being too "remote" to serve the public interest. In strategic terms, that is the word the Minister wishes to use. Technically, I am sure the noble Lord is right. It is possible to say that the strategic health authorities follow local government boundaries. If one draws a line around two counties, or four unitary authorities, it follows local boundaries. The regional understanding is not followed in the catchment areas. I am certain that after a period of years we shall find 32 moving to 15, 9, 10 or whatever; but they will be more regionally based than today.

I accept to a degree what the Minister says about the four directors of health and social care. Of course, we on these Benches welcome any gathering together of health and social care. Indeed, I recall putting forward amendments to numerous Bills introduced in this House providing precisely that, rather than the partnership arrangements first proposed by the Government in the Health Act 1999. We argued strongly for integration. It was delightful that two years later the Government put forward proposals for care trusts which we supported. It goes with the grain of our thinking.

However, the four directors of health and social care who fit into no known region are to take a strategic view without relating to any set of organisations. Yet within the structure of the NHS they are also accountable to the chief executive. That is another layer of management. No doubt the Minister sees it somewhat differently.

I believe that the strategic health authorities will not be strong enough to withstand micromanagement from the centre. That is the key argument. If regional authorities are properly staffed, with properly specialised skills, one will have people of sufficient seniority and expertise to pursue robustly policy in health services in their areas and at the same time to resist micromanagement from the centre.

The government proposals are unsatisfactory. This debate has been an opportunity to hear the Minister's enormous confidence about the new structure. For that I am grateful. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 16 to 28 not moved.]

9.15 p.m.

Earl Howe

moved Amendment No. 29: Page 2, line 21, leave out "are" and insert "is

The noble Earl said: I can deal briefly with the amendment and speak to Amendment No. 34.

In two places, the clause has a plural verb with a single subject. My suggestion to the Committee is that we correct the syntax. I beg to move.

Lord Hunt of Kings Heath

It is an enormously important amendment. I am advised that there are different views as to whether a body which consists of a number of persons should be treated as singular or plural. For example, some people say "the Government is" and others "the Government are". Neither is wrong; it is a question of style. The important point here is that Clause 1 amends existing legislation: the National Health Service Act 1977. The 1977 Act refers throughout to a health authority as a plural body. For instance, Section 16C(1) states: Every health authority will make arrangements with a view to securing that they receive advice appropriate for enabling them effectively to exercise the functions exercisable by them". Section 8(4)(d) states that the Secretary of State may by order change the name by which a health authority are known. The wording in the current Bill follows the same convention in the Act we are amending. I hope that the noble Earl feels that that is a satisfactory explanation.

Lord Turnberg

Before the Minister sits down, is it not the singular name which is at fault? The Bill states that the Secretary of State may by order, change the name by which a Strategic Health Authority or Health Authority are known".

Lord Hunt of Kings Heath

We are following the conventions set out in the 1977 Act in which the words "by which a health authority are known" are used.

Earl Howe

Is the Minister satisfied that this is a consistent feature throughout the Bill? It seems extraordinary to me. In ordinary language we simply do not say "a health authority are". We say, "a health authority is". I know that we speak of the Government in plural terms. That is perhaps a different case; it is a collective noun for a number of people. A health authority is a single body; it is a constituted legal body. As such, it is grammatically singular.

It seems extraordinary that this should occur. Is the Minister satisfied that it is not just a slip-up and that it is consistent throughout?

Lord Hunt of Kings Heath

The point is that, if it is a slip-up, we are being consistent in slipping up. The noble Earl, Lord Howe, has raised a vitally important point. My understanding is that we are being entirely consistent with the 1977 Act. Of course, I would be happy to examine the matter again. No doubt, we will welcome a return to it on Report.

Earl Howe

I shall not ask the Minister to spend a lot of his time considering it. However, it is interesting that a primary care trust should be treated as a singular noun in the Bill, whereas a health authority is not. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 30 not moved.]

Earl Howe

moved Amendment No. 31: Page 2, line 27, at end insert— ( ) Regulations made under subsection (5) shall include the requirement for consultation with health professionals, local authorities, bodies representing patients and such other interested parties as the Secretary of State considers appropriate.

The noble Earl said: It is a commonplace in Committee for amendments to be tabled that propose a requirement for consultation and the substitution of the affirmative resolution procedure for the negative. Nevertheless, in moving Amendment No. 31 and speaking to Amendment No. 35, I make no apology for following that well worn path. I hope that the Minister may be persuaded to follow my lead and my argument.

In this part of the clause, we are dealing with a substantial power to be conferred on the Secretary of State. It is the power to establish a new strategic health authority, vary the area of a strategic health authority or abolish a strategic health authority. Any of those things would constitute a significant change in the structure of the health service. Despite the Minister's helpful explanations this evening, the clause is an empty box.

When the Bill was debated in another place, the Government helpfully conceded that there should be provision for consultation before a strategic health authority order could be made. When it arrived, the amendment looked rather odd. Subsection (5) of the new Section 8 gives the Secretary of State a power to make regulations about consultation. We are usually assured by Ministers that what may seem to be a permissive power is, in practice, a requirement. However, here we also have the uncommon addition of the words, and if he does make such regulations".

The subsection has a more than usually permissive and discretionary ring to it. It also says nothing at all about who will be consulted. With any major change, such as the one we are discussing, there will be a wide range of interested parties, not only doctors, nurses and other healthcare professionals but local authorities which may be directly affected, voluntary organisations and, of course, patients. The patients are, perhaps, especially important. We would do well to remind ourselves that decisions on who plans and directs services can have a major effect on what services are provided and where. Such questions are important to local communities. At present, CHCs have a right to be consulted by the Secretary of State on reorganisation in the health service. I hope that the Minister will take the opportunity to confirm today that regulations for consultation will be drawn up soon and that he will be able to flesh out the detail of those regulations.

I turn briefly to the question of parliamentary procedure. If we leave the procedure as it is, Ministers will be able to alter fundamentally the size, remit or even the existence of a strategic health authority, with only a small chance that another place will have an opportunity to debate and, therefore, contest what is proposed. There is less of a problem in this House with finding debating time for a prayer to annul. In another place, as we know, life is different, and only a fraction of the number of prayers to annul result in a parliamentary debate. It would be possible, therefore, with the barest minimum of parliamentary scrutiny, for a Secretary of State to amalgamate two or more strategic health authorities and in doing so radically alter the relationship between an SHA and the PCTs for which it had responsibility.

I am uncomfortable with that prospect. It may be that after consultation there is general agreement on the proposal, in which case an order would be likely to go through more or less on the nod. But it may equally be that the scheme contains controversial features on which a debate in Parliament should be guaranteed to the Opposition party. It is for that reason that I tabled Amendment No. 35.

I hope that the Minister will be sympathetic to the amendments and the reasons for them. I beg to move.

Lord Clement-Jones

I support the noble Earl in these two amendments. As he said, the way subsection (5) is worded is extraordinary, and if he does make such regulations". I read a letter from Hazel Blears to my honourable friend Dr Harris in the Commons which makes the consultation procedures generally no clearer. I have a letter which deals with the mechanism for consultations above strategic health authority level and with the arrangements for consulting on the decision of strategic health authorities to delegate functions to PCTs. All of that appears to be vague and discretionary. It is therefore an absolutely valid point to make that it should be written on the face of the Bill.

We have had discussions in the past, certainly when the Health Bill went through, on the nature of consultations. Of course the Minister does not like lists—none of us likes lists—but general duties on consultation should at least be clear. There should be some prescription as to how they are carried out. There is little in this Bill and that is one of its flaws.

Lord Hunt of Kings Heath

One thing the National Health Service could never be accused of is undertaking too little consultation. I hope that I can reassure the Committee that consultation w ill be effective in the matter of strategic health authorities in the future.

As the noble Earl, Lord Howe, suggested, this new section was inserted in another place. It effectively ensures that provision will be made for consultation in respect of the names, boundaries and mergers of strategic health authorities. I make it clear that the Minister, in moving that amendment, gave an undertaking that the Secretary of State would make regulations on the matter.

Given the level of detail required, it is appropriate to deal with this issue by means of regulations rather than on the face of the Bill. That will have the effect of ensuring that consultation on strategic health authorities is broadly in line with consultation requirements for other NHS bodies such as primary care trusts and NHS trusts, the detail of which is also set out in regulations.

Making provision for consultation requirements is in line with many of the other provisions in the Bill. If power and resources are to be devolved to front-line organisations, it is only right that those organisations, together with local partners, patients and the public, should be consulted on changes to the health service.

As I indicated, the exact scope of any consultation requirements will be a matter for regulations. What we currently have in mind is that consultees might include local NHS trusts, primary care trusts, neighbouring strategic health authorities, staff representatives, voluntary organisations, local authorities and patient forums. I hope that, having given the general intent of the Government, the Committee will agree that Amendment No. 31 is unnecessary and are reassured that the Government will ensure that the consultation is appropriate and as wide-ranging as I suggested.

As regards orders made under this subsection, they would contain a high level of detail concerning the proposed local arrangements. I do not believe that a case has been made that in the circumstances surrounding strategic health authorities there is a need for the affirmative resolution procedure for every order made under this particular subsection. It does not seem to me that that is proportionate. One has to remember that any orders made will already have been subject to local consultation. Obviously, that would have allowed for a great deal of discussion and input at local level. It seems to me that as regards parliamentary scrutiny we have the balance about right.

9.30 p.m.

Lord Clement-Jones

Perhaps I may probe a little further regarding particular mechanisms. I accept the generality of what the Minister says. For example, in the Minister's letter to my honourable friend she says, Mechanisms for consultation above strategic health authority level. This is an important issue and one that is provided for in existing legislation. The NHS Act 1977 provides for the Secretary of State to direct Strategic Health Authorities to work together to undertake their functions. It is intended that consultation on changes that span strategic health authority boundaries will be undertaken by Strategic Health Authorities working together, and this will be achieved through directions. How this will operate in practice is still to be decided". Those are rather important issues. It is not even going to be in the regulations, but by way of direction, as far as I can see. The letter continues, We see benefits in Strategic Health Authorities working together in a federated way, and also a single Strategic Health Authority taking lead responsibility for the consultation exercise". We are in very vague territory here.

I come to a second example, which is arrangements for consulting on the decisions of strategic health authorities to delegate functions to PCTs. Mrs Blears assures my honourable friend that it comes within Section 11 of the Health and Social Care Act 2001. The letter continues, If delegation would not have any impact on services this would make public consultation unnecessary and indeed irrelevant". I do not quite understand that. If something is delegated to a PCT, ipso facto that requires a level of consultation. But she goes on to say, We intend to issue practice guidance to the NHS in relation to its duty to 'involve and consult', and it will be this vehicle that is used to make explicit that delegation of functions must be consulted upon where it will impact on the services that are used the public". We are getting into very complicated areas here. It seems rather strange that we have these myriad ways of consultation whereas something in the Bill which is relatively straightforward and over-arching would be preferable.

Lord Hunt of Kings Heath

I am grateful to the noble Lord. One has to draw a distinction here. Clause 1(5), which is the subject of the noble Earl's amendment, refers to the consultation concerning strategic health authorities, their abolition—

Lord Clement-Jones

I recognise that that is very limited and a very narrow duty of consultation on those specific matters.

Lord Hunt of Kings Heath

Indeed. But the point my honourable friend Mrs Blears was making was that there are other sections of legislation which cover the wider area of consultation over services. Her reference to Section 11 of the Health and Social Care Act 2001 is a very good example of that. It states, It is the duty of every body to which this section applies to make arrangements with a view to securing, as respects health services for which it is responsible, that persons to whom those services are being or may be provided are, directly or through representatives, involved in and consulted on". The section goes on to describe the area of services on which they should be consulted.

Surely, the important point is whether the NHS of the future will take a vigorous approach to consultation both over issues such as strategic health authority boundaries and, much more importantly, over the future provision of services. We shall have some enormously interesting debates later in Committee on patient and public involvement. It is fully our intent that the health service should continue to be more effective in consultation and public involvement in service provision. I hope that I have reassured noble Lords that it is the Government's intention to issue regulations in relation to Clause 1(5) to ensure that when it comes to changes in strategic health authorities, there will be full consultation that will cover the sort of organisations and bodies to which the noble Earl, Lord Howe, referred.

Baroness Thomas of Walliswood

I am sorry to continue this discussion but may I bring it down to a mundane level? Subsection (5) is in two halves. If it were terminated after the words, "Strategic Health Authority", it would have exactly the same meaning as it does now. It would not have curious phrases such as, and if he does make such regulations", and "requirements (if any)" as it does now. It would say the same as it does now at half the length and without those unusual and complicating phrases.

Lord Hunt of Kings Heath

I am always willing to look again at proposed legislation to see whether we can cut some words from it. The wording is clear. It starts by saying The Secretary of State may make regulations … and if he does make such regulations he shall not make such an order". However, I am happy to look at the wording again.

Earl Howe

I am a little disappointed at the Minister's reply to my proposal for affirmative parliamentary procedure. I should not have thought that consultation, however wide, should itself preclude the affirmative resolution procedure in Parliament. Indeed, I have never heard of consultation being given as a reason for denying Parliament an automatic right to debate a question. Nevertheless, I note what the Minister said and I shall consider the matter further.

I am grateful to the Minister for his assurance about making regulations and for setting out the Government's intentions on the persons and bodies to be consulted. I agree with the noble Baroness, Lady Thomas, that subsection (5) has the look of a discretionary power rather than a mandatory one. On the other hand, we have the Minister's assurance on the record, which is a comfort, but the wording does seem somewhat unnecessarily tentative. I am grateful to the Minister for throwing light on this part of the clause and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 32 to 35 not moved.]

On Question, Whether Clause I shall stand part of the Bill?

Baroness Noakes

I rise to oppose Clause 1 standing part of the Bill and, if I may, I shall oppose Clause 7 and Schedule 1 standing part of the Bill because it is convenient to take these together.

The Minister may have gathered by now that there are several noble Lords who are not enthusiastic about strategic health authorities. Indeed, in opposing Clause I standing part, I echo what my noble friend Lord Howe said in moving Amendment No. 14 and what the noble Lord, Lord Clement-Jones, said in relation to Amendment No. 15 and the others in that group.

We should be under no illusion about the content of these parts of the Bill. With some minor exceptions, they are there to do one thing only, which is to change the name from health authorities to strategic health authorities. To do that the Bill takes the first 44 lines, several lines within Clause 2, 25 lines comprising Clause 6 and six-and-a-half pages of Schedule 1. I suggest that that has wasted the time of parliamentary draftsmen; it was a waste of time in another place when those parts of the Bill were considered; and it is now a waste of time in this Committee. Nothing of substance would be changed by this wasteful legislation. It would be simply changing name plates. With the NHS failing to deliver on all fronts, it is staggering that the Government have wasted so much time to achieve so little.

All this legislative effort is being undertaken in order that the organisations currently called "health authorities" can in future be called "strategic health authorities". That might be acceptable if they were indeed "strategic" bodies, but several Members of the Committee have already cast significant doubt on that.

Let us look at what these strategic bodies will do. The paper Shifting the Balance of Power states that the strategic health authorities will have three key functions The first key function will be to create a coherent strategic framework—but I could not find anywhere in the document what strategy they will be responsible for. As it is clearly the Government's intention that delivery will be in the hands of other bodies—in particular, PCTs and NHS trusts—it is difficult to understand what the creation of a strategic framework will mean in practice.

Can the Minister say what the creation of a strategic framework will mean in practice and explain how, if the requirement is to deliver these strategies somewhere else, such bodies can create strategies but not deliver them? The Minister referred earlier to strategic health authorities "banging heads together", but I am not quite sure how strategic that is.

We have already spoken about specialist services—an issue to which we will return later—where again responsibility filters down to the level of primary care trusts, with the rather vague involvement of strategic health authorities. We were told that it is important that care networks should be coterminous with strategic health authorities, but I am not clear what strategic—or, indeed, operational—involvement the strategic health authorities will have with the care network. That is the first key function.

The second key function is to agree annual performance targets and performance management. I have never seen performance management described as "strategic". It is quintessentially an operational matter and no amount of fancy words can turn it into a strategic activity.

The third key function is building capacity and supporting performance improvement. It would appear that this will involve matters such as supporting systems development across a number of PCTs, NHS trusts and networks. Is that strategic? I think not. It is simply an operational matter at a higher level. Can the Minister explain how supporting systems development and so on is strategic?

The question is whether all this amounts to the creation of strategic bodies? It certainly amounts to the creation of smaller bodies, as are the current health authorities, and while smallness might be associated with strategic bodies it is not a conclusive indicator of strategy.

The Minister referred to the new strategic health authorities being involved in leadership, but the leadership issues seem to concern operational matters. So again I have difficulty in understanding what these strategic health authorities are.

To call the bodies anything but what they are currently called—that is, "health authorities"—is vanity. There is no substance to the proposed title. I would not object to these bodies being a tier above the primary care trusts and the NHS trusts—that is sensible and would provide local focus—but they would not be strategic in intent or likely effect; they would be simply an intermediate tier.

By opposing Clauses 1 and 7 and Schedule I stand part, we would leave things exactly as they are—health authorities would remain health authorities and that would be an end to the matter. The noble Lord, Lord Clement-Jones, proposed calling them "regional health authorities" rather than "strategic health authorities". I certainly prefer that as a more honest description—although 28 of them would be rather a lot—but that, too, would be a waste of the statute book. I commend my simple leave-things-as-they-are approach to the Committee.

9.45 p.m.

Lord Clement-Jones

I should like to add a brief word in support of what the noble Baroness, Lady Noakes, said. She absolutely hit the nail on the head when she said that the status quo is preferable to anything to be found in this Bill in respect of the structure of this clause.

We know that in probably a minimum of nine months' time there will be another NHS Bill with further proposals for reorganisation. Whether as a result of the aftermath of Kennedy, the aftermath of Adair Turner, further consideration of the King's Fund report, further inspiration on the part of the Secretary of State for Health, there will be further proposals. These strategic health authorities—I think the noble Baroness has punched an enormous hole through the Minister's rationale for them—have no real substance. They come within the definition of "a rose by any other name". The Minister would do well to put Clause 1 into early retirement and reconsider its structure.

Lord Hunt of Kings Heath

The noble Lord, Lord Clement-Jones, obviously knows more than I do about next year's legislative programme. If we continue at the same rate of progress that we have made today, I suspect we shall still be debating this Bill next year.

I appreciate the noble Baroness' wide experience of management, particularly in the National Health Service. I did not know that she was another friend of the regional health authorities, but I am glad to welcome her to that rather exclusive club.

I should like to make two substantive points. First, I agree that one should not indulge in name changing for the sake of it. There has to be a substantive reason for calling strategic health authorities "strategic". I believe that there is. It is a visible sign of a real determination to decentralise the National Health Service. Strategic health authorities will have a much more strategic role than that currently performed by the existing health authorities. It will be a critical role in ensuring that the health service makes the progress that we all want it to make. The strategic health authorities will have a very exciting role. They will oversee the work of local NHS trusts and primary care trusts. They will become the headquarters of the NHS locally. Their chief executives will account both nationally and locally for the performance of local health services.

In addition to their local work, we greatly hope that the leaders of the strategic health authorities will also play a major role at national level in leading policy development. I believe that the Department of Health would be very well served by having strategic health authority people to lead national programmes of work, inform the department nationally of front-line issues and generally ensure that the closest possible network of communication and learning exists between the department and the NHS at local level.

The noble Baroness, Lady Noakes, suggested that some of the responsibilities of the strategic health authorities were less strategic and had more to do with operational management. There are two ways of looking at that. I have already listed some of the responsibilities of the strategic health authorities. They would be responsible for the strategic framework; the delivery of services across all organisations; ensuring strong, coherent and professional leadership; performance management; accounting to the Secretary of State for the performance of the NHS in their areas; managing the performance across organisational boundaries; intervening to broker solutions where problems arose, and so on.

I sense that strategic health authorities are indeed being given strategic leadership of a very significant population, a very significant health community. In addition, they are being given levers in terms of performance management to make sure that the strategic leadership they display is effective throughout the health system within their boundaries. For example, if we had simply said that strategic health authorities were to develop a strategic plan/framework without giving them the levers to performance manage primary care and NHS trusts, we would have ended up with a rather powerless organisation. I believe that we have got the balance right: clearly strategic health authorities are strategic. They also have the ability to ensure that the whole health community is marching in the right direction, with a power of intervention to use when things go wrong.

I have listened with a great deal of interest to the concerns that have been expressed by noble Lords. However, this is a significant change. It is about releasing power and resources to the front line; maintaining a strategic direction at the SHA level; and providing levers of performance management to ensure that the whole system is working effectively. In that sense, I believe that Clause 1 is an integral part of the Bill and that it should be supported.

Baroness Noakes

Can the Minister say how he reconciles the intention by the Secretary of State to devolve decision making as far as possible to the front line—that is, to primary care trusts—with what he has just described, which, I believe, is retaining as much power as possible at a level above that; for example, levers over performance management, powers to intervene, and so on? Is the noble Lord saying that what makes an organisation strategic here is the ability to interfere in the decisions of the tier to which the Secretary of State claims to be delegating?

Lord Hunt of Kings Heath

No, that is not how I read the situation. The clear intent is to devolve as much as possible to primary care trusts. But clearly there is a balance to be struck here. We are talking about a national service. Just as concerns were expressed earlier about specialty commissioning and how that will develop, we need a mechanism here to ensure that everyone is working together. As for the ability of a strategic health authority to intervene and to broker solutions where problems arise between local NHS bodies, I should expect that to arise very infrequently.

My experience, derived from my visits to some primary care trusts, is that people are working very well together. However, as part of the strategic leadership that the strategic health authority will carry out, I am suggesting that some levers of intervention may be required. I should expect those levers to be used on a very minimum basis.

Baroness Noakes

If the levers are minimum, can the Minister explain what is meant, in practice, by, creating a coherent strategic framework"? On the one hand, I cannot reconcile primary care trusts being given full freedom, while, on the other hand, the strategic health authorities are given responsibilities. It seems to me that there is a confusion between the two levels. I am not clear how a body can develop a "coherent strategic framework" if it does not have the operational responsibility to deliver. I believe I heard the Minister say that that would be achieved by having levers and powers to intervene. However, that means that we are rolling back on the stated intention of this provision as a decentralising measure. It seems to me that we have an illusion of decentralisation for primary care trusts: we have something that we call "strategic", but it is actually a matter of concentrating true decision-making at the level of the strategic health authority.

Lord Hunt of Kings Heath

I do not believe that to be right. There is no point going down this route unless we empower primary care trusts. The purpose of shifting the balance is to get the key decisions about resources and service commissioning down to the primary care trust level where it lies parallel to primary care, which is responsible for making so many of the decisions that influence the whole of the National Health Service network. There is no question that this is a decentralisation measure. Equally, there are issues that go wider than the primary care trust boundaries. Inevitably, in the provision of national health services, when one looks, for instance at service networks and care networks, they often go wider than would be covered by an individual primary care trust.

The role of the strategic health authority is to ensure that in those circumstances there is an integrated approach, that people are working together and that, if there is a problem, there is an ability to do something about it. That is not a centralising charter. It is getting the balance right between the need to integrate services across care boundaries, but at the same time ensuring that the great bulk of decisions are taken at the primary care trust level.

Baroness Noakes

I thank the Minister for that response. Perhaps I may return to the question that I asked earlier, but not digress into centralisation and decentralisation measures. What is a coherent strategic framework? How shall I know it when I see it in relation to a strategic health authority; and what does that mean for the freedom of action of a primary care trust?

Lord Hunt of Kings Heath

At the moment, strategic health authorities are developing. The designate chief executive will be working, together with the designate chairs of the 28 strategic health authorities, to produce franchise plans. Those plans will set out the key themes and aims of those authorities in their leadership role for the strategic health authority. We have received some outlines, but they are being worked upon. We shall see fuller documentation in the months to come.

From that, we shall have the overall intent and overall direction of the strategic health authority: the kind of care networks and services that are likely to be delivered, the capital programme, the development of information management and workforce development. That will set the strategic framework.

Within that, primary care trusts will have a huge role—an expanded role—in the commissioning of services and will take a leadership role in many of the issues that will have to be decided across the strategic health authority boundary. I believe that that approach gets the balance right between the need to pull some matters together within a care network and the need to decentralise as much as possible.

Baroness Noakes

I thank the Minister. I do not think that he will expect the scepticism on these Benches to have evaporated after those words. I suspect that many of us will want to read his remarks carefully. We may well want to return to the matter another day.

Clause 1 agreed to.

Schedule 1 agreed to.

Lord Filkin

I am aware that the House is sitting tomorrow, and that many of those present will be taking part in those debates. Therefore, there was an understanding that, when it got to 10 o'clock, that might be a good time to adjourn the House. We are about one minute off. Therefore, I beg to move that the House do now resume.

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

House resumed.