National Health Service Reform and Health Care Professions Bill

HL Deb 21 March 2002 vol 632 cc1511-39

5.50 p.m.

House again in Committee.

Clause 9 [Funding of Local Health Boards]:

[Amendments Nos. 78 to 83 not moved.]

Clause 9 agreed to.

Clause 22 [Health and well-being strategies in Wales]:

Lord Roberts of Conwy

moved Amendment No. 84: Page 28, line 30, at end insert ", and indicate which authority is to take the lead in the formulation of such strategies The noble Lord said: Amendment No. 84 relates to Clause 22 and deals with health and well-being strategies. The concept of such strategies drawn up by local authorities and local health boards is attractive. We are all aware of the relationship between people's health and their physical and mental environment, and of the inevitable overlap between the health sphere and the sphere of local government.

There are some areas—I am thinking particularly of social services—where there is a close relationship which is to be found in all parts of Wales. The relationship may be particularly important where there is a high proportion of elderly people in the population, as in the retirement areas of North Wales. There are other areas, such as the valleys of South Wales, where the working environment and its legacy may still be an important determinant of people's health. I am sure that there are other areas where housing conditions are a primary concern. We still have a great deal of pre-1918 housing.

Health and well-being strategies are therefore likely to vary in their priorities in different parts of Wales. Obviously, they will also have much in common, such as health promotion, but my main concern is to establish through the amendment which body is to take the lead in drawing up such strategies.

The clause opens by laying a duty on both types of authority—local government and health authority—to act jointly in formulating and implementing strategies. But, as I am sure the noble Baroness will realise, the danger is that neither will get far without one or other taking the lead, depending on what is perceived to be the major problem of the area and whether it is clearly in the health field or a local government responsibility. The clause is silent on that point. I shall be interested to hear what the noble Baroness has to say. I beg to move.

Baroness Farrington of Ribbleton

The noble Lord, Lord Roberts of Conwy, has raised an important aspect of the Bill in terms of the way in which the formulation of policies will occur within the local health boards. The effect of the amendment would undermine the principle of joint ownership of each health and well-being strategy and the partnership principles which underpin the NHS Plan in Wales.

The National Assembly will give advice in guidance about how the responsible bodies should work jointly to formulate and implement the strategy. In doing so, the National Assembly intends to leave as much as possible to local determination. Local partners, therefore, will determine the local arrangements.

It is the wish of those involved in developing the proposals in Wales that these partnerships will be across local government and the voluntary sector and, as the noble Lord recognised, develop in line with the circumstances prevailing in particular health board areas.

However, I am able to reassure the noble Lord, Lord Roberts of Conwy, that should any problem arise where a particular health and well-being strategy was not being progressed under the joint requirements, the National Assembly would seek to work with the relevant authorities to find a solution. It could ultimately use direction-making powers were they to be necessary. In the light of those assurances, I hope that the noble Lord will not press his amendment.

Baroness Carnegy of Lour

Before the noble Baroness sits down, perhaps she will try to imagine the situation that will arise when this part of the Bill is implemented. I am sure that she is well placed to do so. Would it not be helpful to the Assembly if it was required to decide who was the lead authority? There could be a problem in this area, and all that my noble friend is suggesting is that the Assembly should be required to do that—naturally in consultation. To leave it out would be asking for trouble for the Assembly.

Baroness Farrington of Ribbleton

I have failed to make clear the position which is being taken by the Assembly following detailed consultation. It is taking the view that it is not for the Assembly to direct who the lead authority should be but that that should develop at local level. The local partnership should bring in all parties to consider how best to develop the health and well-being strategy. The view that one authority must be the lead authority imposed by the Assembly is in conflict with the whole ethos of the development of the health service strategy in Wales.

Lord Roberts of Conwy

I am grateful to the Minister for her reply. I made the point simply to highlight the possibility that there could be difficulties so far as leadership was concerned in formulating these health and well-being strategies. She has reassured me. Indeed, I am reassured by the contents of the Bill because Clause 22(6)(b) refers to the fact that, The regulations may, in particular, make provision as to … steps which the responsible bodies must take before formulating the strategy". I heard what the noble Baroness said about the fact that if there is difficulty the Assembly can step in, but it is quite clear—I do not think that she will dissent from what I said earlier—that the primary concerns of these strategies will vary as between different areas. It is important that that point is taken on board and that the Assembly, if necessary, can give guidance as to who should take the lead. Having been reassured by the noble Baroness, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

6 p.m.

Lord Clement-Jones

moved Amendment No. 85: Page 28, line 46, at end insert— ( ) the imposition of a duty on the responsible bodies to include steps to improve the eye health of, and the provision of eye care to, the public in the area. The noble Lord said: In moving Amendment No. 85, I shall speak also to Amendments Nos. 87 and 159. The Minister will note that this is my one foray into Welsh health matters. I do so only because of the importance of the issue of visual impairment. The amendments cover both England and Wales in different ways.

Clause 22 imposes a duty on local authorities and local health boards in Wales to formulate and implement a health and well-being strategy for their area. Amendment No. 85 would help to ensure that regulations made by the National Assembly for Wales could include provision for a duty to be imposed on both to include steps to improve the eye health of, and the provision of eye care to, the public in each area.

Amendment No. 87 is designed to ensure that any health improvement plan drawn up under the Health Act—I apologise if I have confused the Minister. There is a misprint in the amendment. The reference should be to the Health Act 1999, not the Health and Social Care Act 2001. The Bill should include a strategy, to improve the eye health of, and the provision of eye care to, the public in the area", and, of course, that applies to England. These two amendments are promoted by the Improving Lives Coalition, which is composed of over 100 organisations in the field of visual impairment.

Why are the amendments necessary? Eye health is accorded low priority at primary care level and has not been a major feature of health improvement plans. Despite the prevalence figures, eye health has been accorded woefully little importance by primary care planners.

One of the reasons for this is that there is a mistaken assumption that visual impairment is a low incidence disability. That is not correct. Two million people in the UK are affected by uncorrectable sight loss; two-thirds of these have another disability or a serious health problem such as deafness, arthritis or diabetes. Currently, 90 per cent of blind or partially sighted people are aged 60 and over. One in five people over 75 has a sight problem. Within the next 30 years, about 40 per cent of the UK population will be aged 60 and over, which means that 2.5 million people will be living with a visual impairment. Over two-thirds of those who are eligible are not registered as blind or partially sighted.

There is strong evidence that adults in the UK are at risk of developing eye disease and other sight problems because they are not regularly having check-ups. Services have failed to pick up at least 1 million people with an eye condition which is either treatable or remediable, or which could be compensated for in some measure by rehabilitative services and equipment. Eight-five per cent of people over 65 who have cataracts and 75 per cent who have glaucoma have no contact with eye specialists. The number of overall sight tests since the extension of free eye tests to the over-60s has risen by only a small amount. People from certain ethnic backgrounds—for example, Afro-Caribbean and South Asian— are at greatly increased risk of glaucoma and diabetic retinopathy. One in five school-age children have undetected poor sight. People on low incomes are unaware of the exemption categories and low-income concession scheme and are not having sufficient eye tests. Further evidence can be obtained from a recent report from the Patients Association which demonstrates the inadequate information and access to treatments for major causes of blindness and visual impairment.

The detection of eye disease and low vision happens at primary care level—critically, through the NHS sight test, which is also an eye health examination. But unless and until this matter is re-prioritised in local health strategies, and proper monitoring and targets are put in place for addressing under-identification and low take-up of services by at-risk groups, people will continue to lose their sight unnecessarily.

The cost to the NHS of failing to re-prioritise eye health at primary care level will be huge. The risk of hip fracture is doubled in people with poor and moderately impaired vision. The cost to the National Health Service of treating sight-related falls and injuries among older people is estimated at £221 million, as against £25 million for rehabilitation and prevention.

Amendment No. 159 seeks to insert a new clause setting up low vision committees. It would require, each local authority in England and Wales; and … each Primary Care Trust in England and local health board in Wales, jointly to establish and support a Low Vision Committee … for the purpose of co-ordinating multi-disciplinary low vision services for persons with low vision". The purpose of the amendment is to ensure that low vision services become more uniformly available and are better co-ordinated across England and Wales. Low vision affects nearly 2 million people. Low vision services are crucial for rehabilitation, the prevention of accidents and the amelioration of general health. They depend on effective, patient-centred, interdisciplinary working.

There is a nationally agreed framework in England and Wales respectively for the way in which the disciplines can work together to provide effective care for people who lose their sight. However, without statutory provision for low vision committees, services will remain extremely patchy and unco-ordinated.

What is a low vision service? It is a rehabilitative process which provides a range of services for people with low vision to enable them to make use of their eyesight to achieve maximum potential. It involves assessing the person's visual function. It involves providing aid, such as hand and stand magnifiers, telescopes, spectacle mounted aids, task lights and so on. It involves addressing psychological and emotional needs and facilitating modification to the home, school or work environments.

Who provides these services? There are a huge range of practitioners involved in delivering them. Ophthalmologists undertake the clinical diagnosis; optometrists will be involved in low vision assessment, and often the provision of low vision aids. GPs need to be able to refer patients quickly. Rehabilitation workers and local societies for blind and partially sighted people provide advice, information, low vision aids and training. Other specialist practitioners need to be involved; for example, to deliver an effective children's low vision service. I could continue. There are a number of other professionals involved in the process.

Research by the RNIB has found that more than half of the low vision teams contain only one type of professional group. One team in 10 has no link with any other agency. The amendment specifies that the membership of low vision committees must include a range of professionals such as the ones I have mentioned.

Why is the amendment necessary? A lack of low vision services will mean more residential care and attendance costs for local authorities. Such a core rehabilitation service should be uniformly provided in the UK; but two out of every five potential service providers do not deliver any low vision services whatever, with some areas of the country left out altogether.

Challenging AMD in Europe, a report from the AMD Alliance UK published in September, indicated that the UK was among the worst of the countries surveyed in providing rehabilitation services to people with age-related macular degeneration—the leading cause of sight loss in the UK.

Current government initiatives relating to community equipment, pooling budgets and joint assessments—valuable though they are—will not make sufficient impact in this area because they are too generic and do not give a strong steer to PCTs and social services departments to prioritise low vision services. The National Assembly for Wales has begun to address the need for a low vision framework in Wales; but again, without any statutory requirement, services may be slow to develop.

Three years ago, a report was published by the Low Vision Services Consensus Group, chaired by the noble Lord. Lord Jenkin of Roding. I am delighted to see the noble Lord in his place. It involved all the voluntary and professional interests engaged in these issues. Its central recommendation was for low vision committees to be established in every local area. A similar report was subsequently issued in Wales.

The then Health Secretary commended the report to primary care groups, hospital eye departments, social services and voluntary agencies. If the Government still agree with every agency in the visual impairment field that low vision committees provide the best means of ensuring an integrated model of service, they should accept the amendment and insist that such a provision is written into the legislation. I beg to move.

Lord Jenkin of Roding

I completely agree with veverything that the noble Lord, Lord Clement-Jones, has said—with the exception of his ever-generous reference to myself. I did not chair the committee that produced the recommendation, although I played some part in its being set up. Perhaps I may weary the Committee with just a couple of sentences of reminiscence.

I had been invited to join the council of the Guide Dogs for the Blind Association in the late 1980s. That brought me into contact with a number of other national voluntary organisations for the blind and partially sighted. There was no machinery at all for trying to bring those bodies together, although many worked for the same ends. I set up and chaired for 10 years the visual handicap group, which consisted of those national voluntary bodies. We produced a report on better services for the visually handicapped, which was widely received and commented on favourably, not least by the Department of Health. We produced another report on the training of people to work with the blind and visually handicapped—an issue that had fallen through the wickerwork since the old blind workers disappeared with the Seebohm changes in social work.

We also produced a report on low vision—the subject of Amendment No. 159. To many of us—this is not meant to be a pun—it was an eye-opener to see how inadequate services were across the country for people with low vision. Many patients who were examined by an ophthalmologist were simply told, "I am afraid that there is nothing more that medicine can do for you. You are going blind. Have you got somebody to take you home?". As the noble Lord, Lord Clement-Jones, said, it is a terrible shock for a patient to be told that they have an irreversible condition—although many people would now argue that some conditions are not as irreversible as they were once thought to be.

We found that in many cases across the country there were virtually no services to pick up those people and make sure that they were given the help they needed. Some areas were lucky in having an effective voluntary organisation. A year or two after we produced our report, I was presiding over a meeting of the Wanstead and Woodford association for the blind and partially sighted. A consultant from Chelmsford told us what the Essex Voluntary Association for the Blind was doing. He spelt out almost exactly the contents of Amendment No. 159. That was being done in conjunction with the health authority and the local authorities. However, that situation was exceptional. I am not in the least surprised that the body that followed on from the visual handicap group—the body that the noble Lord, Lord Clement-Jones, referred to—came to the conclusion that something more positive is now needed to ensure that there are services to pick up and help patients who are diagnosed as having low vision. Many of them are elderly, but not all.

I strongly support Amendment No. 159, because it seems to be the way ahead. I probably said when I was on the ministerial Bench that we already have a plethora of committees. I have some sympathy with that view, but I am convinced by the evidence that has been produced by Robin Birch and his Low Vision Services Consensus Group. The issue will be dealt with effectively only if every area has to have a low vision committee.

I am not wedded to the full details of Amendment No. 159. It is a brave start, but the issue needs to be discussed fully with Ministers and other bodies to ensure that the provision is effective and workable and not too expensive. However, it is clear beyond peradventure that there is a need for something. The amendment gives us a chance to express a view in support of that. I hope that we shall do so. As the noble Lord, Lord Clement-Jones, said, those with a visual handicap have not been properly recognised in services. There are individual services such as sight tests and people can get glasses, but so much more needs to be done to allow those with low vision to be able to play their full role and develop their potential in the community and to allow old people to live independent lives. We need to address that. It is good that the amendment does so and I therefore warmly commend it.

6.15 p.m.

Earl Howe

I have added my name to the amendments, which raise issues with far-reaching implications for the health service that I believe are of the highest importance for patients. I endorse everything that the noble Lord, Lord Clement-Jones, and my noble friend Lord Jenkin have said. It is difficult to overstate the extent to which eye disease and visual impairment impact on the lives of those so afflicted. As my noble friend has graphically described, to lose one's sight is a deeply traumatic event, which in many cases is a precursor to all kinds of misery, such as unemployment, state dependence and mental illness. As the noble Lord, Lord Clement-Jones, informed us, many people in this country are affected by uncorrectable sight loss and the numbers are growing.

Much eye disease is treatable and preventable if caught early. However, compared with some other countries, we are not nearly as good as we should be in giving eye health appropriate priority at primary care level. Partly because the scale of the problem is not sufficiently appreciated, we tend not to be good enough at bringing information and help to those visually impaired people who need it.

Information for the blind is not an add-on extra: it is an essential part of good quality care that can result directly in improved recovery from illness, the more effective use of health services and the avoidance of serious medical accidents.

In recent years, there has been what I can only call an abdication by some health authorities and trusts of services tailored specifically to the needs of the blind or partially sighted. In the face of that, it is difficult to have confidence that PCTs will be able to establish any more creditable track record without a bit of gentle prodding. If the relevant services are to improve, we need to ensure that there are people tasked specifically with making the right things happen at local level. Low vision services committees provide an ideal mechanism for taking that mission forward. As we have heard, those committees emerged out of the very useful work of the Low Vision Services Consensus Group three years ago, for which my noble friend Lord Jenkin deserves a great deal of personal credit. Since then they have been encouraged by grant funding from the Department of Health.

There are two elements to the rationale for those committees. One is to bring together all the key stakeholders in the delivery of services—doctors, ophthalmologists, social services, specialist workers, service users and others—so that everyone communicates properly. Without such grouping, there is inadequate co-ordination. The second might be called commissioning muscle. Users and voluntary organisations need to he assured that their voice will be heard and their needs will be fully taken into account by PCTs and local authorities when services are being planned. I am convinced that a statutory duty to establish and support those committees would make a huge difference to the current unsatisfactory pattern of services.

What about providing accessible information to the visually impaired? The work of charities such as the RNIB in monitoring the provision of such services goes largely unsung. It should not be up to voluntary organisations to shoulder the task on their own. It should be done at national level, preferably by CHI. Health authorities and trusts are on the whole very dilatory about identifying those in need and having proper procedures and training. We need national benchmarks.

For those reasons I urge the Government to take the amendments seriously. The Minister may say that these are essentially matters for local decision-making, but, as the noble Lord, Lord Clement-Jones, pointed out, the current mechanisms, such as pooling budgets, will not be enough on their own to do the trick, because they do not send out specific messages about the importance of low vision services.

I hope that the Minister will at least reflect on the amendments in a positive spirit before Report.

Lord Hunt of Kings Heath

This has been a very interesting debate. I think that we are all at one in wanting to ensure that good eye care services are available throughout the National Health Service. I am very much aware of the recent survey by the Patients Association which suggested that provision of ophthalmic services is variable across the country and that, as the noble Lord, Lord Clement-Jones, said, eye care is not always seen as a priority by health authorities. I very much agree with the general sentiments that have been raised in this short debate.

I have problems, however, with the suggestion that primary legislation is the route we should take to improve services. I also have problems with the suggestion that we should single out eye care services above all others to include in primary care legislation. I am sorry that the noble Baroness, Lady Cumberlege, is not with us today. In one sense, this debate seems to take us back to our earlier debate—which now seems a long time ago—on Clause I and the dilemma of developing policy and targets for the health service. The criticism in that debate was that the Government are setting the NHS too many targets, offering it too much guidance, and trying to constrain its functions and responsibilities in far too many ways. It is now being proposed that, in primary legislation, we should be very directional by telling the health service what it should do in particular spheres.

Noble Lords' reasons for wishing to do that are quite understandable. I am sure that all noble Lords wish to see improvement in eye care services. However, I am sure that noble Lords will also appreciate that the more we seek to constrain the work of the NHS, the more we shall have a problem of too many targets and too many priorities. It is a dilemma. I should therefore like to explain in a little detail the Government's work on eye care services, and then deal with the work on developing the eye committees which have been established in various parts of the country.

The Government's first action was to restore the free NHS eye test for everyone 60 and over, at a cost of £50 million annually. As the noble Earl, Lord Howe, suggested, that group is most vulnerable to eye disease and stands to benefit most from regular eye examinations. In 1999–2000, there were more than 2 million extra NHS sight tests, following the extension of eligibility for free tests. We are also taking steps to improve cataract services and have allocated an extra £20 million over two years to fund the capital costs of 60 schemes to improve treatment facilities and reduce waiting times. We believe that this investment will considerably improve the standard of eye care and greatly improve the quality of life particularly of older people. I am also glad to report that the number of NHS consultants in ophthalmology has increased by about 4 per cent in each of the past four years and will increase, from the current level of 651, to 895 by 2010.

I therefore hope that noble Lords will accept that the Government are committed to ensuring that good standards of eye care are provided for the population. As I said, I am not at all convinced that this group of amendments would help to improve the position. I know that the noble Lord, Lord Clement-Jones, has corrected the amendment—which was new Clause 24—and that he intended to require that health improvement plans should include strategies for improving eye health and eye care services. That would require an amendment to Section 28 of the Health Act 1999, which places a duty on each health authority to prepare a plan that sets out a strategy to improve the health of those for whom they are responsible and the provision of healthcare to those people.

I stress that health improvement plans—HIMPs— are strategic documents. We believe that, as such, it would be inappropriate for them to contain a lot of detail on specific activity in the health system. Surely it should be for localities to decide how to meet the identified priorities. I also question whether prescribing from the centre what HIMPs should contain would be contrary to the underlying principles of shifting the balance of power to the local level. All noble Lords seemed to agree with those principles when we debated them 10 days ago.

The HIMP process has to work effectively. In future, local voluntary organisations, service users, carers and the public will have a greater role to play in the development of the HIMP. The Health and Social Care Act 2001 underpins the patient's and the public's involvement in the development of the HIM P. The Act places a duty on NHS bodies to involve patients and the public in the planning and development of services. We shall also eventually, although probably not tonight, debate the issue of patient forums which will be established for every trust. They will play a very valuable role in discovering what patients think about the quality of local services, monitoring quality from the patient's perspective, and working with the local trust to bring about improvements. That, too, will inform the local priority-setting and planning process.

The position in Wales is similar. In line with the principle of devolution, the National Assembly will determine the form and contents of health and wellbeing strategies. The National Assembly intends to give advice about how the responsible bodies will work jointly to formulate and implement the strategy. 'The Assembly will also determine how prescriptive the regulations and guidance should be. Where possible, however, we hope that local partners are able to determine arrangements according to local priorities.

New Clause 159 would require each primary care trust in England or local health board in Wales, and each local authority in both countries jointly, to establish a low vision committee for the area for which that primary care trust or local health board 'was established. As mentioned, a report in 1999 by a consensus group of organisations on the future of low vision services recommended the establishment of local vision committees for the purpose of ensuring that services in the UK are provided in accordance with the report's recommendations. I pay tribute to the noble Lord, Lord Jenkin, for his role in the establishment of that group. However, having seen him play a starring role last night in the parliamentary choir's performance of "Messiah", I realise that he has very many hidden talents.

The Secretary of State for Health commended that report to the NHS and local government. As the noble Earl, Lord Howe, suggested, the department is contributing a grant of £120,000 over three years to provide an implementation officer from the voluntary sector to help in setting up local committees. Good progress is being made. My understanding is that, at the start of the year, 24 committees had been set up, and a number of others are under consideration. The noble Earl also suggested that some gentle prodding is needed. The implementation project is set to run for another 18 months. My view is that it would be inappropriate now to impose a requirement for primary care trusts and local authorities effectively to establish statutory low vision services committees. I think that it would make sense to allow the project to continue and for an evaluation of the committees' impact on service provision to be carried out by the implementation group at the end of that 18-month period.

I would also caution against an overly prescriptive approach. It may be possible to have a good, multi-disciplinary, low-vision service without a formal committee. In some areas the primary care trusts may not always cover the area that is sensible in terms of linking and providing low-vision services, and other models may emerge. Under the present arrangement, the committee is not in the ownership of one body, and that emphasises the essential joint working, which would be important for the successful functioning of any of those committees.

In the light of the debate tonight, the department will monitor what is happening and the progress by the implementation group. We already monitor the uptake of sight tests by eligible groups, and waiting lists. Sites that have been allocated funds for cataract improvement, for example, will also submit progress reports.

We are represented on the low-vision services implementation group, which receives progress reports on setting up local committees at its meetings two or three times a year. In addition, there is a requirement for the group to make six-monthly progress reports to the department. I assure noble Lords that the department will continue to take a close interest in the progress of the implementation project. I take the view that legislation is not the appropriate route down which we should go, but I hope I have reassured noble Lords that we take a keen interest. I accept that having made progress in the past two or three years, more progress needs to be made.

6.30 p.m.

Lord Clement-Jones

I thank the Minister for that reply which, in its latter parts, was positive and helpful. In one way it was the reverse of what I expected him to say. I thank the noble Lord, Lord Jenkin, and the noble Earl, Lord Howe, for their supportive comments. The noble Lord, Lord Jenkin, was clearly so enthusiastic and such a major contributor to the group that the people who briefed me thought that he chaired it. I suspect that that was a sign of his influence on them. I took the point he made that we should not expect to replicate best practice in a voluntary sense; we need an engine to spread it in a more statutory way.

I turn to the points made by the Minister on the health improvement plan. If we are not careful, as the Bill goes through the House the Minister will accuse all those who believe in having a pro-active set of national standards of being centralisers. I do not believe that the essence of devolution is to simply wriggle about and say, "I'm sorry; this is not really something we can legislate for or be prescriptive about". "Prescriptive" is a weasel word which has perhaps come back to haunt this side of the Chamber. In the past, we have accused the Government of being over-prescriptive. But there is a median way. The detailed implementation in a decentralised system is a matter for the local primary care trust and the people on the ground. However, when it comes to stating national standards as to how one produces a health improvement plan and what it can contain, one can be entirely strategic in those circumstances.

Lord Hunt of Kings Heath

I am grateful to the noble Lord, Lord Clement-Jones, for giving way. I do not disagree with him when he says that it is right and, indeed, a duty for the Government to set the strategic framework in which HIMPs are developed. That is what we seek to do in the planning priorities guidance that we issue to the health service. That attempts to give a strong steer to the health service on the core priorities it needs to develop. I said earlier that Members of this place can raise a matter which they feel is important—we all agree that eye services are important—but the cumulative effect of treating every service with the same degree of priority would be to end up with a situation in which the health service is presented with 300 different priorities. As we have already discussed in our debates on Clause 1, that would mean ending up with a situation in which there are no priorities.

Lord Clement-Jones

I entirely accept that. I have read all the previous public health White Papers and Green Papers and know about the four key areas of government concentrations and so forth. The argument is not about setting priorities in those terms but about how many targets we set to try to get those priorities implemented. That is where some of the argument about micro-management is concerned. The setting of broad priorities for action is entirely satisfactory. Perhaps the essence of the argument today in terms of low-vision services is to try to push them higher up the agenda in the health service. That is an appropriate way to proceed. I detect that in the second half of his response the Minister accepted some of the argument in that respect.

Therefore, it is not inappropriate to consider that health improvement plans should address that issue. We believe that they should cover a wide range of matters. Expecting them to cover this matter without stating the way in which they should deal with it or the priority it should be accorded is perfectly proper and an entirely strategic way to approach the matter.

I turn to more positive ground. I believe that the Minister gave quite a lot of encouragement in response to the gentle prodding point raised by the noble Earl, Lord Howe. It would be inconsistent of those on this side of the House to expect PCTs, on top of all the other matters with which they have to deal—we have dealt with that in earlier parts of the Bill—to be over-prodded at this stage in terms of those services. However, I welcome the Minister's commitment that at the end of the 18-month evaluation period by the implementation group there will be a review to see how those services are developing, to see whether the voluntary approach has worked, and then to report hack. It is important that the six-monthly progress reports are published and that there is proper dialogue with all the groups to which I have previously referred. That is a fairly formidable coalition. It is highly significant that that has now been formed.

I take encouragement from the Minister. However, I believe that we may well need to return to the matter, depending on the evaluation that takes place after that period. We can always guarantee that there will be a health Bill passing through this place again. Even if we do not return to the matter on Report, we may well return to it in a future Bill. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 22 agreed to.

Baroness Noakes

moved Amendment No. 86: After Clause 22, insert the following new clause— "REPORT ON BODIES ACCOUNTABLE TO THE SECRETARY OF STATE (1) The Secretary of State shall prepare each year in relation to the bodies set out in subsection (2) a report dealing with the matters set out in subsection (3) and shall lay a copy before both Houses of Parliament. (2) The bodies referred to in subsection (1) are any body—

1. (a) over which the Secretary of State has powers of appointment;
2. (b) for Which he provides the majority of its funding;
3. (c) which he may direct as to the conduct of its business,

but shall not include Health Authorities, NHS trusts or Primary Care Trusts. (3) The report shall contain in relation to each of the bodies referred to in subsection (2)—

1. (a) its name;
2. (b) the nature of the Secretary of State's relationship with the body;
3. (c) details of the exercise of any of the Secretary of State's powers during the previous year;
4. (d) the amounts provided to the body;
5. (e) how the annual report and accounts of the body may be obtained; and
6. (f) the Secretary of State's opinion as to the continued need for the body or, if he is of the opinion that the body is no longer needed, how he plans to proceed."

The noble Baroness said: Amendment No. 86 inserts a new clause after Clause 22 dealing with the various bodies for which the Secretary of State has responsibility.

At Second Reading, the noble Lord, Lord Walton of Detchant, who I am sorry is not in his place, spoke about the Government suffering from "quangoitis" and being determined to convert the NHS into a 'quangocracy". It seems that the Government's instinctive reaction to any problem is to set up one or more new bodies. Since 1997 they have created a long list of bodies: the Human Genetics Commission; the Genetics and Insurance Committee; the NHS Information Authority; the Commission for Health Improvement; the National Institute for Clinical Excellence; the Health Development Agency; the NHS Purchasing and Supply Agency; the NHS Logistics Authority; the General Social Care Council and its equivalents in Scotland, Wales and Northern Ireland; the National Care Standards Commission; and the National Patient Safety Agency. There are probably others which I have missed.

In this Bill alone we have a multitude of patients forums, far more than the CHCs which they will replace. We have the Commission for Patient and Public Involvement in Health and the council for the regulation of health care professionals. Since the Bill has been published, the Government have announced, in their response to the Bristol report, the setting up of a council for quality of healthcare. In January, the Chief Medical Officer announced a new national infection control and health protection agency. Only a week or so ago the Secretary of State announced a new board of patient choice trustees. There is no sign that the Government's zeal for new quangos is diminishing.

I am not seeking to debate the merits of any of those bodies individually. The amendment merely asks for an annual report setting out who the bodies are, their relationship with the Secretary of State, the money provided to them and where their annual report and accounts may be obtained. Importantly, the report should also give the Secretary of State's opinion as to the continued need for the body. If nothing else, it would be an opportunity for the Secretary of State to reflect on the size and nature of his quango empire. It would also give both Houses of Parliament the opportunity to consider the issue too.

I am aware that much of this information is already available in other places, for example, in an annex to the Department of Health's explanatory plans and information on the Cabinet Office website. The aim of the amendment is to bring together all relevant information relating to the Department of Health once a year and, crucially, to ask the Secretary of State to give his views as to the continued need for the bodies. That, in turn, would approve the accountability of the Secretary of State for the bodies that he has created. I hope that the Minister is in favour of increased accountability and will support the amendment. I beg to move.

Baroness Masham of Ilton

I support the amendment as it is an exceedingly good idea. I went to the launch of a new body last night. It was launched most eloquently by the Minister. It was to do with safety, but I cannot remember the full title.

Lord Hunt of Kings Heath

It is the National Patient Safety Agency.

Baroness Masham of Ilton

That is a most important issue and I am sure that the agency will grow. It would be useful to have a list of quangos, as it is useful to know how important they are. On matters such as the control of infections in hospitals, for example, we could see how they were doing and the progress on all sorts of issues such as food and so on. The amendment is an excellent idea which I hope the Government will support.

Baroness Pitkeathley

I cannot see the need for this information because it is already available. I was not sure whether the noble Baroness wanted more information, different information or more information in a different form.

I currently chair a non-departmental public body which is sponsored by the DCMS, and I am the former chair of a Department of Health-sponsored body—the GSCC. My experience is that NDPBs and all other bodies already produce huge amounts of information, all of which is available to the public. They are required by the Secretary of State to produce strategic plans, business plans, annual reviews and they must meet all kinds of performance targets, including administration costs.

Clearly they are responsible to Parliament through the Secretary of State. Their boards are appointed through open advertisements by an independent panel and then approved by the Secretary of State. In terms of justifying their continued need, I believe that adequate information structures and systems already exist. I am reluctant to see further requirements being imposed on them, so that they have to spend more time reporting than doing the job that they were set up to do.

Baroness Carnegy of Lour

I agree with the noble Baroness about that, but the point of the amendment is probably that it is very much easier to set up a quango than to close it. I do not know whether the noble Barones has ever chaired anything that the Secretary of State tried to close. I have, and the Secretary of State did not close it. It is really quite difficult to shut something down.

We cannot have an ever-expanding empire when some bodies have passed their sell-by date. Whether or not the amendment is the right way to do it, the point is that subsection (3)(f) would require the Secretary of State to say whether the body was still necessary and, if not, what he will do about it. He has to say it with the knowledge of Parliament because the matter will be laid before Parliament. That is the point of the amendment, and if some way could be found to keep that requirement, it would be very helpful. A mushrooming of quangos is not a good idea if some of them are no longer necessary.

6.45 p.m.

Lord Hunt of Kings Heath

Clearly we do not want unnecessary quangos. I accept that, and it is important that all the activities of non-departmental bodies are kept under close review. If evidence arises that the job can be done better by other means, or that certain bodies are no longer required because life has moved on, I am all in favour of bringing their activities to an end.

The Government have looked at many non-departmental public bodies and have made changes. For example, we debated the proposals of the Chief Medical Officer on Monday on the surveillance and public health arena. It is proposed that one agency should be established in place of four existing agencies. There are other examples of the Government looking at rationalising non-departmental public bodies.

It is also significant that a number of the bodies to which the noble Baroness, Lady Noakes, referred—the noble Baroness, Lady Masham, also mentioned the National Patient Safety Agency—carry out important functions in terms of national standard setting. I am thinking about NICE or the Commission for Health Improvement investigating the quality of services at local level, or the National Patient Safety Agency to which National Health Service organisations will report adverse events. From that reporting, we hope to learn ways of improving the quality and safety of healthcare services. Those are important matters that need to be dealt with.

I would also argue that, having established such national bodies, enabling us to develop national standards, to which the noble Lord, Lord Clement-Jones, referred in the previous amendment, we are then in a much better position to decentralise. We can allow, within that national framework setting, National Health Service organisations at local level to have a much greater ability to decide their own destiny. Throughout the Bill we shall continually debate the balance between national standard setting and local determination. I am convinced that the establishment of a number of agencies at national level will allow us to decentralise more decision-making to local level.

I also agree with the noble Baroness, Lady Noakes, that openness about the roles and responsibilities of non-departmental public bodies is desirable in health, as across government generally. The Government's wish to promote increased accountability and openness for all quangos led to the publication of the measures in Quangos: Opening the Doors. Considerable progress has been made in this area in the past four years.

As my noble friend Lady Pitkeathley suggested, there does not seem to be much point in publishing again, in another format, information about the Department's quangos that is already available from other sources. The noble Baroness, Lady Noakes, mentioned the Cabinet Office's annual publication, Public Bodies, which already contains the majority of information dealt with by the amendment, including that for all the Department of Health's non-departmental public bodies.

In addition, the bodies themselves publish their own annual reports, including on the Internet, which gives that much more detail than is contained in the Cabinet Office's publication. Ministers remain accountable to Parliament for non-departmental public bodies. That includes informing Parliament about decisions relating to the reviewing and abolition of such bodies. It is notable that the Select Committees of your Lordships' House and in another place frequently examine the performance of those non-departmental public bodies. They frequently call in the chair and chief executive of those bodies for what can only be described as fairly searching examination. In addition, if the Secretary of State were to issue any written directions to these bodies, that fact would be published in the department's annual report. We would expect that the bodies concerned would wish to make a similar statement in their own annual reports.

I am convinced from my own experience in dealing with a number of the bodies mentioned in the debate that each of those bodies is under no illusion that we consider it very important that they are open about their activities: that they constantly examine the work that they do; and that they are encouraged to ensure that reports about their activities are published and put into the public domain. On that basis, I do not think that the amendments, while I understand their thrust, are necessary.

Baroness Noakes

I thank the Minister for that response. I thank the noble Baroness, Lady Masham of Ilton, and my noble friend Lady Carnegy of Lour for their support for the amendment.

In tabling the amendment I was trying to draw attention to the multiplicity of the created bodies. The Minister referred to the 2001 publication, Public Bodies. It shows that the Department of Health had at that time 69 bodies. The number is sure to have increased since then. The empire is growing. I understand and do not dispute that having certain kinds of agencies could lead to the ability to support further decentralisation. Indeed, at this stage I am not seeking to dispute the merits of any one of the bodies that I have mentioned or any one of the 69. My point was to draw attention to the increasing number of bodies and the increased use of non-departmental public bodies to undertake functions at the core of the Department of Health.

I am grateful to the Minister. I shall think carefully about what he has said. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 87 not moved.]

Lord Clement-Jones

moved Amendment No. 88: After Clause 22, insert the following new clause— "NHS REGISTERED MEDICAL PRACTITIONERS In respect of registration of persons proposing to practise in the National Health Service, section 19(3)(a) of the Medical Act 1983 (c. 54) (full registration of persons by virtue of recognised overseas qualifications) shall apply as though the words "other than the United Kingdom" are omitted. The noble Lord said: Amendments Nos. 88 and 89 are quite closely related amendments. They spring from a perception of the minefield that any UK citizen who qualifies in a medical school abroad has to step through before he or she can practise in this country.

Amendment No. 88 deals with the International English Language Testing System, the IELTS. Section 19(1)(b) of the Medical Act 1983 stipulates that an applicant for full and provisional registration must satisfy the registrar of the GMC, that he has the necessary knowledge of English". IELTS was adopted as a means of assessing linguistic proficiency following a recommendation from a Department of Health working group. It assesses skills in reading, writing, speaking and listening to English. But nationals of the EEA member states, other than the United Kingdom and others with what are called "enforceable EC rights", are exempt from having to demonstrate proficiency in English as a result of amendments to the Medical Act 1983.

The GMC admits that it would prefer 10 test EEA nationals but it is illegal to do so because EU laws prevent discrimination against EU citizens on the basis of language. Therefore, the people who have to take the test are by and large any UK citizen who qualified outside the EEA and any non-EU citizen who qualified outside the UK. That means that someone who is British but has trained outside the EEA— loosely speaking the EU, but slightly wider—has to take an English language test. That is rather an absurd anomaly that our amendment seeks to get rid of.

It should be noted that there is actually no legal requirement for a Briton who has trained outside the EEA to take the language test. It was the GMC's decision to adopt the language test. It is not mentioned as such in the Medical Act. All that is legally required is for the GMC registrar to be satisfied that a test would be a waste of time and money. So it would be possible for the GMC in these circumstances to get rid of the IELTS requirement.

I do not know whether the Minister has had the opportunity to look at the table produced by the GMC of the tests that are required. The table covers both the PLAB and the IELTS tests. It is almost completely incomprehensible to a lay person. Therefore, we have this absurd situation which I have outlined. We also have the potentially problematic situation of art EU national—no matter where in the world he or she qualified—who speaks no English at all, starting a job in a British hospital without taking any kind of language assessment. It is not possible to get rid of this because of the EU anti-discrimination aspect, but at least we can get rid of the situation where a UK citizen has to take the test even though English is his first language. The amendment would change that situation so that UK citizens would not have to take the language test no matter where they trained.

I move to the second amendment and turn to the PLAB exam. I want to use the example of a medical school that is well known to many Members of the Committee. I see that the noble Lord, Lord Soulsby, is in his place. I know that a number of noble Lords have connections with St George's University School of Medicine. I want to use it as an example of some of the problems that arise as a result of current requirements.

St George's University School of Medicine is 25 years old. This international school boasts an extremely high standard of education for medical students from the USA and from some 30 countries in the world. The standard of success of students can be measured by equating the results of the intermediate examinations which have to be undertaken by American students—currently, 70 per cent of students come from America—compared with USA standard schools. Last year, the results of the two examinations show that St George's has an equal if not improved pass rate in these relative exams. Basic sciences are taught on the islands of Grenada and St Vincent. Following that, students have an option of completing their clinical training either in the USA or in the UK.

What then follows for students who have qualified at St George's University and who then want to practise in the UK? They are able to come and practise in the UK in two ways. First, they must pass what is called the UEB examination. That examination is set and examined by the Society of Apothecaries. Hitherto students who wished to take the examination were assessed by certain UK universities. Having been signed off by the local dean as satisfactory, students were permitted to take this examination. Passing it gave the students registration with the GMC to work in the UK.

The second method of being able to practise in this country is taking and passing what is called the PLAB exam. That examination is set and examined by the GMC and consists of a theoretical and practical examination. In addition, all doctors applying for limited registration with the GMC must have obtained a satisfactory score, as I described earlier, in the academic modules of the IELTS.

The UEB examination in its present form will be changed dramatically. It will not, it now seems, be applicable to St George's students. All students from St George's have been told that in future they will have to take the IELTS and PLAB examinations in order to practise medicine in the UK.

So the spotlight then turns on to PLAB and the requirements for taking that exam. Older, traditional Commonwealth universities whose students have automatically received full registration in the UK include countries like South Africa, Australia and New Zealand, and the University of the West Indies. They were not required to take the PLAB exam. But the GMC has intimated that it wishes to discontinue with this so-called "elite" group of universities to level the playing field, so that overseas applicants who wish to work in this country will all have to take the PLAB examination.

It seems rather topsy-turvy to get rid of this group. One may not think that it is appropriate to have a specific elite group of universities drawn from a very narrow group of traditional universities, but we on these Benches, together with St George's University, feel that the standard of medicine as taught by the medical school at St George's is such that it is at least equal to this élite group.

Instead of disbanding that group as giving automatic exemption from PLABs, it should be increased so that a number of international medical schools with sufficiently high standards, as approved by the GMC, are able to gain full registration. The reason is that we have an acute shortage of doctors in this country. The Government are trying to increase the number of medical school places but that will take time. Meanwhile, 10,000 new GPs are needed and another 7,500 home-grown consultants by 2004—the Government's target. All that the Government are doing in recruiting consultants abroad will not plug the gap. To meet present contractual arrangements, an extra 3,500 physicians are needed at this moment— which does not include any consideration of the working time directive.

Along with other medical schools world-wide, St George's University School of Medicine has the capacity and expertise to train UK students who are unable to start training, perhaps because of a lack of available slots in the United Kingdom. It seems sensible to bring some order to the process whereby UK students do not have to take the IELTS and the PLAB if their medical school is of a sufficient standard. I hope that the Minister will consider the amendments, perhaps discuss the subject with the GMC and look favourably on the principles involved. I beg to move.

7 p.m.

Baroness Carnegy of Lour

I realise that the noble Lord was talking beyond the European Union but I recollect serving on an inquiry about an EU directive which determined that while member states may have to accept individuals working in a particular profession, they may set the standards required. The list of qualifications to which Amendment No. 89 refers would exist for that purpose. Speaking English is obviously a requirement for anyone working in this country. Did not the GMC bring that aspect into the consultation?

Lord Clement-Jones

The amendments are not directed at a UK citizen practising within the EU as regards PLAB but only as regards the IELTS.

Baroness Carnegy of Lour

But presumably a European Union citizen practising in this country would be affected by that directive.

Lord Clement-Jones

The two amendments only relate to UK citizens, not to cross-border working by EU citizens outside the UK.

Baroness Carnegy of Lour

I apologise. I misunderstood.

Lord Soulsby of Swaffham Prior

I support the noble Lord's two amendments. I declare an interest as a member of the academic board of St George's University.

The noble Lord clearly explained the intricacies of British graduates returning to this country from medical schools overseas. In the past, I have been associated with the University of the West Indies. Graduates from that university's medical schools on three islands can come to this country without let or hindrance in many ways. It is anomalous that graduates of a school in Grenada of equal quality cannot do so.

By virtue of the fact that we are short of medical graduates, one could at the stroke of a pen increase the number available and the number going for training. St George's is already set up. If the amendments were carried, it is likely that a greatly increased number of British graduates would take a medical degree at St George's University.

I remind the Committee that the medical programme at St George's is to take the pre-clinical and some of the para-clinical teaching in Grenada. Then the clinical students are farmed out to selected clinical departments in the United States and this country. There is of course a tendency for the United States students to go to the US and for the British students to come here. When graduation takes place, we have British graduates who have been trained at clinical level in British medical schools. Consequently, they are entirely familiar with medical issues, programmes and problems in this country. Such a development would certainly be convenient to the medical profession in terms of supplying well-trained graduates for our health service.

Baroness Howells of St Davids

I support the noble Lords, Lord Clement-Jones and Lord Soulsby. I am confident that my noble friend the Minister is aware of concerns that the provision in question exists for one purpose only—to discriminate unfairly against individuals who obtain their medical degrees outside the so-called white Commonwealth. I understand that the GMC is concerned about that distinction at a time when we freely speak about globalisation. I trust that my noble friend the Minister will undertake to look again at that suspect wording because I understand that the GMC would like the distinction abolished.

Lord Filkin

The amendments raise interesting and important issues in the context of the NHS seeking to ensure an adequate number of trained professionals.

It has been recognised in statute for some years as right and necessary that the GMC should satisfy itself about the English language ability of a person who qualifies in medicine overseas. The only exception is our treaty obligation to our European partners to allow freedom of movement by EU nationals. That does not mean that a French doctor would be able to practise in the UK if his English language skills were poor. He would have a right to register with the GMC but it would still be perfectly possible for a health authority or health trust seeking to employ such a person to satisfy itself that he was suitable by having adequate fluency in English. We need not be fearful that the measure is leading to something grossly inappropriate.

To be fair to all who apply for registration, it is right that the GMC must have a rule of some kind and that it should have as few exceptions as possible. For example, the rule should apply also to people who are British citizens. One can imagine cases where a British citizen emigrated at a young age and may not have the facility in English needed to be a doctor in this country. The GMC wants to be as helpful as possible, both to be fair and because it appreciates the value to the UK of people with overseas qualifications who want to work here. While we do not think that the amendment is the right route, it may be helpful to get the GMC to reconsider how it satisfies itself under its obligations of English language ability. The standard test may not always be necessary, but that is a matter of GMC policy rather than law. I understand that the GMC will follow carefully today's debate and take from it lessons for consideration.

The new clause is also wrong to confine itself to people wanting to work in the NHS. There should be one standard for registration, regardless of a person's intended employment in health professions. So while I cannot support the amendment, II understand the sentiments that motivate it and hope that a solution can be found as I have suggested. If the Government were persuaded in future, in the light of fuller consideration by the GMC, that a change in the law was necessary, an order under Section 60 of the Health Act 1999 would provide an appropriate vehicle.

The noble Lord, Lord Clement-Jones, is correct to say that there is no legal requirement for a British citizen to take a language test. The Act requires that the registrar of the GMC is satisfied that applicants—including British citizens, unless they have EU rights—have the necessary knowledge of English. The test itself is not a requirement of the Act.

The noble Baroness, Lady Carnegy, raised the issue of the directive. We think that it is probably the directive on the mutual recognition of medical qualifications. No, it is not. We shall keep searching.

Baroness Carnegy of Lour

I am sorry for raising the matter without having checked it. I thought that it might be helpful to ensure that the Government had considered that in replying to the amendment. I am sorry if I have wasted the Committee's time.

Lord Filkin

We shall have a further opportunity to reflect on that and, if appropriate, give a subsequent answer. We will of course need to check the specific relevance to the issues we are discussing today.

Amendment No. 89 is also unnecessary. It would compel the GMC to maintain a list of recognised overseas qualifications. As the Committee will know, the GMC already does so and I am unaware of any case in which people seeking a registration or wanting to check a doctor's registration have had any difficulty getting the GMC to share the list with them.

However, this is a good point at which to say something about the substantive issue of recognised overseas qualifications, which several. Members of the Committee have raised. There have been concerns that provisions of the Medical Act 1983 discriminate unfairly against those who obtained their medical degrees outside the so-called white Commonwealth. My noble friend Lady Howells was clear on that point. The GMC would like that distinction abolished and, broadly speaking, we share its view. It proposes—and we support it—to abolish the status of recognised overseas qualification that degrees from 22 universities currently hold. Graduates from those universities will then be in the same position as those from the hundreds of other institutions world-wide whose medical courses are recognised by the World Health Organisation. They would have to demonstrate their competence at the point of registration—as do graduates from the United States or, say, India, currently.

The Government, in the light of the GMC's consideration, will use the next suitable Section 60 order to make the necessary amendments. Discussions with the GMC have already begun on that, and we plan to lay the order before Parliament later in 2002 after full consultation in the normal way.

Some important points were raised about St George's. My noble friend Lord Hunt recently met representatives of St George's Hospital and a group of hospital friends in the UK. He has asked departmental officials to consider the issues raised. He recognises the potential and quality of the medical education at St George's. While the Government's approach is not exactly the same as that proposed by the noble Lord, Lord Clement-Jones, in Amendment No. 89, we feel that it is an appropriate manner in which to proceed. It will ensure that there is no unfair discrimination and that suitably qualified medical people are able to practise in the UK. I urge the noble Lord to withdraw the amendment.

Baroness Masham of Ilton

Before the Minister sits down, perhaps I may ask him whether the provision includes doctors from South Africa.

7.15 p.m.

Lord Filkin

I am fairly certain that the system that I described would apply to doctors from all around the world, and would therefore include those from South Africa.

Lord Clement-Jones

I thank the Minister for his reply, which, as he said, was not entirely in line with what I want. I thank the noble Lord, Lord Soulsby, and the noble Baroness, Lady Howells, for their support for the amendments. They seek to ensure that we make the best of a potential pool of properly qualified, well-trained graduates and that there is no discrimination in favour of white Commonwealth universities—a phrase used by both the Minister and the noble Baroness. It is important that we are not in the business of levelling down. That is where the current GMC proposals and what the Minister had to say are unsatisfactory.

I understand the issue about the IELTS. It may well be possible to persuade the GMC not to apply it to UK citizens. I take the Minister's point about it being up to hospital trusts to vet their doctors, but there is considerable pressure on trusts to take on doctors. If they are already registered on the basis that they have a somewhat rudimentary knowledge of English, it is difficult not to accept them. The essential check is on registration, and UK citizens are being required to take a language test at that point. That seems rather anomalous.

I agree with the Minister that it is perhaps not entirely appropriate to legislate on the matter, but he then went on to say that a change may be made by regulation under Section 60 of the Health Act 1999.

Lord Filkin

I thank the noble Lord for giving way; perhaps I can remark on one or two points. First, British citizenship is not a guarantee of adequate fluency in English. Secondly, a health authority or trust would be grossly irresponsible if it sought to employ someone who did not appear to be sufficiently fluent to carry out his medical duties. There is no more to be said on that. They must act responsibly; they are public protectors. We should rest with comfort that those people treat those responsibilities seriously. Finally, after due consultation, the House will have an opportunity to consider any proposed order, as is right and proper.

Lord Clement-Jones

I thank the Minister for that clarification. But what is sauce for the goose is sauce for the gander. If we believe that hospital trusts have the appropriate mechanisms to vet those doctors who have been registered and apply to them for vacancies— in other words, that they are capable of assessing their language skills—why should that not apply to UK citizens as well? UK citizens are labouring under a disadvantage. If citizens of Italy or France do not have to take the IELTS and we rely on the hospital or trust to vet them, why cannot we do the same for UK citizens, who, percentage wise, have a far better chance of speaking English? The Minister has made my case in his intervention.

Secondly, the GMC may be barking up the wrong tree. I have had some discussions and I believe that the levelling-down point is important. To say that the concept of an elite group of white Commonwealth universities whose product is regarded as fulfilling the requirements and, ipso facto, does not have to take the PLAB exam is clearly discriminatory and therefore should be abolished seems to be going in the wrong direction. There should be a broader, more inclusive group of universities, such as St. George's, which I described, which qualify as far as the GMC is concerned and whose graduates are not required to take PLAB.

This is a minefield. We must recognise the quality and potential of individuals coming out of those universities. That would best be done by exempting them from the PLAB examination. The purpose of encouraging UK citizens to take up places at those high-quality universities is lost if there is the major disincentive of two hurdles to overcome: first, the IELTS, and secondly, the PLAB. I could quote examples of constituents of honourable friends in the other place, who have been offered jobs in hospitals but find that they are unable to find a place for a test. Therefore the hospitals lack their presence and in some cases such doctors may lose their jobs due to the bureaucracy of the exams and the shortage of time or place for them to sit them in order to qualify.

That is a significant disincentive for a young student considering where he is going to qualify and undergo his medical training. A good deal more discussion needs to take place. The passage of the Bill may not be the best place for it, but the airing of the subject today has been 'valuable. I thank the Minister for his consideration and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 89 not moved.]

Clause 10 [Expenditure of NHS bodies]:

[Amendments Nos. 90 and 91 not moved.]

Clause 10 agreed to.

Baroness Noakes

moved Amendment No. 92: After Clause 10, insert the following new clause— "REGIONAL STRUCTURE (1) If in any year the Department of Health has directors of health and social care who have regional responsibilities or if it has regional offices, regional directors or any other regional structure, the Secretary of State shall lay before both Houses of Parliament each year a report containing the matters set out in subsection (2). (2) The report shall contain—

1. (a) the names and qualifications of the relevant directors;
2. (b) the geographic regions covered by the relevant directors;
3. (c) a description of the functions, responsibilities and accountabilities of the relevant directors;
4. (d) the number of staff reporting to the relevant directors and details of the functions of those staff;
5. (e) details of the premises occupied by the relevant directors and their staff;
6. (f) the total cost of the work of the relevant directors and their staff;
7. (g) a description of the relationship between the relevant directors and the National Health Service trusts, Primary Care Trusts and Strategic Health Authorities within their regions;
8. (h) a description of the relationship between the relevant directors and the Secretary of State;
9. (i) a description of the targets or objectives which have been set for the relevant directors and their staff for the year which is covered by the report;
10. (j) a description of the manner in which the relevant directors and their staff have conducted their functions during the year, including whether they have met the targets and objectives set for them; and
11. (k) a description of the targets or objectives which have been set for the relevant directors and their staff for the following year.

(3) In this section "relevant director" means a person who is designated a director of health and social care with regional responsibilities or a person who is in charge of a region, regional office or other part of a regional structure of the Department of Health. The noble Baroness said: The amendment seeks to introduce art annual report on the activities of the new directors of health and social care and any other regional directors that exist or may exist in the future. In the days which some of us now refer to as "the good old days", there was a regional tier in the NHS. There were 14 regional health authorities with full boards and local accountability. For good reasons, that tier was largely removed in the 1990s, although many of the activities formerly carried out by the staff of the RHAs continued to be carried out under a new guise, with the staff becoming the eight regional offices of the NHS Executive, each led by a regional director.

Now the regional directors have disappeared, or are in the process of disappearing, and there are four directors of health and social care covering four areas of the country, although I understand that the regional offices will not disappear until March 2003.

Although not called "regional directors", these directors carry regional responsibilities. They are described on the Department of Health's website as being, 4 Regional Directors (who) will provide a link between the Department of Health and the frontline NHS and social services". That link is important and needs to he made transparent.

I know that on our first Committee day the Minister was at pains to say that the new directors of health and social care are not an extra tier in the NHS but are really a part of the NHS headquarters—a sort of headquarters in the country. Amendment No. 92 does not rest on whether that is a tier as such. It rests on the very existence of the posts which have a potentially significant role in how the NHS operates in practice.

The directors of health and social care have the potential for great influence within the NHS. They generally operate out of the public eye, but occasionally we get a glimpse of what they do. A recent example is a letter written by Mrs Carnall, the director with responsibility for the South, who told her health authorities and trusts that a projected £60 million overspend was "totally unacceptable" and that they must find "solutions". I ask the Minister in whose name the regional directors describe matters as "totally unacceptable"? We have to assume that they speak on the Secretary of State's behalf. That is why we need to see what they do and how they do it.

There is a description of the activities of the four directors in Shifting the Balance of Power, but it is difficult to see these activities providing much for the directors to do, let alone the 40 staff that each of them will have, and that number excludes staff who will work for the regional directors of public health. But "trouble shooting" is listed as one of the roles. Will the directors troubleshoot strategic health authorities, primary care trusts, NHS trusts, general practitioners, or all of those? What powers will they have'' How will they in practice carry out their tasks?

Many questions can legitimately be asked about the four directors. Amendment No. 92 seeks to put some basic facts into the public domain about the directors, their staff, what they do, how they do it and how much they cost. I see that information as shedding light into a corner of the Department of Health which has become obscure over the years. It will provide a good springboard for the Health Select Committee in another place to look at what the directors do and it may also provide an opportunity for your Lordships' House to debate the role and function of that part of the NHS.

But it is not only the relationship of the directors to the NHS that is important. The Local Government Association has expressed its support for the amendment as, one way of tackling the lack of clarity that currently exists in relation to the social care remit", of the directors. It has welcomed the opportunity for parliamentary scrutiny.

I hope that the Minister will clarify the role and purpose of the four new health and social care directors and describe how they relate to the existing regional offices. I hope that he will also describe how and to whom they are accountable. I hope that he will welcome the increased knowledge of their work which would come about if the amendment were accepted. In the interests of transparency, I beg to move.

Lord Smith of Leigh

I share some of the concerns of the noble Baroness, Lady Noakes. However, she is looking in the wrong direction to some extent. We should be looking at the role regional authorities can play in England in managing matters themselves. The noble Baroness is right that those bodies could have influence in the regions. Health matters and decisions about spending affect local areas significantly. They affect employment, regeneration and other matters important to the regions. It is vital that regional health strategies meet the strategies of other bodies that affect the regions.

Regionalism in England is on the march. Regions are beginning to recognise what they are missing out on. A BBC opinion poll in my region of the North West today states that 72 per cent of people would welcome the setting up of devolution in England. In answering the question, I hope that my noble friend will assure us that once devolution for England is proposed in the forthcoming legislation, health in those areas will not be forgotten. Meanwhile, I hope that the health bodies will talk to their regional partners to make sure that the strategies line up.

Lord Clement-Jones

That was fighting talk from the Back Benches opposite. It is great to see such support for regionalism from the Government Benches. Sometimes one does not see quite the same level of enthusiasm from the Front Bench.

7.30 p.m.

Lord Hunt of Kings Heath

I shall pass on the issue of regional government, though I warm to the noble Baroness's sentimental look back at the good old days of regional health authorities. I am beginning to think she should form an annual dinner where we meet to celebrate the past successes of those wonderful organisations.

Of course, it was the previous government who removed the old regional authorities, set up regional offices and then kept this rather peculiar role and office of regional chairman to straddle alongside the regional offices, which frankly did not work. I note also that the previous government did not feel it necessary to put into place the kind of reporting mechanism which the noble Baroness is suggesting today.

I want to make it clear, as I did in our earlier debate, that these directorates of health and social care are headquarters directorates of the Department of Health. It would not be appropriate for them to be the subject of separate processes of annual reporting.

I know the noble Baroness, Lady Noakes, disagrees with me about the significance of those directorates not being a separate tier of the NHS. But it is an extremely important issue. The four directorates of health and social care are members of the Department of Health's management board. They will between them have the main responsibility for working directly with the NHS and performance managing strategic health authorities.

That role will involve the oversight and development of health and social care, ensuring that local health and social care communities are developed in an integrated way to deliver modernised services and supporting the Chief Executive and the Chief Inspector of Social Services at the Department of Health in assessing the performance of the whole system. In public health, the director for health and social care will have a regional director of public health and public health team co-located with each government office. I have already made clear that the regional directors of public health will be jointly accountable to the directors of health and social care, and to the Chief Medical Officer. They will be managing, as part of a national programme, the appointment, development and succession of senior management staff. They will be supporting Ministers through casework, ministerial visits and local intelligence.

As the noble Baroness said, they will deal with troubleshooting. I am fairly clear what that means. It means getting involved when things look as though they are going wrong; banging heads together—as the noble Baroness will be aware, I am very keen on that—and dealing with issues as they arise within the region for which they are particularly responsible. In the first instance they play a major role in developing the new organisations, maintaining close involvement, whenever necessary, with strategic health authorities and focusing very clearly on performance management.

The noble Baroness, Lady Noakes, asked a number of questions about the specifics of how it will all work, or at least her amendment seeks to adduce that information in the fullness of time. First, she is right that regional offices will not be formally wound up until March 2003, but the new directors start their work formally from April this year. The 12-month period is merely a transition to deal with any overlap. Obviously we want to avoid any duplication of effort between the regional offices and the new directors.

In 2002–03 the running costs will amount to roughly £30 million rising to £34 million in the next two financial years. Clearly a number of matters have not yet been settled and I would not want to be held exactly to those figures.

The other point I would make is that those people are national directors. As I said, they have seats on the departmental hoard and we will expect them, alongside their regional responsibilities, to contribute to national work as well. It will be quite likely that a director of health and social care will also take on lead responsibility for national work as well. That reinforces my point that this is not an additional tier; these are merely senior officials of the Department of Health with specific responsibilities as part of their duties for a specific region in England. Accountability is quite clear. They will be accountable to the Chief Executive and Permanent Secretary of the Department of Health.

From what I have said, I hope that Members of the Committee will agree that it would be inappropriate to single out just four members of the management board of the Department of Health for special treatment in that way. I invite the noble Baroness therefore to withdraw her amendment.

Baroness Noakes

I thank the Minister for his reply and for the information contained in it.

Perhaps I should say at the outset that, though I was grateful for the comments of the noble Lord, the amendment was not tabled with any zeal for regionalisation, as he might imagine. It was tabled with a zeal to understand the interface between the Department of Health and frontline NHS and social services, to use the language of the department's website.

I hear what the Minister said as to what will be happening. It will be interesting to see how it works out in practice, which is why the amendment was moved. I hear what he says about this not being a tier, though that is not important. What it encourages me to do is to look at the information available as to what all members of the Department of Health management hoard do; perhaps it should not be confined to these four directors of health and social care. More light perhaps needs to be shed on the workings of the management board in general. I should like to think about that further. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Filkin

I beg to move that the House do now resume. In moving this Motion, perhaps I may suggest that the Committee stage of the Bill begins again not before 8.37 p.m.

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

House resumed.