House of Commons Hansard Debates for 13 Mar 1990

New Clause 3

Constitution of Community Health Councils in Wales

( ) (1) A Community Health Council shall be constituted for each District in Wales and

(a) shall assume in its area, such responsibilities and duties in relation to health matters and services as are undertaken by the existing Community Health Councils ;

(b) shall be invited by the relevant county council to participate in the formulation of Community Care Plans as specified in section 43 of this Act ;

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(c) shall seek to co-ordinate the views of relevant voluntary and charitable groups, the recipients of community care and other health services and their carers, and to convey those views to the appropriate county and district councils, district health authorities, special health authorities and the Health Service Directorate of the Welsh Office as appropriate ;

(d) shall monitor the delivery of health and community care services to people in its area, including the complementary provision of social, health and housing services ;

(e) shall issue an annual report on its work ;

(f) shall receive reports from any Independent Inspection Unit to be established by the Secretary of State as may report on services in its area ;

(g) shall issue reports on specific topics from time to time as it sees fit ;

(h) shall be authorised to hold joint meetings to consider such matters of common interest within the terms of paragraphs (a) to (e) above as are set out in the notice convening the meeting and may seek to reach a common view on such topics in accordance with Standing Orders agreed by the constituent Community Health Councils and approved by the Secretary of State.

(2) Community Care Services in this section shall be those defined in section 43 of this Act.

(3) Districts in this section shall be co-terminous with the areas served by District Councils in Wales.

(4) Community Health Councils established under this section shall be treated as successor bodies to the existing Community Health Councils under regulations to be established by the Secretary of State.'.-- [Mr. Michael.]

Brought up, and read the First time.

Mr. Alun Michael (Cardiff, South and Penarth) : I beg to move, That the clause be read a Second time.

The new clause aims to offer the individual, that is the patient, the consumer and the community in Wales, a real voice in the Health Service of the future. It aims to protect the interests of elderly, disabled and mentally ill people who are to be cared for in the community. It is logical to give the community health council a role in the two parts of the Bill which affect Wales. Health provision and care in the community must be complementary if the new system is to work.

The care in the community proposals need careful monitoring. Otherwise, they may well prove to be a recipe for neglect in the community, which is the genuine fear of all of us who served in Committee. The Government will simply blame housing authorities, social services authorities and the voluntary sector for any failures, although there is grave doubt whether those bodies will be given the resources that they need. Accusations will fly backwards and forwards unless there is a separate local and comprehensive system of monitoring. The CHC has been just such a watchdog in the Health Service and it would be appropriate for the new CHCs to have an expanded role on a more local level to cover care in the community. The CHC's traditional role in the NHS will become even more important if the Bill becomes law because there will be a need for a local monitoring system to ensure that the Government's promises are kept. Ministers have rejected our criticisms of the indicative drugs budget, practice budgets and the finance-led planning of their new health system. They claim that no patient will lose out, will be struck off the list or go without treatment. If their claims are genuine, they will want the local, effective, monitoring system outlined in the new clause.

I am surprised that the Secretary of State for Wales and his junior Minister have not responded to our suggestion

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that the new clause should be accepted as a positive and constructive measure and written into the Bill without the necessity of a long debate.

The new clause sets out to promote the role of CHCs in Wales in several particular ways, based on the special needs of Wales. First, it would enhance the duties of CHCs to advocate on behalf of the users of health and community care services. Secondly, it would co-ordinate such services and discussions about them, particularly community care, at local level. Thirdly, it would monitor such services from the consumer's view and, fourthly, it would communicate its findings to the users of such services at community level. I emphasise the nature of special needs in Wales. Wales has different and more acute health needs than England. First, more people in Wales develop chronic conditions than in England, particularly young children. Secondly, the male mortality rate is higher in Wales than in England, particularly for heart disease, cerebrovascular disease, bronchitis, emphysema and asthma. The prevalence of disability in Wales is over 20 per cent. higher than in England--even higher than the most severely disabled categories. It seems that the Government do not adequately recognise that. Many other statistics prove the point, while the reasons for the relatively poor health of people in Wales are well known. They owe a great deal to the industrial and economic history of the Principality. Those differences in health needs call for differences in health care provision. Proportionally more people in Wales visit their doctor more often than in England--particularly young children and people over retirement age. Fewer people in Wales have chosen to make use of private medical insurance. Fewer elderly people in Wales go to make use of private sector homes in retirement, and others are not in a position to exercise any such choice.

A significantly higher proportion of prescriptions in Wales are exempt from payment by virtue of their recipients' financial circumstances than is the case in England. Some important initiatives have taken place in Wales. Heartbeat Wales, launched on St. David's day in 1985, has already achieved much by working with many sectors of the community, including food retailers, industry and the unions. The Lose Weight Wales campaign and several television series have played their part, but the people of Wales, in many unique ways, rely on their National Health Service.

The new clause is partisan in the best sense of the word. It is a serious attempt to maintain the special relationship between the people of Wales and the statutory provision of health and community care. Before moving on to consider the substantive provisions of the clause, I remind the Minister of the commitment that he made elsewhere that he would report as soon as possible on the operation of the joint Welsh Office--National Health Service working group studying the changeover from the steering committee on resource allocation in Wales--the SCRAW formula, which is currently used to determine resource allocation--to the as yet un-named future formula for Wales. The formula contained in the White Paper "Working for Patients" has already been described by the Chartered Association of Certified Accountants as one which

"emphasises simplicity possibly to the detriment of equity"

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in the same way as the poll tax perhaps. Simplicity to the detriment of equity characterises the Government's proposals for the community health councils in Wales.

The unique health needs of Wales, the wholly different service delivery structure--I remind hon. Members that Wales has no regional health authority--and the huge internal diversity of population density, persuaded preceding Ministers to develop formulae that allowed investent related to Welsh needs, rather than a statistical abstract devised in England. We should ensure that the same is the case in the future. We have already seen how standard spending assessments for social services spending relate to the needs of particular communities. We do not want that disaster to be visited upon the elderly, the infirm and the sick of Wales once again. At present there are structural differences in the Health Service in Wales because it has no regional authority. The Welsh Office fulfils the function of that authority. Therefore, in many cases the Secretary of State is judge and jury in his own decision-making. Wales has several community health councils per district health authority at the moment--two in South Glamorgan, and three or four in most other counties--whereas in England there is one per district health authority. That is an inappropriate structure for Wales. The district health authorities in England cover a smaller area than in Wales where, except in Pembroke, the authority covers the whole county.

The Welsh Office proposes to merge the present community health councils into one per district health authority--one for Mid Glamorgan, one for Clwyd, one for Powys and so on. The maximum number of members for a CHC will be the same as at present--24--so representation will be reduced in every county in Wales, and that is completely unacceptable.

The only argument that the Welsh Office has put forward in favour of a single CHC per district health authority is that it would speak with a single voice on behalf of consumers in the health authority area. Colleagues may reflect that the interests of consumers in Merthyr and Bridgend or Rhyl and Wrexham might be best served by having different voices that are attuned to the specific needs of those communities and the people who live in them.

The suggested parallel with England--where there is one community health council per health authority area--is inappropriate because the population per community health council is much greater in Wales, on the present pattern of community health councils, than is the case in England. It would be totally inappropriate and far worse were the Government's proposals to be followed.

The proposal in the new clause is threefold. First, the number of community health councils should be increased to one per district council area in Wales, thus allowing a strong and more local voice to be heard on behalf of communities. Secondly, a mechanism should be created to allow a joint meeting or a representative meeting on a district health authority-wide basis--again, apart from Pembroke, that means on a county-wide basis--to consider matters on which community health councils want to speak with one voice because they believe it to be in the interests of consumers. Such matters could include the location of district general hospitals and common aspects of the 10-year health authority plan, where it is appropriate that communities throughout the county area should come together to debate the structure.

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Thirdly, the role of community health councils should continue to cover Health Service matters but should be extended to cover care in the community, including a joint provision that involves health, social services, voluntary and private organisations, housing and so on. That would provide a much stronger voice for the consumer and the community. It would be locally focused and it would be appropriate to the community-based provision for the elderly, the disabled and the mentally ill that the Government claim that they wish to create. 2.45 am

If the Bill becomes law, the district health authorities will be run by a small board appointed by the Secretary of State. None of its members will be representative of the community and accountability will disappear. In Wales, the Secretary of State is also the regional health authority and the person who gives resources to the social services authorities, the housing authorities and the voluntary organisations. For there to be any monitoring, accountability or representation of the consumer and the community, it is vital to have the strong community health council structure that the new clause proposes to enable them to undertake the advocate's role on behalf of the consumer and the community.

The Secretary of State has advocated a reduction in the number of community health councils from 22 to nine, but no argument has been advanced for such a reduction. It is not that the Secretary of State is dissatisfied with their work. He acknowledges that the community health councils in Wales

"have done much and valuable work in monitoring health care provision and in providing advice and counselling to patients and the public at large."

The Secretary of State's declared aim in his review is to "strengthen and focus the community voice."

How could he say otherwise? The active participation of the consumer is claimed to be an essential part of the proposed reform of the National Health Service that the Bill seeks to establish. The White Paper "Caring for People" speaks warmly in paragraph 5 of the need at local level to focus attention

"on formulating strategic and operational plans to increase participation and choice by service users".

There are no practical proposals in the Bill to increase participation and choice by service users. Their participation is reduced and will be virtually removed, unless the Government accept the new clause.

The Secretary of State's consultative paper on quality of care looks forward to the development within the National Health Service directorate in Wales of a "genuinely consumer-oriented organisation." How? The mechanism is not there, unless the new clause is accepted. The Secretary of State's proposals seek to reduce the number of community health councils and also, by limiting the numbers of members of the reorganised community health councils to the number of members who currently serve on CHCs, to reduce further representation with a consequent reduction in overall community health council membership. My proposal would allow an increase in local representation, yet could allow a modest decrease in the numbers on each community health council. If there is a larger number of community health councils to address the needs of local communities, each can have a slightly smaller membership. They will focus on much more local issues.

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We also provide a mechanism to bring people together on a county-wide basis in order to provide a small, representative group--something that, apparently, the Secretary of State wants. Consumer protection is now a recognised social policy objective except, it appears, in the Welsh Office. A wide range of legal measures in both industry and commerce exist to further that objective. Little else, besides the community health councils, exists to cover social welfare. In fact, until the appearance of this new clause in respect of Wales, there were no proposals recognising that need in relation to care in the community.

The report of the panel of inquiry into the future of community health councils, which was prepared by the Association of Community Health Councils, makes the case for the advocacy on behalf of consumers that the new clause seeks to protect. It says : "The crucial difference between consumers of health services and most other consumer groups which requires an active body working on behalf of the former group is that a large number of them are weak and vulnerable and are highly dependent upon the continued receipt of services. This makes it extremely difficult for them to complain personally without support, or to pursue a complaint when the administrative system is less than helpful as is commonly the case." That in itself is a persuasive sign of the need to build the new clause into the Bill.

Community health councils are specialists in consumer representation and advocacy. Their independence, accessibility, expertise and experience qualify them uniquely to speak on behalf of patients. Therefore, Conservative Members should have no difficulty in supporting the new clause, which further develops the claimed intention of the Bill--to work for patients. They may be further inclined to support the clause when they learn that, of the total National Health Service 1989-90 budget of £19 billion, only some £7 million is to be spent on user representation. I am sure that they agree--I invite the Minister to say that he agrees--that it is wholly unreasonable that a sum equivalent to only 0.035 per cent. of the National Health Service budget is devoted to what they say is such an important tenet of the changes that they are seeking to bring about. If they do not accept the new clause, it will be difficult to believe that they are serious about that.

The new clause sets out to establish a community health council in each district council area--not in each district health authority area, as the Secretary of State has proposed. Such an arrangement would not only provide for better community representation in respect of health matters, but would better reflect the administrative structure of Wales, its unique geography, and the very different problems that can arise within the boundaries of a district health authority. Paragraphs (b) and (c) of the clause would give effect to such an arrangement.

In the case of Powys, the area is more than 100 miles long from north to south. Consider the variety of communities in Gwynedd. Even in the smallest county--South Glamorgan--the last time a Government tried to have one community health council, the proposal was rejected. That is why we have two community health councils. That is why, in the smallest county of Wales, which does not have the geographical problems of many other counties, a change to one community health council would be totally unacceptable.

Paragraph (c) gives to the community health councils the function of co- ordinating the views of relevant voluntary and charitable groups and of the recipients of

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community care and other health services and their carers. Those views would be conveyed to the appropriate county and district councils, district health authorities, special health authorities and the Health Service directorate of the Welsh Office, as appropriate. What Member of Parliament for a Welsh constituency would argue that there is not a need for that function? Which of us has not come across the need for the co-ordination of information and for communication with those services and voluntary organisations? The co-ordination of those involved in care and service delivery is therefore basic to the new clause and, if the Government's claims are to be justified, should be basic to the Bill. Those two paragraphs ensure that, particularly in relation to community care plans, local needs--and I mean local needs, not just needs on a county -wide basis--are effectively identified, and that resources and services, both formal and informal, are put most effectively to use. I need not rehearse the arguments, which were put forward and largely accepted by the Government in Committee, about the need for full and effective co- ordination of services. However, I should like to illustrate from my own experience how urgent such matters can be and, thus, underline the main message--that the provision of accommodation for the elderly, the disabled and the mentally ill must be arranged to fit with the community care planning by social services authorities, health authorities and voluntary groups. Housing must be taken into account. The district councils and housing associations in an area must be involved, as well as the county council and health authority functions.

In Committee, many examples were given by hon. Members of cases in which resource allocation and quality of provision were important and flexibility was essential. I spoke in Committee of Colin Griffiths, a constituent, who is now tetraplegic following a tragic accident. He is an extremely couragous and extremely independent-minded young man, something in which his parents support and encourage him. He wants to be as independent as he can be--a desire best illustrated by the fact that he wants to help other young adults who face the same problems and encourage them to fight for an independent and full life and a sense of self-worth. When I spoke to him recently, how he could do that exercised his mind more than how his personal needs could be met.

For Colin Griffiths to have the independence to which his courage entitles him, several factors must be fitted together--appropriate housing and day care, help with mechanical aids, transport and so on. As well as guts, this young man has family, Church and community support with which to tackle his position. Tragically, his circumstances are unique, and not all families and communities can offer the same support to the individual.

We have two responsibilities in this case and in many others involving elderly, disabled and mentally ill people in a variety of circumstances. One is to have an efficient and responsive system of health care and care in the community. The second is to make sure that there is an adequate, efficient and local system, which will monitor that provision, give a strong local voice for the consumer and draw together the different ways of providing for individuals in the community and the community as a whole. That is what the new clause is all about.

I draw the Minister's attention to the comments of the National Consumer Council, which also looks at specific examples. The NCC said :

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"Our recent work with elderly people with dementia and their carers has shown that liaison between health authorities, primary care and social services departments is still, in some areas, poor. This has a detrimental effect on those users who may be in need of help from across the sectors and who would benefit from better and more closely co-ordinated planning."

This demands a mechanism to monitor and review the service provided, and the new clause provides the way to do that in Wales. It is not sufficient to anticipate a happy and harmonious unregulated relationship developing between the various local, voluntary and health services. It is true that in Wales such co-operation can exist--one thinks of the all-Wales strategy on mental handicap, for example--but there will be new players in the game in future, the private sector providers of health and social care. I am concerned that the Secretary of State seems reluctant in his review to let even the few community health councils that will survive get too close to National Health Service provision.

In the unlikely event of a hospital trust emerging in Wales--I trust that it will continue to be unlikely--the Secretary of State has been careful to point out that a community health council would deal only with a district health authority and not directly with the trust. Moreover, the community health councils would not have an automatic right of access to routine trust meetings or papers. What is the Minister trying to hide? Are such trusts to remain within the NHS, as Ministers keep telling us? In which case, why have this hand-off to the community health councils? If the trusts are to be within the NHS, why should they be accorded such special treatment? There are important functions for the community health councils to undertake. We come logically to monitoring. Paragraph (d) would ensure that quality is assessed at consumer level. I pay tribute to the high moral tone and the general worthiness of the comments emanating from the Department of Health relating to independent inspection units within districts and the Welsh Office's "Quality Patient Care" document. However, neither mentions the other and both pay little regard to the consumer.

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Let us consider the current position in relation to the work of community health councils. I give the example of North Gwent community health council, the work on which it has reported and its representations to the Secretary of State for Wales recently. It describes its work as follows :

"Members undertake regular and frequent visits to all hospitals, clinics, day centres, etc., where they talk to patients and their visitors, and see conditions as they are. This is considered to be the most important and productive aspect of Members' work." That can be multiplied around every community health council in Wales. The community health council continues :

"if there were only one CHC with 24 members to represent the whole of Gwent, it would not be possible to fulfil these visits, and, indeed, much of the time would be spent in travelling the length and breadth of the County. The geography is such that the County is divided by valleys, most of which with a hospital as well as other health care premises. The distance may not look enormous, but in reality, mileage would be considerable ... it is considered extremely unlikely that anything like the present levels of visits could be maintained."

Is it really the Minister's intention to reduce that invaluable element in monitoring the Health Service? Will he really refuse the proposition in the new clause that that monitoring be extended to how that health provision

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inter-relates with care in the community, such as the social services, housing services and the other services that are needed to give proper provision for people in the community?

The example of North Gwent community health council is not untypical, especially in respect of the independent inspection unit. Do the Government feel entirely happy, despite the arm's length management of such units, that poachers, however reformed, will make the best gamekeepers? The Royal College of Nursing and others have pointed out that the local authority will find itself in a monopoly position on care in the community, with a combination of registration, assessment, procurement and regulatory powers. The community health councils, under the proposals, would provide a meeting place for the noble intentions of the Welsh Office and the independent inspection units of the local authorities, both under the scrutiny of the people who matter most--the patients, the consumers and the community in which they live.

The key point in the communications role of the community health council is as a disseminator of information to people who desparately need accurate and proper information. First, it is difficult to know what services are available. We already see the confusion about that. How does one know that a dog is there if it does not bark? Secondly, it is almost impossible to know what services are available if one does not have direct access to a professional. Thirdly, none of the professionals involved in care in the community has a specific brief to disseminate information and none is required to do so in such a way as to promote access to services. It is only the community health council that can do that. Fourthly, there is after all a proliferation of professionals, all of whom have at best a partial knowledge of the range of services available. Fifthly, most people look for information at a time of crisis. Whether disabled and elderly people receive help depends on their condition, where they live, the structure of the local authority and their luck with professional contacts. We need to guarantee the availability of information as well as services.

The recent report of the King's Fund said :

"Methods of getting information to parents about formal care facilities are very inconsistent. It depends very much on local developments and the interest and enthusiasm of individuals and professionals who want to be involved."

The experience in Wales is that the individuals in the community health councils have that enthusiasm and commitment. With no mechanism in any county in Wales to inform professionals of available services, even carers in regular contact with professionals may be unaware of and, therefore, denied access to support services. They are victims of a vicious circle of mutual ignorance and that applies both to health services and to care in the community.

Paragraph (h) is a serious attempt to meet the apparent need of the Secretary of State for a system once more based on simplicity rather than equity. I hope that he will find the paragraph and the rest of the new clause acceptable. That provision would draw together the community health councils, which would be locally based and well informed about their localities so as to hold joint meetings, and thereby achieve the single voice that Ministers want for the consumer and for communities.

The Secretary of State says that he wants a clear, coherent voice for the consumer. That is a nice idea, but it

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is not easy to deliver, bearing in mind the danger of oversimplification and distortion. Indeed, it can fairly be said that there is no such thing as a coherent consumer voice. The public at large will always have a variety of views about any topic. Is it really the role of the CHCs to reconcile those conflicting views, or should they take on the job of ensuring that all expressions of opinion are articulated to the decision-makers in the NHS? Communities will have different interests to be articulated. That is the real meaning of strengthening and focusing the consumer voice. Our proposal in the new clause would achieve that, rather than the half-baked proposal to reduce the number of community health councils in each county.

Strengthening the consumer voice by reducing the number of CHCs in Wales from 22 to nine is a contradiction in terms. There is no evidence that a CHC in a county would give a clearer and stronger focus to the informed consumer voice than does the present pattern of CHCs. Our proposal would strengthen the local element in the representation of the individual and the community.

The new clause would do the job for the Minister because it would strengthen the local community voice and, where needed, create a single voice. It would do what the Minister says he wants to do, and I appeal to him to support it in the interests of consumers and of communities throughout Wales.

Until now, health authorities have been run by committees that drew on a mixture of backgrounds, such as medical experts, people elected by the local councils and people appointed by the Welsh Office. In future, much smaller boards will be running the system with fewer medical experts and no local representatives and with all their members being appointed by the Welsh Office. In Wales, unlike in England, we do not have the regional health authority. In future, the budget, policy-making and appointments-- all our health authority functions, and much more--will be in the hands of one Minister and his civil servants and there will be no local representation. Where is the voice of the consumer to be heard? How will communities such as Penarth, Merthyr and Bridgend express their views about the type of health services that they need? Who will monitor the way in which the elderly are cared for in the community? Who can listen to the disabled and the mentally ill? The answer is nobody--unless the CHCs can be salvaged from the threat that hangs over them and are made local, effective and coherent, as we propose in the new clause.

Mr. Nicholas Bennett (Pembroke) : The hon. Member for Cardiff, South and Penarth (Mr. Michael) said, basically, that community health council areas should be the same as district council areas. It is a pity that he took half an hour to say it.

Mr. Ted Rowlands (Merthyr Tydfil and Rhymney) : We have a national health system, but it is also a local health system, and it is vital for us to bear that in mind. The system originated in local community health care. It was from the valley communities that the notion of a national health system was created. We must make sure that we achieve the right balance between a genuine National Health Service and a local health service.

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Since those early days we have developed a complex, specialist service which must now be truly national, in Welsh and in British terms. But there is no reason why it cannot be accountable to the community.

As my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) said so eloquently--despite a brief and nonsensical interruption from the hon. Member for Pembroke (Mr. Bennett)--the community health councils have been extremely effective. I can only speak from my own experience, but our CHC has certainly been effective. Mr. Bryn Williams has been active and supportive, raising money and also, on occasion, exercising vigilance and being critical of the service. The Government's notion is to take the word "community" out of community health councils, but, with respect, the community of Merthyr and the Cynon Valley is not that of Mid Glamorgan or some grander district.

Throughout the Bill's passage so far, we have debated--rightly, in my view- -whether patient power, or consumer power, can be increased. Opposition Members reject the idea that it can be increased through the creation of a false or flawed system of competition, which is at the heart of the Bill. In the communities that I represent there will be only one health system : only one district general hospital, only one practice or group of practices , and only one health centre. There will be only one set of arrangements to which those in need can turn. We do not want to create a divisive, competitive system ; we believe that the existing system should be made more responsive. Although we do not need American-style competition between general practices and between hospitals, we cannot be complacent about the current response of the Health Service to people in need. Certainly I am not complacent : I believe that the system must be more sensitive. I want better care and shorter waiting lists for the communities that I represent, and I agree with many of the criticisms. The answer, however, is not to give people the false impression that they can "shop-around" ; we need to develop the present system, making it co-operative rather than competitive, and more accountable and sensitive to the community.

In that regard the CHCs have an important role to play. No one is saying that they are perfect ; they are an imperfect vehicle to express the views of a community, to pick up its complaints, to apply pressure and at the same time to be active and supportive. The CHC has been described as a local watchdog, but mine is also a great fund-raiser. CHCs have backed the facilities of the Prince Charles hospital, and helped to raise money to produce the finest technology available in the Heads of the Valley. That is one of the major functions of CHCs. We should not destroy their community base. We should develop the system further. I reject the philosophy behind the Bill--the notion that the way to promote patient power is by competition.

As I have said, we need a new regulatory system on behalf of patients, consumers and the community. There is a case for establishing new performance standards at all levels. In a unified Health Service in a community such as I represent there must be standards and performance levels that everyone, from consultants throughout the system, must meet.

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The Government have not made that the centrepiece of the Bill because they believe that, in a curious way, competition will deliver that objective, but it will not. The Health Service should be developed by putting more resources into it and it should be made more responsive by establishing new standards and by creating a new regulatory body.

The CHCs could play a vital part in doing just that. The Government's nonsense has no support. The area health authorities, the supposed victims of the CHCs, are against the notion of abolishing them. Whether on the poll tax or education and certainly on health matters and the CHCs, the Government, as always, are on their own. The rest of society rejects them and their proposals.

Mr. Richard Livsey (Brecon and Radnor) : The rationale behind the Government's and the Welsh Office's thinking on CHCs is to diminish their effectiveness in representing their areas. The proposal in the Welsh Office's consultative paper that the number of CHCs should be reduced from 22 to nine is a direct threat to their effectiveness in representing community interests to the nine district health authorities.

It is important to realise that just when the district health authorities are to be streamlined into a corporate type body with 10 directors, five executive and five non-executive, the CHCs in Wales are being irreparably weakened. All members of the new district health authorities will be appointed rather than elected, and that tells its own story. The communities will no longer be represented on the health authorities. In those circumstances, the community interest will not be protected.

The reduction in the number of the CHCs from 22 to nine and the consequent increase in the area that each CHC covers will fatally weaken the democratic checks and balances in the Health Service in Wales. At present, individual communities are protected by CHCs and new clause 3 will increase the democratic accountability of the Health Service in Wales. The move to reduce the number of CHCs to nine is a cynical and deliberate attempt to undermine the effectiveness of CHCs and the checks and balances.

In Powys, Brecon and Radnor community health council currently has 24 members and Montgomery community health council has 16. The proposals are for one community health council for Powys with 24 members. If we consider that the size of Powys is such that if it were put on its end it would run from the Severn bridge to Hammersmith flyover, we can appreciate that a community health council covering such a distance would be pretty ridiculous. In addition, the population sparsity in Powys--it is unique in that it is the most sparsely populated area in England and Wales by a long way--makes it extremely unlikely that members of the proposed community health council in Powys will know what is going on 130 miles away at the other end of Powys.

If anything is to happen, the special situation in Powys needs recognition, in that it needs at least two community health councils, as at present. If we were to take the new clause to its logical conclusion, there would be three councils--one for Montgomery, one for Radnor and one for Brecon. That would give us proper community representation.

At present, community health council members are often volunteers. Often they cannot spend much of the

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week travelling up and down the area--in our case, Powys. They would find it considerably easier under the structure proposed in the new clause.

I make a special plea to the Minister--I have already made one to the Secretary of State. At the very least, Brecon and Radnor community health council and Montgomery community health council should remain in place and separate. That is the only way of effectively monitoring the community needs of the Health Service in Powys. In the present circumstances, an all- Powys CHC is not on. I have received representations from both community health councils in Powys. They wish to keep the present structure. They are representative of the communities. Given the spread of community hospitals, it is vital that there is someone from each community represented on community health councils. That most certainly will not be the case under the Government's present proposals. The new clause advocates a CHC for each district, based on the district council boundaries. That would be an effective counterweight to the new corporate style health authorities proposed in the Bill. As for the functions of the CHCs in Wales, the question is whether the standard of health service in their areas is properly monitored. Their acceptability to the public and their ability to represent the users of service when changes are proposed must surely be embodied in a greater number of CHCs than is presently proposed by the Government. The question is whether those functions can be better carried out if the number of CHCs is reduced, which seems unlikely. It might be administratively more efficient to have corresponding areas of CHCs and health authorities--nine of each--but it will be much more difficult for the remaining CHCs to carry out their tasks. The Government are also begging the question whether it is the CHC numbers that should be changed, not the health authority ones. That issue should be closely examined. If my hon. and learned Friend the Member for Montgomery (Mr. Carlile) is called, he will make that point. In parts of Mid Wales, patients may have problems with a health authority that diverts resources away from their areas. We know that patients leave those areas for treatment in other areas. The last function--that of representing local users--will be well nigh impossible. The needs of some local users may be very different from those in other communities in the same area. Because health authorities and family health service authorities' memberships are to be streamlined to exclude representatives of the community, as well as the professions, it becomes more important, not less, to strengthen CHCs in their ability to do their job. The Welsh Office envisages that local groups will need to be established. That acknowledges the fact that health authorities cover a range of communities. Why not accept that that is the case and have more CHCs--indeed, a CHC for each district? Local groups will not have the clout of fully-fledged CHCs.

It is impossible to escape from the belief that the Government are concerned with quietening voices critical of the way in which the NHS is run. Many of the Government's proposals, such as NHS trusts and contracts, ignore the patient's voice. Reduced numbers of CDCs would be too over- worked and too unrepresentative to be an active and successful patients' champion. Indeed, where hospital closures are proposed, it is vital for those communities that the CHCs based there can make proper

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representations to the health authority to ensure that the interests of the local community are protected. It is unlikely that that will be possible under the new structure. In fact, it may well be a negation of local democracy in relation to the proposed nine CHCs for Wales. It is not a constructive set of proposals, and it is anti- community.

The Parliamentary Under-Secretary of State for Wales (Mr. Ian Grist) : It may help the House if I intervene at this stage Hon. Members have spoken knowing very well that we issued a consultation document in November and have only just closed the list, although representations are still being received. They have come from most Opposition Members and from others, and we shall carefully consider what we have been told. We take the representations seriously and are not trying to ride roughshod over people's views. Of course, we believe in the proposals that we put forward in that document. We shall set them against any contrary views. Many hon. Members who have spoken have already let my Department know their views, so although they are not being repetitious in the terms of the House, they may be in terms of my office.

We do not propose any change in the primary roles of the CHCs, which will continue to monitor the quality of services provided, to comment on issues relating to changing patterns of NHS services--which, the hon. Member for Brecon and Radnor (Mr. Livsey) will be pleased to hear, includes closure or major changes to service--anything that has a bearing on the welfare of patients and, of course, anything that provides assistance to anyone who encounters difficulties with NHS services.

The purpose behind our proposals, which would include the replacement--it has been depicted as the notorious replacement--of the existing 22 CHCs by nine CHCs is designed to strengthen and focus the voice of the CHCs within each district and to allow them to take a more strategic view of the services for which each district health authority is responsible. Currently, four CHCs in certain areas cannot possibly take a strategic view of the health authority's proposals and activities within that health authority's area. We strongly believe that they are too localised.

We have made our proposals in the belief that the new and larger CHCs, not least because they will be better funded, should make a far more effective contribution on behalf of patients--for example, by expanding their work in areas such as patients' surveys and commenting on quality of work.

Mr. Alex Carlile (Montgomery) : How can the Minister say that a community health council which covers 50,000 people and 900 sq miles is too localised? What a load of rubbish.

Mr. Grist : The area health authority of the hon. and learned Gentleman is quite small, as area health authorities go. That is why it does not have a district general hospital in its territory ; 50, 000 is fewer than the number of inhabitants in my constituency. So I would have said that it was localised.

3.30 am

Mr. Michael : The Minister does not seem to be addressing the fact that various communities have different needs. If he does not want to consider Powys, he should take Mid Glamorgan where there are quite a few

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disadvantaged communities. Do not they deserve a voice local enough to focus on their needs? Has he read the new clause to which he is speaking, which offers a way of co-ordinating views at a strategic level within each district health authority area?

Mr. Grist : I think that the hon. Gentleman must have missed my assurance that we are taking the matter extremely seriously and are considering the various points made to us. The points about Mid Glamorgan will be borne very much in mind. He will be aware that there are proposals for the health authority to move its main district general hospital. Therefore, in certain circumstances, with a multiplicity of CHCs, instead of one CHC being responsible for the main district general hospital, wherever it was placed, it would move in and out of different CHCs.

Mr. Michael : The Minister seems not to realise that the health authority will be responsible for the district hospital, and the community health council will be responsible for expressing the views of individuals who live within a specific community. That is what he will destroy if the CHC operates at a county-wide level.

Mr. Grist : Clearly the hon. Gentleman has not appreciated the point that I was making that CHCs are responsible for looking at the delivery of service and the welfare of patients in the hospital structure as well. Therefore, any proposal for closure or major alteration will certainly be of interest to CHCs.

Community health councils should maintain a close link with their local populations. That was precisely why we suggested--it was just a suggestion- -that they might choose to establish local working groups on which CHC members might serve, as would other local people. Those would help the CHC to carry out its day-to-day duties.

The proposals contained in the new clause would further fragment the community health council network in Wales. It is ludicrous to suggest having 37 CHCs. The capacity for the CHCs to be able to watch the activities of the area health authority in any strategic sense would be vitiated. I believe that that would damage the interests of patients.

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