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Column 201Winterton, Nicholas (Macc'f'ld)
Column 201Young, Rt Hon Sir George
Tellers for the Noes: Mr. Bowen Wells and Mr. David Willetts.
Column 201Question accordingly negatived .
`3. Section 12 (supplementary provisions about health authorities) shall be renumbered as subsection (2) of that section and-- (a) before that subsection as so renumbered insert--
"(1) Every Health Authority shall make arrangements for securing that they receive from--
(a) medical practitioners, registered nurses and registered midwives; and
(b) other persons with professional expertise in and experience of health care,
advice appropriate for enabling the Health Authority effectively to exercise the functions conferred or imposed on them under or by virtue of this or any other Act.",
(b) in that subsection as so renumbered,'.
The amendment arises from a commitment that I made in Committee. I made it because of a general concern felt across the professions involved with medicine that their involvement in health authority decisions should not be left simply as a matter of good practice. In response to a full debate in Committee, I made it clear that the amendment would not set out a rigid system of professional advisory committees, because that would simply mean rebuilding the existing structure, which has already proved to be inflexible and which does not encourage arrangements to be tailored to local needs. I made it clear that we would be introducing something new. The existing structure does not take account of the full range of health care professions that need to contribute to a health authority's work. Therefore, the Bill removes the existing regional and district committee structure.
The amendment will add force to draft health service guidelines entitled, "Professional Involvement in Health Authority Work", on which the Government are consulting. I referred to that in Committee and I am pleased to tell the House that there has been an excellent response to that consultation exercise. The Department has written to 92 organisations asking for their comments and it has circulated the draft guidance widely within the NHS community. A total of 57 responses have so far been received, the vast majority of which have been supportive. For example, the vice-president of the Royal College of Anaesthetists said:
"The Royal College of Anaesthetists welcomes the guidance . . . The involvement of doctors and other professionals is essential for the proper planning, development and delivery of optimum health care for patients."
The executive secretary of the British Orthoptic Society welcomed the fact that
"the importance of professional input into Health Authority work is recognised."
The Chartered Society of Physiotherapy said:
"Broadly, we think the guidance is very helpful."
Column 202A consultant in old-age psychiatry from Southampton community health said:
"I thought I should write and say how encouraged I was by this Executive Letter . . . We look forward to the implementation of this letter."
Several professional bodies, notwithstanding their welcome for the Government's guidance, have said that it is important to secure effective professional involvement over and above the guidance. It is to provide that force, which I recognised in Committee and which was referred to by many hon. Members on the Committee, that we tabled this amendment.
The guidelines are not rigid. They stress that models should be considered carefully but not copied unquestioningly. They do not prescribe in detail how professional involvement is to be achieved, but they leave in no doubt the importance of that involvement. The amendment will give additional authority to the guidelines by placing on each health authority a duty to make arrangements to ensure that appropriate professional advice is available to them at every stage. Exactly how that advice is obtained is left to individual health authorities to decide. That is where they need flexibility to adapt to local needs.
A general feeling was expressed that advice must come not just from doctors and nurses but from a range of professions associated with medicine such as physiotherapists, ophthalmic opticians, dentists, pharmacists and dietitians. That point is stressed in the draft guidelines and is made clear in the amendment.
Hon. Members will wish to know what arrangements will be made to ensure compliance with the new legislation and with the guidelines. Regional offices of the NHS executive will monitor individual health authorities closely, especially in the important early stage when arrangements are being set up. They will require that arrangements have a real impact on health authority work and that health authority employees can be confident of easy access to professional input as necessary for their work.
I hope that hon. Members will be reassured that the Secretary of State has powers under section 17 of the National Health Service Act 1977 to give directions to health authorities with which they must comply. The Government will be willing to use those powers if it becomes necessary to ensure that all health authorities implement the new duty effectively. I make that point specifically to underpin the Government's view and to ensure that our commitment to professional advice is not just written into statute but will become an effective and living element of the way in which health authorities work from day to day.
There is one further point, which is made clear in the guidelines but which I should like to take the opportunity to emphasise. The arrangements made must command the confidence of professions locally. In the Government's view, that will not be achieved if health authority management seek to control the agenda too tightly. Some concern has been expressed on that point, and it is that concern which I wish to answer.
It is important that arrangements are flexible enough to allow professionals to initiate discussion on issues of concern to them. One of the representations made by a number of people on the guidelines was: could only the health authority initiate such discussion, or could professional advice be offered if the professional
Column 203organisation wished to take that initiative? I can assure the House that all professionals will have the opportunity to initiate discussions on issues of concern to them. Arrangements will be firmly in place, supported by the amendment, to ensure that such concerns are seriously and carefully considered.
I am convinced that the amendment will give hon. Members and, more important, professions outside the reassurance that they need and have sought. Its purpose is to ensure that every authority does its work, and is seen properly to do so, by seeking professional advice. I give the House an undertaking that any authority that does not seek such advice or does not listen to it when it is volunteered and discussions are initiated will not be complying with the new statutory duty under the Bill.
I commend the amendment to the House. It fulfils a number of the concerns that were expressed by hon. Members in Committee. I hope that hon. Members who spoke on the matter will feel that it also fulfils the commitment that I gave in Committee to table a substantive amendment on Report to deal with those matters.
Mr. Kevin Hughes: The Government plan under the Bill to abolish local and regional advisory committees in England, but are leaving the national advisory framework for Wales in place. In Committee, we challenged the Government on that proposal. In response, they tabled the amendment.
The Government are making a clear statement in statute about the duty to recognise the importance of involving clinicians in the decision-making process. They apparently accept the importance of clinicians' involvement in the decision-making process in the NHS. The Secretary of State was explicit on the point on Second Reading, when she said:
"Sitting on boards is not the only way for professionals to be involved, nor is it sufficient."--[ Official Report , 12 December 1994; Vol. 251, c. 642.]
In spite of those words, however, the Bill still contains a provision that abolishes the local advisory machinery. Therefore, although I welcome the Government's amendment, I can give it only a partial welcome. I am happy that the Government have given the consultation of clinicians a force in statute, which may offer health professionals some reassurance, but I cannot understand the decision to proceed with the abolition of the advisory machinery, which facilitates that consultation and which is proposed under the Bill. 6.45 pm
The local advisory machinery has wide support. The British Medical Association and the Royal College of Nursing have expressed concern about the proposed abolition. The alternative arrangements are still not totally clear. It is only one month since the NHS executive issued its draft guidelines on the matter. Health professionals and their associations have had little chance to consider the guidelines, which were issued well after the legislation abolishing the current machinery. Consultation on the draft is still continuing, so we may not have the final guidelines for some time. Indeed, the Minister told us earlier that he has received only 57 responses so far. Although the Secretary of State talks about wanting an integral place for professional advice in the NHS structure, she cannot tell us what that structure might be.
Column 204She has hived off policy making to the NHS executive, and it is the executive, not the Secretary of State, that is making decisions. The Secretary of State, therefore, is asking the House to abolish something, yet we are not clear what will replace it. That has been typical of the Government's approach throughout the passage of the Bill, which is vague and lacking in detail. The Royal College of Nursing has described the duty in the amendment as welcome, but a "poor replacement" for the present statutory advisory machinery because it does not specify how or at what level in an organisation such advice should be maintained. There must therefore be reservations about the amendment. Welcome though it is as a small move in the right direction, Labour Members feel that it does not go far enough.
The Government tabled the amendment to try to reassure professional organisations, but, as the BMA has made clear, without a formal structure to put before the House for consideration, opposition to the changes will inevitably remain.
The Government appear to justify the abolition of the current machinery on the grounds that, somehow, it is peripheral. Professional associations do not share that view. They have been very supportive of the machinery and are alarmed at the Government's decision to abolish it. We need an alternative if we are to be able to judge the merits of change. To proceed with the abolition of the current arrangements without providing an alternative does not appear to fit in with the Secretary of State's apparent commitment to the importance of professional involvement.
The amendment goes some way to ensuring compulsion to involve professionals, but Labour Members will want to be sure that the consultation is effective and real and that it is certain to be available to all levels in the NHS--locally, regionally and nationally. In that sense, the Government's proposals are a real disappointment.
Proper consultation is the only way to ensure effective allocation of resources. Health care purchasers will need to know which treatments are clinically effective and proven. They will need to know a good deal about new treatments before deciding to proceed with the development of those services locally. Members of the medical profession must be involved in the purchasing and development of health services if purchasing is to be effective.
Without the involvement of the professions in decision making, the efficiency that the Government claim to be pursuing will be difficult to achieve. Purchasing of services can be effective only if managers are aware of the clinical effectiveness of treatments, the difficulties that exist with services or units, the maintenance of quality standards and advice on new procedures and drugs that are available.
The amendment may go some way to reassuring health care professionals of the Government's intentions, and Labour Members are pleased with the Government's decision to move it, but health care professionals have also stressed the need for a formal mechanism for advice to ensure that the views of clinicians are heard at all levels in the NHS.
Column 205I very much regret that the Government, in spite of their fine words, do not think the matter sufficiently important to introduce it in statute, but I look forward to seeing the final guidelines from the NHS executive.
The Minister will recall that I moved amendments in Committee that would have retained the present advisory system, which is working. In Committee, the Minister said:
"The guidelines make it absolutely clear that professional involvement is not an optional extra . . . Will this be a sticking plaster over a commitment or will it be something real that works on a practical, day-to- day level. I can assure him that it is the latter and that it is something that Ministers understand to be fundamental to health authority work."
He went on to say that another important point was that
"the arrangements that are in place are not just tokenism. They do not just go through the motions .. Those professional arrangements will have a real impact on health authority work and decision making. On some issues, professional input may be needed which covers several purchasers."--[ Official Report, Standing Committee A , 7 February 1995; c. 152-3.]
The Minister gave some commitments, and my reaction is similar to that of my hon. Friend the Member for Doncaster, North (Mr. Hughes). The Minister has honoured his commitment but the amendment contains words that need to be firmed up. The consultation period on the draft guidelines, entitled "Professional Involvement in the Health Authority Work", is to end on 28 February. He has so far received 57 responses but I am sure that he will have more by that date, although it is not too far away. The BMA has told me that it has yet to send the Minister its response. That is probably true for nurses, too. Both groups welcome the amendment and are correct to commend it, but some words need further clarification.
The amendment refers to
"advice appropriate for enabling the Health Authority effectively to exercise the functions conferred or imposed on them".
The question that must be asked is who decides the advice to be appropriate? Under the old system, medical advisory groups and other advisory committees representing various groups in the health service decided when they thought advice from them was appropriate. The committees would advise health authorities and, further up the scale, the Secretary of State on what they thought appropriate. In this instance, it is not clear who is to judge the appropriateness. If the Minister wishes to clarify the point, I should be pleased to give way.
Mr. Malone: I am glad to oblige the hon. Gentleman with a little textual analysis so that his mind may be set at rest. I am grateful to him for reporting to the House at such length the speech that I made in Committee. It would not be sensible to have written all that into the amendment, which I know he is not suggesting should have been done.
I direct the hon. Gentleman's attention specifically to the amendment. Proposed subsection (1) states:
"Every Health Authority shall make arrangements for securing that they receive . . . appropriate advice"
from various persons and groups. The reasonable interpretation is that health authorities have a statutory obligation to make arrangements "for securing" such advice. The fact that they shall "make arrangements" gives force to the amendment. The amendment goes on to
Column 206state what health authorities will get once they have made the arrangements. It includes in proposed subsection (1)(a) and (b) those to whom the health authority will look for the
"advice appropriate for enabling the Health Authority effectively to exercise the functions conferred or imposed on them".
That goes to the heart of what the hon. Gentleman is saying. The point is that health authorities must receive advice; it is not simply a matter of their seeking advice. It can be a two-way process: if the professions believe that they have advice that is appropriate, they will be able to tender it to the health authority. I hope that that helps the hon. Gentleman.
Mr. Gunnell: It is helpful, and the professionals involved will have to examine in detail what has been said. The amendment could have been interpreted to mean the subjects where the health authority felt that it was appropriate to have advice. If it in fact refers to when the profession feels that it is appropriate to have advice, the question that arises is what steps will the health authority take to get that advice? Will it set up something akin to an advisory committee? There is certainly a good number of advisory committees at the moment. We still seem to be at a flexible stage in deciding exactly what structure will prove acceptable.
The Minister has ensured that there is a statutory responsibility to get advice, but what structure within the medical profession will provide that advice? Will it, in a sense, be open season and that anyone who wants to give advice can do so? That would probably not be the most efficient way to proceed but, if a more limited structure were set up, we should need a model for involving the right professionals and professional groupings in the giving of advice. I am seeking merely to ensure that the professions are comfortable with the way in which advice can be offered. Let me cite a specific example.
We shortly expect the Secretary of State to make a statement on long-term care, about which there has been considerable speculation recently. She might be able to tell us tonight when we can expect it. We do not know whether her guidelines will leave a specific role for health authorities but, in commenting on what has so far emerged from the Department of Health, some people have said that health authorities will have a role in determining what they consider to be appropriate conditions for long-term care. I should have thought it was an issue in which some medical input was necessary. Such cases are often expensive so doctors might want to comment on individual cases as well as the category of people entitled to long-term care under the NHS. It is a very important issue, which is why we await the Secretary of State's statement with some interest.
I feel that the new arrangements mean that we might be getting closer to the position in the United States, where I lived and where it is essential to have medical insurance offering some hope of long-term care should one be struck with some dreadful, long-term, paralysing illness. However, very few people have a foolproof insurance policy. If we take the view that the health service will in future provide long-term care only if there is some hope of medical improvement or mediation, people will be in a very difficult position if they ever need life-long nursing care.
Column 207We await the Secretary of State's guidance with great interest, but this is just the sort of issue in which the medical profession will want to have an input, for individual cases or in terms of policy for an individual health authority. The question is, at what level should that input be? The Secretary of State might take the view that her guidance is sufficiently clear for there to be no need for medical input, but some matters still need to be clarified. If further clarification is forthcoming, I assume that it will be after the conclusion of the consultation period with the professionals on 28 February.
I join my hon. Friend the Member for Doncaster, North in welcoming the proposals. The professionals also welcome them but there are blurred edges which need to be clarified. We hope that when the full views of the professionals are known, the Minister will clarify the position. Perhaps there will be advice on structures for consultation. Perhaps he will make it clear that ` appropriate advice' is advice that the professionals feel is appropriate, just as much as it is advice that the health authority or the regional office thinks is appropriate.
Mr. John Heppell (Nottingham, East): In some ways, I am reassured that the amendment has no more clarity than most of the other proposals in the Bill. One of the things that has characterised the passage of the Bill is that the Minister has been unable to give us answers. It is always a case of, "Things will evolve", or, "You will hear about that in the future." In the same way, the amendment lacks clarity. It does not describe the mechanism or structure that will enable professional advice to be given to health authorities. Like some of my hon. Friends, I have thought about the way in which advice should be given. I thought that it would be wrong if the health authority just picked a doctor whom it knew would go along with whatever view it decided. We would need to get together a number of doctors at local and at regional level so that they could offer their advice. I then thought, "What would we call the groups?" In the end, I thought that the groups could be called, as they are now, local advisory committees and regional advisory committees. If the Minister has other plans, perhaps he will spell them out to us. The Minister gives the House a wrong perception when he talks about the people who have responded to his notice about guidelines. He talked about "a consultant". Throughout the Bill's passage, there has always been "a consultant in Newcastle" or "a doctor in Birmingham" to prove the Minister's point. The doctor says that whatever the Government are doing is right. I would like to read in detail all the responses from all the professional bodies. I suspect that they are saying, "Yes, we welcome the amendment, but we welcome it only because it is better than nothing." When the Bill began its passage through the House, the advisory committees were disappearing and nothing had been suggested to take their place.
I have here a briefing from the Royal College of Nursing, which says:
"This amendment is being proposed in response to concerns about the Bill's abolition of professional advisory committees at district and regional levels . . . Whilst this improves the legislation, it does not specify how, or at what level within the organisation, such advice should be obtained. It is a poor replacement for the professional advisory machinery that currently exists."
Column 208That is fairly unambiguous. The Royal College of Nursing welcomes the fact that the Government are doing something in response to their concerns, but it does not welcome the changes. It would much prefer the old system to be in operation.
Nurses provide 80 per cent. of patient care, so there is a real case for saying that they should have some involvement in decisions about purchasing. Should they not have some involvement in determining how the money is spent? They probably have far more involvement than Members of Parliament and far more involvement than many of the people who sit on the boards. On Second Reading, the Secretary of State said:
"We want professional advice to be integral in the new structure, and we want professional advice to become professional
involvement."--[ Official Report , 12 December 1994; Vol. 251, c. 643.]
I would welcome that; I would love to see professional involvement, because it does not happen at the moment.
On Second Reading and in Committee, I quoted the fact that of the 240 chairs of family health service authorities and district health authorities, more than half had interests in business, consultancy or finance. That was their background. Of the 240 chairs, only 15 have any sort of medical background. We must ask ourselves whether we are picking the right people. If we do not have on the boards people who have medical experience, we need to ensure that the advisory system is toughened up an awful lot more than would be the case under the amendment.
I know that the British Medical Association has not responded yet to the Minister. A BMA briefing makes the position clear. It says: "There should be comprehensive arrangements for medical advice and it is essential that some formal mechanism should be in place so that the views of doctors can be heard."
The word "formal" is underlined. We cannot leave it to the health authorities to make their own arrangements. As well as saying that advice should be sought, the mechanism and structure by which advice is sought should be spelt out in statute. If we do not have that mechanism and structure, there will be different systems across the country. Some of them may be adequate, but many will be bad. I now turn to the factors that health authorities should take into account when they seek advice. If a health authority intended to purchase obstetric care, the consultant would advise on whether antenatal care, postnatal care and the delivery should be built into the contract. If a health authority was thinking of closing a hospital for the elderly, the GP should advise on the support services that would be needed to allow the elderly patients to live in the community.
When considering the transfer of prescribing responsibilities, the health authority would need advice on the interface between what should be prescribed by the hospital and what should be prescribed by the GP. Obviously, health authorities need advice on such matters. When considering a contract for prostate surgery, there would be discussions on whether use specialist urology surgeons or general surgeons with an interest in urology.
It is almost certain that medical advice would have an impact on every business and financial decision--every decision--made in a hospital. The Minister has missed an opportunity here, as he has missed so many opportunities in the Bill, to do something positive in terms of trying to ensure that the medical advice is adequate and available
Column 209to the health authorities. He could have taken such action, but he has not done so. With this amendment, as with the Bill generally, he has failed to grasp the opportunity in front of him.
"other persons with professional expertise in and experience of health care."
I wonder what that means. I welcome the fact that advice will be sought from medical practitioners, registered nurses and registered midwives, as is right and proper. However, some of my hon. Friends feel that if the Government had wanted the advice of such people to have a big impact, having them as full members of the health authority, with a vote, might have been a better way in which to achieve that aim.
Leaving that aside, the category covering
"other persons with professional expertise in and experience of health care"
is not very explicit. In fact, it is extremely vague. I wonder whether the Minister is considering involving users of health care at some point. Although I have a great deal of admiration and respect for professionals, they do not always know what is best. Sometimes, health care user groups have a perfectly valid and important point of view. If the Minister's intention is that
"other persons with professional expertise in and experience of health care"--
Mr. Malone: Let me prick the hon. Lady's bubble, if I may, before we go too far down that line. The answer to her question, in general terms, is probably no. Proposed subsection 1(b) is drafted as widely as it is to take in the whole range of professionals. The Government did not wish to make an exclusive list. We were faced with the problem of certain professions and specialties emerging from time to time and describing themselves in different ways; so it would not have been wise to have been prescriptive. However, I would not try to suggest to the hon. Lady that the amendment would go beyond what it states to another area and cover, for example, areas which are perhaps already covered by community health councils, which are important for the user group to which she refers.
Ms Coffey: The amendment should cover other areas because although community health councils represent user groups, they do not represent every user group. User groups often change depending on the issues that arise, as I shall illustrate for the Minister. The health commission in Stockport and--I think--the health care trust as well, which is the provider of the service, decided to change speech therapy from a school- based service to a clinic-based service. Since then, there have been horrendous difficulties in maintaining even a clinic-based service because of a certain underfunding of speech therapy and when speech therapists have gone on maternity leave, there has been no provision.
Column 210That move from a school to a clinic-based service has had enormous repercussions in the screening of children at nursery level, which, as Minister will be aware, is the best time for screening for possible speech difficulties which impact on children's educational needs. The service relies on parents to take children to clinics for appointments. I may add that, after two appointments, a parent is not offered a further appointment.
The difficulty that arises, as I am sure the Minister will acknowledge, is that a child with well-motivated parents will receive that speech therapy service, but a child whose parents have difficulties, sometimes with transport, because not every clinic which has a speech therapist is accessible to every parent, will not receive that service. In fact, in one of the most deprived areas of my constituency, there is no speech therapy provision at all in the local clinic. Essentially, that policy has caused difficulties for those children who are perhaps in most need of speech therapy. If there had been an obligation on the health authority to consult a user group, parents and, indeed, nursery and primary school teachers, particular problems with that change in policy would have become evident. Since the health authority saw the change from its point of view--it is a cost-saving exercise because, obviously, it is easier and cheaper to provide services in a clinic than to pay for speech therapists to visit schools--the policy was changed, which was unfortunate.
I put part of the problem down to the fact that the appropriate user group- -teachers--was not consulted extensively, nor, probably, did the health authority see any reason to consult it extensively. I am not saying that the health authority did not take on board some of the comments made by head teachers, but because it had only to ask, the advice given was not viewed as statutory, and perhaps the health authority evaluated it differently.
Another user group which will become increasingly important is that of carers, especially those who care for people who are mentally handicapped or mentally ill or, indeed, elderly parents at home. As my hon. Friend the Member for Doncaster, North (Mr. Hughes) pointed out, many aspects of health care are yet unresolved. One of the biggest unresolved issues is the separate responsibilities of the health authority and the local social services department to purchase health care for the elderly. There are no clear guidelines on that. At the moment, the situation is manageable because the social services have money in their community care budgets to enable the purchase of that health care--although at the expense of other community care--and the health authorities are quite happy for that to continue. The carers, the users of that health care, are not currently involved in any part of the consultation process. The tension exists merely between the health authority and the local social services.
I am very concerned that, when that tension is resolved and local guidelines are drawn up--it is the Secretary of State's intention that local guidelines should be drawn up, issued and transparent--carers will not have any input. Often, the recipients of health care can tell professionals what will work and what will not work. In giving that advice, they can help to ensure that the available resources are effectively spent. History is littered with examples of professionals having good intentions of achieving a