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Lord Graham of Edmonton: How many?

Lord Ennals: My Lords, I am told that it is a 43 per cent. lead. It has gone up since I gave the first figure! Apart from assemblies for Scotland and Wales, there is a debate about English regions. I saw Mr. Gummer yesterday bursting with joy as he proclaimed that Labour was split from top to bottom on this issue. That is not true. What is true is that the patterns of regional activity may vary because needs vary. There may be a difference in structure and performance because that is the wish of the regions concerned. But there will be a regional tier in one form or another. It would be absurd to move in the opposite direction at this stage. I hope that we shall be able to convince Ministers and noble Lords on the other side of the House of this argument during the course of the Committee and Report stages.

6.5 p.m.

Lord Holderness: My Lords, I begin by congratulating the Government, as many noble Lords have done, on this further step forward they are making in the structure of the National Health Service. That service is of immense importance to us all. Not long ago when I was chairman of a special health authority within the National Health Service, I reached the conclusion that the then administrative structure of the service was—if I may put it no more strongly—a little bit weighty. Therefore, I do not share the view expressed by the noble Lord, Lord Ennals, that it is a pity to change the structure. I believe that change is very necessary. With the publication of The Health of the Nation it became even clearer to me that a more simple and sensible structure is necessary if the health service is to attain the very sensible objectives of that newly framed policy.

I agree entirely with the noble Lord, Lord Ennals, that many different contributors have their part to play in making the National Health Service a success. The new health authorities are going to be extremely busy groups of people. They must continue to rely, as did their predecessors, on the vigour of a number of agencies,

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including quite a number outside the field of the National Health Service itself. Among them I hope that I shall be forgiven for mentioning the organisation called Disabled Living Centres. I must declare a personal connection with at least one of them, the William Merritt Centre at Leeds.

In the task of making it possible for people who have been ill or injured to live independently at home, I believe that it will be agreed that the work of these centres is beyond praise. I need say little about it because the contribution made by the centres to supplement the rehabilitative work of the National Health Service is well known to your Lordships. Consequently, any diminution in the efficiency of organisations of that kind would have a considerable effect on the efficiency of the National Health Service which this Bill aims to improve.

Therefore, after speaking very briefly, I hope that my noble friend will be able to assure me that there is no proposal in view to decrease the effectiveness of the centres. The council which helps to service them already works on an extremely modest scale. At a time when care in the community is rightly commended as the way forward and as a supplement to all the things we are trying to do, I believe that disabled living centres should be more important in supplementing the contributions that the new health authorities and various other authorities will have to make.

My plea is that if the centres are to function properly they need resources and the back-up of a supporting body. I hope that the disturbing rumour that the modest support accorded them at present will be reduced can be refuted by my noble friend. That suggestion surprised me, because I am aware of the wide recognition in the department of the excellent results which the council and the centres have achieved. I hope that my noble friend will be able to assure me that there is no foundation to the rumour.

6.10 p.m.

Baroness Seccombe: My Lords, some years ago I took an elderly relative to an outpatients' hearing clinic. The appointment was for 9 a.m. We decided to be a few minutes early to ensure that we were on time. Your Lordships may imagine my surprise and horror when I found that 25 others had had a similar idea and that their appointments were also for 9 a.m. We were sent to a waiting room without an outside window where the door was propped open by a fire hydrant. There we sat, including a lady of over 90 who had not been out of her house for over three years.

As time went by, I decided to investigate and asked the receptionist what was happening. She said that the consultant had not arrived. As it was close on 10 a.m. I thought it fair to ask why not. Her retort—not the friendliest—was that she did not know, she had not heard from him and would I please return to my seat and please close the door as it was not permissible for the door to be propped open. She certainly did not care for it when I suggested that no one could be expected to sit in a cupboard without fresh air.

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With no apologies for lateness, we eventually saw the consultant at about 12 noon. In those days it seemed to me that the NHS was badly organised and that addressing the needs of the patients came very low down on the list of priorities.

Your Lordships may wonder what relevance that story has to the Health Authorities Bill. I suggest that it shows how far we have come since the Government embarked on the reforms five years ago. Today we have a user-friendly service where the patient comes first. In addition, the Patient's Charter specifically deals with the issue of patients being kept waiting longer than 30 minutes after their individual appointment time.

At the time of the 1990 Act, many people thought that the NHS was teetering on the brink. It was, and is, an organisation massive in employee numbers, yet it was administered centrally. It was, and is, funded generously, yet the advantage to the patient of any extra funding seemed minimal. Furthermore, the unfortunate taxpayer was encouraged to believe that whenever a problem arose, the solution was to throw more money at it.

The principle of the 1990 Act in devolving power and responsibility to the local level is unquestionably right, particularly in an organisation so large. The establishment of the NHS trusts, the creation of the new role for local health authorities and the granting of new powers to GPs through fund-holding have transformed the service to patients.

There were 56 hospitals in the first wave of trusts and it is, indeed, remarkable that from April this year 98 per cent. of all hospitals will have trust status. And now GP fund-holding is blossoming also. It is the ability of those concerned with primary care to call the shots that will guarantee the maximum efficiency of a service of which nobody who has used it can properly speak ill.

The proposals outlined in the Bill build on the success of the reforms and so enable the final tranche of organisational change to take place. I believe that the RHAs are now an unnecessary tier of management and that the savings from their abolition will contribute to the total estimated savings of £150 million per year from the Bill—money which can be spent on direct patient care. That should be welcomed on all sides of the House, as should the retention of the overview to ensure that the NHS continues to deliver its objectives and to maintain the high standards of the quality service that is recognised throughout the world.

I must admit that I have always found it difficult to describe the actual role of the RHA, the DHA and the FHSA. As a lay person I have always felt that there must have been a certain amount of duplication. I am therefore delighted that the new structure will be much simpler, with only one authority at local level. It must be right for the power and responsibility and the resultant decision-making to rest with those nearest to the interests of the patients.

To some, the Bill may seem of a technical nature, but to me it seems to put the finishing touches on a creditable and bold change of direction that was begun in 1990. For the future, I hope that many more GPs will join the ranks of fund-holders. That way, working with the local health authority in partnership, they will have

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more flexibility in arranging services for their patients. I am also certain that more and more treatments will take place in doctors' surgeries. Consultants are already taking advantage of that co-operation in some areas. Surgeries could be the mini-hospitals of the future.

As a result of the Bill, the structure will be in place for the development of a comprehensive, high-quality service to tackle the formidable challenges of an ageing population as we enter the 21st century. I look to the future with confidence and excitement as the continuing involvement of local people allows flair and innovation to flourish. That can only be of benefit to patients. I welcome the Bill as an important piece of legislation.

6.16 p.m.

Baroness Dean of Thornton-le-Fylde: My Lords, when the Health Authorities Bill was introduced, press releases that were issued by the Secretary of State for Health in November 1994 said that it completed the NHS reforms that were begun in 1990. I am sure that there was a big sigh of relief when people heard that, but if the Bill is the last tranche of reorganisation, that makes it even more important. Many of us on this side of the House would challenge the proposition that the outcome of those changes in the health service is serving patients well and whether that would have been possible without some of the changes that the Government have introduced.

Perhaps I should declare an interest as a non-executive member of the board of University College, London. I am not speaking this evening wearing that hat but in a purely personal capacity as a Member of your Lordships' House.

It is essential that we get this right. It is essential because the provisions will mean so much to local people both in terms of accountability and representation and in terms of the quality of the service that they receive.

I was interested to hear the story at the beginning of the speech of the noble Baroness, Lady Seccombe. No Member of your Lordships' House could say that that was a proper experience for an old lady. I am sure that we would all condemn such occurrences. However, while I listened to the noble Baroness I wondered why, if those experiences no longer occur, we have a record number of people waiting for a first-time appointment with a consultant. I also wondered whether, if that old lady had needed hospitalisation in years gone by, she would have been kept waiting for a bed in hospital, as are so many old people today, and then, having got her bed, whether she would have been taken out of hospital as soon as possible because of the shortage of beds which has been reported in the press in the past few days.

The Bill has been presented under the guise of removing levels of hierarchy in the health service. If there are fewer levels of hierarchy in an organisation, the managers will have more involvement in the system. However, when I read the Bill, I questioned whether it would achieve that. Will the Bill achieve greater openness, greater accountability and greater efficiency? Most importantly, will it achieve greater quality of

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service for the people this is all about, the patients? I question whether it will do so, just as I question whether the projected savings will actually be achieved. They were estimated originally at £150 million, but I gather that the figure has now been reduced to £60 million. There must be a big question-mark over such figures.

I shall deal with the three themes that come through in the Bill. They are not unique to this debate; a number of noble Lords mentioned them. The first relates to the proposed abolition of the regional health authorities. I am not saying that the present structure of the eight regional health authorities is perfect; that there are no complaints about it; and that it does not need changing. But why throw the baby out with the bath water when the structure has many good elements within it?

Over the past four years a number of changes have been introduced. We had the National Health Service and Community Care Act whereby universities and medical schools had a statutory right to participate in the planning and decision-making with regard to the education and training of clinicians in the health service. With the proposed abolition of the regional health authorities, out will go our national planning for education and training, not just of doctors but of nurses and a whole range of other professionals who work for patients in the health service.

It is all right to say that the new health authorities will decide how many professionals they will need to train for their areas, but their concern and concentration will be on their areas alone. It will not be about the service as a whole. It will not, for instance, take into account the need for nurses in prisons, in local authorities, in the work place and in a whole raft of other areas, including nursing homes, where those services and skills are essential.

One could take that on board and say that it will be taken care of if there is a surplus of nurses in the system, but there is not. In these days of high unemployment, unemployment among nurses runs at about 1.7 per cent. As the noble Baroness, Lady Cox, said, we have seen a 33 per cent. cut-back in training. The College of Occupational Therapists recently conducted a survey with local authorities, the Association of County Councils and a whole raft of local involvement. It found that there was a 15 per cent. shortfall in the number of occupational therapists needed. That is not something that can be pushed to one side; planning is needed. One cannot pluck a qualified nurse or therapist out of the blue. They have to be trained, and that has to be planned for. They have to be recruited and they need a long period of training. Those are some of my worries about the abolition of the RHAs. I have a number of others, but those are my key concerns.

Perhaps I may turn now to the merging of the DHAs and FHSAs. That development is clearly to be welcomed, but I am critical about the way we are doing it. Here again, we are starting with almost a blank cheque. There have been specific placings on FHSAs for a pharmacist, a dentist, a GP and a community nurse. We will not have that with the new health authorities. I know that we talk about management and structures

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within the health service, but we should ask the patients in whom they really have faith. Those in whom they have faith are the doctors and nurses.

If we set up a new body without a statutory requirement for the placing of those professionals on it, the new health authorities will get off to a bad start. The Minister may say that of course the health authorities can appoint a nurse, a doctor or whoever. But we should look at the practical experience of such things. That is not the case at the moment with the district health authorities, which can also do that. The RCN carried out a recent survey. Liverpool said that it had four nurses on its health authority and expected to have a nurse on the new body. If one goes just over the border to Chester, one finds that Chester does not have one and does not expect to have one. When questioned in the survey, 73 health authorities said that they would be cutting back considerably on the number of executive nurses they employed.

Not only is there no provision for a professional to be on the health authority under the Bill, but the health service is faced with the problem of having a smaller number from which to draw. It is important that the standard is maintained. Currently, 52 per cent. of health authorities employ nurse executives; but only 8 per cent. said that they planned to do so when the changes were in place. That should worry us all.

During the course of the debate, a number of key themes have been brought out from different points of view with the different positions of noble Lords. We need to return to them in Committee, and I look forward to doing so. I hope that the Minister will listen to the views put forward by many able and experienced noble Lords and will be prepared to amend the Bill in a way that will make it more relevant to and representative of local people, in particular the patients.

6.26 p.m.

Lord Ironside: My Lords, we have had many reform Bills before the House in recent years, and the passage of some of them has been a marathon. Most have marked up watersheds in our affairs. I am glad that, because of the paving Acts already in place, we are unlikely to have a marathon this time. It is not quite a one-clause Bill; if it were it would be incapable of amendment. It is a Bill with a single purpose in its first clause. The noble Lord, Lord Walton of Detchant, described it as an enabling Bill under which the Secretary of State has power to make alterations, and to update and regulate it through statutory instruments.

We must assure ourselves that current Acts, public policy, and government regulations do not undermine the management of public health care and the translation of scientific research into medical practice. Patients have everything to gain from the new management system now being brought into health care. Your Lordships will wonder why I am speaking in the debate. I admit readily in the presence of so many experts that I have little experience of the organisation of the NHS and of health authority affairs. My only experience is as

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an observer. So, although I may have missed out on the supply side, I have learned a great deal recently about the demand side.

I also declare an interest which many noble Lords heard me declare in debate last year; namely, that my wife is president of RAGE (the Radiotherapy Action Group Exposure) whose members, numbering possibly as many as 2,000 in the UK, have suffered disastrous injuries from radiotherapy treatment following breast cancer surgery as a precautionary measure.

On a more personal note, my grandfather was an FRCS—what was commonly known in the Army as a sawbones; and my mother's stepfather was a professor of anatomy and anthropology at Cambridge. People believed him when he pronounced the Piltdown skull as being genuine. I hope that the mistakes of the past generation will not be visited on its successors.

I welcome the Bill, as I believe it recognises the way the new management strategy is permeating all our affairs. The rapid spread and acceptance of trust hospitals and fund-holding practices shows that the strategy has wide support. The Bill brings the law into line with the watersheds in science, medicine, surgery and treatment techniques which are now driving forward primary and secondary health care. We have heard that there is also tertiary health care, but I do not want to talk about that. The Bill deals with the situation very simply by enabling management to be devolved from the centre in order to serve the patient better. I see health authorities better able to match the demand from everyone entitled to healthcare in the UK to the increasing skills and techniques being provided at hospitals and treatment centres.

My experience in the defence industrial field has given me an insight into the greater value for money that can be obtained from a procurement system, which now works principally on a through-life quality criteria, governed by management as well as performance standards, competition, market testing and, above all, a healthy—probably the right word to use in this debate—interaction between the private and public sectors. The relevance of all these factors in selecting the best way forward for the NHS is important.

In giving my support to the Bill, I wish to draw attention to the breast cancer problem now facing most countries. The EU 1995-99 third five-year action plan in the fight against breast cancer (on which 64 million ecus are to be spent) shows the breast cancer mortality rate in the EU at 24 per cent. of all cancers and incidence and mortality higher by a ratio of nearly 2:1 in the northern EU member states—Denmark, the Netherlands and the UK—than in the Mediterranean member states such as Greece, Spain, France and Italy. Incidence has increased in all states, although it is true that mortality among younger women in some northern member states has started to decrease. The EU goal in the action plan is 15 per cent. by the year 2000.

The problem is two-fold. The first is prevention, which must be one of the goals whether or not it is a pipedream. The second, while cure remains elusive, is treatment. It is clear therefore that, while prevention remains the ideal solution, treatment is crucial.

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However, I do not believe that we can look at the problem of breast cancer in isolation. There are parallels to be drawn with the USA as well as in the context of the EU action. What I am concerned about is to what extent the NHS and health authorities can pursue the problem effectively when it is clear that co-ordinated action is needed in translating research into practice, in getting the quality of treatment right, in getting screening and diagnosis right, in eliminating the risk factors in treatment and in doing a lot of other things which could be done, for example, by creating a one-stop-shop.

The experience of RAGE members before, but particularly after, radiotherapy treatment shows little recognition that a pattern of injury exists and no understanding of why the injuries happened. There is no dispute about the radiotherapy being the cause of injury. But why was it that some many injuries were concentrated at just a few treatment centres and one in particular; namely, the Royal Marsden Hospital? Because of that, the call for the one-stop-shop in breast cancer treatment is now so strong that I wonder whether the Bill will provide the health authorities with sufficient powers to co-ordinate access to such facilities when so many inputs are involved.

One of the inputs in this scenario is quality assurance. My noble friend Lady Cumberlege knows of my anxieties in this area. I do not have to remind her that the health sector is being bombarded with quality issues which need to be resolved. We both know that there is resistance to adopting BS EN ISO 9000 within the healthcare sector and therefore in-house it is dismissed as being unsuitable. When other public sector departments as customers call for quality assurance approval, suppliers have greatly benefited from compliance. I wonder why doctors believe that they are exempt when the quality route can be seen to have so much going for it. Already, the British Standards Institution has registered many elements of healthcare, including radiography, neurosurgery, maternity, accident and emergency. It also covers national blood transfusion services, hospital laboratories, fertility units and general practice. Therefore, I suggest that because of what has been achieved already by the BSI in this field the "NIH, or rejection, factor" in the NHS no longer holds water.

The BSI draws parallels with what the Food and Drugs Administration has done in the USA and the way in which the neurological unit at the John Radcliffe Hospital in Oxford has addressed ISO 9000, which encompasses the whole process of patient referral, diagnosis, treatment, post-operative care and eventual discharge. I have drawn parallels with the USA in mammography, and the way in which that could be picked up here, and for radiotherapy too. The US Mammography Standards Acts 1992 requires facilities to be accredited by the FDA for equipment, operators, film and, last but not least, diagnosis, with yearly renewal of accreditation. With 80 such facilities in England, that would be a welcome advance. My noble friend has not been able to tell me the UK capacity but I understand that the health authority, as speciality purchaser and customer, can call for quality assurance

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standards from the provider. My noble friend Lord Jenkin said that in his experience of Whipps Cross Hospital the unit is looking for credibility in discussion with the purchaser. Surely, the purchaser is able to set the standards. If the health authority has no powers in this respect, perhaps my noble friend will say who has. The power of the purchaser surely wields the quality stick; he is purchasing in order to obtain an effective outcome.

The British Standards Institution, I am told by the chief executive, takes the view that major benefits are to be obtained by having nationally accepted quality standards applied to the healthcare sector. I believe that after the disasters at Exeter and North Staffordshire—and now apparently shortcomings at the Dundee Royal Infirmary—as well as injuries at the radiotherapy treatment centres, something certainly needs to be done to put momentum behind quality assurance in the health sector. I hope therefore that as a result of the Bill becoming law the Secretary of State will set something in motion with the BSI. If powers are not delegated to the health authorities as purchasers, I assume that the Clause 6 powers under statutory instrument are adequate to ensure that quality assurance can be introduced. The EU action plan calls specifically for the introduction of quality assurance controls.

I turn to the defence field. Is my noble friend satisfied with the arm's length relationships that will exist between the Armed Forces and the NHS? For instance, if the RAF Personnel and Training Command at Innsworth has responsibility for the planning and provision of RAF medical services how is it that it can function without some dialogue with the NHS Executive, regional offices and health authorities? As service health profiles by selection are high and greater physical demands are placed on servicemen and servicewomen, the RAF will, for example, want to know that it is getting for its money. I am sure that the waiting lists of hospitals will be unacceptable to the services. If there are to be hospitals with military wings, I imagine that in certain cases it will make sense to have a military presence on a health authority. Presumably, there will be nothing to stop application in any case. Perhaps my noble friend can say more about the lines of communication that are to be put in place. The Royal College of Nursing is calling for places on health authorities. Perhaps it follows that the Queen Alexandra's Royal Nursing Service has just as strong a case for consideration if the NHS is to provide adequately for the Armed Forces.

Finally, I have seen how my general practitioner, as a fundholder, is giving greater value for money in the services he provides. I have seen how the healthcare sector needs a spur as regards quality assurance. I have seen how the Government are determined to deliver improved breast cancer services in a co-ordinated way through their expert advisory group on cancer. I hope that my noble friend will explain to the House and give publicity to the fact that the Government already have in place a national strategy for breast cancer services in view of the fact that, as the Minister is well aware, a Bill has just been introduced in another place to provide for a national breast cancer plan.

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I hope also that my noble friend will give an assurance that when this Bill is enacted, all concerned with its implementation will be able to work together and, in the case of breast cancer, in a way in which all women will have confidence. I support the passage of the Bill.

6.41 p.m.

Lord Lyell: My Lords, I congratulate the Minister and I thank her for her excellent, lucid presentation of the Bill. The Bill is fairly short, in that it has only one or two major, enabling clauses. That is a real luxury when one thinks of much of the health legislation that has passed through your Lordships' House.

The noble Lord, Lord Ennals, is looking at me rather quizzically. He may wonder why I am speaking in the debate. Some 18 years ago the noble Lord, Lord Ennals, who, at that time, was wearing a different hat, attended a great dinner held by the pharmaceutical industry. I was taking an interest in the Bill which was passing through your Lordships' House at that time. At the dinner the noble Lord, Lord Ennals, announced that the Government were taking decisions in relation to the pharmaceutical industry and patents and licences of right. Since that time, I have never lost my interest in the health industry and pharmaceuticals.

I much appreciated what the Minister put forward today and I agreed with many of the points raised by my noble friends, and in particular by my noble friend Lord Jenkin. It is the first time in my memory that I have picked up a Bill and looked at the Explanatory and Financial Memorandum. I was absolutely struck dumb, in that it claims that the savings are in the order of £150 million per year. That must be something of a record. We should all take note of that prediction in the Explanatory and Financial Memorandum because it is an incredible saving.

I ask my noble friend to explain some of the figures given in relation to manpower; namely, the 3,900 staff in the regional health authorities and 1,100 staff in the regional offices of the NHS Executive. I am not sure how those figures come together. Perhaps my noble friend will explain that to me either this evening or at a later stage.

I commend the great patience of the noble Baroness, Lady Jay, in not moving from her seat. I enjoyed her comment about the Roman army but I wonder, very politely, whether she did not put a dart in her own foot. I do not know who —was it Catullus?—made that excellent statement about the disorganisation within the Roman army but, if one looks at the map of the Roman Empire as organised by the Roman army, the organisation cannot have been all that bad. If anyone complained about it, it might have been the Baroness Jay of the day. But if the organisation of the National Health Service today is as good as was the organisation of the Roman army at the time in question, we ought not to have much to complain about.

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The noble Baroness tempted me to look at one of the comments of Cicero. The four words which Cicero wrote were: "si vales, bene est". If you are in good health, all is well. That should be the motto of today's Bill because that is what we are all trying to achieve.

I hope that the Minister will be able to assist me in relation to a number of small, detailed points. If she does not do that this evening, that can be done when we consider the Bill at a later stage. Will the Minister confirm those astonishing figures of £150 million per annum for England and £3 million for Wales? Where can I check up on those figures and obtain independent verification?

Secondly, I believe that I am right in confirming what my noble friend Lord Gray of Contin said on an earlier occasion in relation to local government in Scotland. The provision of the services is not necessarily the most important aspect but the effectiveness of the services provided to the consumer is of crucial importance. Is that the rationale behind the Bill which we are discussing this evening?

Thirdly, I am astonished that there are only eight regional health authorities and I wonder why there are so few. The noble Lord, Lord Ennals, gave us a brief outline of another aspect connected with regionalisation. No doubt those comments will be monitored closely by the press and those who are interested in the wider political sphere.

Fourthly, I hope that the combined functions which at present are carried out by district health authorities and FHSAs will continue to be provided, as far as possible, on the present terms. My noble friend Lord Jenkin raised that matter, as did the noble Lord, Lord Walton of Detchant, in his excellent speech.

Fifthly, I hope that the existing relationships between health authorities and outside organisations—for example, university medical schools—will continue under the new organisation as proposed in the Bill this evening.

The needs of the health service are changing constantly. The noble Baroness, Lady Jay, mentioned a personal interest of hers; namely, HIV and Aids. Between 1987 and 1990, that aspect of health was much under discussion, as it is now. What was the cost of providing remedial treatment then and what is it now? That is only one feature of a constantly moving target for financial providers at all levels within the National Health Service. We must look at that matter.

The Minister invites us to take a close interest in the Bill. I have done so. Perhaps the Minister and her advisers will look at page 35. What on earth do the Dartford-Thurrock Crossing Act 1988 and the payment of tolls have to do with this Bill? I am sure that there is a good explanation for that. I hope that my noble friend will be able to help me with that.

This Bill aims to save £150 million per year, which will be reinvested for the provision of further patient care. With that in mind as a main driving priority, I

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believe that the Bill deserves the support of us all. To assist the noble Baroness, Lady Jay, perhaps I may say that I studied Catullus, who said:

    "Vir sapet qui pauca loquitur".

That means that the noble Lord who speaks briefly does himself a great deal of good and above all, shows wisdom.

6.48 p.m.

Lord Rea: My Lords, in preparing for this debate, I found only one aspect which met with the approval of all the professions involved and that is the one which has met with the approval of all noble Lords who have spoken this evening; namely, the merger of the FHSAs and the DHAs into one HA.

I remember advocating that step when I first reached your Lordships' House 12 years ago. But, as my noble friend said, the Government were not in the mood to listen at that time. However, there are a number of anxieties in relation to that aspect of the legislation which have been raised by those who have at heart the interests of primary health care. This merger is an arranged marriage and, although the two partners know each other extremely well and have always had to co-operate, it has not always been as friendly a relationship as it might have been. The district health authority, being much the richer and controlling the high-powered, high-tech acute hospital services, was always in the stronger position. Since the purchaser/provider split, however, the situation has changed, but still the DHA, as purchaser of the hospital services, is in a position —to use the same analogy—to wear the trousers in the new relationship.

Even though strengthening primary and community care makes sense and is part of the Government's strategy of a primary healthcare-led service, demands for expensive hospital services will still fall on the health authority. There is nothing in the Bill to protect the position of primary and community care in the new health authorities. I hope the noble Baroness will address this in her reply. If I am wrong and there is something on this point in the Bill which I have missed, I hope she will point it out. If that is not the case, we shall move amendments to safeguard FHSA staff and responsibilities in the new health authorities.

Apart from that one sensible part of the Bill, the rest is, in our view and that of all the professions and consumer interests involved, harmful. It is harmful to the interests of the National Health Service, those who work in it and, ultimately, to patient care. We are all against unnecessary bureaucracy but I would draw a comparison here with surgical practice in the 19th century and earlier, and bureaucracy. When dealing with abscesses and other infections, the discharge from them was categorised as "laudable pus and malignant pus". I suggest that types of bureaucracy can also be similarly divided.

Quietly, over the past few decades, regional health authorities have, as many noble Lords have pointed out, played a major part in ensuring the equitable spread of healthcare throughout the country; and maintaining high standards in patient care, teaching and research, not only

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through the distribution of funds but also through a whole variety of other checks and balances. The cost of administering the regional health authorities is tiny compared with the cost of the vast increases in managers and supporting staff that the internal market has spawned. I should point out that we have yet to see research-based evidence that the nation's health has benefited as a result of the National Health Service and Community Care Act 1990 any more than it would have done had it continued under the previous structure. Research to show whether or not health has improved was precluded by the Government when they denied a provision in the Bill that it should be properly evaluated.

By eliminating the regional health authorities, the Government hope to get brownie points, I suggest, through reducing bureaucracy. In fact the effect of the reforms will be to free NHS hospital trusts from regional control and to allow them to operate in a market-driven environment which pays less attention to the needs of the population. As my noble friend Lord Ennals has in particular pointed out, there is a need for a wider view than that of individual health authorities and trusts. This Bill will get rid of that vital planning and resource allocating role.

There are numerous other objections to the abolition of regional health authorities. Before the debate I totted up 15. During the debate all of these except one have been mentioned, as well as five others that I had not listed. During the debate I have been impressed by the repeated anxieties expressed on all sides of the House about the future of man- and woman-power, planning, professional training and research. We need much more explicit assurances about those matters on the face of the Bill. The noble Lord, Lord Lyell, said they were in the Bill. They are not in the Bill. We have had promises but we have not had words in print.

One issue which could well be incorporated into the Bill is the problem of the increasing number of complaints against the National Health Service—up 52 per cent. last year. Alan Wilson's committee, which has looked at the problem of the mechanism for handling complaints, has made recommendations for streamlining the complaints procedure. As many noble Lords have said, since it would appear that this is to be the final Bill on National Health Service reorganisation ever, perhaps this is the time to incorporate his valuable suggestions into legislation. The increase in complaints sits uncomfortably with the claims of noble Lords opposite that things have greatly changed for the better since 1991. In Committee we will bring forward amendments which will give the Government the opportunity to clarify in more detail what the regulations—which are of course the active teeth of the Bill—will say.

But, again, as my noble friend Lord Ennals has said, we are far too familiar with this sort of task. I wonder when the Government will start enacting legislation in a more democratic way by first consulting widely, listening to the views of those involved and drafting legislation to meet concerns, rather than throwing a Bill at us whose detail has not been thought out, allowing

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only a brief, time-limited consultation period (if any), with consultation too often a one-way process with no shift in the Government's position as a result.

However, we are always hopeful. We think that the Government might respond to at least some of the points raised this afternoon by bringing forward amendments of their own. We shall certainly bring before the House probing and substantive amendments which we hope will improve the Bill so that its beneficial effects will be ensured as regards the FHSA and DHA merger, and its other more deleterious effects will be reduced.

6.57 p.m.

Baroness Cumberlege: My Lords, this has been a most interesting, wide-ranging and thoughtful debate. Perhaps that is not surprising as we have in the Chamber this evening two former Secretaries of State for Social Services who have taken part, the chairmen and non-executive members of health authorities and trusts, both past and present, three vice-presidents of the Royal College of Nursing, some very distinguished members of the medical and scientific professions, two vice-chancellors, a former courageous regional chairman on the Liberal Benches, and countless others who are knowledgeable about the National Health Service.

The support for our proposals this evening has been very encouraging. It confirms our view that these are sensible and timely measures. However, your Lordships have identified some important areas which I believe need to be handled with great care. I hope that in these closing remarks I shall be able to offer some reassurance about the Government's approach and I look forward to constructive discussions during the Committee stage.

The noble Baroness, Lady Jay, the noble Lord, Lord Desai, and the noble Lord, Lord Ennals, although giving partial support for elements of the Bill, questioned whether the NHS had improved since the reforms. I believe that there are two health services—the one people read about and the one people use. I care deeply about the image of the National Health Service. I am very sad every time the NHS is denigrated. I feel diminished every time it is rubbished. It lowers staff morale, it affects recruitment, and it knocks the confidence of the British people in what I think is a remarkable British institution.

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