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Baroness Jay of Paddington moved Amendment No. 5:

Page 2, line 7, at end insert:
("( ) that no area for which a Health Authority acts extends into the area of two or more Regional Health Authorities in existence immediately before the passing of this Act.").

The noble Baroness said: Amendment No. 5 stands in my name and that of the noble Lord, Lord Tope. The noble Lord, Lord Peyton, will be delighted to know that it does not involve consultation, whether of a quaint kind or any other.

The amendment is designed to elicit information on the types of area the Government intend to prescribe for the new health authorities. As when we debated Amendment No. 3, we are concerned to establish at an early stage, before this becomes something about which we may have to struggle to consult, that information is available about the size and nature of the new health authorities. It will clearly be of enormous importance to local communities, particularly in the areas of the divide between social and health care, to which I referred on an earlier amendment.

We should like to know precisely what will be the defining limits of the purchasing authorities which are to come into existence? How wide will their purchasing power be? The Secretary of State for Health said in an earlier debate on the Bill that we obviously want smaller and more effective decision-making working bodies. Yet there is a suggestion that some of the health authorities—the new purchasing organisations—will cover considerably larger areas than those of the present commissioning agencies.

How will they be able to combine? As the Minister suggested in her answer to the previous amendment, if they are not coterminous with local borough or district authorities, how broad will the combination be allowed to go? Could the possibility arise that it would not simply cross the boundaries of local authorities and those of previously existing commissioning agencies, but would also cover the area which embraces the boundary between the previously existing regional health authorities? That would obviously lead to an even greater dislocation of services than we have discussed before on earlier amendments.

One of the problems which the Government must acknowledge about the existence of these larger commissioning agencies is that in a sense they are looking for someone to fulfil the strategic function which, as we argued earlier on the first amendment, was most satisfactorily fulfilled by the old RHAs. If we are to have what are in a sense reorganised regional health authorities under another name—I realise that they will not have the same powers—and if they are to extend

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over large areas and to be able to commission services on a very wide basis for a very large number of people, are the Government in fact seeking to achieve some of that strategic overview, which we feel was more satisfactorily fulfilled by the old regional health authorities, in these new health authorities with their very unclearly defined boundaries? How will the existence of these much larger commissioning agencies sit with the Secretary of State's welcome assertion that she wants smaller, more effective decision-making working bodies?

Perhaps I may, without trespassing too far beyond the precise bounds of this amendment, also ask the Minister to comment about the precise area which the regional offices of the new bodies will include. As she will know, there is considerable concern in the Yorkshire and Northern region that this area will be as large as Scotland and also in the south and west that the merger of the South West and Wessex RHA will create for a regional office an area which will stretch from Portsmouth to Penzance.

The idea behind proposing the amendment is to invite the Government to explain slightly more clearly than they have done before how broad these areas for local health authorities will be, how wide their powers of commissioning will become and how they will be able to combine. As we say in the amendment, we hope to establish that they will not be so broad as to cover an area which extends beyond the bounds of an old regional health authority. I beg to move.

6 p.m.

Baroness Cumberlege: We do not intend to be prescriptive about the configuration, size or boundaries of the new health authorities in the Bill. As with the district health authorities, the size of the new authorities will be dictated by what is required for them to discharge their responsibilities effectively, and this may vary according to local circumstances. For instance, what suits a largely rural authority such as Norfolk may not suit inner city Newcastle. I do not consider it appropriate to include a comment on the size or shape of health authorities in the Bill. We must allow regional offices the flexibility to meet differing local circumstances.

As the Committee is aware, regional health authorities will be replaced by regional offices of the NHS Executive in April 1996. The regional offices will be responsible for the health authorities within their area and that area will be formed from the boundaries of the health authorities. We envisage that regional offices will be responsible for a similar area to RHAs. The actual area will, of course, be subject to consultation and the decision of my right honourable friend the Secretary of State for Health. We cannot bind that process by stipulating that boundaries must be within extant regional health authority boundaries.

Regions have been charged with developing a clear view about the desirable size and shape of the new health authorities to ensure effective collaboration with other agencies. They will be responsive to local people and their health needs. The views of the local population

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and interested organisations will be sought through public consultation on the boundaries of the new health authorities. My right honourable friend the Secretary of State for Health will then make a decision on the boundaries themselves.

I am unable to accept the amendment which we feel might jeopardise the ability of a health authority to carry out its functions effectively. I hope that the noble Baroness and the noble Lord will agree to withdraw the amendment.

Baroness Jay of Paddington: I thank the Minister for that reply. I am disappointed by the sense I am getting from her responses that she regards the word "prescription" as being something which is an anathema to her. What we are suggesting in several of these amendments is not some form of prescription in a totalitarian sense but simply a clarity of purpose on the face of the Bill rather than leaving so much in the hands of the Secretary of State or indeed in the regulations which, as we know, are couched in very general terms. We shall return to the subject of how those regulations are couched when we come to a later amendment.

It is obvious that one cannot prescribe the way in which the health authorities will be ordered in terms of their individual boundaries. That is not what we are asking for. We are asking for clarity about the size and the overall perspective for commissioning of each individual health authority. However, I understand that the Minister is reluctant to accept the amendment and so I shall not pursue it at this stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Jay of Paddington moved Amendment No. 6:

Page 2, line 12, at end insert:
("( ) No order shall be made under subsection (1) above until the Secretary of State is satisfied that the establishment of Health Authorities proposed by that order is such as to ensure that the provision of long term health care will meet the needs of the population of each local area.").

The noble Baroness said: This amendment raises an important subject which we have debated in the House on several occasions. It is designed to make explicit the responsibility for purchasing long-term care from health authorities and not local authorities, where, as your Lordships will know, it would be means tested. We bring forward the amendment partly because of the considerable importance that attaches to the responsibility for health authorities in this area and also because we would like to debate with the Minister the new guidelines on this subject which have been published in the past few weeks and which, like so much of health service organisation and administration, have not been brought before Parliament.

The Committee will remember the interesting and important debate introduced by my noble friend Lord Ashley of Stoke on this subject before Christmas when we were looking at the draft guidelines on continuing care and where we identified —this was identified all round the House—considerable confusion about the nature of responsibility for this particularly important

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area. As I said at the beginning, what we are attempting to do by this amendment is to make that responsibility explicit.

The background to the subject is that as regards continuing care, health service beds for this important service have fallen in the past three years from 73,000 to 59,000. That is happening at a time when people are living longer and where there is even greater need for the proper kind of long-term care, particularly for the frail elderly but also for the young and disabled. The fall in the number of beds has been called by authoritative people a stealthy withdrawal of free healthcare. As noble Lords who have taken part in previous debates and Questions on this subject will know, it has led to very bitter controversy between many local authorities, which feel that they are inadequately funded to deal with the social aspects of what they would think of as being healthcare. It has led to what is called cost shunting and there have been particular concerns about early discharge from NHS acute care hospitals into the community and into primary care situations where there is little back-up and very little concern for the social care which would be offered, it is to be hoped, by a local authority.

The new regulations have now been published and they have been distributed widely in the NHS. I must say that they are a very great improvement on the previous draft document. I particularly welcome the words in the document that until explicit criteria are established between local health authorities and local authorities no health authority should reduce its services any further or alter its hospital discharge procedures. Noble Lords will remember that when we debated this subject there was considerable concern about the lack of clarity with regard to hospital discharge and particularly the criteria for qualifying under the regulations for free healthcare.

As I say, the new regulations are much clearer. The rule of thumb (if one can call it that) for qualifying for National Health Service care seems to be now that a patient who needs that kind of care must need consultant supervision from a doctor who is at senior level—in other words, once a week. At least that establishes a line of medical responsibility which is much more helpful than before.

However, there are still considerable queries about it. The considerable queries revolve particularly around nursing care and whether or not, for example, a 24-hour nursing care requirement for somebody who is in their home or somebody who might be regarded as in a convalescent home of any kind, is in or out of the qualifying criteria. That is of particular importance in areas like big cities, particularly in London, where it is very difficult to find placements for nursing in what one used to call convalescent care situations.

There is also the problem about the clear criteria which, according to the new document, must be agreed between local authorities and health authorities. But there is not the sense in which there is national guidance on this which many noble Lords who took part in the earlier debates were very concerned to achieve. What I fear that this will continue to lead to, unless we have

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the kind of explicit assurances which this amendment addresses, is that there will be grave inequities between different local authorities and local health authorities. Where one has a good working relationship between a local health authority and a local social services department and there is a certain amount of flexibility in the local budget, one will get one kind of service and in another area where there is no appropriate consultation or a good working relationship between the local health authority and the local social services department, the situation may break down in the way which has been highlighted rather dramatically and appallingly in many cases recently, and which have been shown by the media.

The other issue which is another improvement in the new regulations is the establishment of independent panels to decide the kind of disputes which may arise when there is not a good working relationship between social services and health authorities. Although the independent panel will exist, if there are no touchstones of national eligibility criteria which seem to be the necessary framework for making this kind of decision-making work in a National Health Service, it is very difficult to see what touchstone the independent panel will use to decide whether a case is legitimate or otherwise.

That is the basic point about the whole issue of continuing care; namely, that if we are to retain the necessary characteristics of a National Health Service with equity of medical care and social care across the wide variety of different populations and different kinds of communities which the National Health Service services, we must ask that there are national criteria to establish what a patient and his or her family can expect from the health services.

The Royal College of Nursing has reinforced that by saying that nationally determined criteria should be set down rather than local standards. It has also drawn attention to the problems where one gets one set of services in one authority which appear to be means-tested, and in another they appear to be legitimately free.

The amendment would clearly identify the new health authorities as having the responsibility for purchasing continuing care for their local population. It would clarify the current confusion faced by many patients and their carers, and potential patients, who still believe that the NHS is withdrawing from its responsibility to provide a free and comprehensive health service. The Government would do a great deal to advance the change that they have made in publishing these new guidelines which, as I say, are a considerable improvement—indeed, it is difficult to imagine they came from the same authors as the previous guidelines—if they accept this amendment and agree to establish a very clear responsibility on the new health authorities for this particularly difficult and yet very crucial part of the National Health Service. I beg to move.

6.15 p.m.

Baroness Cumberlege: It is our belief that this amendment is unnecessary as health authorities are

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already responsible for setting local priorities in response to local needs and circumstances, and there is a clear obligation on them to secure a full range of services to meet the needs of their population.

We are determined that all health authorities should properly discharge their responsibilities in this area. That is why we took extremely seriously the report which the Health Service Commissioner published last year which criticised the failure of one health authority in this respect. As a result we issued guidance to health authorities in February of this year making clear their responsibilities in this area. I am grateful to the noble Baroness for her gracious comments on their improvement over the draft guidance.

The key objectives of the present guidance are, first, it unambiguously reminds health authorities that it is a fundamental responsibility of the NHS to arrange and fund services to meet people's needs for continuing healthcare from the cradle to the grave. Secondly, it requires all health authorities to review their current arrangements. They should draw up policies and eligibility criteria for continuing healthcare and where significant gaps in provision exist they should take action to fill these. The guidance offers a further opportunity to strengthen collaboration between health and local authorities. Thirdly, it sets out a detailed national framework which all health authorities must reflect in their local arrangements. This should lead to much greater consistency across the country in how these issues are handled while preserving an appropriate level of local flexibility to respond to local needs. Fourthly, it reinforces the special care which is required in making decisions about hospital discharge for frail and vulnerable people who are likely to need continuing intensive support, whether on a long-term basis or on a short-term basis, to aid rehabilitation and recovery.

Finally, it encourages greater openness in how decisions about continuing healthcare are taken. Local policies and eligibility criteria will be subject to public consultation. They will be published with details included in community care charters. From April 1996 patients who consider eligibility criteria have not been correctly applied in their case will have the right to ask the health authority to review their case.

This guidance is a key priority for the NHS. The NHS executive will monitor implementation of the guidance to ensure that all health authorities do arrange and fund a full range of services to meet continuing healthcare needs for their local population although some of the public coverage of this issue has perhaps been clouded in that the NHS has never been responsible for meeting all needs for continuing care. Ever since the beginning of the welfare state in 1948, there has been a division of responsibility between the NHS and local authority social services.

Our concern, similar to that of other governments in the past, has been to ensure that health and local authorities work together across the boundary to provide an integrated and effective response to people's needs. That has been one of the driving forces of the new community care arrangements and in particular of the agreements which we have required local authorities and health authorities to reach on their respective

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responsibilities for continuing care and on hospital discharge. The guidance on continuing care builds on this further.

In conclusion, we believe that this amendment is unnecessary. Health authorities are already responsible for securing a range of services to meet the continuing healthcare needs of their local population. The Government are taking significant steps to ensure that health authorities do adequately discharge their responsibilities and that they work together effectively in meeting the needs of people who need continuing support. I urge the noble Baroness to withdraw the amendment.

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