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Baroness Eccles of Moulton: There is a great tradition of consultation between health authorities and the local community. It is hard to believe that anything as serious as these pilot schemes could be contemplated without wide consultation between the first point in the process--the health authority, the local community and the bodies most affected by the proposals. Certainly in my experience the CHCs are most assiduous in requesting a consultation over what sometimes seems to us relatively minor service changes. It is rather surprising to me that it is so important to have this process featured so frequently on the face of the Bill in view of the practice I have experienced so far.
Another point is worth making. Once there are requirements in primary legislation, they place a very weighty sense of responsibility on those who are required to carry them out. That can sometimes have the
effect of delaying very important changes and important progress in carrying out improvements to the way the health service is delivered. I should not like to think that the imposition of a very strict regime of consultation on those responsible could have an overly delaying effect. I should be very surprised if anywhere in the country changes of the sort that are proposed could possibly go ahead without thorough consultation and without that having to be on the face of the Bill.
Baroness Gardner of Parkes: I, too, think that this is rather a mixed idea. Consultation has become so accepted within the health service that I do not for one moment think that there would be any lack of consultation. However, given the way that the requirement is set out, in amendment after amendment, a very long and slow process is envisaged which could be quite self-defeating. The whole idea is to have people coming forward with innovative schemes for possible consideration as pilots and then to have them approved, as pilots only. I believe that full consultation would go on.
In introducing the amendment, the noble Baroness referred to changing local NHS structures and attached great weight to that. I did not envisage these powers as changing NHS structures, and I hope that they would not do so. I hope that NHS structures would continue to exist as they are and that these changes would be possible improvements, subject to the success of the pilot scheme, which might eventually at a later stage change NHS structures, but not at the pilot stage. There is a great tendency for people to give negative judgments in consultations.
The NIMBY theory that we see in planning, where everything is fine provided that it does not affect you, is very much the same in every field. Have Members of the Committee met anyone who wanted to do away with anything that they already had? However, if you suggest putting a mental home or a new fire station next to people, no one wants it. If it is there already, they do not want to lose it. It is very strange, but that is the human reaction. I believe that consultation would happen in any event.
Community health councils are very valuable bodies. Had I been asked 20 years ago, I should have said how appalling I thought they were. That was my belief 20 years ago. I thought that they were so destructive that the idea was hard to believe. I never saw them becoming the valuable bodies that they now are. I am very impressed by how well they work and how closely they follow every event that takes place. Therefore I agree with my noble friend Lady Eccles on community health councils.
The noble Lord, Lord Alderdice, spoke about greater co-operation between health and local authorities. I believe that is happening, and it is very good. However, the crunch point comes in relation to budgets. If the health budget were ever to be submerged in the local authority budget, then health would suffer. For that reason we must keep the two separate. But there should be consultation.
Although I am mildly against most of these amendments, I am very much against Amendment No. 24 on grounds of sheer impracticality. I understood that the whole idea of the Bill was to bring forward not just the odd scheme here or there but lots of new ideas to be tried in all parts of the country. Amendment No. 24 insists on an annual report to Parliament on each decision taken, the findings of all reviews carried out, and,
- "each variation and each termination".
In my experience, whenever people have to be notified of each variation, a variation can be the most minor thing imaginable. If the annual report to Parliament is to cover each variation and each termination--I shall not go through all the words, but they are all set down in the amendment--we shall have something like an encyclopaedia presented to Parliament every year if the Bill produces the number of innovative ideas that are being suggested. It is not a case of having to report the ones that are implemented; it is a matter of each decision, and why an idea was rejected. All the emphasis in the earlier part of our debate today was on encouraging people, nurses, pharmacists and others, to bring forward schemes. That will make any annual report bigger and bigger. As I say, it is not just a matter of schemes that are accepted; it is a matter of each decision. Amendment No. 24 is totally impractical. I oppose these amendments.
Lord Harmsworth: Perhaps the Minister can help the Committee on this point, following the remarks of the two previous speakers. Would flexibility be lost if these amendments were adopted? Would it not be the case that greater precision could be had as the Bill presently stands in so far as, presumably, the numbers and different types of consultee are large and very varied?
Baroness Masham of Ilton: In the past few years there has been a tremendous number of changes in the National Health Service. The public get confused. Therefore it is very wise to write in on the face of the Bill that there should be consultation with various bodies representing the public and different organisations representing the mentally ill, paraplegics and all sorts of different people. Perhaps there is no need for so many amendments; they could be consolidated. However, it is very important to have the goodwill of the community supporting any health issues. If people understand what is going on, they are far more likely to support it. I hope the Minister will be able to bring forward a proposal before the next stage of the Bill.
Baroness Cumberlege: This is a very large group of amendments. I shall take them in the order in which they appear in the Bill. The amendments would require health authorities and boards or, in some cases, the Secretary of State, to consult patients' representatives, the professions and local representative committees on proposals for pilots and reviews.
We welcome the objective behind the amendments. Primary care is the first port of call, as the noble Baroness, Lady Jay, said earlier, when medical or dental
treatment is needed. If the provision in an area is to change, there should be an opportunity for people to make known their hopes and concerns. Similarly, it is essential that in taking forward this new approach to family health services we keep in close touch and take the views of health professionals, who know more than anyone how those services can best be delivered. In some cases, as the noble Baroness, Lady Hayman, said, it may also be appropriate for there to be discussions with local authority services, such as housing and social services.The legislation and the arrangements to enable us to achieve this co-operative approach are already in place. So far as concerns patient representation, it is the role of health authorities and boards to secure local services that meet the health needs of local people in the way they want. As my noble friends Lady Eccles and Lady Gardner said, that process must include appropriate consultation with patient organisations and we will want to satisfy ourselves when considering authorities' approach to piloting that that has been thoroughly undertaken. Similarly, we will expect health authorities to take account of patients' views in the input they provide to evaluations. Community health councils, which represent patients' interests, already have a right to be consulted on major service developments and this will ensure that their voice is heard in discussions on piloting and more permanent arrangements.
Turning to the input of the health professionals, it is worth reminding ourselves of the characteristics of the arrangements the Bill will allow. Those arrangements will not be imposed on anyone. They are for volunteers, and will only happen if GPs, dentists and trusts come forward with innovative proposals which promise improvements in services for local people.
More than that, we will want proposals to mesh reasonably well with other services provided locally. We do not want to push through piloting at the cost of destabilising existing services. That is precisely why we are committed to considering carefully the proposals for pilots that come forward and to proceeding cautiously. That is why the Bill provides for the Secretary of State to require health authorities and boards to carry out appropriate local consultation on proposals. So appropriate consultation will be central to the drawing up of proposals. It will also be crucial when we want to evaluate schemes. That is why the Bill explicitly gives those GPs and dentists involved in providing services under a pilot the right to contribute to the evaluation.
I hope that this demonstrates our commitment to a consultative approach. The amendments under discussion would not add to this, but they would risk imposing inflexible rules. The hallmark of our initiative is diversity. We need to ensure local consultation can be adapted to the types of scheme, and type of situation that will arise. We agree with my noble friend Lord Harmsworth that there is a danger that rigid consultation would inhibit flexibility. That is why we do not want prescription on the face of the Bill. We are setting up broadly based consultative groups to consider the detailed implementation arrangements for piloting
and it will be for these to recommend how we can best ensure that the professions' and patients' voices are heard.The noble Lord, Lord Alderdice, sought reassurance on consultation with local professional bodies. We are committed to working with representatives of the professions at national level on matters such as detailed operational arrangements and general criteria for evaluation of schemes. Locally we will expect health authorities, GPs and dentists to work together on proposals. Local representative committees have a role, particularly in considering the implications of the proposed pilot schemes on existing arrangements. They are already able to do that under their powers in the National Health Service Act 1977. We shall certainly want their views, both on proposals and on their impact when it comes to evaluation.
It is right that there should be appropriate parliamentary scrutiny of government policy on the NHS. It is equally right that there should be reporting to Parliament on the performance of the NHS and the use of public funds. There are well established mechanisms for doing this and we see one of them in operation today. Scrutiny of secondary legislation and the work of Select Committees also ensures that the Executive is properly accountable.
This amendment would take us much further than that. It would involve Parliament in the detail of NHS operations in an unprecedented way. We have no targets for the number of pilot schemes we intend to run. If the early pilots are successful, and there are sufficient volunteers, we may be looking at a fairly rapid expansion of schemes after a year or two. As my noble friend Lady Gardner said, we wonder whether it is appropriate that Parliament should have a report on each scheme and on each review. The same point applies with still greater force in relation to variations of schemes.
The Bill sets two conditions which must be met before the Secretary of State may make an order bringing Clause 17 into force, and with it the legal framework for permanent arrangements. The first is that he must have regard to reviews of pilot schemes which have been conducted. In other words, there are to be no permanent arrangements unless pilot schemes have been tested and found to be successful. The second is that the Secretary of State must be satisfied that it would be in the interests of the health service to set up permanent arrangements.
For something to be in the interests of the health service it seems plain that it must be in the interests of patients. That, after all, is the group that the NHS exists to serve. For something to be in the interests of the health service it must also be in the interests of the NHS as an organisation--by serving to build it up and by promoting the interests of its staff, its greatest asset. Those, surely, are the tests which the Secretary of State would have to satisfy if he were ever to be called to account for the way he had interpreted this provision. It follows from this that in reaching his decision on whether to make an order bringing Clause 17 into force the Secretary of State will have to take into account the interests of patients and of NHS staff. The ways in
which he may do this are various and it would, again, be premature and risky to try to prescribe them now. I would rather have openness and a genuine commitment to the interests of the NHS than any number of ringing, declaratory statements in primary legislation. The true test of the Secretary of State's actions is already there, in the Bill. We do not believe that the amendments would add to it.We agree with the noble Baroness that it is important for representatives of the providers of pharmaceutical services to be consulted about the directions to health authorities or boards for the provision of additional pharmaceutical services. However, this is already done in connection with any proposed changes to the pharmaceutical services regulations. In the Government's view this would apply equally to the directions envisaged in Clause 23. To put the matter beyond doubt, however, I am quite happy to give the noble Baroness an assurance that the same consultation process would apply to directions under Section 41A of the 1977 Act and Section 27A of the 1978 Act, as now applies to regulations made under Sections 41 and 27 at present.
I also understand the concerns of the noble Baroness, Lady Hayman, about the need for consultation at local level with persons or bodies representing potential providers of additional pharmaceutical services. Our belief is that sufficient consultation provisions are already contained within Section 43B of the NHS Act 1977 and its Scottish equivalent. This provides that before a health authority or board makes a determination about remuneration for any service, it shall consult either a prescribed body established to provide advice on such matters or an organisation appearing to the Secretary of State to be representative of persons to whose remuneration the determination would relate. Our belief is that, with national consultation on the services covered by the directions, this would provide a fair measure of discussion with representative bodies. While we would expect health authorities and boards to consult widely about the range of additional pharmaceutical services which their populations need, we do not believe that a specific provision for consulting the representative body of the potential providers is right. Consultation with representatives of the population served would be as important, if not more important. I invite the Committee to reject the amendments.
5 p.m.
Baroness Hayman: I thank the noble Baroness for those assurances, which are extremely helpful, regarding the changes in pharmacy services. I am not sure that Members of the Committee can have it both ways in arguing against putting provisions for consultation on the face of the Bill. Either the consultations would take place in all that detail anyway--in which case there is no need to put them on the face of the Bill and it would not take extra time--or they would not take place and if we had to put them in place there would be great unnecessary bureaucracy and extension of time. But Members of the Committee cannot argue both cases at the same time.
My argument is that it is essential to put them on the face of the Bill. I believe that in the past few years we have seen a profound breakdown in trust in decision-making processes within the NHS. That has been a damaging breakdown because it has ended in an almost automatic opposition to any change, however justified it might be. That is because of a basic distrust of the motivation and direction of health policy. I fear that we could get into exactly the same situation here regarding the potential commercialisation of general practice in primary care through the introduction of commercial companies into providing it.
That is why I believe that it is important that, in the difficult process of rebuilding public confidence in decision-making processes, in taking people through the reasons why "not in my backyard" might not be the best response, the answer is not simply to plonk it in their backyard and tell them that they have to lump it. It is to argue one's case through, to listen to what people are saying and to be prepared to let them have a judgment on what you are saying.
Amendment No. 8 was specifically designed not to be inflexible, not to give a list of everyone who had to be consulted in every possible situation. Perhaps I am more suspicious than noble Baronesses opposite who spoke. We should not leave everything to the assumption that it would be done properly, but should give the commitment on the face of the Bill that consultation would be properly undertaken.
Much has been said about the "encyclopaedia" that would occur if Amendment No. 24 were accepted. Within the health service many professionals are deeply disillusioned, being lectured by politicians and managers about evidence-based medicine and how they should be initiating it but not seeing a great deal of evidence-based policy coming forward from people like ourselves. I believe that somebody should assess all the information in the annual report that we suggest in Amendment No. 24 and if that assessment, the evaluation of the experiments is done at the Department of Health--it would be inconceivable and irresponsible for it not to be done there--it ought to be shared nationally.
These are important issues and I fear that we may have to return to them at another point. I beg to leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 6 not moved.]
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