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Lord Monkswell: The noble Lord, Lord Jenkin, has actually highlighted the difficulties that we have with the whole business of PFI. In contributing to the debate on the basis that amendment talks about services, the noble Lord mentioned capital equipment. That is the sort of confusion about which we need to be most careful. We all recognise the worry that clinicians and doctors have that they may end up being employed by a private company rather than the National Health Service. That is the main worry. However, the difficulty is where you draw the boundary. It is all very well for the BMA to say that it is concerned about the professionals with whom it works closely and that, "We should be protected and our immediate colleagues should be protected". Indeed, we recognise the justification of that concern, but it is not just them; it goes into other areas.

The amendment refers to,

"professional staff which have direct impact on patient care".

There are many other white-collar workers working in a hospital; for example, the manager of the cleaning staff, the manager of the catering staff or the manager of the boilerhouse. Which one of them does not have a direct impact on patient care? If they do not do their job properly, surely that impacts on patient care. As I said, it is most difficult to draw the boundaries.

There is one particular risk that I foresee in providing reassurance to those who are worried about the possible privatisation of patient care. If we set a list of those services or professions which could be construed as being directly involved, we effectively say that everything else that is not on the list is available for privatisation. We must be very careful in that respect. When considering the issue raised this afternoon by the Front Bench opposite about the review which is taking place, the question was posed in terms of the extension of charges. In any review process, I should like to think that we would actually consider how we can eradicate the charges that we have at present. We must think in both directions.

There needs to be some mechanism to provide reassurance not only to the professions involved but also to the public at large that the use of PFI for the next year or so, just to keep the capital building programme going, is not the thin end of the wedge of privatisation. I am fairly confident that my noble friend the Minister can provide that assurance.

Lord Winston: I find myself completely in agreement with the spirit of the amendment moved by the noble Lord, Lord Ezra. However, I also find myself, most surprisingly, in agreement with the noble Lord, Lord Jenkin, over the issue of definitions. It is impossible to define what is a patient service. I should like to extend the proposition made by the noble Lord to include, for example, the operating theatre. There are

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many examples in the working of a large general hospital where there is urgent need of investment which would pertain to, reflect and be important for patient services, which really cannot be distinguished.

What we need from the Government is an undertaking that we will not have a creeping privatisation of the National Health Service. I am sure that that is the spirit of this Government. I hope that we can look forward to hearing some kind of reassurance from my noble friend the Minister in that respect. That is the best we can hope for if the Bill is to proceed as it must.

Baroness Cumberlege: While I very much respect the views expressed by the noble Lord, Lord Ezra, we on these Benches cannot support the amendment for the two reasons given by my noble friend Lord Jenkin of Roding. First, we believe that the approach is too centralist; and, secondly, we have difficulty with the definition of what does or does not have a direct impact on patient care. We are back into those grey areas which so bedeviled the Minister on Second Reading. As the noble Baroness will remember, I pressed her during that debate to define what she meant by the definitions regarding subsection (3) referred to in Clause 1(5). At that time she was unable to do so.

When looking at the BMA evidence--and I am most grateful to the association for sending such evidence to me and other Members of the Committee--it is clear that the BMA has difficulty in defining clinical services. It starts with a list but there is a caveat at the bottom of the list which states that it is not exhaustive. That is the problem with lists. It is far better to build in a degree of flexibility. Those of us who do the weekly shop know how difficult it is to stick to a list and how much we would miss if we did so. We would have none of those little luxuries which make life worth living.

The RCN does not even attempt to define what is meant by clinical services. Although I would expect the new Labour Government with their roots embedded in a history of centralised bureaucracy, to deny local people the power of decision making, I am surprised and sad that both the BMA and the RCN are denying their members the choice which we gave them in our clear policy contained in the National Health Service (Residual Liabilities) Act which covered this ground.

At Second Reading of this Bill the noble Baroness, Lady Jay, was clearly not ready or prepared to define services. In answer to the probing questions that I put she admitted that although the Government had undertaken to present the Bill to Parliament, they had not yet defined what they meant by services. That was unlike the previous government. When I was asked at the Dispatch Box by the noble Baroness during the passage of the National Health Service (Residual Liabilities) Bill what was the position regarding clinical services, I gave a clear answer; indeed, one which her noble friend Lord Carter had no problem at all in understanding. I am glad that the noble Lord is present to listen to this part of the debate. My reply was:

"The noble Baroness also asked about the privatisation of clinical services. I remind her that it is no part of the Government's policy through PFI to transfer the delivery of NHS clinical services into the private sector ... However, if a trust explores local arrangements

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for private sector provision of some clinical and clinical support services we would not stand in its way. As the noble Lord, Lord Carter, said, it is a matter of local determination and it cannot be carried through without the support of clinicians. If a PFI project is submitted for approval and its viability depends on the privatisation of clinical or clinical support services which does not have the consent of local clinicians it would not receive departmental backing".--[Official Report, 21/5/96; col. 785.]

With our policy the decision was left for local determination.

It seems to me a great pity that the people in the service, doctors, nurses, managers, scientists, laboratory staff and so on, who have by far the greatest knowledge of the local situation and of what will work both geographically and professionally, are, under this Government's proposals, being denied the power to influence their own destiny. The Government's approach is to ignore all that wisdom and understanding and to deprive local clinicians of their rightful opportunity to influence the shape of their new facilities--as highlighted by the noble Lord opposite--and give the best possible service to patients. Instead, they will have to conform to a template set centrally by a remote bureaucracy.

I understand from a letter which the noble Baroness sent to me yesterday evening--for which I thank her--that there is to be a list of which services may or may not be included in a PFI contract--no local decision making but a central government list, a diktat. While I have a sense of relief that the Government are at last getting their act together on this part of the Bill, I have serious misgivings that not only will the list be deeply problematical but, like all lists, it will prove to be rigid and inflexible.

One of the great strengths in the 50 years' life of the NHS has been its ability to respond remarkably well to advances in modern technology; to increasing consumer demand; to an ageing population; and to the shift away from institutional care to looking after people in their own homes. Many of those challenges have been met through a sharing of skills and flexibility in working. The enemy of innovation is to place people in a strait-jacket and to give them titles from which they cannot escape. That is exactly what the Minister proposes to do. The Government's unimaginative, rigid and centralised approach will, I fear, set in aspic some of the very attitudes which in extreme cases verge on professional tribalism. I urge the Minister, whom I know does not lack flair and imagination, to try to persuade her colleagues to trust those who work day in, day out, treating, caring and managing patients, for it is they who know and in our policy it is they who would have been trusted to make the important local decisions.

The noble Lord, Lord Ezra, said that he was in no doubt about the Government's intention. I admire his certainty. I refer to the document given to me by the Minister which contains the speech made by her colleague, Mr. Milburn, when he met key stakeholders on 10th June 1997. He said in that speech:

"Definitions of clinical service can be vague, especially in the area of so-called clinical support services, and I have commissioned advice on this thorny issue. I understand and recognise the benefits of including service elements in the current model of PFI scheme".

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That raises a whole series of questions. Perhaps the noble Baroness can give a definitive statement as regards what her colleague was saying on that occasion.

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