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Baroness Hayman: My Lords, I can assure the noble Baroness that I will not be the slightest bit cross. I think that she should go home as soon as possible.

Baroness Cumberlege: My Lords, perhaps I should go before I make my speech.

It is understandable that every new government want to legislate for the NHS. The NHS is probably the most popular institution in this country. It is the one which generates huge concern and it is one of the very few organisations over which the Government still have total control. Its ethic is based on the superb principles of love thy neighbour and each according to his needs; it is

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a highly-cherished principle. But the price of a tax-based service, largely free at the point of use, means that the Government have carte blanche to meddle. As a result, the poor, dear NHS is subjected to a state of constant revolution, as the noble Baroness, Lady Pitkeathley, has said, perhaps matched only by Chairman Mao and his lady wife.

I understand the temptation. Indeed, I understand the necessity to keep up with social changes, developing technologies, rising expectations, demographic trends, and so on. I welcome the themes that have been outlined by the Minister this afternoon--the continuing emphasis on a primary care-led NHS, quality, partnership and local autonomy.

I thank the Minister for the very clear way in which she introduced the Bill. But I must profess disappointment that when initiatives are shown to be a proven success, embodying the very themes which were outlined this afternoon, they are abandoned for ideological reasons. The independent OECD stated that, contrary to what the Minister said, GP fundholders did a better job of purchasing services than health authorities and were more prepared to diversify, to challenge hospital practices and to demand improvements.

The BMA found that fundholders encouraged consumer accountability and GPs were truly willing to share the decision-making process with their patients. The Audit Commission said that fundholders introduced more services to patients, improved communication with hospitals and were more cost effective in their drug prescribing.

I know that the criticism levelled at fundholding was that it was two-tiered and that some patients received a better service than others but, as my noble friend Lord Howe said, instead of a two-tier system we now have a four-tier system. Primary care groups will not only introduce four tiers of service but will diminish patient choice in that they are statutory and cover much larger areas so that patients will not be able to choose to go to a practice which does not belong to such a group rather than one that does.

I could level a great deal of criticism at the concept of primary care groups, especially in relation to cost and the work which has been done as regards total purchasing schemes which are the nearest that we have to primary care groups. But I have this sinking feeling that, whatever we say today or, indeed, throughout the passage of the Bill, PCGs in principle will remain. Sadly I am resigned to that but I am committed to the NHS and am determined that PCGs as amended, I hope, throughout the passage of the Bill should work as well as is possible.

I ask the Minister--and I shall read Hansard for her reply--what incentives the Government have put into the Bill to encourage PCGs to do well. What are the sanctions if they fail? What will happen if a PCG overspends? Is there a presumption that the health authority will bale it out? If it does so, is that fair to patients in other PCGs within that health authority which will presumably have to pay the price by forgoing services which are due to them?

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Neither the Government nor the health authority can lean on or dismiss the chairman or members of the PCG board since they are voted into their positions by their professional colleagues, unlike the primary care trusts whose membership will be appointed. Where are the incentives and the sanctions? Where is the accountability? As I read the Bill, the commission for health improvement has a role of intervention. But what does that mean? It can force prescribed persons to compile reports; but so what? Where is the action and, above all, where are the incentives to do well?

In my experience of running three large organisations, putting the boot in achieves an immediate response but it does not motivate and engender loyalty in the medium and longer term. I share the concerns of my noble friend and those of the noble Lord, Lord Clement-Jones, about primary care trusts. But one hopes that the issues which have been raised today will be clarified early during the passage of the Bill.

My second point is much more important and fundamental. Organisational arrangements, although they make a difference and affect issues of choice, quality, accessibility and effectiveness, are to some extent en passant and ever-changing. But the relationship between the public and the medical profession--the doctor, nurse or therapist--is not. It is fundamental and the very essence of healthcare. Without the confidence and trust of people in those professions, we lose everything. That relationship is the cornerstone, the foundation, on which healthcare is based. Governments are peripheral in comparison. As the noble Lord, Lord Walton, said, a recent opinion poll revealed that doctors, along with nurses, remain the most respected of all professionals. That is no accident. They have worked hard over many decades to gain that respect.

An element which engenders that confidence in doctors is their independence; the fact that it is a self-regulating profession for which, through the Royal Colleges, the GMC and other institutions, standards are set and it is increasingly aware that those standards must be met. It is not the poodle of any political administration. As a recent editorial in the Daily Telegraph stated, peer pressure can be as powerful as any other influence on how professionals behave. But if doctors become mere employees of the state, that could fall away.

No one would wish to defend the situation which arose in the Bristol case or, indeed, in the case of the Kent gynaecologist. From time to time there are of course others who fail in their duty of care. They are not to be protected and their professional behaviour should be exposed and dealt with appropriately. The medical professional can be criticised for being too slow in putting its house in order but I agree with the noble Lord, Lord Walton, that there is no doubt that it wishes to do so and, indeed, is doing so.

When I was a Minister only two or three years ago, with the full support of your Lordships' House, we passed a Bill to strengthen and widen the powers of the General Medical Council. As a result of an inquiry by

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the Chief Medical Officer, there is now an obligation placed on medics to report cases of incompetence among their colleagues. They are obliged to report those who break the profession's ethical code. The confidential inquiry into peri-operative deaths, the regular review of maternal deaths and, through CESDI, of infant deaths, the introduction of medical and clinical audit and so on--all relatively recent initiatives--are making an impact on standards of care.

But perhaps the most encouraging sign is the obvious willingness of the medical profession itself to go further. The highly respected president of the GMC, Sir Donald Irvine, has shown by his leadership a commitment to make the profession more open; to increase the membership of lay members; and to work closely with them. His whole attitude is one of reform. He has not only thought about change but, through his obvious integrity, he has maintained the confidence of his colleagues and instilled in them a realisation that change is inevitable.

I prefer to see those changes led by the profession. As Sir Cyril Chantler, the Principal of the United Medical and Dental School of Guy's and St Thomas' said recently:

    "Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous. The mystical authority of the doctor used to be essential for practice. Now we need to be open and work in partnership with our colleagues and with our patients".

These are eminent men, men of integrity and substance. They know the business; their intentions are honourable; and quite frankly, I put my trust in them before transient Secretaries of State or Ministers, of whatever political persuasion. I put my trust in Parliament and I shall oppose, along with any other Members of your Lordships' House, any Henry VIII clauses which seek without a full debate to meddle with the regulatory system of the health professions. That should not be an issue decided by the whim of a Minister but should be debated publicly in Parliament, since it is the people's business.

My third and last point concerns the pharmaceutical industry. On the whole, governments fail to see beyond the next PES round and industry and commerce, beyond the next quarterly or half-yearly results. In addition, our manufacturing industry and City institutions have progressively moved into the control of foreign hands. The shining exception is the pharmaceutical industry with its huge investment in research and development, its international business and its vast contribution to our overseas earnings.

In so many ways it is a model for this country, especially as its survival depends on the long term. What is more, it values this Government's emphasis on education. Every industry needs a home market; it needs to be cherished; it needs a constant flow of highly educated entrants with originality of mind and determination. Our record is good. Five of the world's top 20 medicines were discovered by the pharmaceutical industry in the UK.

It is tempting for the Government to see the drugs budget simply as a cost, whereas over the past 40 years advances in the use of medicines have helped to free up

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hospital beds. If we take the top 12 major diseases alone, admission rates have fallen by half, making an annual saving of £10 billion a year, about double the cost of all NHS medicines.

Other nations realise the value of the pharmaceutical industry to their country's prosperity: that it is a prize worth winning. They recognise that its prospects are boundless. If we shun the industry, if we bring harsh penalties to what after all is a voluntary system--the PPRS, which has been effective in the past--the industry will go to those who welcome it and who show it respect. It is of paramount importance that it stays here. We should not invest in education, science and technology only to encourage the brightest minds to emigrate.

The Government must seriously do a long-term cost-benefit analysis in the widest sense and look beyond the next PPS round to the very long term. The true benefits of supporting the pharmaceutical industry will be huge rewards in employment and in the education of our society.

So, while recognising the Government's desire to legislate for the NHS, I hope in the spirit of this House they will recognise the sincerity of those who do not share all their views; who share their desire to improve healthcare but not this way of doing so. As is customary, I among others in the House will seek to amend, to improve, but above all to clarify, since there is much in the Bill which is obfuscated and clouded in mystery. Let the Government live up to their rhetoric when applied to others; be honest, open, and above all transparent in their intentions. I look forward to the Committee and other stages of the Bill.

4.41 p.m.

Lord Winston: My Lords, I am sure that the whole House wishes to express condolences to the noble Baroness and her family. I am sorry that she has to leave the debate; we understand why. We recognise her contribution to healthcare in this country under the previous government.

I am a member of the Hammersmith Hospital Trust. Part of that trust was, and still is, Queen Charlotte's Maternity Hospital. Consequently, I came into repeated contact with Lady Robson. I heard only this afternoon, when it was announced, that she had passed away. She is a very serious loss to this House and to our service. I have some wonderful memories of her--not least of her chain-smoking in the corridors of power, an odd thing for someone so totally committed to healthcare. She was a wonderful woman--trenchant, straightforward and honest. We shall greatly miss her.

There are many good provisions in the Bill. The accent is primarily on what has been regarded as the poor relation of the health service, primary care. That is greatly to be recommended. We on this side of the House are very pleased that the Government have focused on that issue. It is very important.

However, it is not entirely clear that the Bill will necessarily always improve standards of general practice. I believe that standards of general practice in this country are among the highest in the world. I cannot

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think of many other places where general practitioners have such wide experience, such good training, such excellent postgraduate support and continued medical education. That is almost unique to Britain. However, one of the problems is that, of necessity, a general practitioner cannot encompass the whole of healthcare. Therefore, placing too much emphasis on primary care will worry a great number of people in the caring professions.

Also good is the fact that the Bill breaks down the barriers between the NHS and other bodies locally and, to some extent, nationally. As we on this side of the House have repeatedly said, although it is not only a Labour message, improving the care and health of people locally is not really a matter of primary or secondary care. It involves much wider health issues, including the environment, education, poverty and so on. If primary care is to be effective, it is important that we pay attention to those mechanisms within government.

My noble friend the Minister said that doctors should be properly trained. I am extremely worried about that. Training depends much more on the structure of the NHS than on any other factor. We do not learn medicine as undergraduates in medical school. I know that from my own experience as a doctor. I see my son, a recently qualified doctor, going through the Cambridge course at the moment. Nothing could be more remote during that training than caring for people. One learns to care for people when one comes into contact with them and becomes responsible for them. Undergraduate training does not prepare one. Training starts after qualification.

I well remember my first training lesson. A patient was brought in unconscious. I diagnosed--as it happens correctly--that she was in a diabetic coma and gave her a massive dose of intravenous insulin. She was at death's door. I then phoned my registrar, who was in the local pub, and told him what I had done. Then I realised that I had given quadruple strength insulin intravenously. That is not the sort of thing you learn as an undergraduate. I was terrified. Fortunately, the patient did not die. It was probably the only thing that saved her. It restored her biochemical balance in the most dramatic way. Those in the biochemistry department said that they had not seen anything like it for some years.

The truth is that training depends on contact with those who have specialist knowledge. That has been the keynote of our health service. I have learnt it, as have all of us, through contact with people who inevitably have a major degree of specialist training. That training may be neurosurgery; equally, it may be general practice.

One of the problems with the Bill, as was pointed out by the noble Lord, Lord Walton, is that there is nothing in it that supports academic medicine or training. Those of us who are in the academic sector are seriously worried, particularly those in the hospital and specialist sector, about the consistent undermining of specialist care. I repeat: we must not divide primary and secondary care. We have to work together in the National Health Service. I do not see enough evidence of that in the Bill. I hope that that will be attended to in Committee.

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Secondary care cannot be under-rated. Each of your Lordships may, or may not, be cured through primary care. But one thing I can promise is that, when you develop cancer, lung disease or heart disease, or have problems with your prostrate or have breast cancer, all of you will require secondary care, as does every member of the community in the British Isles, indeed of the human community. It is the essence of healthcare.

I am afraid that I must refer to a speech made last week by my noble friend Lord Warner. A disagreement arose about the issue of primary and secondary care. My noble friend seemed to imply that secondary care was in some way elitist, that it was too expensive. It is not. It is all part of the same continuum, and we must never forget that. We cannot undermine one at the expense of the other. They must work together. The NHS depends on both.

I am worried that the Bill may do too little to put right the destruction of secondary care which has occurred over a long time in our hospital practice. There has been fragmentation and loss of specialist referrals to centres that can do the teaching and training. There has been a destruction of our knowledge and teaching base. There is all too frequent conflict between universities and the health service all over the country. It is not a conflict that either wants to see. But it is inevitable, due to pressure on finances.

The noble Earl, Lord Howe, in his excellent speech, made an interesting point that suggests almost a misunderstanding. He said that we must recognise the clinical autonomy of GPs and clinicians. Of course, it is the same thing. We are all clinicians and must work to a common goal. We must get away from the separation.

Primary care cannot entirely get to grips with the complexities of modern medicine. To some extent that is inevitable with high technology, which leads much of our knowledge and practice. We run the risk of making our health service second-rate in international terms if we do not recognise it when we legislate.

There are two gaps in the Bill to which I wish to draw attention. They have already been discussed or have been alluded to in part. One is the composition of the primary care trusts. We are naturally nervous about their structure and composition. I hope that during the passage of the Bill through Parliament we can hear some understanding of how the trusts will be composed. It must be clear. Many of us will seek to ensure proper specialist representation on the trusts in order to achieve local standards of the highest order.

I am sorry to reminisce, but when I started my training in the district general hospital the local consultant--be it the chest physician or the heart physician--felt that he had a responsibility for the local community. If there was a factory locally where people were suffering from chest disease, he wanted to be out there doing something about it. Unfortunately, the structure of the health service has now divorced that specialist care from the local area. If we are to have primary care trusts, we must ensure that they are set up

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with that aim in mind. Hospitals must play a major part in how the health of the local community is maintained. There must be interdigitation.

The other gap in the Bill is regulation of the professions. We shall come back to it at the Committee stage. I share the concern so well expressed by the noble Lord, Lord Walton, in that respect.

Finally, one point echoes the remarks made by other noble Lords. It concerns the drugs industry, the pharmaceutical industry, which is one of the jewels in the crown of British industry. We cannot get away from that: it is an area in which we lead. What does the Association of the British Pharmaceutical Industry say at the moment? It says:

    "The UK is becoming a very hostile environment for the pharmaceutical industry and a very difficult location from which to run a global pharmaceutical business."
We cannot afford to lose that inward investment. It is only one example of where we can have inward investment in the health service. There are many other examples to which we shall return. I hope that some of the issues can be explored carefully during the Committee stage of the Bill.

4.53 p.m.

Lord Skelmersdale: My Lords, in recent months the noble Lord, Lord Winston, and I have become sparring partners outside, not inside, the Chamber, especially on occasional Wednesday evenings. Today is not a Wednesday and I do not intend to take up the cudgels with him at the moment.

I begin by thanking the Minister and her team in the department in which I had the honour to serve before the split for the most comprehensive explanatory notes on a Bill I have ever seen. They are a model of what explanatory notes should be, not only explaining what the Bill seeks to do but giving the recent history of the particular part of the health service with which we are chiefly concerned today.

The noble Baroness has perhaps realised by now that it might have been wiser, on reflection, not to be quite so explicit. Unexpurgated versions can cause harm. As my noble friend Lord Howe and the noble Lord, Lord Clement-Jones, might have said--indeed, almost did say--what a contrast with the Bill!

For many years all thinking people who work in the NHS have been suspicious of change. The noble Baroness, Lady Pitkeathley, who is not in her place, I am sorry to say, mentioned it. The Minister talked about the Bill going with the grain of developing NHS thought. I was struck by that phrase and wondered whose thoughts she had in mind. We have clearly been listening to different people. It might be described as the attitude of, "Leave us alone and we will deliver." Whenever change is in the air, we hear it loud and strong; we have all heard it. It happened when we changed the control from local government to central government. We heard it in 1976 while working up the National Health Service Act; in the 1980s, at the time of what came to be known as the Fowler reforms; in the 1990s with the National Health Service and Community Care Act, the Health Authorities Act, the National

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Health Service (Primary Care) Act and now the soon to be Health Act. "Not this time", says the Minister. We shall see.

The changes have come thick and fast and they are getting both thicker and faster. Small wonder that NHS people, both directly and indirectly employed, are becoming fed up. As my noble friend Lady Cumberlege said, governments of all persuasions fail to recognise that the NHS is a vast juggernaut of an organisation. Oh, yes! I know that Ministers--I have done it myself--say that it is the second biggest employer in the world, employing, if that is the word, around 1 million people, a little, but only a little, smaller than the Indian state railways. But they do not consider what that really means. It means that if there is to be a change--whether for better or worse--it needs a long time to bed down because only then will it prove itself--or not, as the case may be. I know only too well that Ministers love interfering. They feel they have to, in order to justify themselves. If I have learnt nothing else during my time in politics, it is that most of the time it is better to see that the existing law is working properly and is obeyed rather than seek to change it radically.

Last week, I had occasion to congratulate the Minister on NHS Direct. That new and expanding service is clearly an advance. But it is not what I am talking about. I am talking about the amazing number of changes that managers in the NHS have had to put up with and adapt to. Not just managers either: the changes invariably affect the frontline staff as well. A patient will inevitably get better slower in a ward of unhappy nurses.

The Minister is right about what the health service exists for. What people want it to do is keep them in good health, help them to better health and, when they are ill, ensure them speedy help. Very few worry about how managerially that is achieved. The Bill is a managerial Bill. But will it help patients get what they need? I doubt it will make much difference in emergency treatment. The NHS has always pulled out all the stops there. It is elective surgery that is slow and, as we have heard, getting slower. If GPs have a modicum of control, as they have under the present system, they can try to obtain and often succeed in getting the faster treatment that they, and at least initially only they, believe their patients need.

I could not agree more strongly with the noble Lord, Lord Winston. This interface is absolutely vital. The Government will say that that is happening now. But is it? Waiting lists are reducing but we all know that that is a myth. For the patient, the person who really matters, waiting does not start with the consultant. It starts when the GP says, "I'll book you in with the consultant.".

This is known in some circles as waiting to get on the waiting list. The figure is becoming larger and larger. In the past year from September to September it grew by over 100,000. That puts the Government's election pledge to reduce waiting lists, that is, consultant waiting lists, by 100,000 into perspective, does it not? Mind you, they cannot do that. Although reduced since the peak in March last year the figure is still almost 150,000 above that which the Government inherited. What will the Bill do for the real figure? My noble friend Lord Howe is

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right. How can we possibly tell from such an obscure Bill, unless my noble friend's amendment is attached and accepted? This House always complains of framework Bills. Like the noble Lord, Lord Walton of Detchant, I await the report of the scrutiny committee with keen anticipation.

But I do not want to be entirely negative. My experiences in Northern Ireland taught me that health and social services worked properly as a seamless web (to use a horrible expression) only if they had a communal budget. I do not have time to go into detail, but at first sight I welcome Clause 24 as a step in the right direction, especially if it means, for example, that a hospital trust can unblock beds by paying social services to provide home helps. However, I have the strong suspicion that the money will go only one way. We shall discover that during the passage of the Bill. We shall also see whether joint consultative committees really have had their day or whether the Government are right in saying that Clauses 21 to 23 will do the trick. But that is a detail and this is Second Reading.

In general, I believe that the Bill if, in the main, necessary at all, comes two years too soon. Twenty-one months of thinking is not, as far as I can tell, enough. I hope that the Minister will explain to the House exactly what underpins the framework and the details of the new system that she proposes. I accept that change in the NHS is necessary, but radically altering and not abandoning, as the Government claim, the purchaser/provider split when it has not properly bedded down is a mistake. I hope that we do not all come to regret it.

5.2 p.m.

Baroness Thomas of Walliswood: My Lords, I shall deal with some aspects of primary care trusts and partnership as expressed in the Bill. The Liberal Democrats did not support the creation of fundholding practices by the National Health Service and Community Care Act 1990. In the event, the ability of GPs to commission secondary healthcare and to be innovative in primary care was well demonstrated. But, as we had feared, the competitive and two-tier nature of the scheme resulted in inequality of access to NHS care, as the Audit Commission report of 1996 and the Dowling report on differential waiting times of 1997 confirmed.

We agree with the thrust of the Bill that a single structure for primary care provision and secondary care commissioning as proposed through primary care trusts is preferable to fundholding. Together with partnership proposals, it offers the hope of restoring the national character of the NHS in a way that is responsive to local need. Unfortunately, as my noble friend said, lack of detail in the Bill may hamper the possibility of bringing this hope to fruition. For example there are a number of widespread doubts about how the transition to primary care trusts is to be managed. The changeover will involve a huge cultural shift as well as more down-to-earth considerations such as a requirement for new specialist staff to manage the commissioning process and adequate IT systems to control budget monitoring. As a member of a shadow hospital trust,

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and later of the real hospital trust board, I witnessed the confusion and waste of resources that resulted from lack of preparation for the role of the new hospital trusts. Only gradually did useful packages of software become available and hospitals understand that they needed skilled contract negotiators to manage their end of the commissioning process. Only gradually did they become capable of detailed monitoring of the budget to avoid a financial crisis in July of every year.

While some former fundholders will no doubt bring commissioning expertise into the PCTs, others may not contain a nucleus of expertise in these areas. Since each is likely to be managing a cash-limited budget of some £60 million or more against a background of ever-increasing demand, we simply cannot afford a long process of self-education through error as happened to an extent in hospital trusts.

Another difficulty that the Bill does not appear to tackle is that GPs in PCTs will be both purchasers and providers of care. They will be both commissioners and suppliers. I do not know the correct terminology, but no doubt I shall learn during the progress of this Bill. Experience of social services departments as they have sought to deal with the problem via reorganisation of their staff indicates that it is not always easy for individuals to straddle both roles. Will the Government provide guidance to general practitioners and other health workers in primary care as to how they should handle this problem?

A related point that concerns a number of professional bodies is whether, and if so how, the GP's status as an independent contractor is affected by membership of a primary care trust board. A further point is that community health councils and others associated with users and the interests of the community at large are also concerned by the absence of requirements imposed upon trusts to consult and co-operate with the local community. For example, the noble Baroness, Lady Pitkeathley, highlighted the potential value of a statutory obligation to co-operate with the voluntary sector. I agree with her.

Under the Liberal Democrat model for a joint health service/social services structure that is governed by a democratic organisation, the role of the CHCs would be redundant. However, the Government are not adopting that approach and so the question remains as to the future role of CHCs.

A related concern, which is very relevant to the needs of elderly patients among others, is that the role of therapists is not always sufficiently valued by the medical profession and that the number of such therapists is insufficient to meet the needs and demands of patients and clients. Do the Government see a role for the professions allied to medicine within the primary care trusts? What efforts will they make to encourage more people to enter the professions? Will the lack of input from the related professions on PCG boards be tolerated with respect to PCTs?

In relation to partnership, there is a general welcome for the duty placed on all parts of the NHS to co-operate with one another in exercising their functions under

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Clause 19, and the new duties imposed upon NHS bodies on the one hand and local authorities on the other to co-operate with one another under Clause 20. Of course, aspiration is not the same as action and there is much detailed work to be done on putting this into practice. Many kinds of organisation appear to be excluded from the requirement to co-operate. It is not unreasonable to be cautious about the ease with which this co-operation can be achieved in practice. The culture of social services differs from that of housing and education departments on the one hand and from the culture of the health service as a whole on the other. I carry the scars of that culture clash, which I acquired when I served on both a county council and a hospital trust board and was treated by both sides with all the enthusiasm that is generally meted out to a messenger.

To take but one example, how is the problem of the charge/no charge culture to be solved in practice? While the organisation of care of the elderly, for example, may be improved, how can we be certain that the level of care will be similarly improved given cash-limited budgets? All of the organisations involved will be working to cash-limited budgets. We have seen how the ideals of care in the community have been sullied by the need to prioritise care only for the most dependent clients under the pressure of cash-limited budgets. Yet how can this need to prioritise help those who could benefit by early assistance in the struggle against dependency?

Of course GPs faced with their cash limits may find innovative ways to provide suitable care for patients outside the expensive hospital environment. However, I must be careful. I note that the noble Lord, Lord Winston, has left his place; nevertheless I take his argument seriously. Are the Government relying on those innovative mechanisms to solve the problem of the growing cost of care in the community?

Some have welcomed the possibility that money can move from the NHS into local authority schemes. But do the Government plan to allow mutual commissioning of services between local authority and NHS bodies? That is not possible currently but it could be useful. Is that one of the provisions to which the Minister referred when mentioning the Local Government Act?

Finally, although we cannot support the unusual amendment to today's Motion moved by the noble Earl, Lord Howe, I wish to emphasise our dislike of the lack of detail in the Bill and the proliferation of secondary legislation that will therefore ensue. Secondary legislation is the bane of our current legislative process. It represents the exaggerated power of the Executive over the legislature in our constitution. I am sure that the lack of detail in the Bill will be challenged by many and will form part of the staple fare of consideration of the Bill at Committee stage and later. Perhaps the Government should remember in this time of constitutional upheaval the effect in another turbulent era of the cry, "The power of the king has increased, is increasing and ought to be diminished".

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5.11 p.m.

Baroness Elles: My Lords, a debate today on a public health Bill is to be warmly welcomed. Those who have taken part in the debate have made major contributions according to their expertise and knowledge. The combined knowledge and experience of your Lordships will contribute to foreseeing the consequences of the Bill--whether or not for the benefit of the public.

Those of us who have seen at first hand the work of the NHS in recent years at some of the teaching hospitals in London have been immensely impressed by the high standards of the doctors and staff employed. Many, in particular nurses, are temporary staff employed due to shortages. Their services have been impressive and have contributed to the high standards in the hospitals. They are irreplaceable.

The proposals in the Bill and in the White Paper setting out provisions published in December 1997--it is already over a year ago--give some cause for concern as well as reassurance. There is reassurance where improvements to the system, quite rightly, are proposed; and concern where improvements are being replaced by radical reorganisation with an increase in time spent on organisation and discussion rather than on patient care.

Retention of the separation between planning of hospital care and its provision--thus ensuring the improvement of health, meeting healthcare needs of the community, and ensuring that the local health service is built around the needs of the patient--is to be warmly welcomed.

Building on the increasing importance of primary care, it is made clear that the community nurse or family doctor represents most of the contact that patients have with the NHS. However those factors will be affected by the imposition of health improvement programmes which, according to the new proposals--I refer to paragraph 2.11--will govern the action of all parts of the local health service to ensure consistency and co-ordination. I am always hesitant to use such words because they seem to have different meanings for different people.

No doubt there will always be some example of failure to provide high quality care. That has already been mentioned. But we want to be sure that the service available under the NHS is aimed at achieving the highest standards of care. It is stated that the aims of the new NHS will be to treat patients according to need and need alone. I wonder whether that will be the result of the Bill. We note the capping of management costs which will affect the possibility of ensuring those standards; and the limits imposed on the financial duties of primary care trusts. Those are two examples where there is no guarantee to meet the expenses which may be involved.

Confusion over the current waiting lists and so-called non-waiting lists, to which reference has been made, is sufficient to raise considerable anxiety about the ability of the Department of Health to identify clearly how to treat patients according to need and need alone.

As with previous governments, the Government will wish to fulfil their aspirations for the best service for the health of the nation. Whether previous governments got

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that right is a matter for individual criticism or praise. However, I am sure that it is the Government's aim to achieve that. To seek improvements on past action is understandable. What is not acceptable is to decry previous systems, which may be improved. To change the system unnecessarily can produce hindrance, delay and extra unnecessary costs. Genuine assistance and the speeding up of the process of care for the patients must remain the paramount, central objective.

The formation of a national service framework, a national institute for clinical excellence and a commission for health improvement, together with new statutory responsibilities, will give opportunities for intervention in the work of the GP, without guaranteeing improvement in either the efficacy or success of the service to the patient. I believe that that is the failure of the Bill at present. During the passage of the Bill through this House, I hope that some amendments will be made to improve it. The current flexibility in the National Health Service should not be replaced with rigidity.

5.17 p.m.

Baroness McFarlane of Llandaff: My Lords, I thank the Minister for her clear introduction of the Bill and for her patience and endurance for the second time within a week.

I speak as one who has worked as a nurse, a midwife and a health visitor, and with an interest in ensuring that the National Health Service delivers a high quality service. I also served on the Royal Commission on the National Health Service from 1976 to 1979 set up by the noble Baroness, Lady Castle. We suggested restructuring the health service. Those suggestions were overtaken by a change of government in 1979. I have also served on a health authority, a district health authority, and as the first appointed chairman of the English national board, and as a member of the UKCC. I therefore speak with a great wealth of experience about how the National Health Service works. I am sure that all noble Lords taking part in the debate share a great deal of experience of the NHS.

I welcome the main objectives of the Bill for modernisation and partnership, and the working arrangements for them. I welcome the objectives of Clause 1 for the abolition of GP fundholding and the provision for the establishment and funding of primary care trusts. I believe that this will contribute to the NHS ethos of equality of access to services and do away with some of the bureaucracy and the culture of competition which has grown up in the health service.

In a service which is to be primary healthcare led-- I take the point of the noble Lord, Lord Winston, about the importance of secondary care--the contribution of nurses, midwives and health visitors is pivotal. Nurses have already developed clinically effective and cost-efficient services in primary care. They are running outreach health clinics for the homeless, diagnosing and treating a range of conditions; and practice nurses run minor injuries clinics in local health centres. Patients with chronic diseases such as asthma, diabetes, Parkinson's disease or irritable bowel disease all benefit

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from nurse-led care. Because of that and because of the importance of primary care nurses in the service, it is essential that nurses are able to commission and develop such services according to the needs of the local population. I believe therefore that we need to look at the governance of the trusts. That is not altogether clear in the Bill as tabled.

The report of the Commons Health Committee published earlier this month stated:

    "We recommend that Primary Care Trusts are not established unless their Board Membership has been reviewed to ensure it reflects the broader professional and community input that is required for PCT status ... Concerns have been expressed about the potential conflict of interest in having a built in majority of provider GPs on PCT Boards".
Is the Minister able to confirm that that recommendation of the Commons Health Committee will be accepted?

There are also problems in the employment of professional staff by primary care trusts. Only last week an article in the Nursing Standard stated that serving on a primary care group could cost nurses thousands of pounds a year--I did not know that they had thousands of pounds a year to lose, but that is what the article maintains--if their contracted hours are affected by PCG duties. The guidance given suggests that an employer is entitled to all or a proportion of the allowance made to members.

Under Clauses 13 to 18 dealing with quality, I welcome the establishment of the commission for health improvement. Some of the early clinical nursing research in the 1960s had as its objective to establish ways of measuring the quality of nursing care. Since that date nurses have been very much involved in establishing ways of assessing the quality of nursing care. The nursing profession would seek assurance that the work of the commission will cover not only medical standards, but also the essentials of care--hygiene, cleanliness and dignity, continence care and information and support for patients. A recent survey published by Help the Aged entitled, Dignity on the Ward, draws attention to some appalling conditions and poor care received by older people in hospital. Hence I seek an assurance that the commission will cover the basic essentials of care in hygiene, cleanliness and dignity.

The aspect of the Bill that is causing the greatest concern among the professions and about which I have received the most representation is the section on the self-regulation of the professions. I do not want to repeat too much of what has already been so eloquently said by my noble friend Lord Walton, the noble Lord, Lord Winston, and others. The registration and self-regulation of nursing, midwifery and health visiting goes back many years and is jealously guarded by the profession. I accept that, 20 years after the Nurses, Midwives and Health Visitors Act 1979, the time is ripe for a review of the role and function of the statutory bodies. But I am disturbed that Part III of the Bill appears almost as an afterthought under the heading, "Miscellaneous and Supplementary" provisions.

The Minister indicated that her department had been exploring with the professions legislation that should take place for nurses, midwives and health visitors.

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I was appalled that this Bill and the provisions on self-regulation appeared without waiting for the publication of the consultations that have been taking place and for the report from the UKCC Commission on Education. That is not partnership. At least we had some verbal information of what the consultations on the Nurses, Midwives and Health Visitors Act were saying and I am delighted, for instance, that it is said that the health visiting profession is to continue as a profession in its own right.

But I am disturbed, as are other people, about the use of Henry VIII clauses to regulate the profession by order. I understood that the report of the Committee of Ministerial Powers, as long ago as 1932, ruled that such powers should be exceptional. I am glad that these are to be subject to affirmative procedure, but I still believe that the professions are exceedingly uneasy about the provisions. We shall certainly want to challenge them by amendment at further stages of the Bill.

5.27 p.m.

Lord Colwyn: My Lords, as the noble Baroness, Lady McFarlane, pointed out in her able representation of the nurses, midwives and health visitors, I too seem to have been on my feet on behalf of the dental profession on several occasions over the past two or three weeks. Like other noble Lords, I receive many briefing papers from representatives of different branches of medicine and healthcare. Among others, they come from physiotherapists, chiropractors, the NHS Confederation, the National Consumer Council, the Royal College of Midwives and from Boots. A brief even arrived from the Association of Community Health Councils since I took my seat this afternoon. All made valid points which I am sure will be examined at the next stage of the Bill.

There are three parts of the Bill which will affect dentists and I intend to confine my remarks to them this afternoon. They are the establishment of primary care trusts to replace primary care groups; measures to improve quality and prevent fraud and a proposal to introduce order-making powers to change the Dentists Act.

The Government have a commitment to provide dental services for the whole population and to improve access where there are difficulties. Where primary care trusts are established to provide health services to the population they serve, dentistry should be represented on the boards of those trusts. This good practice has already been established in Wales with dental representation on local health groups.

Secondly, the provision of dental services, particularly by the hospital and community dental services, must not be adversely affected by these proposals. Safeguards must be given to ensure that the community dental services are not fragmented and the services they provide to special needs patients, who by definition are in the most vulnerable groups within society, must be maintained. The public health role of the community dental services also requires them to establish particular functions across a district and it is important that these arrangements are continued.

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The Bill will place a new duty of quality on NHS trusts. It will also set up the commission for health improvement. Such much-needed measures can only be a success if they are introduced in full consultation with the professions, including dentistry.

The Bill also provides for stronger measures against fraud. Rightly, the Government seek to eradicate fraud whether it is perpetrated by patients or practitioners. The proposed actions which can be taken against dentists who are brought in front of the NHS tribunal accused of fraud are severe, if not draconian, and will prove a deterrent to anyone contemplating a dishonest act. If found guilty, the dentist will be unable to work in the NHS and will almost certainly be unable to work at all. In these circumstances, adequate safeguards must be written into the Bill.

I had hoped to see a provision in the Bill to give the Secretary of State powers to ensure that all dentists and doctors must now have compulsory indemnity. It is of paramount importance that patients who are treated by general practitioners should have the same rights, in the event of any claim, as those who are treated within a trust. While declaring an interest as a member of the Council of the Medical Protection Society, I would support the idea that indemnifiers should be approved by a panel set up by the Secretary of State and would strongly recommend that they provide an occurrence- based rather than a claims-made cover.

Finally, I turn to the Government's proposed order-making powers. The Government's proposals will end the frustration of finding time to open the Dentists Act to get change. Last year, the Government proposed,

    "to simplify the process by which the law regarding professional regulation is kept up to date by amending the Dentist Act by Order".
This Bill will introduce a simpler procedure which will help with modernisation of the General Dental Council and other regulatory bodies such as the General Medical Council. They will, of course, continue to retain their roles as regulatory bodies for education, standards and disciplines.

As my noble friends Lord Howe and Lord Walton and other speakers have pointed out, there are, however, threats in the Bill as currently drafted. It gives wide powers to the Secretary of State under Clauses 47, 48 and Schedule 3, paragraph 1, to amend existing legislation and regulations as he thinks fit. Clarification is needed as to the extent to which these powers will be limited. The core functions listed in Schedule 3, paragraph 8(2), must be exercised solely by the General Dental Council. The schedule, however, allows them to be the responsibility of a "professional body", which is only loosely defined in the Bill. Again, clarification is needed. Although the Government say that they are committed to the principle of professional self-regulation, there are no safeguards to ensure that the existing methods of ensuring this will be preserved.

Dentists consider that the best way to ensure that professional self-regulation continues to be effective in meeting the needs of both society and the profession is to provide for minor changes to be achieved quickly, by order. However, major changes should remain subject to primary legislation, thereby allowing proper debate and consideration by Parliament.

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5.37 p.m.

Lord Ewing of Kirkford: My Lords, I wish to make clear at once that I bring no professional qualifications to today's debate. However, I bring more than 30 years experience of the National Health Service in Scotland. For some time I was Health Minister in the Scottish Office in the 1974 to 1979 Labour Government. For some time I was a non-executive director of an acute hospital trust. For some time I was chairman of Fife Health Care Trust, a position which I relinquished a year ago.

I describe that background in order to make three points before dealing with Part II of the Bill, which relates entirely to Scotland. First, I greatly welcome the abolition of fundholding. I know that the noble Baroness, Lady Carnegy, does not share my view. She believes that it would be far better if all general practitioners were fundholders rather than the small number who took up the option in Scotland. Two measures proposed by the previous Conservative government were never taken up in Scotland. One was opting out of the state education system. Only one school in Scotland chose to do so. The other measure was fundholding. In my former parliamentary constituency of Falkirk East there is evidence of general practitioners who entered the fund-holding system, suffered it for a year and then withdrew. I can name a general practitioner in my native home county of Fife who had to go to university to take a business management degree in order to deal with the paperwork of the fundholding system as it grew up.

One of the best medical examples I can give is of a young boy who was seriously ill, never to get better. His parents claimed their right to have him at home and to have 24-hour care and attention for him. A very expensive care package was put together so that the boy could be discharged into his home environment. Part of the package was a contribution of £50,000 from the general practitioners who were fundholders. The care package collapsed because the fundholding practice refused to make its £50,000 contribution. There is ample evidence to support the claim that a number of general practitioners inflated their prescribing Bill during the year before the introduction of fundholding because their allocation was based on that year's spending. That, too, threw up enormous difficulties with the fundholding principle and I am delighted to see the back of it.

I turn to the pharmaceutical industry. I recognise what was said by the noble Lord, Lord Walton, the noble Baroness, Lady Cumberlege, and my noble friend Lord Winston that the pharmaceutical industry is the jewel in the crown. I recognise that it attracts tremendous inward investment. I recognise, too, that it is the heart of research in this country. However, those three claims and more do not give the pharmaceutical industry the right to overcharge the NHS for the drugs it supplies. When my noble friend Lord Healey, who was in his place earlier today, was Chancellor of the Exchequer and I was the Health Minister in Scotland a well-known drug company, which I shall not name to save it embarrassment, had to repay the then Labour government £3 million for overcharging for drugs. I recognise all those plus points about the

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pharmaceutical industry, but perhaps I may make it clear that they do not give the industry the right to overcharge the NHS for drugs. During our debates we must keep in proportion the importance of industry on the one hand and its freedoms on the other.

The third point that I wish to raise before moving to Part II of the Bill relates to the self-regulatory bodies. It makes no difference whether we are dealing with the professions or the press. There is one common aspect; that they move to put their own house in order only when they are under threat of legislation to do so. We ought not to turn a blind eye to the fact that there has been disquiet about the way in which self-regulatory bodies regulate their professions under circumstances of serious complaint, whether from Bristol or elsewhere. I accept that people have confidence in the medical profession, general practitioners, doctors and the nursing profession, but we will not do the professions any favours if we turn a blind eye to the concerns being expressed about the way in which complaints against those professions are dealt with by the self-regulatory bodies. We shall have the opportunity to deal with this matter in secondary legislation through statutory instruments and the affirmative resolution procedure. One of the weaknesses of such legislation is that it cannot be amended. We can only vote for it or against it; there is no question of amendment. That is something we must all take on board.

I turn to Part II of the Bill which deals entirely with Scotland. In many ways, Scotland is way ahead of England and Wales in the reorganisation of its health service. The primary care trusts, about which so much has been said this afternoon, are already in place in Scotland. The trustees have all been appointed. The reason I was astonished by the noble Lord, Lord Mackay of Ardbrecknish, raising his point this afternoon is that the primary care trusts will come into being in Scotland in few weeks' time, on 1st April. I was formerly chairman of the Fife Healthcare NHS Trust which will now become the primary care trust in Fife. To illustrate the importance that has been placed on primary care, that trust has appointed as a medical director not a consultant psychiatrist or a consultant geriatrician but a general practitioner because it is at that level that we see the sharp end of medicine.

I sometimes wonder whether it is generally understood that for every 100 patients who visit their general practitioner, the general practitioner will treat 100. He or she will give them a prescription. The patients go away with their prescriptions and are usually cured. Only 10 in each 100 are referred to hospital, of whom only four are actually treated in hospital. The other six are returned to their general practitioner with advice to the GP about how they should be treated. They are treated and usually cured. Of the four who go to the secondary sector of the National Health Service, the district general hospital, perhaps one in 100 is referred to the tertiary sector, to the great centres for the treatment of cancer, cardiac problems and so on. That is why the general practitioner is so vital.

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In my view, primary care trusts will be an important element in the strategic planning of health services across any region where they are in place. I have one complaint. I shall leave it with my noble friend Lord Macdonald of Tradeston. I am delighted that he has been in his place on the Front Bench throughout the debate to hear what is said about Scotland. I would have taken this matter further in Scotland. I am not saying anything in your Lordships' House that I have not said at health service conferences in Scotland. I would have abolished the health boards in Scotland as well. Listen to this: it costs £6.1 million per year to run Fife Health Board and it does not treat a single patient. The primary care function of the health boards will be transferred to the primary care trusts. After 1st April, the health boards in Scotland will simply act as bankers on the one hand, allocating resources to the acute and primary care sectors, and as strategic planning authorities on the other hand.

The days have long passed when areas such as Fife, Stirlingshire and the County of Angus had illnesses, diseases and conditions that were peculiar to their own area. The coalmining industry has gone, as has the jute industry in Dundee, and the foundries in Stirlingshire. If one looks across and along that massive area, one sees that certain common illnesses are prevalent, whether in Arbroath or on the boundaries of Stirlingshire and Glasgow.

It is perfectly possible strategically to plan the health service across much wider areas than hitherto has been the case. I advise my noble friend on the Front Bench that that is where the massive savings can be made: in the abolition of the health boards and the setting up of strategic planning authorities comprising the acute sector, the primary care sector and part of local government in the form of social work. Those three elements brought together could easily help us strategically to plan the health service across much wider areas.

I am fairly certain that I speak for large numbers of people in Scotland when I say that we welcome Part II of the Bill. It will allow us to get on with the reorganisation that was promised in the Labour Party's manifesto on which we won the election. We reduced the number of NHS trusts from its high level of 47 to a much more manageable figure of 27 or 28. We have amalgamated a number of acute trusts to give a much better co-ordinated, integrated, acute service to the people served by the acute hospitals.

I come now to a matter that is not for your Lordships' House because I suspect that this will be the last piece of Scottish legislation that we shall discuss. In many ways I am unfairly taking advantage by talking, through your Lordships' House, to the incoming Scottish Parliament. All that I want to see now is even more integration, with the abolition of the health boards, and much more responsibility given to the primary care trusts on the one hand and the acute trusts on the other, joined by the social work departments of local authorities.

Finally, there is also a strong case for that part of the social work department that deals with care in the community being taken away from local government

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and given to the health service. The conflict that has arisen between social service departments and the health service about discharging patients from long-stay hospitals into the community is unbelievable. When a patient is discharged we are told that the money follows the patient. My noble friends can take it from me that when patients have to be re-admitted because of a relapse in their condition, the money never comes back with the patients. Once a local authority gets its hands on the money, it is a prisoner of the local authority. The health service gets the patient back, but the money never comes back with the patient. I leave those thoughts with your Lordships and I am grateful for the tolerance that has been shown.

5.49 p.m.

Baroness Fookes: My Lords, I rise with some diffidence as I do not have the deep and direct experience of the National Health Service evinced by many noble Lords who have spoken. However, I have been in political life a long time. I have seen many reforms and reorganisations heralded in the NHS, local government and other organisations. It is my experience that rarely do all the glorious things expected from the latest reform come to pass. In the fullness of time, further great changes are heralded. I dare say it will be the same with the Bill.

I am sorry--unlike the noble Lord, Lord Ewing of Kirkford--that we are parting with the fundholder principle. I thought it one of the few changes that was working and, had it been allowed to last longer, that would work even better. One of its strengths was its voluntary nature. If doctors did not like fundholding, they did not have to become involved. I gather that that was the case in Scotland. Many doctors who did join found fundholding a rewarding way of managing practices that gave power back to general practitioners. That is important. We are in danger of losing that advantage with the change to primary groups and eventually, trusts.

I understand there will be no voluntary arrangement. Doctors will perforce have to join the new groups or trusts as they are formed. They will be large, and that will make for more bureaucracy. If I were a betting woman, which I am not, I would wager that groups and trusts will produce more bureaucratic procedures than ever existed under the arrangements for fundholding.

I am concerned also about the upheaval for many people who work in the health service. I have a friend who became an administrator of a large multifund in a deprived area of London. She became increasingly enthusiastic about the improved services that it was possible to offer. She is devastated by the decision to do away with fundholding and all the changes involved in moving to the new system. I imagine many others feel the same. I am reluctant to see that change happen. I wish it well but I have grave doubts that it will work as well as the Minister says.

Clause 19 contains a noble expression about the various NHS bodies co-operating one with another. Although that is a noble sentiment, I do not understand what it means. What precise duty can there be? If there

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is a duty, presumably there can be derelictions of duty. Who will be responsible for ensuring that they are put right? To put it crudely, that seems like waffle. It sounds good but will not be particularly practical. I seek guidance on that point when the Minister winds up.

The notorious Clause 47 has been mentioned by several noble Lords who referred to the specific worries of various professional groups ancillary to medicine as to how they will be governed. I want to make a general point about the approach to making legislation. Over the years it has become increasingly obvious that governments favour a light framework to which they can add details later. That seems to give too much power to the government, or in this case the Secretary of State for Health.

It is all very well to say that matters will come before the House under the affirmative resolution procedure and can be debated. However, the point was made well by the noble Lord, Lord Ewing, that it is not possible to alter the provisions. Therein lies the rub. That is where Parliament loses control and the executive gains it. To put it vulgarly, either one swallows the order whole or one spits it out. That does not seem a sensible way of proceeding.

It would be far better if the Bill contained the right for parliamentarians to make alterations. In the absence of that right, I do not think that the Government's power should be exercised as widely as it is. The Government should think again about the whole approach. It would not hurt them to produce something far more detailed and, if they cannot, to make regulation the subject of separate legislation. I do not believe that we are here to make life easy for governments.

5.56 p.m.

Lord Desai: My Lords, when the White Paper was published by the incoming Labour Government, one welcome aspect was their commitment to abolishing the internal market. I presume that we have before us the substitute. I want to understand the new internal market because, whatever one calls it, there is a different kind of market here.

Before fundholding was introduced, the GP was able to deal with patients and was subject to light budgetary constraints on how much he or she could spend on patient treatment. The noble Earl, Lord Howe, pointed out several advantages of fundholding but many people found that system inequitable. There are various ways of dealing with that inequity. Either one makes every GP a fundholder so that no patient belongs to a non-fundholding practice, or one returns to the previous status quo. That would be imperfect.

There are two kinds of inequity in the health service. One relates to fundholding but the other does not. The inequity highlighted by fundholding was that in any local area, some patients might belong to fundholding practices while others might not. Another big inequity, which was disclosed in the Black Report many years ago and more recently in the Acheson Report, was that there are health inequities across the country, due to environmental or economic factors. Although the NHS does its best to deal with them, it is far from resolving

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them completely. Clause 21 is welcome because it places on health authorities a duty to improve health in their regions.

If one wants inequities to be overcome in every area, all patients should have equal access to medical services. At present, across areas people have access to unequal resources, so that poorer areas get more and richer areas get less. I do not know how the primary care trusts will deal with that problem. I have read the Explanatory Notes, but I still find it hard to understand. Perhaps later, during the Committee stage, we will be able to understand it.

It seems to me that a primary care trust will be a very large unit. Indeed, it may span a whole borough of, say, 100,000 people and have a budget of £60 million, with all the GPs belonging to it. I do not quite know how the inequity as between patients within an area will be dealt with by those trusts. Moreover, it is not quite clear as to whether there is any mechanism, as between PCTs, for paying those covering poorer areas more to enable them to look after their patients better, than those that cover more prosperous areas. That remains to be sorted out; indeed, it is very hard to know what we are doing in that respect.

I make the following suggestion with caution. It is just possible that such trusts are too large. Although we want to put every patient in some group or trust, perhaps there ought to be many more of them, thus providing much greater diversity as regards primary care. I have in mind much greater diversity of size and mix of different kinds of medical healthcare. I believe that diversity will lead to experimentation which may, in turn, lead to an improvement in quality. Whereas, if you have a large monolithic primary care trust, it may be difficult for patients to get what they want.

I have but one comment to make about self-regulation. I just wish that the latter had not been made part of the Bill; indeed, I wish that it had been done separately. I can envisage the Committee stage being entirely dominated by discussions on Clause 47, and nothing else. It always happens. If you try to do anything with well-organised professions, they will take up all the time. Doctors and lawyers are like that; but, fortunately, economists are not. There is no licence for being an economist: anyone can be an economist. We have failed somewhere. I am afraid that Clause 47 will dominate our Committee discussions.

I have one final point to make about pharmaceutical price regulation. I very much take on board what my noble friend Lord Ewing of Kirkford said. There are two factors to bear in mind. First, there is no doubting the fact that we have a very good pharmaceutical industry; indeed, it is a world leader. But, secondly, we must bear in mind one of the advantages it has had over a number of years. It has had a single stable buyer--one great purchaser. That has reduced uncertainty to an enormous extent. Pharmaceutical industries in other countries do not have such a large single purchaser. That removes so much uncertainty and frees the industry to carry on the research and development and take risks, because the risks are at the margin of the business and are not the main concern.

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I do not want to detract from the possibility that things could go wrong. Of course, the Association of the British Pharmaceutical Industry is not very happy with this, but it was never happy with regulation. However, if you want to encourage research and development, you should do so through a tax concession and not through overpricing. The pricing should be left so as to allow it to be as reasonable and as efficient as possible. If you want to encourage research and development, you should do something else. I believe that it would be a mixing up of two different objectives to allow people to overprice just because they are good at R&D. I say that because not everyone who overprices is necessarily good at R&D. Indeed, they are two different things. I very much welcome those provisions and am less disquieted than other noble Lords about the concerns of the pharmaceutical industry.

As the possible outcome of this legislation, perhaps not now but during the next 10 to 15 years, I should like to see a greater equity in local health provision as between patients coming from different income classes and inter-regionally--that is, people living in different areas. The kind of evidence produced by the Black and Acheson Reports is something about which we should be seriously concerned. Indeed, we ought to be able to do better.

6.4 p.m.

Baroness Carnegy of Lour: My Lords, as ever, the noble Lord, Lord Desai, has made a fascinating speech and put forward one or two interesting suggestions, which we shall no doubt follow up. However, I go back to the speech made by the noble Lord, Lord Ewing. He knows the National Health Service very well indeed, warts and all; and displayed that in what he said. But, in Scotland's case, it seems to me that the manner in which the Government are proposing the enormous changes contained in the Bill is surprising, to say the least. They are fundamental changes, particularly in primary care.

Part II of the Bill, about which I shall mostly speak, replaces fundholding and the present relationship of GPs to health boards and trusts with new reconstructed trusts, which are as vaguely described in that part of the Bill as they are for England and Wales. Below the primary care trusts there is to be a structure for professional involvement--a combined structure which is considerably different from that proposed for England and Wales. At present, the whole system seems to be understood mainly by those who are preparing for its implementation. As far as I can discover, few, including GPs, are not somewhat mystified and there has scarcely been any public discussion.

In addition to Part II, Clause 47, which relates to professional self-regulation, also applies to Scotland, as do the powers in Clauses 26 to 31 on the price of drugs. On the latter I should point out that the regulation of prices will be of considerable interest to a very large and important pharmaceutical industry in Scotland. It will also be of equal interest to our important university medical schools, and their related hospitals, which

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depend for much of their income and much of their research skill on that which comes to them in the way of new drugs and new inventions.

As my noble friend Lord Mackay of Ardbrecknish suggested in his brief intervention during the Minister's introductory speech to the Bill, all this is being done only 13 weeks before the elections to the Scottish Parliament--a parliament which will be opened on 1st July, its new devolved responsibilities to include this very health service. Clause 51 of the Bill tells us, as one would expect, that, from then on, the responsibilities (which in the Bill are said to be those of the Secretary of State for Scotland) will pass to Scots Parliament Ministers. So we at Westminster are being asked to turn the Scottish health system upside-down and to set up arrangements, which, in less than five months, will be the responsibility of others.

I am glad to see that the Scottish Office Minister, the noble Lord, Lord Macdonald, is sitting in his place today. I wonder whether he will be able to help his noble friend Lady Hayman to explain this extraordinary timing. In his intervention at the beginning of the debate, the noble Lord, Lord Ewing, seemed to think that this did not matter. However, knowing their plans for devolution from the outset, why did the Government put all this in their general election manifesto, rather than waiting and putting it into their manifesto for the Scottish Parliament? It seems to me that it would have been very much more democratic and very much simpler. Perhaps the Minister will also be able to tell us what will happen if the Bill has not become law by 1st July. Judging by the reception that her speech and the Bill have received thus far, that seems a possibility. We shall certainly need to explore the practicality of the timing of the implementation of Part II in Committee. Those are my first questions.

The following questions concern the drafting of Part II of the Bill. It is not at all surprising that so few people working in the National Health Service, and even those whose job it is to develop it, understand Part II which is due to be implemented in April. However, it is difficult to know what is supposed to be happening. The clauses of Part II are drafted almost entirely in terms of amendments to a previous Act, the National Health Service (Scotland) Act 1978, which itself was amended by the National Health Service and Community Care Act 1990. I suggest that this renders Part II of the Bill difficult for noble Lords and interested bodies to comprehend who want to design amendments. It has to be said that the Explanatory Notes do not tell us all that much either as regards Part II. Can the Government help us well before Committee stage by producing a text showing how the existing 1978 Act will read if Part II of this Bill becomes law, with the changes perhaps printed in heavy type? That would help the Committee and those who want to brief us.

I have given the Minister notice of my next point. For the benefit of all concerned in Scotland, now and in the future, will the Government consider including such a text as a schedule to the Bill? It is not unknown in Scottish legislation. Erskine May states at page 532 that an example of such a schedule, sometimes known as a Keeling schedule after Mr. Keeling who proposed the

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idea, was included in the Rating and Valuation (Amendment) (Scotland) Bill 1983. Will the Government consider that kind of clarification?

One of the few clear statements in Part II of the Bill is that GP fundholding practices will cease. As the noble Lord, Lord Ewing, knows, I consider that for Scotland in particular that is a mistake. North of the Border fundholding has been taken up unevenly--the noble Lord is quite right about that--but where it has been adopted it has been used most responsibly and with considerable benefits to patients. In my part of the world, Angus, which the noble Lord mentioned, a group of fundholding GPs were dissatisfied with the slow turn around of blood samples, which are so important to GPs. They were unable to get an improvement within the public system and they approached the private sector. Quickly a twice-a-day collection was established with next day turn around for all patients, not just the patients of fundholding practices. That was a huge improvement. In the Grampian region where fundholding covers 50 per cent. of patients, all patients, not just the patients of fundholding practices, can now have physiotherapy on Saturdays, which was not the case previously.

Most of what we know of the system which is to replace fundholding is to be found in the White Paper Designed to Care and not in this Bill. Even the White Paper is fairly vague, as are the Explanatory Notes in this case. For primary care cash limited funding will pass from health boards to primary care trusts. Those trusts will set up below them voluntary groupings called, in wonderfully Old Labour language--for which I believe the noble Lord, Lord Ewing, may have some affection--local healthcare co-operatives. But what is in a name? GPs, pharmacists, dentists and other professionals will come together in these co-operatives to involve themselves in the development and management of services. They will be allowed a budget if they wish, although, needless to say, the Secretary of State or the relevant Scots Parliament Minister will control its extent.

In my part of the world primary care trusts will include a vast area--the whole of Angus, Perthshire and Kinross. I understand that it is planned in Angus alone to have two co-operatives, one in Dundee and one in Perth, each with its own board and committees of health professionals. These co-operatives will be health professionals' main point of contact with the system. I wonder how much of their time will be taken away from patient care in doing this, and at what cost to the health service.

The Prime Minister in his introduction to the White Paper stated,

    "We are saving £100 million of red tape and putting the money into ... patient care".
I wonder whether that will be the case. How long would it take to effect the change in our local blood test turn around under the new system? I am told that under the new arrangements it would take well over a year to get any change at all, if one got it. Nothing might happen.

That leads me to a point made by the British Medical Association which is anxious about the vagueness of the Bill and indeed the White Paper on another aspect of

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primary care trusts. It wants to know whether there is any role for primary care trusts in Scotland--as there is in England and Wales--to commission secondary services. The BMA suspects there is not. Perhaps the Minister would confirm that when she replies to the debate because it is an important point and we should like to know the answer straight away if possible.

The Minister referred to all this as modernisation, as one would expect. However, it seems to me strangely old fashioned, quite frankly, to move from devolution down to GPs, down to the coal-face, back to centralisation, with people at the coal-face able to communicate only through bureaucratic bodies. I wonder whether that will work and whether it will be cost-effective. In Committee we must clarify precisely what the Bill states in relation to Scotland and the rest of the UK. We must identify the powers which will be in the hands of the Secretary of State and the Scots Parliament Minister. We must look closely at what can be done through statutory instrument. It will be interesting to see what the committee which examines these things on behalf of your Lordships has to say about that. Then we must do all we can to ensure that this Bill is workable.

I am sorry about the Bill. I do not think it is nearly as good as it should be. I am not sure what my noble friend will do about his reasoned amendment but I hope noble Lords will listen carefully to what he says when he speaks at the end of the debate, and that perhaps they will support the amendment.

6.18 p.m.

Lord Harris of Haringey: My Lords, I begin by declaring a current interest as a non-executive director of the London Ambulance Service NHS Trust and a former interest as the director of the Association of Community Health Councils for England and Wales until I joined your Lordships' House.

I welcome this Bill and in particular its objective of improving the quality of healthcare in the NHS through a duty of quality on NHS trusts and primary care trusts. I also welcome its objective of improving the accountability of providers and commissioners of health services. I welcome the new duty of partnership on NHS bodies and between the health service and local government. Although I acknowledge that these will be controversial for many noble Lords, I welcome the provisions to modernise the regulation of the health professions.

I was concerned by the remarks of my noble friend Lord Desai on economists. I take the view that the public have the right to expect that economists should be regulated and that there should be a proper complaints and redress system for the public when the economists get their diagnoses wrong. But perhaps that will be a long time in coming.

It is worth remembering that our NHS is still the envy of the world. As a nation, we have a healthcare system that is more universal, more efficient and more effective than those available in most other parts of the world. What is more, we spend less of our GDP per head on the healthcare system than most other developed nations. However, there remain enormous health

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inequalities, and the gap between rich and poor has widened in the last 20 years. Too many people die prematurely in this country because of the effects of poverty and poor living conditions. I know that the Public Health Alliance has estimated that one jumbo jet per day crashing, with all its passengers being killed, is the equivalent of the number of excess deaths among those who are on lower incomes.

The market orientation of the past few years has done little, if anything, to improve the efficiency of the service or, more importantly, to widen the choice available to individual patients. Indeed, the elements of competition have worked against the co-operation of different parts of the service. That is why the Government's approach of replacing competition with co-operation and introducing a new duty of partnership is so important: mutualism rather than the free market.

At the same time, health authorities will be required to set a framework--the health improvement plan-- for commissioning decisions which will enable improvements in health status to be achieved. So what we have there is a shift in focus to outputs rather than inputs. The emphasis will now be on what should be achieved rather than on the precise agency that does it--dare I say it, very much The Third Way.

There will be collaboration between the NHS and local councils to achieve improvements in health, recognising that such improvements are more likely to flow from tackling the causes of ill health rather than the symptoms of illness, and recognising that such action is going to be collective as well as individual. Yesterday in your Lordships' House we had an interesting series of exchanges at Question Time about the interpretation services in the health service. In my view, it would be the case that Clause 13 of the Bill, which sets out the duty of quality to be laid on each primary care trust and NHS trust, implies an acceptance that each patient should be entitled to equal treatment, irrespective of their linguistic and cultural background. To assist in this, accurate and accessible interpreting and translating services need to be available throughout the health service.

One example may be useful to illustrate the point. How many of your Lordships have had occasion to seek treatment from a doctor or to collect medication from a pharmacy while abroad? Under such circumstances one may be anxious, bewildered, certainly not feeling well and therefore perhaps less able to cope in whatever command we might have of another language. I suspect that in those circumstances the ready availability of interpretation services would be most welcome.

In my local authority area nearly 40 per cent. of the children in the local schools speak a language other than English at home. In such areas--though it is also true across London and in many other parts of the country--good interpretation services are vital within every hospital, clinic and GP's surgery. A modern, dependable service cannot rely on schoolchildren interpreting for their parents or their grandparents.

The importance of a user-centred service--one that is responsive to the needs of those who depend on it and which is built on a true partnership between the patients

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and the professionals--must underpin the provisions of this Bill. I look forward to a number of issues being clarified during its passage through this House. May I therefore pose a number of questions to which I hope it may be possible to return in due course?

First, how is "quality" in Clause 13 to be defined? Is it to be a definition that is medically driven or will the views of patients, carers and other health service users be taken into account in defining standards against which quality is measured in monitoring service provision and in evaluating outcomes? Secondly, why is the duty of quality not imposed on health authorities, which will have a key role in setting the framework within which NHS trusts and primary care trusts will operate? Likewise, in the interim period, should not a duty of quality be placed on primary care groups?

Thirdly, how is the commission for health improvement to operate? May we assume, for example, that its reports will be in the public domain, subject of course to the protection of any individual patient's confidentiality? Will those reports be routinely sent to community health councils with an interest in the services covered by any specific report? Will CHCs be able to trigger an investigation by the commission where they feel that one is merited?

Fourthly, in responding to the reasoned amendment proposed by the noble Earl, Lord Howe, will my noble friend the Minister be able to reassure the House that primary care trusts will have a membership which includes a majority of lay people? Will primary care trusts have a duty to consult widely on their plans and proposals and will CHCs have the same rights as they currently do in respect of health authorities? Furthermore, will CHCs have the right to inspect services directly run by primary care trusts?

Finally, I should like to touch on another issue to do with primary care trusts. We understand that they will be permitted to provide services to private patients and to run private facilities. Can we be reassured that there will be practical safeguards to protect the interests of NHS patients and to make sure that primary care trusts providing private services operate in the generality of their activities for the benefit of the health service as a whole? I am sure that we would all want to make sure that there are no conflicts of interest.

While these questions are important, they do not detract from the overall thrust of the Bill. The proposals in it are good, will be good for patients and will help to achieve the Government's objectives, which I am sure we will all share, of making services more accessible, more equitable and more responsive to the modern needs of service users--creating a new NHS that is truly modern and dependable.

6.26 p.m.

Lord Rotherwick: My Lords, I wonder how community hospitals will fare under a primary care group or a primary care trust. We understand from the White Paper that the PCGs and PCTs will be representative of all the clinical professions in their area. Will that include representatives from community hospitals and will it include physiotherapists and other

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professionals allied to medicine, as the noble Lord, Lord Clement-Jones, mentioned? Will it include alternative medicine practices? We look forward to finding out, and of course we must ask what the results will be for our community hospitals.

Take, for example, the case of the Burford Community Hospital that has fared so badly under the Oxfordshire Health Authority during the life of this Government. Burford Hospital has a deserved reputation for having pioneered nursing practices later adopted nationally and occasionally internationally. For instance, Burford had the country's first nursing development unit. Burford developed "primary nursing", which led to the "named nurse" concept. Burford pioneered patient self-medication and Burford was the first clinical area to introduce "nursing beds", where nurses--not doctors--are responsible for admissions and discharges.

Now this centre of excellence is faced with closure as part of a programme to reduce rural Oxfordshire's health capacity by 52 beds and move the caseload to the John Radcliffe in Oxford. It is claimed that this will save Oxfordshire Community Health Council £1.5 million over four years--and well it may--but the costs of treating patients do not disappear. They are merely transferred elsewhere. For instance, the minor injuries unit at Burford will go but another will be opened at Witney at an anticipated cost of £200,000, to be financed by the health authority with £200,000 of new money. I am no accountant, but is not another word for "new" the much criticised "creative"?

Moreover, the community health council is going to purchase respite and palliative care from the private sector to alleviate the strain of closing 52 rural beds. Fifty-two beds gone from the rural environment and, with them, the nurses, doctors, administrators and ancillary staff! What will be in their place? A round trip of 50 miles from Burford to Oxford, 36 miles from Witney and 48 miles from Chipping Norton. The costs of these extra journeys will be borne, in part, by the patients and their families and friends.

We should also consider the position of the John Radcliffe, one of our leading hospitals with an enviable reputation for treating critical and acute problems. It will be faced with a full-time demand for at least 35 beds--based on 39 beds at an average occupancy of 90 per cent.--removed from Burford alone. Those relatively low cost beds in the rural community have been used to both obviate admissions to Oxford and to facilitate discharges.

I quote from the John Radcliffe response to the consultation:

    "A delay in patient discharge inevitably leads to a delay in patient admission. Therefore, in our present situation, each day we have 16 of our 26 patient assessment areas in the Accident and Emergency department effectively blocked because of unavailability of community hospital beds. A further loss of 52 beds would have a catastrophic effect upon this already intolerable situation".

That opinion was apparently endorsed in the White Paper on the NHS. Again I quote:

    "Too often in the past community hospitals have been sidelined. Their contribution to managing pressures of rising admissions has often been ignored. Patients will be able to use local community hospitals to the full rather than have to travel to more distant acute hospitals. This will be particularly significant in rural areas".

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In the light of this, will the Minister tell us how the Health Bill will enable the Government to use local community hospitals, not close them?

Time does not allow me to relate in detail the very cogent arguments of the community health council against this proposal, but they cover the overwhelming public and professional opposition. The arguments include the unacceptable pressure that will be placed on other parts of the health and social care system; the failure of the proposal to meet local needs; and the waste of development potential in the community hospitals.

However, I cannot ignore the position of the Government who sat in opposition complaining that the NHS was in jeopardy. The Government said in their election manifesto, "We have no plans to close hospitals." We should look more closely at the words, "We have no plans" because there is nothing in the manifesto to stop a government with an overwhelming majority putting pressure on a health authority to do their dirty work for them; nothing to stop the most populist government of all time concentrating on fulfilling a specific pledge--to bring down waiting lists--at the expense of common sense and common decency to all those who voted them into power; and, most despicably, nothing to stop them plundering the results of the money-raising carried out over many years, enthusiastically and successfully, to provide support, buildings and equipment for community hospitals countrywide. Will the Minister say how she proposes to repay the Burford Hospital's comfort fund the £138,000 it spent on a new day unit, opened just a year ago.

Finally, how is it that, after a year of agonised debate, the Secretary of State for Health, Frank Dobson, was unable last week to give a straight yes or no to the delegation which asked him to overturn the Oxfordshire Health Authority decision? One wonders whether this Health Bill, with its draconian powers and, as my noble friend Lord Howe mentioned, its four-tier system, will enable Ministers to bring a halt to the uncertainty that the community hospitals are suffering?

6.34 p.m.

The Earl of Mar and Kellie: My Lords, I, too, am interested in Part II of the Bill, which is of course designed for Scotland. The Scottish clauses are modest--in volume at least--in comparison to those for England and Wales. This is very appropriate in view of the impending devolution of the NHS in Scotland to the Scottish Parliament and Executive. Indeed, there is a small case to make in principle: that there should have been no changes made to the NHS in Scotland on the ground that it ties the hands of the new Scottish Executive to make changes in the foreseeable future. However, I shall not pursue that argument because the removal of fundholding and the internal market is so clearly demanded in Scotland, and the new emphasis on putting the patient back in the centre of the future Scottish health service is so clearly correct.

The plans for greater integration of the various elements of the health service ought to be the basis of delivering a more coherent and co-operative service.

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This can be mirrored by the one-door approach taken by the personal social services in Scotland, as enshrined in the Social Work (Scotland) Act 1968.

The Bill brings in organisational changes for Scotland's 15 health boards, which will be implemented on 1st April this year. In view of the late introduction of this Bill, there are already in place shadow primary care trusts and embryonic local healthcare co-operatives. As someone who is domiciled in Clackmannanshire, I am aware that the Forth Valley Health Board will combine the two acute hospital trusts into one and has set up the shadow Forth Valley primary care trust. This new trust will absorb the work of the Central Scotland Healthcare Trust, which currently delivers community and priority services, and will integrate those services with the work of the two shadow local healthcare co-operatives.

At present, these shadow local healthcare co-operatives are targeted on Falkirk and on Stirling and Clackmannanshire. In view of the approach taken by the Clackmannanshire council in encouraging alliance working, I suspect that a separate local healthcare co-operative for Clackmannanshire will be more responsive than one trying to react to the rightly differing approach of the two local authorities.

These organisational changes will, I hope, bring efficient management and development to the existing health services. But the real test will be this: can the health service begin to reach into the largely uncharted waters of health promotion and the prevention of ill health? Scotland's population generates some pretty awful statistics about the state of its health; it is not good and it must get better. This is probably the first marker for measuring success for the reinstated Scottish Parliament.

Since the cause of much of our preventable ill-health lies across the width of the administrative spectrum, all talk about co-operative and integrated working will need to be real. If the contributory causes of much of Scottish ill-health lie in poverty, poor quality housing, bad diet, lack of exercise, unfocused education, low self-esteem and addiction to or the abuse of tobacco, alcohol and drugs--prescribed or otherwise--then a formidable amount of activity will be required by the authorities in all their forms. There will also need to be a commitment by individual citizens and their families to work towards this goal of a healthier nation.

The Bill aims to set out the basis for a more straightforward health service. The success of the Bill will be judged by the wisdom of those who work in the industry, the willingness of the general public to heed advice and to demand it, and the commitment of the governing class to tackle these real issues. That means abandoning fears about raising sufficient resources. Very few people now believe that you get better value if you pay less. I look forward to the Committee stage of this Bill which could lead to so much.

6.40 p.m.

Lord Warner: My Lords, I speak from a background of over 20 years in the DHSS, six years as a director of social services for Kent County Council and three years

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as chairman of an FHSA in east London. It is clear from my contribution in the debate last week that I strongly support the abolition of GP fundholding which I must say, from my experience, had nothing to contribute in deprived areas. I welcome its replacement with primary care trusts.

Today I wish to address some remarks to Clauses 19 to 25 concerning partnerships between health bodies and the NHS and local government. Those are long overdue changes and, in my view, the Government are to be warmly congratulated on pushing on with those reforms.

Before I do that, perhaps I may strike a dissenting note as regards the idea of a framework Bill. In my view, there is much to be said for leaving to secondary legislation the detail in relation to items which have a strong operational significance. I have seen from my own experience the problems of governments of all persuasions in trying to respond to pressures, often from professionals and managers in the services, caused by changes which are operationally necessary but which the primary legislation prevents.

I suggest that the approach in this Bill will enable us to produce a better and more responsive health service over the years. It is certainly my experience that governments do not ignore in legislation the concerns of powerful professions. The only thing which is scarcer than money is probably parliamentary time. When professions wish to be able to adapt their regulations, it is easier for them to do so if there is provision for that in secondary legislation. The reality is that all governments consult the professions before they draft the secondary legislation. I suggest that we should become a little more relaxed about Clause 47.

I turn now to the issues of partnership. I spent six years as a director of social services in the 1980s and early 1990s trying to make community care work within the current legislative framework. There were many good aspects of the previous government's community care changes. Indeed, some former Ministers deserve enormous credit for risking their political careers in persuading the then Prime Minister that civilisation would not end if local government were given the lead responsibility for community care. That was absolutely the right decision and it enabled care management to be introduced and individualised care packages to be developed. As a result, many more people were able to be cared for at home and in the community rather than in hospitals. Unfortunately, the legislative barriers between health and social care often made it difficult to pass money over what my right honourable friend Frank Dobson has called the "Berlin Wall" in the interests of those needing care.

Health and social care partnership working is a lot like personal relationships. It requires trust and sharing information, resources and responsibilities. There have been some heroic figures who have overcome organisational barriers to make partnerships work. But it often requires huge persistence and people are often looking over their shoulders to see whether the auditors, governing bodies or others are going to challenge their behaviour. I can still remember the endless arguments with the six different health authorities with which

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I dealt about whether it was right for community nursing services to be provided to elderly people in local authority homes as an alternative to the far greater cost of transferring them into hospital. This Bill gives a clear signal that partnership working should be the norm, not an exceptional activity requiring superhuman endeavour.

The whole area of services for people with learning disabilities is a good example of where services have been bedevilled by squabbles between health, housing, education and social services. Those squabbles are usually about who should pay. The people with children with learning disabilities are not interested in the arcane organisational disputes with which they are often confronted. They need some integrated life-time planning for their children's needs and secure arrangements for their own respite care. Too often they are frustrated because the different agencies cannot agree funding for the services they all know are needed. Those parents have enough problems to cope with without having to grapple with different bureaucracies patrolling their territorial boundaries.

Clause 20 makes it absolutely clear that,

    "In exercising their respective functions NHS bodies ... and local authorities ... shall co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales".
I have assumed that primary care groups will also be required to co-operate because they are associated with the health authority. It is sad that we need to introduce such legislative provision but the reality is that we do. Unlike the noble Baroness, Lady Fookes, I do not regard that as waffle. I regard it as a clear statement of statutory intent.

Of course those changes would be empty words if they were not reinforced by the new powers to transfer funds in both directions between health and social care. People will be discouraged from engaging in empty joint planning exercises where worthy objectives are agreed but the money does not flow in support of their achievements. The provisions in Clauses 22, 23 and 24 remove the excuses for not having proper joint working between health and social care. People will no longer be able to say, "Well, we should like to be able to work with our health or social services colleagues on this project but the law", or, "the auditors"--the two favourite excuses--"will not allow us to do so".

I welcome the fact that better partnership working is in place in the context of jointly agreed health improvement programmes rather than simple healthcare services. I believe that that will pose some interesting challenges for NHS managers who may encounter professional tribalism in some quarters. For example, although much is made of the shortage of nurses, we could still make much better use of the nurses we have with more use of trained sub-professional staff in areas like long-term care, health education and community supervision. Just as doctors have passed functions to nurses over the past decade or so, some nurses will have to learn to pass more tasks and responsibilities to suitably trained non-nursing staff.

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It has taken the NHS 50 years to reach this point in partnership working and to begin to understand the importance of more permeable boundary organisations across which funding can flow. It has taken a government of the same political persuasion as that which introduced the NHS to bring about that change. The Minister and her ministerial colleagues will, however, need to keep up the pressure on people to use those new powers.

Lifestyle changes, a better living environment and improved social care and support will often produce greater health gain than healthcare services. That is a difficult lesson for many NHS managers and professionals to act upon, given that many of them have spent most of their working lives in the hot-house atmosphere of the acute hospital. We should not underestimate the extent of institutionalised thinking which may need to be changed both within the NHS and local government. There will be local councillors who do not wish to see local authority funding mingling indistinguishably with NHS money. There will be managers on both sides of the health and social care divide who want to protect projects and ways of working over which they have more direct control. There will be health professionals who are threatened by health improvement programmes that are not healthcare driven.

My noble friend Lord Winston chided me earlier for suggesting that primary care should be developed at the expense of secondary care. That is not so. I know very well that we need both. The failure to have good quality primary care and community care in the more socially deprived areas simply increases the demands and pressures on the secondary care sector. The Bill will go a long way to help redress that balance and will reduce demands on the secondary care sector.

The Bill is the beginning, not the end, of stronger partnership working for better health. I believe, to coin a phrase, that it will enable the NHS to be tough on the causes of ill-health as well as on ill-health itself. I welcome its introduction and hope that it will have a speedy passage.

6.50 p.m.

Viscount Bridgeman: My Lords, the Bill contains much work instituted by the previous government as well as much instituted by this one. The Government will of course take credit for both, and will continue to blame any shortcomings in the field of health on the previous government. But of such is politics.

There are points of a background nature I wish to make which I hope will have some relevance before I address some detailed points arising from the Bill. The first, I suggest, is the rise in consumerism among all sections of the population. People are subjected to television advertisements, the publication of league tables, the identification of "best buy" and an increasing coverage in the media of individual brands of all kinds of goods. Such discrimination and comparison affect the public's attitude to the shape of the health service it is looking for and to which it feels entitled.

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The next point is that healthcare in this country must be structured to keep pace with the ever-increasing (if I may tamper with the dictionary) individualisation of medicine. In the past, every man's medical history and condition is, and always has been, as unique as his fingerprints. But as a result of the ever-increasing onward march of medical genomics it will, in the near future, be possible to identify a person's medical profile to a degree that has never previously been possible. So the statistics that those produce are both a tool and a challenge to the providers of healthcare. I say a tool in that it enables areas of individual need and treatment opportunity to be analysed in great detail. The challenge is to the providers to meet as many as possible of those areas of medical need within the realities of a not unlimited budget.

That very sophistication leads to another requirement concerning what, to the ordinary man, is a bewildering array of treatment, procedures and pharmaceuticals. It is essential for the medical profession to take the public with it in educating people as to what is available, whether they need it and what it does--an approach whereby the GP, in his traditional one-to-one consultation with the patient, will become an educator and an advocate in guiding the patient through the maze of modern medical practice. I feel that the restrictions on the GP's discretion, referred to by my noble friend Lord Howe, will not assist this new and increasing obligation to educate the patient.

Another general point is that the health service must cope with the unexpected. The most striking example is the AIDS epidemic of the past 15 years. And let us look for a moment at Russia. Who would have foreseen that, following the collapse of the Soviet Union, life expectancy would fall by some five years and that alcoholism, diphtheria, and polio--which I thought was a dead disease--would show appalling increases? There is of course no parallel with the National Health Service, but that is an illustration of how events can colour in an unexpected way a country's management of its healthcare. Reference was made earlier to the NHS juggernaut. That juggernaut needs to be fitted with some delicate and effective power steering.

To take the point further, the national management of healthcare must be seen in the context of a unique asset which enjoys different custodians from time to time but must always be responsive to the needs of the times in the way I have described.

I now turn to some detailed points in the Bill, and, first, the abolition of GP fund-holding practices. It is, I think, true to say that it was the intention of the previous government to make fundholding as widely available as possible. It was available to any practice which sought it, and the only ones which remained outside the scheme were broadly those which held out as a matter of political principle and small practices where there was not the organisational capability.

The present proposals appear, by a remarkable sleight of hand, to have achieved the previous government's intention of making funds available to the poorer practices by ensuring that all GPs are part of a primary care group. While improvement in resources will be less

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marked in the established fundholding practices, there should be a considerable improvement in the one-man practices in inner-city areas. That is very much to be welcomed, although we would have liked to see the continuing expansion of GP fundholding. The purchasing power of these groups will be considerable; however, I am concerned that there is a danger of their being of an unmanageable size.

The proposals in Clause 24 to facilitate co-operation between NHS bodies and local authorities is to be welcomed. However, it is not clear from Clause 5 whether or not there is a "best value" element, which is already present with local authority tendering. If that is not factored into these arrangements, there is the danger of cosy arrangements springing up between local authorities and NHS trusts. I welcome the Minister's reference to that in her opening remarks. I hear disturbing reports in one or two areas where the NHS trust and the social services department have made an agreement which will have the effect of shutting out newly created primary care groups, thus maintaining the status quo of control between themselves. While I have reservations about the creation of primary care groups, I should not like to see their introduction prejudiced by a blatant abuse. I should like to take up the matter with the Minister.

I now turn to the purchaser/provider split and the abolition of the internal market. The internal market had the effect in many hospitals of bringing a sense of involvement and an awareness of cost and profitability to all who work there--from porters to consultants. I remain sceptical as to whether the ideals of working "for the service" will be realistic under the new arrangements. On that point, I regard the jury as being out. However, I welcome the retention of the purchaser/provider split, which carries with it in relation to both parties a basic discipline of efficiency.

I have a concern. It appears that when primary care trusts reach level 4--that is, the top level of purchasing and managerial freedom--they rise, as it were, above the purchaser/provider regime and embrace the functions of both with all the dangers of slack cost control which the purchaser/provider system was designed to counteract. I should welcome the Minister's reassurance on that point.

In conclusion, I echo the considerable concern expressed on this side of the House about the Bill's dependence on secondary legislation and on centralisation. Nevertheless, I believe that the Government's intentions in introducing the Bill are sincere, if flawed. I hope that we shall be able to effect some improvements in Committee.

6.59 p.m.

Baroness Emerton: My Lords, I should like to thank the Minister for her introduction to the Bill, and also for her announcement of the publication of the JM Report, an independent review of the Nurses, Midwives and Health Visitors Act, which has been awaited by those professions for some time.

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Like my noble friend Lady McFarlane, I declare an interest, having been a nurse and midwife and chairman of the UKCC; and I am currently a lay member of the General Medical Council.

The need to move forward and modernise the regulatory bodies has, I know, been recognised. Understandably, any change in the form of reorganisation causes a level of anxiety. However, I am sure that when the proposals set out in the JM Report, accepted by the Government, are seen and understood, that will reassure nurses, midwives and health visitors. Especially welcome is the Government's rejection of the proposal not to register health visitors. The public health agenda is huge, with health visiting playing an important and increasing part, and it would have been catastrophic to remove registration. Health visitors will play an increasingly important part in the primary care groups and primary care trusts. Indeed, the inclusion of nurses in the primary care groups and primary care trusts is a welcome step forward and certainly something that will provide a career progression--and an exciting one--for nurses in the community.

There have been many references already to the part of the Bill relating to self-regulation. Turning to Clause 47 and Schedule 3, at the heart of professional regulation is the need to protect the vulnerable public, and within clinical governance there is a requirement for professional self-regulation. It is to be expected that those in the healthcare professions are anxious to ensure that professional and educational standards and regulation through professional conduct procedures are of the highest possible standard. The professions, I am sure, would not wish to stand in the way of changes to facilitate those functions. The assurance in the Bill in Schedule 3 paragraph 7, to which Clause 47 (1) applies, is welcome. The paragraph states:

    "An Order may not abolish the regulatory body of any profession to which section 47(1) (a) applies".
However, with the introduction of the Order in Council power, I know that there are anxieties about paragraph 8 in Schedule 3. As currently drafted, it states:

    "this paragraph does not prevent an Order altering any such function".
As the functions listed in the previous paragraph are the core responsibilities of the regulatory bodies and are interdependent, an order could fundamentally change the regulatory body's raison d'etre. These functions of keeping a register of practitioners require standards to be met. They have to be set through educational programmes and the performance monitored against those standards in order for members of the professions to remain on the register. If there is a failure to do that, the mechanism for protecting the public is to have procedures which can ultimately remove the person from the register as unfit to practise, thus protecting the vulnerable public.

Within the fast changing healthcare programmes and developments, there is a need to facilitate changes which might be required within the functions listed in Schedule 3, paragraph 8(2). Those changes could well be effected by an order, subject to consultation and the affirmative procedures as set out in paragraph 9 of Schedule 3. They would prevent the problem of the

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backlog of individual Bills, which because of the heavy parliamentary programme, have been delayed for as long as three years. This I am sure would be welcomed by the professions, provided that paragraph 7 of Schedule 3 remains intact. It states that:

    "An Order may not abolish the regulatory body of any profession".
Please could the Minister clarify and assure the professions that paragraph 8(3) of Schedule 3 would not lead to fundamental changes in the regulatory frameworks which have been established through primary legislation by Parliament.

The point was made by the noble Lord, Lord Desai, that much time would be spent during the Committee stage discussing regulation to the exclusion of other aspects of the Bill. I think that that is likely because of the important fact that the professions wish to ensure the principle of self-regulation because their concerns lie in ensuring that the vulnerable public are protected by the means of self-regulation.

I have travelled to many countries and looked at the regulatory process relating to nurses. I have come away every time with the clear message that the systems within the United Kingdom are much envied--indeed, so much so that we in the United Kingdom were asked to set up an international conference on a regular basis to assist those countries which are experiencing great difficulties in setting up a regulatory system.

The National Health Service has been described as the envy of the world. I suggest that the professional regulation that we have in this country is also the envy of the world. I am sure that there will be many contributions during the Committee stage and I look forward to contributing to the debate.

7.4 p.m.

Lord Lyell: My Lords, I thank the Minister for presenting this long and complicated Bill so well and clearly. I also thank her for sitting through the debate, listening to all the points we make. I very much look forward to the winding up by my noble friend Lord McColl of Dulwich. Your Lordships will be aware that, with my noble friend and neighbour Lady Carnegy and the noble Lord, Lord Ewing--who is not in his place--we represent a substantial Scottish element today. Outside the Chamber, whenever I consult my noble friend Lord McColl, he rightly reminds me of Private Frazer in the comedy "Dad's Army". He looks at me and says: "You are doomed" and I get rather worried. But then my noble friend says to me: "You are doomed--to listen to my speech tomorrow, next week and in the months to come", and I put a smile on my face.

Quite apart from wading into me in the nicest possible way, my noble friend Lord McColl is a professional. He combines many of the attributes mentioned by the noble Lord, Lord Walton of Detchant. My noble friend is an academic: he teaches, he is a professor of surgery and he still practises to this day. Above all, he is one person who knows how the National Health Service has worked and works now. He also knows of the small problems

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that need to be addressed. That is why, for my part, I am delighted that he is with us today and will be present throughout the passage of the Bill.

I have a few concerns over primary care groups and primary care trusts. They relate to whether the institution of the groups will enable primary care to be given the flexibility that it needs in regard to all the varying diseases, ailments and sicknesses which occur more and more throughout the population. That needs to be addressed at source. I am quite concerned about the flexibility, given the geography and population. I was thinking of England and Wales; I had queries about Scotland but they were answered in the notable speech of my noble friend and neighbour Lady Carnegy. She gave a couple of examples from our neck of the woods in regard to blood testing and physiotherapy. Those subjects are akin to the ailments that affect many people on a day-to-day basis. My noble friend Lady Carnegy pointed out how they could be and had been addressed through the trusts in Scotland. So it is good to see flexibility there.

In regard to the NICE, I am concerned as to whether it will duplicate or replace any existing consultative machinery or advice. No doubt, if not tonight then at a later stage, the Minister will be able to give us advice. I was also interested in what the noble Lord, Lord Walton, referred to as CHIMP, consultational health improvement.

What concerns me most in the Bill is the Pharmaceutical Price Regulation Scheme. I understand that it has been in evidence for about 42 years. The Minister may be trifle startled that 20 years ago I was on the Opposition Front Bench in 1977, having to cope with the Patents Bill. It chanced that I was asked to study the problems of the pharmaceutical industry in regard to patents. I am sure it will be of interest to the noble Baroness that a major vote was carried against the Government on an amendment proposed by a supporter of the Labour Government and a Cross-Bencher. At the dinner held by the Association of the British Pharmaceutical Industry in March 1977--and I should declare an interest: it was an excellent dinner, but that was the only tangible benefit that I have ever received from the industry, although I receive paper and possibly mental intangible advice--the late lamented Minister, Lord Ennals, said that when the Bill returned to another place the Government had no intention of reversing the--I will not call it crushing--important defeat in your Lordships' House. I did not note the words of Lord Ennals at the dinner but 20 years ago during the stewardship of the noble Lord, Lord Ewing of Kirkford, he said he believed that the then voluntary price regulation scheme was an excellent system. I believe that that is still the case.

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