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Baroness Carnegy of Lour: Just on the wording, I have a dislike of bland expressions that do not mean anything and, with the greatest respect, I think that,
- "equality of opportunity for all people",
Baroness Fookes: I entirely agree with my noble friend. There is something not quite right about the phraseology, although I agree that the concept and principle behind it are fine. Are we not dealing with the patients, or the people in the community which the trust will serve, and will not staff already be covered by general legislation on equal opportunities?
Baroness Thomas of Walliswood: I hesitate to intervene, but I should declare that I am chairman of the sex equality group in the Houses of Parliament.
I wonder whether the description given by the Minister of an equal opportunities policy within the health service actually came up to the target of being an equal opportunities employer, which is a good deal more than just showing respect to all different sorts of employees. There is a strict code attached to the designation.
Lord Skelmersdale: In her substantive response just now to the noble Lord, Lord Clement-Jones, the noble Baroness said she would like to take this away and look at it. Given that the beginning of the Bill amends the National Health Service Act 1977, in her consideration will she think about amending that Act to make it much more general than just primary care trusts?
Baroness Hayman: We have had a variety of helpful suggestions about what areas we should consider as regards amendment. I absolutely take the noble Baroness's point; I was trying to make the same point in a rather different way. We need a whole raft of actions if we are to behave satisfactorily in this respect. One small piece of legislation, as the noble Lord, Lord Skelmersdale, points out, in a very narrow field may be an important point at which to start, but certainly not an end point. With the leave of the Committee, I shall take away all the suggestions that have been made and perhaps come back at a later stage.
Lord Clement-Jones: I thank the Minister for her replies. I understand that there could well be other, wider formulations which could usefully be introduced. However, I hope that we do not reach a situation where in a sense the best is the enemy of the good and that we do not try to invent some rocket when actually a bicycle would do. We are talking about primary care trusts and ensuring equality of opportunity, especially as regards access. But that should also encompass other matters.
It would be a shame if we were to spend hours labouring over a formula that would cover every single aspect when it could quite simply be determined for primary care trusts, which, after all, are the key component that we are talking about in this part of the Bill. Of course, it is essentially "access" that we are considering. I accept that a great deal is being done on the ground, but the issue about primary care trusts in particular is that there are many more of them. Indeed, you can reach down in a fairly controlling way into the NHS trusts, into health authorities and so on; but it will be more difficult to get into the practices of PCGs and PCTs. Therefore, my argument would be that it is more important to have this statutory duty for PCTs than it is for any other part of the health service simply because of the issue of management and control. I am delighted that the Minister has agreed to consider the amendment further. I look forward to the Report stage in that respect. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
7.15 p.m.
Lord Clement-Jones moved Amendment No. 21:
The noble Lord said: We are getting very close-- I hope--to the witching hour of 7.30 when we may perhaps be able to take some refreshment. But I have considerable enthusiasm in moving this amendment. In doing so, I shall speak also to Amendment No. 22, as they fall into the same grouping. This is essentially about taking forward the report of the Health Select Committee of another place, which many noble Lords will have read with considerable interest before Christmas. The committee effectively argued--I thought extremely cogently--for greater integration than is currently envisaged in the Government's proposals as set out in the original White Paper. I quoted from the report on Second Reading, and make no apology for doing so again. The quality of the work being done by that Select Committee is of a very high standard. In paragraph 65 of its conclusions the committee said:
I recognise that this would be quite a challenge to an organisation which is already undergoing considerable change. But the former Minister of State was permanently talking about the "Berlin Wall" between social services and health services. If we are to have an effective integration, it seems to us that it cannot be done just by joint working and pooled budgets; indeed, we will actually have to go a step further. What we have tried to do--and, in a sense, this is perhaps a bit of a balloon debate on the subject--is allow for a situation, which may not be perfect, where, once PCTs come into operation for the whole of a local authority area, that local authority effectively assumes the powers of the health authority. Indeed, if a PCT gets to stage four or partially to stage three, it will be in the process of withering away in any event. Matters like public health would then rest alongside social services within the local authority.
I suspect that the Royal Commission on the long-term care of the elderly will also propel that movement. No doubt it will recognise that joint working, pooled budgets, and so on, will all help but that at the end of the day in order to get a coherent system of care, especially for the elderly, there will have to be a much greater level of integration than is envisaged in the Bill. Our contention is that there needs to be some mechanism whereby a local authority can take over the function of the health authority in those circumstances.
One of the issues that was addressed quite strongly in the report of the Select Committee was the democratic deficit. It is not just a question of the actual integration of care and the quality of care between social services and the health service; it is also a question of the democratic deficit in terms of the accountability of the health service. In the pre-1990 days there was an element of representation from the local community on health authorities. That accountability disappeared, and this is also an attempt to try to inject a much greater element of democratic accountability into the process. That was one of the aims of the Select Committee as set out in its recommendations. I commend the latter to the Committee.
It might be considered initially as quite a bold step. But when we consider the amount of work which will need to be done in any event over joint working, pooled budgets, and so on, why should we not take it a step further? This is only conditional; indeed, it is conditional on PCTs covering the whole of a geographical area and does not involve a rushing of the gate in any sense, because the PCTs will need to be formed and people will have to have fairly sophisticated management systems in those circumstances. Therefore, I hope that the Committee will carefully consider this proposal. It is not so outlandish. It is something which will inevitably happen, so why should we have to wait for another few years for further recommendations from perhaps a distinguished Royal Commission, or indeed a review or a report from another Select Committee, before we actually institute such changes? Such changes could be of huge benefit to those receiving a mixture of both social and healthcare at local level; indeed, let us face it, it often is a mixture. I beg to move.
Page 2, line 27, at end insert--
("( ) Upon approval of proposals under subsection (2) in respect of a particular local authority area the local authority shall be entitled to exercise all the powers of the Secretary of State under section 97D of this Act."").
"We consider the current system for continuing health and social care to be very confused. Responsibilities are blurred, professionals face unnecessary problems, and users and carers are suffering because of barriers created by a structural division which is based on a ill-defined and arguably non-existent boundary".
Later, at paragraph 68, it said:
"The [Department of Health's] proposals in Partnership in Action to allow a lead commissioner and integrated provision are a step in the right direction. However we consider that the problems of collaboration between Health and Social Services will not be properly resolved until there is an integrated health and social care system, whether this is within the NHS, within local government or within some new, separate organisation".
It is interesting to note how the Select Committee came to its conclusions. At the end of the day, members of that committee felt that the professions--and, indeed, the managerial evidence--were rather cautious. Their experience on the ground, especially when they went to Northern Ireland and saw how the system operates in practice there in a very integrated fashion--something that the NHS in England does not have--led them to think that it was highly desirable.
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