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Baroness Hayman: Off the top of my head, no, I cannot tell the noble Baroness. I shall make inquiries but I imagine that it diminishes as we go higher up the scale. However, your Lordships' House always teaches us that the contribution people make improves with age. I am sure that the same is true within the health service.
As regards the composition of boards in the future, on which the noble Baroness, Lady Fookes, asked for enlightenment, we envisage a board of 11 members comprising a chair and five lay members. Membership will be open to local authority elected members. The chief executive, the finance director and three professionals will be drawn from the executive. One of the professionals on the board will be the director of clinical governance and there will need to be at least one GP and one nurse on the board, who must have the confidence of the rest of the executive.
If the chairman is a non-lay member, we envisage flexibility to appoint an extra lay person to ensure that the lay majority is maintained. It was the existence of the proposed lay majority that is challenged in Amendment No. 29. The noble Earl, Lord Howe, sought that a majority of the members should be members of a healthcare profession.
It is absolutely right that the board should have access to proper advice from healthcare professionals and they should provide the driving force for the board. But, equally, it is important to ensure that the trust is rooted firmly in the community that it serves, that it is publicly accountable and operates with the highest standards of probity. For those reasons we believe that the board should be properly balanced and that the non-officer members should be lay people to ensure the direct involvement of the community.
However, because we recognise that crucial role of the healthcare professionals, it is our intention to establish a trust executive which would have a clear majority of professionals who would take most of the day-to-day decisions and play a leading role in formulating policy on priorities, service developments and investment plans. Some of those professionals will then also serve as officer members on the PCT board. They will be there to guide the deliberations of the board and take part in strategic decision-making.
However, the board, with a majority of lay members, will be responsible for the performance of the trust, probity and the involvement of the local community.
The executive and the board will need to work co-operatively and closely if the primary care trust is to be successful. We believe that in these arrangements we are putting the proper balance so that there will be a professionally-led service, in accordance with the highest principles of probity and governance, and at the same time with firm ties to the views, skills and aspirations of the community that is served.
Lord Clement-Jones: Perhaps I may intervene to ask the Minister a question. One of the issues that has come over to me strongly in the representations made on the Bill is the extreme unhappiness of some of the professions allied to medicine in terms of their input and their ability to input as full members of a PCG board and their inability to be members of that board.
The noble Baroness will correct me if I am wrong, but it seems that that will be carried through into tier three or the first tier of PCTs. Only when they reach the second stage of PCTs will there be a possibility of some of those professions allied to medicine which are currently excluded being included. One of the reasons for such amendments as Amendment No. 31 was to point out that the involvement of community pharmacists, physiotherapists and opticians was desirable as full board members. If there are no volunteers, obviously they will not be members of the board. But if they are active, involved members of the professions allied to medicine on a local basis who wish to take part in PCTs, why should they be excluded at the first level of PCT? Can the Minister address that point?
Baroness Hayman: I am grateful to the noble Lord. I recognise the issue that he raised. It is one that was put to me from representatives of the professions allied to medicine. I would not wish in any way to denigrate the contribution that they can make to PCTs and PCGs, without necessarily having full board membership. They may give the expertise and advice of pharmacists, physiotherapists and so on--the whole range of professions supplementary to medicine.
Baroness Gardner of Parkes: Will the Minister also take this opportunity to reassure the Committee as to the reports in the press this week that the Secretary of State wishes to appoint the chief executives as well as the chairmen? Can she assure us that there is no truth in those reports? I am concerned that there should not be just a central government department appointing chief executives.
Lord Clement-Jones: For clarification, I was referring not only to boards but also to executives. One of the disappointing features is that one talks about professional input at executive level in the two-tier structure, but on that basis at level three (PCT) the professions allied to medicine do not get a look-in on the executive level either.
Baroness Hayman: I think I made clear that the arrangements for Secretary of State appointments related to chairmen and not chief executives. Those will be determined by the chair and lay members with input
from professional members or the preceding primary care group. That takes into account the view put to us by professional groups about the importance of the chief executive commanding the confidence of the professionals. Finance director appointments will follow a similar pattern but with the chief executive also on the panel.It has been pointed out that the membership of the trust executive will have a professional majority. As with primary care groups, a social services officer nominated by the relevant local authority will provide some of the interface and interconnection that the noble Lord, Lord Clement-Jones, sought earlier. The balance of professional members will differ between level three PCTs (commissioning-only) and level four PCTs (commissioning and providing). That is precisely to allow scope for other professional health service staff like professions supplementary to medicine to be fully involved at level four trusts. Therefore, in the provision of community health services professionals will be able to play a full part. We have allowed for a flexible structure at that level precisely for that reason.
As to level three, that is only a commissioning body. Where GPs have a particular role as gatekeepers and in committing resources, we believe that the argument in one of the amendments about those people being in the driving seat on the board has some weight. But when one comes to level four the Government recognise that it is absolutely essential not to neglect the role of professions supplementary to medicine. We envisage an executive of up to 10 clinicians with significant representation from general practice and a balance of local nurses and other community and public health professionals. There will, however, be some specialist tasks that may require particular professionals; for example a strategic role in respect of nursing.
I hear very clearly the view that PCT governing board arrangements should recognise the contribution that can be made by dentists, community pharmacists, opticians, physiotherapists and others. But we feel that if we impose a straitjacket on the PCT governing board arrangements it will be inconsistent with the fact that such a body will not have particular functions in respect of FHS contractors. It is important to ensure that we consult, as appropriate, dentists, opticians and pharmacists. We do not rule out the possibility of professions supplementary to medicine, or indeed midwives as distinct nurses, from being on the board at level four. The point is that if we begin to specify separate professions we will return to the "list" problem.
There are difficult balances to be struck between those who argue for a professional majority and for doctors to be completely in the driving seat. I point out to the noble Earl, who said that GPs were losing control of the progression towards primary care trusts, that PCGs and local NHS trusts that provide community services, or the health authority, must endorse a proposal before it can go to consultation. In practice we accept that PCGs will be the main generators of proposals. GPs are in the majority on PCGs and therefore will have a key role to play in progression towards primary care trust status. We feel that the need to balance the different
elements is best met by the kind of mixed board to which we have referred with the professional executive below it.8.45 p.m.
Baroness Sharp of Guildford: My Lords, we on these Benches are sorry that the Minister does not see fit to alter the arrangements over the appointment of chairmen given that the power of appointment of members of the PCT already lies with the Secretary of State. We feel that accountability is already there and that it would be a move towards greater democracy if chairmen were elected from among the members of the PCT. We are pleased to receive support from many Members of the Committee for these amendments, in particular Amendment No. 28 and for the other amendments that seek wider representation on the boards of PCTs.
I echo the words of my noble friend Lord Clement-Jones that there is considerable unhappiness among the professions allied to medicine about the current arrangements proposed by the Government. There is a very strong feeling that at present they are not properly representative of the wider community. It is vital that the PCTs command the confidence not just of the professionals but the wider community that they serve. We do not ask for a straitjacket but for arrangements that are properly representative. I take encouragement from the words of the noble Baroness that she will aim to secure wider representation and I hope that that will emerge in practice. We are not convinced that there are enough safeguards written into the legislation as it stands. Therefore, for the present we shall withdraw the amendment but reserve the right to bring it and other amendments back at Report stage. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 27 to 37 not moved.]
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