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Baroness Hayman: My Lords, I listen carefully to what my noble friend says and take his strictures seriously. The commitment in the manifesto to set up the Royal Commission was clear. That has been fulfilled. The task of the Royal Commission was to look at how best to provide sustainable long-term funding for good quality care of the elderly and how those costs should be shared between taxpayers and individuals. That was the remit of the Royal Commission and it has reported with great care. I have not made an instant response to it for the reasons set out in the Statement. I hope that my noble friend will understand that we are not ruling anything in or out until we have carefully considered the report in detail.

My noble friend is being overly gloomy in believing that everyone will need long-term personal care. I suggest that there might be some members of your Lordships' House who can prove that that is not true. It is only one person in five who is in need of long-term personal care and at whom we are looking in the report.

Lord Swinfen: My Lords, I note that a group within the commission dissented and wished to put forward the idea that taxpayers should pay for respite care in priority

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to nursing care. I hope that both will be paid for in the long run because respite care will prevent the ultimate nursing of the carers after the breakdown in their health. Respite care is not an alternative; it produces a long-term saving and should be provided at the same time as proper nursing care.

Will the Minister tell the House whether nursing care includes that in private residential homes as well as that supplied in one way or another by the state? Is she sure that we will produce sufficient nurses in this country? I understand that under the new scheme of training nurses, Nursing 2000, students receive salaries and that many undertake the course in order to receive the salary and having qualified do not enter the nursing profession. Would it not be better to return to the old system of training on the job in hospitals where they gain experience as well as knowledge?

Baroness Hayman: My Lords, the noble Lord tempts me to initiate a debate on nursing education which could take some time. The drop-out rate from nursing courses before the introduction of the new system was also high; perhaps even higher. The issue is not about producing enough nurses--we are increasing the number of training places and conversion courses for nurses who were previously state enrolled--but about how we retain nurses and encourage a return to the profession by many who leave after some years in service. That is a wider issue about nurse education. I can take common cause with the noble Lord. We have broken some of the links between the NHS and nurse education which were previously beneficial, but we are looking at ways to recreate them.

I certainly agree with the noble Lord that there is a vital role for respite care. That was recognised in the Statement made on a national strategy for carers. It is not an either/or situation. We need to support carers in their caring role. However, as I understand it, there were dissenting voices which said that it was counter-productive to try to provide alternatives to informal care by relatives and to follow that route. It was accepted that that caring was done but it was felt better to provide more respite care. The view of the commission is that we need support across the board for carers.

Health Bill [H.L.]

5.30 p.m.

House again in Committee.

Schedule 2 [The Commission for Health Improvement]:

Baroness Sharp of Guildford moved Amendment No. 83:

Page 48, line 9, at end insert ("at least three of whom shall be lay members representing all sections of the community including older people").

The noble Baroness said: We now move from the commission for long-term care to the commission for health improvement. Indeed, we are looking at the question of appointments to the commission for health

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improvement. Those provisions are set out in Schedule 2 to the Bill. As it stands, other than the appointment of a chairman and a representative for Wales, the schedule does not specify how many members there shall be or from which professions they may be appointed.

Once again, the question posed in these amendments is about how far we want the commission to be dominated by healthcare professionals or how far we wish to see wider representation from the community on the commission for health improvement.

The amendments which we have tabled propose to widen the membership to include lay members, including older people; to have representatives from the professions allied to medicine and from the universities; and to include NHS managers and representatives of users in the form of patients and carers.

A key issue covered by the amendments--and in particular Amendment No. 84, in the name of the noble Lord, Lord Harris, and Amendment No. 86--is whether there should be a majority of lay members on the commission for health improvement. In other words, is it to be an organisation established to provide an independent check on local systems of monitoring and improving healthcare which is to have a majority of health professionals judging themselves or is it to have a majority of people from outside the health professions? On these Benches, we should prefer to have a majority of lay members on the commission.

In addition, we recognise the contribution which other organisations can bring to the commission. We believe that it is extremely important that there should be representation from users, patients and especially older patients, carers and the voluntary organisations which represent them. It is important that a variety of skills which make up the NHS are represented on the commission. In that regard, I mention in particular the professions allied to medicine--physiotherapists, radiologists and also NHS managers and their representatives.

Finally, I make a special plea on behalf of the academics who are among the key partners. Academics who are part of medical faculties spend half their time providing patient care. The role of academics as leaders in their disciplines of evidence-based developments of clinical care will be vital to the commission's work. Amendment No. 88 is essentially a probing amendment to discover whether the Government have in mind that there will be significant academic representation on the commission. I commend the amendment to the Committee. I beg to move.

Lord Astor of Hever: I rise to support Amendment No. 83. The demographic explosion which is currently taking place as a result of an ageing population poses enormous ethical and economic problems. That is particularly true with regard to healthcare provision.

Charities which work with older people are worried that age will be used increasingly as a factor in determining whether or not someone receives treatment and what priority the patient is given. I trust that the

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Minister will be sympathetic to an amendment which seeks to ensure that older people are represented on the commission. As such, they would be well placed to ensure that the issue of age discrimination is brought to the fore in any discussions regarding treatment. I cannot believe that the Government would support discrimination against such a vulnerable section of society.

Baroness Gardner of Parkes: I support these amendments. As the Committee will know from our previous deliberations on the Bill, I am not in favour of having a great professional majority. Likewise, I should not wish to see a great lay majority. There should be just a majority of lay members. That means that people must attend the meetings and there is no guaranteed in-built majority for any group. If there is, people become lazy and do not turn up at the meetings. That throws out the whole balance.

When the Minister replies, I ask her to define the word "older". We have discussed already the definition of "older" and the Minister suggested that perhaps 60 was an appropriate definition. Many Members of this House would not consider 60 to be "older". Therefore, perhaps the Minister will be rather more specific than are the provisions of the amendment.

Lord Renton: I suppose that I should confess that I do not feel much different now from how I felt when I was 50. I am sorry to be so personal but I just wished to mention that because I do not want to talk about old age.

I seek some clarification of the word "lay" in the amendments. That word necessarily varies according to the context. If one is setting up a supervisory body over lawyers, "lay" means anyone who is not a lawyer. But here we are setting up a supervisory body over doctors, nurses and administrators within the health service who may be of a very large number. I ask the noble Baroness who moved the amendment whether she will tell me, perhaps even before the Minister replies, what is her opinion of the meaning of the word "lay" in that context.

Lord Walton of Detchant: I wish to ask a question about that particular point. In the health service there are many healthcare professionals and many different categories. There are administrators and a great many other people who, in certain respects, may be regarded as lay individuals. Hence, the definition is important.

It seems to me that Amendments Nos. 83 to 88 have a great deal to commend them because they specify rather precisely the kind of individuals who should be appointed to the commission for health improvement.

Having said that, I believe that there is one problem of which the Committee should be aware to which we have referred on earlier clauses in the Bill. It would be dangerous to be over-specific in relation to the membership of such a body. On Thursday afternoon, as we now know, we shall examine the role of the regulatory authorities in the health field. For example, the General Dental Council has been anxious for many years to increase its lay membership but is unable to do so without primary legislation. We must ask ourselves

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how specific we should be on the face of the Bill. May it not be more appropriate for the actual membership of the commission to be defined more precisely in secondary legislation rather than on the face of the Bill? That is merely a question that I wish to pose to those who have tabled the amendments.

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