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Lord Clement-Jones: My Lords, before the Minister sits down, perhaps I may ask her a question. The noble Baroness seemed to indicate that it was the Government's clear intention to consider the best way forward--to legislate for the best way forward--during the passage of this Bill. Am I correct in saying that it is the Government's intention, once they have considered this matter, to insert an appropriate provision during the passage of this Bill and not at a later date?
Baroness Hayman: My Lords, as there are serious difficulties in drafting the legislation, perhaps I ought to say that I shall certainly give a commitment to report progress on the issue during the course of this Bill. At this stage it would be premature of me to give an absolute commitment to bring forward such an amendment because I do not yet have before me advice on whether we can properly legislate as the noble Lord would wish. However, I give the commitment that during the course of the Bill we shall return to the subject and report progress. I think that I have given the noble Lord an absolute commitment that we want to address these issues. It would be precipitate of me to say anything beyond those two things.
Lord Clement-Jones: My Lords, I thank the Minister for her reply, which slightly disappoints me because it did not go as far as I would have liked in terms of saying that amendments will be brought forward at a later stage of the Bill. I fully understand the Minister's reasons for not giving that full commitment because of the difficulties of drafting. I also realise, as the noble Baroness, Lady Carnegy, pointed out, that I did not recognise all the strictures. However, I tried to put forward a bit of a mix and match in terms of tabling a different set of amendments for the commission for health improvement to see if the House was any more enamoured of them. Therefore, I recognise that the Government are having some difficulty in framing their own amendments. I sincerely believe that it is most
important for all kinds of public policy reasons to amend the Bill at this particular time in a way that we all clearly desire. I very much hope that the Minister will have some better news for us on Third Reading. I beg leave to withdraw the amendment.Amendment, by leave, withdrawn.
Schedule 1 [Primary Care Trusts]:
Baroness Sharp of Guildford moved Amendment No. 7:
The noble Baroness said: My Lords, I rise to move Amendment No. 7 which has been tabled in the names of my noble friends Lord Clement-Jones and Lady Thomas of Walliswood. The amendment concerns the membership of primary care trust boards. Since we debated this issue on the last occasion, we have had the opportunity to study the detailed proposals put forward by the health Minister in his letter to the chairs of health authorities, NHS trusts and primary care groups, which the Minister referred to in her reply in Committee.
The letter makes a distinction between the trust board, which will comprise a majority of lay members, and the executive board which will be responsible for day-to-day management and led and dominated by the healthcare professionals. We accept that distinction. The amendment relates primarily to the composition of the trust board but it also has relevance to the composition of the executive board.
As the Minister made clear in Committee, the intention is that these new primary care trusts should be firmly rooted in their local communities and responsive to the health needs of the community. The purpose of the amendment is to ensure that there is on the face of the Bill an obligation to ensure that the trust board and the executive board are representative of both users and providers of healthcare in their locality. This time we have been careful to avoid the lists which were criticised on all sides when we previously discussed these matters. However, the principle remains the same.
We are anxious that the PCTs should not become enclaves of professionals, run by the professionals for the professionals. We therefore welcome the dominant lay membership of primary care trust boards. But in looking for people to fill the positions of lay members, we are anxious that, among others, the Minister should remember, when making appointments, the need for users in the form of patient and carer groups to be represented, as well as the need for broad representation across age groups, between men and women, and fair representation of ethnic minorities.
In addition, we are anxious to ensure that it is not just GPs and practice nurses who gain representation among the professionals. We have received extremely strong representation from the professions allied to medicine--midwives, health visitors, physiotherapists, radiographers and speech therapists, to mention a few--about representation on boards. As my noble friend Lord Clement-Jones made clear in Committee, they are particularly concerned about their lack of representation
However, in moving from stage 3 to stage 4, the danger is that executive boards will remain much the same. If I may say so, that also raises a gender issue. If the executive boards are dominated by GPs, they are likely to be disproportionately male. Therefore the key issue is representation at stage 4 trust level. As the Minister made clear in Committee, the possibility of their being members of the full trust board, as one of the professional representatives, is certainly not excluded. However, as she also made clear, of the 11 members of a trust board, six, including the chair, will be lay members, two will be ex officio in their capacities as the chief executive officer and finance director of the trust, leaving only three places for healthcare professionals, of which one will be filled by the director of clinical governance for the PCT, one by a GP and one by a nurse. Therefore, as the Minister said, although we do not rule out the possibility of the professions supplementary to medicine--or, indeed, midwives or district nurses--being on the board at stage 4 level, in practice it will be extremely difficult to achieve that aim. As the Minister implied, it would in fact be easier to ensure representation on the executive boards.
In that regard, the amendment is not prescriptive: it is essentially concerned to enshrine the principle of wider involvement in board representation. We should not forget that these PCTs are about "joined-up thinking" on healthcare. That joined-up thinking means that we must consider--and include--all those who are concerned with the provision of primary healthcare; namely, dentists, chiropodists, physiotherapists and midwives. There is a principle involved here and it is an important one. Indeed, it is most important that that principle should be written on the face of the Bill so that there is a commitment to broader representation of healthcare deliverers. I beg to move.
Baroness Carnegy of Lour: My Lords, I believe that this is the point in our proceedings where mention should be made of a communication from the Chartered Society of Physiotherapy and also of a statement by a whole host of healthcare organisations. They are extremely concerned by a letter which was written by the Minister, Mr. John Denham, to NHS chairmen and chief executives stating that he intends to restrict membership of the primary care trust executive solely to GPs and nurses. They are indeed most worried about that for obvious reasons. I believe that that concern needs to be expressed now.
I am not absolutely sure whether this fits in with the discussion on the amendment now before us, but the communication only came to my attention just before I entered the Chamber. It is always difficult at short notice to consider the amendments while reading the Bill and, thereafter, understand the whole thing. However, it would be helpful if the Minister could say something in that respect which is comforting to all
Earl Howe: My Lords, I agree with a great deal of what has already been said, so I shall not repeat any of it. In Committee, the Minister went to some trouble to explain the Government's broad approach to the appointment of the lay element of a primary care trust board. I believe that what she said could be summarised as a wish to ensure flexibility in the representational mix of each board, but also to ensure a balance of representation to reflect the needs and priorities of the local community. Understandably, therefore, the Minister sought to avoid prescriptiveness of any kind. The one element on which she was categoric was the principle of a lay majority.
The only point that I wish to re-emphasise about trust boards is that doctors and healthcare professionals of every kind working for a PCT need to feel a sense of ownership, in however broad a sense, for the organisation in respect of which they are clinically and financially accountable. Even with the comfort of a trust executive with a professional majority, doctors may well feel distanced from the decision-making in a way that--to use a common expression--switches them off. This amendment is helpful in fostering a sense of local ownership, which is why I have put my name to it, but I suggest that the issues here run somewhat deeper.
The first concern is a lack of tightness in the chain of accountability. How in practice will a lay-dominated board exercise the degree of control over doctors that it needs to do if it is to fulfil its responsibilities to the Secretary of State? What incentives are present to ensure that GPs fully accept their own responsibilities? The second concern comes, if you like, from the other direction. Doctors are extremely worried that a non-clinical majority on a level 3 PCT could not only make decisions with which they disagree but are powerless to do anything about but could also initiate and force through a move to level 4. That could see GPs being run by a community trust. There are all kinds of fears associated with that such as a salaried service and so on. I respectfully say to the Minister that if PCT boards are to be lay dominated--I understand why the Government have arrived at that view--there is a need to address the kinds of concerns among GPs that I have referred to. This comes back to the need to instil a sense of corporate feeling and identity in a PCT as much as a sense that the views of doctors carry some weight and are being acted upon at board level.
Page 42, line 5, at end insert--
("(2) The number of persons referred to in sub-paragraph (1)(c) above shall include representatives of key partners in the delivery of NHS healthcare and the promotion of health in the locality.").
4.45 p.m.
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