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Lord Rea: Before the noble Lord sits down, perhaps I may ask him a question. When regulations are drawn up, is attention given to what has been said in debates in your Lordships' House and in the other place?
Earl Howe: It is very reassuring to hear that from the Minister. It makes me feel wanted. On a more serious note, I am grateful to the Minister for his full reply. I shall have to read carefully what he said because I am not entirely sure that he addressed all the points that I and the noble Lord, Lord Clement-Jones, were seeking to make. In the interests of moving on the proceedings, I beg leave to withdraw the amendment.
This is particularly important for patient councils because they will have a more strategic role than patient forums and, in addition to accessing information from individual trusts, they will also need to access information at health authority level. Similarly, patient forums will undoubtedly want to work together on a number of issues and may want information from a health authority when they are looking at those wider issues.
Amendments Nos. 121 and 122 are clarifying amendments. Patient forums will not be set up in Wales by this Bill. The effect of both amendments is to make clear that only trusts and primary care trusts in England will have a member of the board appointed by the patients' forum.
Amendment No. 123 is a minor drafting amendment to ensure that the words inserted by the paragraph are inserted in the right place. It ensures that the power to make regulations about the appointment of directors to trust boards in the 1990 Act is qualified by the provision that one non-executive director is to be appointed by the patients' forum. I beg to move.
With the amendment, I return to a matter I spoke about on Second Reading; that is, my very great concern with the proposal that a member of the patients' forum should be appointed by that forum as an executive director of the trust for which the forum exists.
My concerns relate to the difficulties that I foresee, first, with the impartiality of the patients' forum representative; and, secondly, with the appropriateness of someone who has the right of access and investigation to the trust being then a member of the trust board and required to make decisions on the corporate basis that trust non-executive members are required to do.
I had an opportunity of discussing this matter, very briefly, with the Minister shortly after Second Reading. It would be fair to say that he does not share that concern. But the corporate nature of a board is a very real aspect of it, and nothing in the Bill will change the responsibility that is placed on all non-executive directors for the corporate management of a trust. It seems to me that to have a cuckoo in the nest, someone who has a very real lobbying locus, may be difficult not only for that person but also for the trust itself.
Perhaps I may raise two other concerns that I had at Second Reading. The first is that all non-executive directors are currently appointed by the regional chairman after extensive interviews and "Nolanisation". That duty and responsibility will pass to the advisory committee for the region as non-executives will still have to be cleared on that basis. I understood the Minister to say yesterday that members of the patients' forum will also be selected by the advisory committee. If that is right, it will leave the independence of the forums somewhat adrift when they come to nominate someone for a non-executive role.
My third concern relates to the question of whom the non-executive will replace. Under the present legislation, the number of board members is balanced between executives and non-executives. The present number is five, and I believe that that was done by regulation. If the patients' forum is to have an appointment, there are two possibilities: one is that it has to be yet another executive appointment in order to balance out the patients' forum appointment; the other is that that patients' forum non-executive will replace one of the existing non-executives.
I believe that I am right in saying that none of the non-executives has a specific role. We are all there to manage the trust corporately. But it is a fairly heavily loaded job, as I am sure the Minister will accept. Most non-executives do a good job. Within the board there are usually those who develop an expertise in finance, who are responsible for audits, who are dealing with patients' complaints, for example. To have to replace one of those with someone else seems inappropriate.
Not least among the aspects to be taken into account are patients' complaints, which are presently a matter for the board. Patients' complaints are one of the prime focuses of the patients' forums. Therefore, a person would be excluded from dealing with such an aspect if he or she became a member of the board.
I have rather forlornly, and probably not very expertly, tried to get round this by proposing an amendment which would enable the forum to nominate a person from the forum to the board in an advisory capacity. The position would be a great deal stronger than that of the current community health council representative. At present that representative can attend as an observer but has no right to speak unless the chairman of the board enables him or her to do so. My amendment would enable a patients' forum member to be appointed and to be there specifically to give advice to the board about all the things that the patients' forum is there to do.
I must make it clear that I have no difficulty with patients' forums. I believe that the role of protecting the patient is well placed and well meaning. But we do not want to undermine its capacity by this particular move forward. The Minister was concerned about the patient element. I find that very difficult; what on earth is an NHS trust there for if it is not to look after patients and attend to their complaints and worries? It would mean that the patient focus would be brought to the board by right, although the person would then
Baroness Cumberlege: I support my noble friend Lady Hanham on this issue. I have been engaged in a good deal of work recently with nurses who are on the boards of PCTs and PCGs--mostly PCGs. One of the issues with which they are faced is that many of them have actually been voted on to the board by nurses within their area. A point for debate with every group that I meet is: what is their role? Are they there to represent the nurses who have voted them on to the board, or do they have a corporate responsibility? Alternatively, are they there in their own right?
We are carrying that dilemma further up into the NHS trusts and the PCTs. I believe that the issue needs teasing out. It is important to ascertain whether these people are representatives of the forum, delegates of the forum or whether they are there in their own right. One of the dangers when one gets into this area and says, "We must have one of those, and then we need another of these", and so on, is that one gets all sorts of people--often very good people--who are well-meaning and form a nice group but who are actually not fit for the purpose. The board is not fit for the purpose because, as my noble friend said, one does not go for the skills that are needed to run an organisation; for example, those of finance, human resources and, indeed, just understanding how a very complex, difficult organisation runs.
These trusts are much more difficult to run than many companies in the private sector because they have both different and difficult accountabilities: they are accountable to politicians; they are accountable to their local communities; and they are accountable to taxpayers. The more that we have representatives, delegates, or whatever, on these trust boards the more difficult it is for them to act effectively. It is in all our interests that they should be both efficient and effective.
Lord Hunt of Kings Heath: We are discussing an important matter. I am grateful to the noble Baroness, Lady Hanham, for raising the point. Of course, she speaks from considerable experience of the NHS. I certainly very much agree with her that the contribution that chairs and non-executives make to the health service is crucial. I am also glad to hear about the work that the noble Baroness, Lady Cumberlege, is carrying out in relation to nurses. I believe that we need nurses to be evermore forceful on the boards of NHS organisations.
I understand the issues that both noble Baronesses have raised. There will be some very interesting challenges ahead both for the board and for the patients' forum person who is on the board to ensure that the body acts effectively, that it has a strong patients' voice at the highest level in the trust and that it also acts in a corporate manner. I do not believe that it is impossible for that to happen. It is absolutely vital that we have the benefit of a board member who has
Perhaps I may answer the specific points raised by the noble Baroness, Lady Hanham, about the practicalities of how the process is to be implemented. There is no intention to increase the overall number of trust board non-executive directors. However, it would be wrong to expect a newly-established patients' forum to wait until a convenient vacancy occurred before making the appointment. Therefore, we accept an additional non-executive director, mainly to be appointed temporarily, until such time as a vacancy occurs. Once it is established, the NHS appointments commission (which is due to be established on 1st April of this year) will assume responsibility for appointing trust and health authority non-executive directors. The commission will take that responsibility from the Secretary of State.
However, under the Bill the patients' forum has the power to appoint a non-executive to the trust board. In order to maintain standards of membership and meet basic requirements, regulations will be laid down detailing the selection process. They are likely to contain a reference to qualifying criteria laid down by the NHS appointments commission which will oversee the whole process.
We then come to the crux of the question as to whether such a board can act corporately. I believe that it can. Once appointed, the patients' forum non-executive will assume full board status and will be bound by the corporate governance arrangements, the code of conduct and appraisal arrangements which apply to all trust board members. I was interested in the comments of the noble Baroness, Lady Cumberlege, when she referred to nurses being elected. She talked about the different accountabilities that boards in the NHS have to face up to. I agree with that. There have always been dual accountabilities in the NHS. Board members have always come from various backgrounds to which it might be felt they owed some allegiance.
My first experience in the NHS was as an Oxford City Council representative appointed to the Oxfordshire Health Authority. I soon learned that to be effective within that authority I had to act corporately. I believe that that also applies to nurses and doctors. One might also consider university representatives. A university makes two nominations and the Secretary of State chooses between them. The health service is used to those different kinds of appointment mechanisms and thrives on them. Overall I believe we can be satisfied that our boards act corporately. I also believe that a patients' forum non-executive will add to the performance of a board and that such people will be able to act as corporate members.
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