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Lord Clement-Jones: Was the Minister speaking in the context of both Clauses 52 and 53?

Lord Hunt of Kings Heath: The noble Lord is constantly charging on to Clause 53 before we reach it. Obviously arrangements would be different under the directed model because there might be a need to act more quickly than in relation to arrangements under a voluntary trust. But we should not want to establish directed trusts at the expense of proper consultation.

Baroness Barker: I, too, am in something of a dilemma. I believe that we should have had a general and wide-ranging debate on care trusts. I signal my intention to raise more general questions once we have debated Clause 52. I take the point raised by the noble Baroness, Lady Cumberlege, that not only is it difficult to see what the Government's policy is but it is also very difficult to question that policy. Some of us came

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prepared this evening to listen to explanations from the Minister and to ask him a series of questions thereafter.

However, I take the point that the Minister made about consultation. It is quite clear that consultation and standards of consultation vary. The process of consultation has become significantly devalued in the minds of users, particularly since it first became prevalent following the passage of the National Health Service and Community Care Act. There is a real need to restore the confidence of users in consultation. That is probably the motivation behind some of the amendments which have been tabled this evening.

However, I take the Minister at his word that regulations will cover those matters. I believe that eventually we shall have a parliamentary Session which deals with nothing but regulations and there will be no Bills whatever. We shall be kept very busy just discussing regulations for about seven months. Having said that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 234 to 236 not moved.]

The Deputy Chairman of Committees: I must advise the Committee that if Amendment No. 237 is agreed to, I cannot call Amendment No. 238 because of pre-emption.

[Amendment No. 237 not moved.]

[Amendment No. 238 not moved.]

6.45 p.m.

Lord Smith of Leigh moved Amendment No. 239:

    Page 53, line 32, at end insert--

"( ) Regulations issued about governance arrangements for Care Trusts shall reflect their partnership nature, as between health bodies and local authorities."

The noble Lord said: In moving this amendment, I must remind the Committee of my interest as leader of a local council. I should like to say how much I agree with what the noble Baroness, Lady Cumberlege, said about the difficulties of setting up care trusts.

However, I believe that there is a principle here, which is that patients should come first. The service should be designed to meet the interests of patients rather than the interests of the organisations. We understand the difference in culture between local authorities and health authorities, but we need to go over that, and that is what care trusts need to do.

Care trusts are bound by their nature to be complex beasts. They need to reflect local circumstances and, indeed, local needs. They may involve primary care trusts, singly or severally, acute hospital trusts as well as local authorities. The degree of involvement may vary according to the nature of the service going into the care trust. So if it is a care trust which deals largely with services for the elderly, it would be a somewhat different configuration from that which deals with people with mental health problems, and so on.

Therefore, the arrangements need a certain amount of flexibility, and in this case I believe that the Government are right not to try to put on the face of

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the Bill the detail of the arrangements because there will be different solutions to meet those particular circumstances. In other words, I believe that we can be too prescriptive. I understand and share some of the concerns raised by the later amendments, in particular Amendment No. 247. However, I do not think that we should, for example, stipulate that 50 per cent of the appointments must be local authority members. That may not be appropriate if a particular service was not provided in that way in the past.

As regards governance, we were somewhat reassured by what the Minister said on Second Reading when he referred to a partnership of equals, but there remains a considerable amount of anxiety about governance in the local authority world. The Minister has received letters from the ADSS, the LGA and Unison, to name just a few. Those concerns are not just about status within the new arrangements but they are concerns about confidence and trust, as the noble Baroness, Lady Cumberlege, said, and the effectiveness of those new care trusts.

If there are to be real partnerships, there needs to be confidence on the part of all the players involved. Each of the bodies has ongoing accountability for the services which it starts to have responsibility for. Local authorities will have to have confidence in the quality and availability of the social care element going into the care trust. There is accountability to the Department of Health and, as the noble Baroness mentioned, to local service users. We need to be accountable downwards as well as upwards. That is very important.

As the noble Baroness also mentioned, we need to be concerned about the relative priority given to social care against more acute medical care, which may get priority.

Securing confidence needs to be done at two levels. The first is at board level. We need to make sure that local authority appointments to the board enjoy the confidence of the local authorities which they represent. They need to have the right both to appoint and then, for whatever reason, to change too. That is important at board level.

At operational level, there needs to be an equal contribution from professionals on both sides. I need to remind the Committee that the benefits of local authority involvement means that it is not just social services which are coming on board, although that will clearly be the main element; but there is wider access to local authority services. Those may be housing, leisure services and, if we believe in lifelong learning, it may be education too. The local authority needs to be able to manage the arrangements by which these wider services are brought in. However, perhaps I may remind my noble friend that the key issue is having the confidence of all sides to enter the partnership. I believe that such a partnership can deliver the objectives which I share with the Government. It can deliver the best quality services for patients and service users. If we are to have this partnership of equals, we

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need to be careful about the governance arrangements and ensure that partners feel that they are fully part of it. I beg to move.

Baroness Masham of Ilton: Can the Minister give an assurance that bringing in care trusts will not be an inroad for means-testing people who need services? Some people are suspicious because, at present, social services use means tests while health services are free. Will patients be worse off?

Baroness Barker: I should like to speak to Amendments Nos. 245, 246, and 247 in this group. I echo most of what has been said about the reasons behind the amendments. I do not believe that this is a question of status. Those who have been involved before in some of the joint working arrangements with health have a real and genuine concern that these partnerships should be partnerships of equals. That is a matter to which we need to pay particular attention.

The noble Baroness, Lady Cumberlege, talked about two different cultures coming together. However, I think that this issue involves more than that. There are two different approaches to working; two different bodies of knowledge, history and legislation are coming together. Last year I had the pleasure of working with a PCG to discuss its clinical governance arrangements for vulnerable older people. Those of us who were not from the health service spent two-and-a-half hours trying to explain to doctors that not all older people are patients; that they would not want to be called patients, and would not be overjoyed at the prospect of being put on an "at risk" register. That was a wonderful evocation of how we came from different experiences and almost spoke a different language.

I want to concentrate on some of the questions which follow from the comments of the noble Lord about social services being part of the new arrangements. As I have said, so far, legislation has been very different. We need to be concerned that care trusts will work to social services legislation, which governs a great deal of what happens to vulnerable people. I refer to matters such as the Gloucestershire case, the Sefton cases and so on. Perhaps I may ask the Minister what measures will be put in place to ensure that care trusts not only follow that but follow the guidance from case law as it develops for social services.

An interesting question is this: how will care trusts link with other services, such as those for disabled children and adults under 16? Older people do not live in isolation; they have families with whom they are in touch. How is it envisaged that the expertise of social service departments in holistic assessments, not only of users but of carers, will work their way into the care trusts? Perhaps that is more important than the governance arrangements. However, I understand the fear on the part of local government, particularly those

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which have not had good experiences of working with the NHS before, of how things will work out in practice.

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