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Earl Russell: My Lords, I listened with pleasure to much of what the noble Earl said about the properties of the court and Treasury party. Can he tell us whether a future Conservative government would abandon any of the powers about which he is now complaining?
Earl Howe: Certainly my Lords, but the time for me to set out the Conservative Party's stall lies some time in the future, as I hope the noble Earl would accept. My task today is to criticise the Government. I am doing so on the basis of well established Conservative philosophy.
I was referring to community health councils and the Government's proposals. Everyone agrees that the status quo for CHCs is not an option. But the great merit of CHCs is that they are a one-stop shop. As such, they are easily understood by the public. They are also independent of government and the NHS. Patients therefore have confidence in them. By contrast, the staff of patients forums will not be independent of trusts. They will be inside the loop. No longer will the public have any sort of community-led watchdog in the field of healthcare. As I regret that I have said on many previous occasions, the arrangements for scrutiny, monitoring and complaints work, far from being a one-stop shop, are to be fragmented between a whole raft of different bodies: overview and scrutiny committees, patient advocacy and liaison services, the independent advocacy service and patients forums. Can the Minister tell us how much all that will cost compared to current arrangements?
Nor will there be any mechanism for providing an informed overview from the public perspective of local health issues. The Commission for Patient and Public Involvement in Health, whose job it will be to oversee patient involvement, will have its chair and chief executive appointed by the Secretary of State. What signal does that send out to patients? What will people think of the commission when they find out that it has no formal line of accountability to local communities? What will people think when they realise that Ministers have insulated themselves from the voice of the patient by removing the right enjoyed by CHCs to refer contested decisions to the Secretary of State? Patients forums will not have the same rights to be consulted as do CHCs. Neither the new commission nor patients forums will be able to engage in the kind of pro-active lobbying that CHCs now undertake—often very effectively.
Those are the reasons why we have opposed, and still oppose, the abolition of community health councils. Considered against that background, the Government's rhetoric about greater patient empowerment frankly rings rather hollow. I shall tell your Lordships what else rings hollow. It is impossible to count how many times we have been reassured by Ministers that the Government respect and believe in the concept of professional self-regulation. We believed those assurances.
During the past couple of years, Ministers have encouraged the General Medical Council to reform itself. They have re-shaped the regulatory arrangements for other healthcare professionals. All that is positive. Yet now, what do we find in the Bill? A new council for the regulation of healthcare professionals is to be given powers to overrule and control the policy decisions of the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and other regulators.
Supervision is one thing; direction is another. That power of direction represents a watershed. It is a power that effectively brings professional self-regulation to an end. The ability to overrule the professional majority on the GMC is one that should be given only to Parliament. Instead, it is being given to a body that is nominally independent but on which government appointees will always be in a majority.
The Government may say, as I understand they now do, that the regulatory bodies will not have their work interfered with other than on an exceptional basis. But if we consider these proposals in conjunction with those for a new medical education standards board, which may also have powers of direction over the regulators, it is not going too far to speak of this Bill de-professionalising doctors and other healthcare professionals. The GMC, for example, will no longer have sole control over the medical register, nor over its own ethical code, nor over fixing its rules. It will in effect become a sub-committee of the proposed new council.
I find that disturbing, and at the Committee stage we shall have much more to say about it. We shall have much to say, too, about other provisions in the Bill
that are causing concern: the creation of the new strategic health authorities and the uncertainty and upheaval that goes with that; the financial consequences flowing from the organisational changes, about which my noble friend Lady Noakes will have more to say later; and the altered role of the Commission for Health Improvement.Meanwhile, we should look at the Bill in the round. The Government would do well to pay heed to the comments of 304 chief executives, who were canvassed in a survey by the Health Service Journal on the consultation document Shifting the Balance of Power. One of those chief executives had this to say:
- "This is my sixth reorganisation in a thirty year career in the NHS. I have always responded positively to change previously. However these proposals are a recipe for disaster—a blend of lack of insight, ineptitude and disregard for staff at all levels".
The Bill before us is one that shows up the Government at their worst. For me, at least, it leaves a very bitter taste behind it.
4.10 p.m.
Lord Clement-Jones rose to move, as an amendment to the Motion, That the Bill be now read a second time, at end insert "but this House regrets that Her Majesty's Government are bringing forward this Bill before a full legislative response to Professor Ian Kennedy's report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary (1984-1995) is possible; and before the review of the 10 Downing Street Forward Strategy Unit into National Health Service structures has reported; and urges the Government to postpone the passage of the Bill through this House so that a comprehensive and considered Bill can in due course emerge."
The noble Lord said: My Lords, I thank the Minister for explaining the terms of the Bill in his usual concise fashion. I am afraid that I shall be no more positive than the noble Earl, Lord Howe, was in his well judged speech.
The Minister is aware that, on these Benches, we supported, for the most part, the Health Act 1999, the Care Standards Act 2000 and the Health and Social Care Act 2001. We were also enthusiastic about the NHS Plan, agreed by the Government with a wide range of stakeholders. As regards this Bill, however—as the Minister will have seen from the Motion in my name—we are unenthusiastic to the point of hostility, in company with a large number of managers and clinicians in the health service. We see the Bill as a half-baked attempt at reform, not properly thought through, premature at best, damaging at worst, to the NHS's ability to deliver the plan.
I turn first to the proposed new NHS structure. Since the general election and the realisation by Ministers of only four or so years to go before the Government face the electorate on their management of the NHS, health Ministers have gone into initiative overdrive. We have initiatives on private sector involvement and on overseas treatment for those needing hip and cataract operations. We have the introduction of concepts such as franchising
the management of underperforming hospitals to successful managers and the private sector. We have the initiative on the creation of foundation hospitals for the top-performing NHS trusts. And, of course, we have the so-called decentralisation proposals in the Bill.The Secretary of State and his colleagues clearly have great faith in the ability of new structures to deliver better services. The Minister mentioned culture. I say to the Minister and his colleagues that culture change is far more important in effecting change and in effecting successful delivery than changes in structure. To date, whatever the rhetoric, with the steady erosion of the independence of senior NHS management, the Secretary of State's real signals for decentralisation seem to be set at red, not green. The NHS is sliding into a blame culture.
Perhaps the Minister can answer the central question. What areas of service will actually improve if such restructuring takes place at this time? Many of us are concerned about public health. It is far from clear who will deal with disease control and school health services, let alone whether bodies at local level, such as primary care trusts, will have the skills and systems in place to take responsibility in that area.
There are grave doubts generally throughout the health service as to whether PCTs will be ready for their new role. How measurable will their objectives be? What capacity will they have to deliver? Will GPs play their full part? Will PCTs engage with the public? Before those questions are answered, there will inevitably be risks for patient care implicit in the restructuring. In any event, PCTs could have got by decision of their health authority the powers that are conferred by the Bill but at a pace dictated by local conditions, skills and circumstances. How realistic is it to expect £100 million to come out of management costs in the course of reorganisation? Reorganisation always costs more, as the Conservatives found to their cost every time.
Perhaps the most fundamental objection to the structural provisions in the Bill is that they are likely to be added to or changed in short order. That is the reason for my amendment to the Motion. We have seen Professor Kennedy's excellent report. With one or two exceptions, it is clear that Ministers have not had time to prepare legislation in response to his recommendations. Mr Adair Turner, formerly of the CBI, now working with the Number 10 forward strategy group is considering NHS structures for the future. He will report later this year. Surely, he will make suggestions for change. So we can expect yet another NHS Bill from the Government, helping to demoralise NHS staff further and prevent them getting on with the job. Target fatigue among NHS managers is prevalent enough, without our adding to their woes. It is a Maoist approach to management—bring on new reforms before the old ones have taken effect and dig up reforms before they have had time to take root.
When I come to the provisions relating to the Commission for Health Improvement, I get an acute sense of déjà vu. When CHI was originally created, we
on these Benches strongly supported it but argued that a single system to measure the performance of acute hospitals— whether in the NHS or the independent sector—should be put in place. Likewise, when the Care Standards Bill went through the House, we argued strenuously that CHI should assume responsibility for independent acute hospital inspections. On each occasion, Ministers argued that there were fundamental differences between management and regulation and that our proposal was wholly unacceptable.I hope that the Minster has the decency to blush, now that Mr Milburn has changed his mind. On 17th January, he told us that there would, over time, be organisational integration between CHI, the social services inspectorate and the Audit Commission so that health and social care services are subject to a common set of standards irrespective of whether they are provided by public, private or voluntary organisations. Just so, my Lords. The conversion was worth waiting for, even if it did happen at the point at which the Care Standards Commission was about to come into being.
We would like to see that conversion translated into action and into amendments to the Bill, although we do not wish to see the Audit Commission swept into the same basket. That said, we also want to ensure that, in its newly authoritative role, CHI is responsible for inspection and performance management measurement and is genuinely able to set the quality benchmarks that it sees fit—not simply those determined by Ministers in Richmond House—in the same way that the Audit Commission can on value for money audits. That is the role recommended by the Kennedy report. If Ministers genuinely want to shrug off charges of micromanagement—to which they are extremely sensitive—they should see the wisdom of that course of action.
There is also the thorny issue of community health councils. Many of your Lordships will remember the battle we had during the passage of the Health and Social Care Bill over the abolition of CHCs. A compromise over the powers of new patients' councils might have been reached if the general election had not intervened. There was some cause for optimism when Hazel Blears produced her proposals last September, and there is no doubt that she took on board some of the criticisms made of the previous proposals. Since then, we appear to have gone backwards. The proposals in the current Bill are worse than those in the Health and Social Care Bill. There are at least four organisations due to take over from CHCs: patient advocacy and liaison services, patients forums, the independent complaints advocacy services and local authorities for scrutiny. The functions of CHCs will be fragmented. No single body will have a local overview of health services, and, as the noble Earl, Lord Howe, pointed out, the benefits of the one-stop shop provided by CHCs will be lost.
There are many points of uncertainty surrounding the scrutiny role of local authorities. Forums are not independent of trusts, and their membership is
potentially too much under the control of Ministers. They will have limited powers, even by comparison with CHCs, and will not even have staff of their own.There are many objections to the proposals. I could go on, but time is short. The objections relate to the commission and the forums. As if that were not enough, the cost of the new system has been estimated to be 10 times that of the current system. What kind of reform is that? Scotland and Wales are retaining their CHCs: why are English health Ministers so determined to abolish them?
I turn to prisons. One of the great regrets about the Bill is the failure by the Government to amalgamate the prison health service with the NHS. All close observers of the prison health service know what the right solution is. It is simply not adequate for the Prison Service and the NHS to continue to pass the parcel with prisoners who have health needs. That is particularly true of mental health.
My noble friend Lord Avebury unearthed the particularly disquieting fact that the NHS still appears to be some 500 secure psychiatric beds short. So it is completely unable to meet the needs of the Prison Service, despite the provision of those extra beds having been a target in the NHS Plan to be accomplished by April 2001. The Commons Health Committee made the same point some time ago. What assurances can the Minister give that funding for the necessary number of beds is in place and that they will shortly be provided?
I come to Wales—would not we all want to come to Wales?—and the provisions in that regard will be dealt with by my noble friend Lord Thomas. He may lift the gloom on these Benches by having something positive to say on Clause 22.
Finally, I turn to the council for the regulation of health care professionals. When this proposal first emerged from the early findings of Sir Ian Kennedy's Bristol report, I was baffled. I could not see what usefully could be done by the new council except something ethereal such as a co-ordination job—anathema to those of us who believe in effective leadership and management and something which quite adequately could be done by the health department itself. As the Bill took shape, however, it emerged that the Government's proposals are worse than that and positively dangerous for the future of professional regulation in this country.
The Secretary of State now has ranged against him a combination of the Academy of Medical Royal Colleges, the GMC, the Royal Pharmaceutical Society, the new shadow bodies of the NMC and Health Professions Council, the General Dental Council and the other health regulatory bodies. And of course they are right. The key to the objections, expressed strongly in Committee and on Report in the other place, is the power of direction in Clause 25 to the professional regulatory bodies to change their rules. It is not even a reserve power to be used in exceptional circumstances; it is a general power of direction.
The proposed council will have a majority of lay members. The regulatory bodies, such as the GMC, NMC and Health Professions Council, will have professional majorities. Effectively therefore the Bill is taking an axe to the principle and practice of professional self-regulation. Furthermore, why should the professional regulatory bodies report to Parliament through the proposed council? It will be a quango appointed by Ministers.
Neither those bodies, nor indeed the new medical education standards board not covered by this Bill, should be directly or indirectly the creature of Ministers. We on these Benches firmly look to see that these bodies continue to be independent but publicly and transparently accountable.
In conclusion, our opposition to this Bill in its current form and our wish to see it delayed and heavily amended by the Government before proceeding further is not because we are pessimistic about the future of the NHS. Indeed, we share the desire—the presumed desire—of the Secretary of State to decentralise. But it must be in the right way at the right time. We must make sure that the devolved structures can bear the weight put on them, particularly when it comes to PCTs. When we decentralise we must consider how it fits in with the future regional structure. We must also simplify. We cannot do that simply by putting in place another tier of management and calling it decentralisation.
The BMC recently issued a chart showing the sheer complexity of the NHS and professional governance system which is both in place and due to take effect in respect of performance monitoring. It includes 21 different elements, including appraisal, the Audit Commission, clinical audit, clinical governance, CHI, continuing professional development, the GMC, intermediate procedures, litigation, local performance advisory groups, the medical Royal Colleges, NHS complaints procedure, the NHS Ombudsman, the National Care Standards Commission, the National Clinical Assessment Authority, NICE, national service frameworks, National Patient Safety Agency, patients forums, professional advisory panels and revalidation. For academic doctors the list would be much longer.
Every time a problem is identified Ministers propose a new body. The Council for the Quality of Healthcare is a classic case drawing together and—we have it again—"co-ordinating" numerous bodies. The system of governance is increasingly oppressive even to the most excellent of health professionals and must be simplified if we are going to make professional life half tolerable.
We also believe strongly in the benefits of building on the National Health Service framework and the national plan. We wish to see a strong system of community and patient representative bodies with the power and resources to provide independent advocacy for patients.
The King's Fund report of the splendidly ubiquitous noble Lord, Lord Haskins, points the way in the right direction towards greater autonomy of the NHS,
hospital trusts and more choice for patients. Its proposals merit a full debate. The Government should take time to consider it and adjust their plans accordingly. One commentator called the proposals in the Bill "a wonderful substitute for change". If we have NHS staff scurrying around implementing these structural changes there will be no time to deliver what really matters—services for the patient.The Government have been extremely sensitive to taunts of micro-managing the NHS. They should now step back and devise reforms to the NHS which genuinely represent a move to local autonomy. I beg to move.
Moved, as an amendment to the Motion, That the Bill be now read a second time, at end insert "but this House regrets that Her Majesty's Government are bringing forward this Bill before a full legislative response to Professor Ian Kennedy's report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary (1984-1995) is possible; and before the review of the 10 Downing Street Forward Strategy Unit into National Health Service structures has reported; and urges the Government to postpone the passage of the Bill through this House so that a comprehensive and considered Bill can in due course emerge".—(Lord Clement-Jones.)
4.26 p.m.
Lord Chan: My Lords, this Bill introduces substantial changes to the way the NHS in England operates. Most of those changes should improve the delivery of primary health care and are to be welcomed. But there are also risks associated with such major changes and with this rather abrupt introduction of changes.
Before going further, I declare an interest as a non-executive director of the Wirral and West Cheshire Community NHS Trust, and as ethnic health adviser to the North-West Regional Office of the NHS. I shall confine my comments to Part 1 of the Bill.
Primary care trusts, particularly those coming into existence in April this year, will not be ready to implement their new functions; for example, service planning, which has been the responsibility of health authorities but will be abolished by April this year—two months from today. Senior management personnel and board members of some PCTs have still to be appointed. It is therefore unlikely that PCTs will be functioning optimally for several months, if not a year or more.
My impression is that primary care trust management will be engrossed with human resource issues because more staff will be needed to perform the new functions and arrangements for better healthcare of local people. Furthermore, GPs who are independent of the primary care trust administration will need time to adjust to the changes heralded by the Bill. Can the Minister assure local people dependent on the services of new PCTs that the quality of their healthcare will not deteriorate because of the changes?
Another of my concerns relates to funds for the running of the new PCTs. Some of the money will have to be transferred from health authority budgets while
some will come from community trusts. Some, if not most, NHS trusts are in financial deficit at this time of the budget cycle. How soon after the beginning of April will those new funds be available to the PCT?I turn to the Commission for Health Improvement. I declare an interest as an ethnic health adviser to the commission. The Commission for Health Improvement has been in existence for almost two years. It has been inspecting, reviewing and reporting on NHS acute trusts, mainly hospitals. But that task is not complete and some hospitals have not been visited. The new arrangements aimed at strengthening the CHI and its independence give the impression that the commission has been fulfilling its current remit. But what evidence is there that the CHI has been effective in its work? Who has, or is, reviewing the performance of the CHI? Who will monitor if the recommendations made by the CHI on an NHS trust are being implemented?
Finally, I turn to patients forums. They will have powers to inspect and monitor NHS trusts and PCTs as well as represent patients and the public. It is clear that those appointed to patients forums will require training. The establishment of the Commission for Patient and Public Involvement is essential to supporting patient forum functions. Will the commission also provide training for forum members?
With the abolition of community health councils, a pool of experienced and trained people will be available to assist patients forums. Will former CHC board members and personnel be encouraged to help in that way? Those are some of the current concerns to users of the National Health Service in the north west region. I hope that the Minister will take serious note of them.
4.32 p.m.
Lord Turnberg: My Lords, while I have considerable sympathy for the views expressed by the noble Lord, Lord Clement-Jones, and listened with care to his proposed amendment, I cannot agree that the House should jettison the Bill at this time. Although there is much concern with some aspects of the Bill, there is too much at stake to put it back.
Primary care trusts are an important element of government policy to devolve responsibility for the health service away from the centre to where patients are to be found. PCTs will be responsible for some 75 per cent. of the NHS budget but have much to learn, as they prepare to take on a critical role—and there is a danger that they will not be quite ready.
One anxiety centres on the need to ensure that specialised, so-called tertiary services—neurosurgery, renal dialysis, transplantation and the like—will not be relatively neglected by PCTs. After all, they are responsible for a relatively small number of patients and few among them will need such care. Populations of 1 million or more are needed to contract rationally for specialised care. My noble friend the Minister will be aware of that potential problem but it needs careful attention if important services are not to be neglected.
The other worry about PCTs arises from their responsibility for public health, preventive medicine and, in particular, protection against infectious disease. That role is critically dependent on alert surveillance of outbreaks of infection, isolating the sources and effective eradication. There may be a hiatus in the take-up of those responsibilities as more pressing matters take precedence in the trusts' busy lives.
That danger will be magnified by the simultaneous changes in public health surveillance proposed in the Chief Medical Officer's recent report. Part of the radical proposals is a new health protection agency to take over the Public Health Laboratory Service along with a number of other bodies. I express an interest as chairman of the board of the PHLS.
As the agency takes over, the PHLS will hand over many of the microbiology laboratories that form its network of surveillance throughout the country to individual NHS trusts. In the long run, that may or may not be a good thing but the transition must be handled cautiously, so that a dangerous gap is not left in infectious disease surveillance—which would coincide with a learning gap at PCT level. I hope that the Department will make clear how PCTs will be supported in their efforts to take on public health responsibilities and make sure that there is some co-ordination between that aspect and supporting laboratory and other services for which the PHLS is currently responsible.
When the Commission for Health Improvement was established, it was intended to be supportive—to help trusts achieve a high-standard, quality service—as well as to have an inspectorial role. In fact, the commission has acted largely in the latter mode and its critical inspectorial role is to be strengthened. While that may seem appropriate, it leaves a gap in the standard-setting and helpful role that trusts need the CHI to play. Some non-governmental bodies try to do both. Again, I declare an interest as chairman of the board of the Health Quality Service—a charitable organisation that sprang out of the King's Fund. The HQS and one or two others could fill the gap if it were made possible for them to work more closely with the CHI. They have already done some of that in standard-setting efforts but much more could be done—and that would be welcomed by trusts, which are often overwhelmed by inspection.
As to the proposals for professional regulation, I express an interest from my murky past in postgraduate medical education, as a past president of the Royal College of Physicians and chairman of the Specialist Training Authority when it was established in 1996.
It is hard not to be supportive of the Government's aspirations for professional regulation that is open and transparent, so that health care professionals are accountable to their patients and the public and they in turn will be reassured about patient care. All that seems entirely appropriate but, in aiming at public accountability, the proposals are in danger of deprofessionalising and denigrating doctors, dentists,
nurses and others on whose dedication we all depend. Instead of public accountability, which is highly desirable, we are heading towards state control, which is not.What seems to have united the medical profession—an extremely rare event—is a sense of oppression and suppression. The deans of medical schools, British Medical Association, deans of colleges and General Medical Council all support the idea of the council for the regulation of health care professionals that brings together all the regulatory bodies so that they can share good practice and promote co-operation and the interests of the public and patients. Where they remain united is in their concern at the proposal that the council will have the power to direct a regulated body to change its policy or rules, even where that body felt that to be wrong in the public interest.
The council, with its lay chairman and lay majority largely appointed by the Secretary of State, would also be in a position to examine a case on appeal previously judged by the regulatory body and decide whether it should be referred to a court of law. That leaves room for a large number of appeals on cases of considerable complexity to a body barely equipped to deal with them—unless there are clear criteria and constraints. The council should not be in the position of second guessing regulatory bodies. The power to direct and intervene must be carefully controlled and should preferably be in the hands of Parliament, through the Privy Council. That would provide a safeguard for patients and the professions.
Ministers have been in constructive discussions with the medical and other professions and I encourage that, in the hope of a solution that satisfies the public and the professions. However, another concern centres on the prospect of control of professional regulation by the Secretary of State of the time. Unfortunately, not all Secretaries of State are as supportive of the professions as the current office holder. Occasionally, Secretaries of State have been known to behave in a knee-jerk sort of way. That is, of course, in the past.
Professional regulation very much depends on the involvement and co-operation of the profession, whatever it might be. The medical profession's regulatory body should be answerable to Parliament and the Privy Council, not to a government or Secretary of State of the day. The Government should think carefully about establishing a body to oversee the regulatory authorities that is largely appointed by and answerable to the Secretary of State. I strongly urge a line of accountability that leads to Parliament.
There is yet another regulatory function of the GMC, which relates to medical education. The GMC fulfils this role through its education committee which itself is responsible and accountable directly to the Privy Council, and is therefore somewhat separate from the main regulatory function of the council. The committee oversees undergraduate education in the medical schools by ensuring that the curricula and examinations match up to the criteria it publishes, which are available, and it does a pretty good job at that.
It is unclear to me whether it is intended that the new council, the overarching body, will have a role here and, in particular, whether it will expect to be able to direct the GMC in its educational activities. If it did so, where would it gain its legitimacy and knowledge for so doing? The thought of a Secretary of State of the day laying down his or her ideas about what medical education should consist of fills me with horror. I expect that it would fill most patients with horror too.
That fear, I am afraid, is not eased by recommendations about the control of postgraduate medical education and training, which have emerged in parallel with this Bill and which show the direction in which the Department of Health may seem to be heading. The proposals, described in a discussion paper on a medical education standards board, a new body, have a number of attractions. They strengthen the regulatory function for postgraduate education for specialists and general practitioners in a number of ways and are to be welcomed. But it is the governance arrangements for the new board where the problems arise.
Noble Lords should know that it is the medical royal colleges which publish all the detailed curricula and training programmes for all the different specialties, and set and run all the examinations and appraisals. The Royal College of Physicians, of which I have some knowledge, runs training programmes for some 28 different specialties and oversees training through its system of postgraduate tutors in hospitals around the country. It ensures that hospital trusts have the right facilities and staff to train specialists. The whole process requires enormous effort and is very labour intensive, but it works. In the UK we have specialists who are among the best trained in the world.
I wanted to spell that out because we are heavily reliant on the colleges. When it became necessary for the United Kingdom to have a legally responsible body to oversee postgraduate education under EU regulations in 1996 or 1997, it was clear that the only really competent bodies to form such an entity were the colleges. That is why we were able to persuade the government of the day to set up a new statutory body, the Specialist Training Authority, of which I became the first chairman. Furthermore, the full name of that body recognised the role of the colleges—it was and still is the Specialist Training Authority of the Medical Royal Colleges.
It has had, of course, lay representatives since the beginning, but it has a majority of college representatives because we had the belief that they were in the best position to judge what should go into the training of a specialist. Yet now it is suggested that the new board might have a lay chairman and a lay majority, although there does not appear to be any logical reason why that should be necessary when considering the role it has to play. Again, it places postgraduate medical education in direct line to the Secretary of State of the day.
So here we have both undergraduate medical education through this Bill and postgraduate education through the associated paper I have
described largely out of the hands of the medical profession and into the hands of a lay majority and on to the government of the day. That is rather like suggesting that the Monetary Policy Committee be largely made up of and chaired by those lacking in monetary or economic expertise, and although that may have its attractions, it is not guaranteed to produce the best results.I do hope that the Government will think again about the need for what looks like political control of medical education. Of course those concerned with education should be influenced by the views and opinions of the public and patients—I believe that they are—but having the power to direct education is undesirable and shows a disregard for the judgment of professionals which is unwarranted. It will lead to disaffection of professionals and, in the end, patients will suffer. I hope that my noble friend on the Front Bench will consider very carefully the implications of the power to direct and how it is intended to be used, and in the need for the Secretary of State's direct involvement, instead of the much more desirable alternative of final responsibility residing with Parliament and in the Privy Council.
4.45 p.m.
Lord Howe of Aberavon: My Lords, I listened with some sympathy to the point made by the noble Lord, Lord Turnberg, about qualifications for participating in any function—in particular with regard to my participation in this debate, because they are not very apparent. It has been some 25 years since I was shadow Secretary of State for Social Services and some 35 years since I was first a shadow spokesman on that subject in 1965. I did have some dealings with healthcare during my professional life at the Bar.
I have to confess that, having listened to the two noble Lords who have just preceded me, I feel rather like an under-qualified spaniel in a den of Daniels, and I speak with some hesitation. Having said that, and having listened to what they had to say, following on the powerful speeches made by my noble friend and namesake Lord Howe and the noble Lord, Lord Clement-Jones, the speeches of the noble Lord, Lord Chan, and the noble Lord, Lord Turnberg, my concern about this proposed legislation has hugely increased. I have never heard a Bill greeted with such alarmist responses—I do not use the word pejoratively—as indicated by the speeches, couched in very measured terms, made by the two Lords who know most about the subject. It illustrates why we are rightly concerned about the way in which this legislation has been prepared, is being introduced and is to be carried forward.
One topic I do know something about is that of community health councils. They were proposed and founded during my time in the Heath Cabinet as Minister for Trade and Consumer Affairs. I announced their proposed existence in my first speech in that capacity in December 1972 to the National Council for Social Services. At the same time we announced the establishment of the Health Service
Commissioner. Institutions of that kind, like many others in this country, acquire an authority, a familiarity and an experience so that people know where to go to lodge their complaints. Indeed, people still talk about their doctors as their "panel doctors". The panel was invented in 1911 by Lloyd George. People certainly talk about community health councils as one of the friendly beacons in the service. Thus I am concerned about it. The Association of Community Health Councils has stated:
- "The proposals replace a system of proven efficacy that was easily understood and accessed with a highly complex and confusing structure".
I wish to develop that into a criticism of the way in which the Government are attacking and approaching the whole subject of healthcare reform. The Bill is illustrative of what we have come to recognise as an endless marathon of monolithic upheavals. No sooner is one over than another commences. The Minister, of course, has enjoyed the comfortable experience of delivering his Second Reading speech in which all the complex elements of this legislation have been condensed into smooth-running, consecutive sentences. Nothing is better calculated to persuade a Minister that he is doing the right thing than a well-prepared Second Reading speech, but that is profoundly misleading.
Another characteristic of this Government's approach is the multiplicity of acronyms: PALS, NICE, CHI. My first dog was called Chui, the Swahili for leopard. Although one becomes accustomed to trotting out such acronyms so that they sound reassuring, surely the Government have to learn that attractive acronyms are not an alternative for effective action. However, in order to be as fair as I intend to be, I have to say that they are not the first Government to have fallen into this trap. Perhaps I may cite one example which I think is correct. The National Health Service Reorganisation Act 1973 replaced the governing bodies of the metropolitan teaching hospitals. Keith Joseph was the Secretary of State in charge, and no one could have been more sincere and well-intentioned. However, it was a grave mistake. Had that not been done, then the process of reorganising the teaching hospital structure of the metropolis years later, that bedevilled Secretaries of State in both parties, would not have happened because a process of self-adjustment would have taken place between those bodies. The programme for replacing the community health council is of exactly the same quality.
As I have said to the House, if one goes into any medical staff room or teachers' staff room in any institution in the country and asks, "Now what would you like us to do?" the unfailing response is, "For God's sake, leave us alone". I am reminded of a story, which I do not think that I have told the House, of a Minister on a typically busy tour asking a chap at work in a room in some institution, "My good man, how long have you been working in this institution?" The chap replies, "As far as I can remember, I have been
working here in 17 different departments for 43 different Ministers but always in this room". That is the pattern that is being reproduced now.This legislation fails to tackle the central recommendation of the King's Fund report, summed up in one sentence:
- "creating distance between Government and the National Health Service".
The King's Fund report states that the changes which are necessary should be designed to create the right environment for the National Health Service to take responsibility for reform, to help the development of local leadership. It should be a new organisational form to encourage independence and innovation. I give the Government the benefit of the doubt. They may still think that that is their objective, but the extent to which they are failing to approach it is overwhelmingly convincing. They are doing almost exactly the opposite.
The specific proposal of the King's Fund for a separate health service corporation may not be necessarily the right approach. If one is to do that, one needs something much closer to a genuinely detached pattern of devolution. At page 14, the King's Fund report states:
- "The new bodies would be able to manage the delivery of their services in any way that meets their . . . obligations. They would have the incentive to innovate in order to improve health care. They could be given the power to generate and use financial surpluses to re-invest and reconfigure services, and the opportunity to raise additional finance on the private market. They might manage their own workforce in respect of pay and conditions of service".
My second point—I apologise for having made points which are less related to the Bill—relates to the fundamental question on the funding of healthcare. It is now a truism that in western democracies other than the United Kingdom—France, Germany, The Netherlands, Austria and Italy—the percentage of GDP being spent on healthcare is at least 2.5 or 3 per cent higher than in this country. It is equally true that the gap depends upon the additional resources coming from the private sector. In this country perhaps 1 per cent comes from the private sector. In other countries the average coming from the private sector—I leave the United States on one side—is two-and-a-half or three times that amount. The truth has penetrated to the busy mind of our Prime Minister. He recognises the need to raise the total to that achieved by other countries.
It is not just a question of raising the total of resources. I want to see an expansion of the role of the private sector: those resources would arrive in a fashion which would increase the flexibility of the healthcare institutions. If one designs systems which attract private sector contributions, one gives the people working in the service a real chance of believing that they can influence their own working environment. It is not just a cash question: it is a much bigger idea.
A year or two ago, the Economist summed up the issue in this sentence:
- "The idea of giving the private sector a big role in public services is contentious in Britain. In the rest of Europe, it's commonplace".
- "Socialism in one country".
If it is not too patronising for an "antique" to do at this stage, I commend the leaders of my own party for their current willingness to examine and study what is going on in neighbouring European countries. There is much to be learned and I am delighted that the Conservative Party is leading that search. I congratulate in particular my honourable friend Dr Liam Fox on his willingness to keep an open mind. He has developed a maturity in his approach to the subject since I spoke for him in his battle against David Steel in one of the Border constituencies 100 years ago. His mind is open to new thinking; he is determined that it should not be closed. That is how he needs to approach the issue.
That, I am afraid, is difficult for the party opposite. Nye Bevan was right in his book, In Place of Fear, when he determined that the Palace of Westminster looked like an institution devoted to "ancestor worship". If ancestor worship were a feature of this palace, it is overwhelmingly a feature of the Labour Party's attitude towards the health service.
There are two respects in which one might make that point more substantively. How have we in this country become so hung up on measuring health efficiency by reference to waiting lists? In 1965, in a book called The Conservative Opportunity, I wrote an essay entitled The waiting list society. That was a true insight into our country at that time. In most places waiting lists have disappeared, but not in the health service. Noble Lords may have seen an article in the Parliamentary Monitor for July 2000 in which Mr Jeremy Laurance, health correspondent of the Independent, having toured Europe, concluded:
- "Appointments were easy to make, waiting lists were non-existent (or of no consequence in British terms)".
The second hook is an inhibition from allowing any payment to take place at the point of service for any aspect of the service. Yet the King's Fund diagnosis is clear. It states:
- "Greater opportunities for patient choice should also result in a more dynamic and responsive system".
- "If health care is to serve the needs of patients, then their choices must play a significant role in shaping the way health care providers understand good-quality health care".
The pattern of servicing provided by that series of organisations is totally different. I picked up recently this attractive pamphlet from Specsavers—I go there quite often—stating,
- "unlimited choice for NHS customers for just a few pounds more".
In an article published in May 2001, Professor Timothy Congdon said:
- "A case could be made that the supply of health services under the NHS is the closest approach to the command economy found in a Western liberal economy".
Should we need encouragement to move in the direction of radicalism, it is worth looking at a weekly paper produced in Beijing, the Beijing Review. In the edition for 11th December 2000, the cover story is, "The Price of Health", and the lead line states:
- "No one wants to pay unreasonable costs and be poorly treated when seeing a doctor. The answer? Reform the hospital system".
- "There is no doubt that the reform of China's medical service system will break up monopolies, introduce competitive mechanisms, provide quality service at relatively low costs and curb irrational increases in medicine prices".
I do not necessarily commend the Chinese health service as a model—far from it. Nor even would I commend the market for ophthalmic care as a model in itself, although it should be studied very carefully. But we should be at least as ready to contemplate change and to discard ideology as are our friends in China. We should approach the subject with as much
thoughtfulness, as much breadth of vision and as much courage as the Chinese. We must begin to have the courage to discard ideas—not only those which are 50 years old but those which are even 10 years old. The Government's Bill now before us does not tackle the subject in anything like that way.5.1 p.m.
Lord Thomas of Gresford: My Lords, having heard the broadsides that have been fired from this side of the House towards the Government, and having listened to the noble and learned Lord, Lord Howe of Aberavon, describe the structures proposed as highly complex and confusing, I feel sorry for England.
My noble friend Lord Clement-Jones has gone before me in saying that I will bring good news from Wales. However, perhaps I may start with a quibble—that is, that in looking at the Bill I have to dot around from Clause 6 to Clause 9 to Clause 22 to find the provisions relating to Wales. As I have said on many previous occasions when dealing with other Bills, as we are not allowed to legislate with primary legislation in Wales, why cannot we have a part of the Bill specifically denoted as the "Welsh provisions"?
The Bill is decentralising. The provisions for Wales show the green light, to adopt the metaphor used by my noble friend Lord Clement-Jones. The benefits of devolution are to be seen in the way in which the matter has been discussed and debated by all sides in Wales. It is not surprising that I speak in support of the Liberal Democrat/Labour partnership government in Wales, but many more than ourselves have been consulted on the provisions.
In February last year the Assembly published a plan, Improving Health in Wales, which was followed in July by a consultation document, "Structural Change in the NHS in Wales". There was then a three-month period of consultation and 345 responses were received. As a result of that, the Minister in Wales, Jane Hutt, deleted several of her original proposals. She accepted criticisms from many professional bodies and, in particular, after negotiations with the partnership in the Assembly, she accepted the Liberal Democrat proposal that she should strengthen the Specialist Health Service Commission for Wales. Being a plain-speaking lawyer, as is the noble and learned Lord, Lord Howe, and never cloaking anything in arcane language, that produces a Welsh acronym to beat anything England can provide, which can be pronounced as "SHSCW". That beats CHI, NICE and so on. We prefer to call it "Iechyd Cymru", which means "Health Wales".
It is now accepted that the commission should be able to commission tertiary and acute specialist services on an all-Wales basis; that it should be on an arm's-length basis and not under the control of the NHS directorate; and that it should provide advice, guidance and co-ordination to the local health boards which are to take on a new responsibility and role in Wales.
Far from being complex, the structure in Wales is now simplified, decentralised and devolved. The National Assembly at the head will strengthen its
planning and strategic capacity for the discharge of its health responsibilities and will establish, as arms of the Assembly, three offices in north, mid-west and south Wales so that the functions of the Assembly will not all be Cardiff based.It is proposed to transform the local health groups which were set up as sub-committees of the area health authorities in 1999, to abolish the existing area health authorities and to create 22 local health boards, which will be coterminous with the local authority areas. The purpose of it all is to place real power in the hands of the general practitioners, the community nurses and the health workers, who, as my colleague in the Welsh Assembly, Peter Black, put it, know what people require. The people that patients see most will decide how NHS money is best spent. In Wales we will maintain the community health councils because we believe that they have a very positive role to perform.
So, instead of having a whole series of bodies, we will have the National Assembly at the top, the local health boards very close to the people, and an all-Wales commissioning body, which will be able to commission specialist services not only from Welsh hospitals but from English hospitals as well.
I look at a finger which was broken in the service of your Lordships' House when I was playing rugby football at Twickenham against the other place. That was dealt with at the Robert Jones and Agnes Hunt Memorial Hospital at Gobowen, which is in England, where I had the most excellent service. Those are the kind of cross-border services that we have in Wales.
In addition to that, because there will be 22 local boards coterminous with the 22 local authorities, Clause 22 of the Bill sets out provisions which require there to be a joint strategy by each local health board and each local authority to ensure the health and well-being of the public in their particular area.
Historically, major progress in improving health has been made through local government. Improvements in education, housing and social service provision have led to increases in health and in preventing illness—possibly having more impact than the National Health Service itself. The public health functions of the area health authorities are also to be separately organised on an all-Wales basis.
And so, with a simplified structure—but with the devolution of responsibility to the patient, to the GP and to the nursing services on a local basis—we are looking forward in Wales positively to the results of this legislation when it is carried through. It is perhaps unfortunate that the provisions relating to England fall so far short of what my noble friend Lord Clement-Jones would like.
In Wales, we are seeking to remove inequalities between the various areas. We do not have good health in Wales historically. I am sure that these provisions will help to improve it.
5.9 p.m.
Baroness Finlay of Llandaff: My Lords, I must declare a deeply personal interest as an NHS jobbing clinician in Wales who was on the wards this morning.
I also have interests in education at undergraduate and postgraduate level in medicine and as president of the Chartered Society of Physiotherapy. That is my background of interests.The Minister outlined the changes that have rightly been embraced by professionals to improve healthcare. No one would decry efforts at such improvement. The Kennedy report has been pivotal in bringing about much-needed change. My own University of Wales College of Medicine has already examined its undergraduate curriculum to make sure that we are consistent with the recommendations, but it will be years before those students graduate. The problem is that time is needed for change.
As the noble Lord, Lord Clement-Jones, rightly pointed out, the profession is exhausted. Professionals are exhausted by the deck chairs on the "Titanic" being moved round—as some have said to me—and by the sense that all the cards are up in the air and will land again. But where are the real resources to underpin the service?
The workforce is changing. More than 60 per cent of our graduates are women. That workforce needs to be accommodated if we are not to lose it. Staff retention is a major problem, yet crèche facilities, flexible working and improved working conditions, which will be crucial to maintaining the workforce, do not feature in any of the background descriptors to the legislation. We need skilled professionals to deliver clinical care. The patient needs to be seen by highly trained skilled professionals, however the management structures are arranged around them. If they are emotionally exhausted and worn out, they will not perform as well as if they know that they are supported in the structure in which they know their role. I fear that we have much to learn from Europe.
Voluntary care providers will welcome some of the measures in the Bill. I work as a voluntary provider for Marie Curie Cancer Care. There is a sense that adequate refunding for the core services that many voluntary sector providers now give to NHS patients is long overdue. At least 50:50 funding for core services must be a priority.
Reorganisation comes at a cost at management level as well. That cost is loss of corporate memory. When a health authority is dispersed, the corporate memory of that group is lost. The people know the areas of weakness and the areas to watch and monitor. There is a real fear that those areas of weakness, which cannot be written down and will not be handed on by word of mouth for fear of slandering one area of the healthcare profession or another, need to be monitored closely. Those healthcare bodies in the health authorities are currently getting their heads round doing some of that.
Health authorities in Wales currently undertake 369 statutory functions, but it is not clear which of those will be devolved to which bodies. I should like a list to clarify who will have responsibility for each of those functions. Cinderella services, such as child protection and learning disabilities, need to be co-ordinated across large areas for many reasons. There is a real fear
among those working in the Cinderella specialties that they may be squeezed out and forgotten in the re-jigging of commissioning.Public health has already been alluded to. It is very important in communicable disease control. Our recent legislation against terrorism showed that it is now also part of our national defence. It is unclear how it will have sufficient independent co-ordinated levers to bring about the important health improvements that we need to establish equity.
Equity in healthcare provision is a major challenge. The social problems of two adjacent areas in Wales, such as Blaenau Gwent and Monmouth, are very different. When illness or accidents strike, every person deserves early diagnosis and then treatment. There is concern that one group may view the commissioning of services in a different way from another group. Those secondary care services not often used by any individual local health board area but none the less crucial to the health and welfare of the whole area of south east Wales may not be adequately listened to and funded. Some 75 per cent of the budget is in the hands of primary care services, but I see no evidence that that will save money from secondary care. Early diagnosis is much needed and primary care standards need to be driven up, particularly—sadly—in some areas of Wales. We have some of the best and some of the worst of primary care.
Early diagnosis will put up healthcare costs. Let me give a simple clinical example. A person with cancer of the oesophagus who is diagnosed early will need complex and expensive investigations, probably chemotherapy, then surgery and intensive care post-operatively which will have to be done in a centre where enough such operations are carried out for all the staff to be highly skilled. That person may well also need radiotherapy followed by monitoring and further investigation. One hopes to have added years to life as well as life to years, although that person will almost inevitably still die of the original cancer of the oesophagus some time later.
The sad reality is that if the same patient received poor care at the outset, it is much cheaper. Once patients are diagnosed and the diagnosis is confirmed, they are past the point of any treatment and they go on to die. They consume hospice care services as well. The social cost has never been taken into account in any of the equations. Driving up standards in primary care and ensuring early diagnosis are crucial, but no one should think that money is to be saved on secondary care.
I have alluded to the critical mass of expertise that is needed. There is a tension between local delivery of services and having enough concentrated expertise in one place to develop the skills and support the high-tech equipment that is needed. The strategic overview in planning is crucial. Planning was lost from healthcare some time ago. Strategic overviews are welcome, but I remain uncertain as to how influential they will be in ensuring that we move forward with the best of science and that we underpin research to allow our medical science to move forward. The noble Lord,
Lord Thomas of Gresford, alluded to the strategic role in Wales. I sincerely hope that we manage better strategic planning than we have had in the past and that we beat England in our strategic planning.The noble Earl, Lord Howe, questioned the cost of reorganisation. Have the overt and hidden costs of the reorganisation been calculated and have the benefits that will directly accrue to patients also been quantified?
I am not against change—I have been a catalyst for change. However, I worry that experienced but exhausted and demoralised people in the workforce are being asked to learn new roles and to adjust very rapidly. They have been trying to drive up standards and monitor the standards and audit the care that they are giving. The monitoring of changes will be essential. Some of the widened responsibilities for the Commission for Health Improvement may be welcome. Perhaps this is an opportunity to bring together the National Care Standards Commission and the Commission for Health Improvement rather than planning it at some future date so that the amount of inspection that services are subjected to becomes more streamlined and the recommendations are clearer.
The noble Lord, Lord Turnberg, eloquently outlined the deep concerns about the council for the regulation of health care professionals. I shall not go over those concerns, but I fully endorse and appreciate the clarity with which he explained them to the House.
The monitoring and evaluation of the changes will be crucial. We are creating a natural experiment. There will be at least three—and probably four—different healthcare systems developing in England, Wales, Scotland and, subsequently, Northern Ireland. It is essential that information technology is agreed and data collection streamlined so that meaningful comparisons can be made. Sadly, we do not have meaningful baseline data. Currently, different trusts work with different IT systems, which are different from those used in primary care, while different primary care groups work differently from other primary groups, all using different coding systems—and all those differ from the voluntary sector. Lots of data are being collected, but meaningful, sophisticated comparisons cannot be made. We need a strategic overview of the type of sensitive meaningful data that we collect—not just simple activity data, which is what hits the headlines all the time. Activity data will never be met.
Finally, this Bill represents yet another reorganisation of the 1977 NHS Act, and it incorporates changes to the 1997, 1998, 1999, 2000 and 2001 Acts. To be able to read and understand this complex and fundamental reorganisation, I endorse the plea made by the noble Lord, Lord Thomas, that, given modern word-processing technology, we could have the whole aggregated legislation published in one volume for England and in another for Wales. It would mean that someone simple like me could pick up the document and read it in its entirety instead of trying to rummage through what must be a lawyers' tea party but what, for a clinician, I am afraid, is a nightmare.
5.20 p.m.
Baroness Pitkeathley: My Lords, there is no doubt that the Bill before us is most important—so important, in fact, that I certainly could not support the amendment of the noble Lord, Lord Clement-Jones, which seeks to delay its passage through this House. As other speakers have said, the Bill will bring about the most radical changes in the NHS since 1974. This is the main reason that I support it strongly. It puts patients more at the heart of the service than they have ever been before.
The NHS is a huge organisation, employing well over 1 million people and treating more than 20 million patients each year. I am one of the many to owe my life to it. As the Minister in another place said, it is inconceivable that the sort of care that we want to be available could be delivered by the structures that currently exist, given the pressure on services, the introduction of new technologies, and the speed at which things change in the delivery of medical services.
These then are the reasons why the changes are necessary, though I am only too well aware both from my experience as an NHS employee and as a patient that any proposed changes to the delivery of healthcare are always viewed with suspicion and anxiety. I am not a proponent of change for change's sake, but the changes that have gathered pace in recent years are so profound that we have no alternative but to change our structures to fit with that change. I shall give noble Lords one small example. Could we have imagined how new technology would offer such extraordinary opportunities in terms of information about patients and conditions, still less perhaps that many patients would become so well informed about their conditions and possible treatments via the Internet?
All your Lordships know that this Bill, like Gaul, is in three parts but I shall confine myself to commenting on those parts which affect patients most. I commend the Government for the changes they have been willing to make to this Bill as it passed through another place, and for the way in which Ministers have listened. As a result, the Bill now before us is improved.
Many of us have been saying for years—indeed, I have lost count of how many years I have been saying it—that the delivery of healthcare services should start as near as possible to the patient and his or her family. That means at the primary care level. Yet really, ever since it was set up, the way in which the NHS is funded has been geared to hospitals and to large health authority areas. Successive reorganisations, of which there have been many, have failed to address the issue. Finally, functions are to be devolved to primary care trusts, which will become responsible for all family health services, as well as for the management of, development of, and integration of family health services practitioners. I am certain that this means that the health needs of each local community will be more effectively assessed, and that plans for health improvement will be more rooted in the needs of that community.
I am also very hopeful that the PCTs, as the lead organisation in joint working with local authorities, will enable the communication between health and social care services, which is so vital to patient care, to be more effective. For most people, healthcare means the GP and all the services that are provided in the local surgery. So I believe that all these developments are very much to be welcomed.
I have only two areas of concern, both of which were mentioned previously. The first is the public health function of the PCTs, which I believe is still somewhat unclear at present. I should not want the great concern about public health issues with which this Government have so ably dealt, and which has been so influential in setting health targets in recent years, to be lost. I very much hope that my noble friend the Minister will be able to give us some indication of how the public health function of the PCTs will be organised and promoted. I also have a slight concern about the timetable. Spring 2003 is doubtless not a problem for those PCTs that are already well established. But some are not, especially perhaps those in deprived areas. Is my noble friend confident that the timetable is realistic for all the trusts?
I welcome the strengthening of the role of the Commission for Health Improvement, increasing its independence from government and extending its functions to allow it to carry out inspections of NHS bodies, service providers and persons who provide, or are to provide, healthcare. However, like many who work in the social care field—I declare an interest as the interim chair of the General Social Care Council—I was slightly alarmed by a recent reference by the Secretary of State for Health to integration of inspection bodies at a time when the national care standard commission has not even begun to operate. It would be confusing and unsettling for one system of inspecting social care to be established only to be immediately integrated with another. At the very least, we need an assurance that any review will be most carefully undertaken.
I turn to the arrangements for more patient involvement. I want to say again, as I have said in your Lordships' House previously, what huge strides I believe we have made in this area in recent years. My recent prolonged stay in hospital showed me how much progress has been made in involving and consulting patients to ensure their own needs are always seen as paramount and central. But I am aware that my own experience at the Middlesex Hospital may still not be the experience of many patients, and that is why I feel that more legislation to encourage patient involvement is most welcome.
As is well known, there has been much concern about the abolition of the community health councils. As someone who has kept in close touch with CHCs over many years, I share that concern—especially as I was very briefly a chief officer of one of them in the 1970s. There is no doubt that some CHCs have been very effective in representing patients' views but we must recognise that their contribution has been patchy; indeed, that cannot be denied. I am satisfied that the latest proposals really will put patients
absolutely central inside the NHS, strengthening the power of the patient and giving many more the opportunity to be involved.It is important to remember that the proposals before us in the Bill have not been just dreamt up: they are the result of extensive consultation with CHCs, many organisations in the voluntary sector, and patient organisations. That is clear in the welcome that they have received from all sides. They build on the excellent work that has been carried out over the years by CHCs and by other local and national organisations that put patients first.
I feel sure that the combination of patient forums, patient advocacy and liaison services, and the setting up of an independent body—the Commission for Patient and Public Involvement in Health—will provide patients with a system that is independent, accountable and robust. It is of course vital that membership of these new bodies is drawn from a truly representative group, so that current and future users of the service, especially those from disadvantaged communities, have more opportunity than ever before to influence policy. If we refer to "stakeholders"—a fashionable word, as we have heard many times today—of the NHS, it is important to remember that everyone is a stakeholder when it comes to healthcare. Co-operation and communication between the new organisations will also be vital for their success, as will the issue of resources. I am sure that we shall return to that issue many times during the passage of the Bill through your Lordships' House.
I know that there is concern in some medical circles, and elsewhere, about the powers of the council for the regulation of healthcare professionals that is to be established. But we must recognise that recent events, such as the Bristol inquiry and the Kennedy report, have pointed out weaknesses in regulatory structures. In all conscience, that must be addressed. I particularly welcome the lay majority proposed. I believe that the General Social Care Council, to which I referred earlier, is an example of how a lay majority can provide as much protection as possible for patients and users.
This Bill, with the dramatic changes contained within it, has huge implications for the delivery of healthcare. I am sure that it will command widespread support among the general public—a little more, perhaps, than it has commanded thus far in your Lordships' House today—and deservedly so.
5.29 p.m.
Baroness Cumberlege: My Lords, I chair the medical school council of St George's Hospital, and once a year I make a fairly feeble attempt to thank them for all that they do. Tonight is the night. So I am afraid that I shall not be able to stay, possibly not even to listen to the right reverend Prelate the Bishop of Birmingham and some other noble Lords. However, I shall read Hansard diligently. I shall also ensure that it is not such a good party that I do not come back for the wind-up; of course I would not want to miss that.
It is very tempting in any debate on the NHS to start with a catalogue of statistics. I think that the Minister fell into that trap today. I shall perhaps also fall into that trap. It is very easy to quote statistics—such as that the number of hospital beds has decreased by 6.4 per cent since 1996, the number of people waiting more than 13 weeks for an outpatient appointment has doubled since 1997, and so on—but I do not want to get into all that tonight. I do not want to get into the claims and the counterclaims. I just know that providing health care is so very, very complicated. I also know that too many patients receive too poor a service.
I also know that the vast majority of people working in the NHS do their very best, and that too often the system fails. It fails not because of lack of commitment on their part—your Lordships have only to visit a hospital to see how tired people look at the moment, or a GP surgery to feel the frustration among the primary care team—it fails because we the politicians are forever tinkering, meddling and reorganising them. Of course it is legitimate for us to do so. As the Minister reminded us today, we carry a responsibility for a tax-based service. However, if we really want a service that is fit for purpose, meets the needs of a now very sophisticated society and protects the sick, the weak and the poor, we have to stop meddling. Yet, we have to retain the accountability for public funds.
Politicians are elected to do things, and every Minister knows that a career is not built simply by sitting on one's hands. However, with the enormous complexity that is the NHS, Ministers so often resort—I am as guilty as any—to something that they think they understand: they shelter in the comfort zone of management structures. I think that this Bill is another example of that. Some cynics would say that we are seeking to reinvent regions as strategic health authorities, health authorities as primary care trusts, and so on. We are changing the language and changing the deckchairs, but that is about it.
I have no criticism of the noble Lord, Lord Hunt of Kings Heath, who has an enormous knowledge of the health service. However, I think that we have a corporate failure of the NHS, and that that failure starts at the top. I think it is the Chinese who say that, "the fish rots from the head". An organisation that is so complex, so difficult and that affects so many lives really cannot be managed by a nomadic population of politicians.
All our experience tells us that governments are hopeless managers. However, that does not mean that we need a health service that is run exclusively by private enterprise—I do not think that we do or that the nation would want that. I also do not think that such a health service would work. However, I have been thinking for some time about how we should distance the Government from daily management of the NHS and yet retain this accountability to Parliament. We need a body that is accountable to Parliament but independent. We have a number of good models along the lines of the Environment Agency and the Food Standards Agency, to give but two examples.
Thinking about all this, I was terribly relieved and actually greatly surprised that, last week, I was invited to the King's Fund to listen to them and hear that they had been working on very much the same lines. As my noble and learned friend Lord Howe of Aberavon said, the fund has published a report—chaired by the noble Lord, Lord Haskins, which is very interesting—entitled The Future of the NHS—a framework for debate. I do not, however, share my noble and learned friend's misgivings. I think that it is a very encouraging beginning.
I shall not go through it all today, particularly the summary of responsibilities which very clearly identifies the role of the Government, the new body—whose working title is the NHS corporation—Parliament and primary care organisations, but save that for our consideration in Committee. I should, however, inform your Lordships—this is a Cumberlege warning—that I intend to table a number of new clauses because I really want something like that to happen. I want it to become a reality.
I know, as the Minister will no doubt tell me, that I am being nai ve. However, I also know, when I knock on a thousand doors at election time, that nothing would please the British people more than to get the politics out of health. That is one thing that they are always saying. I do not think that this is a fanciful idea. There will be those who say that no political administration would want to give up its power, and yet we have seen the right honourable Gordon Brown, the Chancellor of the Exchequer, at a stroke take the power to increase and reduce interest rates out of the hands of the Treasury and the immediate administration and give it to the independent Bank of England. It is simply political will that is needed.
I should address the issue of funding now as parliamentary privilege will not, I believe, allow me to table that type of amendment to this Bill. Rather than a hypothecated tax or a percentage of taxes raised, I would like to see all-party agreement on the percentage of GDP to be allocated to health. I stress that the sum is to be spent on health and not solely on the NHS. My model would enable us to rein in during hard times and expand in good times. It would also be directly related to what the country could afford at the time. The percentage should be agreed for a period of about five years, to provide a measure of stability, and the aim would be to increase to the European norm or better.
It may be sad, but the public are infinitely more interested in the NHS than they are in the reform of your Lordships' House. Yet, for the Lords reforms, we are all seeking party consensus. We ought and we need to have all-party agreement on the NHS. Right now, I think that we have to admit defeat. I am so ashamed—I am humiliated—that we, a civilised country, can no longer look after our sick but export them to other nations to care for. It is a disgrace.
As for other aspects of the Bill, there are some contentious issues. However, as my time is short, I shall just make a passing reference to two of them and seek an assurance on the third.
The first issue concerns the abolition of CHCs. The Minister knows the arguments better than perhaps almost anyone. The real fear is that there will no longer be a truly independent body representing patients—a body with a modicum of power, a body to identify and challenge inadequacies. "Divide and rule" has been a very well known Machiavellian strategy for centuries, and with the proposed fragmentation of scrutiny, monitoring and complaints work between the overview and scrutiny committees, the independent complaints advocacy service, the patient advice and liaison service and the patients forum, I really fear that an already fairly muted voice will be further weakened. A good organisation uses criticism positively and to advantage. A weak organisation is defensive and tries to silence its critics.
The second aspect concerns the enormous disquiet about the Bill's proposals on the Medical Education Standards Board as well as the council for regulation of health care professionals. My noble and learned friend Lord Howe addressed that issue so well, and I strongly support his comments. I also share the reservations of the noble Lord, Lord Turnberg, who I know is a very much respected authority on this subject. I am also sure that the noble Lord, Lord Walton, will weigh in later in this debate and refer to the Academy of Medical Royal Colleges.
There is a huge amount of opposition to the measure, not least from the Council of Heads of Medical Schools. They believe that there should be a clear separation of powers between the Secretary of State's role in running the NHS—which, of course, I shall change in the course of the Bill—and a longer term role for Parliament. Parliament should ensure that standards are maintained at a professional level, insulated from day-to-day political issues. While collaboration between professions should be encouraged, the proposals go too far in weakening the role of the GMC in self-regulation. It is absolutely essential that the professions themselves should have confidence in their regulatory system; otherwise, it simply will not function and, I believe, patients will suffer.
Finally, I have given notice to the Minister that the Federation of Ophthalmic and Dispensing Opticians seeks an assurance that the constitution of local optical committees, when rewritten, will encompass all ophthalmic contractors, including those which are corporate contractors and those which are dispensing opticians, on the same lines as the current pharmaceutical committees. I should very much welcome an assurance on that as I know that that will save time later—time which I shall take when I bring forward a legion of clauses.
The Minister in opening the debate said that he felt the NHS needed reform and a new relationship with government. I totally agree and I very much look forward to his close co-operation and agreement to my amendments which will, of course, do just that.
5.41 p.m.
The Lord Bishop of Birmingham: My Lords, I must begin by declaring my interests in two senses of the word. I am a non-executive director of the University Hospital Birmingham NHS Trust. Also, two of my three children work for the National Health Service.
Reading large parts of the Bill gives one a rather strange sense of time. Are we in the present or are we in the past? As regards the mandatory establishment of primary care trusts and the creation of strategic health authorities, surely all of that is already under way. Chairmen and chief executive officers are already being appointed to run the new apparatus. Time alone will tell what difference these changes make to the delivery of healthcare. But two things are certain. The first is the immense human cost of yet another reorganisation. The second is that no structures are ever perfect but we have to make them work. I am reminded of an observation once made by a friend of mine who has given many years of distinguished public service, "There's nothing so daft you can't make it work".
So my plea above all to the Government is this: once this reorganisation is in place, please leave it alone and let people get on with their work. That means, for us, passing at least those parts of the Bill concerned with the establishment of primary care trusts and the strategic health authorities—even if for some noble Lords that may mean holding their noses a little—because not to do so at this stage would cause still more personal distress and upheaval.
Nevertheless, I register a couple of anxieties and only time will show whether or not they are justified. First, are there enough competent managers as well as non-executives of sufficient ability to run all these PCTs? If not, we may be in deep trouble. Secondly, is it wise—this is reinforced in my mind after what we have heard about Wales—to have shown so little regard for the structures of local and regional government in fixing the boundaries of the new layers of administration?
Birmingham, as the Minister well knows, used to have five and then four health authorities. That multiplicity, together with a plethora of competing institutions and special interests, made it impossible for years to effect any rational reorganisation. Then, eight or nine years ago, the four health authorities were merged into one for the whole city. It was that catalyst—one health authority for the whole city—which provided a structure in which it was possible to address the health needs of the city as a whole and to make progress. The noble Lord played a vital and distinguished part in that process, as he well knows. Yet now Birmingham is going back to four PCTs, together with a strategic health authority—it is not a case of renaming the old health authority; that is a fib in the first clause of the Bill—for the whole of Birmingham, Solihull and the Black Country. That is a rather more far-reaching operation than merely changing the name of the old health authority. But one also notices ruefully that the four embryonic PCTs are already setting up joint organs of consultation in order
to deal with the city and the local authority as a whole. Does this mean that, willy-nilly, we shall now have three layers instead of two simply to make the show work?I shall not say anything about the healthcare professions as that is not my field, but I should like to turn to what is termed "patient and public involvement in health". That very formulation raises a question: who are the patients if they are not the public? For the purposes of representation, what qualifies someone to count as a patient over and above having their name on the electoral roll? The key issue in securing effective patient and public involvement is plain: how do we secure the necessary combination of competence and representativeness? Once again, the familiar debate between nomination and representation raises its head.
If one goes for nomination as the Bill suggests, one is more likely to secure the desirable range and level of competence but at the expense of the appearance of democratic legitimacy. If, on the other hand, one goes for election in the name of independence and democracy, one may end up with an ill-assorted, politically motivated and, in effect, self-selected body which will not do very much either for patients or for the service. I understand why the Government appear to have chosen the path of appointment, but it would be good to hear a great deal more about the details. There are far too many instances of the Secretary of State making regulations. The details are important because the process by which people are appointed to such bodies as patients forums will be crucial to their public credibility. It is vital for the health of the service that the public as a whole should have a robust, informed and effective voice in the structures of the NHS.
The old community health councils, for all sorts of reasons, have not always been universally effective or, indeed, truly representative, as the noble Lord and I know. I say that without in any way wanting to denigrate the conscientious work of very many members and officers of CHCs. If CHCs are to go, we need something evidently better—competent, independent and also properly resourced. Again, the question arises: where are all these competent and independent people? In looking for the members of a patients forum, as for non-executives of PCTs, we are fishing in the same pool as those who find themselves looking for school governors and magistrates, to give two obvious examples. Even now, such people are not easily found, particularly in our inner cities, in sufficient numbers. If the Government's measures succeed in developing really effective and publicly credible vehicles for public and patient involvement, that will be excellent. I only raise a few questions in that context.
5.50 p.m.
Baroness Gibson of Market Rasen: My Lords, I personally welcome many of the proposals contained in the Bill, especially those relating to the streamlining of NHS and other agencies so that they can better work together in future, and the emphasis on local
involvement. I also welcome the strengthening of the health inspectorate under CHI. Inspection is a form of monitoring, and monitoring, followed by effective action where necessary, is vital to put into effect key parts of the Bill. Without monitoring, it is impossible to charter improvements or what is needed for further action.I turn to two areas in which I have particular interest. The first involves the NHS and the Prison Service. The provisions in the Bill for joint working between the NHS and the Prison Service have not been mentioned. Noble Lords may wonder why I am particularly interested in that reform. My husband was for 10 years the chair of the Prison Officers' Association and I used to hear at first hand the difficulties that arose between the NHS and the Prison Service over the health and welfare of prisoners. In 1999, the Government set out their views on closer working relationships between the two bodies in the report entitled, The Future Organisation of Prison Health Care. The Bill puts flesh on the bones of the report's proposals.
It is often said that a nation can be judged by the way in which it treats its prisoners. I am sure that we all agree that those who have broken the law should be punished. The punishment is in the deprivation of liberty. After that, prisoners must be shown humanity and care. The Bill will remove existing barriers and allow the NHS and the Prison Service to agree between them which of the two agencies is better placed to carry out functions that are agreed on and how the joint resources of the two agencies should be deployed. It will also allow the overlap of responsibilities that have previously existed to be avoided.
It is obviously common sense to have a pooling of resources in that area. That will allow more flexibility—particularly financial flexibility. It is also common sense for two agencies to delegate functions to one another and to agree between themselves. That move is particularly important and long overdue in relation to prisoners who require certain health services, and who may in the past have found themselves trapped between two organisations with differing views on and differing perceptions of the way in which to provide the needed service. Above all, the emphasis on responding to local needs rather than having an overall response throughout the country is greatly to be welcomed. Prisons differ from place to place and prisoners differ from prison to prison. It is therefore right that health needs should be tailored to the prisoners in any particular prison; only local knowledge can provide and access the help that is needed.
Secondly, I, too, turn to CHCs. I last discussed that subject during the passage of the Health and Social Care Act 2001. I voiced my fears then about their abolition and that of patients councils. The union for whom I worked, MSF—now Amicus—has members who worked in CHCs. The debate on their future has gone on for a long time. It is hard to give of your best when the sword of Damocles is hanging over your head. CHC workers still have great anxiety about their future and need decisions to be taken once and for all.
It appears from the Bill that the Government are determined to abolish CHCs. I am personally sorry about that. If that is the case, we need answers to the questions that were raised in previous debates. One question was about the continued involvement of patients in the NHS in CHCs. I have noted the references to patients forums. Members of the local community will bring local knowledge and views to the forums; if that is done, it can only be helpful. That appears to answer that point.
However, many questions remain. What will happen to those people who currently work in CHCs? Will they be absorbed into the new structures? Is that a growth area, and is there potential for them to extend their expertise and apply their particular skills and knowledge? If so, will there be adequate training and re-training for them, as well as support services, when needed? What will be the salary levels for those workers, in comparison with their present pay? Very importantly, is the timing right? Will the CHCs be phased out at the same time as the new organisations are being established, and so allow any employee movement to take effect without a period of unemployment and ensure continuity of involvement of patients and public? Finally, will there be representation from a variety of public groups that are involved in the new arrangements?
Those are vital questions, which need to be answered, particularly for the employees involved, who face a very traumatic time. I know that I am not the only Peer who is anxious about those questions; indeed, they have already been raised today. In the other place, 26 Labour Members rebelled and called for the re-creation of patients councils, which would in turn oversee patients forums. I am not taking that line because it would overload the system and create one too many layers of involvement. However, anxieties that are expressed need to be taken seriously.
I should welcome reassurances from my noble friend on the points that I have raised. I also want an assurance that the proposals in the Bill for patient and public involvement are on a par with and as robust as the previous arrangements involving CHCs.
There will be a great deal of debate and detailed discussion on this Bill as it goes through this House, and I look forward to taking part in that. The Bill can pave the way for a reformed and revitalised NHS.
5.57 p.m.
Lord Freeman: My Lords, it is a pleasure to follow the noble Baroness, Lady Gibson of Market Rasen. Although she and I are very often on different sides of an argument, I find myself largely in agreement with her second point, which she made so forcefully. I shall confine my remarks to my concerns about the abolition of community health councils.
Although the noble Lord, Lord Clement-Jones, is not in his place, I am sure that the Liberal Democrat Front Bench will convey to him at least my congratulations on his ingenuity in moving a reasoned amendment to the Motion that the Bill be now read a second time. I have suddenly realised that the noble
Lord has secured the unique achievement—this is very much in his favour—of being able to speak twice and also of having the last word. I admire his technique and I very much agree with a good deal of what he said about CHCs.My noble friend Lord Howe made, from the Front Bench, a very powerful speech and correctly pointed out that the status quo for CHCs was not an option. That must be right. I agree with the noble Baroness, Lady Pitkeathley, who is temporarily not in her place. In another powerful contribution, she—and the right reverend Prelate the Bishop of Birmingham—correctly pointed out that the performance of CHCs has been patchy. No one disagrees with that.
I turn to the comments made in another place by the Parliamentary Under-Secretary of State for Health, Hazel Blears, which appear in the Official Report, but which I shall not quote. She is my predecessor bar 12 years in the Department of Health. She said that her vision for the reform of the community health councils would be to introduce a more effective, independent and integrated system. In my brief contribution, I shall use those three tests to analyse what the Government propose.
First, are the patients forums likely to be more effective than the community health councils? I acknowledge from the outset that many patient provisions—services provided by the community health councils—have not been as effective in some parts of the country as they have been in others. From my own experience as a constituency MP, the Northamptonshire North Community Health Council has been effective. Not only has it been a thorn in the flesh of health Ministers from Northamptonshire, such as myself; it has kept local Members of Parliament up to scratch. I pay tribute to what that CHC has achieved. There are only two CHCs in the county of Northamptonshire. If we moved to the reforms that the Minister outlined when he introduced the Bill, we would have seven patients forums in Northamptonshire. Therefore, we would move from two bodies to seven.
Here I pick up a point made forcefully and correctly by the right reverend Prelate the Bishop of Birmingham. He pointed out that it is very difficult to get high quality volunteers to serve on such bodies as the proposed patients forums. Northamptonshire would move from having 24 representatives of the voluntary organisations and independents—I do not refer to those from local government—to, if we assume that we are talking about 12 per forum, a requirement for 84 recruits—that is, volunteers or independent members of the community—to serve on the forums. I say to the Minister that it will be very difficult to find that number of people of sufficient quality and with sufficient interest.
One deficiency of the community health council system to which the Minister referred—I believe that he is right in this regard—is that the CHCs are unable to bring together their concerns in a single national voice. Their views are far too disparate, local and of uneven quality to affect decisions by the Department
of Health. I welcome the initiative of the commission or some other central body to gather together the views of local—as I would wish them to be—community health councils.Secondly, do the reforms pass the test of being independent? Together with a number of other noble Lords, I do not believe that that test is passed. The patients forums will have no staff; they will have to rely on the local offices of the commission for patient and public involvement in health to staff their deliberations; the chairman of the commission is to be appointed by the Secretary of State, as my noble friend Lord Howe indicated, so that, to some extent, they will be a creature of the Department of Health; and it is said that the commission will operate right down to local patient forum level.
It is a top-down initiative or reform; it is not community led. It will require a number of appointees to be found by local commission staff. As my noble and learned friend Lord Howe of Aberavon said—he is greatly familiar with the history of community health councils—it will be difficult to argue that the local patients forums are genuinely independent and stem from the community if the commission has encouraged their growth and largely found and promoted the individual members in the first place.
The final test is whether this initiative—that is, the new patients forums—can be regarded as being integrated. Clearly it does not pass that test because the individual citizen and patient will have to express his or her concerns about the health service through different patients forums: one for the ambulance service; one for the healthcare service, which deals, for example, with mental health provision in the community; one for hospital services; and, of course, one for primary care services. Therefore, it is not joined-up government; it will be confusing for the local citizen and patient.
As the noble Lord, Lord Clement-Jones—he is now in his seat; in his absence I paid him a compliment about his parliamentary techniques—rightly indicated, we have not only patients forums but the patient advice and liaison service, the independent complaints and advocacy service, and, of course the overview and scrutiny committee of local government. If we pass this Bill, we shall shatter the community health councils for ever and lose that integrated service.
Mr David Hinchliffe, the chairman of the Health Select Committee, introduced an amendment to the Bill in the other place. As the noble Baroness, Lady Gibson, mentioned a moment ago, 26 Labour dissident Members of Parliament voted for his amendment. I believe that the amendment was reasoned and sensible, and I do not consider that one can argue that Clause 15(4) will work. That provision requires the forums to work together. It is not an adequate substitute for retaining the community health councils, reformed as they may be. Therefore, I look forward to the noble Lord, Lord Clement-Jones, and, indeed, the Cross-Benchers, together with, I hope, some dissident Members of your Lordships'
House on the government Benches, supporting the necessary amendments to the Bill when we reach later stages.6.6 p.m.
Lord Walton of Detchant: My Lords, we were, of course, forewarned. When I picked up the Bill I could not suppress an audible groan at seeing yet another reorganisation of the NHS. It is almost 57 years since I graduated in medicine. Of those years, I spent 43, happily and enthusiastically, in the National Health Service in clinical practice, in medicine and, later, in neurology as a trainee, a consultant and, subsequently, as a clinical academic. That continued until, in 1992, I was precluded from further clinical practice in the NHS on the grounds of age.
During my professional career, at a rough count I have seen 17 reorganisations—some major, some minor, some good and some disastrous for the NHS—being imposed on an increasingly disenchanted and now desperately embattled group of healthcare professionals.
In the debate which I was privileged to open in your Lordships' House on 21st November on the subject of education and training in the NHS, I pointed to the fact that, with an ageing population and very important and effective new drugs and new technology, public expectation and demand has escalated very properly. But it has done so in the face of a growing shortage of acute beds and the closure of community hospitals, such as that in Burford, which in the past have made an invaluable contribution to the so-called "bed-blocking" phenomenon.
But, above all, there is still a desperate shortage of doctors, nurses and healthcare professionals at all levels. That is a song which I have sung to governments of every political complexion for over 30 years. We have half as many GPs and half as many consultants in every specialty, not least in my own specialty of neurology, as highlighted yesterday in the correspondence columns of The Times, as the country needs to fulfil and provide a fully effective health service.
Despite those factors, the vast majority of doctors, nurses and others are giving expert, dedicated care, sometimes under intolerable conditions. The Prime Minister's tribute to public service workers in Newcastle on Saturday last was most welcome. I also pay tribute to this Government for their wish to increase substantially funding of the NHS, although it will take time to work through the system. I also pay tribute to the collaboration and willingness to listen of the Minister and his predecessor, the noble Baroness, Lady Hayman, not least in the debates during the passage of the Health Act 1999, which resulted in substantial modification in this House.
How I wish I could be equally complimentary about the Bill. If enacted as it stands, it will impose another period of turmoil on an NHS in despair. A new administrative load will divert many clinicians from time available for clinical care and new massive pressures on managers at all levels will be equally a
problem. In my view the Government are suffering from an acute attack of "quangoitis" and is determined to convert the NHS into a "quangocracy".Clinical judgment is not an exact science. Even in the best and most experienced hands, during long hours of work and under relentless pressure, some mistakes are inevitable; happily they are remarkably few. But every medical slip-up that comes to public notice is splashed across the media in an orgy of doctor-bashing and NHS-bashing. So-called scandals are regularly manufactured. Many, like the North Staffordshire paediatric problem, which led to the unjustified two-year suspension of a capable and dedicated professor—now reinstated with his reputation intact—have proved to be totally spurious. Even Government Ministers and shadow Ministers are not immune from instant but often unsubstantiated and misconceived comments.
Cases like that highlighted in the Bristol heart inquiry; the appalling behaviour of Dr Shipman; the problems of Rodney Ledward and others did—very reasonably—dent public confidence in the medical profession. Yet public opinion polls continue to show that satisfaction with the performance of doctors and nurses remains top of the list. Public satisfaction with the present NHS, beset by declining morale and a rash of early retirements does not. I say in passing that following Alderhay, 10 per cent of consultant pathologist posts in the NHS are now vacant with no applicants.
Will the Bill do anything to improve patient care and the delivery of health services across the board? Will it improve morale, recruitment and retention of NHS staff? In my view the reverse is likely to be the case. I welcome the proposal to devolve funding to a more local level. However, like the noble Lord, Lord Turnberg, I am concerned that this massive diversion of resources to primary care groups, though welcome in itself, may have an adverse effect upon the funding of tertiary and highly-specialised services such as cardio-thoracic surgery, neurosurgery and many more. Perhaps the strategic health authorities will be able to deal with that problem if implemented.
The press comment on foundation hospitals did not seem to me to be encouraging. Why is there no mention in the Bill of teaching and research, which are so fundamental a part of the National Health Service? The teaching of our medical students, the education and postgraduate training of our doctors and nurses and others is of fundamental importance and is not even mentioned. Have the Government lost their heaven-sent opportunity to establish jointly-based hospitals which are jointly managed by the NHS, the universities and their medical schools as recommended some time ago by the House of Lords Select Committee on Science and Technology.
Clauses on CHI are perhaps acceptable; at least most of them are. But CHI surely must be merged in time with the National Care Standards Commission to create one quango out of two. Why not reform the community health councils? Why replace them with poorly-defined patients fora—I may be a dinosaur but
I refuse to say "forums"—and a new overarching commission? I am reminded so much of the Government's decision to abolish the Health Education Council, to replace it with a Health Education Authority and then to abolish that and to replace it with yet a third body. A rose by any other name would smell as sweet.My major strictures on the Bill, however, relate to the council for the regulation of the health professionals. I regard that proposal as being wholly inappropriate, dangerously misconceived and potentially damaging. Some years ago the highly respected late Lord Hailsham wrote a paper called, How to Destroy the Professions. He said that professional self-regulation was one of the glories of a civilised society but it must not be done without full and capable lay participation—I wholly agree—and it must not be a cover for incompetence or inefficiency. In his Jephcott lecture to the Royal Society of Medicine, the then Sir Ralf Dahrendorf, now the noble Lord, Lord Dahrendorf, said that professional self-regulation was crucial. In his view, the alternative of regulation by the state was fearful and to be condemned. He spoke with great authority, having formerly been a German citizen, where he saw the malign effect of state control of medical registration and medical education.
The constitution and powers of the General Medical Council, General Dental Council and the other regulatory authorities are being well revised following the Health Act 1999. They all have a substantial lay involvement representing the patients' voice, which is an important matter, as highlighted by the noble Baroness, Lady Pitkeathley. But now, to impose upon those bodies yet another overarching government quango answerable directly to the Secretary of State in my view is a serious mistake. It is reminiscent of the McKinsey-designed reform of the NHS of 1974, where we had regional health authorities, area health authorities and district health authorities. Consensus management was introduced, so that if one wanted to appoint a new registrar that had to go through 15 committees at local and national level so that the decision-making process congealed.
If the Government force through the proposal concerning the council for the health care professions—I fervently hope that they will think better of it—the reserve powers of the Secretary of State—I almost said Big Brother, with shades of Nineteen Eighty-Four—are totally unacceptable and must be deleted. The regulatory authorities must be independent of political interference, answerable only to Parliament and through the Privy Council.
While I am on my feet perhaps I may refer to the proposed medical education standards board. A document is now out for consultation. In my view, that is another irrational and unprecedented attack on the independence of the medical profession and on medical educators. I shall keep my powder dry until that is translated into legislation. However, it is extraordinary that an official Department of Health consultative document seems so ignorant of the
provisions of the Medical Act. It is not the General Medical Council which is responsible for medical education. It is in the Act that it is the education committee, broadly based with powerful lay representation, which is responsible. It is not solely responsible for undergraduate education. The words of the Medical Act—which I know well—state that that education committee has the responsibility not only for promoting high standards of medical education but for co-ordinating all stages of medical education, including, it follows, postgraduate education.Having admired, as I have, many of the things that this Government have done and are now trying to do to improve the NHS, I wish that I could endorse the Bill. I congratulate the Minister on his brave attempt in his opening remarks to defend the indefensible. These are strong words. I know that it pains me to say them, not least because of the high regard I have for the noble Lord. However, I ask the Government to consign many parts of the Bill to the dustbin, where they belong. For pity's sake, will the Government stop tinkering with the NHS? Will they get on with increasing resources; increasing the number of acute hospital beds and long-stay beds in the community, and increasing the establishment of medical and nursing staff while allowing them to fulfil the responsibilities for which they have been trained; that is, to serve patients and the community?
6.20 p.m.
Baroness McFarlane of Llandaff: My Lords, I must begin by apologising to the Minister and to the House. I have a long-standing engagement in Manchester tomorrow morning and I shall almost certainly have to leave before the end of this debate.
Many noble Lords, when reciting interests in the Bill, have taken the opportunity to rehearse their glorious youth. I want to add my interests to theirs. I have worked within or alongside the health service for the whole of my professional life. That dates from before the inception of the National Health Service. I well remember standing as a student nurse on the appointed day wondering whether the end of the world was about to descend on us. We should all celebrate the great achievements of our National Health Service; yet changes are necessary.
I look back also on my experience serving on an area health authority, from which I resigned in order to serve on the Royal Commission on the National Health Service. That was set up by the noble Baroness, Lady Castle of Blackburn, and was under the chairmanship of Sir Alec Merrison. We laboured for three years looking at the structure of the National Health Service and at every level of worker in it. We travelled and looked at health services in other countries. After three years we reported and suggested that there should be structural changes. Unfortunately, none of those took place because the government changed shortly after the report was completed.
So far as concerns professional regulation, I was the first nurse chairman of the Joint Board of Clinical Nursing Studies which was responsible for the clinical post-basic education of nursing. I say the "first nurse chairman" because before that it was unthinkable that a nurse could chair something to do with clinical nursing; it had to be a doctor. So progress in the regulation of the professions was being made.
The work of the joint board was later subsumed under the work of the English National Board. I was appointed as its first chairman and so was ex officio a member of the UKCC for nursing, midwifery and health visiting. So it is with that background of a long-lasting and deep interest, both in the structure of the health service and in professional regulation, that I come to this debate. At this point, much of what I wanted to say has already been said. I do not want to reiterate those matters, but perhaps to underline a few issues and some of my areas of concern.
I begin by saying that I give full support to the proposals to widen the remit of the Commission for Health Improvement and particularly the emphasis laid on incorporating the patient environment into the definition of the quality of care. I served on the Sub-Committee of the Select Committee on Science and Technology which dealt with resistance to antimicrobial agents. We received vivid evidence of the lack of hygiene in the patient environment. Looking back on a long professional career, I wonder why we need this role institutionalised because, in my early days, the patient environment, cleanliness and hygiene were readily accepted as being the responsibility of every professional worker in the health service. But I am glad to see that this is now to be included in the remit of the Commission for Health Improvement.
When we look at the many facets of inspection and audit—it may be by CHI, clinical audit and the office for information on healthcare—these are only the beginning of the many systems that we have heard enumerated earlier in the debate. While we recognise the need for these systems of quality control for clinical care and education, they place a considerable burden of time and paperwork on those involved. Some of these strategies only add to the burden carried by professional people in the health service. We should make every effort to synchronise inspections for different purposes and to rationalise the record keeping as they detract from the time available for direct clinical care of patients.
I suppose that it is under the aegis of the regulation of healthcare professions that I have had the greatest number of representations. I believe that the establishment of the council for the regulation of health care professionals—I note what the noble Lord, Lord Walton, has said—has been accepted by most of the statutory bodies. None of the professions would argue against the continuing need for a robust and accountable regulatory framework for the protection of the public and for public satisfaction.
The noble Lord, Lord Walton, and I had the privilege of working with the General Dental Council on its revision of its structure and functions. Most of
the statutory bodies have made great strides in that direction. But the proposals in the Bill for the council for the regulation of health care professions are of concern because they place excessive power in the hands of the Secretary of State. They move the locus of accountability away from Parliament and the Privy Council towards the Secretary of State. If the Bill is passed in its present form, the council will be given power to direct the existing regulatory bodies to change their rules. These may be important rules. For example, there will be a requirement for the General Medical Council to co-operate with the council. We can only hazard a guess as to what "co-operate" may mean.The Kennedy report recommended an overarching body to look at standards of postgraduate medical education, which the noble Lord, Lord Walton, has already mentioned. Kennedy suggested that the body should be answerable to the General Medical Council. But the consultative document Postgraduate Medical Education and Training suggested that a Medical Education Standards Board should sit alongside the General Medical Council and overlap it in its responsibilities for monitoring standards in postgraduate medical education. Certainly the Council of Heads of Medical Schools, with its colleagues in dental and nursing schools, found that regrettable. They also find it remarkable that nowhere mentioned in the document is the role of universities.
It is right and proper that the department should have a real interest in the training of health care professionals for specific tasks and roles. But to make that a narrow kind of training is wholly unenlightened. We need to bear in mind that education for professionals should have a far broader perspective. We need to have a broad knowledge base for processional practice with up-to-date research. We need to train the students of our professions to learn how to learn, so that they can be both innovative and adaptable.
I look forward to future stages of the Bill and the ability to debate the amendments.
6.30 p.m.
Baroness Hanham: My Lords, my interest in the Bill stems from two sources: first as chairman of an acute NHS trust; secondly as a member of my local authority.
As has been said throughout the debate, structural changes are no stranger to the health service. Their rationale can be justified only if they bring benefit and improvement in their wake. Various governments have found deficiencies in all the structures created since Aneurin Bevan's initial concept. As a result, reform of both strategic and local organisations has taken place on what I think all your Lordships would agree has been too frequent a basis. In my time, I have been a member of an area health authority, a district health authority and a regional health authority. I do not take it terribly personally that all of them have been disbanded—perhaps as a result, perhaps not.
As the noble Earl, Lord Howe, said, the latest initiatives are once again seismic. They will take time to settle down and will last for only as long as they can be seen to deal with the practical aspects of the healthcare service that confront us today, many of the solutions to which are substantial and long-term but are set against the background of immediate, short-term governmental imperatives.
As the noble Baroness, Lady McFarlane of Llandaff, said better than I, much has been made of the inspectorate regime. The strengthening of the CHI is relatively uncontroversial. As the chairman of a trust that has been through a CHI inspection, I would say only that on the whole we found it helpful and constructive. That would be fine if CHI were the only inspectorate, but an inordinate amount of senior officers' time is spent providing material and support to various organisations that keep on popping up. Yesterday, I found another one, which turned out to be the winter emergency service taskforce. We are delighted when someone comes to look at A & E to see what is the problem about emergencies. But that ties up senior officers for another full day dealing with what has to be done.
So somewhere along the line—I hope, in the Bill; but, if not after—serious consideration must be given to the number of inspectorates and helpful people who keep arriving and who need enormous support, which is diverted from elsewhere. Much is said about the amount of administration in the health service. I can assure your Lordships that in acute trusts it is limited—and, at middle-management level, non-existent. The Government must consider what is to be done about all the inspectorate regimes and other helpful bodies that keep on appearing.
It is not too fine a point to say that the acute sector is currently strained to the limits to deliver a humane, efficient and successful service. It cannot operate alone, and there is an urgent need for a much closer relationship between it, the primary care service and social services—which the Bill is intended to provide. Protocols need to be developed to ensure that while patients can always be referred to hospital, GPs can—and do—carry out many more procedures and care at primary care level. Patients should be cared for either in their own homes or in facilities which are near to them—or, at least, to their family and friends.
That is becoming more difficult. In the borough in which I live and which I represent, during the past six months we have lost two major homes for elderly care. About 200 beds have gone. People lived locally and felt comfortable about going somewhere close to their family in an area that they knew. Some of them are now in Lambeth, I believe. Such facilities cannot easily be replicated, however much money the Minister provides. That serious problem must be considered.
Those who need specialised care, diagnosis and planning of treatment will need the acute sector. Its facilities should allow for a rapid turnaround and an expectation that, except for the most acutely and seriously ill, the stay in hospital is of the shortest
duration necessary to ensure that care and future management is sorted out—in other words, that a larger share of the burden of care is shouldered by those in the primary care sector. The tertiary care problem has already been mentioned, with which acute trusts will always be dealing—willingly.The new structures are predicated on that, but power is money and the great test of their success will be how the new PCTs allocate the resources passed to them and what safety nets the Government will maintain financially to support the many initiatives they have set up against challenging targets. Strategic health authorities have not been given a reserve role in that respect, as no funds for that are being allocated to them. They will have to be arbiters and adjudicators on finance without any levers to ensure that equity between the primary and acute sectors is achieved.
Funding has been agreed for this year with current health authorities, but with the new PCTs only in embryonic form there is great concern that the policies and cross-trust financial arrangements for the following year will be hard to implement sufficiently early. Trusts will need to work with their colleagues in both the acute and community sectors to develop future ways of working. In the short term, we may need stability funding. I wonder what consideration the Minister has given to that.
Every acute trust is labouring against the problem of more patients with greater expectations being treated against the background of some challenging government-set targets. It is what I call the squidgy jelly syndrome. I am sure that your Lordships all remember squidgy jelly: when one puts one's hand here, it pops up there. Where waiting time targets or emergency admissions, for example, are achieved, some other target is almost inevitably jeopardised. If elective surgery times are achieved, there is a back-up in emergency admissions. If bed discharges cannot take place sufficiently quickly, other admissions cannot be implemented. Every day in the acute sector is one to be juggled for the best results that can be obtained. That puts the most enormous pressure on the system.
I want to emphasise that there is no shortage of enthusiasm and no lack of commitment or deficiency in practical application of solutions. Forward, backward and lateral thinking occurs all the time, but it will take all the effort of the acute, primary and local authority sectors working together to have even a chance of achieving the results on which the Bill is predicated.
The Bill also implements proposals in the Health and Social Care Act 2001 for patients forums. During the passage of that Act, as the Minister may well remember, there was considerable discussion about how the members of those forums would be selected, especially as one of their number will be elected to serve on the related trust board.
As a result of concern expressed on several fronts, I believe that members will now be appointed by the regional commission. That means that they will pass through the procedures to which representatives on
health bodies are normally subject. But, as the right reverend prelate the Bishop of Birmingham pointed out, there will be an enormous number of them. When the Minister replies to the debate, perhaps he will confirm that that will be the procedure and that the regional commission will be involved.That may resolve one of the questions that caused concern about the representative to be elected to the trust board. The appointment could be seen to equate to that of the other members of the board. However, I have not yet heard addressed the further question of whether that patients forum representative is to replace, or be in addition to, an existing board member, or what guidance is being issued about that member assuming the corporate responsibilities of the board, while having a specific patient focus. It is an important matter, as the patients forums are to have the right of inspection of any aspect of the trusts, including primary care trusts, and to refer any matters of concern to the local authority overview and scrutiny committee, thus extending the remit of that body.
I am anxious that, from the outset, the roles and responsibilities of the patients forum board members be spelt out and that there be no confusion or conflict of interest. They will need to be trusted by their board colleagues, executive and non-executive, and it may be that the Minister will think it appropriate to exclude the patients forum board members from taking part in inspections in their own trust, although they will clearly be expected to involve themselves in the other work of the forum and to know and understand the trust on which they serve.
I apologise for going on about this, but, as the chairman of an acute trust, I am acutely aware of the potential conflicts that can arise for the patients forum board director. Their roles and responsibilities must be resolved. We must know when they are working for the patients forum and when they are working for the board. The board must be clear that confidentiality concerning that patients forum board member applies to the trust board, if that is required. The mix of roles and responsibilities must be resolved at this stage.
6.42 p.m.
Lord Prys-Davies: My Lords, as I read the Bill, I asked myself what changes were emerging. It seemed to me that, as regards the point at which healthcare is received—the surgery, the clinic, the outpatients department or the ward—the answer was none, or very few, at least in the short term. The essence of the relationship between patient, doctor, clinician and nurse will remain undisturbed.
On the other hand, there will be substantial changes in the administrative structure of the NHS. The hope must be that those administrative changes will make it easier for GPs, clinicians and nurses to improve the standard of care for patients and ensure continuity of care. However, I tend to be cautious. The NHS has been subjected to so many administrative changes during the past 30 years.
I am bound to endorse almost every word uttered by the noble Lord, Lord Thomas of Gresford, relating to the impact of the Bill on the NHS in Wales. The
distinctive Welsh provisions of the Bill are greatly welcomed in Wales. The National Assembly for Wales is anxious that its part of the Bill should be enacted with the minimum of delay. The noble Lord, Lord Thomas of Gresford, has explained the impact of Clause 6. In conjunction with the Government of Wales Act 1998, the Assembly will introduce secondary legislation to abolish the five existing area health authorities and devolve their functions and powers to 22 local authorities, coterminous with the 22 unitary authorities. That arrangement is, obviously, different from that proposed for England, but it is consistent with the great stress placed in the devolution debate on bringing government closer to people.At a meeting with several Welsh Peers last Monday, Jane Hutt, the Welsh Assembly Health Minister, assured us that there was an adequate supply of senior managers with the skills, expertise and vision to serve the 22 health boards in Wales. That was reassuring.
I want to welcome the drafting of Clause 6. It enables the Welsh Assembly to introduce, by secondary legislation, the structure that it considers appropriate to the needs of Wales. I hope that other Whitehall departments, when they come to draft legislation affecting the devolved areas, will pay due regard to Clause 6 of this Bill.
The new NHS structure in Wales, providing strong lay representation at district and all-Wales level, gives full recognition to the public interest. According to my count—I may be wrong—that will mean that about 200 to 250 laypersons, plus Members of the National Assembly, will be involved in the management of the NHS in Wales. We may really be returning to the kind of structure established by Aneurin Bevan in 1947.
The lack of attention to monitoring the efficiency and effectiveness of the NHS has been an important failure. I am, therefore, very pleased that the role of the Commission for Health Improvement is to be strengthened. With its history of ill health, Wales can benefit greatly from the work of the commission. However, apart from the work of the commission, it is not clear by whom and at what level that important work will be undertaken in Wales. Will it be undertaken by the Welsh Assembly, by the universities or by other bodies?
Part 2 of the Bill creates the council for the regulation of health care professionals. I am sure that the entire House will support the aspiration of the Government to improve standards of care and professional standards of conduct in the NHS. However, the House will have listened with growing unease and concern to the powerful speech made by my noble friend Lord Turnberg and to the powerful criticism of Clause 25 that was also expressed by the noble Lord, Lord Walton of Detchant. Both spoke with great authority. They raised the concern that the council will have power to direct any one of the regulatory bodies to make rules to achieve what it considers to be a desired end.
I have the honour of being a member of the Select Committee on Delegated Powers and Regulatory Reform. I should like to refer to the 11th report of that
committee, which draws the attention of the House to the significance of the power in Clause 25(2). Paragraph 8 states:
- "The House may share our concern that circumstances could arise where the Council give directions that might amount to an unjustified interference with the independence of a professional body. We recommend the introduction of a measure of Parliamentary control by providing that any directions shall take effect from a date to be specified by order made by the Secretary of State".
The committee goes on in paragraph 9 to recommend that the order should be made subject to the affirmative procedure. I venture to urge my noble friend on the Front Bench, and the Government, to give serious consideration to this clause and the criticisms of it addressed by distinguished Members of the House.
6.51 p.m.
Baroness Masham of Ilton: My Lords, I have to begin my contribution to this National Health Service Reform and Health Care Professions Bill debate by asking the Minister a question on the very first clause: why change the name of the English health authorities to strategic health authorities? In Scotland and Wales they do not include the word, "strategic". I am sure many people want to know the answer.
People who use the National Health Service want a good efficient service with accurate communication between the patient, primary and secondary health services and, when necessary, transfer to a specialising service which may be out of the area—OATS, or what used to be known as an extra contractual referrals. There is no doubt that in health the experts know best.
I hope that the Minister will be able to give the House an assurance that specialised services will not be damaged in this reform. I am concerned about the overloading of primary healthcare. At the moment many people are fearful that they cannot obtain an appointment to see their GP for several days. To give an example, a young woman I know arrived back from a trip abroad in agony. She telephoned her GP only to be told that there was a four day wait. She went to the Accident and Emergency Department of the Chelsea and Westminster Hospital, which found that she had an ectopic pregnancy. Had she left the condition for a few more hours she might have died.
It is no wonder people throughout the country are concerned about the pressures on our much-needed National Health Service. To get it right there needs to be an immense amount of support from all corners of the country. The National Health Service is far too important to be pushed around for the sake of political gain. People's lives are at stake.
The Government—it does not matter which government—need public support in running the NHS. We live in a complex society with increasing violence to hospital staff, an increase of patient neglect due to a shortage of beds and pressure on an overloaded service. Changing health authorities and
doing away with community health councils will not solve the problems. The Government at this present time face a huge challenge.The House of Lords, before the election, agreed on the importance of lay-led structures of local accountability. There is still great anxiety that the Government's proposals to replace the CHCs in England will confuse the public. It would be far better to have patient councils which could be reformed and made much more proactive and non-patchy. They would be independent and belong to the people.
Many people are strong supporters of their local health services, especially when they are good. The Government should be careful not to alienate the public by complicating the patient/public representation by fragmentation. People in need of advice and help should have a friendly body with an understandable name to which they can have easy access. I hope it is not too late for the Government to understand that.
Carrying on from yesterday's Question on patient complaints, I hope a really quick and efficient complaints procedure will be set up to replace the slow and cumbersome one which can drag on for a long time, causing frustration. People move on, which sometimes makes a clear picture difficult to comprehend. One needs to try and mediate wherever possible. Litigation is costing the NHS millions.
Getting those matters right is important, but with this Bill I wonder whether there will be even more fragmentation. A long time ago one of my grandfathers was a public health doctor in Glasgow. Public health is as important now as it was then; in fact, there seem to be even more new demands on the service now. There is concern that no one in government seems to be monitoring trends across the country.
Good data should be available on the whole population. With so many changes proposed in this Bill, can the Minister put his hand on his heart and say that there will be good planning, integration and co-ordination across the country so that the new arrangements will not bring islands of excellence and deserts of misery.
Public health includes epidemiology, health information, statistics, preventive medicine, health promotion, communicable diseases, environmental health, health surveillance, development and evaluation of health services, teaching and research. The Acheson Committee on Public Health in England in 1988 defined public health as,
- "The science and art of preventing disease, prolonging life and promoting health through organised efforts of society".
It is understood that each strategic health authority will have a doctor with appropriate strategic management skills as a member of the executive team with responsibility for that, but that the doctor need not be a public health doctor. The BMA is concerned that with such flexibility of appointment to those key public health posts, at both PCT and SHA level, potentially some areas of the country may be without the expertise of the public health doctor. But the BMA
is pleased to see the creation of a public health director in the government regional offices. It is hoped that they will act as advocate for their patient population.The BMA, while seeking to revise the structure of the NHS, believes that it is an opportunity missed not to consolidate and confirm the Government's commitment to the health of the population by defining the role and specifying the mechanisms of the new public health services on the face of the Bill. Perhaps it is not too late. I ask the Minister to consider tabling an amendment to that effect in Committee.
Is the Minister aware of the growing increase in sexually transmitted diseases? I pay tribute to the doctors and nurses in genito—urinary clinics who do a sensitive and difficult job that must remain confidential. Who will commission that much-needed service—which includes an increasing number of people with HIV and AIDS? Some social help—such as meals on wheels—has already been cut by local authorities. They have cut also the funding of children sent to the day centre family unit at Mildmay hospital in Hackney, which gives much-needed respite to desperately ill mothers with HIV, who can become isolated and lonely. Many of them are African. I read yesterday that London is the richest city in Europe. It makes me sad that society is becoming mean and uncaring towards the most needful, ill and disabled people trying to exist in the community.
I end on a hopeful note. Clause 21 is about joint working with the Prison Service. For many years, I served as a member of a board of visitors at a young offenders institution. Many of the young people had serious health problems that had been neglected for years. Many inmates—male or female—have serious mental health problems. Working closely together with the NHS and the Home Office can only help overcome some of the difficult problems, if funds are forthcoming.
I am concerned at a letter that I have just received from the noble Lord, Lord Hunt, in answer to a question that I put during a debate on national minimum care standards on 14th June, about the number of residential places available specifically for young people in England and Wales for the treatment of drug and alcohol abuse.
The Minister informs me that there are only about 20 such places because residential treatment is aimed at the most chaotic and complex cases. I am sure that the reason for there being so few places and so many closures is that local authorities do not want to fund such treatment.
I asked about alcohol abuse but that was not mentioned in the letter. Alcohol abuse is a growing problem, especially among young girls. The Minister will find hundreds of youngsters age 15 or 16 with drug or alcohol problems locked up in institutions. If that is not residential, what is? I hope that the Minister will soon visit young offender institutions, with a view to looking at the treatment of young people with drug and alcohol abuse problems. If they are in prisons, local authorities do not have to pay and can wash their hands of those difficult young people. Out of sight, out
of mind—but those young people eventually leave with a criminal record, more drug habits and more effective ways of committing crime.That will be an added challenge to the National Health Service. The Government may find that they have opened a can of worms. I hope that the Minister will not always believe what his civil servants write but will go out and look for himself.
I am fortunate to be under the care of an enthusiastic surgeon in the prime of his life at a London hospital. One of his operating sessions has been cut. He is not exhausted but full of energy. He says that it is cheaper to have him sitting in his office than operating on patients. That does not make sense, when patients are being sent to France for operations. Why cannot such matters be sorted out before creating more muddle in our important health service? Reorganisation on reorganisation is expensive and makes staff insecure and confused. I understand why the noble Lord, Lord Clement-Jones, has tabled his amendment.
7.6 p.m.
Lord Harris of Haringey: My Lords, it is always a pleasure to follow the penetrating and thoughtful contributions of the noble Baroness, Lady Masham. She made reference to people with AIDS, the particular problems in the capital and London being the richest city in Europe. London also contains within its boundaries some of the most deprived districts in the country. Even within those districts there are pockets of enormous deprivation and problems. Clearly, we must look at specific localities, not just the city as a whole.
I declare an interest as a non-executive director of the London Ambulance Service, a senior associate of the King's Fund and a consultant to Wyeth. I am also a former director of the Association of Community Health Councils for England and Wales.
The Bill makes an enormous contribution to the Government's progress with the national plan published in July 2000. The proposal to wind up regional offices and to give a new and clear role to a smaller number of strategic health authorities is sensible. That is about streamlining and bringing decisions closer to the communities affected by them—which will be beneficial. I do not share the cynicism of the noble Earl, Lord Howe, about powers of direction. My recollection of NHS legislation over the years is that there have always been powers of direction. All the Bill does is replicate those functions.
Bringing decisions closer to the people affected by them is a way of increasing accountability and making sure that decisions are more relevant. I welcome also the proposal to strengthen the Commission for Health Improvement. The commission is gaining increased authority as it continues its work and is a vital part of ensuring that the NHS delivers high-quality services and is seen to do so.
Similarly, I welcome the proposed transparency in relation to the regulation of health professionals. I have never been entirely convinced by the benefits of
self-regulation. The Bill's proposals will enable codification of some of the differing standards and arrangements between the professions, which is a welcome development. I am pleased that the body overseeing that regulation will comprise a majority of lay people, not members of the professions themselves. That is an important step on the road to dispelling the belief that the professions are looking after their own rather than the public they are meant to serve.I turn now to the proposals on patient and public involvement. Some noble Lords may remember that I was deeply critical of the initial proposals that emerged from the Government following the publication of the NHS Plan and the one-line statement that community health councils would be abolished. What was proposed then was, quite frankly, wrong and misconceived, and certainly ill thought out. Indeed, as the months have gone by, we have seen successive iterations and more thought has been given to particular elements, so that the proposals have changed and developed.
In October 2000 I introduced a short debate in your Lordships' House. At the time I set out certain principles that I thought were necessary in order to achieve an improvement on the existing system. I recognise that there have been and no doubt continue to be very wide variations in the quality of the work of CHCs. Many CHCs do outstanding work which is of enormously high quality. Some CHCs, however, carry out work which is of rather limited quality, while a handful of CHCs are, frankly, dysfunctional. If the proposals to abolish CHCs were in reality an intention to deal with the dysfunctional CHCs because there was no other mechanism, that would be an interesting approach to a problem soluble by other means, but it certainly would not be the only approach. The point I sought to put in the debate in October 2000 was that the Government were laying themselves open to the charge that they were sweeping away bodies that they found made uncomfortable criticisms, criticisms which perhaps they found difficult to deal with—removing people making waves and causing difficulties—and that there was a real danger, although I am sure it was one that Ministers and colleagues in the Department of Health would wish to avoid, of this being described as a form of control freakery.
I believe that, over the ensuing months, helped no doubt by the loss of the legislation and the intervening general election, the Government have managed to apply considerably more thought to the matter. Perhaps I may misquote Churchill, talking about the United States, when he said, "You can always rely on the Department of Health to do the right thing, but only after it has considered every conceivable alternative". We are now approaching the right thing so far as concerns patient and public involvement.
I believe that any system set up to represent the interests of the public and patients within the NHS has to have structures which are independent of the bodies it is monitoring and has to be well supported in what it does. It must be accessible and responsive to the
public's needs, and there must be clear pressure on NHS organisations to respond to what it is saying. The Government have proposed patients forums applying to each trust and to each PCT. The noble Earl, Lord Howe, expressed his concerns about the staffing support arrangements. Perhaps I have misinterpreted the Bill but I understood that his specific concern that staff supporting the new patients forums would come from local authorities and trusts had been overcome and that now there is a clear statement that the new commission for patient and public involvement in health will be the body to provide the staffing and support of the new bodies. Thus one of the concerns expressed in the past has been removed. That is a considerable step forward.I turn now to the question of who will serve on the patients forums. I hope that, when he replies to the debate, my noble friend Lord Hunt of Kings Heath will make it explicit that the process to be followed will be "Nolanesque", whereby those applying to take on these roles will be appointed on the basis of merit by an independent body, either the new commission for patient and public involvement in health or the new independent NHS Appointments Commission. It should be clearly differentiated from the arrangements that might exist if, say, the local trust or the strategic health authority were to make those appointments. The reason that is important is because otherwise there will be the danger of the health authority or the trust picking people they feel they can do business with, those who are going to be easy or satisfied with being consulted about such weighty matters as the colour of the bedspreads rather than wanting to focus on the most important issues affecting the quality of healthcare. The independent appointments process will be extremely important.
I hope that we shall also receive assurances from my noble friend Lord Hunt with regard to how staff appointed by the new commission will relate to the patients forums. I hope that, while they will be subject to quality and managerial control through the commission for patient and public involvement in health, there will also be a mechanism whereby the patients forums are able to direct at least a significant part of the work programme of those staff supporting them and that they will not simply be there to take the minutes and ensure that actions are followed through. The work programme should be set in part, perhaps the major part, by the patients forums concerned.
Another change, which I regard as a welcome development over the previous arrangements for CHCs, is that there is now to be a clear mechanism for the quality control of what will be patients forum work. There was no effective mechanism for the quality control of CHC work in the past. If there was a mechanism, it was exercised by the regional offices of the NHS, which were often unclear as to whether their role was to keep the CHCs in order or whether it was to encourage them to be innovative and difficult. That, too, is a development.
We also have, in the panoply of new organisations, the arrangements for the independent complaints and advocacy service. Again, the Government seem to
have listened to some of the concerns raised and have related those clearly to the new commission. It would be helpful if the Minister could clarify precisely the relationships that are going to exist. Is it expected that ICAS services will be commissioned or run by people employed by the CPPIH, or will they form a part of the patients forum structures? Again, it is important that those bodies are seen explicitly to be independent and a long way away from the immediate structures of the trusts and health authorities that they are to monitor.Because of the remit given to the commission in terms of the quality, standards and monitoring of activities in respect of the ICAS service, we have an opportunity to learn from the issues and complaints that are raised. One of my major concerns with regard to the previous proposals was that there was no method of integrating the lessons learnt from each of the new patients forums as a result of dealing with the complaints received so that that knowledge could be applied elsewhere in the NHS structure. I believe that the new commission will be able to provide that.
The Government have also heeded the warnings expressed by many noble Lords in respect of the PALS in trusts. Those are no longer regarded as advocacy bodies. They never could have been advocacy bodies; they will now provide advice and liaison services within the trust structure. They will be, as it were, a customer relations arm of the trust. That does not mean that they are a vital part of involving the patient and the public in the health service, but they will provide a valuable mechanism for improving the quality of service. The Government have learnt that.
The Government have also accepted the argument that it is possible for patients forums to refer matters to local authority overview and scrutiny committees. That, too, is an important change, one that has now been placed explicitly on the face of the legislation. That is to be welcomed.
Perhaps I may turn briefly to the national and strategic levels of patient and public involvement. At the national level, I believe that the creation of the new commission will form a vital part of the new arrangements. We shall need assurances about the appointments process to the new commission. We need to be assured that the Secretary of State understands that the commission must contain people who are going to be robust, who will be happy to be difficult and, if the occasion merits it, will be happy to stand up to the professionals and, if necessary, on occasion stand up to the Secretary of State. It may require a leap of faith by any Secretary of State to be comfortable with something like that not only now but also in the future. We need to be reassured that that is the understanding and mechanism by which that aim will be achieved.
Finally, on the strategic structure, we are told in some of the documentation circulated in recent weeks that at the strategic health authority level the patient and public involvement will be secured by the strategic health authority working with the patients forums of the PCTs with joint overview and scrutiny committees of local authorities to address issues. They will be
supported by the networks and staffing of the commission for patient and public involvement in health. That is workable. However, there are issues about how the work of the patients forums is co-ordinated at local level to ensure that there is no duplication and that the issues raised and lessons learned by the different patients forums are drawn together.One small change to the Bill would solve the problem. Clause 15(1)(b) states that there will be a patients forum for each primary care trust. It should be explicit in the Bill that the forum applying to the primary care trust in each area should be the primus inter pares of patients forums for that district. It will be the patients forum relating to the body which is purchasing the bulk of local services. The body relates to a locality as opposed to a specific institution. If the Government can make that clear, and how such a patients forum will bring together the various strands of the work of the patients forum, the proposals will demonstrate an improvement on CHCs and ensure a stronger voice for patients and public within the NHS.
If the Government's objectives on making the NHS more responsive to the needs of patients are to be met, it is crucial that there is a strong and vibrant mechanism to ensure that such involvement takes place and that that voice is heard. That is almost here in the Bill. A few minor changes by the Minister will ensure that it occurs.
7.22 p.m.
Baroness Howarth of Breckland: My Lords, I rise with some trepidation as I must declare an interest as a board member of the National Care Standards Commission. I had hoped that the noble Lord, Lord Walton, would not be present to see this member of the quango rise to speak. I realise that the hour is late. I shall try not to repeat points raised but to talk about two issues about which I am concerned.
Perhaps I may make one point about the people who may come forward for many of the positions discussed. The right reverend Prelate the Bishop of Birmingham and the noble Baroness, Lady McFarlane, spoke about the issue. I speak as someone who has recruited over a number of years hundreds of volunteers in another field. There are hundreds of people out there of outstanding calibre who, with encouragement and a little training, could make a huge contribution to this nation's work. We should not be deterred. They are out there. They just need help. They are not always in the places where we choose to look. That is something I have learnt.
Noble Lords will be aware that the Care Standards Act 2000 created the new regulatory framework for all the currently regulated social care and independent healthcare services. We were originally concerned about regulating the specialised healthcare field but we grasped the challenge with application. Having heard of depression among various parts of the organisations—I am sorry that the Minister is not now present to hear what I say—the National Care Standards Commission is in very good heart, very
enthusiastic and is grasping the challenge in the way that the Government envisages. That has not been easy. We have set up a new service across the country with 72 new offices, transferring hundreds of staff from local authorities and health services and recruiting new staff. When considering change in the current organisations, perhaps we might look at the management of that change and the continuing enthusiasm.The regulations and national minimum standards for independent healthcare were developed with government after extensive consultation with a wide range of stakeholders, including patient groups. They give the NCSC powerful tools with which to ensure high quality patient care. We intend to use those powers judiciously and are confident that in the great majority of cases providers will wish to respond positively and share our concern that patients' and persons' interests should be uppermost in our methods and processes for inspection. I use the word "person" as well as "patient" because sometimes the word "patient" distances us from the people receiving our services.
We hope to work closely with CHI. However, the NCSC has powers at present which exceed those of CHI. The commission is able to grant or refuse applications, give permission on whether or not to operate, impose conditions such as the limiting of certain activities and ban admissions until urgent improvements have been demonstrably achieved. It is able to prosecute registered providers for breaches of the Care Standards Act and its regulations. Those are powers under the current legislation. They have been transferred. They are not extra, new powers which are being added to the burden of bureaucracy. They already exist.
I hope that the Minister will agree that those powers need time to become effective before there is further change. Having set up the organisation, with enthusiasm, it would be a great pity if the staff then found themselves in an insecure situation because further change, as indicated in another place, was on the books.
It is important to realise that the commission will not use those powers if there are other means of ensuring co-operation and improvements. Where necessary, we shall discuss at great length with service providers the provision that they are making unless there is a risk to health or well being. We have other ways of considering improvements. We will publish reports so that patients can see for themselves how well hospitals or clinics measure up to standards. Reports will include data on deaths, infection rates, complaints and other key performance indicators. That is a way of ensuring that we and the general public can see what is happening.
How shall we know what is going on? We have the power to interview a wide range of staff and to consult patients and other relevant parties. We hope that we shall do so with sensitivity and care. We can obtain any information reasonably required with certain restrictions on access to clinical records. The
inspection methods will require inspectors to triangulate sources of evidence to ensure that a comprehensive and accurate pictures are built up. We do not want partial information.We shall be effective. The current system is weak. We have seen some of the results of that weakness. That is why the Government have brought in these radical reforms. The new legislation is more powerful and more relevant to modern services. The old legislation regulated only private hospitals as nursing homes. The new inspectorate will be trained, have greater expertise and, I hope, be better managed because it will be a single focus. It will stick to the knitting. It will not be diverted.
There is a real desire by the commission to record good ideas and new services. We shall take a holistic, not partial, view of services. We shall throughout consult with users. The executive at present is looking carefully at how that consultation can take place. I hope that that will form part of our learning from patients and people what they believe they need, as well as what we think they need.
That leads me on to a comment about the issues surrounding professional bodies. I am a social worker, and so I know all about criticism. I have been a director of social services and I know all about interference. I would feel more sympathy towards my colleagues in the various medical professional bodies if they were more flexible in changing themselves to meet modern services and modern needs.
The light-hearted remark of the noble Lord, Lord Turnberg, spoke for itself when he said that adversity draws people together. I was at a meeting this afternoon where we were discussing long-term care and the development of strategic services for severely physically disabled people. It became very clear that chief executives in that field are having difficulties in engaging the various colleges in understanding what is needed and gaining a response.
Demarcations between aspects of social and physical care are becoming obscure; they are slowly eroding. Certain care professionals are having delegated to them responsibility for some medical care, and issues in regard to insurance have developed in some areas but not in others.
Little expertise in relation to long-term disability care is being developed within hospitals because people do not stay in hospital any more; they get most of their care outside. Therefore, if you find yourself in residential accommodation, it is very difficult to get that care transferred into your service. With more disabled people surviving longer and more elderly people becoming disabled, change in this area is urgent if we are to meet the needs of our communities.
I am not a great advocate of constant change— I have lived through enough local authority reorganisations to know how much energy it can take—but I fear that it is here to stay. We need to find a way of ensuring that the change is positive and grasped, and that the energy released is not lost but goes towards patient and person care.
I hope that the Bill moves forward. Amendments are needed, but at least we have already started to put some of the services in place—a point made by the right reverend Prelate the Bishop of Birmingham and the noble Lord, Lord Harris. It would be a great pity if they cannot now move forward.
7.32 p.m.
Lord Roberts of Conwy: My Lords, I shall focus on the provisions in the Bill which relate specifically to Wales, as did the noble Lord, Lord Thomas of Gresford. I make no apology for that because the NHS is of great importance to Wales, and the Welsh proposals represent a major change.
The proposals have been highly controversial for a number of reasons. First, of course, they were not approved by a plenary session of the National Assembly until after the Bill had received its Second Reading in the other place. This was not the way that primary legislative proposals from the Assembly were meant to be handled, if I understand the Government of Wales Act correctly. They should first have been approved by the Assembly before being presented to this Parliament. It simply cannot be right for the UK Parliament to approve proposals for primary legislation in a devolved area such as health before the National Assembly has fully endorsed them. I am sure that the Government are aware of this because I have raised the matter previously on the Floor of the House.
The Government will also be aware that the conflict between the Assembly's timetable for its discussions and the Government's legislative timetable here at Westminster may well be used in due course as a dubious argument for the transfer of primary legislative powers to the Assembly. I would strongly advise the Government to get to grips with the problems in this area—and the sooner, the better.
But let me give credit where credit is due. I was delighted when the Minister responsible for health in Wales at the Assembly, Jane Hutt, came to your Lordships' House on Monday last to talk about the Welsh aspects of the Bill with interested Peers. I hope that by coming here she has set a precedent for other Assembly Ministers requiring primary legislation and that she will be the harbinger of more such informative visits.
The second reason why the Welsh proposals are controversial is their content. The Labour/Liberal administration in Cardiff proposes to abolish the five existing health authorities and substitute 22 local health boards, coterminous with the local government unitary authorities and based on local health groups—the Welsh equivalent of English primary care trusts. They will exercise a range of functions, subject to directions from the Assembly. I agree with the noble Baroness, Lady Finlay of Llandaff, that it is very unclear exactly who will have responsibility for some of the functions currently allocated to the area health authorities.
The 15 health trusts in Wales are to be retained for the time being—bar one. There are those—including Mr Win Griffiths, MP, the former Health Minister at
the Welsh Office, as I was a long time ago—who believe that the trusts would have been a sounder basis for an alliance, as proposed in England, but they have not persuaded the administration in Cardiff.The noble Lord, Lord Prys-Davies, is right to say that the thrust behind these proposals is devolutionary—power to the lowest level—but he will be aware, as I am, that there has been criticism that the administration is taking devolution a step too far in this context and that the proposals are too complex and impracticable. There is some validity—a dangerous validity—in this criticism.
The local health boards, which will have about 20 members—I am not exaggerating—will be supported by, I am told, between 10 and 12 non-statutory bodies to ensure effective partnership arrangements in the formulation of health strategies, as envisaged in Clause 22. There will also be three regional offices, as we have heard, and a "complex web"—that description belongs to the Minister, Jane Hutt—of national bodies with specific functions and responsibilities. So there is a curious centralising tendency in this restructuring, as well as the devolutionary bias.
Understandably, doubts persist about the bureaucratic and somewhat confused nature of these proposals and their relevance to the current problems of the NHS in Wales, where the numbers of people on waiting lists of one kind or another have doubled since 1997 in spite of increased spending and a 9 per cent increase in staffing.
Nevertheless, the administration appears determined to go ahead. There is a national steering group in place, chaired by the Minister, and an implementation group, chaired by the director of the NHS in Wales, and no fewer than nine task forces to execute the planned reforms.
Your Lordships will know that while the Government decided to abolish community health councils in England, the Assembly decided to preserve them in Wales—where, indeed, as I understand it, their role is to be extended. There are no fewer than 20 community health councils in Wales. That adds to the impression of a scattered, bottom-heavy organisation—all Indians and no chiefs, if I may put it that way.
The entire restructuring begs the question of where the strategic direction is to come from. True, there is to be a health and well-being partnership council, headed by the Minister, but the word "strategic" is missing from its description in the administration's consultative document Structural Change in the NHS in Wales. The new authorities in England have "strategic" in their title. That emphasises the point of difference. None of us with experience of the NHS doubts the need for firm strategic direction.
The Conservative Opposition in the Assembly favour a single health authority for Wales, responsible for planning and commissioning all services and having overall responsibility for the NHS to the Welsh Assembly. That would have the merit of taking politicians out of the day-to-day running of the health
service, which would be commendable to many who feel that the NHS in Wales is currently a little too politicised and in danger of becoming more so with direct funding from the centre and closer links with local government.The Welsh clauses and schedules in the Bill are largely concerned with the establishment and funding of the local health boards and their collaboration with local authorities in the formulation of health and well-being strategies. We shall have to wait for the draft Bill on the NHS in Wales—promised in the Queen's Speech and expected later this year—to see the full and final shape of the NHS in Wales.
I understand that both Welsh Liberal Democrat Members of the other place voted against the Bill—not in a show of solidarity with their colleagues in Cardiff. One of the most remarkable criticisms came from the right honourable Denzil Davies, the Labour MP for Llanelli, who is a former Treasury Minister. He also voted against the Bill on the grounds that the proposals would lead to,
- "the most bureaucratic health service in western Europe".—[Official Report, Commons, 20/11/01; col. 250.]
My preliminary view is that the proposed restructuring will do little except obscure—and possibly worsen—the current difficulties of the NHS in Wales by diverting precious resources from the front line of patient care. I share the view of the noble Lord, Lord Walton of Detchant. It is reported that there is a 10 per cent vacancy rate among consultants in Wales and that there are 200,000 patients waiting for a hospital appointment. That is a very serious situation in a country of 3 million people.
As for the longer term, the holistic approach implied by closer links with local authorities makes sense up to a point. Of course there is a connection between people's health, their environment and social services provision, but establishing the connection and developing it meaningfully will not end ill health. There will always be the acute sector, accident and emergency and so on.
The inherent danger in the proposals is the creation of a low-quality, costly and paralysing local bureaucracy. If it does not make sense to have five health authorities, how on earth does it make sense to create 22, which will probably be of lower quality, together with more supervisory bodies at national level icing the organisational cake?
A survey last year showed that 80 per cent of Welsh NHS Confederation members did not believe that there was sufficient capacity to sustain the management and support of 22 local health boards. They may well be right. I am not as sanguine as the noble Lord, Lord Prys-Davies.
There is a certain amount of confused thinking stamped on the proposals, which are mainly permissive, therefore leaving scope for more confusion. I hope that we shall examine them more closely in Committee.
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