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Lord Clement-Jones: There would be far greater coterminosity under the regional proposals than there could be with any strategic health authority boundaries. To that extent, I hope that the noble Baroness is entirely satisfied with the scheme from these Benches.

Baroness Masham of Ilton: I am rather suspicious about the four care authorities. Does that arrangement mean that people might have to pay for their needs? At present, under the health authority, they do not have to pay. Under social care, there is a means test. Some individuals desperately need certain aids—particularly severely disabled and elderly people. Otherwise, they will get into real difficulties.

I asked "Why strategic?" on Second Reading. The word "strategic" may not be as well understood by the local population as the word "region".

Lord Hunt of Kings Heath: I did not think that I would ever hear a speech in which the idea of bringing regional health authorities back into existence would be met with such enthusiasm. I well remember a debate in another place in the late 1980s in which RHAs survived by two votes. It almost brings tears to my eyes to know of the enthusiasm with which some of your Lordships regard regional health authorities.

My experience is that RHAs were uncomfortably placed—too far from the coal face and too large, given the areas and populations that they covered, to be particularly effective. The great advantage of strategic authorities is that they are large enough to deal with some of the strategic issues that I mentioned in the previous debate but not so large as to be removed from the public that SHAs exist to serve.

Strategic health authorities do follow local government boundaries, and the consultation process supported that; and SHA boundaries are consistent with those of the government offices in the regions. Trying, as ever, to pull together the needs of the NHS with the requirement for consistency across governmental boundaries, we have got as close as we can to a sensible arrangement.

The noble Lord felt that the directors of health and social care would have little work to do. I fear that he has misunderstood my point. I was answering a point

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made by the noble Earl, Lord Howe, when he suggested that with the new arrangements we would end up with three tiers of management. I said that the four directors of health and social care and the staff to work to them should not be seen as another tier—an intermediate tier, as it were—between the Department of Health and the strategic health authorities.

The directors of health and social care will be senior officials of the department and should be seen as occupying a headquarters function. They will be on the board of directors. It is simply that, as part of their major responsibility, they will have oversight of one part of the country's National Health Service. They will have a vital role to play. For example, as part of a national programme they will be managing the appointment, development and succession planning of all senior NHS management staff; they will support Ministers through case work visits and local intelligence; and they will be trouble-shooting. Importantly, they will bring the NHS and social care together. There is great advantage in bringing the two together under one person. To take an issue that we know well, the interrelationship between the NHS and local government, the new structure is likely to encourage a much more integrated approach to performance management.

I assure the noble Baroness, Lady Masham, that creating directors of health and social care will have no impact on the question of means-tested payments, or whatever, for personal social care. The NHS is free at the point of delivery. There will be no impact on those traditional arrangements.

The answer to the question of the noble Baroness, Lady Finlay, about regulation of the institution that she mentioned is that that will become the responsibility of the National Care Standards Commission. It will be the responsibility of that authority, which will take over the present responsibilities of health and local authorities.

The noble Lord, Lord Clement-Jones, mentioned commissioning of specialist services as an example of the need for a region. We shall debate that later, but I assure him that national specialty commissioning will continue to be undertaken at national level. I am confident that the kind of specialty commissioning that needs to take place at more local level will be undertaken effectively by primary care trusts, with the back-stop that if there are problems the strategic health authority will have a role in intervening and performance managing those trusts.

We do not need regional authorities in the new structure. Strategic health authorities provide the right balance between strategy and closeness to the population and will serve us well in taking forward NHS reform.

Lord Clement-Jones: I thank the Minister for that reply. I am delighted to note his enormous confidence in the new structure, which, as will become increasingly apparent in our debates, is not shared by many others. The Minister's point was that regions are too large to be effective. It is somewhat perverse that,

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alone among government departments, the Department of Health has decided that the region is not an appropriate unit of management or strategy. Every other department has chosen the region as its unit; government offices are testimony to that.

Lord Hunt of Kings Heath: The noble Lord has reminded me that I did not respond to his earlier point about public health. Clearly in public health it is important that there is a strong relationship between the NHS and the regional offices of government. That is why there will be a public health specialist who will work both to the directors of health and social care and to regional government offices. That is a good illustration of the flexibility of the arrangements which, while preserving the integrity of the NHS boundaries to serve NHS purposes, will none the less allow for integration and joint process with regional government offices.

Lord Clement-Jones: I am delighted that at least in one respect the Government accept that argument. I wish that they accepted it for the other 80 per cent of the health service. These public health directors will be rather lonely creatures. They will have no other health professionals to whom to talk. No doubt they will talk to their fellow officers in other disciplines in government offices, but it will be rather peculiar that there will be no other health professionals to advise them or to whom they can relate.

However, without elaborating too far, it seems somewhat strange that the Minister regards the suggestion for regions as being too "remote" to serve the public interest. In strategic terms, that is the word the Minister wishes to use. Technically, I am sure the noble Lord is right. It is possible to say that the strategic health authorities follow local government boundaries. If one draws a line around two counties, or four unitary authorities, it follows local boundaries. The regional understanding is not followed in the catchment areas. I am certain that after a period of years we shall find 32 moving to 15, 9, 10 or whatever; but they will be more regionally based than today.

I accept to a degree what the Minister says about the four directors of health and social care. Of course, we on these Benches welcome any gathering together of health and social care. Indeed, I recall putting forward amendments to numerous Bills introduced in this House providing precisely that, rather than the partnership arrangements first proposed by the Government in the Health Act 1999. We argued strongly for integration. It was delightful that two years later the Government put forward proposals for care trusts which we supported. It goes with the grain of our thinking.

However, the four directors of health and social care who fit into no known region are to take a strategic view without relating to any set of organisations. Yet within the structure of the NHS they are also accountable to the chief executive. That is another layer of management. No doubt the Minister sees it somewhat differently.

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I believe that the strategic health authorities will not be strong enough to withstand micromanagement from the centre. That is the key argument. If regional authorities are properly staffed, with properly specialised skills, one will have people of sufficient seniority and expertise to pursue robustly policy in health services in their areas and at the same time to resist micromanagement from the centre.

The government proposals are unsatisfactory. This debate has been an opportunity to hear the Minister's enormous confidence about the new structure. For that I am grateful. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 16 to 28 not moved.]

9.15 p.m.

Earl Howe moved Amendment No. 29:

Page 2, line 21, leave out "are" and insert "is"

The noble Earl said: I can deal briefly with the amendment and speak to Amendment No. 34.

In two places, the clause has a plural verb with a single subject. My suggestion to the Committee is that we correct the syntax. I beg to move.

Lord Hunt of Kings Heath: It is an enormously important amendment. I am advised that there are different views as to whether a body which consists of a number of persons should be treated as singular or plural. For example, some people say "the Government is" and others "the Government are". Neither is wrong; it is a question of style. The important point here is that Clause 1 amends existing legislation: the National Health Service Act 1977. The 1977 Act refers throughout to a health authority as a plural body. For instance, Section 16C(1) states:

"Every health authority will make arrangements with a view to securing that they receive advice appropriate for enabling them effectively to exercise the functions exercisable by them".

Section 8(4)(d) states that the Secretary of State may by order change the name by which a health authority are known. The wording in the current Bill follows the same convention in the Act we are amending. I hope that the noble Earl feels that that is a satisfactory explanation.

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