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Baroness Symons of Vernham Dean: My Lords, there is an enormous amount of wisdom in the comments of the noble Lord, Lord Thomson. I hope that the Government have been seen to be firm in their resolve. My noble friend and my right honourable friends have done their best to work behind the scenes to secure the objective about which we have been clear. As the Statement indicated, we have been working for suspension from the councils of the Commonwealth for a matter of months. The noble Lord is right. This cannot be seen to be a one-country show.
As the Statement indicated, it was clear early on in the discussions that the Zimbabwean Government would do everything that they could to make this an issue between the white Commonwealth—those predominantly from the European-based nations—and those from the African-based nations. That would have been an extremely damaging development had it had any success. But it was not successful, which is exactly the point. The value of the troika was that President Obasanjo and President Mbeki both have great wisdom and experience. It will now be extraordinarily difficult for Mr Mugabe to claim that
it was some sort of conspiracy led by the United Kingdom. The United Kingdom took no part in the troika. We are also extremely grateful for the part played by Prime Minister Howard.It is right to ensure that this is not seen as the United Kingdom being out alone on the issue. We have a special relationship with Zimbabwe. We have a historical relationship and 40,000 of our citizens live in that country. We have particular responsibilities, which none of us want to set on one side. Having said that, we have constantly made it clear that this is a matter for the whole Commonwealth. I am delighted that the Commonwealth has acknowledged that and that it will be working in the next year to try to bring the Government of Zimbabwe to a more sensible course of action.
Lord Stoddart of Swindon: My Lords, the noble Baroness has done well to remind us that there are 40,000 British citizens still living in Zimbabwe. We also know from experience that Mr Mugabe and his party are spiteful. In the event of their taking out their spite on those 40,000 British citizens, are there contingency plans to make sure that they will be rescued and defended?
Baroness Symons of Vernham Dean: My Lords, there is a contingency plan, but I stress to the noble Lord, Lord Stoddart, that there is a similar contingency plan for many other countries. As many of your Lordships will know, we have a warden network around the country to enable us to maintain good communications with the resident British community. I assure your Lordships that that civil contingency plan is reviewed and updated regularly.
The responsibility for ensuring law and order in Zimbabwe cannot be shouldered by the British mission in Zimbabwe. The responsibility lies full square on the Zimbabwean Government's shoulders. I should not want anything that I have said about civil contingency plans— important though they are—to be thought in any way to be relieving the authorities of that country of their obligation to look after all citizens, irrespective of their nationality or where they live. I hope that that message will be firmly understood.
Lady Saltoun of Abernethy: My Lords, following on from what the noble Baroness, Lady Park of Monmouth, said, how can the Government ensure that any financial support given to restore democracy in Zimbabwe is used for that purpose and does not go towards lining the pockets of the present government?
Baroness Symons of Vernham Dean: My Lords, in countries where we have had the problem of the possibility of governments diverting aid funds from the legitimate purpose for which they were sent and using them for illegitimate purposes we have channelled funds through non-governmental organisations. I am sure that that issue is under review by my colleagues in the Department for International Development. It is another of the functions of our
extremely hard-working mission on the ground, and others, to ensure that such matters are kept fully up to date.I am sure that none of your Lordships would wish to imply that we should not send much-needed aid for food. As I tried to explain, the levels of hunger and food shortages are enormously difficult problems in Zimbabwe. It is right to send what aid we can to ensure that democracy, fragile as it is, has a chance to flourish and that civil life has a chance to grow as well. We try to do what we can through the NGOs but we also keep very close observance on the ground about what happens to our funds.
National Health Service Reform and Health Care Professions Bill
4.15 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.
Moved, That the House do now again resolve itself into Committee.—(Lord Hunt of Kings Heath.)
On Question, Motion agreed to.
House in Committee accordingly.
[The DEPUTY CHAIRMAN OF COMMITTEES (Viscount Allenby of Megiddo) in the Chair.]
Clause 6 [Local Health Boards]:
Lord Roberts of Conwy moved Amendment No. 76:
- Page 7, line 17, after "is" insert "issued,"
The noble Lord said: I shall also speak to the remaining amendments in this group.
The proposal that there should be local health boards in place of the existing health authorities in Wales is controversial for a number of reasons. Amendment No. 76 proposes that there should be consultation before an order establishing a board is issued by the National Assembly for Wales. There is already provision for consultation in the event of variation or revocation of a local health board order. In our view, prior consultation is essential before boards are established.
If the boards are to be coterminous with local authorities, there will be more of them than the present five area health authorities. There could be as many as 22—one for each local authority. I should have thought that the Assembly would seek to avoid such proliferation if only for reasons of economy in terms of staff and resources. There will obviously have to be consultation with the existing health authorities, local authorities and health trusts before the final geographical map of health boards is decided. It is important that the map is the best that can be devised and that it is satisfactory to all concerned.
I can recall the reorganisation of local government in the early 1990s when the present 22 unitary authorities were established. Indeed, I can remember the previous reorganisation in the 1970s. My enduring
memory of both is the difficulty that we had in getting proposals accepted and boundaries agreed. These new proposed health boards will prove just as contentious when the Assembly gets down to the business of deciding the precise localities that they are to serve. People are naturally very sensitive about such issues.There is a further complication that not all the boards will have the same functions. They will have a variegated pattern of functions and responsibilities. Some will have major hospitals within their areas, and others will not. Again there will be considerable scope for argument and the Assembly would be well advised to consult before the pattern is imposed which, I dare say, will happen.
Many people in Wales, both within the National Health Service and outside it, have grave doubts about the practicability of the new system. For it to have the smallest chance to succeed, there must be extensive consultation with all the parties involved. We would be foolish not to provide for it in statute, especially when the Bill already provides for consultation in the event of variation or revocation of an LHB order.
The Minister may say that of course there will be consultation before an LHB order is issued and that we can take that for granted. I do not think that that is an adequate reply to the argument. Without the amendment we shall be storing up trouble for the Assembly and for the National Health Service in Wales.
Amendment No. 77 is a probing amendment. It seeks to find out how the Assembly proposes to direct the local health boards at national level. In other words, who precisely in the Assembly is to issue directions? Presumably they will be authorised by the Minister in the Assembly on the advice of the NHS directorate. We should like to know more about that top structure.
I imagine that there will be an infinite variety of directions related to different aspects of the NHS. Some will be purely local and apply only to a particular board or boards; others will be national in scope. As we have said before, the NHS in Wales will clearly need an all-Wales dimension, which is currently not defined in the Bill. It is very important that we have some idea as to what that all-Wales structure will be. We debated this point last Thursday when we considered the new clauses proposed by the noble Baroness, Lady Finlay of Llandaff.
I had ministerial responsibility for the NHS in Wales between 1979 and 1983. That was a period, I am glad to say, of extensive new hospital building and innovative strategies such as our mental handicap strategy which pioneered the transfer of people with learning difficulties from hospital into the community. We did not have a regional health authority in Wales; the regional authority was the Welsh Office and its Ministers. So I have some idea about the enormous range of NHS activity in Wales even 20 years ago.
It is quite clear that the thrust of the Welsh provisions in the Bill is to devolve responsibility to local health boards, but it is also clear that there will have to be some central direction in order to ensure a
degree of uniformity and fairness all round. It is therefore necessary, as I have said, for us to know what kind of structure the NHS will have at Assembly and ministerial level.I referred a few moments ago to the noble Baroness, Lady Finlay of Llandaff, who introduced new clauses asking for a national health agency for Wales. The noble Baroness not only enjoys an international reputation, but she has a high reputation in Wales as vice-dean of the University of Wales College of Medicine and as honorary professor of palliative medicine. In short, she knows the NHS in Wales. She knows the scene very well indeed.
Last week the noble Baroness told us of the concerns expressed at the conference of Welsh local medical committees as recently as last Wednesday. She said:
- "They cannot take on the huge number of functions about to be devolved to them".—[Official Report, 14/3/02; col. 994.]
As the noble Baroness hinted in the debate last week, there is a threat of fragmentation here and, I would add, an incoherent, possibly conflicting guidance to local heath boards from the various directorates. I hope that further consideration will be given to the single primary care directorate and the significant body that the local medical committees want,
- "to handle contractor services to protect both professional interests and those of patients".—[Official Report, 14/3/02; col. 994.]
With regard to secondary and tertiary care, it is proposed to strengthen the Specialised Health Services Commission for Wales, to commission tertiary care and advise, guide and facilitate the commissioning of secondary care. But the remit is still being worked out, as the noble Baroness told us. The noble Baroness, Lady Farrington, confirmed that the Specialised Health Services Commission for Wales is to be given an enhanced role. But that is as far as we got in learning about the national structure.
So what can we make of that? The structure of the NHS in Wales is being built from the bottom up. That makes sense, provided that the builders know how the structure is to be completed. The foundations have to match the superstructure, and vice versa. That is where the current problem lies. There seems to be no clear idea as to what the final structure will look like or how it will work. Any help that the Minister can give on this matter will be most welcome.
Amendments Nos. 90 and 91 are different in character from previous amendments but still deal with local health boards. I have tabled Amendment No. 90 to seek clarification on certain aspects of local health board expenditure. My understanding is that they will have very little income, other than the allocations given to them by the Assembly. Such
allocations will be the major part of their revenue. Clause 10(9) defines general Part 2 expenditure under the Act. That means expenditure in connection with the council for the regulation of health care professionals, and appeals. My amendment deletes subsection (2) of Clause 10(9) which excludes four kinds of expenditure that may clearly be incurred by local health boards; otherwise they would not be specified for inclusion in the way that they are. This subsection must be read in conjunction with new Sections 97H and 97G which deal with resource limits of local health boards and their financial duties. Subsection (2) of new Section 97H states that,
- "no account shall be taken of ... general Part 2 expenditure",
My first question is: why is Part 2 expenditure open ended? Is it demand led? It does not say much for the Assembly's sense of priorities that regulatory expenditure is open ended.
Secondly, why are there the four specific exclusions from the definition? They are a mixed bag. I hope that the Minister will comment on each. I am particularly interested in Clause 10(6)(b), which refers to,
- "remuneration referable to the cost of drugs".
Finally, who, if not the local health board, will pay for these excluded items? I am bound to say that the whole of the resource and expenditure situation of local health boards is complex, to say the least, in the Bill.
Amendment No. 91 seeks to introduce the principle of equity into the National Assembly's annual apportionment of remuneration for the cost of drugs. Drugs expenditure is clearly no longer demand led and open ended. There is no commitment here on the part of the Assembly to meet a local health board's drugs bill in its entirety and whatever it may be. Indeed, under Clause 10(9), new paragraph 6C(4) states explicitly that the Assembly will exercise its discretion in paying for drugs ordered by a board on its own account. That seems a shot across the bow for boards that respectfully follow clinical judgment in drug prescribing. The same applies to primary care trusts in England.
I hope that I have properly understood the financial provisions and that the Minister will be able to answer some of my queries. I beg to move.
4.30 p.m.
Baroness Carnegy of Lour: Those of us who are particularly interested in the workings of devolution are bound to be interested in this part of the Bill, which establishes for the first time an arrangement set up by Westminster in Wales—upon which the National Assembly will make many decisions and within which framework it will operate.
There are many provisions in the Bill for secondary legislation. The Delegated Powers and Regulatory Reform Committee, of which I am a member, examined that aspect of the Bill with care and on the whole—as the Minister knows—the Committee is satisfied with the way in which the secondary legislation is arranged. It seems to have been well drafted.
The Bill allows the Assembly enormous freedom to make the arrangements to which my noble friend referred in the way that it wants and which suits Wales. Far be it from me even to imagine the scene, because I have not seen the Assembly in action, but it should be having an interesting time.
Westminster must decide what should be on the face of the Bill and what should not—and what consultation should be set out by Westminster. Defining the board areas is obviously important. My noble friend made a good point when he said that there must be consultation before orders are made, not just the varying of orders afterwards. Amendment No. 76 probably has a lot going for it. It will be interesting to hear the Minister's response.
The clause about which I believe many of your Lordships are doubtful emanates from the arrangements for England and Wales—as does much of the pattern of the Welsh clauses. We must be sure that the pattern that is right for England is right for Wales.
The clauses in question imply that the Assembly will have enormous freedom to spend money on the health service in Wales in the way that it wants. How will the Government fix the Assembly's block grant in relation to health? I do not know whether my noble friend disagrees but that seems so open ended that it might be difficult to do. We need to know whether there is any basis for knowing the overall sum within which the Assembly will have to operate.
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