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Lord McIntosh of Haringey: My Lords, it is more complicated than that. A different proportion of each of the amounts goes to the National Health Service according to contribution rates. Again, I believe that there are historical rather than rational reasons for that, and thus there is no single figure. However, I have said that, broadly speaking, some £7 billion will go to the National Health Service allocation while, I think, a comparable figure will go into the National Insurance Fund. But it cannot be tied down to any particular contribution.

The noble Lord asked me about the balance on the National Insurance Fund and quoted from the report of the Government Actuary. Of course the figure of one-sixth of expenditure to which the Government Actuary refers is a minimum figure. The fact that the figure, at £24 billion—which the noble Lord, Lord Higgins, is quite correct to point out is substantially larger than that fraction—is the result of the fact that the balance on the fund is the difference between two very large figures indeed. Even what seems like the large figure of £24 billion is not such a large figure as all that. This is the fifth year that we have seen an increase in the balance of the fund. The point I wish to make here is that what we do about income and expenditure from the fund has to be consistent over a period of years.

If we were to over-react to a particular surplus in one year by allowing, as suggested by the noble Lord, Lord Higgins, a benefits or a tax holiday, that would be extremely dangerous. I do not believe that any government of the noble Lord's persuasion would want to do that either. We should remember that in 1993-94 there had to be a very substantial Treasury grant, which at that point in the economic cycle was not particularly appropriate.

The noble Lord also asked me about the state second pension and the case for an identifiable fund for it. He made the point that switching between the two schemes is undesirable. To an extent, I think that we have to admit that switching in and out of the state second pension, or in and out of its predecessor, SERPS, is to some extent inevitable if we have a situation such as that which pertains at the moment; that is, where the number of final salary schemes is reducing. If we see a much longer trend of people changing jobs a number of times during their working life and thus making final salary schemes less attractive, then clearly there will be more switching in and out. What we are much more concerned about is to ensure that, wherever it comes from, people should be making adequate provision for their pensions. The fact that those pensions might be made up from more than one source is not necessarily a bad thing.

The noble Lord's final question concerned the estimate of the liabilities of the fund. We are now just about within a week of moving over to resource accounting and the almost complete abandonment of cash accounting in the public accounts as the main

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measure. The point made by the noble Lord about having a balance sheet as well as an income and expenditure account is, to my mind, well made. It is one which I think should be brought up and deserves parliamentary time as we move towards the new method of public accounting.

Turning to the second order, I was asked by the noble Lord, Lord Addington, whether we were using the correct index from the point of view of poverty. The point about using the Rossi index, which is RPI with certain housing costs excluded from it is, first, that it has been used for this purpose since 1983. There are advantages in consistency. Secondly, it maintains the differential between in-work and out-of-work provisions, as I hope I made clear when introducing the order. Different measures are used for different benefits and purposes in government.

Again, some of those measurements exist for historical reasons rather than for reasons which we could now rationally justify. For example, the fact that sometimes we take prospective RPI and sometimes past RPI is difficult to justify rationally, except on the basis of using a swing from one measure to another for base party political purposes. We are not doing that here.

On Question, Motion agreed to.

Tax Credits Up-rating Order 2002

8.20 p.m.

Lord McIntosh of Haringey : My Lords, I beg to move.

Moved, That the draft order laid before the House on 14th February be approved [20th Report from the Joint Committee].—(Lord McIntosh of Haringey.)

On Question, Motion agreed to.

Lord McIntosh of Haringey: My Lords, I beg to move that the House do now adjourn during pleasure until 8.37 p.m.

Moved accordingly, and, on Question, Motion agreed to.

[The Sitting was suspended from 8.20 to 8.37 p.m.]

National Health Service Reform and Health Care Professions Bill

House again in Committee.

Clause 11 [Duty of quality]:

Baroness Northover moved Amendment No. 93:

Page 17, line 29, after "quality)" insert—

"( ) in subsection (1), after "of" there is inserted "the Department of Health"; and"

The noble Baroness said: This amendment was first proposed by my honourable friend Dr Evan Harris in another place. It seeks to include the Department of Health itself in the inspection process.

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The purpose of the amendment is simple. The danger is that CHI will spend its time inspecting the work of hospital and primary care trusts; but the trusts are simply doing what the department is asking of them.

Obviously, the Government must set priorities in the NHS. That is what they are elected to do, and they will be called to account at election time. But quite how their policy towards the health service is implemented depends a great deal on how the department itself operates.

If, as the Government claim, they do indeed manage to de-centralise, and also—as we seek—more proposals are brought directly to Parliament for approval, or if the NHS is put at arm's length from government, the role of the department might not be so critical. However, that is not the case—and will not be the case even if this Bill as drafted completes its passage. Therefore, the amendment explores the idea that it is also of key importance to patient care to see whether the actions of the Department of Health are also in the best interests of patients.

The Audit Commission has a remit over the Department of Health in terms of how resources are spent. So, for example, the Audit Commission has commented adversely on resources used to reduce waiting lists when these did not greatly assist in patient care. It was also argued by the Minister in the other place that CHI could comment on the commissioning procedure. But that is at a stage down the track from the Department of Health.

We in Parliament clearly have a key role to play in bringing the Government to account for actions within the Department of Health. But if it is indeed appropriate for the Audit Commission to assess whether the department is spending its resources wisely, then surely it is also worth considering having expert assessment of whether the Department of Health, in its priorities and procedures for running the health service, is actually acting at all times in the best interests of the patients.

It is often difficult to gain access to that information as parliamentarians. I point to a report in today's Guardian on the Commons Science and Technology Committee, investigating what is happening to resources for cancer. I have raised this matter previously, and sought Written Answers from the Minister last September. My question was: precisely what happens to money earmarked for cancer since so little of it seems to be reaching its intended target—this despite a government fanfare on the matter. The Guardian article quotes Gordon McVie, of Cancer Research UK, as wondering whether the money,

"has been absorbed like creosote into the fence post of the administration of the health service".

Quite so.

The Science and Technology Committee reports the difficulty of getting any information on this matter out of the Department of Health. Clinicians on the ground dare say little, lest they offend against all the rules barring them from commenting. Surely there is a case for an inspection body having the right and the duty

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to go into the Department of Health to make its own investigations and recommendations. It might well say that the department had failed in the way that it had dispatched the money to protect it from marauding administrators trying to fill black holes. Or it could conclude that ring-fencing, when there were so many desperate needs in the health service, was inappropriate. Either way, its expert investigation and report would help to inform both parliamentarians—and indeed the electorate—who are supposed to be able to bring the Government to account.

I do not expect that the Minister will consider the amendment to be a very good idea; nor may those advising him. But while we seek ever more transparent and effective scrutiny procedures in the rest of the NHS, and of those working in the health professions, surely the Minister must also give consideration to such scrutiny closer to home. I beg to move.

Earl Howe: I add my support to the amendment. I completely endorse everything that the noble Baroness has said. The odd thing about Section 18 of the Health Act 1999 is the narrowness of its compass. The duty of quality created in that section falls on health authorities, PCTs and NHS trusts. It is expressed as a duty,

"to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care which it provides to individuals".

That section is one of the most important in the Act, yet something big appears to be missing from it. Like the noble Baroness, I am struck by the absence of any duty on the Department of Health or the NHS as a whole to promote quality in healthcare.

The Minister's reply is likely to be that the department as such does not deliver healthcare services. There are two rejoinders to that. One is that, while it may not deliver services at the front line, it is instrumental in providing those services—which is the term used in Section 18. I am thinking in particular of the public health role of the CMO. When we debated public health earlier this week, the Minister made it clear that the CMO was ultimately accountable within the body of the NHS for the effective delivery of the Government's public health policy. It seems strange that only lower down the NHS chain of command should a duty of quality be laid down. I might have expected a government amendment to this Bill creating a duty of quality on the NHS as a whole, including the Department of Health, accompanied by a power for the Secretary of State to devolve or delegate that duty to NHS bodies at the front line.

If the Department of Health has been exempted from the duty of quality because it does not commission healthcare services, the same could be said of strategic health authorities, but I take it that they, as successor bodies to health authorities, will be subject to the duty. Perhaps the Minister could clarify that point.

The second rejoinder to what I suspect the Minister will say is to point to the multitude of powers that will continue to reside with the Secretary of State,

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notwithstanding the devolutionist flavour of the Bill. Those powers include an ability to intervene directly in the affairs of PCTs, the power to impose targets on the health service, the power to dispense or withhold money according to how well or badly those targets have been met and so on. If there is no duty of quality on the Department of Health, as I read it the centre can legally direct PCTs and trusts in a manner that need take no account of the duty of quality, yet expect PCTs and trusts nevertheless to adhere to that duty. An obvious example springs to mind—the waiting list initiative. If such an initiative obliges PCTs and trusts to override clinical priorities so that those waiting longest, and not necessarily the sickest patients, are treated first, it is very difficult to see how PCTs and trusts can claim, while fulfilling that directive, to be improving the quality of healthcare that they provide.

The noble Baroness has pinpointed an interesting and potentially far-reaching anomaly in the Bill and in the 1999 Act. It will be illuminating to hear what the Minister has to say.

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