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Baroness Northover: My Lords, we are very grateful that the Government have accepted that wording.
On Question, amendment agreed to.
Earl Howe moved Amendment No. 2:
- Leave out Clause 1.
The noble Earl said: My Lords, I have tabled the amendment because I want to explore the functions of strategic health authorities. In Committee, we debated them quite extensively. In particular, I want to explore what the term "performance management" means in the context of strategic health authorities. We are told by the Government that by 2004 primary care trusts will control 75 per cent of the entire NHS budget and will thereby acquire a great deal more autonomy than hitherto—"shifting the balance of power" to the front line.
There are many of us who cannot help being somewhat sceptical about this shift in the balance of power. The reason for that is that the powers of the Secretary of State to intervene in the affairs of the health service and to micro-manage remain unaltered. Indeed, by virtue of the Bill those powers are considerably augmented. The Government say that in order to preserve proper accountability to Parliament it is necessary to retain such reserve powers. I wonder how "reserve-like" the Secretary of State's powers feel to those in the NHS who battle daily with the welter of targets, directions and instructions that descend on them from health authorities and from Whitehall. Last week I heard from a doctor that there is an instruction relating to the degree of lustre which must be achieved on polished surfaces in NHS buildings.
However, let us look at the mechanisms being established in the Bill and their functions. We are told that strategic health authorities will be there to set the strategic framework, to knock heads together, to broker solutions, to performance-manage, to lead policy development and so on. As the Minister emphasised in Committee, they will be there,
- "accounting to the Secretary of State for the performance of the NHS in their areas".—[Official Report, 14/3/02; col. 1039.]
How will that work in practice? It might be illustrative if I cited one example of the heavy-handed way in which strategic health authorities are already making their presence felt on the ground. At a recent trust board meeting—I shall not say which one for obvious reasons—the directors found themselves unable to present a finance plan for the year we are just entering because of last-minute restrictions imposed by the strategic health authority. The relevant PCT was told that it will begin the year underfunded by some £500,000. As a result, earmarked funds allocated last year for the various national service framework programmes on cancer, mental health and the NICE agenda have gone out of the window. The money has to be used instead to plug shortfalls in the budget. Any additional shortfalls have to be plugged by what is termed "repayable brokerage"—in other words, short-term loans.
The language used by the board to describe the actions and attitudes of the strategic health authority is revealing. The strategic health authority, said one board member, was being "excessively prescriptive and restrictive". Another said that the strategic health authority was behaving like "control freaks".
That is the kind of decentralisation and operational freedom which we are going to see rolling out across the National Health Service. It is the tone of things to come. As my noble friend Lady Noakes said in Committee, what all this amounts to is an illusion of decentralisation in which true decision-making takes place at the level of the SHA.
The noble Lord, Lord Clement-Jones, has expressed his concern that strategic health authorities will not be strong enough to withstand micro-management from the centre. I think that I would put the argument slightly differently: they have been created expressly as vehicles to implement and enforce centrally driven directives.
Ironically, this brings us back full circle to some of the conundrums that we were wrestling with in Committee: what to do about those activities and services for which a single PCT is not equipped individually to perform, but which can only be delivered across a wider area—teaching and research, specialist services and public health. The Government's answer is that in many cases of this kind there should be a PCT with lead responsibility within an informal grouping of PCTs. But that sounds extraordinarily cumbersome. How many informal groupings will a PCT find itself in simply because the Government are determined that no higher tier of management in the health service should take responsibility for these broader strategic matters? Why not recognise the operational leverage vested in strategic health authorities, rather than labour under the illusion that PCTs will be the drivers of decision-making?
I do not intend to anticipate our later debates on these matters. However, it seems to me that in these areas of broader relevance for the health service we should acknowledge that here is a way in which strategic health authorities can sensibly play a lead role.
Finally, I turn to a question that I asked the Minister in Committee, but which he did not answer. If there is a conflict or divergence of opinion between one strategic health authority and another, what mechanisms are there in place to resolve such disagreements? That is not such a simple question as it may sound. If one imagines a strategic health authority brokering sometimes difficult solutions across several primary care trusts for the benefit of the population in an area, how will it be capable of compromising such a brokered solution, merely because there are objections from the strategic health authority down the road? If there are two opposing and conflicting views of what is strategically best for an area, who decides which way to go? I beg to move.
Lord Clement-Jones: My Lords, I agree with a great deal of what the noble Earl, Lord Howe, has just said. One of the key debates in Committee was over the setting up of these strategic health authorities. In Committee, the Minister claimed that the key roles of these strategic health authorities would be performance management, capital investment strategy, workforce development and information management, but not
other functions such as public health and specialised commissioning. We shall have the debates later on those particular topics, but it is still not clear to us on these Benches why not?Furthermore, why should it be at this level of 28 strategic health authorities and not at regional level? What makes the planning of capital investment more apposite to the level of strategic health authorities rather than at regional level, whereas public health is handled at regional level? Why are strategic health authorities being set up that bear no relationship to local government boundaries or the Government's own regions?
As I mentioned in Committee, over the years there have been a massive number of changes to the structure of health services. In 1974, area health authorities were established; then came district health authorities; and then health authorities. Now we are to have strategic health authorities. One constant has been the NHS region, although there have been boundary changes and some consolidation. There will be nine regional directors of public health, who could well fit into a regional structure—certainly more comfortably than could the four regional directors of health and social care, whose areas will bear no relationship to any regional or local government boundaries.
In any reorganisation, it is vital to ensure proper accountability for health strategy. That could be secured by a regional organisation but is unlikely to be secured through strategic health authorities. In Committee, the Minister said that he saw a key role for strategic health authorities in performance management and banging heads together. Yet the Government's most recent document about delivering the NHS Plan states that although in effect they will be the local headquarters of the NHS and will hold to account the local health service, build capacity and support performance improvement, three-year franchises to run strategic health authorities will be let, with performance judged against a published annual delivery contract with the Department of Health.
That is Burger King come to Richmond House. Strategic health authorities will clearly be an integral part of the NHS administration, yet they are to be franchised. The Secretary of State has a well known infatuation with the private sector, but that is a love affair too far. Despite our debates in Committee, the new announcements only make the department's plans appear more half-baked. I urge the Government to think again. Why do they not at least consolidate the reforms in the Bill and the recent White Paper and return in a few months' time?
3.30 p.m.
Lord Peyton of Yeovil: My Lords, I support every word so far spoken about the amendment. As I have a great respect for the noble Lord, Lord Hunt of Kings Heath, I offer him my genuine and profound sympathy for the heavy burden that he now has to carry in justifying this rubbishy clause.
The clause deserves to be known as a large slice of Milburn. I hope that it will be strung around his neck. It has his fingerprints and foot-marks on it to the full:
first, in all the importance that he attaches to names; and secondly, in his almost unlimited appetite for powers.I remind your Lordships of subsection (4), which states:
- "The Secretary of State may by order . . . vary the area of a Strategic Health Authority".
I should like your Lordships to vote against the clause and remove it altogether. It is a rubbishy and tiresome provision. The only vice from which it is free, but from which the rest of the Bill suffers—I am pleased to see the noble and learned Lord, Lord Brightman, in his place—is the sin of legislation by reference. However, later in the Bill there are plenty of examples of that, to which I shall endeavour to call your Lordships' attention.
I cherish the hope that the noble Lord, Lord Hunt, will remember that he gave undertakings to try to remedy the horrors of the Bill by making the Government's purpose clearer. I have looked hopefully for an amendment containing a Keeling schedule, or something like that, but I have so far failed to find one. If the noble Lord has by any chance fulfilled his undertaking, I hope that he will immediately call my attention to that and I shall give him a humble apology. I hope that the amendment will be carried.
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