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Lord Lipsey: I had planned to play a full part in the deliberations on the Bill, many parts of which interest me, but unfortunately I must user-test one of our great hospitals. Therefore, this may be the only opportunity that I have to speak. On the issue of governance raised by the amendment my feelings are so strong that I hope the Committee will indulge me and allow me to say what I profoundly believe.

I start with two preliminary points. First, in our opening debate this afternoon, speakers on all sides of the Chamber were worried about the over-politicisation of the health service. They wanted an independent agency. That might be one method; there could be others. None the less, they were worried that there was too much politicisation and too much political intervention in decision-making. But this Bill seeks to create a system that embeds politics in the management of our hospitals. Is that what we want?

As someone who takes a keen interest in electoral matters, perhaps I may be forgiven a second observation. I observe not only in this country but throughout the world a decline in participation in elections. At the Brent by-election I believe that the turnout was 36 per cent. That poses grave questions in

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all kinds of areas. However, to respond to a decline in public eagerness to participate in elections by creating yet more seems to me most eccentric. We are in danger of inviting people to spend their whole lives going out and voting, which is the last thing they want to do. What they want is a better health service which provides for their care.

Like the noble Earl, Lord Howe, who raised this matter, I believe that a profound confusion is causing us to go adrift here. It is a confusion between something that is absolutely good and important—that is, democratic accountability—and one particular method which is occasionally appropriate for promoting that, which is election. The two are not the same. I could give examples of many methods by which democratic accountability can be well promoted, such as citizens' juries, consultation exercises and polling. A full range of very interesting techniques achieve what most people want and enable that to be fed in, but I am afraid that election is not a very good instrument in that respect.

We must think about consequences when aiming for better patient care. What are the consequences of elections? Let us be concrete and get away from the abstract. First, I believe we can be fairly certain from experience that most elections will be run on a party-political basis. There will be a Labour slate for the hospital, together with a Tory slate and a Liberal Democrat slate. That is what happens with local councils and with every other kind of election. Of course, where there are party slates, there are whips. Before long, in many cases our hospitals will be run by whipped party activists, many of whom will be good people and many of whom will be bad. However, I do not believe that that is an enormous leap forward to democratic accountability.

Secondly, in some cases—I hope, a small minority—the elections will present an opportunity for extremists; for example, the National Front, which does not want immigrants to be treated. Under the proposal, that organisation will have only to sign up a few of its people and pay a few quid and the votes will be purchased to elect extremist candidates. Will that lead to better patient care? In my judgment, it will not.

The third consequence will be the single-issue candidate. The primary care trust, in setting priorities, will say, "We are not going to spend so much on grommet operations in future. They don't work and we don't much like them". The surgeon who is threatened by that may say, "Oh God, save our grommets". He will have a patient, whose child has recovered from an ear infection, saying, "You know, it's the grommet that did it. I must stand for election and stop this happening". That patient will stand and it will be a very attractive campaign. It will receive media attention and there is a good chance that he will be elected.

The final consequence will be a deep conservatism—not with a large "C" but a small "c". It will make the process of change, which is so desperately needed in our health service and our hospitals, not easier but harder because people will be elected precisely because

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they resisted change, just as the Member for Wyre Forest in another place resisted the closure of his local hospital. He had every right to do so; I do not claim that he should not have done. However, I do claim that hospitals governed in that way will be less well governed from the point of view of the only thing that matters—that is, patient care.

On the general concept of foundation hospitals, I can see what the Government are trying to achieve and I am not unsympathetic to it. But surely it would be tragic if a good idea was spoiled because it became mixed up with some half-baked thinking about democracy and democratic accountability when we could have better thinking in relation to all those things and make a greater success of what we are proposing. Because the amendment of the noble Earl, Lord Howe, tends to suggest ways in which we could consider the issue and make progress, I support it and I hope that the Government will think again about the governance arrangements. I say "think again". That gives them the benefit of the doubt in suggesting that they might have thought about them in the first place.

6.45 p.m.

Lord Peyton of Yeovil: I shall be brief. I have a knee-jerk fear of any proposal which suggests that we should have more reviews. We live in a country full of people who are reviewing and monitoring other people, examining the results and reporting them because it is their duty to report. The country is flooded with quite unnecessary, rather ill-written paper which results from such activities.

It is not part of my intention to be over-helpful to the Minister on this occasion, but here I find myself wondering what the effect of my noble friend's amendment will be. Only a limited proportion of the people engaged in the National Health Service are at the sharp end and ever have the effect of making someone feel better, which is the object of the exercise. I should like to know whether my noble friend is certain that his proposal will not take up the time of people who might be better engaged looking after and caring for patients and repairing the patients.

Lord Hunt of Kings Heath: Rather like my noble friend, I was attracted by the wording of the noble Earl's amendment, although not by the arguments that he used to further his cause. As we have already discussed this afternoon, I believe that there is a case for a serious examination of democratic accountability in governance within the health service that does not confine itself only to foundation trusts but looks at the whole organisation of the NHS in a holistic way. I do not believe that we can run away from the fact that we need to consider this matter from the point of view of the whole system rather than simply NHS trusts.

However, I believe that the noble Earl is wrong when he says that patients should not be involved in running hospitals. I believe that they should be involved, just as I believe that it is right that we, as

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parents, now have a big say in the running of our children's schools. Surely we have something to offer as users of services, not only in a consultative way but in helping to run those organisations, which, after all, are there to serve the public of this country.

I believe that some of the risks that have been postulated around involving local people in the running of their hospitals have been exaggerated. Surely the first point to make is that there is not a hope in hell of transferring accountability from national politicians to the local level without a democratic process at the local level. That is why I do not agree with the national agency approach. The only way in which that can hang together is if local people have a democratic involvement and a right in running their own local health services. That is why it is so important to have a governance structure that allows local people to put their names forward and to be involved.

Hand on heart, I do not pretend that the governance structure in the Bill is perfect. There are problems and I still believe that there is a problem in terms of the powers of the governing body. I disagree with the noble Baroness, Lady Hanham. I believe that the problem is that the governing body has not been given sufficient powers. As far as I can see the only power that it has is the nuclear option of the appointment and replacement of the non-executives and the ratification of the appointment of the chief executive.

I hope that when foundation trusts take forward their proposals they will look closely at ways of involving the governing body in the decision-making process. The worst option would be for people to be elected to the governing body and then to find that all power resides in the board of directors. It will be very important indeed for the board of directors to ensure that when the governing body comes together the board is asked to be involved in the decision-making process.

On an optimistic note, I do not accept the fears of my noble friend Lord Lipsey that the involvement of local people in running their hospitals will lead to a fossilisation or will be a bar against progress. I advise, in an honorary capacity, my own local trust—the Birmingham University Trust—and I have been really excited by the proposals that it has put forward in its consultative document about the way in which it wants to involve local people. The trust also wants to co-opt on to the governing body the leaders of local government, the Churches and industry and for there to be strong staff involvement. Far from being a conservative body, or a body that will get in the way of progress, I believe that it will add enormous strength to that organisation. The progress that has been made in the past few years in that institution will be enhanced and increased in the future.

By all means let us look at democratic accountability across the whole range of NHS services and commissioning, but let us also see whether we can improve the governance structure. I hope that at the

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end of the day we shall accept in Committee that local people and patients have the right to be and should be involved in the running of their local services.

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