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Baroness Hanham: I hate to disagree in any way with the noble Lord, Lord Hunt, but I do not believe that I said what he said I said. I said that I thought that the board of governors at the moment was inchoate, and that the Bill gives it no particular role. The danger is that it may then become something with which nobody wants to be involved. I agree with him that there must be some parameters if there is to be a board of governors.

I have a great many concerns about this matter, but a particular one which I believe I can raise now is that I am not sure what happens when there is a disagreement between the primary care trust which is commissioning the services, the board of governors that has on it representatives from the local community, which wants to do something entirely different, and the board of directors of the hospital that is trying to manage within a tariff system that does not stack up and against long-term contracts for which it is not being adequately reimbursed.

That seems to me to be a remedy for completely stultifying any system of management and movement at all. There is much to be said for considering the issue more closely if there is to be democratic involvement. All of us in the NHS and managing the NHS have embraced the idea of patient involvement. In my own hospital we have patient/user groups for practically every chronic disorder. That is extremely important because it is suggested that patients will want to be involved on a long-term basis; indeed, the noble Lord, Lord Hunt, said as much. But there is a difference between those patients who come in for a five-day operation and those who are involved in the hospital for months and years because they have a chronic disorder, and consequently become involved and interested, willy-nilly, in the way that the hospital operates.

Is it right that the people who should be involved are those representing people with chronic disorders? Those people will be interested because they already have organisations behind them to enable them to take part in an electoral system. That goes back to what the noble Lord, Lord Lipsey, said about the people who will get on to the board as it is constructed at the moment; they will be people who have the muscle and the power behind them, whether a politician or those who already have a well set-up group behind them. That point needs to be teased out as well as the possible problem of a great deal of disagreement between the three or four elements involved in the whole arrangement, all of which could lead to an impasse if a way forward is not agreed.

Perhaps in passing I may wish the noble Lord, Lord Lipsey, rapid restoration to full health so that he can take part in the remaining stages of the Bill.

Lord Walton of Detchant: Perhaps I may inject a note of caution, echoing some of the concerns expressed by the noble Lord, Lord Lipsey. I hark back

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to the past: I wonder how many Members of the Committee can remember under a previous Labour administration a White Paper entitled Democracy in the National Health Service. That White Paper, which ultimately led to legislation, doubled the number of local authority councillors and representatives on health authorities. Frankly, in many respects the result was disastrous because health authority meetings were dominated by sectional interests and, as the noble Lord, Lord Lipsey, said, the whole health service was politicised.

I agree entirely with the democratic principle. There must surely be a democratic component, but I believe that the independent component must always dominate over the democratically elected people on the governing bodies of the trusts. I hope that the Minister will take note of that concern based upon experience.

Lord Warner: This has been a very interesting discussion. Before responding to some of the points and setting out the Government's position I assure the noble Earl, Lord Howe, that we were not seeking to thwart him in his quest for knowledge. He received an earlier draft of the governance source book. There was already an annex D but he was not privileged to have it. We shall give him a copy after this session. There is now a full version and I believe he had the version that did not contain some of the annexes. We shall check with the noble Earl and we shall place the full version in the Library.

I am grateful to the noble Lord, Lord Peyton, for his concerns about my welfare. I shall refer to some of the points that he raised as they have some substance. I share many of the concerns mentioned in the perceptive remarks made by my noble friends Lord Harris and Lord Lipsey, whom I also wish a good encounter with the NHS and a speedy return to the House.

Some of the debate has been a little pessimistic about the ability of people to engage with the agenda and participate in the running of their local health services. We know that direct elections have had falling turn-outs, but they have often been for multiple-purpose organisations. In many ways health is a single-interest issue that affects all families. We know from other work that has been carried out that single-interest issues attract many people and much participation. We could be being too pessimistic about that.

We have also put safeguards into the Bill to address some of the concerns that my noble friend Lord Lipsey raised about what may be described as entryism by particular interest groups or particular sections of the community. We were pleased to accept amendments in the other place that will ensure that NHS foundation trusts are committed to real engagement with their membership—not just at the outset, when applicants want to secure the Secretary of State's support or regulator approval.

Under Clause 6(2)(b), the regulator will need to be satisfied that the foundation trust has made arrangements to ensure a representative membership.

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Under Clause 36, following authorisation, the regulator may require the NHS foundation trust to take steps to ensure a representative membership; and under Schedule 1, paragraph 24(2)(b), each foundation trust must report on the steps that it takes each year to secure a representative membership. Those records will be made public and copies provided to the regulator, enabling him to assess whether he needs to include requirements in the authorisation. So review mechanisms are enshrined in the Bill for the regulator to continue to reassure himself that the body is a representative of the local community.

7 p.m.

Lord Lipsey: I am extremely interested in what my noble friend is saying. Will he explain what miraculous powers are given to the regulator or, on his instructions, to hospitals to force people to get involved when they do not want to?

Lord Warner: The regulator cannot force people to get engaged if they do not want to. He can review the authorisation of the trust if it cannot demonstrate that its body is representative of the local community. Although my noble friend Lord Desai earlier suggested that there was a politburo in Richmond House, I do not think that we have yet reached the point where we think that we can use the regulator to compel people to participate in the health service.

It is worth repeating the arguments about why foundation trusts are different. They are a new form of social ownership, where accountability for health services is to local people rather than to central government. In that way, a much stronger connection is established between the providers of health services and their local communities, extending beyond the current arrangements for consultation.

Although other systems that have been developed over the years provide for consultation and engagement, they are often perceived by the public and patients as management tools. They are put in place by managers and are liable to be ignored if the results do not fit with what is wanted. To cynics, they represent no real shift of power. Direct election takes the process a significant step further. It provides the right to take part in decision-making and can be the key to delivering genuine improvement.

I am surprised by some of the remarks made when one considers the extent to which parents have been engaged with the education sector. Let us face it, many people elected to local authorities may be what one Member of the Committee earlier described as bungling amateurs, but when they are first elected, they have to take decisions about priorities and expenditure on behalf of their local communities. To suggest that people are incapable of growing into that decision-making is to ignore experience in other areas of public service.

The Bill will provide for democratisation of NHS providers, as we hope that all NHS trusts will become NHS foundation trusts in due course. As I said earlier, we also have no objection in principle to applying democratic or foundation principles to PCTs.

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However, I am a bit doubtful about mandating the review in the way suggested by the amendment. To enshrine that in legislation would commit us to another piece of bureaucracy, which many Members of the Committee have argued strongly against.

However, I should like to reflect further on many of the remarks made by Members of the Committee and consider whether the thinking behind the amendment could be adapted and delivered in another way.

Baroness Carnegy of Lour: I do not think that the Minister should put too much faith in the comparison with the way in which parents are involved in schools. Parents have to do more than half the educating of their children; they are partners with the school all the time in bringing up and educating their children. So they want to be, and are, very much involved. That does not necessarily happen by means of a single parent representing other parents; it is much more about many parents going into schools to discuss with teachers, as the Minister well knows. So I do not think that that is a good comparison.

Also, when the Minister says that he will consider carefully what has been said, I hope that he will pay enormous attention to what was said by the noble Lords, Lord Harris and Lord Lipsey, and my noble friend Lady Hanham. They are people who, from their different standpoints, know very well what happens when people are put on bodies—they are probably members of many other bodies; they go along and take part—and how they justify their existence. I have been one of those people. At one time, I was on about 70 different bodies. I am sure that the noble Lord, Lord Harris, has been on many more ex officio. That may well happen in this context.

I think that what those three Members of the Committee said should point out to the Government that they are taking a very old-fashioned approach to the governance of hospitals, which is in itself a magnificent idea. They may spoil it by using that old-fashioned approach.

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