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Lord Blackwell: I support the spirit of these amendments for practical reasons concerned with the efficiency of governance of these institutions. As set out currently in the Bill, there are two explicit layers of governance—the board of governors and the board of directors. In reality there will be a third level of governance which is the continuing close involvement that the central executive, the Treasury and the various regulators will have.

If a board of directors does not include the key medical directors, the reality is that there would be a fourth layer of governance because there would then have to be an executive group—executive board—that would discuss matters and take the real decisions. A potentially disastrous situation could exist in which a paper being prepared and discussed in an executive committee one week is discussed by the board of directors the next week, by the board of governors the

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following week and then by the regulators. The poor chief executive would spend all his time redrafting, editing and discussing the same paper up and down the chain.

If the board of directors is where real decisions are taken, it is essential, as far as possible, that it includes enough of the real medical practitioners effectively to be the executive group that does not have to be duplicated within the hospital. Often a board of directors in a company will be accompanied by an executive group, but there will not be a board of governors over the top of that—only those two layers. For efficiency we need to avoid having yet another layer of governance within the management processes.

Lord Hunt of Chesterton: Although I am not a medical doctor, I intervene to say that there are many organisations which find that a professional representative on their board is very important. The Met Office has a chief scientist, the GCHQ has a chief mathematician, Rolls-Royce has a chief technical director and British Airways I understand has a pilot—thank goodness. So I think that these thoughts are very important. Managers and finance directors are very important. Great strength and comfort is given to everyone using an organisation to see the professional abilities reflected. Therefore, I support the amendment.

Lord Warner: I cannot tell the Committee how much pleasure it gave me to hear the noble Baroness, Lady Cumberlege, compare our scheme of governance and this legislation to an impressionist painting, when one thinks of the pleasure and value of such paintings. So I take great comfort from that analogy as a result of today's debate.

I have a good deal of sympathy with the arguments made by the noble Baroness, my noble friend Lord Turnberg and others about the role of doctors and, indeed, nurses. Over many years I have listened to the wisdom of the noble Baroness, Lady Emerton, and I listened very carefully to what she had to say today. There is certainly no intention on the part of the Government to diminish in any way whatever the contribution that, in particular, nurses make to the NHS. Indeed, perhaps I may confess that as a very young civil servant I was heavily involved in the Salmon committee and in the writing of its report on the senior structure of nurses. That is where nurses came of age as managers and were recognised as managers in the NHS. So we are not in any way trying to diminish their contribution.

Having expressed my sympathy, I must express some doubts about whether these amendments quite do the trick intended. The amendments are not the same. They cannot all be accepted because they would produce different outcomes. So I shall try and suggest a possible way forward which may help deal with the fact that they do not achieve the same objectives.

We have specified that there should be appointed a chairman, a chief executive, and a director of finance. I am grateful for the recognition of the noble Baroness, Lady Noakes, on the finance issue. However, this does

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not mean that a foundation trust will be established without input on the board. The primary purpose of these organisations is the provision of healthcare. It would be extraordinary if that were not reflected in the constitutions of the board when NHS foundation trust applications are put forward.

The process is that constitutions will be drawn up in response to consultation. The Secretary of State will then examine proposals put forward by applicants, which should include information on the size and composition of the board of directors. I can categorically assure the Committee that no application will be supported by the Secretary of State without clear proposals for robust, clinical leadership at board level, covering medical, nursing and other professionals.

I hope that kind of reassurance will enable noble Lords to reflect further on the issue and not to pursue the amendments today. I also hope that by putting this issue clearly on the record, it will reassure the various professional interests outside this Chamber who have expressed their concerns, which I understand and with which I have a good deal of sympathy. However, I think we may end up with constitutions, which produce a more favourable outcome than some of these amendments might actually produce, if we let that process take place and leave the Secretary of State to reject or accept matters on the basis of their ability to convince him that there are robust, clinical leadership arrangements in the constitution at board level covering healthcare professionals.

Baroness Carnegy of Lour: Before the Minister sits down, perhaps I could ask him whether he agrees with me about something. It has been gradually dawning on me that this board of directors—and since I listened to my noble friend Lady Cumberlege I realise it more clearly—will have politically motivated people upon it. It is very likely that some governors will put on people who they hope will govern for some particular group or other. It may be politics with a big "P" or with a little "p"—often with a little "p". That kind of body is very far from the committee of the Met Office, which wants to have a professional this or that upon it. The nursing profession, and indeed the doctors, have to think about how in a specific situation they are going to be in the strongest position with the board of directors.

Quite often in the education service professionals prefer always to be present, always advising and putting in their input, but not having actually to engage with what may turn into a somewhat political discussion over some aspects of what the directors have to do when managing the hospital trust. So there is another model. If I was organising this, I should want to ask a trust whether they would prefer not necessarily to ask for particular people as members, but to have people present who could have an input without engaging in political discussion. Very often people who have come from the outside world into a trust pay more attention to it than do the professionals. So there is another model. Does the Minister agree that that might be how it could be done,

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or does he not want to enter into that discussion? I think that it is a very important point, but perhaps he does not wish to discuss it.

Lord Warner: I am not sure that I want to trade models with the noble Baroness at this particular point in the Committee. All I would say again is that we want to ensure that there is robust, clinical leadership represented on the board. I do not quite accept her view that it is a foregone conclusion that there will be many politically motivated people on boards of governors. We all have different views and those boards of governors will reflect a wide spectrum of views. That is what one gets in a healthy democracy.

Lord Clement-Jones: Once again, I think that the noble Baroness, Lady Cumberlege, may have put her finger on the issue. In the last NHS reform Bill, I think we had the character of Mrs Arbuthnot as a running theme in the same way as the former Minister had his own mantra. I think that we now have this strong picture of the Minister standing before his canvas, slapping on the paint and wearing his smock. I do not know whether he is Degas or Renoir or what his favourite subject is, but we shall see.

We have had a wealth of experience in this short debate which has been extremely valuable and interesting. I was very interested in the actual experiences put forward by the noble Baroness, Lady Emerton, by the noble Lord, Lord Turnberg, and, in particular, by the noble Baroness, Lady Cumberlege. I thought that what the noble Lord, Lord Blackwell, had to say about four tiers was extremely interesting because there will be a management board unless the clinical side is on the board of directors. So we will have this nightmare of tiered layers of management and governance rising up to departmental level.

However—and perhaps this is unusual for these debates—I was very heartened by the Minister's response. He was robust in the way he responded to this issue, even though he does not accept the case for inclusion in the primary legislation. I think that the insistence that no application can be accepted unless—and I think I am quoting him—"robust, clinical leadership is represented on the board" is a very good step. Of course I should like to see that in the schedule in some shape or form. But the response to the concerns expressed is very good. I think we can build on it. So I beg leave to withdraw Amendment No. 45.

Amendment, by leave, withdrawn.

[Amendments Nos. 46 and 47 not moved.]

Baroness Noakes moved Amendment No. 48:

    Page 110, line 29, at end insert—

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