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Baroness Finlay of Llandaff: This amendment is extremely important, going right to the heart of one of my concerns about issues of equity of provision for those who are ill. Within the population around a hospital applying for foundation trust status, fortunately the vast majority will be well and not in need of the services of that hospital. If we look at the example of King's College, which has already been cited, that hospital has a very large liver unit. Fortunately, so far as I am aware, the local population does not suffer an excessive incidence of liver failure, but many patients come to the hospital because they are completely dependent on those services to remain alive. The unit provides services of excellence that need to be continued and supported. However, I can envisage a local population beginning to resent the amount of time and resources used up by a highly specialised service for people coming from far away. They may take a different view.

I am also concerned that the most vulnerable people who need to use the service would not be adequately represented by the population-based tokenism set out in these proposals. As the noble Earl, Lord Howe, pointed out, it would be almost impossible to detect large pressure groups hidden in whatever statistics the trust may use. They could say, "We represent this percentage of ethnic minorities" or "We represent this age group", and so on, but within that there could be concealed very powerful single-issue pressure groups putting forward very powerful views.

7 p.m.

Lord Warner: As we have made clear throughout the Committee's discussions, NHS foundation trusts will be a new form of social ownership where accountability for health services will be to local people rather than to central government. We start from a rather different position from some Members of the Committee on the Benches opposite. In this way, much stronger connections will be established between providers of NHS services and their local communities, extending beyond the current arrangements for consultation and building on the sense of ownership that many people feel for their local hospitals.

In listening to the discussions, I am reminded that in many other areas reformers have always been challenged to prove a negative in the future. I have a slight sense of that on this occasion. We have made

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clear in the Guide to NHS Foundation Trusts, paragraphs 2.9 and 2.10, that this is a policy designed to secure inclusion, not exclusion. We are trying to bring people into an engagement with their local hospitals. It is not simply about engaging the people who already support the trusts—for example, through patient support groups or the League of Friends. Access to membership needs to be opened up as widely as possible. Applicants for NHS foundation trust status will be expected to demonstrate innovative approaches to ensuring genuine community membership. They will need to demonstrate that they are establishing new and meaningful ways of connecting with the public, patients and their staff.

They do not have to be socio-economic researchers, as someone said, to engage in a more constructive way with the wide range of people who use their services. We have debated user involvement in services for at least two decades, to my own knowledge and experience. We are not starting afresh. We are operating in a context where large numbers of people involved in health and social care have been trying to engage with their communities and users.

As the noble Earl said, concerns were raised in another place that the governance arrangements of NHS foundation trusts might be subject to, he called it crudely, "entryism"—I am quite comfortable with the term; we know what it means—by interest groups or particular sections of the community. Similar concerns were raised by the Health Select Committee in paragraph 43 of volume 1 of its report on NHS Foundation Trusts. It stated:

    "Foundation Trusts must proactively attempt to extend registration so as to achieve real and representative community engagement. This, including the involvement of disadvantaged groups, should be an issue both in assessing applications for FTs and an on-going responsibility for the attention of CPPIH or, failing that the Regulator".

So there is a real understanding across Parliament—certainly in another place—that there has to be an attempt to make the membership of foundation trusts broadly based.

We have listened carefully. Noble Lords have sometimes suggested that the Government have not been listening, but we have listened both in another place and here. I have already agreed to a number of amendments and to consider further other amendments. We have listened to the concerns about entryism expressed in another place and we have accepted amendments there which ensure that NHS foundation trusts are committed to real engagement with their memberships. The requirement for the regulator to be satisfied that an NHS foundation trust's membership will be representative as a condition of authorisation is one such provision. The amendment moved by the noble Earl would remove this provision and weaken the safeguards against entryism.

If noble Lords are concerned that it is not within an NHS foundation trust's gift to ensure that its membership is representative, and that therefore an applicant may be refused authorisation simply because

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it has not been able to build up a representative membership, I can assure them that that is not the case. An NHS foundation trust will not have to persuade every person who is eligible for membership to get involved in order to achieve a representative membership. We are not being unrealistic about this. However, it is important that they are proactive about engaging minority or "hard-to-reach" groups. A number of noble Lords have raised concerns about such groups. We are trying to ensure that a real effort is made to engage with them. It has often been the case in the past that the NHS has failed to engage with some of these hard-to-reach groups.

There are many mechanisms for doing this, and to help applicants develop their membership and governance arrangements the department has produced a governance sourcebook, which has been made available to noble Lords and a copy placed in the Library. This provides for a range of good practice and case studies showing different approaches that have been applied in other areas. It has been put together by the Department of Health drawing on a wide range of contributions from business, public and third sector organisations.

Some noble Lords have suggested that we have been engaged in a silo approach, beavering away in Richmond House to draft all this without engagement with the outside world. I agree that life may be more comfortable like that, but that is not the way we have been working. If you look at the sourcebook you will see that we have not been afraid to look at good practice in other areas relevant to this field. The sourcebook is, as they say in the trade, a "living document". It will be supplemented with learning from the experience of the first wave applicants. I have already given assurances on that.

As I said, it would be perfectly acceptable for an applicant to start off with a relatively small membership, provided its application included suitable proposals for engaging its stakeholders and increasing its membership.

We recognise that this is a great change; we recognise that Rome was not built in a day. In bringing forward their proposals we are asking people to show that they have considered the issue of reaching a good cross-section of people who could reasonably be expected to be a part of the membership and how they are tackling the problem of trying to engage with hard-to-reach groups.

We have tried to respond to the concerns expressed in another place about entryism. I hope that the noble Earl will not pursue the amendment because it would damage those safeguards.

Baroness O'Neill of Bengarve: The Minister has given excellent arguments for being inclusive and for good practice in recruiting, but he has not given any arguments for thinking that those good practices will end up producing a representative cross-section of those eligible to be members. It would be better if it were not stated on the face of the Bill that the target of good practice is to produce something that is

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representative or a cross-section. The Minister stated that that was not the intention. Could he not remove these words from the face of the Bill?

Lord Warner: We do want it to be representative. I said exactly the opposite. I said that we accept that it may take time in the initial stages to build up processes to ensure that a good cross-section of people representative of a particular foundation trust are involved in the membership of that organisation. As I have said before, we are saying that in their application, they need to show that they have a game plan for addressing that issue and will move forward in an orderly way to ensure a better cross-section. We are unapologetic about trying to be bolder in this area.

Earl Howe: The noble Baroness, Lady O'Neill, hit the nail on the head. It is fine to have an aspiration for achieving a representative balance of members, but do we need to have that on the face of the Bill? This is a very difficult requirement to fulfil. The Minister seems to have given us a way forward for foundation trusts that is essentially a fudge.

I asked whether a hospital was supposed to engage in socio-economic research or not. The Minister suggested not. I cannot see how it can fail to have to do that if it is to demonstrate to the regulator that it has fulfilled the requirements laid down here. How, in practice, is a trust supposed to achieve a balance of membership that is truly representative? It can reach out to hard-to-reach groups, but how is it to enlist members who do not show any interest in becoming members? The trust may make an effort, but what if it does not succeed? What happens if a hospital—

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