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Baroness Finlay of Llandaff: My Lords, this has been a very complex debate to date. We have had complex speeches previously and very powerful speeches at this stage. I do not wish to detain the House for very long. I would simply like to represent to the House the concerns of healthcare professionals. In every system that they have worked in, they try to look after patients who are extremely ill.

New technologies are emerging very fast in healthcare—faster now than in the days when I qualified. There is a very real concern among those trying to deliver frontline care—the care that counts at the end of the day—that the changes proposed will truly enable them to do their job better than they do at the moment. There is a desperate plea to remove the hand of interfering politics from the way in which healthcare is delivered. Healthcare has to be delivered to absolutely everybody with a degree of equity based on need, not on demand.

I sincerely believe that the healthcare professionals will function professionally in whatever system is in place, because they have high ethical standards and codes. The Minister has certainly listened very carefully to comments that have been made and I will not be speaking to my amendment in this group because it has been superseded by a much better amendment tabled by the Minister.

This has been a complex debate, but we are being asked to take a leap of faith. Will the new arrangements improve or burden the top end of the health service? Will consulting with local people really improve the way that healthcare is delivered at the coal-face with this revolution before us, or were we better off looking at evolutionary change? Change is certainly needed. Nobody is a dinosaur. Nobody is against change, but there are some real concerns about how these arrangements will work in practice.

Many of your Lordships will have received correspondence from population groups concerned that somehow they will not be consulted on hospitals that they use. A sense of disenfranchisement is beginning to be felt by some groups from the hospitals that they would like to have a role in.

The Minister has a huge burden on his shoulders and I do not envy him, but the task to convince many Members of this House that the proposals before us will really bring about change and will be worth the expenditure and upheaval involved in them is difficult to undertake.

Baroness Barker: My Lords, the noble Lord, Lord Lipsey, set us off on the right question for this debate—whether the legislative process in relation to this Bill has worked. We on these Benches are convinced that, at this stage, it has not. We have in front of us one central question to answer: do the proposals add up to a National Health Service delivering a truly national health service with all that

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is good about local knowledge, involvement, participation, flair and imagination? Is what is proposed fit for its purpose? At the end of a very long and detailed Committee stage, we have come to the conclusion that it is not. The noble Earl, Lord Howe, pinpointed the one factor that belies that—the way in which the Secretary of State runs through this legislation from beginning to end as the final arbiter.

The noble Lord, Lord Desai, in a characteristically rambunctious speech and the noble Lord, Lord Turnberg, and others, have talked about the dead hand of regulation on the NHS. This proposal will not change that at all, but it could be changed very effectively and quickly. The best thing that could happen to the NHS is a bonfire of targets, but we do not need this legislation to do that. In fact, it makes it worse. The Bill is the worst of management-speak and targets.

The noble Lord, Lord Hunt, was near the mark, but wrong. He described the Committee stage as long on detail and where there were many answers. That is true, but there were many key issues on which there were either no answers or the wrong answers. Those of us who care about a National Health Service that works well locally have considerable concerns about the equity—as the noble Baroness, Lady Finlay, mentioned—and ethics of setting healthcare targets, and about the need to safeguard those with specialist needs and those who are the expensive patients in this new world of tariffs and diagnostic treatment centres. We did not receive convincing answers on these matters, which are the key issues we have to decide.

I have not yet met a healthcare worker who has not said that what they want is to provide healthcare, which is what they should do. We should be requiring local hospitals to focus completely on that. It is not their job to give the Electoral Reform Society a run for its money on questions of governance. Ultimately, we have failed very badly in the proposals in this amendment.

Many of the early hospitals in this country were charities. In my working life I advise charities on governance structures and constitutions. I would not advise a charity to accept these proposals and hope that they would be fit for any purpose, still for less for running a hospital service on which, as the noble Lord, Lord Lipsey, said, people's lives depend.

In voting against these amendments today I believe that we give ourselves and another place one more chance to do our job properly. It is for us to sort out a system of clear membership, decision-making and accountability. It is for us to do our job properly so that health workers can do theirs without hindrance.

12.30 p.m.

Baroness Noakes: My Lords, I shall not repeat what my noble friend Lord Howe said at the beginning of this debate, but address one specific issue which the noble Lord, Lord Hunt, has described as generosity itself, which is to say, the government amendments to Schedule 1. We concede that the Government have tabled some amendments which help to tidy up the drafting. That was in response to points pressed by a

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number of noble Lords in Committee. But we wish to make it quite clear that these are not concessions or generosity, but the ordinary act of a department tidying up an ill drafted Bill. Ultimately, there are many significant concerns—and the noble Baroness, Lady Barker, referred to some of them—which are completely untouched by these amendments. I wish noble Lords to be quite clear on our position on the amendment.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner): My Lords, it has been a colourful debate: we have had reference to ships and barnacles and gothic architecture and buttresses. It has also been a pretty synthetic debate as regards contributions from some parts of the House. I am grateful for the wise and balanced contributions from my noble friends Lord Desai, Lord Hunt, Lord Dubs and Lord Turnberg, from the right reverend Prelate and from the Cross Benches, particularly the remarks of the noble Baroness, Lady Finlay. I am also grateful for the temperate and balanced response from the noble Lord, Lord Blackwell. I hope that I shall be able to detach him from his party, having heard what I have to say.

I wish my noble friend Lord Lipsey a speedy recovery despite his remarks. I share his views on the staff at St Thomas's hospital and on NHS staff generally, but not those on the Government's arrangements. I doubt whether I shall change his views with my advocacy. We shall not have time during this debate to go through the details of this group of amendments.

As I said, I believe that there is a synthetic quality to this debate. The Conservative opposition say that they believe that our approach is fundamentally right, but our proposals on NHS foundation trusts do not go far enough. They are in alliance with the Liberal Democrats, who believe that they go too far. From these totally different perspectives they want to combine to wreck a core element of the Bill, the establishment of NHS foundation trusts. Talk about my enemy's enemy is my friend!

The biggest would-be wreckers are the Conservatives, who do not appear to be content with deleting Clause 1. They appear to want to remove the whole of Part 1 of the Bill. At least the Liberal Democrats have confined themselves to Clause 1. It may be that they want the image of a mini-opposition. The noble Lord, Lord Clement-Jones, is reported in the Independent today as saying that we are cack-handed. But lining up with the Conservatives on this issue hardly seems to be a masterpiece of political coherence.

Perhaps I may briefly remind noble Lords opposite that the NHS needs a huge level of investment after the long period of neglect by the party opposite. It certainly looks as though the NHS would return to that parlous state if the new Conservative leader, crowned today, I believe, ever reaches No. 10 Downing Street. We have invested about 8 billion in capital since the 2000 NHS Plan, that is to say, over the

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period 2000–01 to 2003–04, and we are increasing revenue expenditure by over 7 per cent a year in real terms for five years in succession.

The noble Earl, Lord Howe, brushes these considerations aside and asserts that the needs of foundation trusts would deny the rest of the NHS access to the huge amount of extra money that we are providing. That is simply not true. If the foundation trust applicants remained as NHS trusts they would still be competing for the enhanced resources with other NHS trusts. There would be a priority system in that capital allocation process. We have not changed the rules of the game in that respect; all we have done is to give foundation trusts far more freedom.

The idea that we are damaging the NHS through this Bill and that the Conservatives are the saviours of the NHS by wrecking it will convince very few people other than their own supporters, whose morale needs to be maintained. Our huge investment in the NHS has to be accompanied by modernisation and reform with far greater local freedoms for the NHS at its heart. My noble friend Lord Hunt has put the case extremely well.

NHS foundation trusts bring these local freedoms, but removing Clause 1 would prevent that. We know that local staff and communities have often felt disempowered by top-down control of the NHS while a lack of local accountability has impeded local services being properly attuned to the differing needs of their communities. These are the important considerations to which the right reverend Prelate was alluding when he spoke about trying to produce the most satisfactory ethos for the NHS.

The scare-mongering approaches that I read in the paper and which were mentioned by others today, whipping up arguments about extremists in the BNP taking over boards of governors, do them no credit. We have brought in safeguards against that. It will also be possible to make further amendments in regulations, as I believe is well known. That is why I referred to the synthetic quality of some of the debate.

The party opposite does not appear to want local people to have a bigger say in how the NHS is run although it claims to want to have local sheriffs. If the noble Lord, Lord Clement-Jones, wants to improve the governance arrangements he should settle down with us today and tidy up Schedule 1 rather than endlessly looking for reasons for not trusting local people to have a bigger say in the NHS.

The creation of NHS foundation trusts is part of the process of moving from an NHS controlled nationally towards an NHS where standards of inspection are national, but delivery and accountability are local, with far more diversity of provision including the involvement of the private sector, offering more choice to patients. That will create the kind of beneficial ethos that the right reverend Prelate was rightly concerned about with far more local involvement by staff and patients in their local healthcare system.

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The noble Lord, Lord Walton, and the noble Baroness, Lady Finlay, rightly drew attention to the concerns of the healthcare professions. These changes will give them far more autonomy and freedom than there is at the moment. They will have a bigger say in the way in which their local NHS is run. Despite whingeing about excessive control, throughout the consideration of this Bill some of the parties opposite have consistently wanted to stop the devolution of power, if their amendments are to be believed. They are certainly giving out the message to all those applying for NHS foundation trust status that their views and preferences do not count.

Perhaps I may turn to that point and remind noble Lords opposite of what I said on the first day in Committee. As we speak, 25 NHS trusts are consulting on proposals to apply for NHS foundation trust status from next April. Now, another 32 have applied to be considered in the next wave. They include many deprived areas where healthcare systems can be better adapted to local needs. If all those applications were successful, more than 25 per cent of the population in England would have access to NHS foundation trusts by the end of 2004. We have said that there is no reason why all NHS trusts should not achieve NHS foundation trust—

12.45 p.m.

Lord Hoyle: My Lords, before my noble friend sits down, will he tell me why, if this is such a good thing, we did not have a pilot or pilot schemes? That would have allayed the fears of people like me who believe that we are setting up a two-tier health service.

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