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Lord Hunt of Kings Heath: My Lords, I hope that the House will support my noble friend and reject the Motion proposed by the noble Earl, Lord Howe. We have debated the issue of foundation trusts through the many stages of this Bill. Although noble Lords have expressed some concerns and issues have been raised at each stage, the fact is that this House has asked the other place to think again, the other place has done so and, by a majority of 17 votes, it has decided to support the implementation of the policy to introduce foundation trusts.

Surely the role of this House, as a revising Chamber, has now been fulfilled. It has asked the House of Commons to think again, which it has done. We could argue about the size of the majority, but a majority is a majority and, for me, a majority vote of 17 is sufficient for the decision to have been made.

The role of this House is to question, to challenge and to revise. Were any objective commentator to look at the process of this Bill, he would conclude that the Government have listened. My noble friend has accepted a number of amendments proposed by myself and other noble Lords. In fact, a considerable number of amendments have been voted on and accepted by the Government.

Today, the Government have accepted a suggestion that the first wave of foundation trusts should go forward and then should be subject to review by an independent body before other NHS trusts are allowed to become foundation trusts. What could be fairer than that in terms of listening to, thinking about and accepting the views and concerns of noble Lords in this House? The Government have said that they will review the position. They will ask an independent body to look at what progress has been made before any further NHS trusts can become foundation trusts. Is not that the purpose of this House? Noble Lords have asked the Government to look again at their proposals and the Government have done so. They have

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modified their plans to accommodate a review of how the first tranche of foundation trusts goes forward before others are allowed to follow. On what possible basis can this House now say that it will reject the views of the elected Chamber?

What is the purpose of the creation of foundation trusts? Surely it is this: it is to ensure that, over the next few years, the NHS is governed and run in the most effective way possible. After the way in which the NHS has so far been run—through micro-management, central diktat and a central accountability to Parliament which inhibits and gets in the way of innovation and local implementation of national policies—does anyone suggest that we ought not to move on to a more devolved system of administration? That is what foundation trusts will do. Surely we should put our trust in local people to elect their fellow citizens to take part in the governance of the NHS in the future. That is what foundation trusts will do.

The Government have listened. They have revised their proposals and, ultimately, the other place has decided, through a democratic vote, the way in which it wishes to go. For the sake of the NHS, surely we should now allow these measures to go through.

Baroness Finlay of Llandaff: My Lords, at this late stage of the Bill I hesitate to return to the core issue, but I should like to do so. The devolved administrations of Wales and Scotland do not wish to head towards foundation trust status and yet people in central administration in those bodies are extremely close to the populations they serve. That is not in any way to swipe at Parliament as it stands, but it is worth noting.

It is also worth noting that the BMA wrote to MPs prior to the vote today and reiterated its arguments. It has been following closely the debates in this House and there is concern in the profession that this marks a return to the internal market of the early 1990s and that the establishment of foundation trusts will prove divisive and exacerbate the inequalities in the NHS—and no one denies that there are inequalities in the NHS.

The encouragement of competition could fly in the face of the fantastically good work that has been done with the establishment of collaborative clinical networks, particularly the cancer networks, that have been driving up improvements in clinical care.

Not all hospitals are of an equally high standard and we should aim to level up standards of care. There is a real concern that those in the first wave will have an advantage. What will happen if foundation trusts concentrate on the areas of service provision that are profitable and easy to manage, as seen within the private sector? Prior to coming into the Chamber today, I phoned a consultant in ITU to check that I had my facts right. Patients eligible for NHS treatment but treated in private hospitals are indeed transferred to NHS ITUs when resources are not available in the private sector. That is because the NHS as it stands is able to provide comprehensive care for the very sickest people in our population. But it is not profitable care

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and I cannot see how a foundation trust will want to indulge in the most unprofitable parts of care provision, particularly with the targets set as they are at present.

The primary care trusts' commissioning powers could potentially be undercut by these new providers within the hinterland of their governing body. I listened to the debate in another place and the Minister did indeed refer to a review after the first year. But, of the questions that were posed, two were not answered. First, what happens if these foundation trusts are failing? Will they revert to the NHS as they were before? The second question that was not answered was whether the review would address the impact of a foundation trust on the total health economy of the population being served. Unless a review addresses that, we will simply be putting blinkers on those conducting it regarding the way in which a total health economy could be affected by these changes.

It has been said that there is no evidence that foundation trusts will damage local health economies, but is there any evidence that they will improve care and the local health economies? I have pleaded on many occasions for evidence-based management in the NHS, and I make that plea again. We are looking at an idea driven by any political mantra that one might choose. I speak as a Cross-Bencher and not a party member, but I work in the NHS and I find myself in a bizarre position because of that. I see the burgeoning pressures on the service as it is now, the imbalance between capacity and demand. How do we put the patients' needs back at the heart of all aspects of healthcare?

Currently, the priority seems subtly and inexorably to have shifted from the patient to the paperwork and the management response to targets. I am not sure whether evidence as such—scientifically evaluated evidence—is really driving this debate or whether it is political ideas and headlines.

Perhaps the whole NHS needs a very simple message, and it may be completely obvious. First, every healthcare professional at every level should make sure that the patient is comfortable in body, mind and spirit, however that needs to be done. Secondly, they should ensure that the relatives are calm and understand what is happening. Thirdly—and this should be done only after the first two tasks have been completed—they should fill out the paperwork and see whether the management targets have been met. Perhaps we could prioritise patients again by going over to a mantra of "123", rather like "ABC" for resuscitation. I am not convinced that management changes at the top will achieve that.

The way in which the patient is made comfortable must be evidence-based. Similarly, management changes must be evidence-based. I ask the House to look at whether there really is evidence that these management changes will bring about the outcomes that are hoped for in the Bill.

I do not want to comment on the way in which votes have been cast in one way or another. It feels uncomfortable to be speaking with a time limit of the

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end of this Session of Parliament. I sincerely believe that if we had had more time to look through these proposals, more might have been achieved.

10.15 p.m.

Lord Phillips of Sudbury: My Lords, I should like to take up one point made by the noble Lord, Lord Hunt of Kings Heath, whose views on these matters the House respects greatly. He rested his case on the need for greater devolution in respect of hospitals. I think he would accept that these Benches need no lessons on the virtues of devolution. It is an article of faith for us that government has been far too centrally administered by this and previous Administrations, and that the more devolution we have, broadly speaking, the better for this country. The issue, however, as was well stated by my noble friend Lord Clement-Jones, is whether the means and extent of devolution which these proposals would entail might be discriminatory and unequal in their impact.

If we are to have devolution—and, in principle, these Benches are wholly in favour of it—let us have devolution for all. Let us avoid some of the discriminatory effects that will flow from the Government's proposals and the bureaucratic and governmental flaws that we believe are part of the proposed system.

Baroness Noakes: My Lords, my noble friend Lord Howe has already eloquently set out the views of these Benches on why we continue to believe that the foundation hospital proposals are misguided in this Bill and why they are harmful to the NHS overall. We are quite used to the Minister not listening to the views of these Benches—

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