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It stretches the imagination to think of Saudi Arabia in the context of gender equality but it also stretches the imagination to see it as a developing country. I wonder why it is in the G20 in that case.

I know that my noble friend will be prevented from commenting on this aspect of less than good governance because of diplomatic protocol, but I raise it to illustrate how we the member countries need to build smart alliances with other like-minded players to prevent perverse outcomes which simply heap ridicule on bodies which have important roles.

The UN agencies operate in challenging environments and perhaps our expectations of them are too high. However, as the multilateral aid review points out, it is our obligation to secure the best possible outcome for UK taxpayers and we must continue to press for our reform priorities if we are to maintain public confidence in the UN system, which it benefits us to do.

8.51 pm

Lord Judd: My Lords, while I congratulate my noble friend on his initiative in securing this timely debate, I must also thank UNA-UK for the very helpful briefing material that it has provided.

In our now completely interdependent global community, the value of effective international co-operation cannot be overstated. It is essential to generate a real sense of community and of shared challenges and shared objectives in meeting those challenges. We must be ready to learn from each other and avoid counterproductive dangers of competition for influence and power as part of which we may be tempted to misuse our aid programme. That is why the UN agencies, with their representative global membership, are so important. However, I am certain that to fulfil their potential it is essential to improve their integration and co-ordination.

I will concentrate in this debate on three vital agencies facing actual and potential shortfalls in funding. These are agencies that would particularly benefit from strong UK support, financial and political. The UK is on the governing board of all these three agencies.

The first is UNESCO. UNESCO is currently facing a shortfall of at least $65 million and has been forced to temporarily halt some activities as a result of the sad US decision to withhold dues following the acceptance of Palestine as a UNESCO member. Two US laws enacted in the 1990s prohibit the funding of any bodies that admit Palestine as a member. Therefore, the US is not paying the dues that it owes for this year of $65 million and has suspended future funding. The US normally contributes 22 per cent of UNESCO's budget. Israel has also frozen its contributions and Canada has indicated that, while it will continue to pay its regular dues, it will not provide any additional funding.

I warmly congratulate the Government, who have just been elected to UNESCO's executive board, on having indicated that they will not cease funding. The UK could play a significant role in supporting UNESCO during this period. I know that the agency scored poorly in the March 2011 DfID multilateral aid review, but its funding was not cut because the review confirmed its unique contribution to education, development, science, culture and heritage. The agency has since

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undergone a reform process that has seen, among other things, a stronger focus on girls' education. The UK should work closely with other executive board members to ensure that UNESCO improves its performance and to encourage other states to plug the funding gap.

The UN Population Fund, which is the UN's lead agency for population matters, reproductive rights and family planning, is also coming under fire in the US. Pro-life Republican representatives have blocked the Senate Appropriations Bill, which contains the US voluntary contribution to the agency. The fund categorically states that it does not promote abortion and nor does it espouse coercive policies such as China's one-child policy, a claim made by the agency's critics in the Senate. The agency of course had its funding frozen during the George W Bush era, even though a 2002 State Department investigation absolved it of these charges. President Obama reversed the decision in 2009. Over 90 per cent of the agency's funding is voluntary.

This year, the global population breached 7 billion people. An estimated 215 million women who wanted to delay or avoid pregnancy were unable to afford or access contraception, and half a million women and girls died from childbirth-related complications. The fund's work to support family planning and safe motherhood, and to provide essential information on population trends, has never been needed more. Given the UK's strong focus on women's and girls' health, it is imperative that it does all it can to support the fund's work, both financially and politically. As with UNESCO, the UK is in a key position as a member of the agency's executive board.

UN Women, the new UN agency for gender equality and women's empowerment, began work this year. In the past, the four main UN bodies working on gender issues lacked the cash, clout and co-ordination effectively to champion equality and empowerment. UN Women consolidates these bodies, absorbing their mandates and acting as a voice and focal point for gender issues within and outside the UN system. In 2010, the UN General Assembly agreed a budget of $500 million for the new agency-far short of UNICEF's $3 billion, but significantly more than the combined budgets of the four previous gender entities, one of which of course was UNIFEM. However, the agency has faced a severe shortfall in funding from the outset-just 1.4 per cent of UN Women's budget comes from the UN's regular budget, and, six months into operation, it had received a little more than a fifth from member state contributions.

The UK's decision to provide UN Women with £10 million a year for the next two years is to be warmly welcomed; but it is essential that the UK-which is on its executive board-reviews whether there is more it can do, both financially and politically, to support this new agency. UN Women is not only a vital tool to further the UK's gender and development priorities but a flag bearer for improved UN co-ordination and reform.

The current world situation, of which the Arab spring is a telling example, means that the ILO is potentially a particularly relevant player in global

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affairs. I am therefore glad that the UK Government will remain a member and that our basic dues will continue to be paid. However, I am deeply concerned that DfID is no longer to provide additional voluntary funding. This averaged £6.6 million from 2006 to 2010. I fervently hope that it is not an inflexible position, and that DfID will indeed continue to contribute funding for specific in-country projects on a case-by-case basis.

There is room for some concern, lest the criteria used for the multilateral aid review might not always have reflected the remit and mandate of some of the UN agencies under scrutiny. For instance, the criteria appeared to be weighted towards shorter-term interventions in the poorest and most fragile states. Those are utterly worthy and proper objectives in themselves. However, many of the agencies-for example, the FAO-place more emphasis on medium to long-term development. Others have also had wide-ranging programmes that cannot be classified as aid and mandates to operate in developed as well as developing countries. That has always been their purpose. Are we really changing our basic attitude towards organisations that we helped to found?

As I said in my introductory remarks, international co-operation is absolutely essential to our future. The Government seem to be taking a positive and responsible position. If we can spur them on to put even more muscle into the international dimension of policy, particularly as the economic situation recovers-we hope-the better it will be and the more it will deserve support from all parts of the House.

9 pm

Lord Liddle: My Lords, we all owe a debt of gratitude to the noble Lord, Lord Hunt of Chesterton, for initiating this debate in this rather late dinner break. It has provided us with food for thought, even if we will not get much real food later as a result of it.

The noble Lord, Lord Hunt, reminded us what a visionary concept the United Nations was, coming out of the Second World War, and how it saw the problems of the world in terms not of a narrow diplomacy of interstate relations but of global issues that needed to be tackled collectively. That logic has grown more powerful, not less, over time, given the collective action deficits in areas such as climate change with which we now have to grapple. Therefore, the logic of UN agencies is very strong. As the noble Lord, Lord Hunt, reminded us, there are many achievements. As the noble Lord, Lord Judd, reminded us, those agencies tackle many difficult issues of central concern such as population and the rights of women.

Britain should strongly support this kind of multilateralism because we should aim to maximise our impact in the world through a pooling of efforts. Multilateralism through the UN has a special legitimacy. I am sorry if this sounds like a political point in a partisan debate, but given the Foreign Secretary's talk of restoring traditional diplomacy is there not a risk that we are devaluing the importance of multilateralism and the good that it can do? I speak particularly of the United Nations in that context. Britain has always believed that it can punch above its weight in the

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world. We can and we do, but all the time, as economic power is shifting away from Europe towards the East and other parts of the world, that weight is declining and punching above it is less effective.

It is a mistake to prioritise traditional bilateral diplomacy at precisely this time when what we need is more multilateralism, so we should strongly support the UN agencies. It is easy to criticise some of the aspects of their management. I welcome the multilateral aid review that DfID has carried out. DFID, of course, approaches these issues from its own distinctive development perspective. There are arguments for agencies that concern not just international development, as the noble Lord, Lord Hunt, pointed out. For instance, the work of the ILO in promoting decent labour standards is absolutely fundamental if we are going to maintain a world of free and fair trade. It needs to be developed. It does not often deal with the problems of the very poorest countries, but it does deal with issues that are vital if the legitimacy of the world trading system is to be maintained.

Let us not knock the UN and its agencies, and let us not apply too narrow criteria in assessing their work. The UN, for all its imperfections, is something on which we need to build. Of course we should have a credible policy for reform, but I do not think that we can lecture the rest of the world about the need to reform the UN agencies when we take such a negative view of reform when it comes to the management of economic institutions such as the IMF and the World Bank. It gives us no credibility to call for reform in other areas.

We will not get very far simply by lecturing people from the outside. We have to work on a reform agenda with people who share our concerns. In particular, we have to try to identify the best people for top management positions, and we should offer to support those people on merit and not on nationality, as the noble Baroness, Lady Falkner of Margravine, has said.

My noble friend Lord Hunt emphasised that we should press for greater transparency. His key recommendation was that we should have regular reports to Parliament on the work of the agencies, and that documents to do with the agencies should not be secret but should be publicly available. I would welcome the Minister's views on these topics tonight. Are the Government looking into providing greater transparency? We should certainly be pushing for clearer objectives for measures of success in for accountability for spending and all those things. However, let us first carry that out in practice domestically, as my noble friend Lord Hunt has recommended.

We have had an interesting debate here. The UN agencies fulfil a vital role, and while pressing for reform we should be strong supporters of them as well.

9.07 pm

Lord Wallace of Saltaire: My Lords, I was not entirely sure what to expect from this debate. There are a great many agencies, boards and programmes in the world. I remembered when I started to read the briefings beforehand that I used to teach a course on international organisations at the London School of Economics. As I discovered, the students were hoping that this course

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would help them to get good jobs in international organisations. It evolved over the years into a course that, as I told them in the first lecture, was intended to dissuade them from joining an international organisation.

I did my best to explain the structural problems that all international agencies unavoidably suffer from, and the necessarily good work that they do in some rather difficult circumstances. As the noble Lord, Lord Hunt, pointed out, functional agencies long pre-dated the UN. Some of them were 19th century agencies such as the Universal Postal Union and some riparian bodies. The International Labour Organisation was founded just after the First World War. Then the United Nations sponsored and provided a degree of accountability for a whole generation of new bodies. There are now a great many. Unfortunately, some duplicate each other's activities and there is some overlap.

That is part of the problem of assessing how valuable they all are. I recall that the FAO, the World Health Organisation and UNESCO had enormous problems in their secretariats and in their effectiveness 30 or 40 years ago. All agencies have suffered from American ambivalence. The Americans wanted agencies to serve the global good, as the United States saw it, which meant, in those days, opposing the Soviet Union; and Russian, Chinese and Saudi ambivalence has been a problem for many years. Agencies are unavoidably imperfect, even more imperfect than national Governments. Recruitment and appointment is part of the problem. The noble Lord, Lord Liddle, said that we should find the best people on merit, not on nationality. He knows very well from his time in the European Commission that that does not apply even in the European Union. It is much harder to apply in organisations that have well over 100 state members and in which the Finance Minister of a particular country wants to get his nephew into a really good job, or the President wants to get his son into a really good job. Those are the problems with which we have to deal.

There are also perverse outcomes, as the noble Baroness, Lady Falkner, has pointed out, not just in UN Women but on the Human Rights Council, with which, in this imperfect world, we have to deal. I can recall taking part in a conference associated with the UN Convention on the Law of the Sea, in which I dared to crack a joke about the Iraqi approach to a number of matters, whereupon I was immediately denounced by the Iraqi delegate at this informal conference and an official apology was asked for. One has to be very careful how one behaves in international bodies.

The United Kingdom is an active and major player in this complex world. We provide between 6 and 7 per cent of contributions to these various agencies and our contributions are rising. The United Kingdom is now the largest contributor to international agencies in Europe. As the United States becomes a more ambivalent player, in a number of ways we are becoming more important; we are an engaged player. I hope noble Lords agree that the multilateral aid review was a very constructive assessment of the limited effectiveness of a range of different bodies. It was extremely complimentary about the effectiveness of some and constructively critical of a number of others.

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The noble Lord, Lord Judd, whom I think I remember first meeting at a UN association meeting a very long time ago-

Lord Judd: A very long time ago.

Lord Wallace of Saltaire: -when I was young. The noble Lord talked about the problems of a number of agencies, in particular UNESCO, with the loss of US funding and with the United Kingdom having just been elected to the executive board. UNESCO continues to have a number of problems with effectiveness. This new blow will be an additional one, but we also recognise that UNESCO carries out a number of functions that are not provided by other international agencies, and it is in all our interests that those functions continue to be effectively provided.

I should perhaps admit to a very small personal interest; I was rather upset that the noble Lord, Lord Hunt, did not point out that Saltaire is also a world heritage site. I hope that he will visit it soon.

The UN Population Fund is also under fire from the American right, but that is not a new story. Agencies have been under fire from the American right for as long as I can remember. The Cold War had even more attacks of that sort. The UK is again playing a constructive role on the executive board. UN Women, a reorganised body, is too young for us to be able to see how effective it will be, but we are giving it our full support.

The International Labour Organisation, on which the noble Lord, Lord Liddle, commented, has a number of problems. Only 40 per cent of its staff are currently working in the developed world. The International Labour Organisation, as the noble Lord, Lord Liddle, will know, has negotiated and agreed a very large number of conventions on aspects of labour, many of which still lack enough national ratifications to be carried into practice. There is a limit to how useful it is to design things on child labour, and other such things, which are not then carried through to ratification and implementation by the majority of the members of the organisation.

The noble Lord, Lord Judd, thinks that we are a little too critical of the Food and Agriculture Organisation. I would suggest that we remain constructively critical of an organisation which has been in deep trouble in the past, and is now improving but has some way to go.

Noble Lords asked about the British approach, and how far Britain should press on its own for improvement. Of course we should work with others, and we do. One of the pleasures of my work in government, as someone who goes to regular Foreign Office ministerial meetings, is to hear how frequently the Foreign Secretary says, "Well, the most important thing in this is that we must work with our European partners to maximise our influence in X, Y or Z". Of course we do that. We work with all of the partners we can do-European and Commonwealth-through as many networks as we can. However, we often discover that the Western caucus within these organisations has to be careful not to upset what is still seen as the G77 caucus and that tensions within these agencies about who tells whom what to do remains a source of problems. The question

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of who pays and who does not pay is a rather different thing. The multilateral aid review, as a national contribution, was a constructive contribution. It provides a basis from which we can talk to other Governments about what needs to be done.

The noble Lord, Lord Hunt, talked about reports to Parliament and parliamentary oversight. He may recall that there have been suggestions in this House in the past four or five years that we might experiment with an ad hoc committee on international organisations which might look at the how Britain relates to international agencies and which ones provide us with the best value for money. That suggestion might again, if he wishes, be raised with the Liaison Committee.

It is right that the British Government should be asking, since we are a major contributor, what value for money we receive from these bodies. Since we are on a rising curve in our international aid budget, and in our contributions to these organisations, we have to have some concern about public acceptability. Perhaps not every noble Lord in this Chamber reads the Daily Mail with as much attention as I do every day, but the Daily Mail is not an enthusiast for rising British contributions to international agencies. It is not enormously enthusiastic about international agencies as such, be they the European Union, the FAO or the UN Population Fund.

The noble Lord, Lord Hunt, talked about the balance between the FCO and other departments. These are functional agencies and it is therefore proper that the functional departments should provide the lead. A lot of the work, particularly that of some of the environmental and meteorological agencies, is highly technical and expert and there is an expert community, particularly in the climate change world, which works with the Government and with their counterparts in other countries to progress the work that is under way. The FCO does not attempt to duplicate that work. It has a small department which co-ordinates what others are doing and works with them through our representatives and our delegates in those various agencies when they meet. Engagement with outside experts and lobbies is high. At the UN conference on climate change, the number of British lobbies represented has been astonishingly high. It is not something that takes place behind the scenes.

I say to the noble Lord, Lord Liddle, that I do not see the contradiction he suggested between prioritising bilateralism and downgrading multilateralism. We are doing both and it seems to me that the stronger one's bilateral relations, the stronger one's multilateral relations can also be. We are working with others to try to improve these organisations. Building coalitions within organisations such as the European Union, the Commonwealth and many other global organisations seems to be the way forward.

I end where I started. These agencies will never be perfect. As we all know, internationalism suffers from structural problems. We have our own ideas about how the world should be organised and how agencies should be organised, which are not always shared by the Governments of all other countries, so we have to work with them.

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Lord Liddle: Will the noble Lord give a commitment to consider the proposal of the noble Lord, Lord Hunt, for a regular report to Parliament and greater transparency?

Lord Wallace of Saltaire: I will gladly commit to considering that. The British Government, here as elsewhere, are very concerned about transparency. I apologise: I should have taken up the point that the noble Lord made about transparency of data. Data are extremely important in many of these areas. We are doing our best to provide better data. In the multilateral aid review, a great deal of emphasis was placed on how much data are available about the effectiveness of work on the ground, in-country, by particular agencies. That is very much part of the way forward.

Lord Hunt of Chesterton: Could there not be a commitment to be more IT? We are in an IT world and I would like to be able to read more stuff from the Foreign Office on my BlackBerry. How about that?

Lord Wallace of Saltaire: I promise to write to the noble Lord on that. I have now extended my time. In spite of the fact that we are running a little short, I should probably draw my remarks to a close. Again, I thank the noble Lord for raising this issue. We ought to spend more time looking at how international agencies work. They play a very important part in holding the world together and I agree with him that we pay much too little attention to the work that they do and to assessing its quality and how it might be improved.

9.22 pm

Sitting suspended.

Health and Social Care Bill

Main Bill page
19th Report from the Delegated Powers Committee
18th Report from the Constitution Committee

Committee (7th Day) (Continued)

9.28 pm

Amendment 104

Moved by Lord Warner

104: Clause 20, page 17, line 14, at end insert-

"( ) In discharging its duty under this section the Board shall, after consultation with Monitor under subsection 171(4) and the appropriate clinical commissioning group, advise the Secretary of State whether or not the NHS service configuration in a particular area is financially or clinically unsustainable within the mandate issued or proposed to be issued by the Secretary of State."

Lord Warner: My Lords, this is probably not the best time of night to be concentrating on this set of amendments, because it brings us to the difficult and controversial issue of service reconfigurations. Let me start with why I think that we need to move upstream from the full-scale failure regimes which are provided for in this Bill, and with why I do not consider that one can rely totally on local commissioners and elected Health Secretaries to undertake the scale of service reconfiguration that the NHS requires, or as quickly

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as it requires. In making that statement I start from a position that the best predictor of future behaviour is past behaviour. In the field of service reconfigurations past behaviour has not been a speedy or easy process to start, let alone finish.

I do not want to spend long on why it is urgent, but the essence of this is the Nicholson challenge, which is £20 billion of productive improvements in the NHS in the four years to 2015-16. As the Health Select Committee has pointed out, no health system in the developed world has ever delivered this level of productivity. To say that it is a big ask is a masterpiece of understatement. The NHS's track record on productivity improvement is, putting it at its best, modest, so we are dealing with a difficult set of issues, on top of which there are constant pressures from demography, advances in science and rising public expectations in the UK healthcare system and, indeed, in virtually every advanced healthcare system. That is what confronts the NHS.

It is crystal clear that the public and politicians are beginning to recognise more openly that the historic patterns of service provision built around district general hospitals do not meet current or future healthcare needs. They certainly have a capacity to gobble up resources without necessarily delivering the type of services that many patients of the NHS need and which could be delivered more cost-effectively but probably not using the present pattern of hospital configuration. What that means is that we are facing a situation where in many parts of the country we have to change those hospital services very rapidly indeed, and we have to make some painful decisions on those service configurations, which can often mean closing some services, doing some services in a different place, redeploying and retraining staff and, in some cases, in all probability making some staff redundant. That is why this is contentious territory and why it has proven difficult to do. We are now moving towards a financial situation where we cannot put off the job of reconfiguring these services much longer.

The difficult problem we have in the way this Bill is structured and in the way we are approaching this is that we are expecting this painful stuff to be done in a situation where we are saying that local clinicians and local people have got to face up to these difficult decisions. They have got to start the process, unless it gets so bad that Monitor is required to trigger a failure regime. In many cases, the problem manifests itself in an acute hospital, but often you cannot solve the problems of that acute hospital without looking at the wider health economy within which it is situated, so we have a situation which is asking quite a lot of local clinicians, certainly based on experience, to start the process of reshaping those services however right it is in principle to expect local people to take the initiative in these areas.

Historically, we have faced a situation where elected politicians in the form of MPs have found this extremely difficult territory-whether they are going to be Kidderminstered, or whether they are going to find themselves having a very small majority and feeling honour bound to carry a placard around outside the local hospital without making a change. That is not a criticism of them; that is a fact of life. Asking local

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elected politicians and local people to, in effect, fall on their sword to some extent in relation to changing these hospital services is a big ask. This amendment tries to face up to some of those realities. It suggests that waiting for things to fail, to get so bad that they trigger the failure regime, is putting Monitor in a pretty tough situation.

This amendment tries to move upstream from that and to advance the argument that Monitor, with the support of the national Commissioning Board, should be able to look upstream and see the hospital services that are heading towards failure-in this case, I have taken a period of 12 months before failure-and start to do something about it. In co-operation with the national Commissioning Board, Monitor could trigger an independent panel to work with local people to come up with a set of proposals for reconfiguring services within a reasonable timescale set by Monitor that would make those services sustainable financially and clinically for the future. That is not to say that local people should be excluded but we should have a trigger that brings in some facilitation to help them get there.

Fast-forward, then, to the end of that process. We have often talked about the Chase Farm example. Seventeen years is a bit of a long time to sort out an A&E department, but that is what it has taken. My noble friend Lady Wall is still struggling with what comes next. We have to have something better than that. Elected Ministers are also constituency MPs. They understand the problems that some of their colleagues face. Sometimes they even understand the problems that their opposition colleagues face in these situations. It is not surprising that they find it difficult to take decisions quickly, even armed with the current independent review panel. No stone is left unturned in trying to give local people an endless chance to stop progress. We call it public consultation but it is in fact a stopping of progression of the reconfiguration.

What my amendment also does is to say, at the end of that process, that the Secretary of State cannot be taken out of the loop, but if he is going to turn down this independent panel's set of proposals for making services sustainable clinically and financially in a given area, he has got to give his reasons to Parliament for doing that and has to come up with an alternative proposal for making those services sustainable. That is why I think we badly need a process of this kind where there is a trigger, some independent facilitation and some lock on the ability of the Secretary of State to endlessly procrastinate or avoid taking a decision coming out of an independent panel.

I am the first to recognise that this may not be enthusiastically received by the elected political class. It is probably a bit much to stomach appointed Peers proposing this idea. However, I am putting this forward on a non-partisan basis in the hope that we can move forward in this area on a basis similar to the one that I am proposing. At the end of the day what I am doing is pinching something. This is not a totally original thought. I am pinching it from Canada's experience, where in the 1990s the healthcare system in Ontario was literally going broke and they had to find a way of not bypassing the elected political class but facilitating

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a set of changes that made it easier for elected politicians to take difficult decisions. That is the purpose of this amendment and I move it in that spirit, as a constructive attempt to deal with what I acknowledge is an extremely difficult and complex problem. I beg to move.

Lord Hunt of Kings Heath: My Lords, we are indebted to my noble friend for raising what I think is one of the most difficult issues the health service is going to face. There is no doubt that if the efficiency challenge is to be met, there has to be a major reconfiguration of services. Yet, as my noble friend has said, we know that this is often very difficult to undertake and get local sign-off. Both my noble friend and I enjoyed-if that is the word-experience as Minister for the health services in London, and both of us have been involved in some of the agonised discussions with the outer-lying hospitals and boroughs. The whole London area is littered with proposals that have been made for many years and which have not been put into effect. There are other examples up and down the country. The problem is that the health service no longer has the luxury of being able to rely on the uncertainties that are caused by the current system. Reconfiguration needs to take place, and rapidly, over the next two or three years.

I am enormously sympathetic to my noble friend's amendment. It is interesting that in our previous debates the view has been expressed that ministerial intervention has often caused the problem. My noble friend would still push this substantive decision back to the Secretary of State. That is probably right, because in the end, however much the Government might wish to push this back onto the health service or onto the NHS Commissioning Board, I should have thought that the interest of MPs in reconfiguration issues would have sucked the decision back to the Secretary of State one way or another. We have to assume, therefore, that any process that is put forward does involve the Secretary of State.

I have no doubt that the noble Earl will say that we do not need to go down this route and that he is confident that clinical commissioning groups will be able to embrace reconfiguration of acute services and get sign-off from the appropriate or relevant local authority. I am sure that there may be some areas where that might happen, but of course, one has first of all to recognise that if a major reconfiguration is proposed, it will involve a number of clinical commissioning groups. The first test will be whether a number of CCGs will be able to come together to achieve a strategic outcome. Secondly, even if that happens, those clinical commissioning groups have yet to feel the heat of battle. They may well theoretically sign up to a reconfiguration, but they are inexperienced, I would suggest, in the kind of pressure that they will come under from politicians and the public. I suspect that one or two will find it very difficult to hold the line.

The other problem with the current proposals of the Government is that clearly they wish the NHS Commissioning Board to have a leadership role. However, the Commissioning Board will have much less legitimacy than Ministers when it comes to controversial decisions

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such as closures of accident and emergency departments. It is easy to see how these may come, in the end, to little fruition.

I certainly support my noble friend. The only question I put to him is whether his process is really tough enough. I wonder whether what really needs to happen is that every area of the country should be reviewed by some kind of independent body as to whether the configuration of services is safe and appropriate. It no doubt could have examinations in public, similar to the old strategic planning process that we have had in the planning system. I would favour a much stronger statutory approach to this, which forces each health economy to come to the table, to put their viewpoint, but then to have an outside group of experts who would then make strong recommendations to the Secretary of State. I fear that without such external views we will find it very difficult to make progress. I suggest to my noble friend that he should consider whether he might need something stronger to make this bite.

9.45 pm

Lord Warner: I never thought that I would be outflanked on the Stalinist wing of the Labour Party by any Member of your Lordships' House, but clearly I have that all wrong. I would be happy to strengthen these proposals because I rather share my noble friend's view that I may be being a little wimpish here, but I was deferring to the elected politicians on this, probably unwisely. I am producing this rather wimpish proposal, but somewhere along the way we certainly have to have a trigger that is independent of the political process. We need some outside facilitation of change with the local people and we have to restrict, to some extent, the ability of elected Ministers to totally undo or avoid taking decisions in this area, possibly as much as my noble friend is saying.

Baroness Cumberlege: Those words are so warm to my heart, I cannot tell the noble Lord how much. One of the things that really concerns me is delay. I am worried that if we get this outside group it will delay matters, because some of this is very urgent at the moment. What is the relationship between this and the independent review panel-I am not sure what it is called-which deals with hospitals at the moment?

Earl Howe: It is the Independent Reconfiguration Panel.

Baroness Cumberlege: I am indebted to my noble friend for that. Does the Independent Reconfiguration Panel play a part in this? Is it something different? Do we have to go through that as well, in which case it will take even longer?

Lord Warner: Something equivalent to the Independent Reconfiguration Panel was used earlier in the system. It was put in to bat with the local area by Monitor when it saw trouble coming down the railway track in the form of failure. I envisage that a standing group of people would be approved to work in this area, which Monitor would be able to assemble very quickly. My amendment proposes that a timescale is set for this

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panel to work with local people and to come back with a solution to the problem, but I think that more people than are currently approved for the reconfiguration panel will be needed because of the points made by my noble friend. In many parts of the country we are likely to have to intervene quite quickly because we have spent a lot of time over the past 10 or 20 years putting off decisions about some of these places. A lot of these places will come to Ministers, the national Commissioning Board and Monitor over the next few years, so we will need quite a few different panels.

Earl Howe: My Lords, this group of amendments usefully focuses us on reconfiguration and the sustainability of NHS services. The sustainability of services will be centre stage for commissioners and providers alike. I should like to set out some key features of the Government's reforms, which I hope will reassure noble Lords that the system we have put in place will deliver sustainable NHS services. The first key feature is that local clinical commissioners will be responsible for securing continued access to healthcare that meets the needs of local communities in consultation with health and well-being boards. Any proposals for service change will be locally led by clinicians in consultation with patients and the wider community.

The second key feature is that the continuity of services regime requires Monitor to support commissioners to secure continued access to NHS services. Monitor will do this by undertaking an ongoing assessment of risk and intervening to support recovery and to prevent failure where possible. Therefore, the onus is on commissioners and providers to address any problems with the sustainability of NHS services. Only as a last resort where commissioners and providers have failed will Monitor step in to appoint an administrator to take control of the provider in order to secure continued access to NHS services.

The noble Lord, Lord Warner, suggested that there would be nothing between a locally led process leading to an agreed reconfiguration and Monitor triggering the failure regime. That really is not so. It may be helpful to the Committee if I explain. There are various levers available to Monitor before failure is even thought of. First, regulatory interventions are available to Monitor through the licence in order to protect patients' access to essential services where Monitor considers that a foundation trust is at risk of becoming clinically or financially unsustainable. I agree that there should be a way for the system to respond when, as the noble Lord put it, trouble is seen to be coming down the railway track.

Where it is appropriate, Monitor would be able to direct a provider to appoint turnaround specialists that would provide additional capacity and expertise to support a provider's management in turning an organisation around. Monitor would also be able to appoint a pre-failure planning team to work with commissioners to develop plans for securing continued access to services in the unlikely event that turnaround was unsuccessful. That process may identify reasons why service reconfiguration would be needed to secure sustainability, but it would remain a commissioner-led process. I hope that I have made it clear that it is appropriate for local clinical commissioners and not

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Monitor to lead this process with support from the NHS Commissioning Board. The board will be able to support clinical commissioning groups by providing support and advising on the possible effects of larger changes, and Monitor will support commissioners in protecting patients' access to essential services through the licensing regime.

The noble Lord, Lord Hunt, suggested that the board should play a leadership role. The Bill allows for that to happen in a number of ways, using commissioning guidance to set expectations on how CCGs should deal with reconfigurations that span CCG boundaries. It would also provide access to advice in the form of senates to help them develop their proposals. Ultimately, where a local authority challenges a proposal, the board will be able to direct the CCGs on their plans, so there is an interest in making sure that those plans are robust to start with.

Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Earl for giving way. I understand that, but is not the problem as my noble friend said? If you look back over the past 20 to 30 years, the NHS has found reconfiguration decisions very difficult indeed. The new system potentially has weaker bodies, in the form of the clinical commissioning groups, covering smaller areas, such that taking a bold decision on matters such as closing an accident and emergency department would be very difficult. In one way or another, what is being suggested is some kind of external mechanism that essentially forces the local health economy, both commissioners and providers, to come to terms with the latest knowledge in relation to safety and quality. They would actually have to face up to the challenge.

This happens in a way with the various inspections of the colleges and the deaneries, and we know of a number of hospitals where the viability suddenly goes because of an inspection and they are not approved for training. This has a devastating domino effect on the rest of their services. But surely the time has come for a much more proactive external review of each local health economy area. It would be of assistance to those who wish to move and modernise services because they would be able to turn to the mechanism, whatever it is, and say, "We have to change". If the Government are simply relying in this legislation on local forces, my fear is that that simply will not happen quickly enough.

Earl Howe: I understand the noble Lord's point; it is one that we have thought carefully about, as he might imagine we would. The trigger for local service reconfiguration is often a joint decision by commissioners and providers that the current configuration of services does not offer the highest quality care or that it does not meet current and modern clinical practice. It is usually a dialogue between commissioners and providers which identifies services as being, in some way, not optimal for patients, and that a reconfiguration is the most appropriate way to improve and modernise services, rather than smaller scale operational change.

We are proposing that commissioners should engage and consult on these changes in the normal way, working closely with providers and engaging with

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patients, the public and local authorities in developing their proposals. However, I agree that there are clear roles for the board, and for Monitor, in ensuring that this process is given a fair wind. They have an interest in ensuring that services are of high quality and sustainable and they will wish to add value to the process.

We talk as if all reconfigurations were long and drawn out-we all know of some that are like that-but the successful reconfigurations tend to be those that have involved more, rather than fewer, local stakeholders. That is why we are strengthening the powers provided by the Bill, so that reconfigurations can take place in a genuine spirit of local engagement and partnership.

Lord Beecham: What does the Minister mean by local consultation and local considerations? One can envisage a situation when hospitals serve just a particular locality. However, in many areas, there are trusts and hospitals serving a much wider community-a sub-regional or perhaps even a regional community-and who then is to lead the process? Who then is to take the decision? There could be several commissioning groups involved, looking at the facilities in question, rather than just the one or two in a particular town or county.

Earl Howe: The noble Lord is absolutely right. In that kind of situation the process would inevitably become more complex. I do not know whether the noble Lord noted the comments of Dr Jennifer Dixon of the Nuffield Trust when she gave evidence to the Commons committee, but she said:

"If you look at some of the more successful attempts at reconfiguration, more involvement of local groups was necessary in order to get change. Some of the unsuccessful ones have been those where they have communicated less and involved fewer people".

So paradoxically, she said, having more local organisations involved,

I think that that was a very perceptive comment. We think that the Bill should strengthen and encourage these relationships, either within a local area, or within a larger one, where services are commissioned over a larger area, as very often they will be, and you will get a broader dialogue taking place. The main object for all of us is to ensure that the mechanisms for this kind of partnership-working and local engagement are in place.

I take the point of the noble Lord, Lord Warner, about the length of time that some reconfigurations have taken in the past. We are very conscious of that. Under our plans, local authority scrutiny functions will be required to publish a timescale for when they will make a decision on whether to refer proposals for substantial service reconfiguration. We intend to change the existing regulations so that, where scrutiny functions are delegated to joint committees of two or more councils, councils could not step in and exercise those functions. This should prevent proposals which have taken time to develop and agree through a joint

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overview and scrutiny committee from falling apart at the end of the process by one local authority choosing to refer.

I understand the noble Lord's concerns and will of course reflect on his proposal. However, I think that we are creating what could be an effective framework that would allow commissioners and providers to work together to reconfigure services where that is needed to protect patients' interests. To support that, the Bill sets out a commissioner-led framework. We think that it is right for patients that it should be framed in that way. With the prospect of continuing dialogue on this subject, which I think will rear its head on more than one occasion as we go through these Committee proceedings, I hope that the noble Lord will feel content for now to withdraw his amendment.

Lord Warner: My Lords, this has been a useful piece of-if I may put it this way-foreplay on this subject before we get down to real business. I want to say a couple of things to the Minister as he goes into reflective mode.

We tried turnaround teams with individual trusts in 2005-06 in the aftermath of financial failure. The trouble was that they tried to solve the problems of a particular hospital within that hospital and not within the health economy. I listened carefully to a lot of what the Minister said. Many long-standing problem trusts cannot solve their problems. You can keep coshing them into insensibility, but they cannot solve them on their own. They need to be solved within a much wider context. I would pray in aid north London, which in my judgment has something like three district general hospitals too many for the income that is likely to be available. Those hospitals cannot be saved on their own. There is a massive reconfiguration exercise to be done in a wider health economy. I give turnaround teams three out of 10; we need something better than that.

I wish the Minister and the Government well in trying to tackle this subject. It may be that all Governments have to go through the difficult process of learning by disaster, which is what may happen here. We are dealing with a deep cultural problem in the NHS. It believes that, somewhere along the line, a cheque will come through the post to bail it out at the local level. Unless that culture is changed dramatically, I do not believe that the Minister's well intentioned approach is likely to deliver the change that we need.

I, too, shall reflect, but I think that we shall come back to this matter and look for something which may not be as draconian as my noble friend would be satisfied with but which moves in the same direction if we are to see the changes that the NHS needs made in the timescale that is needed. I beg leave to withdraw the amendment.

Amendment 104 withdrawn.

Amendments 104A and 105 not moved.

House resumed.

House adjourned at 10.03 pm.

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