§ 3.8 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)
My Lords, I beg to move that this Bill be now read a second time.
The Health Authorities Bill puts the finishing touches to the reforms which began with the National Health Service and Community Care Act 1990. That Act brought about a major change in the way that the health service is run. Despite annual increases in government funding, the service was inflexible and unresponsive to the needs of patients.
The 1990 Act introduced a new way of funding and organising services. NHS trusts took on responsibility from district health authorities for the management of hospitals and community health services. Trusts have been a great success. Ninety-six per cent. of hospitals and ambulance services are now in trust hands and this figure will rise to 98 per cent. in April of this year. We have given trusts freedom to manage. As a result more patients are being treated than ever before. And in any one of the 419 trusts there are stunning examples of how the quality of service has been improved, reflecting a new sensitivity to the needs of patients.
The 1990 Act also established GP fundholders. GPs who wished to join the scheme were given the funds to purchase certain hospital services and other treatment for their patients. Fundholders have beaten a path towards better patient care, and our intention is that the rest should follow the best. Fundholders have shown 12 that, where family doctors are given responsibility for purchasing, better quality services can be provided more effectively. We are determined to extend the benefits of fundholding as widely as possible in line with the advice of the Audit Office, the King's Fund and the OECD. Last year we announced a major expansion of the scheme.
Finally, the 1990 Act created a new role for health authorities. District health authorities became purchasers of health care. Freed from the day to day concerns of running hospitals and community units, they can now concentrate on identifying the health needs of their population. They negotiate agreements with hospitals and others who provide health care to meet those needs.
The effect of these changes is to transfer the focal point of responsibility and decision-making to those closest to patients—doctors, nurses, therapists, managers and so on. Key decisions are no longer taken centrally, several times removed from the place and the people where they have a direct impact. The NHS is now a flexible and dynamic organisation in place of the flat-footed monolith it was in danger of becoming.
Regional health authorities played an important role in the old NHS. Their management skills were vital, not least in the hands-on management of hospitals and in directing district health authorities. But, as trusts and strong local purchasers have developed, a large regional organisation has become unnecessary. This has not come as a surprise to regions as they have worked their hearts out to implement the reforms. In doing so, they knew that their success would bring about the demise of their own jobs. People may deride management. Some have been all too ready to pour scorn on administration; but quietly and without fuss RHAs have shown others that working for a service may mean putting the good of others before your own—an attitude not always evident in life, We should spare a moment to thank them: chairmen, non-executives and regional staff.
This is a simple Bill. Only Clause I makes major provisions; the rest makes consequential changes. Clause I does two things. It abolishes the regional health authorities and it replaces district health authorities and family health services authorities with new integrated health authorities.
The Government propose that regional health authorities will be replaced by eight regional offices of the NHS Executive. They will be very different from old RHAs. They will be far smaller, employing a maximum of 1,100 staff, compared with the 2,600 currently employed by the regions, and they will operate with a lighter touch. They will concentrate on the essentials—only those things which have to be carried out at regional level. There will be no unnecessary duplication between health authorities and regions, or between regions and the centre, and as much management responsibility as possible will be delegated to local health authorities.
The second change in Clause 1 is the replacement of district health authorities and family health services authorities with new integrated health authorities. This is a measure which should command the support of the whole of your Lordships' House. The new health authorities will bring together responsibility both for 13 primary care and for purchasing hospital and community services. Many district health authorities and family health services authorities are already working closely together under a joint chief executive. They are eagerly awaiting the statutory changes, and they are right to be eager.
Health authorities will co-ordinate health care for the people they serve. They will work with local authorities and others in a way that has not been possible before. They will work closely with GPs, both fundholders and non-fundholders, to assess local health needs and to ensure that those needs are met. They will lead progress towards our goal of a primary care-led NHS.
There is one further—and substantial—benefit of this Bill. It will cut bureaucracy, and with it, management costs. We estimate that, when fully implemented, the Bill will result in savings of about £150 million a year in England and around £3 million a year in Wales. These savings will be spent on the front line—on direct patient care.
I shall not go through the other provisions of the Bill in great detail. But I should like to explain its major parts to your Lordships before going back to a few of the most important issues. Schedule 1 to the Bill makes the consequential changes needed to reallocate functions from the old NHS to the new authorities. It includes many minor amendments which simply remove references to authorities that are to be abolished, and inserts references to the new health authorities. But there are other, more significant provisions which I shall highlight in a moment.
Clause 3 and Schedule 2 provide for the transition to the new structure. Clause 3 gives health authorities wide powers to work together, so that, by 1st April 1996, they will be completely ready for a merger. This will ensure a smooth change from the old system to the new, and minimise disruption to services.
Schedule 2 provides for the reallocation of staff, property, rights and liabilities of the authorities which are being abolished. In a time of such change, there will inevitably be some disruption to staff. But we will do all we can to minimise that: for example, by setting up clearing houses, counselling services and sensitive relocation packages.
The reallocation of regional health authority functions can be explored in Committee, but I should like to outline the principles and some areas of particular interest to your Lordships now. Ministers will remain responsible, and accountable, to Parliament for setting the policies of the NHS and its strategic direction. They will be responsible for deciding the allocation of funds in line with the principles of weighted capitation. The implementation of Ministers' policies is the role of the NHS Executive, assisted by the regional offices which are an integral part of it.
The regional offices will monitor the performance of health authorities and NHS trusts and will be responsible for admissions and allocation of funds to the GP fundholder scheme. These responsibilities are clearly best carried out at regional level.
14 As many regional health authority responsibilities as possible will be passed down to the new health authorities in the spirit of devolution. For example, health authorities will be responsible for buying more specialised services; for more public health functions; and they will become the local supervising authority for the supervision of midwives. The Royal College of Midwives has welcomed this move.
Small groups of health authorities and NHS trusts will also take on responsibility for purchasing education and training. Over time, this will include most NHS staff apart from very small specialist groups and apart from medical training. I will explain the medical arrangements in a moment. Regional offices will initially be closely involved in this work. The NHS Executive, nationally and regionally, will continue to take responsibility for education planning. It will ensure that local plans continue to meet the national requirement for trained and skilled staff. In Wales, the Welsh Office acts as commissioner of nurse education, working closely with health authorities and trusts.
I know that medical education and training is a matter of particular interest to many of your Lordships. It was, after all, this House which established the new post of Director of Research and Development, and I know that many of your Lordships are eminent in this field and play an influential role in medical education both in this country and abroad. The new arrangements will be slightly different. The postgraduate deans will continue to be responsible for commissioning postgraduate medical education and training, and for GP vocational training, working with regional advisers for general practice. In particular, we are proposing that the deans should be responsible for the educational contracts of junior doctors (registrars and senior registrars) so that important arrangements such as training rotations are protected.
The deans form a vital link with the universities as well as holding substantial funds for training. We are making good progress in agreeing with them the details of their future role and contractual arrangements.
The Government are committed to maintaining and improving the essential partnership between the universities and the NHS, and to maintaining high standards in the training of doctors. For that reason, regulations will require that health authorities whose area contains a medical or dental school shall have a university non-executive member.
By and large, however, it is not our intention that health authorities should be made up of representatives of different interest groups. Members of health authorities should be appointed because of the personal qualities that they can bring to the work of the authority. My right honourable friend the Secretary of State recently issued guidance on the appointment of members of health authorities and trusts. It showed that, above all, appointments should be made on the basis of merit; and it contains important measures for making appointments more open and accessible. The regional chairmen, who, in the new structure, will be retained as members of the NHS policy board, will continue to advise Ministers on appointments.
15 We want the new health authorities to be compact and streamlined, following the model of district health authorities. The regulations, which we propose to lay shortly after Royal Assent, will require that there are five executive members. There will normally also be five non-executives in addition to an independent chairman. We recognise, though, that some of the new authorities may be covering a larger area than others. We will therefore leave flexibility, if the health authority makes a case to Ministers, for up to seven non-executives to be appointed.
In line with our general approach to membership, few places will be reserved for particular people. In addition to the university member in the relevant authority, only three will be prescribed in regulations: the chief executive, the director of finance, and, for the first time, a prescribed place for the director of public health.
Some health authority members will, of course, have backgrounds in nursing, medicine and other relevant professions. However, membership is not the only, or the most important, way of achieving a professional input to the work of health authorities. Prescribing that each health authority should include a doctor and a nurse would still leave gaps. What about the important input from dentists, pharmacists, and so on? A single nurse or doctor could not hope to represent the range of expertise needed even from their own profession. Individual nurses and doctors, chosen for their personal qualities, can make a very major contribution to health authority work; but that is still no substitute for wider involvement.
Let me therefore outline how the Government intend to secure that wider involvement. The Bill will abolish the old statutory structure of professional advisory committees. It was useful in some areas, but was not flexible enough, and it involved only a limited range of professions instead of the very wide range that we wish to see. It was too easily sidelined. My right honourable friend the Secretary of State has made clear that the Government want professional advice to be integral in the new structure.
To show how seriously we take this, the Government tabled an amendment to the Bill in another place. The amendment requires health authorities to set up arrangements to ensure that professional advice is available to them. It makes clear that professional advice must come from doctors; but not just from doctors. The nursing profession must be fully involved. I agree with the Royal College of Nursing that nurses have a special expertise to bring to purchasing, based on their front line experience across the whole range of patient care. Nurses have 80 per cent. of patient contact in the NHS and their experience is needed to give purchasing plans clinical credibility. Our proposals in no way exclude nurses. Many other professions are also important. Each health authority's arrangements must also cover a whole range of professions, such as dentists, pharmacists, physiotherapists, psychologists and dieticians. I could not hope to provide an exhaustive list in this speech.
The legislation will not be rigid. It will not prescribe how professional involvement is to be achieved; that would be going back to the faults of the old system. 16 Health authorities will need flexibility to decide that locally. But the Bill leaves in no doubt the importance of professional involvement.
Let me now turn to the Government's plans for public health. A good deal of public health work is currently carried out at regional level. In the new system, the focus will move to the local health authorities. District directors of public health will report on the health of their populations and will be free to comment on the factors affecting health in their areas. For example, they will take on greater responsibility—in co-operation with other authorities where necessary—for communicable disease control, cancer screening and national confidential enquiries.
Regional directors of public health, working within the regional offices, will monitor the work of health authorities. They will ensure that important public health programmes, such as breast cancer screening and immunisation campaigns, are properly co-ordinated. Regional directors will also contribute to policy making in the central department. No longer will they be frustrated "lone rangers" but influential policy makers. This is an important advance on the old system. Together with the new statutory requirement of an executive director of public health at local level, it will make sure that public health work is sensitive to local needs and feeds into the national picture.
The new authorities will have major responsibilities, so they must be fully accountable to the people they serve. The Bill strengthens local accountability by simplifying the structure of the new NHS. Most members of the public do not know—and, quite frankly, are not interested in—the fine distinctions between district health authorities, family health services authorities and regional health authorities. They just want to know to whom to turn for help or information. In future, this will be clearer: there will be just one health authority at local level. The structure will be simple, clear and accessible.
That is reinforced by the code of conduct and accountability which my right honourable friend published in April 1994. It outlines the responsibilities of NHS bodies to adhere to three crucial public service values: accountability; probity; and openness. Each health authority must promote confidence between itself and its staff, patients and the public.
That is why we require health authorities to publish annual reports. That is why we encourage them to develop purchasing plans which command local support and confidence. We have made clear the need for authorities to be in regular discussion with local people and to take account of their views. That means consulting widely with CHCs, other statutory bodies, voluntary organisations, NHS trusts, Members of Parliament and the wider public. Only this weekend, when reading my local paper, I saw how East Sussex is doing just that.
We have also made clear that NHS contracts are public documents and that health authorities need to involve hospital clinicians and other interested parties locally in drawing them up. 17 The Government have shown how seriously we take accountability and openness in the guidance on appointments, to which I have already referred. The process will be more open to scrutiny and accessible to people from a wider range of backgrounds. There will be greater advertising of posts. Candidates will be sifted and interviewed by panels of local chairmen and non-executives. They will be kept fully informed about the progress of their nomination, and selection will be based on nationally agreed criteria. Those procedures build on current best practice. They will provide a sound basis for future appointments. Consideration for appointments to new authorities in Wales will follow procedures established there already.
As part of our commitment to NHS accountability, we have published the Department of Health's annual departmental report for 1995. The report gives the public, as patients and taxpayers, a clear and informative account of the whole range of the department's work. It completes the chain of accountability—from community and hospital, to health authority, to the NHS Executive, to the Secretary of State and, ultimately, to Parliament.
Since 1990, the NHS has changed enormously. Through that time of change, we have not just maintained services to patients; we have improved them. Through The Health of the Nation we have set targets for lasting improvements in people's health and, in most cases, made good progress towards them. Patients are getting higher standards, better information and more choice through the Patient's Charter. The Bill will support all those initiatives. It will reduce bureaucracy and release a further £150 million to be spent on patient care. It will remove an unnecessary tier of administration. It will reinforce local innovation and local flexibility. That must be welcome news to all of your Lordships who care about the National Health Service, to all of us who use it, and to that vast army of intelligent, talented, and committed people who work in it. I invite your Lordships to give this important Bill a Second Reading.
Moved, That the Bill be now read a second time.—(Baroness Cumberlege.)
§ 3.30 p.m.
§ Baroness Jay of Paddington
My Lords, let me first thank the Minister for the clear and helpful way in which she introduced the Bill. I am also grateful that the noble Baroness has set this further reorganisation so firmly in the context of the so-called "reforms" that have taken place in the past few years. It is precisely that broader picture that we on these Benches are anxious to examine and evaluate.
In principle at least we support one of the central provisions of the Bill: the merger of district health authorities and family health service authorities. However, we are firmly opposed to the abolition of regional authorities. We are not convinced by the Government's case for sweeping away this very important tier in the structure of a national health service.
The Government have presented the Bill as the final keystone in the triumphal arch of the reformed NHS. Your Lordships will not be surprised to hear that we do 18 not share that view. We fear that the whole arch, far from being triumphal, is crumbling and that some of the measures proposed today may provoke a final collapse.
In opening the debate the noble Baroness repeated what has become a rather familiar litany of statistics designed to prove that reorganisation has achieved health care miracles which are appreciated by the whole population. We could spend fruitless hours this afternoon trading competing statistics, but, more pertinently, one has only to look at the many Questions and Motions on health issues raised on all sides in your Lordships' House to appreciate the widespread anxieties about the present state of the health service. Those anxieties are reflected throughout the whole country.
For example, recently we have discussed continuing care for the elderly and the disabled; specialist intensive care; accident and emergency services; and nurses' pay. Many questions have been asked about appointments to health authority and hospital boards, the number of managers in the new NHS, numbers on waiting lists and the special problems of London's hospitals. Deep concern has been expressed about all of those matters, based often on your Lordships' personal experience. Sadly, the health service frequently revealed by those experiences is different from that seen by the Department of Health.
Perhaps I may remind your Lordships of the accurate assessment made by Mr. John Maples, vice-chairman of the Conservative Party, published before Christmas. He said:People perceive the reforms as clumsy and believe what doctors and nurses say about them, which is almost universally hostile".
Mr. Maples also advised that the best thing for the Conservative Party would be to keep the spotlight away from the NHS for the next year. Fortunately for all of us who care about the NHS, the Government have ignored that advice and have brought forward two pieces of legislation in rapid succession: today the Health Authorities Bill and the mental health community supervision Bill next week. Both will give your Lordships refreshing opportunities to keep the spotlight on the NHS and to consider in government time the whole spectrum of health policy and NHS reorganisation.
Given that broad context, it is useful to consider the fundamental criteria by which health policy should be judged and how successful or unsuccessful the proposals before us may be in meeting those criteria. I suggest five basic tests for any change in the NHS. Does it improve the effectiveness of the service? Does it improve efficiency? Will the change lead to greater equity? Will it lead to greater public accountability? The last question, which is perhaps the most important but also the most difficult to assess or measure, is whether the change will improve the overall health of the nation's population. In the jargon, what is the health gain or benefit? Will it be achieved?
As I have said, those of us on these Benches do not in principle oppose the reorganisation of the DHAs and the FHSAs to form one local commissioning health authority. Indeed, the Labour Party has suggested this for some time. Merging the functions of the DHAs and FHSAs will clearly make it easier to achieve planned 19 co-ordination between hospital and community services. It should be possible for the new general health authorities to assess their populations' total health needs and commission appropriate services to meet them. Resource management should be better streamlined as the purchasing of secondary and primary care is brought together. Many individual health agencies have pre-empted the legislation and now work informally in partnership under one chief executive. To judge by the test of improved effectiveness and efficiency, so far these arrangements seem to be going pretty well.
But the areas that we shall need to explore carefully in Committee are those relating to equity and accountability. For example, there is nothing in the Bill that addresses the two-tier system produced in many places by GP fund-holders getting preferential treatment for their patients. Equity might also have been improved by ensuring that in the legislation health authority area would include roughly the same number of people and be coterminous with local authority boundaries so that funding and services could be more equitably distributed across the country. The Government could have used this opportunity to deal with the familiar criticism that the services you get depend on where you live, not on what you need. But there are no provisions to achieve that.
There is nothing to improve the financial accountability of fund-holders and the overall probity of primary care funding. The Audit Commission in a report published shortly before Christmas described the present system as somewhat weak and ineffectual. The Minister said this afternoon that there would be progress towards a so-called primary-care-led NHS, but there are no proposals here for achieving that in a responsible way.
The vexed question of the membership of the new health authorities is buried deep in paragraph 59 of Schedule 1. Whatever the Minister says about the new clarity of the composition of health authorities, the membership of existing health authorities and hospital trust boards has become a political scandal. The Nolan Committee reports that it has received more representations on this subject than on any other. I shall pre-empt the Minister's, I am afraid, rather predictable observation that I myself am currently a member of a commissioning authority by telling the House once again that I have held a similar position for over 20 years, long before the present party political bias was introduced. I also repeat the comments of my honourable friends in another place that if Ministers can name all the health board members who are members of the Labour Party, frankly there cannot be many of us!
The truth is that the vast majority of the people who hold these posts are Conservative Party supporters personally selected by the Secretary of State. Recently the Department of Health responded to widespread criticism by issuing guidance suggesting that local vacancies could be advertised. But under the new legislation the chairmen and members of the new unitary health authorities will continue to be directly appointed by the Secretary of State. The Government have not taken this opportunity to make health authorities more open and democratically accountable. We shall wish to 20 Pursue the detailed questions of who will serve on these bodies and to whom they are accountable at a later stage.
On balance, the potential achievements of improving effectiveness and efficiency by creating new local health authorities seem to justify the change. The abolition of the regional authorities is a completely different matter. Here the Government are launching a frontal assault on many of the systems by which the NHS has maintained standards of excellence. Under threat are standards of excellence in medical and nursing training, in research and development, in public health and in health promotion. The Minister repeated this afternoon that all of this was to be done in the name of reducing expenditure on bureaucracy. In the Bill's original explanatory and financial memorandum the Government talked of saving £150 million annually through these changes. That was the figure mentioned by the Minister this afternoon. That was later revised in another place to £60 million. Although my right honourable and honourable friends in another place made strenuous efforts as the Bill progressed to get an accurate picture of precisely how much would be saved and by what methods, they had little success. We shall try again.
We on these Benches have been very critical of the enormous rise in the number of NHS managers and the corresponding rise in salary costs. I remind your Lordships that in 1987 the NHS had 500 general managers; in 1993 it had 20,010. In 1987 management costs were £25 million; today the cost is £49.8 million. But this explosion has not occurred at a regional level. It has been lower down the line in trusts and local purchasing authorities. Indeed, the number of people employed in RHAs has actually fallen from 7,845 in 1992 to 2,613 in 1994, even though in 1992, under the first stage of the so-called reforms, regional officers were given a wider and stronger role. Now apparently, three years later, they are redundant. But it is still unclear who will perform many of their important functions.
Some, the Minister told us, will continue to be in the hands of the regional outposts of the Department of Health, which of course means in the hands of civil servants. Frankly, that will often be completely inappropriate. Some of the other functions will be passed along to the smaller, local bodies where there may be little expertise to fulfil them. For example—again the Minister explored this but, I thought, did not explore it sufficiently—there have been important links until now between universities and medical schools and the regional health authorities. That has enabled the professional education bodies to contribute directly to strategic planning at that level and to be integrated into the health service management structure. It has been the region which has held the contracts for the training grades of hospital doctors. I would remind your Lordships that that means all levels up to consultant. They have overseen nurse education and vocational training for GPs.
All of this is now in the melting pot and, in spite of what the Minister said, there seems to be no firm long-term plan for maintaining the employment and training arrangements which up to now have ensured 21 high standards both in medicine and in nursing. The British Medical Association, the Royal College of Nursing and the deans of medical schools have all warned of the potential dangers of devolving responsibility to individual local providers who may not have the capacity to offer complete training. It is hard to see either effectiveness or efficiency being improved by this change. Public health is another matter which the Minister mentioned and is another area where the National Health Service has a reputation for excellence and where until now the regions have played a crucial role. Regional directors of public health have been senior, independent doctors, experts in their field. They have often led the way in new policies, co-ordinating, for example, the response to HIV and AIDS in the past few years and taking a strategic overview of some of the so-called "Cinderella services"; for example, mental health care and drug abuse. These kinds of services may never be attractive to small purchasers and providers who will be operating in the competitive market. But up until now they have been rightly guarded and protected by the regional tier. Professor David Hunter, director of the Nuffield Institute for Health at Leeds University, has recently described this particular strategic function as,providing a challenge to local myopia in service development and commissioning".
Do the Government really believe that a few civil servants manning Department of Health outposts will give a similar challenge?
Two of the Government's own flagship initiatives—The Health of the Nation and the NHS research and development programmes—have been developed, as the Minister said, by the regions. Both initiatives have gained prominence in recent years and both have been designed to improve the effectiveness of health service delivery and to achieve that elusive goal of health gain for the population. In each programme individual regions have been given a lead role in spearheading specific projects. I have personal experience of both The Health of the Nation and the research and development work in the North Thames Region. Indeed, I must declare an interest in that I am the current chair of the North Thames Advisory Committee for research and development. The role of the region has been vital in supporting, for example, health promotion across wide sectors, creating the so-called healthy alliances of The Health of the Nation policy or urging local purchasers to accept research findings that can improve patient services. It is here, at the regional level, that the drive to create a "knowledge based effectiveness led NHS" has been strongest.
What will happen to those initiatives now? How can we expect that the ambitious targets set, if I may remind your Lordships, by the Government to improve health will be met? These targets include reducing coronary heart disease, cutting deaths from strokes and lung cancer and lowering our miserably high level of mental illness. If they were successful, all of these could help to reduce the stark inequalities in health which still exist in Britain. It really is shameful that in 1995 we should have widening gaps between the health of the richest and poorest people in Britain. This was once again 22 demonstrated by the recent Rowntree Foundation Report. Those gaps can only be addressed strategically through a broad approach. It really is wildly over-optimistic to expect that local health authorities will have the necessary skills or resources even to begin to do it.
So, abolishing the regions, on my criteria, improves neither equity nor health gain, and there is no evidence to suggest that health services will be run more effectively or efficiently; and, of course, the loss of the regional management tier reduces accountability. The lines of democratic responsibility and public accountability between the Department of Health and Parliament and the local health authority will be both longer and weaker. I would remind your Lordships that the slimmed down regional outposts will be staffed exclusively by civil servants, bound by the Official Secrets Act and answerable only to the Secretary of State. There will no longer be a regional authority chaired by a lay person.
Many current regional chairmen and indeed members may owe their appointments to political patronage but at least they were part of a separate statutory authority and they have in the past sometimes given a strong independent view of health policy and strategy. Their accountability has been both upward and downward. The Minister has herself not very long ago been a distinguished regional chairman. It is very hard to accept that she genuinely believes that all the valuable work undertaken by her and the regional health authority can now be responsibly devolved to local purchasers and providers or left to a small cadre of civil servants. The Government's case as it stands really is very unconvincing and we shall look forward to exploring the detail of the new arrangements with the Minister in Committee.
This Bill seems extraordinarily to achieve both fragmentation and centralisation at the same time, with little benefit to the National Health Service or to us, its users. Its real purpose is still unclear. Has it been designed to pave the way for easier privatisation of services? Is it really just a cost-cutting exercise, in which case it seems very unsuccessful? Is it intended to muzzle the few remaining independent voices in the health service structure; or is it just another reorganisation to try to disguise the failures of the present changes?
I hesitate in your Lordships' scholarly House to cite a classical authority but I cannot resist the words of Petronius Arbiter in AD65. He was complaining of Roman military organisation and wrote—I hope your Lordships will think this appropriate:Every time we were beginning to form up we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising, and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation".
The National Health Service will not survive further confusion, inefficiency or demoralisation. On these Benches we shall seek to amend the Bill so that that can be avoided, so that the excellence of the professional 23 staff and the professional standards of the health service are maintained and the democratic accountability of this outstanding public service is improved.
§ 3.49 p.m.
§ Baroness Robson of Kiddington
My Lords, I apologise for speaking from the second Bench on behalf of the Liberal Democrats. It is not because I disapprove of its policy on the health service, but because I have a very bad back at the moment. I need something to lean on otherwise I shall be unable to stand up. I am in great need of the services of the National Health Service at the moment.
As has been said, this Bill is supposedly the last piece of legislation in the reorganisation of the health service which has been taking place since 1990. As such, this Bill is a peculiar piece of legislation. It has four pages only, but a total of 50 pages of schedules. To me, that is an extraordinary example of the transfer of power into the hands of the Secretary of State through regulation open only to negative resolution in this House which cannot be amended.
The Government claim that the purpose of the Bill is the devolution of decision-making, not centralisation. How can the abolition of the regional health authorities and their replacement by civil servants from the Department of Health possibly be called devolution? Thanks to an amendment in another place, the Government have conceded that one lay member per regional office will be appointed. With only eight regional offices, how can one person in each be expected to represent all the various interests of such large areas? The Minister herself said that it was difficult for one doctor on a district health authority to represent the interests of the medical profession. The former is going to be a much more difficult job.
How are the new health authorities to deal with the responsibilities previously carried out by the regional health authority? Many of those responsibilities have already been mentioned, but the most important ones I should like to repeat are those which worry me most of all. Above all, there are the decisions on regional specialities; the statutory supervision of midwives nationally; the strategic planning of nurse education as well as former links between the regional health authorities and universities with medical schools. There is also the question of monitoring cancer screening services.
All those functions will now be controlled by a consortia of health service authorities and trusts who, by their very nature, will be more parochial in their outlook and will concentrate more on their local needs than on a national strategy for health. For instance, the Royal College of Nursing is deeply concerned that local consortia will fail to take into account the need for nurses beyond the NHS; in local authorities, in prisons, nursing homes and in the work place.
There exists great concern as regards maintaining cancer screening services. It was difficult enough in the past, even in this House, to get nationwide information from the Department of Health when it had only to 24 collate information from 14 regional health authorities. How much more difficult is it going to be with over 100 health authorities involved in the collection of data. What guarantee is there that they will all be using the same system so that the data obtained are truly comparable. If we have to have a further reorganisation it is a pity that the opportunity has not been taken to establish a strategic planning body for the whole of London. Ever since 1974 when I first became a regional chairman, it has been obvious that to divide London first into four regions and now into two, was a great mistake. When I was a regional chairman and London was divided into four regions the Department of Health set up the London Co-ordinating Committee because obviously the system was not working with four different authorities running London. We wasted much time and achieved very little in that co-ordinating committee. London really needs a strategic planning body of its own.
Like the noble Baroness, Lady Jay, we also welcome the proposal to merge district health authorities with the family health services authorities. That merger must lead to better planning and a more efficient use of resources as long as adequate safeguards are built into the system. It will be essential to ensure an appropriate balance on the health authorities of both district health authorities and family health services authorities. The Minister has already said that she is not going to do it, but can she assure us that each authority will have representatives of both the medical and nursing professions as well as consumer representation? We should also like reassurance that the position of community health councils will be safeguarded and their right to attend health authority meetings restored, including their right to attend hospital trust meetings.
Under the powers given to the Secretary of State to merge health authorities, we also require reassurance as regards instances where one health authority, because of the merger of two health authorities, may still be served by two community health councils. As regards the merger of two health authorities, it is too much to ask one community health council to cover that enlarged area. We should like to see both retained.
The House is aware of how difficult a time these past few years have been for the wonderful National Health Service staff who have had to cope with endless changes and the detrimental effects which those changes have had on service morale. Can the Minister say how the merger between district health authorities and family health services authorities will be dealt with from the staff point of view? As in previous cases, will they be made to apply for their own jobs yet again, or will the problem be dealt with through a voluntary redundancy scheme?
The Secretary of State has made much of her claim that all these reorganisations will save money which will be returned to the service to achieve better patient care. However, the cost of these reorganisations now runs into hundreds of millions of pounds, and they have to be 25 paid for. How many years will pass before this money has been recouped and the service itself feels the benefit of these so called savings?
§ 3.59 p.m.
§ Lord Walton of Detchant
My Lords, I too congratulate the Minister on the exceptionally lucid and concise way in which she presented the principles underlying this difficult measure. In my view it is a Bill which cannot be regarded as representing light, bedside reading in its present documentary form. It is a document which leaves so many unanswered questions. Essentially this Bill is an enabling measure. So many issues remain to be resolved by regulation that I believe it would be right to ask the noble Baroness to allay many anxieties that I feel about its provisions and to offer some reassurance on a number of important points of principle.
In common with other noble Lords who have spoken, I welcome the decision to merge the DHAs and the family health services authorities. I believe that that is long overdue and that it is a measure that is likely to achieve the degree of closer integration and collaboration between the hospital services and the services in the community which we would all commend. However, I have some serious reservations about the proposal to abolish the regional health authorities.
One of the greatest joys in our National Health Service, and one of the greatest safeguards in keeping down the costs of the NHS as a proportion of gross national product in comparison with expenditure in many other developed countries, is the gatekeeper function of the general practitioner. That gatekeeper function means that the individual seeking specialist care will, as a rule, first consult his or her general practitioner before learning whether specialist care is appropriate. That is a very important safeguard.
Another crucial safeguard that I believe has been fundamental in the history of the National Health Service since 1948 is the principle of regional planning. Perhaps I may ask the Minister first whether in the newly integrated DHAs and FHSAs there will be a satisfactory mechanism through which the voice of the general practitioner (and of the nurses and the other health care professionals) will still be heard. So that those professions may have confidence I believe that it is crucially important that the regulations which will follow the merger should be exposed and examined in your Lordships' House. Will those combined authorities have the accountability to enable them to monitor such matters as GP fund-holding?
One of my greatest concerns about regional planning is this: in medical care, primary care is provided by general practitioners and, to a much lesser extent, in the accident and emergency departments of our hospitals. Secondary care is the specialist care that is provided by consultants and their staff in general hospitals. Tertiary care is the care that is provided in the super-specialties. One of the great strengths of regional planning has been that certain specialties, such as plastic surgery and a number of others, have been regarded as sub-regional specialties. They are not provided in every general 26 hospital, but in a selected number of general hospitals, whereas tertiary care—with its extremely expensive facilities and all of the supporting equipment and staffing required in such disciplines as neurology, neuro-surgery, cardiology, cardiothoracic surgery, and many others—has been provided in regional centres which have been so planned to take in the patients requiring those special services from a variety of feeding general hospitals.
In the new system what will prevent the kind of problems that have arisen in the United States, where every small district hospital, for reasons of prestige, has felt it necessary to have its own cardiothoracic surgeon and its own neuro-surgeon? Will the monitoring process of the regional offices of the National Health Service Executive, to which the Minister referred, be able to ensure that independent trusts do not inappropriately put their money into the support of the glamour specialities while neglecting, at the other extreme, the perhaps less attractive specialties such as geriatrics and mental health? That is a matter of very great concern, but it may arise as a result of the abolition of the regional planning authorities which have existed in the NHS to date.
One of the other important issues relates to medical and other professional advice. It was good to hear from the Minister that the Secretary of State introduced an amendment in another place to make it a statutory requirement that such professional advice should be sought by the newly merged health authorities. Will the Minister explain how that advice will be obtained? Will the regulations specify exactly the nature and extent of that advice to the newly merged authorities? At regional level, I understand that it has been agreed (although it is not on the face of the Bill) that the regional director of public health would be one of the three key executive members at the regional office. But that would involve that doctor being transferred to be a member of the Civil Service. May we be assured that when he or she becomes a member of the Civil Service that will not in any way constrain his or her right to give independent medical advice?
Turning to the issue of the university voice, I was delighted to hear from the Minister that she had agreed that the newly merged district authorities will have, as of right, a non-executive member appointed by a university with a medical or dental school. That is not on the face of the Bill, although I understand that it will be included in the regulations. I believe that it is vital that the regulations embodying that requirement should be examined and discussed with the Committee of Vice-Chancellors and Principals before those regulations are promulgated.
In 1990, when we debated the National Health Service and Community Care Bill in this House, we had many discussions until a very late hour over the crucial issue of university links. I am absolutely convinced that, in the light of the important developments in medical care, in medical education and research and in the education of the other caring professions, such a link between the universities and the National Health Service authorities is even more important now than it was at that time.
27 However, it is equally important that that university voice should be heard at regional level. How will the universities have formal representation—I know that the Minister dislikes the word "representation"—and how will their voice be heard at regional level? There are innumerable reasons why it must be heard. The Minister referred to the crucial importance of post-graduate education in medicine, to vocational training for general practice and to the role of post-graduate deans. Post-graduate deans are at present employed largely by the universities, but with funding from the regional health authorities. Indeed, the same is true of the regional advisers in general practice who play such an important role in vocational training in general practice. How will those appointments be maintained, and what will their link be with the regional office?
As the noble Baroness, Lady Jay, mentioned, the crucial importance of research and development following the publication of the Culyer taskforce report is another issue which makes one highlight the importance of a regional mechanism for looking at such processes. Culyer recommended that that should be dealt with in three streams: that the R&D budget of the NHS will have a stream which will fund nationally agreed priorities for health service research through the office of Professor Michael Peckham; but there will be a second stream that will be handled by the regional directors of research and development. It is important to know exactly how they will be linked to the new regional offices of the NHS management executive.
Perhaps of even greater importance to the universities is the distribution of that animal known as SIFTR—the service increment for teaching and research. It used to be nothing but SIFT until the Select Committee of your Lordships' House added what might be called the "R component" in 1988—an addition which led to the appointment of Professor Michael Peckham. That R component is absolutely vital in providing the infrastructure in hospitals throughout the land and provides the environment in which the research that is vital to the future development of the National Health Service and the future improvement of patient care can be conducted. Somehow or other, the universities must have a vital voice in the distribution of SIFTR from the regional level. It is not something which, in my view, can possibly be properly delegated to individual trusts or health authorities at district level.
Some of your Lordships will know that I am, at the moment, chairing a sub-committee of the Select Committee on Science and Technology, which is examining research in the NHS in the light of the Culyer Report. We hope to be able to make some recommendations towards the end of April this year. It is crucial that effective, statutory liaison arrangements should be achieved between the universities with medical and dental schools; between those involved in the education of the nursing and other caring professions, on the one hand, and the NHS regional office on the other. Those are questions which are unanswered in the Bill at present. That kind of liaison 28 is vital to the continuum of quality care, education, teaching, and research upon which depends the future vitality of the NHS.
§ 4.11 p.m.
§ Lord Jenkin of Roding
My Lords, it is a bit daunting to have to follow two distinguished regional chairmen—a distinguished chairman of a regional research committee and a distinguished former chairman of the GMC and president of the BMA. I come before your Lordships as one of those political appointees—as chairman of an NHS trust. I happen also to have been a former Secretary of State, but perhaps in that context that is regarded as irrelevant. I declare an interest as chairman of the Forest Healthcare Trust, about which I shall have one or two things to say.
I should like to go back to look at the period when in opposition, as shadow spokesman for health, I was having to work out—in the same position as the noble Baroness, Lady Jay—what would be the Government's policy if we came into power. I discussed with a great many people in the health service and outside whether we needed to have regional health authorities. When the signal was given by the then Prime Minister that we could have brief discussions with the Permanent Secretaries of the departments that we were shadowing, I sought a meeting with Sir Patrick Naime. I said that I wanted to reserve the position as to whether we retained regional health authorities. I said, "It does not seem to me to be unreasonable that that is a tier of administration and management which might go". He begged me not to do this. He said, "I am glad that you have reserved your position and not committed it, because it is your only handle on the service".
Indeed, that is what I found in the service of 1979. It is all very well for the noble Lord, Lord Ennals, to stand outside the Chamber and nod. He should stay to listen to what I have to say. Because in a top-down service, which is what the NHS was, when everything went down from the Secretary of State to the regional health authorities, as they were then, to the area health authorities, to the districts, to the units, it may well have been the case that the regional health authorities were an indispensable link. Indeed, I regarded the quarterly meetings that I had with regional chairmen—the noble Baroness, Lady Robson, attended with unfailing regularity, and how we admire her courage in speaking today despite her back problem—as extremely valuable, because we were then running a top-down service.
I was persuaded that it was essential to keep the regions. However, since then we have had the reforms. From the point of view of delivery of services on the ground, the providers —whether they be the few remaining provider units or now the great mass of health trusts—do not look upwards with hands ever held out to regions, the management executive or the department, for guidance, resources, wisdom as to what to do; they are accountable to their purchasers, to the commissioners, and through them they are accountable to the people whom they serve.
In those circumstances, the fact of the reform and that one has now devolved so much responsibility and decision-making right down to the local level—if my 29 trust is any guide, devolution goes on down to individual care groups, to care group managers, to clinical directors who have financial responsibility—that makes the whole situation different. I therefore reject completely the case that was made with such force by the noble Baroness, Lady Jay, that it is essential to keep the regional tier to maintain the NHS. On the contrary, because the pattern of reforms has gone the way that it has, and because it has worked to devolve authority and decision-making so far down the line nearer to where patient care is delivered, one can look, as it were, at the superstructure in an entirely different light.
§ Lord Ennals
My Lords, having invited me back into the Chamber, I hope that the noble Lord will not mind if I ask a question. When he was Secretary of State, did he not feel that the organisation of the NHS was suffering, not from having a regional structure, but from having far too many district and area structures? Did he not find at that time that the planning role of the regional authorities was essential? If he did not feel that, why did he allow it to go on?
§ Lord Jenkin of Roding
My Lords, because the service was top-down. The noble Lord is right. I inherited far too many layers. The Bills that I introduced got rid of three layers of administration within the NHS. I take his point on that, but in a top-down service one needs all this detailed planning at regional level. But once the decision-making is devolved to purchasers, the commissioners—the health authorities as they will be under the Bill—and the delivery of service to the providers, then a great deal of that top hamper becomes—if I may put it this way—supererogatory. It does not need to exist. There are some functions—the noble Lord, Lord Walton of Detchant, correctly pinpointed a number—in which there will have to be continuing involvement at the region. I have been provided by the department with a list of the services that will become part of the regional outposts of the management executive. Many of the subjects upon which he touched are on that list. I have no doubt that my noble friend will expand on that point when she replies.
Because one has maximum devolution right down to health authorities, to GP fundholders and to trusts, that has the effect also of making the service a great deal more responsive to the needs of the customers—to the patients —and to those who represent them.
It so happens that this morning I had a good example of that in my trust. I was due to pay a visit to the special care baby unit at Whipps Cross Hospital. Many noble Lords will be familiar with the astonishing work that such units can do in saving lives and the health of very premature babies—babies born seriously underweight; babies born with other problems (the mothers may have been drug addicts); and babies born with serious immediate problems, infections and so on. I saw some of those mites lying in their incubators. I was absolutely astonished that they should be alive at all.
When I was discussing that unit's future with the clinical director—a very distinguished paediatrician—and the care group manager, what did we talk about? We talked about the negotiations that they are currently 30 having with their purchaser to convince the purchaser that the quality of care that that SCBU is giving is better than that given by other potential suppliers of that service. They are producing figures of, for instance, rates of survival of babies born at 23 weeks, 25 weeks, 27 weeks, and so on. But, more than that, they are giving the subsequent medical histories, because it is no good enabling people to survive if they are then seriously mentally or physically handicapped if that could have been avoided. Outcomes of care are what the contracting system is now, not forcing out, but drawing out from providers. This has given rise to a higher profile for medical and clinical audit. Providers can prove that the service that they are giving compares with the best in the country. They can then convince their purchasers and others in the area that theirs is the place to take the cases. They can convince the GPs that their cases are in good hands in a particular unit.
That example is repeated in many other parts of the trust. The purchaser/provider system makes the providers look outwards to the community that they serve rather than upwards to some shadowy regional authority. It is bringing direct improvements in the quality of care—and quality is what it is all about.
Contrary to the view put forward by the noble Baroness, Lady Jay, reforms are alive and well in north east London. I do not say for one moment that life is easy for everyone; our nurses are extremely hard worked, not least during flu epidemics and other emergency admissions. Whipps Cross is a busy, hard-pressed hospital and is delivering high-quality care to those in the surrounding area.
Everyone is in favour of the merger of DHAs and the family health service authorities to form the new health authorities. However, I too do not believe that it should be another "Suetonius" event. I did not use that word but called it the shaking of the kaleidoscope: when one shakes it and then looks down the tube the colours are the same but the pattern is slightly different. The merger should be a major stride towards the more direct involvement of general practitioners in the purchasing and commissioning of secondary care from their providers. The health authorities should increasingly become strategic authorities, with a firm co-ordinating role. They should be small strategic bodies, leaving most of the decision-making as regards the contracts to the general practitioners.
That does not mean that they must all be fund holders. They may well be, but again there is an interesting example in my area. A group of 25 GP practices north of my area but south of the M.25 got together and concluded that they wished to put most of their secondary care to the Forest Healthcare Trust. They were not fund holders and did not have direct control of the funds. However, they approached the North Essex Health Authority and asked that the contracts should be drawn up enabling them to express that preference on behalf of their patients.
That illustrates how, if one devolves the authority down the line, those closest to the patients—namely, their own general practitioners—can begin to express 31 choices on behalf of the patients. That is what one means by primary directed care. It is care of which the primary sector is at the forefront.
Everyone talks about that and it is beginning to happen. However, one of the difficulties is the fact that GPs are worried that they will not be able to cope with the extra responsibility. One must ask—how can one enable GPs who have never previously done this to take on an extended role? Some of the best GPs and the most lively practices are able to take it in their stride, but many are not. I see this as a real duty which rests on the new health authorities. They will include the old FHSA, which has had the responsibility for GPs, and they should take on the task—lead GPs and guide them and help them to make their purchasing decisions more effective.
I turn now to GP supply. One is told that in London in particular—and it may be the case in other parts of the country—there is a shortage of young doctors who wish to become general practitioners. If it is seen that the health service is increasingly becoming a GP-led service, young men and women coming out of medical training will see the service as a more effective way of being able to carry out their professional duties on behalf of their patients than pursuing an ever-more recondite specialty in a hospital setting. The GP supply needs to be addressed and I hope that my noble friend will comment on that.
As regards medical education, no one has mentioned Calman. As regards those of us who employ large numbers of consultants and doctors in training, the Calman reforms in medical education are yet another area of considerable change in upheaval. I believe that the reforms in the Bill have not fully meshed with those that are being promoted through the Calman Report. I wish to be reassured about that.
Perhaps I may reinforce the point made by the noble Lord, Lord Walton of Detchant, about the place of universities and medical schools in the new structure. I too was delighted that in another place the Government agreed to add university representatives to the new health authorities. I was one of those who in 1990 argued that they should have a position on relevant trusts and that was accepted. I believe that there should be a more formal link than oral representations, or whatever, between the universities and the new regional bodies. I too have received communications from the Committee of Vice-Chancellors and Principals. I shall not bore the House by quoting from them but the committee makes a case that needs to be listened to.
If the Calman reforms are bringing about substantial changes in the pattern of medical education, if this Bill is bringing about valuable changes in the structure of the delivery of health care, somehow them must be a better linking between those two processes. Some form of clear university representation at the regional level is most important.
I warmly welcome the Bill and I believe that it will be to the benefit of patients. It will achieve all the five things that the noble Baroness, Lady Jay, suggested that reforms should achieve. I differ from her in almost all 32 that she said about the Bill, except her comments about the health authorities. I wish the Bill very possible success.
§ 4.28 p.m.
§ Lord Monkswell
My Lords, I am in illustrious company. My only qualifications to speak on this subject are that I am the son of a GP, who unfortunately has not practised for some years, and as a user of the National Health Service. For some years I was a member of the Stockport Community Health Council and later of the Manchester Family Practitioner Committee. Following reorganisation I received a letter informing me that my services were no longer required. I suspect that that was partly due to the fact that I was seen to be an active member of the Labour Party and not a Conservative supporter, but I may be wrong. I am also an engineer. I seek to assess the latest reorganisation of the health service on the basis of the practical effects.
I was pleased to hear the noble Lord, Lord Jenkin of Roding, explain the problems of GP practices endeavouring to send their patients to a particular hospital. That clearly demonstrates what has changed in the National Health Service under this Conservative Government. It is similar to what has happened with the privatisation of the public services about which we have heard. I take the example of the electricity industry. Before it was privatised, we were all shareholders. Fifty million people were equal shareholders in the nationalised electricity industry. I heard recently that there are now 3 million shareholders of the privatised electricity utilities. We have gone from a situation in which there was openness and freedom in which 50 million people were involved to a situation in which fewer than 3 million people are involved.
Before this Conservative Government came to power, GPs could refer their patients to any hospital and any consultant throughout the land. They had access to literally thousands of consultants and hundreds of hospitals. Now they are restricted to a particular hospital with which their group, within the National Health Service, has a contract. They can send patients only to those hospitals with which contracts exist. They are denied the facilities to send their patients to the consultants and hospitals of their choice. That is very stark; I am glad that the noble Lord, Lord Jenkin of Roding, mentioned it.
The noble Baroness, Lady Cumberlege, said that the purpose of the Bill is to remove an unnecessary tier of administration. She added that there would still be regional offices. If there are still to be regional offices—I shall say more about that in a few moments—we are not doing away with a tier at all. We are changing the system. In practice, we are hiding away that tier from the public eye. That is not very sensible in a democracy.
Why does that regional tier exist? Let us compare the National Health Service with the national education service. The national education service provides schooling for all children in the country between the ages of five and 16. That provision is made under the aegis of local education authorities. Over the years the revenue support grant has been established through 33 which the Government help to fund the education service. That is done on a formula basis. Over the years it has been adjusted. The mechanism provides automatic funding from the centre. That has never existed in the National Health Service. Provision for funding at local level is not well established on a formula basis, Historically, the distribution of resources in the National Health Service has been determined within regions by regional health authorities.
The Government's objective may be to use a formula funding mechanism to ensure that there is a sensible distribution of resources at local level. But that is not yet in place. In practice, decisions will have to be made at regional level to determine where the resources go within that region. I am concerned that the distribution of resources will take place behind closed doors, administered, effectively, by a commissar—I repeat, a commissar—on a clear Stalinist model. That is not the right way to distribute resources which are so important to the people of this country.
We all recognise the importance and the positive gains which will flow from merging district health authorities and the FHSAs. But I enter two caveats. First, it is extremely important to ensure that at that level we maintain a voice for the professions involved in the provision of primary services—in particular, general practitioners, opticians, dentists, pharmacists and, of supreme importance, midwives. It is extremely important that those five professions are plugged in effectively to the district level. From the introduction which the noble Baroness gave, it does not seem that their voices will be heard sufficiently.
Secondly, there was no mention of the growing integration and inter-relationship between the National Health Service at local level and the social services provided by local authorities. We must recognise that essential integration. This Government started the process by absolving themselves of any responsibility in relation to community care. They laid that enormous burden of responsibility on local authorities and, in particular, their social services departments. We must recognise the importance of the integration at district level of the National Health Service and social services departments and make those operations coterminous. The new district health authorities covering the primary care sector need to be coterminous with local authority social services departments. Unless that is so, we shall lose the opportunity to ensure that the integration of service delivery goes ahead much better than it is doing at present because of the separation of those two areas of responsibility.
I suspect that we shall not be able to make many changes to the Bill. I am sure that noble Lords on all sides of the House will fight for what they see as improvements but I suspect that the Government have made up their mind. On the advice of the deputy chairman of the Conservative Party, John Maples, they are trying to take the National Health Service off the agenda by getting rid of regional health authorities and replacing them with commissars who operate behind closed doors. Notwithstanding the Official Secrets Act, 34 I hope that the public will be able to hear enough about what is going on to alert them about the Government's management of the National Health Service.
§ 4.38 p.m.
§ Lord Dainton
My Lords, I too congratulate the Minister on her clear explanation of the Bill. Indeed, there is much which will be welcomed in the Bill but the Minister will not be surprised to know that I wish to draw attention to three practical matters arising from it which, unless they are properly attended to, may handicap it seriously; namely, the education of medical and dental students in both their undergraduate and postgraduate phases and basic medical research.
Unlike the noble Lord, Lord Walton, with whose comments I largely agree, I am not a medical doctor but for many decades, I have been involved with medical education and research in a variety of senior capacities. It seems to me that the Department of Health, and indeed all its precursor bodies, have constantly to be reminded of a fundamental fact which applies whatever the organisation that is set up. To make my point, I wish to quote what I said nearly five years ago in the Second Reading debate on the National Health Service and Community Care Bill. On that occasion I said,The quality of health care received by patients depends more"—
I believe this still to be true—on the skill, motivation and commitment of their doctors, nurses and ancillary staff than on anything else".
It goes above organisation:And those essential attributes receive their major cultivation in the clinical phase of the education of aspiring doctors … Responsibility for maintaining the quality of the teaching lies wholly with the universities and is exercised through their full-time members of academic staff, assisted by NHS staff holding honorary contracts and posts. The major part of clinical research in this country is also carried out by those academic doctors and their staffs".—[Official Report, 3/4/90; col. 1300.]
I further argued on that occasion that, as with all previous Bills from 1974 onwards, a principle had been conceded; namely, that for training, research and patient care to be truly effective and properly interdigitated, one with another, it was essential that the university which had responsibility for that education and research, and which for that purpose owned—and indeed still owns—accommodation in hospitals, should have a say in the deliberations of the policy and governing bodies of such hospitals, which in those days were of course, as has been mentioned, the district health authorities (teaching) and the regional health authorities.
Five years ago the National Health Service and Community Care Bill incorporated this principle for the newly introduced trusts which the Bill proposed to introduce in place of the district health authorities. But totally inconsistently on that occasion the Bill rejected the same principle for the DHAs (teaching) by withdrawing the right of membership by universities in the governance of those district health authorities (teaching) which for many years had at least one university member. Fortunately, in response to pressure in this House, the then Secretary of State, Mr. Kenneth Clarke, saw the damaging illogicality of this situation and its unworkability and he agreed to amend the Bill 35 to provide for appropriate university representation on the district health authorities, as the noble Lord, Lord Jenkin of Boding, has already mentioned.
The Bill before us today proposes new health authorities to replace the existing district health authorities and family health services authorities. I think most of us applaud that. As originally drafted, the Bill contained the same error as five years ago; that is to say, no university member was to be on the new health authorities. But, fortunately, as has already been mentioned, that error was spotted last December in another place and in response the Secretary of State said—I was delighted to hear the Minister confirm it today—that she will introduce a requirement for universities with a medical or dental school to have membership of a new health authority, and that that will be put in the regulations. Why it cannot be put into the Bill I cannot imagine.
Naturally the universities welcome the possibility of restoration of membership by whatever means, which in my view, as I have mentioned, should always be statutory. However, given that it is to be prescribed in regulations, it obviously makes sense if the universities can be satisfied that the whole of that part of the new arrangements which are to be incorporated in the regulations will be practical and workable, and to that end they have sought prior consultation on those regulations before they are drafted. That has been refused. May I ask the Government to think again? The Government, the health service and its patients now and in the future have everything to gain and nothing to lose by that kind of consultation which, in my view, is bound to result in better regulations.
The problems of the university/health service interface do not end there because, as the Minister reminded us, under this Bill it is proposed that the regional health authorities in England and Wales will be replaced by regional offices of the National Health Service Executive. As the Bill now stands there will be no provision for the relevant universities to be involved as of right in the deliberations of the executive in the decision-making process. All that is proposed in the Bill is that the regional director be reminded—I emphasise that—that universities are taken account of in appropriate circumstances. That is hardly the approach to ensure that universities have a real say in the decision making. Instead of a mere reminder to the regional directors, in my view they should receive an instruction to consult the universities.
Another important and cognate matter concerns the postgraduate deans, to which brief reference has been made, who are responsible for postgraduate medical and dental education and for academic standards. Hitherto, they have been employed either by the universities alone or sometimes jointly by the universities and the NHS. It is vitally important that that link with the universities be not lost and that the universities retain responsibility for the postgraduate deans, at least for the academic part of their work including, especially, immediate postgraduate pre-registration house officer training.
36 If the postgraduate deans are responsible solely to the regional directors—which appears to be a possibility under the Bill—I am sure those regional directors will see their major responsibility merely to satisfy the needs of patient care today. If that is the case, the training of doctors for future service in the NHS and elsewhere will inevitably suffer as will, of course, the prospects of medical care in the NHS of the future because that quality of teaching and research in the future is critically dependent on the preparation of doctors. I shall omit references to research and development which I had intended to make in view of the passage of time, and simply say that I support all that the noble Lord, Lord Walton, said on those matters.
§ 4.47 p.m.
§ Baroness Cox
My Lords, this is the first major legislation relating to health care since the National Health Service and Community Care Act 1990. As my noble friend the Minister outlined so clearly, it contains a relatively small number of provisions but they have far-reaching implications.
Noble Lords have spoken about many of the key issues. I shall therefore confine myself to those which reflect my own interest as a vice-president of the Royal College of Nursing. I wish first, however, to welcome the proposed merger of district health authorities and family health services authorities. This sensible streamlining can only improve the commissioning of primary and secondary care services. The integration of the two types of authorities is already taking place in some areas with the appointment of a single chief executive. The Bill will enable the policy to develop consistently across the country.
The merger of DHAs and FHSAs has been warmly welcomed by a wide range of organisations. For example, in its evidence to the review of community nursing undertaken in 1985 by my noble friend Lady Cumberlege, the Royal College of Nursing called for the merger of DHAs and FHSAs, known previously as family practitioner committees, and for the creation of primary health care authorities. With two authorities working separately it was inevitable that some people with health and/or social needs would fall through the safety net of care. Greater integration of hospital, community and primary care services will help to provide a seamless web of services for patients, clients and carers. Therefore this proposed merger is, we believe, warmly to be welcomed. Moreover, by combining the expertise of both acute and community care services, the provisions of the Bill will strengthen the new health authorities' ability to commission appropriate services for their own local populations.
So far so good. And mention of the word "expertise" leads me to the main issue on which I wish to focus. The membership of the new health authority boards will be crucial. It is therefore of the utmost importance that the right decisions are made now about the membership as it is board members who will to a large extent determine whether patients receive good quality health services, appropriate to the local population and sensitive to individual needs.
37 As my noble friend the Minster said, there will be three executive board members prescribed in regulations: the chief executive, the director of finance and the director of public health. It has also been noted and welcomed that a non-executive director will be appointed from a university medical or dental school where one exists.
While appreciating the proposed membership as far as it goes, I do not believe that it ensures sufficient professional expertise on key aspects of policy in the health service. I urge serious and sympathetic consideration of what I believe is an overwhelmingly powerful case for the executive membership to include nursing expertise. I know that the Government are familiar with the arguments and, indeed, agree that nurses have a crucial contribution to make to the purchasing team. Last summer the Department of Health published a report called Building a Stronger Team in which it praised the role of nurses in purchasing. Only last week my honourable friend the Minister of State for Health in another place told a King's Fund conference:If purchasing authorities are to carry out their job even more effectively it is vital that they work hand in hand with nurses who have 80% of patient contact in the NHS. Nurses give purchasing plans clinical credibility based on longstanding and widespread experience".
Qualified nurses are the largest professional group in the NHS, constituting approximately 50 per cent. of the NHS workforce. Nurses also account for 40 per cent. of current expenditure in the NHS and 3 per cent. of total public expenditure in Britain as a nation. Thus, if purchasing bodies are to be cost effective they must ensure optimum use of nursing resources. Clearly, nurses themselves are the most appropriate source of knowledge to advise on professional issues such as staffing and skill mix.
I do not advocate the representation of nursing expertise on boards as a way of promoting nursing's interests in any sectional or partisan way. I do so because nursing expertise is needed for effective purchasing. Assessment of clients' needs and an understanding of the costs of providing care, participation in clinical audit, and monitoring standards of care are all part of nurses' everyday responsibilities. Nurses' expertise spans all clinical areas and their contact with patients is continuous rather than episodic. No other profession is better placed than nursing to give informed, detailed advice on services needed by patients, families and carers.
Organisations representing patients emphasise the important part that nurses play in the purchasing process. For example, the director of the Alzheimer's Disease Society, Mr. Harry Cayton, wrote to the general secretary of the Royal College of Nursing claiming:We recognise that nurses' regular contact with people with dementia and with their carers mean that they have a unique contribution to make at the most senior level of the purchasing team...Unless the Health Authorities Bill gives legislative force to the importance of nurses in purchasing there is a risk that the quality of services could be poorer as a result".
Therefore, there seems little dispute that nurses have the knowledge and skills to make an essential contribution to the purchasing authorities. However, opinions differ on the mechanism through which their contribution can 38 be ensured. The Government have argued that there is no need to prescribe a place for nurses on health authority boards because there must be flexibility in each area to decide whether a nurse is needed. My honourable friend the Minister in another place told a Standing Committee that the Government fully expect that in many cases executive members will be appointed who have nursing qualifications and that the Government have encouraged that in the past and will continue to do so. While we welcome such great expectations and encouragement, that is not enough to ensure that nurses attain key posts.
A survey by the Royal College of Nursing in January this year found that only about one half of existing DHAs and FHSAs have nurses in executive positions and that even fewer intend that to happen under the new arrangements. There is already evidence of nurses in executive board positions losing their jobs as authorities merge in preparation for April 1996,
There is a related issue on which I would welcome reassurance from the Minister. Last month the Government published guidance on good practice on appointments to NHS trusts and health authorities. Many of the suggestions are to be welcomed as they will indeed improve appointment procedures. However, I have one anxiety relating to the disqualification criteria at the very end of the document, identifying those who will be ineligible for appointment as non-executive directors of trusts and health authorities. For example:The Secretary of State would not normally expect someone who works for one health body to be appointed as a non-executive director to another".
That disqualification would appear to exclude many nurses and other health professionals working in the NHS from serving as non-executive directors on the new health authorities. Most of those who are eligible will be working outside the NHS, for example in occupational health services, prisons, universities or the Armed Forces. I appreciate their professional services, but the exclusion of those working in the NHS, as it appears from the wording of the document, means the exclusion of those with particular experience and expertise within the NHS which makes them such strong candidates for full involvement in all stages of decision-making, essential to the remit of the authority. I shall be grateful if the Minister can clarify that point, not only as it relates to nursing but also as it relates to other professionals. If so many well qualified nurses are to be disqualified from membership and if there is no statutory requirement for nurses to be executive members, the Government's hope that many nurses will become board members is not likely to be realised.
I believe that it would be very serious if purchasing boards were to become an exclusion zone for nurses. Ultimately, it would be the patients and their families who suffered from the lack of nursing input on the boards. I shall be very grateful if my noble friend will consider some statutory provision for the inclusion of nursing experience on the boards.
I understand and welcome the amendment, to which the Minister referred, already incorporated into the Bill, requiring health authorities to seek advice from professional practitioners, including doctors, nurses and 39 midwives. However, that is not the same as ensuring their professional input at initial and other key stages of policy formulation.
Finally, I shall be grateful if my noble friend will clarify the implications for nurse education. With the abolition of the RHAs, responsibility for commissioning nurse education will fall to local purchasers and providers who will presumably base their decisions on local needs, as the noble Baroness, Lady Robson of Kiddington, highlighted. I therefore share the anxiety, also expressed by the Royal College of Nursing, that such local decisions may not ensure adequate provision of the range of nursing specialties needed for national requirements or for long-term strategic planning for nursing services both within and outside the National Health Service.
There are signs that the need for nurses in the future has been under-estimated, as shortages are already evident around the country. Moreover, there were cuts of 33 per cent. in the number of student nurse places between 1987 and 1994. Trusts are increasingly looking to agency and bank nurses to fill the gaps. However good those individual agency and bank nurses may be, they cannot provide the continuity of patient care and thus the quality of relationships with patients and families which lie at the heart of good nursing. Furthermore, the Royal College of Nursing has received reports that even agency nurses are in short supply, for example in London, Manchester and Bristol.
Those shortages are serious, and must be taken seriously, if present problems are to be alleviated and a crisis is to be averted. I would warmly welcome assurances from the Minister that steps will be taken to ensure the involvement of nurses in the key decision-making bodies of the future NHS and that the new arrangements will ensure that education and employment of appropriate numbers of nurses overall, and of specialists in clinical areas, will be provided to enable the provision of health care for all people in the years ahead.
I emphasise that, although I speak as a nurse, I do not seek to promote the interests of nursing as such, as I have already said. My overriding concern is to seek to take the opportunities afforded by this valuable Bill to maximise the efficiency and effectiveness of the new authorities in providing the highest possible standard of care in the most cost-effective way and in ways which are most finely tuned to present and changing health needs, individually and nationally.
I welcome the Bill. I hope that my noble friend will be able to give assurance on the issues I have raised because I believe that they are essential if the Bill is to achieve its very worthy objectives.
§ 5.1 p.m.
§ Lord Desai
My Lords, perhaps I may begin by saying that I have an engagement later this evening. Given the rate at which the debate is proceeding, it may not be possible for me to stay until the end, for which I apologise.
40 Let me say, first, a word or two in defence of dinosaurs. In introducing the Bill, the noble Baroness said something about the NHS in the old days being like a flat-footed dinosaur. Dinosaurs lasted 2 million or more years. Human civilisation will be lucky to last that long. Dinosaurs did not die out because they were inefficient; they just had a nasty shock. Therefore let us not hear anything against dinosaurs; they are good. I wish that humans were that good.
If my memory serves me correctly, in the late 1960s and early 1970s, by and large, people were not dissatisfied with the National Health Service. Indeed, everyone was proud of it. Then when the late lamented Lord Joseph was in charge of health it was thought that the health service should be reformed, and that reform would bring progress and all kinds of other good things. Therefore the service was reorganised. We have had reorganisations ever since, and every reorganisation has promised progress. But if one asks the people in the streets, they are more dissatisfied with the National Health Service than they ever have been. The noble Baroness will tell us how much more money is being spent, how many more patients are being treated, and so on. However, at ground level the dissatisfaction with the National Health Service is much greater than previously; and that cannot be denied.
I have my doubts whether this reform—it is the fourth or fifth in about 20 years—will perform miracles. As my noble friend Lady Jay said, reform by reorganising is a non-solution to a problem. We are not so much abolishing regional health authorities as transforming their nature and making them rather more subservient than at present. The only other reform has been welcomed by this side of the Chamber; and I have nothing further to say on that.
It is often argued that removing one tier such as the RHA decentralises and gives more power below. I believe that exactly the opposite occurs: the more one abolishes middle tiers, the more power is concentrated in the centre because one sets up weaker and weaker authorities on the ground which do not have the power or resources to stand up and challenge the central authority. We have seen that occur regarding education. We now see it happening within the health service. I do not believe that decentralisation always leads to giving power to the people.
Let me give an extreme example. Someone might say that Parliament is an intermediate level of authority between the ruler and the people. Therefore let us get rid of Parliament and local authorities; let us give power to the people themselves. What would happen? The people would not gain much power. One needs bodies at certain levels to concentrate power and authority. Without them one only makes the centre more powerful.
In its report on priority setting, the health committee in another place made a number of good suggestions about why some of the priority settings and analyses of health care need to be comparative across regions, age groups, classes and so on. Who will undertake such analyses? If we do not have regional health authorities, that would be undertaken by some specialist group, but without proper feeling for the opinions of the people.
41 Some noble Lords may have read in this morning's newspapers about the King's Fund—on whose sober authority there was reliance about a reorganisation of hospital care in London. The Tomlinson Report followed. At that time we all considered that the King's Fund had some expertise. Now that body has changed its mind and tells us that it was all a ghastly mistake and should perhaps be stopped. Throughout the Tomlinson reform the ordinary people had a suspicion all along that London needed not fewer hospital beds but more. Perhaps there should have been better ways of consulting the patients and users of the National Health Service. I am sure that there are methods of consultation. But the methods used have failed to spot the problem which the people saw and the experts did not.
I am not sure whether the removal of one tier and bits of reorganisation address the problem that we face: that the people's confidence in the National Health Service has been and is being eroded. That is happening despite more money being spent. In that case, we should be doubly worried. If that loss of confidence occurred when money was not being spent, one could understand it; but it is occurring despite more money being spent. We ought to consider how to improve the situation. Short as the Bill is, I see very little which addresses the problem.
The noble Baroness said that the provisions would save money. I have heard that said before and I have never found it to be true. That was promised when the National Health Service was reorganised in the 1970s. When local government was reorganised in the 1970s, it was promised. Every time some service is reorganised, that is what is promised. But all that happens is that another tier of professionals is hired. No one ever goes away; more and more people come in. If I were a betting man I should place a bet—I am not sure that one is allowed to take bets in your Lordships' House—that five years on we will find that not a penny has been saved and the whole package may have cost about £500 million, give or take £100 million.
I do not believe that the Bill, short as it is, will improve the National Health Service very much. At a later stage I hope that we shall be able to consider more constructively how we can restore the people's faith in the National Health Service. As the noble Lord, Lord Walton, said, the National Health Service is one of the most efficient services around. All that we are doing is to make it less efficient and less popular. I wish that we could do better.
§ 5.9 p.m.
§ Baroness Gardner of Parkes
My Lords, unfortunately I too must leave before seven as I had earlier accepted an invitation to a pharmaceutical dinner tonight and I must go. I apologise. I become cross when I hear other people saying exactly that to the House, but it is difficult when one is asked to accept an invitation well in advance and then one finds at the last moment that it clashes with a debate.
The Bill appears to be both a simple and yet a complex one. It is simple because the aims are very straightforward. The abolition of the RHAs, the merging of DHAs and FHSAs will help to remove some 42 unnecessary bureaucracy from the health service and should benefit patients and staff. It will free funds for more direct patient care.
It is complex because the changes require a huge number of consequential amendments to a large variety of Acts. That will make the Act a nuisance in terms of the legalities of using the law when the Bill is enacted. I am sure that other Members of your Lordships' House will appreciate the need after this for a consolidation Act sooner rather than later.
From 1990 to 1994 I was vice-chairman of the North-East Thames Regional Health Authority. After years of involvement in the NHS administration and general dental practice, I found it most interesting to be working at the strategic level. Among other responsibilities, we were closely involved with the formation of the new NHS trusts. I welcomed those, as it seemed to me to be returning the control of the health services to those most closely concerned with direct patient care.
Earlier, I had served on an area health authority for all the time that such authorities existed. We sat in an office, remote from all hospitals, determining how the hospitals should be run. At the same time, I was a member of the retained board of governors of the Brompton and National Heart Hospital, where meetings were held on the premises and governors really knew the particular needs of patients, staff and even the building. The area health authorities were abolished, as noble Lords know, and that brought management closer to the point of delivery of services to patients, with just the region and districts. NHS hospital trusts are, I believe, run in ways more or less the same as the hospitals were run years ago and I am convinced that that has benefited patients. The RHAs have largely done their job now and I think that it is good to remove that extra layer and again to bring control back closer to people. Now, combining the district health authorities and the family health service authorities will again bring control to a more local level.
Much has been said about how little say patients have and I agree with the noble Baroness, Lady Robson, that it is important that community health councils should not be reduced to only one per new authority. I echo that. I am now chairman of the Royal Free Hampstead NHS Trust on which we have a great deal of consultation and time spent with the Hampstead Community Health Council, and now the Barnet Community Health Council, as those are largely the two areas that we cover. A separate Islington Community Health Council covers the other area, with the University College Trust. They would find it tedious to have to come to the many meetings we hold, just as the Hampstead people would find it tedious going to the other meetings. If we want good local consultation, we must keep it at a sufficiently local level.
There has been much comment during the debate on NHS appointments. My vice-chairman is a lifelong Labour supporter, a real stalwart and also a tremendous asset to me, with his local knowledge and awareness of the history of all that has gone on in Hampstead for many years. I have no idea of the politics of my other members; I do not care about that. The members are 43 there because they are efficient and capable; they have the knowledge that we need to run the trust. We believe in working closely with local authorities and I believe that the noble Lord, Lord Monkswell, mentioned the need for closer liaison, which is important. However, the connections must be built up over a period and I do not agree with him that it is essential for them to be coterminous. Patients do not consider themselves coterminous with anything. They still wish to go to the hospital with which they have had past associations or which are more conveniently situated. If people live across the borough boundary, they still go to the hospital of their choice, as they are entitled to do. As a general principle, coterminosity may be good but one cannot restrict patients by the same coterminous rules.
The Royal College of Nursing sent me a statement which I found interesting. I emphasise the point made by my noble friend Lady Cox that there is grave anxiety about whether we will have enough nurses. We are already finding a shortage of agency nurses and I have doubts about the. Project 2000 scheme for nurses. We are losing the identity and association that nurses used to have with the training hospital where they learnt their nursing skills. I appreciate that educationally it is considered better, but the scheme is changing the nursing scene, taking nurses away from the hospital, giving them an education with a different flavour. There will not be the same allegiance to hospitals as there was in the past. However, my anxiety in this debate is not how nurses are trained; it is to ask the Government to ensure that we have enough, under whatever body controls the system.
The National Consumer Council wrote to me suggesting that a rather complicated and cumbersome process of consultation should be brought in. I thought it was quite impractical. The council suggested that the new commissioning authority should advertise what form of consultation it intended to introduce as a start and then it would be able to work out the consultation. By the time one has consulted to see what kind of consultation might be introduced, and then reconsulted people, the whole issue has gone so far that the system is quite hopeless and we hope that it will not be brought in.
There should be good liaison with the community health councils. Years ago, I would have spoken and probably did speak against community health councils. When they were first introduced in the days of the area health authorities, I thought that they were nothing but obstructive. If the area health authority took two hours for a meeting, the community health council took four to six hours for the equivalent meeting. I was then chairman of social services and health in the Westminster City Council. We advertised and interviewed people so that we were far ahead, but to find people to represent the local authority was extremely difficult. My husband was appointed and served for four years, at the end of which I suggested he might like to be reappointed. He said: "Never! I couldn't possibly stand any more of it". The process was hopelessly cumbersome and time consuming.
44 Since then I have seen a gradual change in community health councils. Their attitude and interest in what they are doing, their understanding of medical and hospital problems and even the commissioning problems have changed to the extent that the councils are an active partner within the health service. If I had been asked 10 or 12 years ago I would never have thought that I would stand here and say that, but I believe that they now have a great role to play and will continue to play it.
I end by echoing some of the points brought out by the noble Lord, Lord Desai. The man in the street is probably dissatisfied with the health service. After my 40 years in it, I consider that I am accurate in assessing the reason. It is partly because treatments have progressed unbelievably. Forty years ago, if you had a bad heart you were given bed rest, and that was all there was. Now the list of treatments available is enormous and expectations have increased tremendously, as well as awareness of what is available.
Another more worrying point is that there is an awareness of what one is entitled to. We have seen much on television about malpractice suits and years ago as a dentist in this country you could almost cut the patient's head off, but if he had faith in you he would not mind. As time went on, patients reached the point where they questioned everything one did. Recently a professor explained that dentists might be carrying out unnecessary fillings. From that day on, I hardly did a single filling without the patient questioning whether it was needed. So we have created a whole different atmosphere for patients. That is one of the disadvantages.
We have to realise that we shall never be able to satisfy the expectations that people have. We just have to do our best to see that the patients really do receive treatment to the highest standard and with the greatest care that we can possibly give.
§ 5.20 p.m.
§ Baroness McFarlane of Llandaff
My Lords, like many Members of this House, I thoroughly support the merging of the district health authorities and the family health services authorities. I listened carefully to the persuasive arguments of the noble Baroness the Minister about the disbanding of the regional authorities. I was almost persuaded—almost. But I need some convincing and I want to be assured that, for what seems a very small saving when you look at the total cost of the National Health Service, we have systems in place that will undertake the very important services which we have heard today that regional health authorities undertake.
I want to focus my remarks on two issues. I feel some embarrassment, because they are the two issues about which the noble Baroness, Lady Cox, has already spoken. Therefore, I shall not detain the House and repeat all that she said. We have not been in collusion, but it is evidence that we feel deeply about the same issues. I speak as one who spent almost 30 years in nursing education and then, for a short while after the 1990 Act, served as a member of a district health authority and was chairman of its complaints committee.
45 So far as nursing education and training are concerned, it is that experience that I want to share with the House. My memory goes back long, long before the "flat-footed monolith" about which the noble Baroness the Minister spoke, to the days when district hospitals recruited individually—and under-recruited for their needs. The national need for nursing staff was met only because teaching hospitals over-recruited. I have a great fear that we may quickly find ourselves in that position again.
The Minister and the noble Baroness, Lady Cox, described how the regional authorities have responsibility at the moment for determining the demands of employers for nurses and for purchasing education and training places. Under the provisions of the Bill, that strategic planning function is to be devolved. It is to be taken on by the local' consortia of health authorities and trusts, which will make an estimate of their local needs. The plans will be monitored by the new regional offices.
I have a deep concern that there is no intention to continue with a national overview for nursing manpower needs. Without such an overview, it will be impossible to detect and prevent impending shortages. That situation may very quickly be upon us. Both the noble Baronesses, Lady Cox and Lady Gardner of Parkes, mentioned the cuts in training places; and I am told that a further cutback of 55 per cent. over the years between 1993 and 1997 is envisaged.
The inevitable conclusion is that there will be many fewer trained nurses and that the skill mix, both in the community and in hospital, will be diluted to the point where the quality of patient care will suffer. I do not wish to advocate the misuse of highly trained nurses and expensive staff. But I wish to point to the evidence that says that patient outcomes and patient turnover is vastly improved where registered nurses are employed. I believe that that points to a need for a national overview.
Increasingly, as the noble Baroness, Lady Cox, said, nurses are being employed on a casual basis—on short-term contracts or as agency or bank nurses, in the interests of cost saving. The implication is that we have a highly mobile and volatile nursing workforce. The implications of that for the quality of care can only be imagined. The ethos of the institution in which one works, or even of a ward and its working procedures, can take time to absorb, and the continuity of care which individual patients need is lost.
At the same time, there are numerous commendable government initiatives in Health of the Nation targets and in care in the community for frail and disabled people which demand more, rather than fewer, skilled nurses. Furthermore, it is difficult for any local determination of manpower needs to take into account the training demands of small, highly specialised groups such as paediatric intensive care nurses. We have heard that indications are that the service is already under strain. That strain will be exacerbated by wholly devolving manpower planning to a local level.
My years in nursing education have made me aware that, for courses to be economically viable, a critical mass of students and suitably qualified staff is needed. If the future demand for students is underestimated and 46 training places are cut back, then the colleges and higher education institutes will cease to offer courses. Besides nurse tutors facing redundancy, it will be difficult to reinstate the courses once the true manpower needs are identified. In other words, the infrastructure for nursing education will have been lost. I trust that the Government, in devolving the regional responsibilities, will recognise the need for a national overview of nursing education and manpower planning.
My second point is related to the membership of the new health authority boards. Again I reiterate that I am not making the point for the representation of sectional interests. We have already heard that five particular professions were named. The basis of trying to be representative in the membership of health boards is just not feasible. However, I am making a case for the necessary expertise and knowledge in the planning of the nursing manpower needs that the health authority will have to undertake.
We heard from the noble Baroness, Lady Cox, that nurses form a major component of the healthcare team. They provide 80 per cent. of direct patient care and account for a great deal of the National Health Service budget. Nurses involved in purchasing therefore have an intimate knowledge of what is a major component of the work of district health authorities. From my experience of serving on a district health authority, I would say that that knowledge of manpower planning in nursing and purchasing is needed by the authority.
Nurses also bring an important dimension to the general management of health authorities. They work across all clinical areas and understand the role and contribution of other staff at all levels. Nurses in purchasing have the credibility to challenge practice in provider units and to negotiate contracts from a standpoint of clinical knowledge.
Each NHS trust is required by statute to have a nurse executive on its board. It seems only logical that the purchasing health authority should have an equivalent executive position to negotiate contracts from an informed position and to advise on the balance of provision between different services. Indeed, the Department of Health's own draft guidance on the involvement of professionals in the work of health authorities emphasises the importance of nursing involvement:the skills and knowledge which nurses bring include an appreciation and clear understanding of health care drawn from practical experience across all clinical areas, an ability to challenge clinical practice and an understanding of nursing costs and how staffing and skill mix can be fine tuned to achieve optimum use of resources".
It seems to be accepted that nurses have a pivotal role to play in the work of purchasing authorities. The Government have recognised that and issued good practice guidance for consultation on involving them at various levels in the work of health authorities and have incorporated into the Bill a requirement to seek their advice.
My concern is that, despite those welcome measures, there will be no statutory force behind the involvement of nurses at the highest level. That is in contrast to the present legislation, under which district health 47 authorities in Wales must have a nurse executive member on their boards, family health service authorities in England and Wales must have a non-executive member with community nursing experience, and, as I said earlier, trust boards must include a nurse executive.
The Bill will remove any existing requirements to include nurses on boards, with no adequate replacements. Despite the assurances of the Government that nurses who are able will automatically rise to such positions, it appears, as the noble Baroness, Lady Cox, said, that they may not even be eligible. I believe that unless the Government give statutory force to nurses' involvement at board level, few able and skilled nurses will reach those key positions and their knowledge and expertise in purchasing will be lost.
§ 5.33 p.m.
§ Lord Dean of Harptree
My Lords, I too welcome the Bill and the lucid explanation that we received from my noble friend the Minister when she introduced it. It follows naturally from previous reforms. However, I was also glad to hear that it is regarded as the final step in the progress of NHS reforms.
However necessary reform may be, inevitably it creates uncertainty, particularly for those who work in the service. It involves a lot of time and effort in planning and implementation and, however well thought out the reforms may be, difficulties will arise and unforeseen snags will appear. Therefore, although I welcome the Bill, I am glad that it is regarded as the last in the line.
There has been a general welcome both in this House and outside for the formation of all-purpose health authorities to replace the existing DHAs and FHSAs. That is in contrast to the controversy that arose when the National Health Service was first formed. At that time GPs were fearful that the new organisation would mean that their voice would be swamped by that of the hospitals. As a consequence, the family practitioner committees were set up and in one form or another have continued from that day to this. The fact that there is now a general welcome for the all-purpose authorities shows very clearly the progress that has been made over the years in viewing the service as a whole, with the family practitioner as the first link in the chain involving the GP surgeries, services in the community and in people's homes and services in hospitals.
The composition of health authorities has been mentioned on many occasions this afternoon. I too welcome the statement that a growing number of members of health authorities will have a background in nursing, medicine and other relevant professions. It is clearly highly important in such a specialised service, with so many professional disciplines involved, that the voice of those who have experience in these matters should be clearly heard. I hope that in considering that point my noble friend the Minister will be able to give a sympathetic response to the plea on behalf of the British Medical Association that the voice of primary care should be clearly represented on the health authorities.
48 I agreed very much with the point made by my noble friend Lady Cox and other noble Lords. It was a powerful plea for the representation of nursing. I hope too that we shall not lose sight of the importance of having an independent element on the health authorities. We want some people who are gifted amateurs and do not have a health service axe to grind. People who are experienced in management are also needed. If we are to have rounded health authorities, all those aspects are required.
I should like to raise with my noble friend the Minister three specific points. The first relates to the co-ordination of services, particularly the relations between health authorities and local authorities. One of the most difficult problems with which I had to deal when I represented a constituency in the other place concerned the demarcation disputes that sometimes arose in that area. Such problems arise most obviously in connection with services for the elderly or the mentally ill. For example, there may be an elderly lady in hospital who has had her treatment and is ready to be discharged; but she is not fit enough to go back to her own home and look after herself. Naturally, the hospital wants the bed. In many cases the local authority or voluntary organisation does not have a place. That comes partly from the inevitable pressure on services, which is bound to grow as the number of elderly people in the community grows. But also it arises from the different funding arrangements for the National Health Service and for local authorities.
I wonder whether my noble friend can say whether the health authorities are likely to be in a better position to deal with those kinds of demarcation disputes. Can she say also whether joint funding arrangements are likely to be able to make some contribution to the solution to such demarcation problems, which can be very distressing?
My second specific point concerns the community health councils, which were mentioned by the noble Baroness, Lady Robson. I am very glad that they are to be retained. Not everybody agrees that they are necessary but it seems to me that they provide a valuable safety valve and watchdog. Can the Minister say whether their role will continue as before under the new arrangements?
My third specific point concerns relations between the National Health Service and the private sector. I declare an interest as a former governor of BUPA. When I was on the BUPA board I was able to see first-hand some of the valuable work done by that organisation in its own hospitals and also the fruitful co-operation that existed between the private sector and the NHS. In my view, the NHS and the private sector are complementary and not competitive. I hope that my noble friend will be able to give an assurance that the co-operation between these two sectors will be encouraged to develop further.
The background to this Bill is the massive government investment in the National Health Service. My noble friend was too modest to mention that in her speech today. I remind the House that spending on the NHS has increased by no less than 66 per cent. in real terms since 1979. Even in last autumn's very tough spending round the NHS was able to get an increase of 49 1 per cent. in real terms, which was an extra £1 billion. These are impressive figures. They are the essential wherewithal for the great progress that has been made in curing disease and alleviating the pain and suffering of millions of our fellow countrymen each year. I believe that this Bill will help that progress to continue.
§ 5.42 p.m.
§ Baroness Eccles of Moulton
My Lords, I start by declaring an interest as chairman of a district health authority. I was originally appointed by the Secretary of State in 1988. I am proud of it. We have come a long way in the past four years since the first wave of trusts came into being as the most obvious and well publicised element of the fundamental set of changes to take place in the National Health Service.
As far as public awareness is concerned, although press coverage has concentrated on trusts and GP fund-holding, the new role of the district and family health authorities is of great importance for the improvement of health care for local people. This Bill will strengthen the way in which local health authorities improve services. It will certainly have a big effect on the way that local hospital and primary care is managed. I hope to be able to demonstrate that the authorities in west London are ready for it, and to indicate how important it is that the powers conferred by the Bill are used sensitively.
This afternoon and at other times it has been asked whether the new health authorities will have the capacity to carry out the responsibilities devolved to them from the regional health authorities. In part answer to that question, perhaps I may say that at our district health authority meeting last week we considered a list of over 30 service areas for which responsibility was being taken through devolution to the authority of a substantial proportion of the region's previously top-sliced budget. Many of the services on that list are ones that we already manage where the funding has for historic reasons been top-sliced, and all of the items relate to activities with which we are familiar.
As one would expect with an authority that plans and provides services across a wide spectrum, from home bathing to heart by-pass surgery, one needs to have the benefit of advice and guidance from a wide range of clinical specialists, GP advisers, public health specialists, nurses, psychologists and many other disciplines. Many of the specialties that we plan and fund which are provided by hospitals and other services have been subjected by the authority to service reviews. Each review team relies considerably on medical input. This means that the statutory obligations to take professional advice which the new health authority will be under will be a continuation of what we do at present.
Alongside the greater devolution of funding—this year some £360 million of public money is being shared by the two local authorities in my district—one must have greater accountability. I welcome the proposal that the chief executives of health authorities and trusts will become more accountable to Parliament by being designated accountable officers. Clearly, it is unreasonable that the chief executive of the entire NHS, 50 no matter how able he is, can realistically be held to account for how services are organised in west London or any other part of the country.
I turn now to relationships within our district. It has always been important for the local health service to work closely with the local authority, the voluntary sector and other services. In addition, over the past few years the contribution of the private sector has grown substantially. Since the introduction of Care in the Community, local authorities have taken the lead, but work in tandem with health authorities to provide a tailored package of care for each person in need. In order to ensure that this system works, it is essential that the new health authorities are in a position to play their part fully. That can be greatly assisted by up-to-date and relevant funding mechanisms, and also by both authorities—one part of a national service and the other locally determined—taking their full share of responsibility.
The merger of health authorities will allow services to be planned so that those of GPs and hospitals are better co-ordinated than has been possible to date. In west London we are well ahead. Soon after Working for Patients came into effect, the erstwhile North West Thames Regional Health Authority encouraged all DHAs and FHSAs to become coterminous with one another and the local boroughs. That was implemented very successfully. In our case, the FHSA was already coterminous with three London boroughs. The merging of one part and two whole DHAs in April 1993 enabled us to work as a health agency, thus combining the two statutory authorities covering three boroughs. That may sound rather laborious, but it makes the point that the coterminosity of the authorities and the boroughs is of great importance. For us, this proved to be a neat arrangement which provided an essential foundation to bring together the work of the two authorities. A year ago we moved into one building in the centre of our area. That has contributed greatly to the degree of integration that we have achieved.
Local differences, even in a superficially uniform area of west London, are significant. The development of services that reflect the particular needs of localities and ethnic groups is crucial to our new role. Twenty-five per cent. of our population comes from a wide range of ethnic groups. Across the whole country there are considerable local variations in the structure and needs of the population. This is inevitable, and it is also to be valued. As the effects of this legislation take hold, these differences must continue to be respected.
Comments made in support of the manpower and functions review, which was the forerunner of this Bill, stressed the increasingly light touch applied by the centre to local management of the NHS. My noble friend the Minister mentioned this in her speech this afternoon. Policy needs to ensure that this philosophy prevails and that local diversity is respected.
51 I welcome this Bill as an opportunity for the highly competent management of existing health authorities to meet the challenge and take the NHS forward as a modem service, well equipped to meet the health needs of the local populations that each serves.
§ 5.49 p.m.
§ Lord Ennals
My Lords, I wish to express my personal thanks to those who have spoken who play an important role in the operation of the National Health Service. I may be critical in a moment or two, but I am not critical of the time that is given by Members of this House to serve and improve the National Health Service.
This is the first time I have spoken in a debate on the organisation of the NHS since the National Health Service and Community Care Act 1990 came on to the statute book. Much has happened since that very fundamental reorganisation. I welcome the reaction of the noble Lord, Lord Dean of Harptree, that this is the last of the reorganisations. I have not been happy about most of the previous ones. One of my feelings about this Government has been that whenever they see anything their first thought is, "How can we reorganise it?"—not always with very satisfactory results.
Much has happened since that reorganisation in the health service. For example, the number of senior and general managers in England has shot up since 1986 from 5,000 to more than 20,000. That is quite an achievement. Secondly, total bureaucratic costs have more than doubled since 1987–88 as a result of that reorganisation. Thirdly, the trend towards political appointments to paid posts, with much higher pay than 10 years ago, has accelerated. I await with interest, as I am sure will the whole House, the comments of the Nolan Committee on the politicisation of quangos, including the NHS quangos.
Fourthly, local authority representatives on NHS management bodies have been removed. I do not mean that none plays any part but none has a right to. That was a very derogatory step which we fought against hotly when the Bill was before the House. The Bill also removed or reduced greatly the role of non-governmental organisations, which are so important in the National Health Service, and reduced the role of the professional organisations, including those of doctors and nurses.
Fifthly, the role of community health councils has been reduced in recent years. They play a very important and healthily critical role in the National Health Service. Sixthly, whatever may be said about episodes of treatment and whatever may be the figures for episodes of treatment, the total number of patients on hospital waiting lists has increased and passed the 1 million figure for the first time. The trend is still upward.
Seventhly, concern about the Conservative handling of the National Health Service has steadily increased. That concern is reflected in every kind of election and opinion poll. The public, who value their National Health Service almost more than any other service, do not believe that it is in safe hands or that it has been in 52 safe hands for many of the years past. I do not suppose that they will be interested in this Bill but we who are here debating it are interested in it. I believe that the extraordinary unpopularity of the Government owes more to their handling of the NHS than to any other single issue. The public feel more deeply about the National Health Service than anything else.
From my introduction one might suppose that I oppose the whole of the Bill. I do not. During the progress of the National Health Service and Community Care Act I supported on behalf of noble Lords on this side of the House the concept that DHAs and FHSAs should not retain their separate status. It is a pity that the proposals that were made and voted on did not see the light of day. At that stage the Government did not believe that it was a good idea.
That brings me to the abolition of the regional health authorities, which the Government present as a streamlining of management and a reduction of administration. There are strong arguments against the proposal that is the main part of the Bill, though I certainly welcomed the decision that was taken some time ago to reduce the number of regions from 14 to eight. That is not a bone of contention. Apart from putting at risk 1,500 jobs—unless everyone is to be turned into a civil servant, which I cannot believe is the Government's intention—there are many reasons for believing that the Government's proposals are a great mistake.
I am not happy about the role of regional health authorities, which over the years has been a very important one, being taken over by civil servants who by their very title and definition are arms of central government. I am glad that the noble Baroness, Lady Robson, who spoke so well, is present, in spite of her bad back, because we had many happy days, weeks and years when I was Secretary of State and she was a regional chairman. As I said in an intervention during the speech of the noble Lord, Lord Jenkin of Roding, I believe that regions have an important planning role. That somehow or other that planning role is to be reduced by all that has happened in the reorganisation of the National Health Service is absolutely wrong. Their role ought to be increased rather than decreased.
Both the noble Baroness, Lady Jay, and the noble Lord, Lord Walton of Detchant, have emphasised research as a critical part of the role of regional health authorities. One asks about the supervision of regional specialities. If that is to be done by civil servants it can only be on the instruction of their Ministers. That step goes further to take away any independence of thought from the National Health Service which might have existed. Much was done in the National Health Service and Community Care Act to take away that independence. A regional officer or civil servant serving health Ministers is not an adequate replacement for the regional structure.
A number of consequences will flow if this decision is carried into law. First, it will undermine the ability to provide a strategic and planned service, which is essential for a comprehensively equipped NHS. It will be a further step away from the National Health Service which was so proudly created long years ago by a 53 Labour Government. Secondly, it will weaken the service's ability to regulate and monitor the internal market activities, with a resultant threat to health care. Thirdly, for reasons that have already been given, it will further damage the already enfeebled accountability of the service. Fourthly, it will result in the NHS losing access and expertise in areas such as intermediate treatment or estates planning. One could give countless examples.
Such services and advice will now have to be either duplicated at local level or bought in from the private sector, both of which would be more expensive for the National Health Service. In my view the regions have played and should go on playing a very important strategic role.
No doubt Ministers would be glad to say that the days are gone when we tried to make of the National Health Service a national service where planning documents were brought out annually to indicate which regions needed to have more provision in one field than another. Those days are gone. A regional health authority plays an essential role in allocating resources to local purchasing authorities. It is important that a region-wide perspective is retained and that an intermediate tier is involved in ensuring the implementation of national priorities at regional level. Clearly, some RHA functions will be undertaken by the new National Health Service Executive regional offices which the Minister so clearly described. But there again, they are civil servants. I have nothing against them, but it is a question of simply taking away any element of independence from the National Health Service.
Perhaps I may look for a moment at regulation and monitoring the internal market activity. I know that the health service unions strongly believe that the market system will not deliver a comprehensive, equitable service which offers equality of access and is free at the point of use. Unless checked the logic of the market will lead to inequitable provision and to a two-tier service where cost rather than need becomes the driving factor. Everyone in your Lordships' House can give examples where that is already happening.
Regional health authorities have a vital role in monitoring and, if necessary, regulating the activities of the market. While purchasing authorities have a primary responsibility for monitoring providers, trusts should have to account for their performance to wider audiences than simply their purchasers. On the purchasing side, RHAs have a more direct responsibility for holding authorities to account for their performance. They should influence the strategy and objectives, if not the detail, of the purchaser's plans at their inception.
In addition, RHAs need to monitor the contracting process through which purchasers and providers interact to ensure that the process is in the public interest. If necessary, they should mediate where problems arise. Although the new NHSE officers will be expected to undertake some of this work, we have to question whether it is better that that is done by eight government offices or by an integrated part of the National Health Service, which I believe most noble Lords on this side of the House wish to preserve. The whole question of accountability within the National Health Service, and 54 other public services, is currently a matter of great public concern. I believe that the public will be interested in what decisions are taken in the passage of this Bill.
We shall have plenty of opportunity during Committee stage to try to deal with some of these issues by amendment. The Government make it very difficult when they virtually ensure that there is nothing in the Bill and that everything is done by regulation. That has become a very bad habit of this Government. It undermines the principles of parliamentary democracy when we are not given on the face of the Bill the essential decisions that the Government intend to take.
I am sorry that I have taken a few minutes longer than I intended, but perhaps I may conclude with a final argument which I know will not appeal to noble Lords opposite. I believe that the Labour Party will win the next election. Noble Lords would expect me to believe that. No doubt all noble Lords will look askance that it is possible for opinion polls to show a 42 per cent. Labour lead—
§ Lord Ennals
My Lords, I am told that it is a 43 per cent. lead. It has gone up since I gave the first figure! Apart from assemblies for Scotland and Wales, there is a debate about English regions. I saw Mr. Gummer yesterday bursting with joy as he proclaimed that Labour was split from top to bottom on this issue. That is not true. What is true is that the patterns of regional activity may vary because needs vary. There may be a difference in structure and performance because that is the wish of the regions concerned. But there will be a regional tier in one form or another. It would be absurd to move in the opposite direction at this stage. I hope that we shall be able to convince Ministers and noble Lords on the other side of the House of this argument during the course of the Committee and Report stages.
§ 6.5 p.m.
§ Lord Holderness
My Lords, I begin by congratulating the Government, as many noble Lords have done, on this further step forward they are making in the structure of the National Health Service. That service is of immense importance to us all. Not long ago when I was chairman of a special health authority within the National Health Service, I reached the conclusion that the then administrative structure of the service was—if I may put it no more strongly—a little bit weighty. Therefore, I do not share the view expressed by the noble Lord, Lord Ennals, that it is a pity to change the structure. I believe that change is very necessary. With the publication of The Health of the Nation it became even clearer to me that a more simple and sensible structure is necessary if the health service is to attain the very sensible objectives of that newly framed policy.
I agree entirely with the noble Lord, Lord Ennals, that many different contributors have their part to play in making the National Health Service a success. The new health authorities are going to be extremely busy groups of people. They must continue to rely, as did their predecessors, on the vigour of a number of agencies, 55 including quite a number outside the field of the National Health Service itself. Among them I hope that I shall be forgiven for mentioning the organisation called Disabled Living Centres. I must declare a personal connection with at least one of them, the William Merritt Centre at Leeds.
In the task of making it possible for people who have been ill or injured to live independently at home, I believe that it will be agreed that the work of these centres is beyond praise. I need say little about it because the contribution made by the centres to supplement the rehabilitative work of the National Health Service is well known to your Lordships. Consequently, any diminution in the efficiency of organisations of that kind would have a considerable effect on the efficiency of the National Health Service which this Bill aims to improve.
Therefore, after speaking very briefly, I hope that my noble friend will be able to assure me that there is no proposal in view to decrease the effectiveness of the centres. The council which helps to service them already works on an extremely modest scale. At a time when care in the community is rightly commended as the way forward and as a supplement to all the things we are trying to do, I believe that disabled living centres should be more important in supplementing the contributions that the new health authorities and various other authorities will have to make.
My plea is that if the centres are to function properly they need resources and the back-up of a supporting body. I hope that the disturbing rumour that the modest support accorded them at present will be reduced can be refuted by my noble friend. That suggestion surprised me, because I am aware of the wide recognition in the department of the excellent results which the council and the centres have achieved. I hope that my noble friend will be able to assure me that there is no foundation to the rumour.
§ 6.10 p.m.
§ Baroness Seccombe
My Lords, some years ago I took an elderly relative to an outpatients' hearing clinic. The appointment was for 9 a.m. We decided to be a few minutes early to ensure that we were on time. Your Lordships may imagine my surprise and horror when I found that 25 others had had a similar idea and that their appointments were also for 9 a.m. We were sent to a waiting room without an outside window where the door was propped open by a fire hydrant. There we sat, including a lady of over 90 who had not been out of her house for over three years.
As time went by, I decided to investigate and asked the receptionist what was happening. She said that the consultant had not arrived. As it was close on 10 a.m. I thought it fair to ask why not. Her retort—not the friendliest—was that she did not know, she had not heard from him and would I please return to my seat and please close the door as it was not permissible for the door to be propped open. She certainly did not care for it when I suggested that no one could be expected to sit in a cupboard without fresh air.
56 With no apologies for lateness, we eventually saw the consultant at about 12 noon. In those days it seemed to me that the NHS was badly organised and that addressing the needs of the patients came very low down on the list of priorities.
Your Lordships may wonder what relevance that story has to the Health Authorities Bill. I suggest that it shows how far we have come since the Government embarked on the reforms five years ago. Today we have a user-friendly service where the patient comes first. In addition, the Patient's Charter specifically deals with the issue of patients being kept waiting longer than 30 minutes after their individual appointment time.
At the time of the 1990 Act, many people thought that the NHS was teetering on the brink. It was, and is, an organisation massive in employee numbers, yet it was administered centrally. It was, and is, funded generously, yet the advantage to the patient of any extra funding seemed minimal. Furthermore, the unfortunate taxpayer was encouraged to believe that whenever a problem arose, the solution was to throw more money at it.
The principle of the 1990 Act in devolving power and responsibility to the local level is unquestionably right, particularly in an organisation so large. The establishment of the NHS trusts, the creation of the new role for local health authorities and the granting of new powers to GPs through fund-holding have transformed the service to patients.
There were 56 hospitals in the first wave of trusts and it is, indeed, remarkable that from April this year 98 per cent. of all hospitals will have trust status. And now GP fund-holding is blossoming also. It is the ability of those concerned with primary care to call the shots that will guarantee the maximum efficiency of a service of which nobody who has used it can properly speak ill.
The proposals outlined in the Bill build on the success of the reforms and so enable the final tranche of organisational change to take place. I believe that the RHAs are now an unnecessary tier of management and that the savings from their abolition will contribute to the total estimated savings of £150 million per year from the Bill—money which can be spent on direct patient care. That should be welcomed on all sides of the House, as should the retention of the overview to ensure that the NHS continues to deliver its objectives and to maintain the high standards of the quality service that is recognised throughout the world.
I must admit that I have always found it difficult to describe the actual role of the RHA, the DHA and the FHSA. As a lay person I have always felt that there must have been a certain amount of duplication. I am therefore delighted that the new structure will be much simpler, with only one authority at local level. It must be right for the power and responsibility and the resultant decision-making to rest with those nearest to the interests of the patients.
To some, the Bill may seem of a technical nature, but to me it seems to put the finishing touches on a creditable and bold change of direction that was begun in 1990. For the future, I hope that many more GPs will join the ranks of fund-holders. That way, working with the local health authority in partnership, they will have 57 more flexibility in arranging services for their patients. I am also certain that more and more treatments will take place in doctors' surgeries. Consultants are already taking advantage of that co-operation in some areas. Surgeries could be the mini-hospitals of the future.
As a result of the Bill, the structure will be in place for the development of a comprehensive, high-quality service to tackle the formidable challenges of an ageing population as we enter the 21st century. I look to the future with confidence and excitement as the continuing involvement of local people allows flair and innovation to flourish. That can only be of benefit to patients. I welcome the Bill as an important piece of legislation.
§ 6.16 p.m.
§ Baroness Dean of Thornton-le-Fylde
My Lords, when the Health Authorities Bill was introduced, press releases that were issued by the Secretary of State for Health in November 1994 said that it completed the NHS reforms that were begun in 1990. I am sure that there was a big sigh of relief when people heard that, but if the Bill is the last tranche of reorganisation, that makes it even more important. Many of us on this side of the House would challenge the proposition that the outcome of those changes in the health service is serving patients well and whether that would have been possible without some of the changes that the Government have introduced.
Perhaps I should declare an interest as a non-executive member of the board of University College, London. I am not speaking this evening wearing that hat but in a purely personal capacity as a Member of your Lordships' House.
It is essential that we get this right. It is essential because the provisions will mean so much to local people both in terms of accountability and representation and in terms of the quality of the service that they receive.
I was interested to hear the story at the beginning of the speech of the noble Baroness, Lady Seccombe. No Member of your Lordships' House could say that that was a proper experience for an old lady. I am sure that we would all condemn such occurrences. However, while I listened to the noble Baroness I wondered why, if those experiences no longer occur, we have a record number of people waiting for a first-time appointment with a consultant. I also wondered whether, if that old lady had needed hospitalisation in years gone by, she would have been kept waiting for a bed in hospital, as are so many old people today, and then, having got her bed, whether she would have been taken out of hospital as soon as possible because of the shortage of beds which has been reported in the press in the past few days.
The Bill has been presented under the guise of removing levels of hierarchy in the health service. If there are fewer levels of hierarchy in an organisation, the managers will have more involvement in the system. However, when I read the Bill, I questioned whether it would achieve that. Will the Bill achieve greater openness, greater accountability and greater efficiency? Most importantly, will it achieve greater quality of 58 service for the people this is all about, the patients? I question whether it will do so, just as I question whether the projected savings will actually be achieved. They were estimated originally at £150 million, but I gather that the figure has now been reduced to £60 million. There must be a big question-mark over such figures.
I shall deal with the three themes that come through in the Bill. They are not unique to this debate; a number of noble Lords mentioned them. The first relates to the proposed abolition of the regional health authorities. I am not saying that the present structure of the eight regional health authorities is perfect; that there are no complaints about it; and that it does not need changing. But why throw the baby out with the bath water when the structure has many good elements within it?
Over the past four years a number of changes have been introduced. We had the National Health Service and Community Care Act whereby universities and medical schools had a statutory right to participate in the planning and decision-making with regard to the education and training of clinicians in the health service. With the proposed abolition of the regional health authorities, out will go our national planning for education and training, not just of doctors but of nurses and a whole range of other professionals who work for patients in the health service.
It is all right to say that the new health authorities will decide how many professionals they will need to train for their areas, but their concern and concentration will be on their areas alone. It will not be about the service as a whole. It will not, for instance, take into account the need for nurses in prisons, in local authorities, in the work place and in a whole raft of other areas, including nursing homes, where those services and skills are essential.
One could take that on board and say that it will be taken care of if there is a surplus of nurses in the system, but there is not. In these days of high unemployment, unemployment among nurses runs at about 1.7 per cent. As the noble Baroness, Lady Cox, said, we have seen a 33 per cent. cut-back in training. The College of Occupational Therapists recently conducted a survey with local authorities, the Association of County Councils and a whole raft of local involvement. It found that there was a 15 per cent. shortfall in the number of occupational therapists needed. That is not something that can be pushed to one side; planning is needed. One cannot pluck a qualified nurse or therapist out of the blue. They have to be trained, and that has to be planned for. They have to be recruited and they need a long period of training. Those are some of my worries about the abolition of the RHAs. I have a number of others, but those are my key concerns.
Perhaps I may turn now to the merging of the DHAs and FHSAs. That development is clearly to be welcomed, but I am critical about the way we are doing it. Here again, we are starting with almost a blank cheque. There have been specific placings on FHSAs for a pharmacist, a dentist, a GP and a community nurse. We will not have that with the new health authorities. I know that we talk about management and structures 59 within the health service, but we should ask the patients in whom they really have faith. Those in whom they have faith are the doctors and nurses.
If we set up a new body without a statutory requirement for the placing of those professionals on it, the new health authorities will get off to a bad start. The Minister may say that of course the health authorities can appoint a nurse, a doctor or whoever. But we should look at the practical experience of such things. That is not the case at the moment with the district health authorities, which can also do that. The RCN carried out a recent survey. Liverpool said that it had four nurses on its health authority and expected to have a nurse on the new body. If one goes just over the border to Chester, one finds that Chester does not have one and does not expect to have one. When questioned in the survey, 73 health authorities said that they would be cutting back considerably on the number of executive nurses they employed.
Not only is there no provision for a professional to be on the health authority under the Bill, but the health service is faced with the problem of having a smaller number from which to draw. It is important that the standard is maintained. Currently, 52 per cent. of health authorities employ nurse executives; but only 8 per cent. said that they planned to do so when the changes were in place. That should worry us all.
During the course of the debate, a number of key themes have been brought out from different points of view with the different positions of noble Lords. We need to return to them in Committee, and I look forward to doing so. I hope that the Minister will listen to the views put forward by many able and experienced noble Lords and will be prepared to amend the Bill in a way that will make it more relevant to and representative of local people, in particular the patients.
§ 6.26 p.m.
§ Lord Ironside
My Lords, we have had many reform Bills before the House in recent years, and the passage of some of them has been a marathon. Most have marked up watersheds in our affairs. I am glad that, because of the paving Acts already in place, we are unlikely to have a marathon this time. It is not quite a one-clause Bill; if it were it would be incapable of amendment. It is a Bill with a single purpose in its first clause. The noble Lord, Lord Walton of Detchant, described it as an enabling Bill under which the Secretary of State has power to make alterations, and to update and regulate it through statutory instruments.
We must assure ourselves that current Acts, public policy, and government regulations do not undermine the management of public health care and the translation of scientific research into medical practice. Patients have everything to gain from the new management system now being brought into health care. Your Lordships will wonder why I am speaking in the debate. I admit readily in the presence of so many experts that I have little experience of the organisation of the NHS and of health authority affairs. My only experience is as 60 an observer. So, although I may have missed out on the supply side, I have learned a great deal recently about the demand side.
I also declare an interest which many noble Lords heard me declare in debate last year; namely, that my wife is president of RAGE (the Radiotherapy Action Group Exposure) whose members, numbering possibly as many as 2,000 in the UK, have suffered disastrous injuries from radiotherapy treatment following breast cancer surgery as a precautionary measure.
On a more personal note, my grandfather was an FRCS—what was commonly known in the Army as a sawbones; and my mother's stepfather was a professor of anatomy and anthropology at Cambridge. People believed him when he pronounced the Piltdown skull as being genuine. I hope that the mistakes of the past generation will not be visited on its successors.
I welcome the Bill, as I believe it recognises the way the new management strategy is permeating all our affairs. The rapid spread and acceptance of trust hospitals and fund-holding practices shows that the strategy has wide support. The Bill brings the law into line with the watersheds in science, medicine, surgery and treatment techniques which are now driving forward primary and secondary health care. We have heard that there is also tertiary health care, but I do not want to talk about that. The Bill deals with the situation very simply by enabling management to be devolved from the centre in order to serve the patient better. I see health authorities better able to match the demand from everyone entitled to healthcare in the UK to the increasing skills and techniques being provided at hospitals and treatment centres.
My experience in the defence industrial field has given me an insight into the greater value for money that can be obtained from a procurement system, which now works principally on a through-life quality criteria, governed by management as well as performance standards, competition, market testing and, above all, a healthy—probably the right word to use in this debate—interaction between the private and public sectors. The relevance of all these factors in selecting the best way forward for the NHS is important.
In giving my support to the Bill, I wish to draw attention to the breast cancer problem now facing most countries. The EU 1995–99 third five-year action plan in the fight against breast cancer (on which 64 million ecus are to be spent) shows the breast cancer mortality rate in the EU at 24 per cent. of all cancers and incidence and mortality higher by a ratio of nearly 2:1 in the northern EU member states—Denmark, the Netherlands and the UK—than in the Mediterranean member states such as Greece, Spain, France and Italy. Incidence has increased in all states, although it is true that mortality among younger women in some northern member states has started to decrease. The EU goal in the action plan is 15 per cent. by the year 2000.
The problem is two-fold. The first is prevention, which must be one of the goals whether or not it is a pipedream. The second, while cure remains elusive, is treatment. It is clear therefore that, while prevention remains the ideal solution, treatment is crucial.
61 However, I do not believe that we can look at the problem of breast cancer in isolation. There are parallels to be drawn with the USA as well as in the context of the EU action. What I am concerned about is to what extent the NHS and health authorities can pursue the problem effectively when it is clear that co-ordinated action is needed in translating research into practice, in getting the quality of treatment right, in getting screening and diagnosis right, in eliminating the risk factors in treatment and in doing a lot of other things which could be done, for example, by creating a one-stop-shop.
The experience of RAGE members before, but particularly after, radiotherapy treatment shows little recognition that a pattern of injury exists and no understanding of why the injuries happened. There is no dispute about the radiotherapy being the cause of injury. But why was it that some many injuries were concentrated at just a few treatment centres and one in particular; namely, the Royal Marsden Hospital? Because of that, the call for the one-stop-shop in breast cancer treatment is now so strong that I wonder whether the Bill will provide the health authorities with sufficient powers to co-ordinate access to such facilities when so many inputs are involved.
One of the inputs in this scenario is quality assurance. My noble friend Lady Cumberlege knows of my anxieties in this area. I do not have to remind her that the health sector is being bombarded with quality issues which need to be resolved. We both know that there is resistance to adopting BS EN ISO 9000 within the healthcare sector and therefore in-house it is dismissed as being unsuitable. When other public sector departments as customers call for quality assurance approval, suppliers have greatly benefited from compliance. I wonder why doctors believe that they are exempt when the quality route can be seen to have so much going for it. Already, the British Standards Institution has registered many elements of healthcare, including radiography, neurosurgery, maternity, accident and emergency. It also covers national blood transfusion services, hospital laboratories, fertility units and general practice. Therefore, I suggest that because of what has been achieved already by the BSI in this field the "NIH, or rejection, factor" in the NHS no longer holds water.
The BSI draws parallels with what the Food and Drugs Administration has done in the USA and the way in which the neurological unit at the John Radcliffe Hospital in Oxford has addressed ISO 9000, which encompasses the whole process of patient referral, diagnosis, treatment, post-operative care and eventual discharge. I have drawn parallels with the USA in mammography, and the way in which that could be picked up here, and for radiotherapy too. The US Mammography Standards Acts 1992 requires facilities to be accredited by the FDA for equipment, operators, film and, last but not least, diagnosis, with yearly renewal of accreditation. With 80 such facilities in England, that would be a welcome advance. My noble friend has not been able to tell me the UK capacity but I understand that the health authority, as speciality purchaser and customer, can call for quality assurance 62 standards from the provider. My noble friend Lord Jenkin said that in his experience of Whipps Cross Hospital the unit is looking for credibility in discussion with the purchaser. Surely, the purchaser is able to set the standards. If the health authority has no powers in this respect, perhaps my noble friend will say who has. The power of the purchaser surely wields the quality stick; he is purchasing in order to obtain an effective outcome.
The British Standards Institution, I am told by the chief executive, takes the view that major benefits are to be obtained by having nationally accepted quality standards applied to the healthcare sector. I believe that after the disasters at Exeter and North Staffordshire—and now apparently shortcomings at the Dundee Royal Infirmary—as well as injuries at the radiotherapy treatment centres, something certainly needs to be done to put momentum behind quality assurance in the health sector. I hope therefore that as a result of the Bill becoming law the Secretary of State will set something in motion with the BSI. If powers are not delegated to the health authorities as purchasers, I assume that the Clause 6 powers under statutory instrument are adequate to ensure that quality assurance can be introduced. The EU action plan calls specifically for the introduction of quality assurance controls.
I turn to the defence field. Is my noble friend satisfied with the arm's length relationships that will exist between the Armed Forces and the NHS? For instance, if the RAF Personnel and Training Command at Innsworth has responsibility for the planning and provision of RAF medical services how is it that it can function without some dialogue with the NHS Executive, regional offices and health authorities? As service health profiles by selection are high and greater physical demands are placed on servicemen and servicewomen, the RAF will, for example, want to know that it is getting for its money. I am sure that the waiting lists of hospitals will be unacceptable to the services. If there are to be hospitals with military wings, I imagine that in certain cases it will make sense to have a military presence on a health authority. Presumably, there will be nothing to stop application in any case. Perhaps my noble friend can say more about the lines of communication that are to be put in place. The Royal College of Nursing is calling for places on health authorities. Perhaps it follows that the Queen Alexandra's Royal Nursing Service has just as strong a case for consideration if the NHS is to provide adequately for the Armed Forces.
Finally, I have seen how my general practitioner, as a fundholder, is giving greater value for money in the services he provides. I have seen how the healthcare sector needs a spur as regards quality assurance. I have seen how the Government are determined to deliver improved breast cancer services in a co-ordinated way through their expert advisory group on cancer. I hope that my noble friend will explain to the House and give publicity to the fact that the Government already have in place a national strategy for breast cancer services in view of the fact that, as the Minister is well aware, a Bill has just been introduced in another place to provide for a national breast cancer plan.
63 I hope also that my noble friend will give an assurance that when this Bill is enacted, all concerned with its implementation will be able to work together and, in the case of breast cancer, in a way in which all women will have confidence. I support the passage of the Bill.
§ 6.41 p.m.
§ Lord Lyell
My Lords, I congratulate the Minister and I thank her for her excellent, lucid presentation of the Bill. The Bill is fairly short, in that it has only one or two major, enabling clauses. That is a real luxury when one thinks of much of the health legislation that has passed through your Lordships' House.
The noble Lord, Lord Ennals, is looking at me rather quizzically. He may wonder why I am speaking in the debate. Some 18 years ago the noble Lord, Lord Ennals, who, at that time, was wearing a different hat, attended a great dinner held by the pharmaceutical industry. I was taking an interest in the Bill which was passing through your Lordships' House at that time. At the dinner the noble Lord, Lord Ennals, announced that the Government were taking decisions in relation to the pharmaceutical industry and patents and licences of right. Since that time, I have never lost my interest in the health industry and pharmaceuticals.
I much appreciated what the Minister put forward today and I agreed with many of the points raised by my noble friends, and in particular by my noble friend Lord Jenkin. It is the first time in my memory that I have picked up a Bill and looked at the Explanatory and Financial Memorandum. I was absolutely struck dumb, in that it claims that the savings are in the order of £150 million per year. That must be something of a record. We should all take note of that prediction in the Explanatory and Financial Memorandum because it is an incredible saving.
I ask my noble friend to explain some of the figures given in relation to manpower; namely, the 3,900 staff in the regional health authorities and 1,100 staff in the regional offices of the NHS Executive. I am not sure how those figures come together. Perhaps my noble friend will explain that to me either this evening or at a later stage.
I commend the great patience of the noble Baroness, Lady Jay, in not moving from her seat. I enjoyed her comment about the Roman army but I wonder, very politely, whether she did not put a dart in her own foot. I do not know who —was it Catullus?—made that excellent statement about the disorganisation within the Roman army but, if one looks at the map of the Roman Empire as organised by the Roman army, the organisation cannot have been all that bad. If anyone complained about it, it might have been the Baroness Jay of the day. But if the organisation of the National Health Service today is as good as was the organisation of the Roman army at the time in question, we ought not to have much to complain about.
64 The noble Baroness tempted me to look at one of the comments of Cicero. The four words which Cicero wrote were: "si vales, bene est". If you are in good health, all is well. That should be the motto of today's Bill because that is what we are all trying to achieve.
I hope that the Minister will be able to assist me in relation to a number of small, detailed points. If she does not do that this evening, that can be done when we consider the Bill at a later stage. Will the Minister confirm those astonishing figures of £150 million per annum for England and £3 million for Wales? Where can I check up on those figures and obtain independent verification?
Secondly, I believe that I am right in confirming what my noble friend Lord Gray of Contin said on an earlier occasion in relation to local government in Scotland. The provision of the services is not necessarily the most important aspect but the effectiveness of the services provided to the consumer is of crucial importance. Is that the rationale behind the Bill which we are discussing this evening?
Thirdly, I am astonished that there are only eight regional health authorities and I wonder why there are so few. The noble Lord, Lord Ennals, gave us a brief outline of another aspect connected with regionalisation. No doubt those comments will be monitored closely by the press and those who are interested in the wider political sphere.
Fourthly, I hope that the combined functions which at present are carried out by district health authorities and FHSAs will continue to be provided, as far as possible, on the present terms. My noble friend Lord Jenkin raised that matter, as did the noble Lord, Lord Walton of Detchant, in his excellent speech.
Fifthly, I hope that the existing relationships between health authorities and outside organisations—for example, university medical schools—will continue under the new organisation as proposed in the Bill this evening.
The needs of the health service are changing constantly. The noble Baroness, Lady Jay, mentioned a personal interest of hers; namely, HIV and Aids. Between 1987 and 1990, that aspect of health was much under discussion, as it is now. What was the cost of providing remedial treatment then and what is it now? That is only one feature of a constantly moving target for financial providers at all levels within the National Health Service. We must look at that matter.
The Minister invites us to take a close interest in the Bill. I have done so. Perhaps the Minister and her advisers will look at page 35. What on earth do the Dartford-Thurrock Crossing Act 1988 and the payment of tolls have to do with this Bill? I am sure that there is a good explanation for that. I hope that my noble friend will be able to help me with that.
This Bill aims to save £150 million per year, which will be reinvested for the provision of further patient care. With that in mind as a main driving priority, I 65 believe that the Bill deserves the support of us all. To assist the noble Baroness, Lady Jay, perhaps I may say that I studied Catullus, who said:"Vir sapet qui pauca loquitur".
That means that the noble Lord who speaks briefly does himself a great deal of good and above all, shows wisdom.
§ 6.48 p.m.
§ Lord Rea
My Lords, in preparing for this debate, I found only one aspect which met with the approval of all the professions involved and that is the one which has met with the approval of all noble Lords who have spoken this evening; namely, the merger of the FHSAs and the DHAs into one HA.
I remember advocating that step when I first reached your Lordships' House 12 years ago. But, as my noble friend said, the Government were not in the mood to listen at that time. However, there are a number of anxieties in relation to that aspect of the legislation which have been raised by those who have at heart the interests of primary health care. This merger is an arranged marriage and, although the two partners know each other extremely well and have always had to co-operate, it has not always been as friendly a relationship as it might have been. The district health authority, being much the richer and controlling the high-powered, high-tech acute hospital services, was always in the stronger position. Since the purchaser/provider split, however, the situation has changed, but still the DHA, as purchaser of the hospital services, is in a position —to use the same analogy—to wear the trousers in the new relationship.
Even though strengthening primary and community care makes sense and is part of the Government's strategy of a primary healthcare-led service, demands for expensive hospital services will still fall on the health authority. There is nothing in the Bill to protect the position of primary and community care in the new health authorities. I hope the noble Baroness will address this in her reply. If I am wrong and there is something on this point in the Bill which I have missed, I hope she will point it out. If that is not the case, we shall move amendments to safeguard FHSA staff and responsibilities in the new health authorities.
Apart from that one sensible part of the Bill, the rest is, in our view and that of all the professions and consumer interests involved, harmful. It is harmful to the interests of the National Health Service, those who work in it and, ultimately, to patient care. We are all against unnecessary bureaucracy but I would draw a comparison here with surgical practice in the 19th century and earlier, and bureaucracy. When dealing with abscesses and other infections, the discharge from them was categorised as "laudable pus and malignant pus". I suggest that types of bureaucracy can also be similarly divided.
Quietly, over the past few decades, regional health authorities have, as many noble Lords have pointed out, played a major part in ensuring the equitable spread of healthcare throughout the country; and maintaining high standards in patient care, teaching and research, not only 66 through the distribution of funds but also through a whole variety of other checks and balances. The cost of administering the regional health authorities is tiny compared with the cost of the vast increases in managers and supporting staff that the internal market has spawned. I should point out that we have yet to see research-based evidence that the nation's health has benefited as a result of the National Health Service and Community Care Act 1990 any more than it would have done had it continued under the previous structure. Research to show whether or not health has improved was precluded by the Government when they denied a provision in the Bill that it should be properly evaluated.
By eliminating the regional health authorities, the Government hope to get brownie points, I suggest, through reducing bureaucracy. In fact the effect of the reforms will be to free NHS hospital trusts from regional control and to allow them to operate in a market-driven environment which pays less attention to the needs of the population. As my noble friend Lord Ennals has in particular pointed out, there is a need for a wider view than that of individual health authorities and trusts. This Bill will get rid of that vital planning and resource allocating role.
There are numerous other objections to the abolition of regional health authorities. Before the debate I totted up 15. During the debate all of these except one have been mentioned, as well as five others that I had not listed. During the debate I have been impressed by the repeated anxieties expressed on all sides of the House about the future of man- and woman-power, planning, professional training and research. We need much more explicit assurances about those matters on the face of the Bill. The noble Lord, Lord Lyell, said they were in the Bill. They are not in the Bill. We have had promises but we have not had words in print.
One issue which could well be incorporated into the Bill is the problem of the increasing number of complaints against the National Health Service—up 52 per cent. last year. Alan Wilson's committee, which has looked at the problem of the mechanism for handling complaints, has made recommendations for streamlining the complaints procedure. As many noble Lords have said, since it would appear that this is to be the final Bill on National Health Service reorganisation ever, perhaps this is the time to incorporate his valuable suggestions into legislation. The increase in complaints sits uncomfortably with the claims of noble Lords opposite that things have greatly changed for the better since 1991. In Committee we will bring forward amendments which will give the Government the opportunity to clarify in more detail what the regulations—which are of course the active teeth of the Bill—will say.
But, again, as my noble friend Lord Ennals has said, we are far too familiar with this sort of task. I wonder when the Government will start enacting legislation in a more democratic way by first consulting widely, listening to the views of those involved and drafting legislation to meet concerns, rather than throwing a Bill at us whose detail has not been thought out, allowing 67 only a brief, time-limited consultation period (if any), with consultation too often a one-way process with no shift in the Government's position as a result.
However, we are always hopeful. We think that the Government might respond to at least some of the points raised this afternoon by bringing forward amendments of their own. We shall certainly bring before the House probing and substantive amendments which we hope will improve the Bill so that its beneficial effects will be ensured as regards the FHSA and DHA merger, and its other more deleterious effects will be reduced.
§ 6.57 p.m.
§ Baroness Cumberlege
My Lords, this has been a most interesting, wide-ranging and thoughtful debate. Perhaps that is not surprising as we have in the Chamber this evening two former Secretaries of State for Social Services who have taken part, the chairmen and non-executive members of health authorities and trusts, both past and present, three vice-presidents of the Royal College of Nursing, some very distinguished members of the medical and scientific professions, two vice-chancellors, a former courageous regional chairman on the Liberal Benches, and countless others who are knowledgeable about the National Health Service.
The support for our proposals this evening has been very encouraging. It confirms our view that these are sensible and timely measures. However, your Lordships have identified some important areas which I believe need to be handled with great care. I hope that in these closing remarks I shall be able to offer some reassurance about the Government's approach and I look forward to constructive discussions during the Committee stage.
The noble Baroness, Lady Jay, the noble Lord, Lord Desai, and the noble Lord, Lord Ennals, although giving partial support for elements of the Bill, questioned whether the NHS had improved since the reforms. I believe that there are two health services—the one people read about and the one people use. I care deeply about the image of the National Health Service. I am very sad every time the NHS is denigrated. I feel diminished every time it is rubbished. It lowers staff morale, it affects recruitment, and it knocks the confidence of the British people in what I think is a remarkable British institution.
§ Baroness Jay of Paddington
My Lords, I hope the noble Baroness will forgive me for intervening but will she indicate where, in any of the contributions made by the three speakers to whom she referred, that is myself and my noble friends Lord Desai and Lord Ennals, we did anything but praise the services of the NHS? It is the structure and management we do not agree with.
§ Baroness Cumberlege
My Lords, if the noble Baroness will be patient she will hear more. Certainly she said that services had deteriorated. The noble Baroness, Lady Dean, said that waiting lists were longer and commented on the present service.
The views of the people who use the NHS matter even more to me than the views of political commentators. I take encouragement from those views. 68 The British social attitudes survey published in November 1994 shows increased satisfaction with GPs, hospital outpatient services and waiting times. Since the Government's health reforms the number of people expressing dissatisfaction with the service has fallen noticeably with more people satisfied than dissatisfied with the way the NHS is run. My noble friend Lord Dean of Harptree rightly reminded us of the huge investment made in the NHS, which I suspect has much to do with that.
The noble Baroness, Lady Jay, shed tears for the regions whose members' and officers' roles can only be described as administrative. I am surprised that, in line with her policy of reducing management numbers, she does not welcome this slimming down and streamlining of bureaucracy.
The noble Baroness, Lady Dean of Thornton-le-Fylde, was less than generous when mentioning waiting times. She will know, surely, that before the reforms the average wait for in-patient treatment was 8.6 months. Today it is 4.6 months. I sincerely hope that as a non-executive member of a trust she is aware that from 1st April this year, for the first time ever, standards will be set for waiting times for outpatient appointments. I say that I sincerely hope that she is aware of this because she and the other members of her trust will be responsible for meeting those standards.
Some of your Lordships expressed anxiety that there would be a loss of accountability at local level when regional health authorities are abolished. The noble Baroness, Lady Jay, and the noble Lord, Lord Ennals, suggested that the abolition of RHAs would mean the end of strategic planning for the NHS. That is not the case.
The role of the NHS Executive headquarters and regional offices will be to co-ordinate health policy across the country and to determine the overall strategic direction of the NHS. For example, the executive will develop and evaluate the overall NHS research and development strategy. It will set the policy framework for the provision of education and training in the National Health Service, and it will provide support for consortia of health authorities in purchasing specialised services.
The role of the regional offices will be quite different from that of the old regional health authorities. In the old NHS structure it was appropriate for RHAs to be separated from the Department of Health, but in the new system health authorities will be the main operators. They will take most of the decisions which directly affect local people. They will continue to be open and accountable through public meetings, published reports and public consultations.
The regional offices will have a different role. They will contribute to the development of national policies for the NHS and monitor health authorities and trusts, intervening where necessary. It is entirely appropriate that such tasks should be performed by members of the Civil Service.
Information held centrally which is not of a confidential nature is, and will continue to be, available under the open government policy. Information about 69 the NHS Executive, of which the regional offices will be an integral part, is also made public in the executive's annual report, in a new series of quarterly reports and in a variety of statistical and other bulletins.
The noble Baroness, Lady Jay, and the noble Baroness, Lady Robson, queried the savings that were being made, as did some other noble Lords. My honourable friend the Minister made it quite clear what savings will be made and how they will be achieved. Perhaps I may repeat what he said. We estimate that the abolition of RHAs and mergers of DHAs and FHSAs will result in savings of approaching £60 million in 1995–96. By 1997–98, when the new structure is fully implemented, those savings will rise to approaching £150 million a year. Some £100 million of the total savings will result from the abolition of RHAs and the consequent reduction in overlap of work between the central department and the regions. The remainder is due to the replacement of DHAs and FHSAs by the new integrated health authorities.
My noble friend Lord Lyell, after a skirmish round the Roman army, asked about particular savings and how they were to be achieved. Those savings will be achieved at regional level through the new light touch approach to management by the regional offices and also through the reduction in overlap between regions and the Department of Health. For example, there will be no more overlap in areas such as performance management and checking of statistics, nor in development and implementation of national policy. Regional health authorities employed 3,900 staff in March 1993. That figure has already been reduced to 2,600, and once the regional health authorities are abolished only 1,100 staff will be needed.
At local level the reduction in numbers of statutory authorities will mean fewer authority members, savings in accommodation costs, streamlined and integrated management structures, and economies of scale; for instance, in purchasing skills which will be deployed for a larger population. Unlike the Roman army, my noble friend showed some mercy. Perhaps I can write to him on the other detailed questions he raised, including the Dartford and Thurrock crossing.
The noble Lord, Lord Walton, the noble Baroness, Lady Jay, and the noble Baroness, Lady Robson, raised the question of regional directors of public health. In my experience, RHAs are artificial entities in public health terms. The new health authorities will be much more appropriate places for public health work. Their areas will be smaller than regions and they can be more sensitive to local variations in health and health care needs. They will have better links with local government, which has an important public health role.
In the new system most public health functions will be carried out by the health authorities. District directors of public health will report on the health of their local populations and will be free to comment on the factors affecting health in their area. The regional directors of public health will have a new and important role in contributing to national policy and ensuring it is implemented at local level.
70 The noble Lord, Lord Monkswell, and the noble Lord, Lord Ennals, raised the question of the distribution of resources. The noble Lords were concerned about how resources would be allocated to health authorities in the new structure. I can assure them that this will continue to be done on a national basis fairly, diligently and carefully, by the NHS Executive. I can also assure them that we remain guided by the principle of equal access to health care for those of equal need.
The noble Baroness, Lady Jay, the noble Baroness, Lady Robson, the noble Lord, Lord Walton, my noble friends Lady Cox and Lord Dean, and many other noble Lords referred to the membership of health authorities. I tried to be straightforward. I made clear that the Government do not in general support reserved places on authorities for representatives of particular groups. I have been asked today to reconsider that approach, particularly in relation to the nursing profession.
I have a great respect for the nursing and midwifery professions, and I wish to reinforce the Government's view that we see an increasing role for nurses over the coming years, not only in taking day-to-day decisions for their patients but also in using their skills to shape our services for the future. There is nothing to stop health authorities appointing executive members with nursing experience. Indeed, I should be very surprised if the majority do not do so. But where that is not the case, indeed, even where there are nurse members, health authorities will still need input to their purchasing decisions from employees with nursing qualifications and from nurses outside the health authority. That happens now, as my noble friend Lady Eccles so vividly described in relation to her health authority. I know that in Leicester and in Camden and Islington health authorities nurses are used to review specific services such as mental health. In the South East London and Dorset health authorities nurses are employed on a consultancy basis to review particular services, for example, for people with learning disabilities.
The Government's new guidance on professional involvement is intended to promote just such initiatives and to draw upon the expertise and knowledge of health professionals. The Bill as it now stands will require health authorities to ensure professional involvement, including that of nurses. We believe that that will be a more constructive and effective solution than reserving places for people who would inevitably come to represent particular sectional interests.
I am grateful to my noble friend Lord Jenkin of Roding for his powerful and illuminating speech—I think almost more of a tutorial. I am sorry that I shall not be able to answer all the points he raised. One related to the crucial issue of the training of future doctors, a matter also referred to by the noble Lord, Lord Dainton, the noble Lord, Lord Walton, and others. The Government recognise and are committed to high standards of medical education but it is a complicated area which needs to take into account, as my noble friend said, not only the Calman Report but also the Government's policy of achieving a reduction in junior hospital doctors' hours. It is therefore essential that we work closely with the Committee of Vice-Chancellors and Principals, the British Medical Association and the 71 Royal Colleges. We have taken them into our confidence and are continuing to consult and work with them.
I have explained that postgraduate medical education will still be the responsibility of postgraduate deans. They will work closely in both the NHS and the medical schools. We are discussing fully with the deans the contractual and support arrangements which will enable them to carry out their role effectively and maintain the necessary lines of accountability to the regional offices and the universities.
The deans will also play an important role as members of the new regional education and development groups (REDGs). Those groups will represent health authorities, GPs, and health care providers, both NHS and non-NHS. The REDGs will have important, but slightly different, roles in both medical and non-medical education. For the medical education side, the groups will be able to advise the dean on future staffing needs and training arrangements. I can reassure noble Lords that we are committed to a vital partnership between the universities and the new NHS. Where new health authorities have a medical or dental school within their area, there will be a requirement for a university representative on the authority, as I mentioned in my opening remarks.
The regional offices will be very different from the old RHAs. They will have boards on which different groups arc represented; so it would not be appropriate to have a university representative within the regional office. However, my right honourable friend the Secretary of State has asked the regional policy board members in each region to take a particular responsibility for building links between the universities and the NHS. In relation to non-medical education, for example nursing, REDGs' role will be to co-ordinate and oversee the education purchasing plans drawn up by groups of health authorities, special health authorities and trusts. Those consortia will take on responsibility, in a controlled way, for purchasing non-medical education from those who provide it. The NHS Executive will continue to set the national framework and be responsible for the overall national supply of trained staff.
Through the NHS Executive, Ministers are in the process of agreeing a joint statement with the Committee of Vice-Chancellors and Principals. This will set guidelines for education contracting and satisfy the concerns of professional bodies. In particular, the regional offices will have clear criteria for deciding when consortia are ready to take on their new responsibilities.
My noble friend Lady Cox and the noble Baroness, Lady McFarlane, both of whom I believe are vice-presidents of the RCN and outstanding nurses, wondered why membership of health authorities was so constrained. My noble friend asked about the policy of not appointing as health authority members people who have contracts of employment with another NHS body such as an NHS trust. I can confirm that that is our approach. I am sure that my noble friend will accept that separating purchasers from hospital providers is the key 72 to our reforms. We endorse the views expressed by my noble friend Lord Dean of Harptree that it would not be right for non-executive health authority members who are there as independent voices from the local community to be working for local trusts. Them are other and better ways of securing input from providers.
My noble friend Lady Cox raised the issue of nurse workforce planning, as did the noble Baroness, Lady McFarlane. The Government recognise the need to ensure an adequate supply of appropriately trained nurses. That is why we are putting in place arrangements for commissioning education and training which will take place within a policy framework and guidelines set by the NHS Executive headquarters.
The NHS Executive will maintain a national overview of demand and supply, taking account of the needs of the NHS and other providers of health care. Most importantly, we are ensuring professional input at every level of the new arrangements. We will be supporting the development of workforce planning and education commissioning skills at local levels.
More flexible arrangements and better use of professional skills mean that nurses and midwives are remaining in their posts longer and more people are returning to the profession after career breaks—a fact that we welcome. But it is reflected in the reduced student numbers. Of course, longer term supply of nurses has to be constantly kept under review. I can assure your Lordships that that is what the national policy framework is intended to do.
The vital role of research and development will continue to be recognised in the new NHS. The Government believe that R&D must underpin the development of priorities for the NHS. In December my right honourable friend announced a new system of funding and supporting R&D in the NHS, based on recommendations from Profession Culyer's task force, referred to by the noble Lord, Lord Walton, in his questioning speech. The noble Lord will know that the announcement was warmly welcomed by the academic and research communities. I am sure that he will be relieved to know that that report will be put in place at the same time as the measures in the Bill, on 1st April 1996. The new system will target funds towards high quality R&D which meets the needs of the NHS. The NHS will continue to work in partnership with the universities, the research councils and users of health and health care services to develop a clear understanding of health issues and research solutions.
The noble Baroness, Lady Robson, my noble friend Lord Dean, and the noble Lord, Lord Monkswell, expressed concern about the future of CHCs, as did my noble friend Lady Gardner who gave a rather different perspective. Community health councils are the community's watchdog of the National Health Service. They are perceived as independent by the public. In the 20 years they have been operating, they have developed a reputation for speaking out and making positive and valuable contributions to the development of health services. The health service has learned to respect CHCs' independence. It is a respect they have earned and it must be protected. That principle has underpinned our approach to future arrangements for CHCs. 73 Currently they are set up and established under regulations by regional health authorities. But when RHAs disappear new arrangements are needed and in principle we have agreed that the overall responsibility for establishing CHCs is to be moved to the new regional offices. This protects the independence of the CHCs better than any other practical option. It would not, of course, be appropriate for CHC staff to become civil servants, so we are discussing where the employment contracts of staff will be held. It need not be with the establishing authority. My honourable friend the Minister for Health hopes to make an announcement fairly soon.
My noble friends Lord Jenkin and Lady Seccombe spoke about the role of GPs, including GP fundholders in a primary care-led NHS. I agree that health authorities will have an important role in supporting and monitoring GP fundholders and a strategic role. It is encouraging to see how constructive partnerships are already being developed locally. In the new, simpler system, that co-operation will be easier to achieve. Health authorities and GP fundholders will be able to work together to develop strategies across primary and secondary care boundaries.
I am grateful to my noble friend Lady Eccles not only for the work she does as chairman of a very challenging health authority but for spelling out clearly the importance of boundaries and working together with local authorities, and to my noble friend Lord Dean for setting that in the context of community care. We agree that health authorities and local authorities must work together to provide an integrated and effective response to people's needs. The replacement of DHAs and FHSAs with the new health authorities will make that collaboration easier. Local authorities will have just one health authority in each area to deal with. That health authority will be responsible for both primary and secondary care. A high proportion of recent DHA mergers have resulted in a simplified relationship with local authority social services directorates, for example, avoiding the cutting of boundaries.
My noble friend also mentioned private health care. I can assure your Lordships that the Government want to see cost-effective co-operation between the NHS and the independent sector to increase choice and patient satisfaction. We are committed to ensuring that co-operation with the independent sector will continue to develop after the implementation of the Bill.
Many of your Lordships have expressed support for at least limited parts of the Bill. I am grateful to my noble friends Lord Lyell, Lord Ironside, Lord Holdemess and Lady Seccombe for their wholehearted support. As my noble friends said, the NHS has to face the challenge of an ageing population and the advances in sophisticated modern technology concerning cancer care, and we believe the Bill will do it. My noble friend Lord Holderness spoke most eloquently about the valuable and important work of the disabled living centres. I can assure him that the new integrated health authorities will be even better placed to deal with them in the future.
74 In conclusion, I echo the words of the noble Lord, Lord Dainton, and the inspiring words of my noble friend Lord Jenkin. I believe that the NHS is daily performing minor miracles. My noble friend highlighted neo-natal intensive care and we know that through the NHS there are many more examples. Blind people have their sight restored, people dying of kidney failure are given new organs and new life, stroke victims are rehabilitated, and mentally ill people restored and brought back into domestic family life. Of course, expectations may run ahead of possibilities and, sadly, sometimes the search seems to be for failure. Triumphs are disregarded.
This Bill is about management structures, which may appear ancillary but, like any other thrusting, dynamic organisation, without good management the NHS would not work. Good management has to adapt quickly to serve the needs of medicine. One of management's essential roles is to set an example to those they lead. Management in the NHS has already given the whole country a lesson in flexibility and service that enables so many people to enjoy a new life. I believe that the Bill will give us an NHS fit for the challenges of the 21st century. I commend it to the House.
On Question, Bill read a second time, and committed to a Committee of the Whole House.