Draft National Health Service (Wales) Bill

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Kevin Brennan (Cardiff, West): Does the hon. Gentleman agree that he has described a historical legacy of underspending and that it would be extremely foolish to leap in one jump to the levels of spending that he describes for other countries? It would be unsustainable to do so. That is a serious point. Does he agree that the Government's ambition to reach at least the European average level is right, but that they cannot inject all the money at once, as the NHS would not be able to sustain such a change?

Hywel Williams: I believe that spending in Wales is actually higher than the European average. I take the hon. Gentleman's point. However, I am puzzled by the Government's unwillingness to examine the historical record. A phrase in Welsh,

    ''yr euog a ffu heb neb yn eu herlid'',

means ''the guilty flee unpursued''. It strikes me that Governments sometimes have that attitude to the historical record.

Mr. Jon Owen Jones: Will the hon. Gentleman get to the point now?

Hywel Williams: Yes, I will.

As I said, we welcome the extra spending that was announced but, despite its importance, it is not the only consideration for developing our health service. Therefore, we also give a broad welcome to the proposals in the Bill for the retention and reform of community health councils, which will give them more power and responsibility. I want to refer to the membership of community health councils. A considerable body of research shows that such organisations often find it very difficult to recruit members from socially excluded groups such as people on low incomes, people who belong to ethnic groups and, for that matter, Welsh speakers. Research by Rowntree on the consultation on the NHS and community care in Powys in the early 1990s shows the intense difficulties that were experienced in recruiting into the process people from those groups, specifically Welsh speakers.

We also welcome the establishment of the Association of Welsh Community Health Councils, which will have responsibility for the performance of CHCs, and the fact that it is a national Welsh body. The Wales Centre for Health, an independent training, advisory and research body, is very welcome, as is the Health Professions Wales body to monitor the standards of training.

However, we now face the sixth major structural reform in the past 13 years. It promises to be a bureaucratic nightmare with, as the hon. Member for Cardiff, Central has pointed out in the past, 52 bodies taking control: 22 local health boards, 15 health trusts, 12 or so local partnerships and three Assembly

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regional offices. Restructuring often works best when it makes things simpler. The proposed structure is complicated and labyrinthine—quite apart from the effects of the probable implementation lag, which might be 6 or 18 months.

As has been pointed out, it is incumbent on Opposition parties not only to criticise, but to put forward positive alternatives. What more could have been done? The Bill could have addressed the cost of long-term personal care in Wales, as has been done in Scotland, if only because of the scale of the problem in our country. Wales has a higher proportion of elderly people—17.3 per cent. of the population in Wales is aged over 65. In England, that percentage is 15.6.

Mr. Jon Owen Jones: I thank the hon. Gentleman for giving way yet again. Wales could have done those things, but if it had, it would have taken money away from the rest of the health service. If the hon. Gentleman is proposing that that should have happened, would he propose from where he would take the money to fund it?

Hywel Williams: In answer to the hon. Gentleman's question, the assessment that we have had is that it would cost £40 million in the first year, which would have risen in the future, but the proportion of the gross domestic product spent would be consistent. We believe that that is a matter for the National Assembly to decide.

Mr. Llwyd: Of course it is.

Hywel Williams: Of course it is. The proportion of elderly people in Wales is higher, as I said. We accept that, since 1 April, the first six months of personal care is free, and we welcome that. Plaid Cymru is in favour of any care being free. As the royal commission states:

    ''Care in the NHS is free—the risks and costs are best pooled. Needing care when older cannot be predicted and that risk and that cost should be shared as widely as possible.''

Free care is simple and cheap to administer. It is transparent and fair, unlike the Government's proposed system. For example, it eliminates the need to decide whether a bath is being given for social or medical reasons.

As it is, each person will need to be assessed, which will take about an hour every three months. The assessment will be carried out by NHS nurses. It is estimated that 1,800 will be immediately needed in Wales, and that is just the start. How long will it take, and how much will it cost? The hon. Member for Cardiff, Central is interested in saving money; here is a way of doing that. Can he seriously claim that that is the best possible use of resources when confronted with the fundamental causes of bad health?

We are to see the establishment of the Wales Centre for Health. In May 1998, the Wales Office published the consultation document ''Better Health Better Wales'', concerning new approaches to tackling the underlying causes of bad health. In October 1998, a strategic framework was published reflecting responses to the consultation document and setting out aims and priorities for improving health and reducing health inequalities. A number of changes were proposed, including the setting up of local health alliances, the development of a health promotion strategy and the

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establishment of a Wales Centre for Health to provide a focus on this.

As the Welsh Affairs Committee note on page 19, that was one of 15 priorities for 1999–2002. Four years after ''Better Health Better Wales'', we welcome the creation of the WCH. Hopefully, the centre will do much to draw attention to the underlying causes of ill health and come up with long-term strategies for tackling such causes as the health divide. The Welsh index of multiple deprivation shows clearly that bad health is linked to low income. Life expectancy of manual workers is between five and eight years shorter than that of professional people, and mortality and morbidity from heart disease is worse in poor and deprived areas. That is the broad view of health, rather than a focus on clinical interventions. Bad housing is another cause. Life expectancy for homeless people is 47 years—30 years less than for those with proper housing.

Wales continues to have a high level of unfit housing with more people living in damp, cold conditions and suffering poor health. Interestingly, the Welsh index now shows clearly that that is a rural as well as an urban problem.

Smoking is another cause of bad health and needs to be addressed. There are 7,000 tobacco-related deaths in Wales alone each year. The BMA has voted to ban smoking in hospitals, but staff and visitors huddle outside hospital entrances to smoke, as I have seen for myself. That is bad for patients, staff and visitors.

On the Welsh language, the Select Committee on Welsh Affairs expressed concern that there was no provision in the draft Bill to apply the Welsh Language Act 1993 to HPW, although there is provision to apply it to CHCs. The Assembly's Minister with responsibility for health has assured us that HPW will be covered and that discussions are currently being held with the Welsh Language Board to facilitate that. It has called for that to be included in the Bill.

I have fundamental problems with Welsh language plans. The Welsh Language Act 1993 and the Welsh Language Board seem to address the frills of services: letters, telephone calls, answering telephones and so on. We want an assurance—even a guarantee—that face-to-face services will be provided in patients' language of choice whenever possible. We are a long way from that. In an interesting paper to the guild of graduates of the university of Wales, Bangor on 28 June, Gwerfyl Roberts, a colleague of mine, stated that 50 years after the establishment of the NHS we still lack a basic Welsh vocabulary of standard terms associated with pain. That would be a straightforward clinical tool, but it is not available. Furthermore, the work carried out by Andrew Misel for the Welsh Consumer Council demonstrates clearly the lack of provision in Welsh, which I have also experienced in mental health practice.

In conclusion, we welcome the draft Bill and the scrutiny process, but it is modest in the face of the

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enormous scale of health needs in Wales. With due regard to the fact that both the Secretary of State and the Minister represent valleys constituencies, may I say as a mere Gog that our response is not, ''Yes, butty''; it is, ''Yes . . . but''.

12.18 pm

Mr. Martin Caton (Gower): During the three or four hours for which the hon. Member for Caernarfon (Hywel Williams) spoke, he brilliantly undermined the thesis of my hon. Friend the Member for Cardiff, Central. Clearly, we have a long way to go if we want the Welsh Grand Committee to become involved in pre-legislative scrutiny. Around 90 or 95 per cent. of the hon. Gentleman's speech did not address the draft Bill. That would be the danger if a Committee such as this, which tends to divide on partisan lines, were allowed to engage in pre-legislative scrutiny. A Select Committee works as a corporate body. Much of its work is tedious and much less interesting than having a go at the Opposition, but important if we want to scrutinise law.

I am a member of the Select Committee on Welsh Affairs and enjoyed and valued our first exercise in pre-legislative scrutiny. We should have liked more time to ascertain the views of the various players on the health stage in Wales and I am sure that we can further improve the way in which we co-ordinate and work with the National Assembly when we undertake such a role in future. I think that we did a good job and I am sure that it is appropriate that the next stage of scrutinising the draft Bill should fall to the Welsh Grand Committee—I was fairly confident of that until a few moments ago.

As a Select Committee, we were restrained in choosing a task to take on. In the main, we did not become involved in the wider political debate. We deliberately avoided arguments about the merits of the approaches adopted in other parts of the United Kingdom compared with those proposed for Wales in the draft Bill. We refused to be tempted into the enticing role of improving and enhancing the draft Bill by using it as a vehicle for our favourite health service hobby horses. Even when those who submitted evidence tried to persuade us to take on their favourite health service hobby horses, we resisted. That was not because we disagreed with measures such as banning smoking in public buildings, improving healthy living promotion or getting over health data collection problems created by data protection and human rights legislation. My guess is that the overwhelming majority of Committee members would support such objectives. However, the Bill is not the means to those ends. Its scope is much more limited, as has been said. It focuses on: keeping community health councils in Wales, but providing for change, and giving them a bigger role; creating a Wales Centre for Health with the functions that have been described; and the establishment of Health Professions Wales.

The Committee considered how the draft Bill set about achieving those objectives, and made recommendations that we believe will help the final Bill to achieve them. The debate in Committee was about, ''Is this the best way to do it?'' Practically none

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of it was about, ''Should we be doing this?'' or ''Is this the best way forward for the NHS in Wales?'' That is mainly thanks to the fact that Opposition Members who served on the Committee saw the Select Committee as a legislation-improvement mechanism for the Bill rather than a party political forum. I think that they were right to adopt that approach, and I pay tribute to them for it. I am sorry that the two Conservative Members who served on the Committee, who probably had the greatest philosophical difficulties in adopting that approach, are not present to hear me say so. I also accept that that means that they kept their powder dry; they remained free to bring out their political objections later in the legislative process.

For my part, I welcome and support each of the three purposes of the draft Bill. I believe that reformed and enhanced community health councils will be the right people's watchdog for the health service in Wales. As an ex-member of a community health council, I believe that it is vital that the scrutiny role and the advocacy role are tied together in Wales.

I am sure that the Wales Centre for Health, with its advice, research and training remit, can give independent assessment and support that will provide a hub for partnership between the various sectors that provide or utilise information or evidence on health questions. I am confident that Health Professions Wales is a step forward, building on the remit of the old Welsh National Board for Nursing, Midwifery and Health Visiting to include health care support workers and allowing the inclusion of other health care professions over time.

It is not just I, or the Committee, who supports the objective. Just about everyone who gave or submitted evidence to us began by expressing general support for the intentions of the draft legislation, although some had specific concerns, questions or criticisms. It is those that I should like to address briefly.

Looking first at the provision for community health councils, we were asked whether there should be provision in the Bill to ensure that CHCs became more truly representative of the communities that they spoke for in terms of sex, age, class, race, disability and so on. In the main, we thought that that was a subject for the Assembly and the CHCs themselves to grapple with, possibly in secondary legislation. However, we believed that an important way of enabling younger working people to participate was to give CHC members a statutory right to time off work for their public duties. That really only brings those duties in line with other forms of public duty. If we are looking for an enhanced role for CHCs, that is something that we need to take on board.

We also considered whether the Bill should require the coterminosity of local health board boundaries and CHC boundaries. We understood the strength of the argument but in the end felt that that was a matter for the Assembly. The draft Bill gives the Assembly the power to set CHC boundaries as it sees fit. We thought that that was right, but that local health board boundaries should be a primary consideration when it comes to drawing them up.

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We were also asked whether the Bill should go even further in allowing the remit for CHCs to be extended. At present, the draft Bill plans to empower CHCs to deal with private homes and primary care providers as well as carry out their traditional functions in hospitals and other institutions. The representatives of community health councils were happy with the proposals in the draft Bill but worried about any further extension without resources and training to match.

I thought—and the Committee agreed—that we should give the National Assembly the power to extend the scope of CHC powers to include inspecting premises and requiring information anywhere and from anyone involved in the provision of publicly funded health care. The draft Bill does not include a requirement for the provision of information. In the question-and-answer session that we had with Ministers, they acknowledged that omission, and I am sure that that measure will find its way into the final Bill.

The extension of the remit of CHCs may not happen in the near future, but now is the time that we should provide such power. I should like them to become involved in prisons and young offender institutions. That suggestion is a result of a Select Committee inquiry into young people from Wales who are in prison. One of our main worries after visiting men and women prisoners in Bristol was the absence of appropriate medical assessment and care facilities, especially psychiatric assessment and care. I know that prisons have their own inspection and lay visitor systems, but inspections by a group of informed people who could make a direct comparison between health provision in prison and outside it would be useful.

The last matter that I wish to draw to the Committee's attention could be described as a ''Who watches the watchdog?'' question. Most of the evidence that the Select Committee received centred on the importance of protecting the independence of CHCs and maintaining their responsibilities to their local communities. However, Professor Warner of the Welsh Institute for Health and Social Care placed equal emphasis on the consistency of performance of CHCs throughout Wales and their accountability.

At one stage, it was envisaged that the Association of Welsh Community Health Councils would have a performance management and central accountability function, but its role now seems to be more supportive and advisory. A regular reporting system from CHCs to the association and from the association to the Assembly would at least provide a monitoring base to assist and encourage better performance. The Assembly will need to keep an eye on that, but the Committee recognised that, to keep a balance between the need for locally based independent CHCs and consistency of performance throughout Wales, it would be better in the long term to come down on the side of independence.

It was interesting that worry about the independence of the Wales Centre for Health was also an issue when we were taking evidence. Under the draft Bill, the Wales Centre for Health will be obliged to comply with any direction of the National

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Assembly. Understandably, that set alarm bells ringing about the ability of the centre to provide independent information and advice. Moreover, worry was expressed about the public perception of the centre if it were believed to be unduly influenced by the Assembly. Neither the Assembly nor the Government envisage the control that such witnesses feared, but the draft Bill needs to be changed explicitly to limit the Assembly's powers of direction over the Wales Centre for Health.

We came across similar worries when we investigated the creation of Health Professions Wales. As drafted, the Bill provides the Assembly with the power to direct it. The Nursing and Midwifery Council and the Royal College of Nursing were worried about that power because, as drafted, they feared that the Bill could undermine the autonomy of Health Professions Wales or even that, under direction from the Assembly, it might run counter to the requirements of the Nursing and Midwifery Council or the Health Professions Council. Ministers have made it clear that that is not the intention of the clause, but a requirement to consult in respect of functions carried out by Health Professions Wales, where the Nursing and Midwifery Council or the Health Professions Council has a role, is eminently sensible and would relieve worries.

Most organisations and individuals who gave evidence to the Select Committee declared their support for the devolution settlement. Many urged that the legislation should be as wide as possible, so that the Assembly could be empowered to pursue its direction through secondary legislation. However, there was some questioning of the plan for Wales to lead the way in the regulation of health care support workers, especially if that involved the production of a code of conduct. Some organisations considered that that should be dealt with on a United Kingdom-wide basis. In evidence, the Welsh Assembly Health Minister assured us that it was envisaged that United Kingdom regulatory standards for health care workers should and would be established. Indeed, I gained the impression that the initiative being taken in Wales is likely to bring closer that much-needed regulatory framework.

The Select Committee commented on many other important aspects of the Bill and proposed some changes. I have chosen a few issues that were raised by some important contributors to the delivery of health services in Wales. They focused on matters that we must deal with in the post-devolution United Kingdom in the process of lawmaking for Wales. My hon. Friend the Member for Clwyd, South spoke again today about making history in this pre-legislative scrutiny exercise. I think that it is true that the Bill is important, not only because of the measures that it contains, but because it demonstrates the sorts of issues that we will always have to face from now on when we deal with primary legislation for Wales. We do not serve the cause of devolution or good government for Wales if we frame legislation in a way that gives the impression that power is being

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centralised in the Welsh Assembly Government in Cardiff, especially as—with community health councils, the Wales Centre for Health and Health Professions Wales in this Bill—that is not what the Assembly itself intends.

This is a good Bill, but if the Welsh Affairs Committee's recommendations are followed, it will be better.

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Prepared 16 July 2002