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Lord Henley: My Lords, my noble friend is right to draw attention to the situation on Salisbury Plain. We hope to see considerable intensification of training there. However, I hope that by the various measures we propose to take, and the spending of quite a considerable amount of money, we shall not cause any damage either to the natural environment or to the archaeological environment to which my noble friend refers. I can confirm that there are something of the order of 2,000 archaeological sites of considerable interest on Salisbury Plain. In similar parts of the world where the Ministry of Defence has not been present for a number of years many such sites have long since been lost to the plough.

Lord Williams of Elvel: My Lords, it is not just a matter of Salisbury Plain. Did I understand the Minister to say that there would be no new area apart from the seven major training areas we have at the moment? I believe he said that the emphasis would be on more intensive use of those areas. Does he therefore accept

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that the ambient noise arising from training is an environmental problem, not only for Salisbury Plain but also for mid-Wales?

Lord Henley: My Lords, I agree with the noble Lord that noise can be a considerable problem. As regards whether there may be a new area, I think that we must wait until the full effects of the drawdown have been assessed to see what we need. At the moment it seems that there will be some intensification of use of all our major training areas in the United Kingdom.

I understand that there have been considerable complaints about noise recently, particularly on Salisbury Plain, resulting very much from in-service testing of the new gun, the AS90. A much higher charge has been used than is normally the case in training; I understand that it is referred to as charge 8. Normally, one trains with up to charge 5 or charge 6, producing a much lower noise threshold.

Lord Campbell of Croy: My Lords, will the Government continue the benign policy which has had the effect of creating places of special environmental interest within the training areas, allowing plant and wildlife to flourish undisturbed despite the shelling and use of heavy tracked vehicles?

Lord Henley: My Lords, my noble friend is right to draw attention to the benign policy which the department has pursued. The shelling and the use of tracked vehicles can have a beneficial effect on occasions. I give two examples. The shelling on Salisbury Plain has done much, I understand, to improve the habitat of the Stone curlew, a species of bird of which there are few left. The birds are mostly to be found on Salisbury Plain. The shelling provides them with a habitat. I can also confirm that the tank tracks and the water that collects in them on Salisbury Plain have done much to assist development of the Fairy Shrimp.

Defibrillators: Airport and Aircraft Use

3.1 p.m.

Lord Clinton-Davis asked Her Majesty's Government:

    Whether they have any plans to introduce legislation to require the main United Kingdom airport terminals and larger British passenger aircraft to carry defibrillators, and whether they intend to raise this issue at European Union level.

Baroness Miller of Hendon: My Lords, the Government have no such plans or intentions.

Lord Clinton-Davis: My Lords, is the noble Baroness aware that in Australia it is a requirement that all 53 international 747 and 767 aircraft and the main terminals should be provided with defibrillator equipment? Is she further aware that the equipment has been used about 50 times; of which 29 times were for cardiac arrests—16 times on aircraft and 13 at air terminals? Is there not a strong case for investigating the

6 Mar 1995 : Column 10

applicability of that on a wider scale, not confining it to the United Kingdom but taking it to the European Union?

Baroness Miller of Hendon: My Lords, the view of Qantas and Virgin is not shared by the Civil Aviation Authority, British Airways or, so far as we know, other airlines around the world. The Civil Aviation Authority, which is the Government's independent expert, has already considered the matter and believes that it is of little benefit. The use of defibrillators is not appropriate in every heart attack situation. If a patient is sick enough to need a defibrillator, he also needs immediate access to an intensive care unit, drips, medication and so on. While access to such equipment at airports might be thought appropriate, airports are no different from other public places such as sports grounds, leisure facilities, railway stations and ferry ports. In addition, like all other public places, airports have access to emergency services.

Lord Hailsham of Saint Marylebone: My Lords, can my noble friend lighten my darkness and explain to the House what is a defibrillator and why it should be thought necessary in the way the Question suggests?

Baroness Miller of Hendon: My Lords, I thought that someone might ask that question, but I was not sure whether it would be my noble and learned friend. A defibrillator is a device which applies external electrical stimulation to the heart for the purpose of restoring it to its normal rhythm. Defibrillators are regarded as medical treatment rather than first aid.

Lord Rix: My Lords, is the Minister aware that at least one person in your Lordships' House—that is, myself—has received the benefit of the use of a defibrillator on four occasions? However, it has been under strict medical supervision. Does the Minister agree that defibrillators can only be used under such supervision and that they cannot be used by air crews without special training?

Baroness Miller of Hendon: My Lords, it is true that in certain instances in order to use a defibrillator the crew would need to have special training. That is absolutely right. Dr. Chamberlain, the consultant cardiologist at the Royal Sussex County Hospital, has made a study of the use of defibrillators in public places. He has said that the essential requirement, after the use of a defibrillator, is to get the patient to a coronary care unit within 15 to 30 minutes. That cannot be met with an aircraft in flight or even with an aircraft taxiing on the ground with its doors shut. So I believe that the noble Lord is correct.

Lord Cocks of Hartcliffe: My Lords, can the Government give an estimate of the cost of installing the defibrillators mentioned in the Question?

Baroness Miller of Hendon: Yes my Lords, I can. A defibrillator on its own costs £5,000. With its battery and an extra battery, which is an essential part, the cost would amount to about £6,500.

Lord Clinton-Davis: My Lords, the noble Baroness said that defibrillators were likely to be of little benefit

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to passengers. However, they were apparently of some benefit to the 29 people who received treatment on Australian aircraft or at terminals to the extent that their lives were saved. Is the Minister aware that all 370 flight service directors on Qantas aircraft are extensively trained in the use of the equipment? All I ask the Minister is that the issue should be further examined. Consultation with Qantas is clearly desirable. This is not a matter where the doors should be shut on the use of the equipment.

Baroness Miller of Hendon: My Lords, if I did not make it clear then perhaps I ought to now. The matter is constantly kept under review and the Civil Aviation Authority has considered it on several occasions. The authority believes that the benefit that would be gained would be arguable. In addition, with the Australian experience all the evidence is that it was because the airports were so close to hospitals and the ambulance and emergency services that there was that success. As noble Lords appreciate, I am not a doctor, but we believe many of those people would have been saved in any event by ordinary cardio-pulmonary resuscitation (CPR).

Insurance Companies (Reserves) Bill

Brought from the Commons; read a first time, and to be printed.

Health Authorities Bill

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

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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 1 makes major provisions; the rest makes consequential changes. Clause 1 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

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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.

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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.

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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 Nairne. 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

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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.


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