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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.

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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

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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.

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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

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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 are 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

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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. There 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.

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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 Holderness 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.

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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.

Humberside (Structural Change) Order 1995

7.22 p.m.

The Minister of State, Department of the Environment (Viscount Ullswater) rose to move, That the draft order laid before the House on 16th February be approved [10th Report from the Joint Committee].

The noble Viscount said: My Lords, I beg to move the draft Humberside (Structural Change) Order 1995 and at the same time I should like to speak to the North Yorkshire (District of York) (Structural and Boundary Changes) Order 1995.


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