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Lord Dubs moved Amendment No. 23:


Page 10, line 23, leave out subsection (2) and insert--
("( ) A statutory instrument containing any regulations under this Act shall be subject to annulment in pursuance of a resolution of either House of Parliament.
( ) A statutory instrument containing an order under paragraph 4 of Schedule 2 shall not be made unless a draft has been laid before, and approved by resolution of, each House of Parliament.
( ) A statutory instrument containing--
(a) an order under paragraph 9 of Schedule 2 made without a draft having been laid before, and approved by resolution of, each House of Parliament; or
(b) an order under section 7(5)(b) or 12(1) or paragraph 2(2) or 12(6) of Schedule 1,
shall be subject to annulment in pursuance of a resolution of either House of Parliament.").

The noble Lord said: My Lords, this amendment might look somewhat indigestible on first sight but its practical effect is quite simple. It takes up the very useful suggestion made by the Delegated Powers and Deregulation Committee on the procedures to be adopted for subsequent amendments to the code of conduct, guidelines and procedural rules. In the Bill as it stands, the first issuing of these documents will be approved under affirmative resolution procedure. Subsequent amendments, however, would be by the negative resolution procedure. The committee accepted that the negative resolution procedure was an acceptable route for subsequent revisions to the statutory documents, while calling on members of both Houses to be aware of proposed changes and to pray against them if they considered that they required fullest parliamentary scrutiny. The Committee also suggested,

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however, that the Government consider the option of having a choice of either the affirmative or negative procedure.

That has up till now been a fairly unusual approach, mainly associated with European legislation; but we believe it is a helpful suggestion, and highly appropriate for this Bill. We do not believe it will be a good use of parliamentary time to require a debate on any revision of, say, the commission's procedural rules when these may be entirely technical; but, equally, we accept that there is at least a potential of fairly substantial changes to the guidelines, for example.

Your Lordships may ask how the Government will decide which option to use. I cannot, of course, set out any fixed rules, but I can assure your Lordships that each case will be considered carefully on its merits. Our commitment to the fullest possible scrutiny has been demonstrated by our decision to use a Bill procedure rather than an Order in Council, and we shall not be seeking to smuggle major changes through without appropriate scrutiny. Depending on what we perceive to be the gravity and significance of the changes, we shall decide which procedure is appropriate. And, of course, if any noble Lord or Member of the other place believes the changes are significant and should require a debate and a vote, it is open to them to pray against an order which has been laid by the negative resolution procedure.

I believe that this is a pragmatic and helpful amendment, and I urge acceptance of it.

Lord Cope of Berkeley: My Lords, the whole of today's proceedings have demonstrated the wisdom of the Government in bringing forward these proposals as a Bill rather than as an order, as the Minister said. I am grateful to the Minister for proposing this amendment, which we culled from the Select Committee and advanced to him earlier.

On Question, amendment agreed to.

Clause 17 [Interpretation]:

Lord Dubs moved Amendment No. 24:


Page 10, line 38, leave out ("Commission established by section 1") and insert ("Parades Commission for Northern Ireland").

On Question, amendment agreed to.

Lord Dubs moved Amendment No. 25:


Page 11, line 13, at end insert (", whether or not involving the use of vehicles or other conveyances").

The noble Lord said: My Lords, I am happy to introduce this amendment, which I think largely speaks for itself. The noble Lord, Lord Molyneaux, has discussed on several occasions the disturbance which politically inspired processions or cavalcades of motor vehicles can cause. Such vehicle processions have been covered by legislation up till now and I believe that it is important that they should continue to be so covered. I accept that the present drafting of the Bill does not make that sufficiently clear and I believe that this

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amendment, which restores the wording of the 1987 public order order, does what is necessary to provide that reassurance.

Lord Molyneaux of Killead: My Lords, I am deeply grateful to the Minister for the careful and sympathetic attention that he has given to this problem. I know that his decision will be welcomed throughout the community in Northern Ireland, with the exception of certain evil-doers, who are not the main concern of your Lordships.

On Question, amendment agreed to.

Clause 19 [Short title, commencement, transitional provision and extent]:

Lord Dubs moved Amendments Nos. 26 and 27:


Page 11, line 23, leave out ("etc.").
Page 11, line 25, leave out ("and to section 3(5)").

The noble Lord said: My Lords, with the leave of the House I shall take Amendments Nos. 26 and 27 en bloc. I beg to move.

On Question, amendments agreed to.

Schedule 2 [Provisions relating to code of conduct, procedural rules and guidelines]:

Lord Dubs moved Amendment No. 28:


Page 15, line 4, leave out paragraph 5.

On Question, amendment agreed to.

Schedule 3 [Amendments]:

Lord Dubs moved Amendments Nos. 29 to 34:


Page 15, line 29, leave out ("etc.").
Page 15, leave out lines 33 and 34 and insert--
(""The Parades Commission for Northern Ireland.".").
Page 15, leave out lines 38 and 39 and insert--
(""The Parades Commission for Northern Ireland.".").
Page 15, line 45, at end insert--
("( ) In Article 4(6) for the words from "liable" to the end there shall be substituted the words "liable on summary conviction to imprisonment for a term not exceeding 6 months or to a fine not exceeding level 5 on the standard scale, or to both.".").
Page 16, line 16, at end insert--
("( ) In Article 5(6) for the words from "liable" to the end there shall be substituted the words "liable on summary conviction to imprisonment for a term not exceeding 6 months or to a fine not exceeding level 5 on the standard scale, or to both.".").
Line 3, leave out from ("of") to end of line 4 and insert ("the Parades Commission for").

On Question, amendments agreed to.

An amendment (privilege) made.

Lord Dubs: My Lords, I beg to move that this Bill do now pass.

Perhaps I can briefly say a word of thanks to all noble Lords who contributed to the discussions at all stages of this Bill, both in the Moses Room, at Report stage and again today. We have demonstrated that the procedure adopted by the Government to introduce a full Bill to deal with this difficult and vexed issue was fully justified in the event. We have made the Bill a better Bill on behalf of the people of Northern Ireland.

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I am grateful for the good tempered and positive way in which noble Lords responded to the issues. They are extremely difficult issues, as we saw last year and in previous years during the marching season. I hope that the people of Northern Ireland will see this as a positive move forward; that they will accept that the Parades Commission is an even-handed body which will do a useful job in conciliation and in making determinations as necessary. I hope that we shall have better marching seasons in the coming years than in the past years as a result of the Bill.

I end on the note I mentioned earlier; that is, that 12th July is a momentous day in the marching season. It is also the day of the World Cup Final and I hope that that also sends a positive message to the people of Northern Ireland.

Moved, That the Bill do now pass.--(Lord Dubs.)

On Question, Bill passed, and sent to the Commons.

The New NHS

3.52 p.m.

The Minister of State, Department of Health (Baroness Jay of Paddington): My Lords, with the leave of the House, I should like to repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

    "Today I am proud to announce the publication of our proposals to renew and modernise the National Health Service. These are set out in our White Paper, The New NHS.

    "This White Paper is a turning point for the NHS, the 1 million staff who work in it and all of us who use it. This Government were elected to save the health service. We were also elected to change it for the better. We want to give it a new lease of life. Today we outline a 10-year programme of modernisation which guarantees that the NHS gets better each year--delivering quicker higher quality services for patients. The pace of change will be measured, but each year will bring new and visible improvements. Our plans will give our country a modern and dependable health service that is once again the envy of the world.

    "We will make a start straight away. This White Paper abolishes the wasteful and bureaucratic competitive internal market introduced by the Tories. It sets out how services will respond more readily to patient needs and describes new targets against which performance will be judged. Doctors and nurses will be in the driving seat. It spells out a whole new approach that we have called 'integrated care'. It will break down the Berlin Wall between health and social care so that patients get swift access to care and treatment rather than being passed from pillar to post.

    "The changes we are outlining today will put quality, fairness and efficiency at the heart of the National Health Service. Quality will give patients a guarantee of excellence wherever they live. Standards will be raised right across the country. Fairness will

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    give patients an NHS that is there for them when they need it, where they need it, regardless of their ability to pay--a one nation NHS. Efficiency will deliver more money for patient care. There will be a relentless drive to cut out waste and unnecessary bureaucracy.

    "We will abolish the internal market because it has failed. It has failed to deliver quality of care, fairness for patients or efficient services. It set doctor against doctor; hospital against hospital. Its business culture has been at odds with the ethos of the NHS and those who work within it. Patients want an NHS where staff can work together to provide better services, rather than having to compete against each other.

    "When I became Secretary of State I promised that we would listen to the people in the front line--the nurses and doctors, midwives and other professionals, and all the staff in the National Health Service. We have kept that promise. We have listened. That is why our proposals go with the grain. We are building on what has worked. But we are discarding what has failed. For us what counts is what works. There will be no return to the command and control structures of the 1970s. Nor will there be a continuation of the divisive fragmentation of the 1990s. Instead there will be a third way--a new model for a new century.

    "We will keep the separation between planning and providing services. But we will end competition and replace it with a new statutory duty of partnership so that local health services pull together rather than pull apart. We will end fundholding and replace it with primary care groups in each area putting doctors and nurses in charge of shaping services for all patients. We will end the culture of secrecy and commercialisation and replace it with a new duty of openness that will share best practice for the benefit of all patients. We will end short-term contracts, cost per case contracts and extra contractual referrals and replace them with long-term agreements that offer stability and focus on quality. Our detailed proposals for doing all this are set out in the 81 pages of the White Paper.

    "We will set up primary care groups involving family doctors and community nurses in every area. They will be responsible for commissioning services for their local communities and will account to health authorities for their activities. GPs and community nurses will have a choice about the form their primary care group takes. For example, they will have the power to become freestanding primary care trusts, able to run community health services, including community hospitals. They will have a single unified budget, no part of which will be capped. So, the money will always be there to guarantee that patients get the medicine they need, when they need it. The new unified budget will give GPs maximum choice over how patients' needs are met. All primary care groups will work closely with social services to provide properly integrated care.

    "For the first time, NHS trusts will have statutory obligations to co-operate with other parts of the NHS and to meet quality standards. They will remain

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    responsible for treatment and care. Hospital doctors will have a greater say in shaping local services for patients.

    "Health authorities will, over time, relinquish most of their commissioning responsibilities. The proposals will cut the number of commissioning bodies from around 4,000 to about 500. They will be leaner bodies with stronger powers. They will draw up long-term programmes for improving the health of their area in consultation with local NHS trusts and primary care groups, but also with local authorities, voluntary bodies and education and research institutions. These health improvement programmes will provide the broad framework for local action to improve general health and health services.

    "All of us who use the NHS deserve a guarantee of excellence. There will be new national action to extend quality and efficiency into every part of the NHS, backed by a new performance framework which measures what counts for patients.

    "There will be a new national institute for clinical excellence to give a strong lead on clinical cost-effectiveness, drawing up new guidelines from the latest scientific evidence. There will be new national service frameworks that will guarantee consistent access to services and quality of care for all patients. They will draw on the best evidence available, to set out the best ways of providing particular services. To underpin this drive for quality, there will be a new commission for health improvement to spread best practice and tackle shortcomings.

    "Patients will also have a guarantee that public money is being used to best effect. NHS trusts will no longer be competing. But they will be comparing. Comparison, not competition, will drive efficiency. A national schedule of comparative costs of treating different conditions will be drawn up and each NHS trust will be judged against it. Management costs will be capped. There will be clear incentives and sanctions to help drive improvements in performance at every level. Trust performance will be benchmarked for both quality and efficiency and the results will be made public.

    "Over the lifetime of this Parliament, these changes will shift an extra £1 billion from bureaucracy into frontline patient services. This will be on top of the extra £1.5 billion which the Chancellor has made available for the NHS over this year and next. And we will continue to raise spending on the health service in real terms every year.

    "These changes will give patients a modern and dependable health service which makes the best use of developments in modern medicine and information technology to offer readily available and high quality services. We have already promised to cut waiting lists. We will have done so by the end of this Parliament.

    "Today I want to announce three new milestones by which we will chart our progress towards the new NHS. At home, everyone will be able to contact NHS Direct, a new 24-hour telephone advice line staffed

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    by nurses. Three pilot care and advice helplines will begin in March next year. By the year 2000, the whole country will be covered.

    "At community level, patients will benefit from quicker test results, up-to-date specialist advice in the doctor's surgery and on-line booking of out-patients appointments by connecting every family doctor to NHSnet--the NHS's own information superhighway. We will have demonstration sites up and running by next year. By 2002, these services will be available to GPs throughout the country.

    "In hospital, everyone with suspected cancer will be guaranteed a specialist appointment within two weeks of their GP deciding they need to be seen urgently. This will start for everyone with suspected breast cancer in 1999 and be extended to all other cases of suspected cancer by the year 2000.

    "We have great ambitions for the National Health Service. We will take on those who say the NHS has had its day and all we can do is preside over its decline. We will work with the million people who make the NHS so special to turn it into a modern and dependable service for the coming century. We know that doctors and nurses and all the staff of the NHS wish to rid themselves of the unfairness and inefficiency of the current system. That is our ambition too. It is what they want and what the people of this country want.

    "Next year the health service celebrates its 50th birthday. A Labour government founded the NHS and this Labour Government are now modernising the NHS to prepare it for the challenges of the next 50 years--a new National Health Service drawing on new technology, new drugs, new quality standards and new ways of working; a new National Health Service based on its timeless principles that the best health services should be available to all; the best for all, quality and equality, for the new century."

My Lords, that concludes the Statement.

4.3 p.m.

Earl Howe: My Lords, I am most grateful to the Minister for repeating the Statement. It is a Statement which has been long anticipated and which, now that we have heard it, is undoubtedly of fundamental significance for the future of the NHS. Indeed, so multi-faceted are the changes now adumbrated that it is difficult for me to give a full or considered response from these Benches today. For that reason, until the details and implications of what is proposed have been carefully studied, my reaction to the Statement must inevitably be a somewhat guarded one.

I can, however, congratulate the Government on their boldness. I do not doubt that Ministers are seeking in their own way to improve the health service. That is laudable. What some may doubt, however, having listened this afternoon, is whether the course they have charted will remotely be able to deliver the improvements they seek. My instant reaction to the proposals is that they have a great deal of sound and

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fury about them, but the central question always has to be: will they deliver better care more efficiently to patients?

The proposition put before us is of a health service in decline and disarray. I cannot accept that for one second. Surely to goodness, any dispassionate analysis must acknowledge one truth obvious to all of us who depend for our well-being on the NHS; namely, the admirable and robust ability of the health service over many years--but particularly over recent years--to meet the ever-increasing demands placed upon it. It has succeeded in doing so triumphantly, thanks to the dedication and professionalism of those who work for it. But, in the same breath, let us also acknowledge the enabling part played by government. Spending on the NHS has risen by 74 per cent. in real terms in England since 1979 and over 80 per cent. more NHS treatments per year are carried out now compared with 1978. Those figures do not speak of decline.

As the Government have recognised, there will always be pressure for more money and greater efficiency. The pressures felt by the NHS are nothing new. Ever since 1948 it has had to contend with a growing demand for treatment, an ageing population and the relentlessly rising cost of medical technology. For any government to respond to those challenges, it is necessary to demonstrate not only a commitment to a proper level of resources but also some flair and innovation so as to ensure that those resources are efficiently directed. Those are the two tests on which the Government will be held to account at the next general election.

We have heard much in the Statement about the alleged inadequacies of the previous government's health service reforms. I am saddened that Labour, now that it is in office, cannot be fair minded enough to give credit where credit is due. Those reforms, introducing as they did the distinction between purchaser and provider, better accountability to patients and devolved budgets to fund-holding GPs and trusts, were a vitally necessary set of changes which have been of huge benefit to the quantity and quality of health care delivered by the NHS since 1991. Of course there have been difficulties in effecting those changes. It would be extraordinary if there had not been. Of course we all want to minimise unnecessary bureaucracy, and large slices were indeed eliminated by the previous government. But those, like the Minister, who condemn the internal market should reflect on the transformation that that market has brought about in waiting times, in the information available to patients and in the quantity and quality of treatment delivered. Those are real bench-marks of success and of value for money.

The Statement says that NHS staff want to be rid of the current system. I have yet to come across a GP fund-holding practice which regrets its decision to adopt fund-holding status. There is no doubt whatever that fund-holding has injected new life into the NHS from top to bottom. Yet here we are with an announcement which heralds the end of the internal market and the end of fund-holding as we currently understand the term. In their place we find the proposal that primary care groups

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should take responsibility for a much greater part of the NHS budget and to a large degree take over the role of health authorities.

If the object of these changes is to open the way to greater efficiencies, I feel bound to ask the Minister how they will do so. The proposals appear to amount to an extension of fund-holding. But we are told that they do not amount to fund-holding. So what are the mechanisms, in the absence of the internal market, which will bear down on waiting lists, conduce to better care and ensure better value for money? It is not clear from the Statement whether the distinction between purchaser and provider is to be retained. Will it be; and if it is, how will it manifest itself? But more than that, how are GPs supposed to be equipped for this new role? To run a budget covering hospital and primary care, and perhaps some areas of social services as well, will require management skills and large amounts of management time.

We are told that the Government are keen to get rid of bureaucracy. But how will these arrangements avoid yet another form of bureaucracy, multiplied hundreds of times across all the GP practices or primary care groups in the country? It is effectively another layer of administration in the NHS.

In moving away from fund-holding, doctors are bound to wonder how their ability to take decisions will be circumscribed by the needs of other doctors in other practices, and to wonder, too, what will happen when there is a direct conflict of opinion. Seven or eight doctors in one practice can agree relatively easily. A committee of 50 is another matter.

The mechanism that we are asked to accept as being the driver of financial discipline is a cap on management costs. How will those be defined? Can the Minister confirm absolutely whether or not there will be a cap on the drugs budget? If not, do the Government have any plans for controlling such expenditure? I ask again: where are the mechanisms to ensure that GPs prescribe within budget?

The Statement also speaks of NHS trusts comparing and not competing. I am not sure how much of that is semantics and how much a real departure, but to base comparisons on a national schedule of comparative costs of treating different conditions is not a facility that comes by waving a wand. The data underpinning such comparisons will need to be collected in detail, and often, if it is to have validity. How will that be done without extensive paperwork and form filling? Will the resultant benchmark be as applicable in London as in Liverpool, or as realistic in Plymouth as in Perth? I need to be convinced about the credibility of such figures and the cost effectiveness of gathering them.

The Government have high ambitions for the NHS and I welcome them. I welcome also their ambition to bring health and social care closer together. It will be admirable if that can be achieved. I shall be grateful if the Minister can expand on how the Government propose to achieve that.

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In other respects my heart sinks at the terms of the Statement. The word "new" appears in it an off-putting number of times. I am suspicious of the word "new", as it conjures up marketing-speak. It would have been better if the Government had stuck to the substance without trying to doll it up. Further analysis will determine what these proposals amount to. At present I am fearful that the new NHS will mean new bureaucracy. I would genuinely like to believe the best of these proposals, but for the time being the jury is out and I suspect that it will remain out for some considerable time.


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