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Earl Howe: I rise with some reluctance because, from these Benches, I do not feel that we can support the amendments proposed by the noble Lord, Lord Clement-Jones. I shall not go into too much detail in the interests of brevity, but I believe the kind of path that the noble Lord is inviting us to go down would lead to a lack of clarity in responsibilities. Indeed, it could lead to confusion in the rules surrounding propriety in the use of public money. In general, I think it is undesirable to transfer health functions to bodies which are not concerned with the management of health as a full-time business. Therefore, I am afraid I cannot support the amendments.

Lord Renton: I warmly support what my noble friend Lord Howe has just said. It would be very dangerous to pass responsibility and power to local authorities in these circumstances. With the health

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authorities, we are going to get a good deal of consistency across the country as regards administration of this scheme, just as we had under the former National Health Service. But if we are going to give overburdened local authorities these specialised responsibilities we shall not get an even pattern across the country. We could get a serious variation. I hope that the Minister will also resist these amendments.

Lord Skelmersdale: I touched on this matter on Second Reading--as the Committee will recall--speaking from my experience as a former health Minister in Northern Ireland. The system we are discussing only works there because you have one body, a health and social services board. There is a good argument for rolling the four boards into one, but I shall not go into that at this moment. However, if one side or the other is dominant--which is what I think these two amendments propose--one is in danger of coming across all the difficulties that my noble friend Lord Renton has foreseen, and has just stated.

Baroness Thomas of Walliswood: I wish to make a couple of brief points in support of my noble friend. It seems to me to be quite sensible--this is a direction in which I feel we are bound to move at some point--that the commissioning of healthcare (that is, how the money is spent) is, as it were, united with the commissioning of social care under one authority. My noble friend has suggested that that should come under the local authority. I find that satisfactory for the following reason; namely, that in that way a democratic accountability would be introduced.

I was a member of a local authority and of a hospital trust at the same time. The most uncomfortable element of membership of the trust board was that I had no standing vis-a-vis the people to whom that health trust delivered services. There was no way in which I could go to them and ask, "What do you think about this?", because that is not the way it works. Had I done that, I would simply have been removed from the health board, as I am sure my fellow members would not have thought that that was a proper thing for a member of a board to do. The difficulties involved in the relationship between hospital trust boards and their surrounding communities should be an example to us of the advantages of placing the health service within a democratic context.

Baroness Hayman: I believe that the health service is in a democratic context, but it is within a national democratic context. Some of the contributions that have been made to the debate have recognised the importance of that point and of the maintenance of a devolved structure. They have recognised the importance of establishing mechanisms through local boards and through some of the provisions we have discussed today for ensuring that local decisions reflect the views of local communities. I have tried to be helpful to the Committee as far as possible. However, I shall adopt the strictures of those on the Benches opposite who have spoken against this provision and be firm in my rejection of the amendment.

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I do not do so because we in any way wish to downgrade the issue to which the noble Lord, Lord Clement-Jones, spoke in detail; namely, to ensure that we dovetail services for individual patients, and that there is not some false divide between the care that is given by social services departments and the care that is given by the health service. Indeed the provisions that we shall discuss later in the Committee's deliberations under the partnership section of the Bill are designed to do just that and to go wider than a consideration merely of social services. We should consider the whole of local authorities' functions in order to achieve more effective co-operation between the NHS and local authorities. Those provisions have been widely welcomed.

However, the amendment we are discussing would have a much more far-reaching effect. It would allow local authorities to assume the functions of health authorities, effectively bringing local health services under local authority control. That is quite simply not the Government's policy for the health service. I recognise the point that the noble Lord, Lord Clement-Jones, made regarding the recommendations of the Health Select Committee. I shall discuss those in detail shortly. However, it is worth noting that that committee recognised in its report that its proposals had received little support from those who gave evidence to it. That included the Secretary of State, who made it clear in his evidence that he felt major structural reorganisation was both unnecessary and would be highly disruptive. Earlier in the afternoon we debated how disruptive change can be, even measured change in limited areas.

What we are trying to do is to allow an approach that does what both local authorities and the NHS have asked for; namely, to remove the longstanding legal barriers to joint working without imposing the turmoil of major upheaval. Provisions in the Bill will allow for integrated working where that would lead to better outcomes for patients and for clients. However, as regards the evidence that was given to the Select Committee, and the responses that we received to our Partnership in Action discussion document, it was made quite clear to us that the kind of major structural change that this amendment would involve would not be helpful. We can achieve the ends that we seek to achieve through the partnership arrangements. I urge the Committee not to pursue this amendment.

Lord Clement-Jones: I thank the noble Baroness for that not unexpected reply. I am not surprised at that response. When I introduced the amendment I did not seek to minimise the lack of support for the provision among those who gave evidence to the Select Committee. I believe that the Select Committee is composed of some pretty far-sighted people. I say that because I agree with them! They have looked several years ahead to consider the impact of joint working arrangements and pooled budgets. Some of them have had a long involvement in the health service. After taking evidence--even the negative evidence, as the noble Baroness has mentioned--it was their considered view that the provision would not be sufficient.

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I make my next point with all due deference to the noble Lord, Lord Skelmersdale. I appreciate his experience of the Northern Ireland situation, but he did not say whether he thinks that the standard of integrated care is higher in Northern Ireland as a result of the system that is adopted there. One can have this one way or the other. One can have the health service undertaking all these functions or local authorities undertaking them. We propose that they should be undertaken by local authorities. Our view is that after a period of time it will become quite clear that the mechanisms that are being set up under the banner of partnership, with the best of intentions--we fully support that intent--will not be sufficient to provide healthcare in the seamless way in which everyone in the voluntary and the health sectors is striving to achieve. Clearly, however, we have some way to go in the persuasion stakes. No doubt the campaign will continue--"la lutta continua". This is an area of considerable importance, and will continue to be so. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 22 and 23 not moved.]

Clause 2 agreed to.

Schedule 1 [Primary Care Trusts]:

[Amendments Nos. 24 and 25 not moved.]

Lord Hunt of Kings Heath: This may be a convenient moment to break for dinner. I suggest that we reconvene at eight o'clock.

[The Sitting was suspended from 7.28 to 8 p.m.]

Baroness Sharp of Guildford moved Amendment No. 26:

Page 42, leave out line 3.

The noble Baroness said: In moving Amendment No. 26, I wish to speak also to Amendments Nos. 27, 28, 30, 31, 32, 33, 34, 35 and 36. Amendment No. 29 will be spoken to from the Official Opposition Benches.

These amendments concern the governance of the primary care trusts, In particular they are intended, first, to make the membership of the board of the primary care trusts more representative, both in terms of the healthcare professions and in terms of local voluntary organisations, carers and lay members of the community; and, secondly, to make selection of the chairman more democratic, so that the body chooses its own chairman rather than the Secretary of State.

We on these Benches are most anxious that the boards of the primary care trusts are not run by the medical profession for the medical profession but that they represent the broader community in which they are located. In particular we are anxious that they represent both those who are providing care and those who are receiving care. It is vital that the professions allied to medicine are included, as well as the voluntary bodies and the carers.

I shall run quickly through the different amendments. Amendments Nos. 26 and 30 are allied to Amendments Nos. 33 and 34. They make it clear that we would like to see the members of the trust choose their own

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chairman from among their own members, rather than having the chairman chosen by the Secretary of State. Amendment No. 27 argues that a majority of the members of the trust should not be officers of the trust. Amendment No. 28 lays down that the various members of the trust shall include lay members representing the local community. Amendment No. 31 lays down that, in addition to lay members, there shall be representation from members of the other healthcare professions and not just general practitioners. Such professions would include community and practice nurses, social services, dentists, pharmacists, physiotherapists and opticians. Amendment No. 32 concerns the range of skills that we would like to see represented within the primary care trust. It is especially important that patients and carers, and those who have been patients and carers, are represented on the primary care trusts as consumers of primary care. Amendment No. 35 again makes it clear that the regulations shall include not only representatives from the medical professions but also representatives from the professions allied to medicine and from the nursing and midwifery professions. Amendment No. 36 places an obligation on the Secretary of State to consult widely within the community about appointments to the primary care trusts. We are anxious to ensure that those selected are widely known and respected within their communities.

As I have said, Amendment No. 29 comes from the Official Opposition Benches. As far as we are concerned, it goes in the opposite direction. By laying down that a majority should come from the medical profession, the amendment does not exclude the possibility that the medical profession could dominate the PCTs, which we would be unwilling to see. I beg to move.

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