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Lord Astor of Hever: I rise to support Amendment No. 28. There is real concern that older people are often discriminated against in the NHS because of their age. I hope that the Minister will see the wisdom of having at least one lay member on trust boards representing the interests of older people. Organisations working with older people are told time and again of instances where older people are suffering in certain conditions because they are old. As a result, old people are often too frightened to complain. PCTs will have responsibility for a greater number of treatments which primarily affect older people. I therefore hope that the Minister will support the amendment.

Lord Clement-Jones: Due to the rushed nature of our eating requirements, I did not appreciate that marshalled in this group of amendments was the one concerning older people, which is of considerable importance.

As many of us know--not only from our own experience but from the representations made to us--there is an increasing concern that people are being discriminated against in the NHS because of their age. Amendment No. 28, which was referred to by the noble Lord, Lord Astor, is, in our view, of considerable importance as regards ensuring that discrimination does not continue. It is specifically important that there

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should be older people on primary care trust boards. We shall be talking later about amendments which relate to old people, but there is no doubt that there is an enormous degree of concern, not only about access but about treatment. There exists, in a sense, a kind of rationing. In order to tackle that kind of problem, we should be very conscious of the kind of representation we have on the primary care trust boards. That representation should specifically include older people, who will well be able to appreciate the problems that older people face.

One could argue that there should be representation for every one of every type among the lay members, but I seek to make a special case for older people. They are massive consumers of healthcare--they face almost unique problems in the way in which they interface with primary care--and it is very important that they are not just, in a sense, passive users, but people who are able to drive forward primary care provision in a positive way by their representation on trust boards.

Lord Rowallan: I rise to support Amendment No. 28 because old people and children take an enormous amount of the budget of any national health service.

I am concerned about Amendment No. 31, which is grouped with Amendment No. 26. It contains another list and, as we have already discovered, anything containing lists is extremely dangerous. We should remember that there is a huge body of people in professions in the NHS which used to be laughed at. I refer to the alternative medicine brigade. There are now very large clinics in some areas which practise medicines such as acupuncture, osteopathy, reflexology, kinesiology and so on. It is beholden on us to remember that an enormous number of people want to go to alternative medicine practitioners as opposed to using the National Health Service proper. We must take some of those large practices into account as well. Therefore, I do not support Amendment No. 31, but Amendment No. 28 is good.

Baroness Gardner of Parkes: I support Amendment No. 28. I do so because the Government's claim that there is no age limit on appointments to any NHS body is a complete fiction. I meet people who tell me all the time that an invisible barrier is definitely there. I understand that there may be a problem with older people if there is a risk that they may develop senile dementia. None of us is immune to that. But to get round that, the appointments of older people could be made for a limited time and would be renewable only if the people were suitable. By that I mean that they remained mentally alert.

It is wrong and hypocritical when we hear that age is irrelevant that the first thing one puts on any application form for a National Health Service position is one's date of birth. Those looking at those forms then sift through them. I should like to know how many older people will

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be on NICE and so on. This amendment is required on the face of the Bill to make it clear that there should be an obligation to consider older people.

Baroness O'Cathain: I support Amendment No. 28 but I should like to look at the issue in another way. The amendment states:

    "including lay members representing all sections of the community including older people".
Enough has been said about older people and I will certainly support that. But let us not forget people at the other end of the spectrum. I refer to younger people.

In our area we have a local patient support group. It has representatives who include a 17 year-old, a single mother with two children and a disabled person. It also includes several elderly people because that reflects the demographics of the area. It has worked like a charm, particularly for the 17 year-old and the 23 year-old. They have now had experience of working on a committee, of listening to people's views and of going to their sections of the community and feeding back information to the doctors and to the practice manager. It has revitalised the involvement of the community with the practice and has made people realise exactly how much work doctors do and how they need to be safeguarded against people who do not turn up for appointments. The young people are going to their friends and saying, "You can't make a doctor's appointment and not turn up". It is not the older ones who are doing that. The older ones represent people's needs in terms of access for disabled people, the requirement for hearing tests and so on. But it is the youngsters who are coming forward and stating the problems. I suppose they could even alert the doctors to where the drugs scene is becoming serious in the area.

If the Government really want to be an inclusive government, they ought to start now and consider including quite young people in these groups, if only for a limited period of time--perhaps three years or so. They will benefit, the groups will benefit and certainly the young people will benefit. Young people generally will feel that their views are taken into account. I do not want to put on the face of the Bill the words "including young people", but I hope that the Minister will take the point on board.

8.15 p.m.

Earl Howe: I rise to speak to Amendment No. 29 which ventures to take an opposite path to amendments tabled by the Liberal Democrat Benches in that it relates to the question of who should constitute the majority on the PCT board and proposes that that majority should rest with those who are professionally qualified. I do not think it is a contentious statement to make that if the NHS is to be asked to tolerate yet another period of adjustment, as it is, it is important that the changes are soundly based. A sound base involves our being very careful indeed that we take the doctors with us; indeed, not just doctors--of course not--but I single out doctors because, unless GPs feel that they own the new system, they will not respect it. Doctors will not want to feel dragooned into PCTs.

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Let us suppose that there is a proposal to convert a PCG into a PCT. What everyone understood from the original White Paper was that progress up the PCG ladder would be entirely voluntary, but it appears that that is not so. A proposal can be initiated by anyone in the PCG, by the local community health services or by a health authority. Let us suppose that the proposal goes out to consultation and the Secretary of State decides. If GPs do not like it there is no veto for them. A PCT is then established. The one thing that doctors will want to feel once they are in it is that they have a real measure of control and real responsibility for what the PCT does. If GPs see in PCTs a structure of decision making that erodes the degree of influence and responsibility that they enjoyed in a PCG, there is a risk that confidence in the system will evaporate. GPs will see it as an attempt to impose line management on them.

We have to remember that a general practitioner is an independent contractor. A doctor will not accept a system that threatens to interfere with the one relationship above all which counts for him--the relationship with his patient. Nor will he embrace a structure which lacks a sense of corporate feeling and identity. I believe that the Government's proposals for PCTs, which originally, it has to be said, looked like manna from heaven to many doctors, have had the gloss decidedly knocked off them by fears of this erosion of influence at management level. It is perfectly true that expressions of interest in PCT status have been quite numerous, but I wonder how many of those will develop into firm applications once people have reflected more deeply on the Government's proposals.

At Second Reading the Minister said that the Government wanted to build on what was best in the NHS that they inherited. But putting aside for one moment our disagreements about the merits or demerits of fundholding, one of its undisputed benefits was the way in which it put GPs in the driving seat and in so doing drove up standards of healthcare. That is the broad principle the Government say they want to preserve and carry forward in the new arrangements. I sincerely hope that they know what they need to do to make that objective a reality for doctors. If they do not achieve it, the risk to the NHS is substantial.

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