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Lord Rowallan: My Lords, I, too, support this amendment. I, too, received the letter alluded to by my noble friend Lady Carnegy of Lour which appears to suggest that 11 associations connected with medicine, representing 130,000 health professionals, are all prepared to boycott PCTs at level 3. This is a rather frightening situation; namely, that there is such a huge backlash to try to stop things happening in this regard

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from within the NHS. The Government must seriously reconsider this matter. As I said, I support the amendment.

Baroness Hayman: My Lords, it has been helpful to have dealt with the proposals that concern the make-up of primary care trust boards and their governing arrangements in perhaps a little more detail than we did at Committee stage. The noble Earl, Lord Howe, is right; namely, we need to get the balance right and we need to establish a sense of corporate feeling in this area. We need to ensure that the views of doctors and general practitioners who have particular concerns are heard. However, I take the point that the noble Lord, Lord Rowallan, and the noble Baroness, Lady Carnegy, made; namely, that there are other groups who also have their concerns and their fears in this regard.

One of my objections to this amendment concerns the term "key partners", because if we suggest that some partners are more key than others we may cause exactly the problems that are being manifested now. However, at the end of the day we have to establish the right governance arrangements. There are obviously a limited number of places on a governing body but I hope that we can provide some reassurance in this regard, particularly to professions supplementary to medicine. We intend to bring forward a government amendment so that primary care trusts, like health authorities, are required to secure appropriate professional advice in carrying out their functions. I shall discuss that in a little more detail in a moment. There will also be significant lay involvement in the running of PCTs.

I hope the House will forgive me if I switch for a moment to PCGs and clarify the analogy that I gave to the noble Lord, Lord Skelmersdale, as regards who could be outvoted by whom on a PCG board. Professional members could not be outvoted by lay members on a PCG board because, unlike the PCT, the lay members would not be in a majority. We discussed the views of general practitioners. General practitioner members--especially if they had not exercised their right to be in a majority of professional members--could be outvoted on that board. I suspect that I may have muddied the waters slightly as regards the terms "professional" and "GP". I take this opportunity to put that right.

I return to the governing arrangements of PCTs. As has been pointed out, they will be established under the overall supervision of a lay majority board but with a trust executive where health professionals will be in the majority. We hope here to have struck the right balance. The aim is for professionals to exercise through the executive major influence in shaping service policies and investment plans but within the wider framework of accountability--that has been mentioned--offered by the lay majority on the trust board. We envisage a board of 11 members, comprising the chairman, five lay members, the chief executive, the finance director and three professional members drawn from the executive, of which at least one will be a GP and one a nurse. One of the professionals will be a director of clinical governance. That is obviously essential if we are to establish the clinical governance provisions.

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A difficulty has arisen with regard to the professional make-up of the executive varying between level 3 and level 4 PCTs. A level 3 PCT will consist of up to seven GPs, up to two nurses, one professional with public health or health promotion expertise and a social services officer, as well as the PCT chief executive and finance director. A level 4 PCT will consist of up to 10 clinicians as well as the chief executive, the finance director and the social services officer. It may be helpful if I explain why there is different professional membership at levels 3 and 4, as this is an issue that I know is of concern to the professions allied to medicine. There are two reasons. At level 3, the composition of the executive--with GPs allowed a majority--reflects the commissioning-only role of these primary care trusts. We believe that GPs must have a key role in commissioning because of their role as gatekeepers and in committing resources through their referral and prescribing decisions. This unique role is reflected in the make-up of a level 3 executive.

At level 4, however, PCTs are commissioning and providing bodies. The make-up of the executive must balance significant GP representation alongside local nurses and other community and public health professionals. There also needs to be flexibility in the precise balance of professional members. This is because the configuration and range of services that level 4 PCTs will provide may differ from place to place. Therefore we need to allow flexibility for the balance of professional members appropriately to reflect local variations.

I assure the House that the Government recognise the extremely important contribution that a wide range of groups, including secondary care clinicians, the universities, academic medicine and the professions supplementary to medicine could bring to primary care trusts at level 3 as well as level 4. We will expect PCTs to work closely with all the key local stakeholders, including academic interests. This will be particularly important when PCTs commission services from teaching hospitals, to ensure the interests of NHS teaching and research are fully taken into account.

I appreciate from my own discussions with members of professions allied to medicine their deep concern that the expertise at health authority level as regards commissioning services, particularly therapy services, should not be dissipated or lost completely in the move to primary care groups. As I said earlier, it is for that reason that I intend to bring forward a government amendment--I hope in time for Third Reading--so that PCTs, like health authorities, have a duty to make arrangements to secure appropriate professional advice. The House will understand that while we wish to avoid the problem of lists on the face of the Bill, we shall seek to ensure that the amendment is sufficiently wide to cover academic medicine, the acute sector and the professions allied to medicine.

I am grateful to the noble Lord, Lord McColl, who drew attention to this point during the Committee stage. We are currently considering a suitable amendment to Section 12 of the 1977 Act. I hope that in the light of those assurances the noble Baroness will feel able to withdraw the amendment.

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5 p.m.

Baroness Sharp of Guildford: My Lords, I thank the Minister for her reply. In the light of her assurance that she will be bringing forward an amendment--we look forward to seeing it--I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Earl Howe moved Amendment No. 8:

Page 42, line 37, after ("members") insert (,"provided that not more than half of the membership appointments are vacant,").

The noble Earl said: My Lords, this is a very simple amendment. From time to time, and particularly over the past 18 months, we have seen NHS trusts struggling to cope with board vacancies that remain unfilled, some for quite lengthy periods of time. The question I pose to the House is what will happen if this situation is replicated in primary care trusts? As the Minister said, at the moment the government proposal is for a board comprising 11 members, including the chair. This amendment to paragraph 7 proposes that if six of those positions are for any reason unfilled, the PCT board is automatically inquorate.

It is not simply that the business of the trust would otherwise end up being decided upon by too few individuals but that a rump board of five or fewer would not be truly representative of the various interests which the trust is meant to represent. As we know from experience with NHS trust boards where there are vacancies, the additional workload that falls upon the shoulders of the remaining directors--in the case of the PCT it will be members--is unfairly heavy. We should not ask a minority to take on such responsibilities. What I hope from the amendment is that it will act as a spur for the Secretary of State never to allow a PCT to arrive at such a position in the first place. I beg to move.

Baroness Gardner of Parkes: My Lords, I wish most strongly to support this amendment. I have been appalled by the delays in filling the vacancies for non-executive directors on trusts and area health authorities. It has been very unfair to people. There has been no excuse whatever for it. In the instance about which the noble Baroness has heard me speak before, we interviewed 16 people, of whom six were considered immediately appointable. One was appointed months after the vacancy occurred. When I wrote to ask why the second vacancy was not being filled--this is out of five non-executive appointments, so it is a very small number--the answer I received was that they were waiting until they could find someone suitable from an ethnic minority. I do not see why that was necessary when another vacancy was in the pipeline and was due to come up within four months. In the original trawl, ethnic minority members were interviewed but were found unsuitable. Only two were eminently suitable for interview and, at interview, it turned out that they clearly were not suitable. One really thought she was applying for a job and did not understand what a non-executive directorship was; and the other was unsuitable for a different reason altogether. The point I wish to make is that the Government specifically kept that vacancy open for that great length of time for no

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reason whatever when another vacancy was shortly to follow. I think that appointment was made approximately 11 months later.

When I have previously raised this matter with the noble Baroness she has always said, "We are improving. We are getting better at appointing these people". I certainly hope so, because the present position is very unfair, both to the organisation--whatever the organisation is that is active in the health service--and, as my noble friend said, to the remaining members of a board who have to carry the extra burden.

My noble friend is not asking for very much. I said before that a majority is not much to ask for. He is very modest in everything that he asks for and he is being modest again in asking for this provision to apply only when not more than half the positions are vacant. Again he is adopting the same very reasonable tone. I cannot see why the Government would not accept the amendment.

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