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Lord Clement-Jones: I want briefly to back up the comments of my noble friend Lady Barker and the noble Earl, Lord Howe, on this group of amendments. I also want to discuss Amendment No. 233.

On the proposals relating to care trusts, I am most concerned about the provisions involving compulsion in Clause 53. That raises the issue of "failing". I cannot see a definition of that word, which is highly subjective. The intention of Amendment No. 233 is to introduce a rather less subjective provision; it involves consultation with other expert health and social services bodies. One could choose from a range of bodies in this context, including CHI, the Social Services Inspectorate, NICE and the Audit Commission. I am sure that other noble Lords could propose other bodies. All of those bodies have at least one thing in common; namely, that they would have reported on and reviewed whether a body was not performing as it should, and they would have made a clear statement to that effect. That would give some assurance that the powers would not be used arbitrarily. I am not a fan of the clause, but if it is going to operate, it needs such a safeguard.

Baroness Cumberlege: I inform the Minister that Mrs Archibald would be very pleased with the clauses--she would be delighted that there was a care trust in the offing.

All of us should agree that it is right for health and social care to be brought closer together. To digress for a moment, I chaired the Brighton health authority for five years, where we ran hospitals and community services. We were probably acting illegally--I do not think that there were any provisions at that time that enabled us to do so. We devolved our budgets to the patch teams of social workers and to the

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neighbourhood nursing team in a given area. It was magical--the results were absolutely amazing. We delegated revenue budgets and capital assets. The first thing that the group did was to bulldoze a residential home that was long out of date and contained 64 beds that smelt to high heaven. In its place, we built a nursing home and some housing association sheltered housing. The impact was amazing and its effect on Brighton General Hospital was incredible, in that very few people were admitted--they were contained in the local community instead. I am a strong advocate of such an approach.

I went back about 10 years after I had left Brighton and found that the whole scheme had folded and that the system had gone backwards and towards what it had been previously. I sought to find out why that had happened. The scheme folded because the champions had left and budgets had been tightly squeezed. That contains some lessons for us in this context.

I am in favour of the proposed approach but some difficult issues have to be teased out to get social services, local authorities, health authorities and NHS trusts to work together. There is a rumour in the health service--the Minister may not be aware of this--that the Government are already setting targets and that they have decided on the number of care trusts that they want by next year. The rumour is that they want at least one.

I have done much work on current developments in joint services. I have studied three areas in this country and I am enormously impressed by what is going on without care trusts and through other mechanisms, as Members of the Committee have mentioned. A plea that comes to me from the service is, "Please do not make us run before we can walk". We must assess whether we have a shared philosophy and clear principles about what we should achieve. We have to ensure that the outcomes are clear, achievable and agreed. The governance, about which I have serious reservations, needs to be clear and efficient. The finance needs to be set in a framework that is agreed by everybody. Local government is nervous that the money that is set aside for care trusts will be siphoned off to acute services. We are already seeing that happening with primary care trusts and patient care groups.

An important issue involves charges. There are free services in the NHS and charges in social services. There must be an opportunity for organisational development and training, and we must iron out, or at least understand, some of the cultural differences that exist. We are considering two organisations with different histories, different accountabilities and different cultures. Neither is right or wrong; they both have strengths. Bringing them together is a huge challenge. There need to be robust relationships, based on trust. I am sure that the Minister will know the area in the West Midlands, to which I am referring, where huge strides are being made. The schemes have been built over 10 years and there is enormous trust between both bodies. It is interesting that those who pioneered

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them are still there 10 years later. That is quite unusual, especially in the health service, where people gyrate round at an alarming rate.

However willing the spirit, the mechanisms are complicated. It is essential that they are worked through with clarity. I have been reading Care Trusts--emerging framework, which was produced by the Department. Interestingly, paragraph 3 states:


    "The policy is being developed as the detailed issues emerge and are considered."

I am surprised at that and find it worrying. The Government must decide their basic policy before those involved in the field can respond. Of course, it is right that the people concerned should be involved in the details about mechanisms, and so on, but it behoves the Government to decide their policy before asking Parliament to agree to legislation. It is policy being made on the hoof, which is worrying.

Paragraph 7 of the document states:


    "Care trusts can only succeed where partners are fully committed to, and can influence the direction of the new organisation."

I agree with that, which is why I am so concerned about the power being given to the Secretary of State. I have listened to the Minister, who says that there can be other mechanisms besides the care trusts. Surely we have learnt that when a scheme is voluntary, it is much more likely to succeed. I know that the present Government had reservations about GP fundholding, but it was a voluntary scheme, which had great strengths. PMS pilots, which were also introduced by the previous Government, have proved to be a success. People are building on that voluntary scheme. I do not understand how the Secretary of State can think that by forcing two bodies together and forcing a shotgun marriage to take place that will work.

The report continues:


    "Care trusts will be a partnership between the NHS and the local council".

On governance, it states:


    "The Government is considering how the board can best be constituted given the different streams of accountability ... Care trusts will also need to be accountable to the users of their services, and will have representation from the Patients' Forums and the Patients' Advisory and Liaison services."

It continues:


    "Links with user groups, citizen's panels etc will need to be made".


    Local authority scrutiny committees will also be involved.

I wonder how that board will look--it will comprise councillors, NHS people, and so on. I am afraid that it will be not a board, but a conference. So many people will be chattering away, without decisions being made. There needs to be much more clarity about that issue. I can see the scrutiny committees being mischief makers if, for example, there are one or two disaffected councillors who think that their budgets are being eroded.

I agree with the principle, but I do not think that the Government have thought through the issue. It behoves them to set out their policy clearly before bringing it to Parliament.

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6.30 p.m.

Lord Clement-Jones: I take this opportunity to inform the Minister, so that he does not have to rifle through his notes, that I was speaking earlier to Amendment No. 253, which appears in a later grouping.

Lord Hunt of Kings Heath: It is clear that we would have enjoyed a general debate about care trusts before going on to the specific amendments. I know that some of the substantive points that have been made will come up in later amendments.

I shall respond to some of the key points, especially those raised by the noble Baroness, Lady Cumberlege. I assure her that Mrs Archibald has been very much in the minds of the Department of Health since our debate on Monday. If she were living in Brighton, she could enjoy some of the services that have been developed there. As the noble Baroness knows, Brighton was the forerunner of patient advocacy and liaison services, and it deserves congratulation on having the courage to pioneer it. I agree with the noble Baroness that success in the health and social care field is dependent on having champions who have the guts and leadership to stick with it and change things.

Rumours in the health service are generally to be avoided. I agree that the policy will not work unless there is enthusiastic ownership by the health services and local government. Surely that is the answer to concerns about targets. Unless both partners are willing to go into it, it will not happen.

We shall come to issues of governance and accountability. They are important, but the parties interested in evolving into care trusts must understand the rules of the game at the start, so that arguments can be sorted out in the beginning, rather than being confronted during the process. On cultural differences, I have always accepted that the nursing and medical model and the social care model have not always co-existed effectively.

Like the noble Baroness, I am really encouraged by what has happened in the past few years on the partnership between health and local government. There have been enormous improvements. I always quote the example of our winter planning this winter. I do not believe that we would have withstood the pressures on the health service unless we had the wholehearted support of local government and social services. I am optimistic that there has been a sea change in attitudes, which will come through in care trusts, enabling us to deal with cultural differences.

I am not sure that I agree with the noble Baroness on the need to set out the rules at the beginning. At the development stage, we need to be open to ideas, and we need to be informed by health and local authorities, so that we get it as right as we possibly can.

On the issue of the amendments before the Committee, I was disappointed by the remarks of the noble Baroness, Lady Barker, when she referred to the record on NHS consultation, particularly in relation to voluntary organisations. The NHS Confederation once produced a very good book on NHS voluntary

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organisation relationships which I would commend to her because, again, I believe that we need to encourage the NHS to work much more closely with voluntary organisations. One way to do that is through Clause 11, which imposes a new duty on the NHS to involve and consult patients and their representatives.

I am absolutely certain that in care trusts, with their patients' forums and representation from voluntary organisations, unlike with community health councils, there will be people from voluntary organisations who are able to have access to the leadership of that care trust. I am sure that that will be an enormous enhancement of that dialogue.

I want to assure the Committee that we shall set out consultation arrangements in regulations and directions so that all stakeholders will be able to take an active part in developing proposals for voluntary and, indeed, direct care trusts. I will come back to that when we debate it later.

Like a number of other amendments which have been tabled in relation to consultation, I never think that it is helpful to set out on the face of the Bill those organisations which must be consulted. We know that when those organisations are listed, others are bound to be missed off. It is important for me to make it absolutely clear that there will be full consultation. We propose that through the regulations under Clause 52(7) and (8) and Clause 53(7), which deal with conditions which must be satisfied before an application can be made, we shall ensure that that guarantees effective consultation.

Perhaps I may comment on the wording of some of the amendments. They have tended to focus on patients. Obviously patients' views are important but we need to go wider than that. We need to embrace professionals, employees and other private and healthcare providers.

I hope that I have assured the Committee that consultation will be an integral part of the process by which care trusts are created.


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