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Baroness Cumberlege moved Amendment No. 1:

(1) There shall be a body corporate to be known as the NHS Agency for England (referred to in this Act as the "English Agency") for the purpose of carrying out the functions transferred or assigned to it by or under this Act.
(2) The functions of the English Agency are performed on behalf of the Crown."

The noble Baroness said: I start by declaring an interest. I am employed by the NHS, sometimes in a voluntary capacity, sometimes paid. I serve as a trustee on several charities. I chair St George's Hospital Medical School Council and am a senior unpaid associate of the King's Fund.

In moving Amendment No. 1, I speak also to Amendments Nos. 2 to 6. I speak in the knowledge that these amendments may have the familiarity of a dear and much loved but sadly in the past rejected friend. Some noble Lords may remember that I moved similar amendments 18 months ago when the National Health Service Reform and Health Care Professions Bill was before this House. Your Lordships were generous and my amendments received a good deal of support but, sadly, not from the then Minister, the noble Lord, Lord Hunt of Kings Heath. I hope that the noble Lord, Lord Warner, our current Minister, will be of a different mind and acknowledge the undoubted value of these proposals, which actually enhance the Government's drive to devolution.

I should like to thank the noble Lords who have put their names to these amendments, including the noble Baroness, Lady Finlay of Llandaff, and the noble Lord, Lord Alderdice, who both work in the NHS and experience the daily frustrations of the current arrangements. With the noble Lord, Lord Desai, a past Labour spokesman on health and an internationally distinguished economist, they cover all sides of the Committee. The noble Lord, Lord Haskins, one of the original architects of the concept I am promoting, chaired a group established by the King's Fund. Although he is a strong advocate of these amendments, sadly, he is unable to be here today. Finally, I should like to pay tribute to the King's Fund and its inspirational director, Rabbi Julia Neuberger. I have been working on these amendments with her team.

In the intervening 18 months we have examined the arguments of those who feel that these proposals are at worst misguided or at best are impractical, and we agree with them. We think that it is naive to think that it is possible, or indeed appropriate, to exclude politicians from taking responsibility for the NHS. Rather, we seek to put politics into its rightful place. We seek to strengthen the role of Parliament, increase accountability

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and ensure that decisions are made in a transparent way. We want to separate the responsibility for making policy from the responsibility of implementing policy.

The foundation of medicine is based on the Hippocratic oath. One of the key elements of the oath is that all people engaged in the provision of medical services should be bound by it, and that is a good principle. However, in providing medical services, successive governments have selfishly served party political dogma to the great resentment of those who work in the NHS. They and the majority of users believe that we need a service that is above party politics but subject to the most rigorous examination by Parliament and its elected politicians.

One of the great tenets of the Hippocratic oath is that a doctor should do his patients no harm. In the past, it is the party divisions that have done the NHS great harm—never I believe maliciously, but sometimes misguidedly or by pursuit of short-term political gain. We have used the most powerful and emotive issue of life and death for base reasons and that should stop. We should cease playing party games with the NHS. We should have a common oath subscribed to by every party. I believe that now is the time, in the words of the former chief executive of the NHS, Sir Alan Langlands,

    "for a serious re-evaluation of the argument for putting the NHS at arms length from government".

That is what these amendments seek to do.

The clauses I am moving today do not further disrupt the delivery of services to patients. They do not give birth to another quango. Rather, they build a new relationship between the public, Parliament, government and the NHS staff. They seek to re-establish trust in the NHS, to strengthen commitment and to ensure that we have a service that is efficient, timely, compassionate and above all well managed with a minimum of interference. The NHS does need improvement; it is not very well. Is it not a disgrace that not only do we have to scour the world for doctors and nurses to work in this country, but that we export our sick to be treated in other countries? That is no way for a rich, civilised nation to behave.

Just over three years ago, many of us welcomed the NHS Plan. Good will was created by including all parties in drawing it up. However, that good will has now evaporated, largely because new policies have been developed without open debate or collective agreement. That is a view shared by the Government. Only last week, on the BBC's "World at One" programme, John Reid, the Secretary of State for Health, acknowledged that the concept of foundation hospitals would have been better received if there had been consultation in the form of a White Paper. I, too, believe that much of the opposition would have been diffused if this particular Exocet had not exploded without warning.

Throughout the history of the NHS there has been a pull between central direction and local autonomy. Sir Roy Griffiths, in his 1983 report, said:

    "The centre is still too much involved, in too many of the wrong things, and too little involved, in some that really matter".

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Today the NHS would resonate with that. We need to define the roles of Parliament, government and the NHS, coupled with a strong mechanism for accountability. I believe that an agency would do just that.

So my first amendment inserts a new clause before Clause 1. This clause establishes a new corporate body, to be known as the,

    "National Health Service Agency for England",

whose functions are performed on behalf of the Crown. An NHS agency would put politicians and parliamentarians in their rightful and authoritative place, working in public to develop and refine health policy. It would bring transparency to the way in which the Government are managed and it would increase their accountability. It would give greater ownership of targets by staff working in the NHS, and it would avoid the Exocets that explode when Ministers are under pressure from the media and feel that they have to do something.

An agency which puts the responsibility for implementing policy at arm's length from the Government creates a new space—a new space between government and those who manage and provide health services. This space could be used to construct a system for holding the Government and the NHS agency to account for their respective responsibilities. From time to time the Secretary of State would be required to put before Parliament an agreed framework defining the boundaries within which the agency should work, its targets and the details of its funding. The agency would report at least annually to Parliament and be subjected to a regular review by parliamentary Select Committees. Parliament would hold the chief executive to account for the performance of the service.

Using Parliament as the forum for agreeing the tasks of the agency and the targets of the service would ensure greater openness and more vigorous debate over standards, targets and the impact of implementing policy. This in turn would allow Parliament and the public to focus their scrutiny of government on questions of strategic direction, funding and the coherence, quality and effectiveness of policy. It would enable governments to broaden their horizons away from a preoccupation with accountability for each and every action within the NHS towards a more general concern for the impact on health of poverty, environment, food, housing and education, all factors which have a far greater impact on the health of the nation than any healthcare service.

The second clause sets out the composition of the agency—with 12 members, a chairman, a deputy chairman and five non-executive and five executive members. The chairman of the agency will appoint a chief executive, the appointment to be approved by the Secretary of State. This proposal seeks to get the commitment of both the board and the Secretary of State. Without that—the confidence of both parties—the chief executive simply could not hope to succeed. Since this agency is going to be pivotal in managing the NHS, I have given the Secretary of State the power to prescribe its constitution by regulation.

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The third new clause prescribes the functions of the English agency and gives powers to the Secretary of State to amend the functions through affirmative regulation and the power to give directions on strategic matters relating to its functions. The fourth proposed new clause concerns the transfer of property, rights and liabilities that is necessary for the discharge of its functions. The fifth proposed new clause concerns the financing of the agency and the accountabilities necessary for a body spending public money and the sixth and final proposed new clause ensures that the agency is accountable to Parliament, which will have a greater responsibility to scrutinise the agency's activities.

In the past few months several annual reports have been published by public bodies including the Audit Commission, the Commission for Health Improvement, the National Institute for Clinical Excellence, the Department of Health, and possibly several more that have passed me by. These are public bodies carrying out serious activities that affect our daily lives. The reports enter the public domain and yet they are seldom, if ever, debated in Parliament. Those bodies should be held to account and there should be a systematic process whereby their activities are debated in Parliament. Healthcare scrutiny is rich in reports yet poor in accountability. The national service frameworks are major influences shaping the NHS. They are often welcomed but there is no required parliamentary system to scrutinise their progress and ensure that they fulfil their promise. So there is a piece missing in our accountability structure, and the agency is that missing piece.

I am under no illusions that the proposed new clauses could be improved, and we have many models on which to build. There are now 192 established executive non-departmental public bodies in the country from which to learn: the Higher Education Funding Council for England, the Medical Research Council, the Food Standards Agency, the Audit Commission, the BBC—perhaps not the BBC—and so on. Each one is unique and tailored to its purpose, which should not prevent Ministers in the department using their skills and imagination to do the same for the NHS. As the Chancellor of the Exchequer showed the nation when he gave away Treasury powers to the independent Bank of England, it is the political will which is necessary.

In conclusion, governments have a pretty disastrous record of managing organisations. They are poor at it because the majority of members have no experience of running an organisation, although I recognise that the Minister is an exception. They have to work with an impossible electoral cycle and they are nomadic. Ministers and Secretaries of State do not last so there is no continuity. The speed of change in medicine is a huge challenge. Change needs a robust organisation to manage it. We need a separation of powers. We as parliamentarians have a role, the Government have a role and the NHS has a role. However, the picture is confused. An agency would introduce clarity and enhance Parliament's duty of scrutiny, and the Government's role of strategic direction and funding.

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I hope that the Minister will look favourably on these amendments, consider them carefully, recognise the purpose behind them, discuss them with his colleagues and initiate the work necessary to bring them to fruition. I beg to move.

3.30 p.m.

Lord Alderdice: In supporting with some enthusiasm this group of amendments, I declare an interest as a part-time consultant psychiatrist working in Northern Ireland health and social services. Although I and some others involved in the debate may declare a professional or other interest, there is no one in your Lordships' House or, indeed, in the country who does not have a very personal interest in the health and welfare of health and social services.

Over the past 50 years or so health has become such an important and central issue, and its delivery so crucial, that no one can seriously consider it to be outside the province of government. It is not something that can be left simply to the market or to chance. The question is not whether government are involved but how government are involved in this area and in many others too. Few of us do not have a sense of concern that government are not as appropriately involved in this area as they might be. It seems to me that there are at least three important areas of discontent and concern about how government deal with important matters such as health. It is, of course, health that we are considering today.

The first of these matters for all parliamentarians and all Members of your Lordships' House is the question of the accountability of the executive to Parliament. That seems to consist largely of tabling Written and Oral Questions and initiating debates. There is a general sense that those are no longer entirely satisfactory ways of holding the executive to account. Parliament, and indeed most Members of your Lordships' House, are not happy that the executive is being held appropriately to account. The extraordinarily complex area of health cannot be satisfactorily explored or dealt with by simply tabling Questions.

Secondly, although there is a sense in which the executive is more untrammelled than previously, it is also less powerful in terms of making a change than it was previously. For that reason Ministers tend to involve themselves in more and more micro-management and detail because they are less and less sure what to do about the bigger picture. To some extent that is made worse in our parliamentary system, particularly in the other place, because Members are elected as constituency Members. As time has gone on, due to the laudable development of community politics, they have become increasingly concerned to show their connection with the population by dealing with specific local agenda items. Ministers are expected to deal with the specifics of healthcare delivery in a particular constituency—and that is repeated some 650 times in the other place—rather than deal with the broader issues. Indeed, we even notice during elections that sometimes the accosting of

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a Minister or a Prime Minister by a particular individual in a particular constituency results in a very dramatic announcement to address that particular matter. That is not the best way to deal with the extraordinarily complex National Health Service which we have. The tendency towards micro-management is not very satisfactory.

The third concern was mentioned by the noble Baroness, Lady Cumberlege, towards the end of her remarks; that is, the problem regarding continuity. All of us who are involved in patient care know perfectly well how unsatisfactory it is for a patient as an individual if their carer changes all the time. One of the complaints we frequently hear at outpatient clinics is a patient saying, "I come along and every six months there is a new junior doctor. The first one says, 'It is nice to get to know you'. The second time you see him or her, they say, 'I shall see you again'. The third time you ask whether there will be a different doctor the next time". In those cases there is some continuity but in others an endless stream of locums deal with patients. We all know that healthcare needs a degree of continuity. It is the same for the service that delivers the healthcare; it needs a degree of continuity. When change takes place—in every system it needs to take place from time to time—it needs the opportunity to bed down and to develop and for people to assess the outcome of the change or reform.

My noble friend Lord Clement-Jones pointed out at Second Reading on 8th September that this Government had introduced some five or six health reform Bills. But in a sense this Bill is no different from its predecessors as health service reform has been repeated time and time again. Every time there is a difficulty the answer is to change the whole board. That often is not the answer but it seems to be the most ready answer. If it is not a radical enough change or proposal, the next time it will be even more radical. "Radical" usually means changing the name and putting in more administrators. Is it possible to address these three problems of the lack of accountability to Parliament, the question of overinvolvement and micro-management and the difficulty regarding continuity?

In the six amendments, we have some move in that direction and, at the very least, an encouragement to think of it. The agency would not be determined or dependent for its staffing on the electoral cycle or Cabinet reshuffles. It is no reflection on any individual Minister—indeed, in some cases it may be because of their sterling value to the Government or the Prime Minister—that they move from one post to another, but it is not satisfactory for a service. Every Minister who comes in wants to make an impact and impression on his or her portfolio and service. The tendency for change on the basis of the electoral cycle or the presence of a particular Minister is enormous, and it is not satisfactory. If it were possible to have an agency with a staff who had some continuity right at the very top, there would be a possibility of some continuity in flow and an absorption of any reforms.

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Some of the other amendments, particularly Amendments Nos. 2 and 3, which describe the functions and membership of the agency, give the flavour of an agency that could see more professionalisation of the administration in the health service, rather than the politicisation and sometimes managerialisation that there has tended to be. It might even be possible to have a professional healthcare worker as the chairman or chief executive of the agency. Just think that we might actually have a doctor or nurse or someone like that running the health service. What a radical thought.

Of course, it is not that some of those who have been involved have not been doing their best. However, there is a fundamental difference between a person who decides at a relatively early age to devote their whole life, professional time and career to healthcare delivery, and who at some later stage then takes a very senior responsibility for it, and someone else who happens to have been in a finance department, or even a position such as Secretary of State for Northern Ireland, who then comes in to be the head of a complex organisation such as the National Health Service. It would be an improvement to have someone there who had actually spent a great deal of their life working in the service and being at a very senior level in running it.

One of the most appealing suggestions is the notion that we might improve parliamentary accountability. Amendment No. 6 in particular, but also proposed new subsection (3) in Amendment No. 3, indicates how much better parliamentary accountability might be if an agency were required to produce at least annual reports, and perhaps other reports on specific developments or areas, and lay them before Parliament. Under proposed new subsection (3) in Amendment No. 3, any change would require resolution of each House of Parliament and, under Amendment No. 6, Parliament itself would have the opportunity to explore, discuss, debate and hold to account in a more thoroughgoing way the operation of the health service.

There is a real opportunity for us to improve accountability and continuity, and to ensure a change to the temptation of politicians to either make their name or improve their local popularity for the next election by over-involvement in the particularities of the health service. Politicians would do what they are much better at doing, which is making the broad strategy, deciding the wider policy, conveying the general views of the population, and leaving the professional development and service delivery to people who have committed themselves to that, in the context of an arm's-length agency. I am delighted to support the proposals.

3.45 p.m.

Baroness Finlay of Llandaff: I have added my name to the amendments, and have thought them through in great detail. I also must declare an interest as a working clinician in palliative medicine. Of course, I work in Wales, which is not directly covered by the amendments. I have not tabled amendments specific to Wales because, quite simply, I have not had a chance

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to do the amount of research that I would need to do on the way in which the devolved administrations would handle an NHS agency in order to table comprehensive amendments at this stage.

The noble Baroness, Lady Cumberlege, pointed out two major truths. The first is that, in medicine, the first principle is do no harm. The second is that all is not well in the health service. The health service does a lot very well, but sometimes it does not do things well. It is sad to say that at the moment the staff are demoralised. I spoke to as many people working in the NHS in England as I could prior to adding my name to the amendments. No one working as a front-line clinician disagreed with the idea that staff were demoralised, or with the principle that somehow the running of the NHS needs to be taken away from the electoral cycle and the pressures of the ballot box.

There is a need for long-term planning and strategy in the NHS. That strategy needs to be enacted at a local level. The clinician faced with 40 patients coming into an out-patient clinic and then faced with targets has a huge dilemma. The person in front of him or her may not fit into any target sector, but may have very complex and time-consuming clinical needs that far outweigh the, say, five people who fit neatly into some target package. At times, the clinicians find themselves torn in half in different directions, with the pressure of still trying to take ethically sound decisions for the patients in front of them.

Resources are limited. It always was so and always will be so. There will never be infinite resources to meet the needs and demands of the population. However, the agency as proposed would have very specific responsibility in delivering healthcare in the longer term. That would then free up the Minister and the Department of Health to look at the overall strategic direction to be given to the NHS. It would allow information from NICE to be delivered to the NHS in a more planned way than is currently available. It would mean that the inspectorate systems proposed through the new CHAI and so on would inform the NHS agency, Parliament and the Minister. It would also mean that, if the agency did not deliver, it could be called to account immediately.

The NHS would not be part of a list of items on a ballot paper that influence how people vote, perhaps affected by foreign policy or whatever, as we do not have a separate referendum on how the NHS is to be run. The NHS agency would also be allowed to enter a long-term and consistent dialogue with clinicians and with those concerned about the strategic direction of clinical services, such as the royal colleges responsible for education, to make sure that the process has long-term, staged planning. Such an agency would allow the principles of subsidiarity to be adhered to, and would re-establish some concept of trust between the patient and the clinician, the clinician and the part of the service in which he or she works, and that part of the service and the greater whole within the concept of a national health service.

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It was with great pleasure that I added my name to the amendments. I have also read the report from the King's Fund and heard the people who have been involved in thinking the issues out. Those issues have been thought out to a careful degree.

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