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Lord Clement-Jones: That just shows that the noble Lord was too busy studying his brief to notice the interventions that I made. If he listens very carefully, he will notice that my current intervention will be entirely of the devolutionary kind of which I am sure he will approve.

One might say that the rot set in with the merging of the roles of Permanent Secretary and NHS chief executive under Sir Alan Langlands. The report of the King's Fund, chaired by the noble Lord, Lord Haskins, claimed that the NHS had become far too politicised. But the term "political football", which was used by the noble Earl, Lord Howe, has been the allegation made consistently. Probably the first time that I heard it was over Keith Joseph's reforms of the NHS in the early 1970s. This is not a new phenomenon. The allocation of resources is often a highly political act.

That said, many of us object to the fact that the Secretary of State has a huge and inordinate amount of power in relation to the NHS. There is common ground on that issue between nearly all Members of the Committee who spoke in the debate. The Bill is meant to be devolutionary, but the powers granted to the Secretary of State are yet again increased. I would hate to think how many additional powers the Secretary of State is taking under the Bill.

There is a very good case for much looser political control over the NHS. But we believe in a much more radical form of devolution for the health service. That is the bone of contention with the current amendments. We believe in a much more devolved system. We believe in national standards, but we believe in regional strategic management of the NHS whereby, regionally, voters can increase the resources available for the NHS if they need or wish to do so.

We believe in locally accountable commissioning, closer to patient needs and tied into local government. That leads in turn to the integration between health and social care, to which the noble Lord, Lord Chan, referred. We believe in a mixed economy of providers, including mutual providers and public benefit organisations. We believe in an independent regulatory system of fewer but effective regulators. We believe in a genuinely plural system of devolution. That is where we differ from the terms of the amendment.

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The essence of any new devolved system must be greater public engagement in the commissioning process and in the prioritisation of public health, preventive health and the marriage of health and social care.

Lord Desai: I agree with much of what the noble Lord says, but is he not confusing depoliticisation and devolution? The amendments under debate refer to depoliticisation of the NHS. Devolution is a separate issue that comes later in the Bill.

Lord Clement-Jones: I am arguing the case for devolution, but, at the same time, it is impossible to devolve without political resource allocation. That is what the amendment is all about. We need to be persuaded that this will not be a monolithic organisation that is unresponsive to patient needs. That is the crux of the argument.

In conclusion, we agree very much with the diagnosis of the Members of the Committee who have spoken in the debate and the amendments tabled. But we do not agree with the prescription set out in the amendments.

Lord Warner: The new clauses would place the responsibility for the management of the NHS in England in the hands of a new agency set up for that purpose. Let me say at the outset that that is not what the NHS or the public need. I fear that I will disappoint the noble Baroness as much as did my noble friend Lord Hunt when he stood at the Dispatch Box previously, and as he did successfully earlier.

I sympathise entirely with the noble Baroness's wish to avoid excessive central interference in the running of the NHS. I am sure that we can all agree with that overall intention. But the primary purpose of the Bill is to do just that. I do not doubt the sincerity of the noble Baroness's view on the subject, and she has been consistent in her advocacy of the agency approach. The King's Fund continues to promote the idea, which I freely acknowledge has had appeal in many quarters over many years. Trying to interpret events in Blackpool yesterday, I believe that Dr Liam Fox now seems to want to go down that path, although I note that the Opposition Front Bench in this House seem to be more cautious on the subject.

The King's Fund report and the amendment are only the latest in a succession of so-called attempts—

Baroness Carnegy of Lour: I do not think that the Minister can quite get away with that remark. What makes him think that our Front Bench in this House differs from my right honourable friend Dr Fox?

Lord Warner: I did not hear the Front Bench spokesman say that he would support the amendment if a vote was taken on it. My understanding was that the noble Earl was rather more cautious on the matter.

Earl Howe: It may assist the Committee to know that the amendment does not correspond to what Dr Liam Fox announced in Blackpool yesterday.

Lord Warner: We are still trying to puzzle out what Dr Fox was suggesting in Blackpool yesterday. His

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comments sounded remarkably similar to many of the ideas advocated in the amendments tabled by the noble Baroness, Lady Cumberlege; hence my remark. I am grateful for the noble Earl's clarification. It will be very interesting to find out the Conservative Party policy on the issue as the Bill proceeds.

The King's Fund report and the amendment are only the latest so-called attempts to deal with the problem of the NHS being a political football. Many Members of the Committee have talked about the unreasonableness of British citizens approaching their politicians to have their grievances about the NHS addressed. They seem to suggest that putting in place a board would prevent that happening. There is no evidence whatever from the events of the past 50 years that people would not still expect elected politicians to address seriously problems raised by them.

The idea of an agency, board or commission—whatever we call it—has emerged under governments of different political persuasions and at different times. But the rationale for the idea has always been the same: to improve the quality of NHS management by removing it from nefarious political micromanagement. The noble Lord, Lord Alderdice, who has attached his name to the amendments, made that point not only today but at Second Reading.

The difficulty is that it is nothing like as easy as the noble Baroness has suggested to separate policy from management. Her right honourable friend Michael Howard demonstrated the problem in relation to the Prison Service in a previous administration.

The Guillebaud committee considered the idea in the mid-1950s and rejected it as flawed. The Royal Commission on the NHS considered the idea again in 1979 and rejected it. I shall give a short quotation from that report:


    "A commission might act as a buffer between the NHS and parliament but the NHS would remain dependent on the willingness of parliament to vote funds. The effect, therefore, might be to duplicate functions that at present are carried out, however unsatisfactorily, by the health departments and the top tier of health authorities".

Earl Russell: I am most grateful to the Minister for giving way. Does he understand that it is impossible to avoid the dangers of excessive centralisation while we have only one purchaser, and that that is the thought underlying the proposal for regionalisation?

Lord Warner: I understand the case, but I do not accept the argument put forward by the noble Earl's party that that is the only way of solving the problem.

In 1983, the late Sir Roy Griffiths, a staunch advocate of good NHS management, came to a similar conclusion to Guillebaud and the Merrison commission:


    "A case could be made for an independent corporation . . . this has a variety of defects, not least that one would have to formalise unnecessarily the role of the corporation vis-a-vis the Secretary of State, which would be extremely difficult in such an intensely politically sensitive operation".

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I look forward to hearing how the Conservative Front Bench will address that problem if they wish to pursue the argument. Sir Roy, respected across party lines and with a gift for the pithy, said it all. Although a public corporation has some superficial attractions, it has as many disadvantages as it has advantages. It would mean another reorganisation, which so many in this Committee seem to abhor.

First, and most important, is the issue of accountability. Those who advocate the removal of the NHS from the political arena have never fully satisfactorily explained how proper political accountability would be maintained in a publically acceptable way. As I said, the various expert committees and commissions over the years have all concluded that this is the crux of the matter. Until the advocates of a separate corporation deal satisfactorily with that point, we must treat with the utmost caution any proposals that might interfere with the ultimate route of accountability through Ministers for the NHS. I do not think that those who have spoken in favour of the amendment have done that today. Dr Fox yesterday showed his own confusion by trying, in the same speech, to argue for a contentious health vouchers policy that would undermine the NHS and then claiming that he wants a board to reduce political interference in the NHS.

There is another respect, however, in which these new clauses are defective and which goes right to the heart of what the Bill is about. There is absolutely no guarantee that removing the NHS from under the purview of ministerial control would remove the risk of over-centralisation. A body such as these new clauses would establish would be able, and in my view quite likely, to impose a centralised model of control over the whole system. That would be a return to the nationalised industry territory, which until yesterday, I thought had been vacated by all the political parties and is surely not something the noble Baroness, Lady Cumberlege, and her supporters would regard as desirable. It is certainly pretty difficult to square with Liam Fox's aspiration to reduce bureaucracy. It is the exact opposite of what the Government are trying to achieve through this Bill and their practical actions on a day-to-day basis.

A million-strong health service should not be run from Whitehall or any other central point. The NHS is not the Red Army. For patient choice to thrive, it needs a different environment in which there is greater diversity and plurality in local services which have the freedom to innovate and respond to patients' needs. Within a framework of clear national standards, subject to common independent inspection—provided for in the Bill—power needs to be devolved to locally run services. These amendments would not achieve that.

The Government have devolved day-to-day administration of the NHS to 28 strategic health authorities in England, similar to the regional approach argued for earlier by the noble Lord, Lord Clement-Jones. They oversee the work of local NHS trusts, PCTs and private providers. They have become the local headquarters of the NHS. Their chief executives account, both nationally and locally, for the performance of local health services.

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The real power and the huge additional resources that we have provided to the NHS are moving to the NHS frontline. Since April last year, locally-run primary care involving professionals and patients has been up and running in all parts of the country. The reports from Blackpool yesterday strongly suggest that that news has not yet reached Conservative Central Office.

We need to stick to the purpose of this Bill, which establishes NHS foundation trusts as a new type of NHS organisation that will provide local ownership and greater involvement of local communities in the NHS, alongside the huge injections of resources that the Government have made. This may be the first time that the NHS has been allowed to run with an adequate provision of resources. This Bill shifts power to the front line. The amendments would not do that or achieve many of the benefits wished for by their advocates. I recommend that the House does not accept the amendments.

4.45 p.m.

Baroness Cumberlege: I thank the Minister very much for his reply. I had hoped that he would have a warm feeling towards the amendments, but I suspect that it has been a cold shower. However, I would like to thank noble Lords for taking part in the debate. With one very notable exception and a few minor reservations there has been whole-hearted support for the amendments, for which I am very grateful.

The noble Lord, Lord Alderdice, and the noble Baroness, Lady Finlay of Llandaff, brought some additional strengths that enhanced the agency concept still further. It is extremely good to have the expert advice of the noble Lords, Lord Chan and Lord Walton of Detchant. Those who work or have worked in the health service really bring home the reality of what it is like and what this agency could do. I echo the tribute paid by my noble friend Lord Peyton of Yeovil to the noble Lord, Lord Walton of Detchant. I sense that he has had a modest conversion, for which I am extremely grateful.

My noble friend Lord Peyton of Yeovil asked about the role of the Secretary of State. If the agency were established, it would be most important for the Secretary of State to have confidence in the agency. As I said before, we have 192 different role models from which to build and which are succeeding. None would succeed, however, if the Secretary of State did not have confidence in them, so some accountability to the department, Ministers and, ultimately to the Secretary of State, is essential.

On the appointment of members to the agency, the chairman is appointed through the well-established independent appointments commission. Likewise, the appointments commission would appoint the non-executive members. However, when it comes to the appointment of the chief executive, the appointment is made by the chairman, but it is important that the Secretary of State has some say about whether he or she has confidence in that individual. Clearly, the agency would fail without that.

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The other mentions of the Secretary of State in my amendments also relate to accountability. However, I wish to stress that in no way do we have all the answers. It takes a long time to work through something as fundamental as this. I appreciate that the amendments are not perfect, as I said at the beginning of the debate. They need more work and I will not press them to a vote this afternoon. I am trying to build a case, over time, that I believe to be irrefutable. It took me 17 years to get neighbourhood nursing recommendations adopted by the government as a national scheme, and to get something as simple as nurse prescribing to happen within the National Health Service.

When we debated similar amendments 18 months ago, I warned your Lordships that I would bore for Britain, which is exactly what I intend to do. I believe that change will not happen overnight. The noble Lord, Lord Warner, is absolutely right that we cannot suddenly do something like this: it needs a lot of working through. That is why I am grateful to have an organisation such as the King's Fund which has considerable intelligence and brainpower in its team to work on the problem.

My noble friend Lady Carnegy of Lour asked about the Manpower Services Commission. Clearly, the agency would have the answer to such detailed questions. Whether the department could answer for the agency depends entirely on the rules of engagement. That is something that would need to be worked out. With regard to the National Health Service in Scotland, I do not know whether the King's Fund has approached the Scottish Parliament. I shall let my noble friend know.

I thank my noble friend Earl Howe for his welcome to the debate and for his careful analysis and wish to give the concept a further push forward. I also thank the noble Lord, Lord Clement-Jones. I agree with him that the rot set in when the role of chief executive merged with that of the Permanent Secretary. I welcome his endorsement of at least the thrust to devolution and to the amendments.

The Minister made a point about the Prison Service, which is an interesting parallel. He is right that in the mid-1990s, there was a considerable hiccup within the devolved Prison Service and we all remember the issue that followed in terms of the chief executive's position. However, the devolved Prison Service is still there. That framework still exists. It exists because there is clarity about who is responsible for what. We are getting better at working with non-departmental government bodies because we are beginning to clarify which role is whose and where the responsibilities lie.

The National Health Service is a candidate for that approach. It is wrong that politicians should be involved in the day-to-day running of the service. Politicians have a serious role, but it is not a role in micro-management or in "targetitis", however enjoyable it might be for past Ministers who have taken part. The role of politicians is strategic; it relates to the sense of direction, and they should not be distracted from that. Our present system does not

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allow that to happen, and the National Health Service is in serious danger when we come to elections. Only one issue need blow up, and, suddenly, there are different strategies and different policies. Politicians shoot from the hip, and nobody has worked it through because we have aggressive media that prompt such things to happen.


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