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Lord Warner: I remind the noble Baroness that many carers and families would say that they are deeply involved in the healthcare of their children and relatives—just as much as parents are involved in the education of their children. I was not trying to make a direct parallel; I was trying to make the point that in other parts of our public services we have engaged people in their running and management.

As I said, we should carefully consider the points made by many who have taken part in the debate, who I acknowledge have a great deal of experience in this area. However, I am questioning—as was the noble Lord, Lord Peyton—whether the amendment is the way to address the problem.

Earl Howe: This been a very good debate and I am grateful to all those who have taken part in it. I also thank those who have seen merit in my amendment. I confess that, as I mentioned at the beginning, my intention was to use the amendment as a hook on

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which to hang a debate on the role of local democracy generally in the governance of hospitals. I have certainly succeeded in that aim, even though the views from around the Chamber have differed widely on the subject.

Once again, we look to the experience of the noble Lord, Lord Walton, who delivered a salutary lesson from history on how local democracy can upset and impede the effective governance of hospitals. I listened with great care to what the noble Lord, Lord Lipsey, said and agreed with almost all of it. I join other Members of the Committee in wishing him a speedy recovery and a swift return.

One of the noble Lord's points that I should like to pick up is that of voter apathy. There is much voter apathy: one has only to look at the vacancy rates on school governor boards to realise what an uphill task it is to get people interested in running schools. But the idea that, as the Minister said, a trust may lose its foundation status if it cannot drum up sufficient democratic support is quite extraordinary. That may well have nothing to do with how good or bad the hospital is itself. It seems very strange that the whole thing should hang on the enthusiasm of the voters. What matters is surely whether the hospital is good or bad.

Lord Warner: I am grateful to the noble Earl for giving way. I did not say that everything hinged on participation by local communities. There is a distinction between what the noble Earl claims I said and what I actually said. I said that one of the levers available to the regulator was a qualification or change in the authorisation if it was not satisfied that the body was representative of the community it served.

Earl Howe: I would be interested to know what sort of qualification or change the noble Lord is talking about. I thought that the regulator could take away the authorisation or leave it in place. It is not clear to me what kind of halfway house there is where the democratic base falls short of expectations. We may need to cover that territory as we debate the later parts of the Bill.

My noble friend Lady Hanham posited some not improbable situations that could easily lead to gridlock. I was not aware that the Minister answered those points, which seemed well made.

The noble Lord, Lord Hunt of Kings Heath, foreshadowed some of his later amendments on granting further powers to foundation hospital governors. That path is extremely dangerous and potentially disastrous, so I do not think that we will see eye to eye on it.

My noble friend Lord Peyton got to the heart of the question, as ever, when he asked me about the opportunity costs of the proposals in the amendment. He is quite right, as ever, that what matters is patient care and we must not be distracted from that. I will reflect on the noble Lord's concerns very carefully before Report stage.

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It would be helpful if the updated guide to governance arrangements could be circulated to all Members of the Committee who have taken part in the debate to enable us to see what thinking has emerged from the Department of Health on the crucial question of the model constitution. Once again, I thank all Members of the Committee. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The Deputy Chairman of Committees (The Countess of Mar): Before I call the next amendment, I must tell noble Lords that, if Amendment No. 11 is agreed to, I cannot call Amendments Nos. 12 to 22, as the pre-emption rule applies.

7.15 p.m.

Schedule 1 [Constitution of public benefit corporations]:

Baroness Barker moved Amendment No. 11:


    Page 108, line 12, leave out paragraph 3.

The noble Baroness said: I declare an interest in the whole Bill, as I am an employee of Age Concern England. That is my usual declaration, but, on this occasion, I shall go further. My role in Age Concern is to work with small local organisations and to provide them with advice. Germane to this discussion is that frequently I advise small local organisations on constitutional arrangements. It was therefore a great delight to read the governance arrangements proposed in the Bill, not least because they are so curious.

Before discussing the detail of this group of amendments, many of which are probing amendments, I wish to ask the Minister one key question that may enable us to see our way through many of the curiosities in the Bill. Why did the Government not take any of the existing forms of charity governed documents? There are a number of standard formats, such as a company limited by guarantee. Not only are there distinct formats, but they are also governed by charity and company law. There is an in-built framework covering many of the issues that have been raised and those that will be raised in subsequent amendments; for example, auditing and accounting. Why did the Government not pick one of those? Why cook up this very strange arrangement? That question has been burning in my mind.

The amendments hinge upon Amendment No. 40. The noble Lord, Lord Clement-Jones, whose name is also attached to the amendments, and I apologise, as we did not intend to delete paragraph 6. The amendments about the format of the board of governors and stakeholders will actually apply to proposed paragraph (8A). Members of the Committee may have experienced some misunderstanding, for which I apologise.

I intend to discuss many of the issues raised by Members of the Committee in the debate on Amendment No. 10, but I shall do so from a different standpoint. It has not been mentioned that one of the biggest fears of those who have considered foundation

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trusts as proposed is the consideration of acute provision in isolation, not just from primary care, but from the whole field of social care.

My amendments address the governance of a foundation trust within a whole system of health and social care. That is particularly clear if one considers the composition of the board of governors under Amendment No. 40. There should be a board of governors that is much more powerful than that proposed by the Government, and which involves different stakeholders—I am not keen on the word "stakeholder" but it is shorthand for an idea—such as representatives of employees, PCTs, local authorities and, crucially, representatives of patient bodies and the voluntary sector. Members of the Committee will understand why I am keen to include that.

The amendments also deal with limitations of periods of office. Deliberately they take out individual membership—for three reasons. First, although direct democracy has some merit, as outlined today, it comes at a huge cost. We estimate—perhaps the Minister will advise me whether it is correct—that the servicing of an individual membership is likely to cost a foundation trust upwards of a quarter of a million pounds per year. In that circumstance, it is reasonable to look at a more representative framework for involvement.

The second reason for our stance on individual membership has not been mentioned. Various Members of the Committee have talked about entryism. I was interested in that point, as I am always interested in the ideas put forward by the noble Lord, Lord Lipsey. But nobody has mentioned the provision of specialist and minority services. Recently, as part of my daily work, I had the experience of talking to a representative of a primary care team in the company of a number of people concerned about the provision of services for older people. With refreshing candour, he said, "What you must realise is that the profile of this borough includes a very high number of very wealthy, articulate parents of small children. They are the people who will be right at the top of the PCT agenda". The comment was disheartening on one level, but it was very refreshing to have that level of openness from someone in the NHS.

At Second Reading, I spoke about the disincentives to dealing with the problems of old age under a tariff system, as the noble Baroness, Lady Hanham, discussed earlier. My concern is that under a system of individual membership, as the noble Baroness, Lady Hanham, said, those without ready access to a pre-formed group or organisation to enable their needs to be articulated will lose out. That is one reason why we have talked about having not one representative for the voluntary sector—as in PCTs—but five, because there are different client groups.

Given the strength of the argument that the noble Earl, Lord Howe, made about the representative boards, he will not be terribly pleased with the set of amendments. However, I have one point for him and for the Minister: a whole industry is growing around consultation. There are people who spend most if not all of their time involved in organising consultation

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about health. The noble Lord, Lord Peyton, is no longer in his place, but if ever a review was needed, it is one that correlates the amount of time spent with output, because for all the level of consultation, very few people who are consulted about health matters, either locally or nationally, feel that that consultation brings about any change.

There is a good reason for that: the process of consultation is often at an operational level and rarely makes it to the strategic level. Precisely because we think that there is a need for a strategic overview of health at the heart of the foundation trust government, a comparatively big and representative body is a good idea. We also hope that it will replace many other similar bodies that are also working throughout the field of health and social care.

There is one reason why the model we are talking about has merit. As I have said before, the idea for foundation trusts was first mooted in the NHS Plan, which was the Government's response to the Wanless committee report. That report spoke at considerable length of the need to develop services of a preventive and rehabilitative nature. There is a great danger in the Bill's proposals that there will be not only a concentration but a unique focus on acute care. As the noble Lord, Lord Lipsey, knows, I believe that that is an expensive way of managing demand on our health services.

I am sure that the Minister will say that many of the amendments are flawed—they are preventive—but I believe that there is much to commend having a representative and strategic body at the heart of the government foundation hospitals. Having that would allay many of the fears expressed so far about the Government's proposal.


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