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Lord Ennals: My Lords, having invited me back into the Chamber, I hope that the noble Lord will not mind if I ask a question. When he was Secretary of State, did he not feel that the organisation of the NHS was suffering, not from having a regional structure, but from having far too many district and area structures? Did he not find at that time that the planning role of the regional authorities was essential? If he did not feel that, why did he allow it to go on?
Lord Jenkin of Roding: My Lords, because the service was top-down. The noble Lord is right. I inherited far too many layers. The Bills that I introduced got rid of three layers of administration within the NHS. I take his point on that, but in a top-down service one needs all this detailed planning at regional level. But once the decision-making is devolved to purchasers, the commissionersthe health authorities as they will be under the Billand the delivery of service to the providers, then a great deal of that top hamper becomesif I may put it this waysupererogatory. It does not need to exist. There are some functionsthe noble Lord, Lord Walton of Detchant, correctly pinpointed a numberin which there will have to be continuing involvement at the region. I have been provided by the department with a list of the services that will become part of the regional outposts of the management executive. Many of the subjects upon which he touched are on that list. I have no doubt that my noble friend will expand on that point when she replies.
Because one has maximum devolution right down to health authorities, to GP fundholders and to trusts, that has the effect also of making the service a great deal more responsive to the needs of the customersto the patients and to those who represent them.
It so happens that this morning I had a good example of that in my trust. I was due to pay a visit to the special care baby unit at Whipps Cross Hospital. Many noble Lords will be familiar with the astonishing work that such units can do in saving lives and the health of very premature babiesbabies born seriously underweight; babies born with other problems (the mothers may have been drug addicts); and babies born with serious immediate problems, infections and so on. I saw some of those mites lying in their incubators. I was absolutely astonished that they should be alive at all.
When I was discussing that unit's future with the clinical directora very distinguished paediatricianand the care group manager, what did we talk about? We talked about the negotiations that they are currently
That example is repeated in many other parts of the trust. The purchaser/provider system makes the providers look outwards to the community that they serve rather than upwards to some shadowy regional authority. It is bringing direct improvements in the quality of careand quality is what it is all about.
Contrary to the view put forward by the noble Baroness, Lady Jay, reforms are alive and well in north east London. I do not say for one moment that life is easy for everyone; our nurses are extremely hard worked, not least during flu epidemics and other emergency admissions. Whipps Cross is a busy, hard-pressed hospital and is delivering high-quality care to those in the surrounding area.
Everyone is in favour of the merger of DHAs and the family health service authorities to form the new health authorities. However, I too do not believe that it should be another "Suetonius" event. I did not use that word but called it the shaking of the kaleidoscope: when one shakes it and then looks down the tube the colours are the same but the pattern is slightly different. The merger should be a major stride towards the more direct involvement of general practitioners in the purchasing and commissioning of secondary care from their providers. The health authorities should increasingly become strategic authorities, with a firm co-ordinating role. They should be small strategic bodies, leaving most of the decision-making as regards the contracts to the general practitioners.
That does not mean that they must all be fund holders. They may well be, but again there is an interesting example in my area. A group of 25 GP practices north of my area but south of the M.25 got together and concluded that they wished to put most of their secondary care to the Forest Healthcare Trust. They were not fund holders and did not have direct control of the funds. However, they approached the North Essex Health Authority and asked that the contracts should be drawn up enabling them to express that preference on behalf of their patients.
Everyone talks about that and it is beginning to happen. However, one of the difficulties is the fact that GPs are worried that they will not be able to cope with the extra responsibility. One must askhow can one enable GPs who have never previously done this to take on an extended role? Some of the best GPs and the most lively practices are able to take it in their stride, but many are not. I see this as a real duty which rests on the new health authorities. They will include the old FHSA, which has had the responsibility for GPs, and they should take on the tasklead GPs and guide them and help them to make their purchasing decisions more effective.
I turn now to GP supply. One is told that in London in particularand it may be the case in other parts of the countrythere is a shortage of young doctors who wish to become general practitioners. If it is seen that the health service is increasingly becoming a GP-led service, young men and women coming out of medical training will see the service as a more effective way of being able to carry out their professional duties on behalf of their patients than pursuing an ever-more recondite specialty in a hospital setting. The GP supply needs to be addressed and I hope that my noble friend will comment on that.
As regards medical education, no one has mentioned Calman. As regards those of us who employ large numbers of consultants and doctors in training, the Calman reforms in medical education are yet another area of considerable change in upheaval. I believe that the reforms in the Bill have not fully meshed with those that are being promoted through the Calman Report. I wish to be reassured about that.
Perhaps I may reinforce the point made by the noble Lord, Lord Walton of Detchant, about the place of universities and medical schools in the new structure. I too was delighted that in another place the Government agreed to add university representatives to the new health authorities. I was one of those who in 1990 argued that they should have a position on relevant trusts and that was accepted. I believe that there should be a more formal link than oral representations, or whatever, between the universities and the new regional bodies. I too have received communications from the Committee of Vice-Chancellors and Principals. I shall not bore the House by quoting from them but the committee makes a case that needs to be listened to.
If the Calman reforms are bringing about substantial changes in the pattern of medical education, if this Bill is bringing about valuable changes in the structure of the delivery of health care, somehow there must be a better linking between those two processes. Some form of clear university representation at the regional level is most important.
I warmly welcome the Bill and I believe that it will be to the benefit of patients. It will achieve all the five things that the noble Baroness, Lady Jay, suggested that reforms should achieve. I differ from her in almost all
Lord Monkswell: My Lords, I am in illustrious company. My only qualifications to speak on this subject are that I am the son of a GP, who unfortunately has not practised for some years, and as a user of the National Health Service. For some years I was a member of the Stockport Community Health Council and later of the Manchester Family Practitioner Committee. Following reorganisation I received a letter informing me that my services were no longer required. I suspect that that was partly due to the fact that I was seen to be an active member of the Labour Party and not a Conservative supporter, but I may be wrong. I am also an engineer. I seek to assess the latest reorganisation of the health service on the basis of the practical effects.
I was pleased to hear the noble Lord, Lord Jenkin of Roding, explain the problems of GP practices endeavouring to send their patients to a particular hospital. That clearly demonstrates what has changed in the National Health Service under this Conservative Government. It is similar to what has happened with the privatisation of the public services about which we have heard. I take the example of the electricity industry. Before it was privatised, we were all shareholders. Fifty million people were equal shareholders in the nationalised electricity industry. I heard recently that there are now 3 million shareholders of the privatised electricity utilities. We have gone from a situation in which there was openness and freedom in which 50 million people were involved to a situation in which fewer than 3 million people are involved.
Before this Conservative Government came to power, GPs could refer their patients to any hospital and any consultant throughout the land. They had access to literally thousands of consultants and hundreds of hospitals. Now they are restricted to a particular hospital with which their group, within the National Health Service, has a contract. They can send patients only to those hospitals with which contracts exist. They are denied the facilities to send their patients to the consultants and hospitals of their choice. That is very stark; I am glad that the noble Lord, Lord Jenkin of Roding, mentioned it.
The noble Baroness, Lady Cumberlege, said that the purpose of the Bill is to remove an unnecessary tier of administration. She added that there would still be regional offices. If there are still to be regional officesI shall say more about that in a few momentswe are not doing away with a tier at all. We are changing the system. In practice, we are hiding away that tier from the public eye. That is not very sensible in a democracy.
Why does that regional tier exist? Let us compare the National Health Service with the national education service. The national education service provides schooling for all children in the country between the ages of five and 16. That provision is made under the aegis of local education authorities. Over the years the revenue support grant has been established through
The Government's objective may be to use a formula funding mechanism to ensure that there is a sensible distribution of resources at local level. But that is not yet in place. In practice, decisions will have to be made at regional level to determine where the resources go within that region. I am concerned that the distribution of resources will take place behind closed doors, administered, effectively, by a commissarI repeat, a commissaron a clear Stalinist model. That is not the right way to distribute resources which are so important to the people of this country.
We all recognise the importance and the positive gains which will flow from merging district health authorities and the FHSAs. But I enter two caveats. First, it is extremely important to ensure that at that level we maintain a voice for the professions involved in the provision of primary servicesin particular, general practitioners, opticians, dentists, pharmacists and, of supreme importance, midwives. It is extremely important that those five professions are plugged in effectively to the district level. From the introduction which the noble Baroness gave, it does not seem that their voices will be heard sufficiently.
Secondly, there was no mention of the growing integration and inter-relationship between the National Health Service at local level and the social services provided by local authorities. We must recognise that essential integration. This Government started the process by absolving themselves of any responsibility in relation to community care. They laid that enormous burden of responsibility on local authorities and, in particular, their social services departments. We must recognise the importance of the integration at district level of the National Health Service and social services departments and make those operations coterminous. The new district health authorities covering the primary care sector need to be coterminous with local authority social services departments. Unless that is so, we shall lose the opportunity to ensure that the integration of service delivery goes ahead much better than it is doing at present because of the separation of those two areas of responsibility.
I suspect that we shall not be able to make many changes to the Bill. I am sure that noble Lords on all sides of the House will fight for what they see as improvements but I suspect that the Government have made up their mind. On the advice of the deputy chairman of the Conservative Party, John Maples, they are trying to take the National Health Service off the agenda by getting rid of regional health authorities and replacing them with commissars who operate behind closed doors. Notwithstanding the Official Secrets Act,
Lord Dainton: My Lords, I too congratulate the Minister on her clear explanation of the Bill. Indeed, there is much which will be welcomed in the Bill but the Minister will not be surprised to know that I wish to draw attention to three practical matters arising from it which, unless they are properly attended to, may handicap it seriously; namely, the education of medical and dental students in both their undergraduate and postgraduate phases and basic medical research.
Unlike the noble Lord, Lord Walton, with whose comments I largely agree, I am not a medical doctor but for many decades, I have been involved with medical education and research in a variety of senior capacities. It seems to me that the Department of Health, and indeed all its precursor bodies, have constantly to be reminded of a fundamental fact which applies whatever the organisation that is set up. To make my point, I wish to quote what I said nearly five years ago in the Second Reading debate on the National Health Service and Community Care Bill. On that occasion I said,
I further argued on that occasion that, as with all previous Bills from 1974 onwards, a principle had been conceded; namely, that for training, research and patient care to be truly effective and properly interdigitated, one with another, it was essential that the university which had responsibility for that education and research, and which for that purpose ownedand indeed still ownsaccommodation in hospitals, should have a say in the deliberations of the policy and governing bodies of such hospitals, which in those days were of course, as has been mentioned, the district health authorities (teaching) and the regional health authorities.
Five years ago the National Health Service and Community Care Bill incorporated this principle for the newly introduced trusts which the Bill proposed to introduce in place of the district health authorities. But totally inconsistently on that occasion the Bill rejected the same principle for the DHAs (teaching) by withdrawing the right of membership by universities in the governance of those district health authorities (teaching) which for many years had at least one university member. Fortunately, in response to pressure in this House, the then Secretary of State, Mr. Kenneth Clarke, saw the damaging illogicality of this situation and its unworkability and he agreed to amend the Bill
The Bill before us today proposes new health authorities to replace the existing district health authorities and family health services authorities. I think most of us applaud that. As originally drafted, the Bill contained the same error as five years ago; that is to say, no university member was to be on the new health authorities. But, fortunately, as has already been mentioned, that error was spotted last December in another place and in response the Secretary of State saidI was delighted to hear the Minister confirm it todaythat she will introduce a requirement for universities with a medical or dental school to have membership of a new health authority, and that that will be put in the regulations. Why it cannot be put into the Bill I cannot imagine.
Naturally the universities welcome the possibility of restoration of membership by whatever means, which in my view, as I have mentioned, should always be statutory. However, given that it is to be prescribed in regulations, it obviously makes sense if the universities can be satisfied that the whole of that part of the new arrangements which are to be incorporated in the regulations will be practical and workable, and to that end they have sought prior consultation on those regulations before they are drafted. That has been refused. May I ask the Government to think again? The Government, the health service and its patients now and in the future have everything to gain and nothing to lose by that kind of consultation which, in my view, is bound to result in better regulations.
The problems of the university/health service interface do not end there because, as the Minister reminded us, under this Bill it is proposed that the regional health authorities in England and Wales will be replaced by regional offices of the National Health Service Executive. As the Bill now stands there will be no provision for the relevant universities to be involved as of right in the deliberations of the executive in the decision-making process. All that is proposed in the Bill is that the regional director be remindedI emphasise thatthat universities are taken account of in appropriate circumstances. That is hardly the approach to ensure that universities have a real say in the decision making. Instead of a mere reminder to the regional directors, in my view they should receive an instruction to consult the universities.
Another important and cognate matter concerns the postgraduate deans, to which brief reference has been made, who are responsible for postgraduate medical and dental education and for academic standards. Hitherto, they have been employed either by the universities alone or sometimes jointly by the universities and the NHS. It is vitally important that that link with the universities be not lost and that the universities retain responsibility for the postgraduate deans, at least for the academic part of their work including, especially, immediate postgraduate pre-registration house officer training.
If the postgraduate deans are responsible solely to the regional directorswhich appears to be a possibility under the BillI am sure those regional directors will see their major responsibility merely to satisfy the needs of patient care today. If that is the case, the training of doctors for future service in the NHS and elsewhere will inevitably suffer as will, of course, the prospects of medical care in the NHS of the future because that quality of teaching and research in the future is critically dependent on the preparation of doctors. I shall omit references to research and development which I had intended to make in view of the passage of time, and simply say that I support all that the noble Lord, Lord Walton, said on those matters.
Baroness Cox: My Lords, this is the first major legislation relating to health care since the National Health Service and Community Care Act 1990. As my noble friend the Minister outlined so clearly, it contains a relatively small number of provisions but they have far-reaching implications.
Noble Lords have spoken about many of the key issues. I shall therefore confine myself to those which reflect my own interest as a vice-president of the Royal College of Nursing. I wish first, however, to welcome the proposed merger of district health authorities and family health services authorities. This sensible streamlining can only improve the commissioning of primary and secondary care services. The integration of the two types of authorities is already taking place in some areas with the appointment of a single chief executive. The Bill will enable the policy to develop consistently across the country.
The merger of DHAs and FHSAs has been warmly welcomed by a wide range of organisations. For example, in its evidence to the review of community nursing undertaken in 1985 by my noble friend Lady Cumberlege, the Royal College of Nursing called for the merger of DHAs and FHSAs, known previously as family practitioner committees, and for the creation of primary health care authorities. With two authorities working separately it was inevitable that some people with health and/or social needs would fall through the safety net of care. Greater integration of hospital, community and primary care services will help to provide a seamless web of services for patients, clients and carers. Therefore this proposed merger is, we believe, warmly to be welcomed. Moreover, by combining the expertise of both acute and community care services, the provisions of the Bill will strengthen the new health authorities' ability to commission appropriate services for their own local populations.
So far so good. And mention of the word "expertise" leads me to the main issue on which I wish to focus. The membership of the new health authority boards will be crucial. It is therefore of the utmost importance that the right decisions are made now about the membership as it is board members who will to a large extent determine whether patients receive good quality health services, appropriate to the local population and sensitive to individual needs.
As my noble friend the Minster said, there will be three executive board members prescribed in regulations: the chief executive, the director of finance and the director of public health. It has also been noted and welcomed that a non-executive director will be appointed from a university medical or dental school where one exists.
While appreciating the proposed membership as far as it goes, I do not believe that it ensures sufficient professional expertise on key aspects of policy in the health service. I urge serious and sympathetic consideration of what I believe is an overwhelmingly powerful case for the executive membership to include nursing expertise. I know that the Government are familiar with the arguments and, indeed, agree that nurses have a crucial contribution to make to the purchasing team. Last summer the Department of Health published a report called Building a Stronger Team in which it praised the role of nurses in purchasing. Only last week my honourable friend the Minister of State for Health in another place told a King's Fund conference:
Qualified nurses are the largest professional group in the NHS, constituting approximately 50 per cent. of the NHS workforce. Nurses also account for 40 per cent. of current expenditure in the NHS and 3 per cent. of total public expenditure in Britain as a nation. Thus, if purchasing bodies are to be cost effective they must ensure optimum use of nursing resources. Clearly, nurses themselves are the most appropriate source of knowledge to advise on professional issues such as staffing and skill mix.
I do not advocate the representation of nursing expertise on boards as a way of promoting nursing's interests in any sectional or partisan way. I do so because nursing expertise is needed for effective purchasing. Assessment of clients' needs and an understanding of the costs of providing care, participation in clinical audit, and monitoring standards of care are all part of nurses' everyday responsibilities. Nurses' expertise spans all clinical areas and their contact with patients is continuous rather than episodic. No other profession is better placed than nursing to give informed, detailed advice on services needed by patients, families and carers.
Organisations representing patients emphasise the important part that nurses play in the purchasing process. For example, the director of the Alzheimer's Disease Society, Mr. Harry Cayton, wrote to the general secretary of the Royal College of Nursing claiming:
Therefore, there seems little dispute that nurses have the knowledge and skills to make an essential contribution to the purchasing authorities. However, opinions differ on the mechanism through which their contribution can
A survey by the Royal College of Nursing in January this year found that only about one half of existing DHAs and FHSAs have nurses in executive positions and that even fewer intend that to happen under the new arrangements. There is already evidence of nurses in executive board positions losing their jobs as authorities merge in preparation for April 1996.
There is a related issue on which I would welcome reassurance from the Minister. Last month the Government published guidance on good practice on appointments to NHS trusts and health authorities. Many of the suggestions are to be welcomed as they will indeed improve appointment procedures. However, I have one anxiety relating to the disqualification criteria at the very end of the document, identifying those who will be ineligible for appointment as non-executive directors of trusts and health authorities. For example:
That disqualification would appear to exclude many nurses and other health professionals working in the NHS from serving as non-executive directors on the new health authorities. Most of those who are eligible will be working outside the NHS, for example in occupational health services, prisons, universities or the Armed Forces. I appreciate their professional services, but the exclusion of those working in the NHS, as it appears from the wording of the document, means the exclusion of those with particular experience and expertise within the NHS which makes them such strong candidates for full involvement in all stages of decision-making, essential to the remit of the authority. I shall be grateful if the Minister can clarify that point, not only as it relates to nursing but also as it relates to other professionals. If so many well qualified nurses are to be disqualified from membership and if there is no statutory requirement for nurses to be executive members, the Government's hope that many nurses will become board members is not likely to be realised.
I believe that it would be very serious if purchasing boards were to become an exclusion zone for nurses. Ultimately, it would be the patients and their families who suffered from the lack of nursing input on the boards. I shall be very grateful if my noble friend will consider some statutory provision for the inclusion of nursing experience on the boards.
I understand and welcome the amendment, to which the Minister referred, already incorporated into the Bill, requiring health authorities to seek advice from professional practitioners, including doctors, nurses and
Finally, I shall be grateful if my noble friend will clarify the implications for nurse education. With the abolition of the RHAs, responsibility for commissioning nurse education will fall to local purchasers and providers who will presumably base their decisions on local needs, as the noble Baroness, Lady Robson of Kiddington, highlighted. I therefore share the anxiety, also expressed by the Royal College of Nursing, that such local decisions may not ensure adequate provision of the range of nursing specialties needed for national requirements or for long-term strategic planning for nursing services both within and outside the National Health Service.
There are signs that the need for nurses in the future has been under-estimated, as shortages are already evident around the country. Moreover, there were cuts of 33 per cent. in the number of student nurse places between 1987 and 1994. Trusts are increasingly looking to agency and bank nurses to fill the gaps. However good those individual agency and bank nurses may be, they cannot provide the continuity of patient care and thus the quality of relationships with patients and families which lie at the heart of good nursing. Furthermore, the Royal College of Nursing has received reports that even agency nurses are in short supply, for example in London, Manchester and Bristol.
Those shortages are serious, and must be taken seriously, if present problems are to be alleviated and a crisis is to be averted. I would warmly welcome assurances from the Minister that steps will be taken to ensure the involvement of nurses in the key decision-making bodies of the future NHS and that the new arrangements will ensure that education and employment of appropriate numbers of nurses overall, and of specialists in clinical areas, will be provided to enable the provision of health care for all people in the years ahead.
I emphasise that, although I speak as a nurse, I do not seek to promote the interests of nursing as such, as I have already said. My overriding concern is to seek to take the opportunities afforded by this valuable Bill to maximise the efficiency and effectiveness of the new authorities in providing the highest possible standard of care in the most cost-effective way and in ways which are most finely tuned to present and changing health needs, individually and nationally.
I welcome the Bill. I hope that my noble friend will be able to give assurance on the issues I have raised because I believe that they are essential if the Bill is to achieve its very worthy objectives.
Lord Desai: My Lords, perhaps I may begin by saying that I have an engagement later this evening. Given the rate at which the debate is proceeding, it may not be possible for me to stay until the end, for which I apologise.
Let me say, first, a word or two in defence of dinosaurs. In introducing the Bill, the noble Baroness said something about the NHS in the old days being like a flat-footed dinosaur. Dinosaurs lasted 2 million or more years. Human civilisation will be lucky to last that long. Dinosaurs did not die out because they were inefficient; they just had a nasty shock. Therefore let us not hear anything against dinosaurs; they are good. I wish that humans were that good.
If my memory serves me correctly, in the late 1960s and early 1970s, by and large, people were not dissatisfied with the National Health Service. Indeed, everyone was proud of it. Then when the late lamented Lord Joseph was in charge of health it was thought that the health service should be reformed, and that reform would bring progress and all kinds of other good things. Therefore the service was reorganised. We have had reorganisations ever since, and every reorganisation has promised progress. But if one asks the people in the streets, they are more dissatisfied with the National Health Service than they ever have been. The noble Baroness will tell us how much more money is being spent, how many more patients are being treated, and so on. However, at ground level the dissatisfaction with the National Health Service is much greater than previously; and that cannot be denied.
I have my doubts whether this reformit is the fourth or fifth in about 20 yearswill perform miracles. As my noble friend Lady Jay said, reform by reorganising is a non-solution to a problem. We are not so much abolishing regional health authorities as transforming their nature and making them rather more subservient than at present. The only other reform has been welcomed by this side of the Chamber; and I have nothing further to say on that.
It is often argued that removing one tier such as the RHA decentralises and gives more power below. I believe that exactly the opposite occurs: the more one abolishes middle tiers, the more power is concentrated in the centre because one sets up weaker and weaker authorities on the ground which do not have the power or resources to stand up and challenge the central authority. We have seen that occur regarding education. We now see it happening within the health service. I do not believe that decentralisation always leads to giving power to the people.
Let me give an extreme example. Someone might say that Parliament is an intermediate level of authority between the ruler and the people. Therefore let us get rid of Parliament and local authorities; let us give power to the people themselves. What would happen? The people would not gain much power. One needs bodies at certain levels to concentrate power and authority. Without them one only makes the centre more powerful.
In its report on priority setting, the health committee in another place made a number of good suggestions about why some of the priority settings and analyses of health care need to be comparative across regions, age groups, classes and so on. Who will undertake such analyses? If we do not have regional health authorities, that would be undertaken by some specialist group, but without proper feeling for the opinions of the people.
Some noble Lords may have read in this morning's newspapers about the King's Fundon whose sober authority there was reliance about a reorganisation of hospital care in London. The Tomlinson Report followed. At that time we all considered that the King's Fund had some expertise. Now that body has changed its mind and tells us that it was all a ghastly mistake and should perhaps be stopped. Throughout the Tomlinson reform the ordinary people had a suspicion all along that London needed not fewer hospital beds but more. Perhaps there should have been better ways of consulting the patients and users of the National Health Service. I am sure that there are methods of consultation. But the methods used have failed to spot the problem which the people saw and the experts did not.
I am not sure whether the removal of one tier and bits of reorganisation address the problem that we face: that the people's confidence in the National Health Service has been and is being eroded. That is happening despite more money being spent. In that case, we should be doubly worried. If that loss of confidence occurred when money was not being spent, one could understand it; but it is occurring despite more money being spent. We ought to consider how to improve the situation. Short as the Bill is, I see very little which addresses the problem.
The noble Baroness said that the provisions would save money. I have heard that said before and I have never found it to be true. That was promised when the National Health Service was reorganised in the 1970s. When local government was reorganised in the 1970s, it was promised. Every time some service is reorganised, that is what is promised. But all that happens is that another tier of professionals is hired. No one ever goes away; more and more people come in. If I were a betting man I should place a betI am not sure that one is allowed to take bets in your Lordships' Housethat five years on we will find that not a penny has been saved and the whole package may have cost about £500 million, give or take £100 million.
I do not believe that the Bill, short as it is, will improve the National Health Service very much. At a later stage I hope that we shall be able to consider more constructively how we can restore the people's faith in the National Health Service. As the noble Lord, Lord Walton, said, the National Health Service is one of the most efficient services around. All that we are doing is to make it less efficient and less popular. I wish that we could do better.
Baroness Gardner of Parkes: My Lords, unfortunately I too must leave before seven as I had earlier accepted an invitation to a pharmaceutical dinner tonight and I must go. I apologise. I become cross when I hear other people saying exactly that to the House, but it is difficult when one is asked to accept an invitation well in advance and then one finds at the last moment that it clashes with a debate.
It is complex because the changes require a huge number of consequential amendments to a large variety of Acts. That will make the Act a nuisance in terms of the legalities of using the law when the Bill is enacted. I am sure that other Members of your Lordships' House will appreciate the need after this for a consolidation Act sooner rather than later.
From 1990 to 1994 I was vice-chairman of the North-East Thames Regional Health Authority. After years of involvement in the NHS administration and general dental practice, I found it most interesting to be working at the strategic level. Among other responsibilities, we were closely involved with the formation of the new NHS trusts. I welcomed those, as it seemed to me to be returning the control of the health services to those most closely concerned with direct patient care.
Earlier, I had served on an area health authority for all the time that such authorities existed. We sat in an office, remote from all hospitals, determining how the hospitals should be run. At the same time, I was a member of the retained board of governors of the Brompton and National Heart Hospital, where meetings were held on the premises and governors really knew the particular needs of patients, staff and even the building. The area health authorities were abolished, as noble Lords know, and that brought management closer to the point of delivery of services to patients, with just the region and districts. NHS hospital trusts are, I believe, run in ways more or less the same as the hospitals were run years ago and I am convinced that that has benefited patients. The RHAs have largely done their job now and I think that it is good to remove that extra layer and again to bring control back closer to people. Now, combining the district health authorities and the family health service authorities will again bring control to a more local level.
Much has been said about how little say patients have and I agree with the noble Baroness, Lady Robson, that it is important that community health councils should not be reduced to only one per new authority. I echo that. I am now chairman of the Royal Free Hampstead NHS Trust on which we have a great deal of consultation and time spent with the Hampstead Community Health Council, and now the Barnet Community Health Council, as those are largely the two areas that we cover. A separate Islington Community Health Council covers the other area, with the University College Trust. They would find it tedious to have to come to the many meetings we hold, just as the Hampstead people would find it tedious going to the other meetings. If we want good local consultation, we must keep it at a sufficiently local level.
There has been much comment during the debate on NHS appointments. My vice-chairman is a lifelong Labour supporter, a real stalwart and also a tremendous asset to me, with his local knowledge and awareness of the history of all that has gone on in Hampstead for many years. I have no idea of the politics of my other members; I do not care about that. The members are
The Royal College of Nursing sent me a statement which I found interesting. I emphasise the point made by my noble friend Lady Cox that there is grave anxiety about whether we will have enough nurses. We are already finding a shortage of agency nurses and I have doubts about the Project 2000 scheme for nurses. We are losing the identity and association that nurses used to have with the training hospital where they learnt their nursing skills. I appreciate that educationally it is considered better, but the scheme is changing the nursing scene, taking nurses away from the hospital, giving them an education with a different flavour. There will not be the same allegiance to hospitals as there was in the past. However, my anxiety in this debate is not how nurses are trained; it is to ask the Government to ensure that we have enough, under whatever body controls the system.
The National Consumer Council wrote to me suggesting that a rather complicated and cumbersome process of consultation should be brought in. I thought it was quite impractical. The council suggested that the new commissioning authority should advertise what form of consultation it intended to introduce as a start and then it would be able to work out the consultation. By the time one has consulted to see what kind of consultation might be introduced, and then reconsulted people, the whole issue has gone so far that the system is quite hopeless and we hope that it will not be brought in.
There should be good liaison with the community health councils. Years ago, I would have spoken and probably did speak against community health councils. When they were first introduced in the days of the area health authorities, I thought that they were nothing but obstructive. If the area health authority took two hours for a meeting, the community health council took four to six hours for the equivalent meeting. I was then chairman of social services and health in the Westminster City Council. We advertised and interviewed people so that we were far ahead, but to find people to represent the local authority was extremely difficult. My husband was appointed and served for four years, at the end of which I suggested he might like to be reappointed. He said: "Never! I couldn't possibly stand any more of it". The process was hopelessly cumbersome and time consuming.
Since then I have seen a gradual change in community health councils. Their attitude and interest in what they are doing, their understanding of medical and hospital problems and even the commissioning problems have changed to the extent that the councils are an active partner within the health service. If I had been asked 10 or 12 years ago I would never have thought that I would stand here and say that, but I believe that they now have a great role to play and will continue to play it.
I end by echoing some of the points brought out by the noble Lord, Lord Desai. The man in the street is probably dissatisfied with the health service. After my 40 years in it, I consider that I am accurate in assessing the reason. It is partly because treatments have progressed unbelievably. Forty years ago, if you had a bad heart you were given bed rest, and that was all there was. Now the list of treatments available is enormous and expectations have increased tremendously, as well as awareness of what is available.
Another more worrying point is that there is an awareness of what one is entitled to. We have seen much on television about malpractice suits and years ago as a dentist in this country you could almost cut the patient's head off, but if he had faith in you he would not mind. As time went on, patients reached the point where they questioned everything one did. Recently a professor explained that dentists might be carrying out unnecessary fillings. From that day on, I hardly did a single filling without the patient questioning whether it was needed. So we have created a whole different atmosphere for patients. That is one of the disadvantages.
We have to realise that we shall never be able to satisfy the expectations that people have. We just have to do our best to see that the patients really do receive treatment to the highest standard and with the greatest care that we can possibly give.
Baroness McFarlane of Llandaff: My Lords, like many Members of this House, I thoroughly support the merging of the district health authorities and the family health services authorities. I listened carefully to the persuasive arguments of the noble Baroness the Minister about the disbanding of the regional authorities. I was almost persuadedalmost. But I need some convincing and I want to be assured that, for what seems a very small saving when you look at the total cost of the National Health Service, we have systems in place that will undertake the very important services which we have heard today that regional health authorities undertake.
I want to focus my remarks on two issues. I feel some embarrassment, because they are the two issues about which the noble Baroness, Lady Cox, has already spoken. Therefore, I shall not detain the House and repeat all that she said. We have not been in collusion, but it is evidence that we feel deeply about the same issues. I speak as one who spent almost 30 years in nursing education and then, for a short while after the 1990 Act, served as a member of a district health authority and was chairman of its complaints committee.
So far as nursing education and training are concerned, it is that experience that I want to share with the House. My memory goes back long, long before the "flat-footed monolith" about which the noble Baroness the Minister spoke, to the days when district hospitals recruited individuallyand under-recruited for their needs. The national need for nursing staff was met only because teaching hospitals over-recruited. I have a great fear that we may quickly find ourselves in that position again.
The Minister and the noble Baroness, Lady Cox, described how the regional authorities have responsibility at the moment for determining the demands of employers for nurses and for purchasing education and training places. Under the provisions of the Bill, that strategic planning function is to be devolved. It is to be taken on by the local consortia of health authorities and trusts, which will make an estimate of their local needs. The plans will be monitored by the new regional offices.
I have a deep concern that there is no intention to continue with a national overview for nursing manpower needs. Without such an overview, it will be impossible to detect and prevent impending shortages. That situation may very quickly be upon us. Both the noble Baronesses, Lady Cox and Lady Gardner of Parkes, mentioned the cuts in training places; and I am told that a further cutback of 55 per cent. over the years between 1993 and 1997 is envisaged.
The inevitable conclusion is that there will be many fewer trained nurses and that the skill mix, both in the community and in hospital, will be diluted to the point where the quality of patient care will suffer. I do not wish to advocate the misuse of highly trained nurses and expensive staff. But I wish to point to the evidence that says that patient outcomes and patient turnover is vastly improved where registered nurses are employed. I believe that that points to a need for a national overview.
Increasingly, as the noble Baroness, Lady Cox, said, nurses are being employed on a casual basison short-term contracts or as agency or bank nurses, in the interests of cost saving. The implication is that we have a highly mobile and volatile nursing workforce. The implications of that for the quality of care can only be imagined. The ethos of the institution in which one works, or even of a ward and its working procedures, can take time to absorb, and the continuity of care which individual patients need is lost.
At the same time, there are numerous commendable government initiatives in Health of the Nation targets and in care in the community for frail and disabled people which demand more, rather than fewer, skilled nurses. Furthermore, it is difficult for any local determination of manpower needs to take into account the training demands of small, highly specialised groups such as paediatric intensive care nurses. We have heard that indications are that the service is already under strain. That strain will be exacerbated by wholly devolving manpower planning to a local level.
My years in nursing education have made me aware that, for courses to be economically viable, a critical mass of students and suitably qualified staff is needed. If the future demand for students is underestimated and
My second point is related to the membership of the new health authority boards. Again I reiterate that I am not making the point for the representation of sectional interests. We have already heard that five particular professions were named. The basis of trying to be representative in the membership of health boards is just not feasible. However, I am making a case for the necessary expertise and knowledge in the planning of the nursing manpower needs that the health authority will have to undertake.
We heard from the noble Baroness, Lady Cox, that nurses form a major component of the healthcare team. They provide 80 per cent. of direct patient care and account for a great deal of the National Health Service budget. Nurses involved in purchasing therefore have an intimate knowledge of what is a major component of the work of district health authorities. From my experience of serving on a district health authority, I would say that that knowledge of manpower planning in nursing and purchasing is needed by the authority.
Nurses also bring an important dimension to the general management of health authorities. They work across all clinical areas and understand the role and contribution of other staff at all levels. Nurses in purchasing have the credibility to challenge practice in provider units and to negotiate contracts from a standpoint of clinical knowledge.
Each NHS trust is required by statute to have a nurse executive on its board. It seems only logical that the purchasing health authority should have an equivalent executive position to negotiate contracts from an informed position and to advise on the balance of provision between different services. Indeed, the Department of Health's own draft guidance on the involvement of professionals in the work of health authorities emphasises the importance of nursing involvement:
It seems to be accepted that nurses have a pivotal role to play in the work of purchasing authorities. The Government have recognised that and issued good practice guidance for consultation on involving them at various levels in the work of health authorities and have incorporated into the Bill a requirement to seek their advice.
My concern is that, despite those welcome measures, there will be no statutory force behind the involvement of nurses at the highest level. That is in contrast to the present legislation, under which district health
The Bill will remove any existing requirements to include nurses on boards, with no adequate replacements. Despite the assurances of the Government that nurses who are able will automatically rise to such positions, it appears, as the noble Baroness, Lady Cox, said, that they may not even be eligible. I believe that unless the Government give statutory force to nurses' involvement at board level, few able and skilled nurses will reach those key positions and their knowledge and expertise in purchasing will be lost.
Lord Dean of Harptree: My Lords, I too welcome the Bill and the lucid explanation that we received from my noble friend the Minister when she introduced it. It follows naturally from previous reforms. However, I was also glad to hear that it is regarded as the final step in the progress of NHS reforms.
However necessary reform may be, inevitably it creates uncertainty, particularly for those who work in the service. It involves a lot of time and effort in planning and implementation and, however well thought out the reforms may be, difficulties will arise and unforeseen snags will appear. Therefore, although I welcome the Bill, I am glad that it is regarded as the last in the line.
There has been a general welcome both in this House and outside for the formation of all-purpose health authorities to replace the existing DHAs and FHSAs. That is in contrast to the controversy that arose when the National Health Service was first formed. At that time GPs were fearful that the new organisation would mean that their voice would be swamped by that of the hospitals. As a consequence, the family practitioner committees were set up and in one form or another have continued from that day to this. The fact that there is now a general welcome for the all-purpose authorities shows very clearly the progress that has been made over the years in viewing the service as a whole, with the family practitioner as the first link in the chain involving the GP surgeries, services in the community and in people's homes and services in hospitals.
The composition of health authorities has been mentioned on many occasions this afternoon. I too welcome the statement that a growing number of members of health authorities will have a background in nursing, medicine and other relevant professions. It is clearly highly important in such a specialised service, with so many professional disciplines involved, that the voice of those who have experience in these matters should be clearly heard. I hope that in considering that point my noble friend the Minister will be able to give a sympathetic response to the plea on behalf of the British Medical Association that the voice of primary care should be clearly represented on the health authorities.
I agreed very much with the point made by my noble friend Lady Cox and other noble Lords. It was a powerful plea for the representation of nursing. I hope too that we shall not lose sight of the importance of having an independent element on the health authorities. We want some people who are gifted amateurs and do not have a health service axe to grind. People who are experienced in management are also needed. If we are to have rounded health authorities, all those aspects are required.
I should like to raise with my noble friend the Minister three specific points. The first relates to the co-ordination of services, particularly the relations between health authorities and local authorities. One of the most difficult problems with which I had to deal when I represented a constituency in the other place concerned the demarcation disputes that sometimes arose in that area. Such problems arise most obviously in connection with services for the elderly or the mentally ill. For example, there may be an elderly lady in hospital who has had her treatment and is ready to be discharged; but she is not fit enough to go back to her own home and look after herself. Naturally, the hospital wants the bed. In many cases the local authority or voluntary organisation does not have a place. That comes partly from the inevitable pressure on services, which is bound to grow as the number of elderly people in the community grows. But also it arises from the different funding arrangements for the National Health Service and for local authorities.
I wonder whether my noble friend can say whether the health authorities are likely to be in a better position to deal with those kinds of demarcation disputes. Can she say also whether joint funding arrangements are likely to be able to make some contribution to the solution to such demarcation problems, which can be very distressing?
My second specific point concerns the community health councils, which were mentioned by the noble Baroness, Lady Robson. I am very glad that they are to be retained. Not everybody agrees that they are necessary but it seems to me that they provide a valuable safety valve and watchdog. Can the Minister say whether their role will continue as before under the new arrangements?
My third specific point concerns relations between the National Health Service and the private sector. I declare an interest as a former governor of BUPA. When I was on the BUPA board I was able to see first-hand some of the valuable work done by that organisation in its own hospitals and also the fruitful co-operation that existed between the private sector and the NHS. In my view, the NHS and the private sector are complementary and not competitive. I hope that my noble friend will be able to give an assurance that the co-operation between these two sectors will be encouraged to develop further.
The background to this Bill is the massive government investment in the National Health Service. My noble friend was too modest to mention that in her speech today. I remind the House that spending on the NHS has increased by no less than 66 per cent. in real terms since 1979. Even in last autumn's very tough spending round the NHS was able to get an increase of
Baroness Eccles of Moulton: My Lords, I start by declaring an interest as chairman of a district health authority. I was originally appointed by the Secretary of State in 1988. I am proud of it. We have come a long way in the past four years since the first wave of trusts came into being as the most obvious and well publicised element of the fundamental set of changes to take place in the National Health Service.
As far as public awareness is concerned, although press coverage has concentrated on trusts and GP fund-holding, the new role of the district and family health authorities is of great importance for the improvement of health care for local people. This Bill will strengthen the way in which local health authorities improve services. It will certainly have a big effect on the way that local hospital and primary care is managed. I hope to be able to demonstrate that the authorities in west London are ready for it, and to indicate how important it is that the powers conferred by the Bill are used sensitively.
This afternoon and at other times it has been asked whether the new health authorities will have the capacity to carry out the responsibilities devolved to them from the regional health authorities. In part answer to that question, perhaps I may say that at our district health authority meeting last week we considered a list of over 30 service areas for which responsibility was being taken through devolution to the authority of a substantial proportion of the region's previously top-sliced budget. Many of the services on that list are ones that we already manage where the funding has for historic reasons been top-sliced, and all of the items relate to activities with which we are familiar.
As one would expect with an authority that plans and provides services across a wide spectrum, from home bathing to heart by-pass surgery, one needs to have the benefit of advice and guidance from a wide range of clinical specialists, GP advisers, public health specialists, nurses, psychologists and many other disciplines. Many of the specialties that we plan and fund which are provided by hospitals and other services have been subjected by the authority to service reviews. Each review team relies considerably on medical input. This means that the statutory obligations to take professional advice which the new health authority will be under will be a continuation of what we do at present.
Alongside the greater devolution of fundingthis year some £360 million of public money is being shared by the two local authorities in my districtone must have greater accountability. I welcome the proposal that the chief executives of health authorities and trusts will become more accountable to Parliament by being designated accountable officers. Clearly, it is unreasonable that the chief executive of the entire NHS,
I turn now to relationships within our district. It has always been important for the local health service to work closely with the local authority, the voluntary sector and other services. In addition, over the past few years the contribution of the private sector has grown substantially. Since the introduction of Care in the Community, local authorities have taken the lead, but work in tandem with health authorities to provide a tailored package of care for each person in need. In order to ensure that this system works, it is essential that the new health authorities are in a position to play their part fully. That can be greatly assisted by up-to-date and relevant funding mechanisms, and also by both authoritiesone part of a national service and the other locally determinedtaking their full share of responsibility.
The merger of health authorities will allow services to be planned so that those of GPs and hospitals are better co-ordinated than has been possible to date. In west London we are well ahead. Soon after Working for Patients came into effect, the erstwhile North West Thames Regional Health Authority encouraged all DHAs and FHSAs to become coterminous with one another and the local boroughs. That was implemented very successfully. In our case, the FHSA was already coterminous with three London boroughs. The merging of one part and two whole DHAs in April 1993 enabled us to work as a health agency, thus combining the two statutory authorities covering three boroughs. That may sound rather laborious, but it makes the point that the coterminosity of the authorities and the boroughs is of great importance. For us, this proved to be a neat arrangement which provided an essential foundation to bring together the work of the two authorities. A year ago we moved into one building in the centre of our area. That has contributed greatly to the degree of integration that we have achieved.
Local differences, even in a superficially uniform area of west London, are significant. The development of services that reflect the particular needs of localities and ethnic groups is crucial to our new role. Twenty-five per cent. of our population comes from a wide range of ethnic groups. Across the whole country there are considerable local variations in the structure and needs of the population. This is inevitable, and it is also to be valued. As the effects of this legislation take hold, these differences must continue to be respected.
Comments made in support of the manpower and functions review, which was the forerunner of this Bill, stressed the increasingly light touch applied by the centre to local management of the NHS. My noble friend the Minister mentioned this in her speech this afternoon. Policy needs to ensure that this philosophy prevails and that local diversity is respected.
I welcome this Bill as an opportunity for the highly competent management of existing health authorities to meet the challenge and take the NHS forward as a modern service, well equipped to meet the health needs of the local populations that each serves.
Lord Ennals: My Lords, I wish to express my personal thanks to those who have spoken who play an important role in the operation of the National Health Service. I may be critical in a moment or two, but I am not critical of the time that is given by Members of this House to serve and improve the National Health Service.
This is the first time I have spoken in a debate on the organisation of the NHS since the National Health Service and Community Care Act 1990 came on to the statute book. Much has happened since that very fundamental reorganisation. I welcome the reaction of the noble Lord, Lord Dean of Harptree, that this is the last of the reorganisations. I have not been happy about most of the previous ones. One of my feelings about this Government has been that whenever they see anything their first thought is, "How can we reorganise it?"not always with very satisfactory results.
Much has happened since that reorganisation in the health service. For example, the number of senior and general managers in England has shot up since 1986 from 5,000 to more than 20,000. That is quite an achievement. Secondly, total bureaucratic costs have more than doubled since 1987-88 as a result of that reorganisation. Thirdly, the trend towards political appointments to paid posts, with much higher pay than 10 years ago, has accelerated. I await with interest, as I am sure will the whole House, the comments of the Nolan Committee on the politicisation of quangos, including the NHS quangos.
Fourthly, local authority representatives on NHS management bodies have been removed. I do not mean that none plays any part but none has a right to. That was a very derogatory step which we fought against hotly when the Bill was before the House. The Bill also removed or reduced greatly the role of non-governmental organisations, which are so important in the National Health Service, and reduced the role of the professional organisations, including those of doctors and nurses.
Fifthly, the role of community health councils has been reduced in recent years. They play a very important and healthily critical role in the National Health Service. Sixthly, whatever may be said about episodes of treatment and whatever may be the figures for episodes of treatment, the total number of patients on hospital waiting lists has increased and passed the 1 million figure for the first time. The trend is still upward.
Seventhly, concern about the Conservative handling of the National Health Service has steadily increased. That concern is reflected in every kind of election and opinion poll. The public, who value their National Health Service almost more than any other service, do not believe that it is in safe hands or that it has been in
From my introduction one might suppose that I oppose the whole of the Bill. I do not. During the progress of the National Health Service and Community Care Act I supported on behalf of noble Lords on this side of the House the concept that DHAs and FHSAs should not retain their separate status. It is a pity that the proposals that were made and voted on did not see the light of day. At that stage the Government did not believe that it was a good idea.
That brings me to the abolition of the regional health authorities, which the Government present as a streamlining of management and a reduction of administration. There are strong arguments against the proposal that is the main part of the Bill, though I certainly welcomed the decision that was taken some time ago to reduce the number of regions from 14 to eight. That is not a bone of contention. Apart from putting at risk 1,500 jobsunless everyone is to be turned into a civil servant, which I cannot believe is the Government's intentionthere are many reasons for believing that the Government's proposals are a great mistake.
I am not happy about the role of regional health authorities, which over the years has been a very important one, being taken over by civil servants who by their very title and definition are arms of central government. I am glad that the noble Baroness, Lady Robson, who spoke so well, is present, in spite of her bad back, because we had many happy days, weeks and years when I was Secretary of State and she was a regional chairman. As I said in an intervention during the speech of the noble Lord, Lord Jenkin of Roding, I believe that regions have an important planning role. That somehow or other that planning role is to be reduced by all that has happened in the reorganisation of the National Health Service is absolutely wrong. Their role ought to be increased rather than decreased.
Both the noble Baroness, Lady Jay, and the noble Lord, Lord Walton of Detchant, have emphasised research as a critical part of the role of regional health authorities. One asks about the supervision of regional specialities. If that is to be done by civil servants it can only be on the instruction of their Ministers. That step goes further to take away any independence of thought from the National Health Service which might have existed. Much was done in the National Health Service and Community Care Act to take away that independence. A regional officer or civil servant serving health Ministers is not an adequate replacement for the regional structure.
A number of consequences will flow if this decision is carried into law. First, it will undermine the ability to provide a strategic and planned service, which is essential for a comprehensively equipped NHS. It will be a further step away from the National Health Service which was so proudly created long years ago by a
Such services and advice will now have to be either duplicated at local level or bought in from the private sector, both of which would be more expensive for the National Health Service. In my view the regions have played and should go on playing a very important strategic role.
No doubt Ministers would be glad to say that the days are gone when we tried to make of the National Health Service a national service where planning documents were brought out annually to indicate which regions needed to have more provision in one field than another. Those days are gone. A regional health authority plays an essential role in allocating resources to local purchasing authorities. It is important that a region-wide perspective is retained and that an intermediate tier is involved in ensuring the implementation of national priorities at regional level. Clearly, some RHA functions will be undertaken by the new National Health Service Executive regional offices which the Minister so clearly described. But there again, they are civil servants. I have nothing against them, but it is a question of simply taking away any element of independence from the National Health Service.
Perhaps I may look for a moment at regulation and monitoring the internal market activity. I know that the health service unions strongly believe that the market system will not deliver a comprehensive, equitable service which offers equality of access and is free at the point of use. Unless checked the logic of the market will lead to inequitable provision and to a two-tier service where cost rather than need becomes the driving factor. Everyone in your Lordships' House can give examples where that is already happening.
Regional health authorities have a vital role in monitoring and, if necessary, regulating the activities of the market. While purchasing authorities have a primary responsibility for monitoring providers, trusts should have to account for their performance to wider audiences than simply their purchasers. On the purchasing side, RHAs have a more direct responsibility for holding authorities to account for their performance. They should influence the strategy and objectives, if not the detail, of the purchaser's plans at their inception.
In addition, RHAs need to monitor the contracting process through which purchasers and providers interact to ensure that the process is in the public interest. If necessary, they should mediate where problems arise. Although the new NHSE officers will be expected to undertake some of this work, we have to question whether it is better that that is done by eight government offices or by an integrated part of the National Health Service, which I believe most noble Lords on this side of the House wish to preserve. The whole question of accountability within the National Health Service, and
We shall have plenty of opportunity during Committee stage to try to deal with some of these issues by amendment. The Government make it very difficult when they virtually ensure that there is nothing in the Bill and that everything is done by regulation. That has become a very bad habit of this Government. It undermines the principles of parliamentary democracy when we are not given on the face of the Bill the essential decisions that the Government intend to take.
I am sorry that I have taken a few minutes longer than I intended, but perhaps I may conclude with a final argument which I know will not appeal to noble Lords opposite. I believe that the Labour Party will win the next election. Noble Lords would expect me to believe that. No doubt all noble Lords will look askance that it is possible for opinion polls to show a 42 per cent. Labour lead
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