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Lord Monro of Langholm: The noble Earl, Lord Mar and Kellie, is about the only chap in this building who thinks that health should be put entirely in the care of local government. As the Minister who introduced area health boards in 1972 when we reorganised the health service in Scotland into a single-tier system, which has worked well ever since, I shall be sorry to see them go. But what worries me is that we are setting up under the area health board an acute and primary care trust. It will devolve its powers into the co-operatives for managing the practices. One begins to wonder what the area health boards are going to do. I have been told that they will be there for the grand issues of long-distance planning and finance but that day-to-day management of the health service in any one area will be in the hands of the acute and primary care trusts.
What worries me in relation to the amendment is the sheer geographical size of Scotland. For instance, the area health board in my area stretches from Gretna Green to Stranraer and from the Solway Firth right the way up to Sanquhar and Kirkconnel. It is a huge area, enough for any organisation to run a health service within it. To think that that health board might stretch over the whole of Scotland fills me with some degree of awe.
The Minister must justify what each area health board is going to do within the current health board areas and what its relative operation control will be over the trusts and the co-operatives to be set up under the present Government's plans. Frankly, I feel we are setting up an extremely bureaucratic situation that is going to be of no advantage to the poor patient who is there to receive the benefits of the health service and at the end of the day we will ask why on earth we have gone through this enormous somersault and reorganisation of the health service in Scotland which is entirely unjustifiable.
Baroness Carnegy of Lour: Briefly I must add my voice to protest at the way the Government are treating Scotland. It is now one o'clock in the morning and we are discussing an enormously important part of the Bill which turns the health service in Scotland upside down. We are doing it when it should be the job of the Scottish Parliament, as my noble and learned friend said.
My noble and learned friend mentioned the speech of the noble Lord, Lord Ewing. He is not in his place; I do not believe he has been here today so presumably he does not wish to pursue this matter. However, he pointed out that in Fife, the health board costs £6.1 million per year. That, by my calculation, is a middle-sized health board. It is one of 15, so it may well be that the running costs alone of the health boards are something of the order of £90 million. That is a lot of money. As the noble Lord, Lord Ewing, stated, the health boards will have two roles: they will be bankers, allocating money from the Scottish Parliament to the trusts in their area, and they will do strategic planning, which is easy to do nowadays on a larger scale.
The noble Earl, Lord Mar and Kellie, who, I believe, aspires to be a member of the Scottish Parliament, can see the Scottish Parliament wanting to do that job. I could see his eyes sparkling at the idea, and he will not be alone. Would the Government not be right to make that possible? I support the amendment.
Lord Macdonald of Tradeston: I am glad to hear that Members of the Committee opposite found the information that we were able to supply of some use to them. It was with great humility and diffidence that I offered guidance in these matters to the noble Lord, Lord Monro, or even to the noble Lord, Lord Ewing, well versed as they are in Scottish Office matters.
I take the point too made by the noble and learned Lord, Lord Mackay. However, I believe that we are due to have a debate on the devolution provisions on Thursday. Perhaps I may say to the noble Baroness that I do not think it is entirely the doing of this side of the House that we are still here at five past one. However, I should like to take in some of the points raised by the
Many of our changes have been achieved within existing legislation. Those include reducing the number of National Health Service trusts in Scotland to 28; introducing co-operative mechanisms to promote partnership through the development of health improvement programmes and the setting up of the clinical standards board for Scotland to assure quality.
The provisions in the Bill deal only with those few matters where the law needs to be changed; that is, formally abolishing GP fundholding; enabling the appropriate National Health Service trust to take responsibility for family health services under Part II of the 1978 Act; changing trusts' financial arrangements; and imposing a duty of quality on the National Health Service in Scotland.
The proposals come as no surprise. They were all signalled clearly in our manifesto at the 1997 general election. They were set out in detail in our White Paper, Designed to Care published in December 1997. The National Health Service in Scotland is already building on them.
I turn to the amendment. There is nothing in the existing Section 2(3) of the 1978 Act to stop the Secretary of State creating an all-Scotland health board should he wish to do so. The noble Lord has set out what he believes would be the advantages of such a step, but I am not convinced. The Government believe that health boards continue to have a key role in bringing a local dimension to the planning and commission of services.
The national perspective is provided by the management executive of the National Health Service in Scotland. It is difficult to see how a pan-Scotland health board and the management executive could sensibly co-exist. I am surprised that the Bill, and the arrangements set out in Designed to Care, should be read as bringing about a reduction in the role of health boards. The White Paper is about making clear the different roles within the National Health Service.
In broad terms, health boards are responsible for strategy and planning. National Health Service trusts are responsible for the delivery of services. That takes forward, in a constructive way, the distinction between the two roles introduced in 1991. Health boards have a number of specific roles which are of great importance to the health and well-being of the populations. Apart from distributing resources to trusts, they are responsible for assessing the health needs of the local populations.
As the recent White Paper, Towards a Healthier Scotland, also pointed out, health boards are responsible for protecting and improving the health of the resident populations in promoting public health issues and ensuring fully co-ordinated community care policies. Health boards work closely with local authorities. The Government are anxious to encourage working across the boundary between health and social care. The effect
Whatever structure we adopt, some boundary will exist. The important principle must be that the patient's care comes first, and the patient should not be aware that there is a boundary. To achieve this, the National Health Service in Scotland and local authorities need to develop close working relationships, and we are consulting on this aspect. The paper, Modernising Community Care: an Action Plan was published last October. It emphasises better and faster decision-making and caring for people in their own homes. Any changes thought necessary will be a matter for the Scottish Parliament. Health boundaries must not act as constraints on the care provided for patients. There is increasing emphasis on designing services from the patient's perspective, and the re-design of services to suit the needs of the patient does not allow health board boundaries to get in the way.
A further example of the work of the acute services review, which reported last June, and one of the fundamental assumptions, was that the review should not be constrained by health board boundaries. Its key recommendation is the development of managed clinical networks and anticipates that many of these will operate at regional and national levels. Just as people want to be treated locally if possible, I believe that they also want services planned at a local level where it makes more sense to do so. Health boards have the expertise to assess the needs of the local populations.
I have sought to explain why the Government take the view that a single health board covering the whole of Scotland is not appropriate. Nevertheless, as I mentioned at the start, there is nothing in the existing legislation to prevent a future government making that change if they choose. It will of course be open to the Scottish Parliament to consider the number of health boards and their role. The amendment is therefore unnecessary, and I hope that the noble Lord will not press it.
Lord Mackay of Drumadoon: I am very grateful to the Minister for his full explanation. I fully accept two of the main points he made. These proposals have been heralded for some time. A number appear in the Labour Party manifesto, some in the White Paper. However, as he rightly says, this is probably more a matter for debate on Thursday, and also the fact that they have come too late. However, there is force in the final point he makes that the legislation as drafted could be construed as allowing the Secretary of State by order to vary the number down to one. With that assurance from him that the Government accept that that is the correct construction of the existing legislation, I beg leave to withdraw the amendment.