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Lords Chamber

Volume 597: debated on Thursday 25 February 1999

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House Of Lords

Thursday, 25th February 1999.

The House met at three of the clock: The LORD CHANCELLOR on the Woolsack.

Prayers—Read by the Lord Bishop of Ripon.

Royal Assent

My Lords, I have to notify the House, in accordance with the Royal Assent Act 1967, that the Queen has signified her Royal Assent to the following Act:

Social Security Contributions (Transfer of Functions, etc.) Act.

Afghanistan:Funding Of Ngos

Why they have restricted the funding non-governmental organisations in Afghanistan.

My Lords, the Government are maintaining their support for humanitarian assistance programmes of non-governmental organisations in Afghanistan where these can be delivered in an effective and principled manner by local staff. We believe that there are serious threats to the security of expatriate staff, and obviously we must organise our funding for NGO activity accordingly.

My Lords, I thank the Minister for that reply. However, does she recognise that the aid agencies already take Foreign Office advice on security seriously, and that this new policy is unfair and makes an unprecedented link between security and funding? Does she agree that the policy is causing unnecessary delays when there is a continuing humanitarian crisis in Afghanistan?

My Lords, I cannot agree in this instance with the noble Earl. Noble Lords will be aware of the serious situation in Afghanistan. During 1998 there were a number of developments which have had a direct and indirect impact on aid operations, including fatal attacks on UN personnel and other security incidents and a deteriorating human rights situation. All expatriates, but in particular British and US expatriates, have been specifically targeted. This is not a matter of the general kind of risk which NGOs and other members of international organisations take when they go into a conflict situation. This is a matter of a specific and targeted risk. The Department for International Development and the Government feel strongly that we cannot continue to support the funding of NGO organisations in Afghanistan where the lives of individuals may be put at risk. However, we continue to support humanitarian programmes where they can be delivered by local staff.

My Lords, does the noble Baroness accept from me that during the period of the Soviet conflict in Afghanistan between 1980 and 1990 NGOs were funded by the British government under circumstances at least as dangerous as those which obtain today under the Taliban regime, and that those circumstances did not prevent courageous NGO workers, both British and Afghan, from performing extraordinarily useful tasks under conditions that were often difficult and dangerous? Does the noble Baroness agree that the conditions in those days were rather more dangerous even than those which obtain today?

My Lords, I think I said in my answer to the supplementary question from the noble Earl that many members of NGOs and international organisations continue to work in difficult and dangerous situations. However, in this particular situation there has been a specific threat to expatriates. We have adopted a carefully considered position given the knowledge and information available to us. It is not the first time that we have reached this conclusion. We came to the same conclusion at one time in Sierra Leone. However, the NGOs at that time agreed with our stance and pulled out. Some years ago in Cambodia the same thing happened. It has also happened in Chechnya. I cannot agree with the noble Viscount.

My Lords, have other countries with NGOs like ours taken a similar decision? Has there been consultation with the European Union on these matters, as sometimes happens?

My Lords, there has been consultation with the European Union. In fact the European Union reached a common position on this matter while the UK held the presidency. We have agreed a number of clear objectives, including trying to promote stability and development for the whole region; looking at issues concerning respect for human rights; and the need to provide effective humanitarian aid. There is also a strategic framework within which UN organisations are working. However, not all organisations have adopted the same position as the UK, although it is important to stress to the House that the UN has withdrawn its personnel—those personnel have not returned—and there are other countries which have adopted the same position.

My Lords, on the broader front, can the Minister say whether the US sanctions are still in place; whether sufficient leverage is being exerted; and what are the current dividing lines between the individual members of the six plus two initiative?

My Lords, I am not entirely sure what the noble Viscount means when he talks about dividing lines. The UN special envoy visited the region last October, when he met the Taliban leader. It was an extremely successful meeting which diffused the tension between the Taliban and Iran. The focus then shifted to a proposed meeting between the six plus two group of neighbouring states, plus the UN, Russia and Afghan factions. However, what the focus of the meeting should be, which factions should attend and the agenda for the meeting have still to be agreed. As to US sanctions, I will come back to the noble Viscount on that matter.

My Lords, given the remarkable and vital work done on the ground by the dedicated NGOs in Afghanistan—work that cannot be done from afar—why, since November, have Her Majesty's Government stopped the aid on condition that expats do not go in? What are the government policy guidelines for suspending or restricting aid to a particular country?

My Lords, as to the last point of the noble Baroness, she may wish to look at the announcement made by my right honourable friend the Secretary of State for International Development on 8th December, which set out very clearly the Government's position on this matter. Since then we have issued criteria to NGOs about the kinds of programmes and projects we are prepared to fund. We are in the process of allocating that funding, on a six-month basis, which will be reviewed at that time.

Our funding has not stopped. In 1998 our commitment in Afghanistan totalled £8.5 million, which was channelled through the UN, the International Committee of the Red Cross and some NGOs.

Genetically Modified Food

3.14 p.m.

What steps they are taking to improve public understanding of gene technology applied to food.

The Parliamentary Secretary, Ministry of Agriculture, Fisheries and Food
(Lord Donoughue)

My Lords, the Government are committed to providing consumers with the information they need to be able to make an informed choice about genetically modified food. This is being achieved by various means, including publishing information on the MAFF website; up-dating and producing new explanatory booklets and brochures on biotechnology and the safety assessment of GM foods; and co-funding a mobile exhibition on food biotechnology organised by the Science Museum.

My Lords, does the Minister realise that, despite the valiant efforts of Mr. Jeff Rooker and the Prime Minister, the Government seem to be losing the battle against the scaremongering which has been whipped up about genetically modified food by some sections of the press? Will the Government perhaps encourage the Royal Society, and all those who care about science, to face head on the often unscrupulous propaganda of Greenpeace and Friends of the Earth, whose increasingly anti-science bias and blanket condemnation of biotechnology, rather than judging each case on its merits, is likely to do more harm than good to the causes of health and the environment?

My Lords, I thank the noble Lord for what he has said about my colleague in another place. I do not believe that we are losing the battle. It is not an easy battle. To modify an old aphorism, in the newspaper circulation war the first casualty is truth. We shall continue to put the arguments in favour of genetic science; we shall also bear in mind the genuine public concerns. We have in place a regulatory mechanism which will support that, but we are currently looking to see whether it is necessary to strengthen it further.

My Lords, does the Minister agree that we need to differentiate between the gene transfer within the species, which is the natural process of evolution, and the gene transfer across the species, which negates the presently accepted Darwinian theory of evolution and must therefore be of extreme danger to the natural world?

My Lords, I have taken a decision not to be drawn down any scientific paths such as that. Unlike the noble Earl, I do not feel myself to be a master of them. I am aware of the distinction and we obviously share his concern.

My Lords, can the Minister assure us that notice is being taken of the clear, scientifically-based evidence which is beginning to emerge from organisations such as English Nature of the environmental implications of genetically modified crops? I declare an interest in that I chair English Nature. Can the Minister further assure us that the very real, scientifically-based evidence of the impact of genetically modified crops on the wider environment will also be clearly explained to the public?

Yes, my Lords, I can give that assurance. We share those concerns. We welcome the advice we have received from English Nature and others. No genetically modified crops are currently under commercial development. Field trials are taking place and we shall assess what they tell us. We are certainly conscious of the environmental implications of these developments, and we wish to be reassured on that issue before full-scale commercial development is allowed to take place.

My Lords, does the Minister accept that many of the problems he faces do not stem from the wickedness of the newspapers and scare stories but from the memories which many of us have of assurances on Thalidomide? We had assurances on Thalidomide, and we now see people walking around with little hands sticking out of their shoulders. There was the rather patronising attitude towards my noble friend Lady Mar when she began to suggest that there were problems with the use of organophosphates, which were regarded as total nonsense; and we have seen the pictures of Mr. Gummer ramming hamburgers down his child's throat—no doubt on expert advice—to demonstrate that no danger at all arose of the transfer of mad cow disease. Does the Minister believe that, while it is important that we get the truth one cannot take for granted, given the experience of many cases over a period of years, everyone will accept expert advice without question, rather like the noble Lord who has taken up the cause of battering Greenpeace?

My Lords, it is true that we operate against the historical background of all of the episodes which the noble Lord described. Above all, the BSE experience is one which understandably has led the public to be very suspicious of developments in these fields and to be reluctant to accept reassurances from industry that benefits commercially or from scientists. Well, I must assure the noble Lord that Ministers come to this job with that background. It is why in this House I have always listened carefully to the noble Countess, Lady Mar. Ministers have children too. We are aware of the dangers but we can proceed only on the basis of rational evidence. The noble Lord referred to the newspapers. They are exploiting those genuine fears and are scaremongering, which is unhelpful to all.

My Lords, can the noble Lord say whether there is yet a statutory obligation on those who are selling food in the marketplace to indicate that there are genetically modified ingredients in the food they are selling? If that is not the case, would it not be logical for the public to be offered a choice?

My Lords, the position on information is that we pressed for and secured in the European Union the new regulation of last Autumn which makes compulsory the labelling of genetically modified foods on sale. That still requires backing by regulation, which we expect to be introduced quite soon, having carried out consultation. We are also looking to extend it to catering establishments, including schools and day-care premises.

Territorial Army: Disaster Relief

3.22 p.m.

Whether they will support an enhanced role for the Territorial Army in rapid relief response to natural and man-made disasters.

My Lords, our Armed Forces play an important part in disaster relief in support of the appropriate civil agencies. The Territorial Army makes a significant contribution to this. Natural and man-made disasters always require a very rapid response. Reservists have civilian jobs and may be less readily available at short notice than regular personnel. In the first instance, therefore, we tend to deploy regulars to help with emergencies. Where we can make use of the TA, we certainly do so.

My Lords, I thank the Minister for that positive and encouraging reply which I totally endorse. Is he aware of a recent report published by the Fontmell Group entitled Overseas Disaster Relief: Nobody's Baby, which is critical of the Government's perceived lack of commitment to disaster relief and is also concerned about lack of co-ordination on the ground, which has caused loss of life and a waste of resources? Will he therefore consider sympathetically one of the recommendations in that report that the Territorial Army reserve forces may be used more effectively by utilising their very real expertise, commitment and eagerness to support NGOs at critical stages of disaster response?

My Lords, I am obliged to the noble Baroness. Yes, I am aware of the report. In fact, I have a copy on the Dispatch Box in front of me. The Government accept several of its suggestions but not all of them. We certainly agree that there is a need for the response to emergencies to be better co-ordinated. We are making a good deal of progress in that direction. It is fair to say that, with the setting up of DfID, we had some initial problems. We are getting those out of the way. Co-ordination between the Ministry of Defence, the Foreign Office and DfID is now extremely good. The report referred to the Government's commitment to these matters. I think the whole House would wish to be aware that, whenever we deploy the West Indies guard ship, the personnel have special training in disaster relief before they go out. They go out with special supplies on board and they have a Royal Fleet Auxiliary equipped with special supplies in case there are catastrophes in that part of the world. At the moment, HMS "Westminster" is on humanitarian patrol off Sierra Leone.

My Lords, I should perhaps declare an interest as a former director of Oxfam and a continuing member of the Oxfam Association. I noticed that the noble Baroness, Lady Cox, referred to support for NGOs. Can the Government assure the House that, in taking forward this interesting idea, if it is to be taken forward, either with regulars or territorials, it is most important to do so in close consultation with those NGOs that have been bearing the brunt of the immediate front-line response to disasters of this kind; and, if I am allowed to say so, often doing it very well?

My Lords, I would certainly endorse what my noble friend said about the role of NGOs and their invaluable contribution in these situations. Of course Her Majesty's Government would be happy to discuss these matters with them. But I do not want to raise any hopes that the Government are thinking of setting up a special disaster relief organisation within the Armed Forces with that exclusive responsibility. There are all kinds of problems, as I am sure the noble Baroness and the noble Lord understand, that stand in the way of that suggestion.

My Lords, bearing in mind that early last year the Government declared an intention to reduce the size of the Territorial Army but made it clear last night that they were not going to do so, can the noble Lord give your Lordships specific figures as to what the Government envisage will be the size of the Territorial Army in the few months ahead?

My Lords, it would be rather difficult for me to give the noble Lord precise figures for the few months ahead. We started off with a nominal strength of about 60,000, which was never met. If the noble Lord has studied the several debates we have had on the subject, he will recall that we based our study on operational requirements which gave a figure of 25,000 for the Territorial Army; and as a result of a series of ministerial decisions we increased that to the order of 41,000.

My Lords, before one considers an enhanced role for the Territorial Army, or for that matter for the Regular Army, it is necessary to review very carefully our training facilities within the United Kingdom. Does the noble Lord agree that those facilities are under pressure at the moment due to certain maldisposals of Army land? Will he take steps to ensure that the training facilities in this country as well as in Canada, because we are now going that far, are adequate to perform these duties?

My Lords, my noble friend is quite right to say that we train in Canada. In fact, various elements of Her Majesty's forces have for many years trained from time to time in areas far more remote from this country than Canada. I am not quite sure what the noble Lord is alluding to in respect of the disposal of Ministry of Defence land. If he would write to me about any case he has in mind, I should be happy to try to respond to him.

My Lords, would my noble friend agree with those NGOs which say that, repeatedly, what has been absent is a unit at the site of the emergency to co-ordinate the activities going on there, unless, they say, the French happen to be present? Does my noble friend agree that that could be achieved quite simply with a single battalion headquarters?

I am not sure that I follow all my noble and learned friend's points. The essence of emergency relief is that it must be rapid. Rapid response is most easily made available through the regular forces of this country.

European Parliament Elections: Gibraltar

3.30 p.m.

In the light of the decision of the European Court of Human Rights on 18th February, whether they will introduce emergency legislation to allow Gibraltarians to exercise their democratic right to vote in the forthcoming European Parliament elections.

The Parliamentary Under-Secretary of State, Foreign and Commonwealth Office
(Baroness Symons of Vernham Dean)

My Lords, we shall be taking all available steps to secure extension of the EP franchise to Gibraltar, in the light of the decision of the European Court of Human Rights. However, we can do so only by amending the 1976 EC Act on direct elections. That will require the agreement of all member states. Her Majesty's Government will seek such an amendment in the current negotiations in Brussels on establishing common principles for EP elections. We shall not be introducing emergency legislation because the UK does not have the power unilaterally to extend the EP franchise to Gibraltar through its domestic legislation.

My Lords, those of us who have supported Gibraltar on this matter will be extremely disappointed by the Minister's reply. I have read the judgment carefully. The vote was 15:2 that not only was the United Kingdom guilty, but that the remedy was a matter for the United Kingdom—not Spain, and not other European countries. Therefore, will the Government move quickly and without delay to bring in and secure for the people of Gibraltar the right to vote in the forthcoming European elections? Does the Minister agree that my noble friend Lord Bethell was absolutely right in his amendment and was supported by many Members of this House?

No, my Lords, I cannot agree. The arguments deployed by Her Majesty's Government over this case were largely the same as those deployed by the Conservatives when they were in power. That is the legal advice.

The noble Baroness is right. It is the obligation of the United Kingdom Government to comply with the judgment. But the way to do that is through amendment of the 1976 EC Act. To do otherwise through domestic legislation would put us in breach of that Act. If the noble Baroness is so keen on this, I point out that there were 13 years when her party was in government after that Act was passed when they might have taken that kind of action. Her Majesty's Government are moving swiftly. We shall table the amendments next week in Brussels, and we are briefing all our posts in Europe accordingly.

My Lords, whatever the faults of the previous administration in this regard and the doubt as to who is legally right, the Government or the noble Lord, Lord Bethell, will the Minister give an undertaking that the matter will be raised in a forum within the European Union? If it is not accepted, it will be very clear who is guilty. It should not be left to an uncertain arrangement as a consequence of the negotiations that are going on behind the scenes. Let it be seen clearly who is guilty.

My Lords, I hope that I have made it clear to the whole House that Her Majesty's Government will raise this matter in the discussions that we are having on the principles that bind us in relation to the way in which elections to the European Parliament take place. We shall also be briefing all our EU posts accordingly. The reason that this is important is that the obligations placed upon the United Kingdom Government, direct as they are, are also, by extension, placed upon our partners, and that includes Spain.

My Lords, I think that it is the turn of the noble Baroness, Lady Williams.

My Lords, we on these Benches welcome the Government's eagerness to comply with the decisions of the European Court. We also welcome the strong support that the Official Opposition has given to that position. Will the Minister confirm that it is probable that efforts to bring about changes in legislation will not be in time for the next European elections. However, will the noble Baroness and the Foreign Office consider other ways in which, until elections occur with the full representation of Gibraltar, other steps will be taken to allow the concerns of the people of Gibraltar to be registered in this House, not least through the scrutiny committee on European legislation.

My Lords, regrettably, I agree. I do not think that the timetabling will allow any changes to be available in time for the European elections. No one is in any doubt that negotiations to secure the unanimous agreement of our EU partners will be extremely difficult. Having secured that agreement, if it is possible, we shall then have to go through a ratification process. In the meantime we shall have to consult about the ways in which we can do our best to take into account, as we always do, the feelings and wishes of our friends in Gibraltar.

My Lords, however hard the noble Baroness tries to pass the buck back to the previous government, the decision of the European Court of Human Rights was given this month. The court made it perfectly clear, and perhaps I may quote from the press release rather than the longer judgment, that,

"notwithstanding the transfer of competences to the European Community, Contracting States remained responsible for ensuring that Convention Rights were guaranteed".
That is straightforward. It is our responsibility. If the Government bring forward a Bill, we will expedite it through this House to make sure that the citizens of Gibraltar have their rights respected in June, so that the human rights convention, which the Government are always keen to obey, is followed. Is it not better to be in breach in a manner that Spain does not like, rather than continue to be in breach of the human rights convention?

My Lords, I am not passing the buck anywhere. I have stated a matter of fact in relation to what the previous government did. The noble Lord cannot gainsay that, however hard he tries. I have been very clear about the responsibilities: they are for Her Majesty's Government. The Government will shoulder those responsibilities unshrinkingly. We hope to do so next week, and we shall brief everyone accordingly.

My Lords, I think the feeling of the House is that the noble Lord, Lord Bethell, should be heard.

My Lords, will the Minister confirm that the Prime Minister is to meet his Spanish opposite number in the next couple of days? Will she indicate whether it is likely that Mr. Blair will raise this matter with Mr. Aznar? Will she also confirm that, whatever the outcome of those meetings, it is only the Foreign Office's opinion that domestic legislation will not work? The Foreign Office's opinion on this question has turned out more than once to be erroneous.

My Lords, I can confirm that my right honourable friend is to see his Spanish counterpart, probably within the next 24 hours. It is very likely that these matters will be considered, although I have not seen an agenda or any briefing papers for the meeting.

I have spoken to the House, as did my noble friend Lord Williams, on the basis of legal opinion. At the risk of making the noble Lord, Lord Mackay, very cross indeed, I point out that legal opinion has been pretty consistent throughout. The difference now is that we have a judgment from the European Court of Human Rights which places obligations not only upon Her Majesty's Government—I have been very clear on that point—but also upon Spain and our other European partners.

Rating (Valuation) Bill

3.38 p.m.

Brought from the Commons; read a first time, and to be printed.

Financial Services And Markets: Joint Committee

My Lords, on behalf of my noble friend the Leader of the House, I beg to move the Motion standing in her name on the Order Paper.

Moved, That this House do concur with the Commons in their message of 23rd February that it is expedient that a Joint Committee of Lords and Commons be appointed to report on the consultative document on the draft Financial Services and Markets Bill presented by Her Majesty's Command on 21st December 1998 and any further draft of the Bill which may be laid upon the Table of both Houses by a Minister of the Crown and to report by 30th April 1999.—(Lord Carter.)

On Question, Motion agreed to, and a message was ordered to be sent to the Commons to acquaint them therewith.

Health Bill H L

3.39 p.m.

My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.—( Baroness Hayman.)

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Clause 1 [ Repeal of law about fund-holding practices]:

Page 1, line 10, at end insert ("from 31st March 2000").

The noble Earl said: At the start of our Committee proceedings, perhaps I may say that regardless of the profound difficulties which we on these Benches have with many parts of the Bill, I shall be guided in what I say both today and on Monday by two principles. The first is that where we oppose, we shall oppose in a constructive fashion. It is no part of our purpose to wreck the Bill, nor will we do so. We will, however, seek to press those issues where we believe we are right and where we believe we can create a better Bill to a Division where necessary. That approach is consistent with the functions and traditions of your Lordships' House and will, I hope, be understood and accepted by the Government.

The second principle to which we shall try to adhere is brevity. I humbly suggest to the Committee that with the sheer number of amendments ahead of us during the two days, we shall assist ourselves by being as concise and punchy as is called for by the amendment we happen to be debating. I hope that other Members of the Committee will share that view.

Unfortunately, I cannot be as brief as I would wish with the first amendment, although I shall try. Its purpose is to defer by 12 months the date on which fundholding formally comes to an end. I propose it not in any kind of "die-in-the-ditch" spirit, nor in any way to frustrate the Government's intentions to establish primary care groups and primary care trusts, but to do precisely the opposite.

The Government have had over a year to prepare for the advent of primary care groups and in some areas the transition to PCGs is proceeding reasonably satisfactorily. But that is not the case in a great many other areas. There is an enormous number of obstacles still faced by PCGs and board members in attempting to establish the new structures.

The work involved is considerable. To start with, there is wide dissatisfaction over the question of PCG boundaries and at the moment no mechanism to allow for independent review of health authority proposals. The amount of money made available for the development of PCGs has been woefully inadequate. Many GPs and others have had to give up substantial amounts of their own time, without remuneration, to organise meetings, to discuss the new arrangements with health authorities and to set up steering groups. With PCG boards, the guidance on election arrangements and payments to PCG board members has resulted in appointments being rushed and a woeful lack of information about the time commitment that a board member will need to devote to his or her responsibilities.

Even at this late stage, many PCGs are still in the throes of negotiating their management budgets. Without those budgets, they will not, of course, be able to decide on anything; not their management structures, nor their activities, nor the responsibilities that they wish the health authority to delegate to them. The key issue in many areas is that the per capita level of support is far too low.

There is terrible uncertainty as a result among fundholding staff about their future employment. Where staff have been made redundant, the redundancy payments are often being met out of the pockets of GPs who have had to face the whole messy business of redeployment and redundancy of practice staff with precious little information to assist them.

Local services are being terminated early. We have assurances that contracts for the delivery of specialised services such as chiropody, dietetics and physiotherapy, as well as consultant-led clinics in GP surgeries, would not have to be brought to an abrupt end as a result of PCGs. But that is exactly what is happening in some health authorities where the edict has gone out to terminate those contracts before 1st April.

Guidance is being issued late and piecemeal. Even the revised standing orders and financial instructions for health authorities have yet to be distributed. There is still no information about the IT structures and reporting requirements that PCGs will be expected to implement. Many PCGs have not even got premises from which to work.

The simple fact is that the whole exercise in what is a major change for the NHS has been rushed. At local level, the NHS is simply unable to cope with the timetable that has been thrust upon it by the Government. The result is that many GPs are still, to put it at its mildest, unenthusiastic about PCGs because they see an underdeveloped idea being forced upon them at too rapid a pace, with grossly inadequate financial and managerial support. There is demotivation. They see nothing ahead of them but extra workload. Some of the work will take them away from patient care, without providing their patients with replacement doctors. The doctors are being put in the firing line to take the flak from patients and the public when the NHS finds itself unable to deliver the necessary care because of the woeful degree of under-funding.

My point is therefore a straightforward one. ft is to say to the Government: "Stop rushing. Stop making life impossible for doctors and patients all around the country. There is still time, if you choose to take it, to ensure that this important transition is made smoothly and to everyone's satisfaction". For that reason and that reason alone, I beg to move.

I support my noble friend Lord Howe in his amendment. The PCGs will be much bigger units than anything equivalent which has been known before. They will be drawn from a diverse series of practices. The fundholders in the first wave are very different in character from many in the later waves of the practices. They will include many sole practitioners with little or no back-up. They will require a tremendous amount of training, to which my noble friend referred. The very size of the PCGs and their diverse nature throughout the country make it advisable that we delay this for a year, as my noble friend suggested.

I too support the amendment. The question of redundant staff is causing great anxiety to general practices which find that they have to dispense with their practice manager in order to go into the bigger unit where someone else will carry out the management. Funds do not seem to be available to meet the redundancies.

I too support my noble friend largely on the grounds that he has explained; namely, the problems faced by the participants in this enormous change. I was extremely grateful to the Minister for the meeting that she arranged with her team of civil servants who between them knew everything there was to know about the Bill. They were extremely helpful. The Minister even brought three civil servants down from the Scottish Office.

At that meeting I asked about the legality of the position given that arrangements both north and south of the Border were proceeding regardless of the fact that the Bill was only at the early stages of its passage through Parliament. We were told that much that was happening could be done without legislation, but that is not the answer. Not everything can be done without legislation.

This particular clause is essential to the Government's arrangements. It shows an extraordinary disregard for Parliament and is another example—we see more and more—of the Government being prepared to proceed with a scheme, an integral part of which is the abolition of fundholding, before they know whether or not the Bill will become law. For all we know, fundholding may be restored during the passage of the Bill. I understand why the Government are optimistic that it will not be, but they should not make that assumption. This is a very strange way in which to proceed. For that reason the amendment will increase the legality and credibility of the Government's actions and I hope that they will accept it.

I am somewhat surprised by the very muted way in which the noble Earl moved his amendment. It reminded me of his party's policy on the euro. It does not like it but it does not want to say that and it will do it some other day. It would be nice if he argued that we should keep fundholding. As the noble Baroness, Lady Carnegy, said, perhaps he should have argued for the retention of fundholding. It might have been fun.

I am grateful to the noble Lord for giving way. I remind him that it was a manifesto commitment of his party, and we do not wish to upset that.

That is very good to know. If it has been known for some time that the Labour Party will remove fundholding and consultative papers have been issued, those involved should have prepared for it. It has not happened suddenly. Intelligent people should be able to take account of forthcoming events and make allowances for them. This has been known about for some time. Either it has been known for some time that the Labour Party will do it, and therefore adequate notice has been given, or the noble Earl does not like what we are doing. Either way I do not believe that he has an argument.

Perhaps I may remind the noble Lord, Lord Desai, that running a rural practice in particular and a primary care group is not exactly the same as running a department of economics. At the moment the people on the ground who are involved in fundholding practices are being poached to set up primary care groups. Anecdotally, in one practice I know very well the person in charge of fundholding has been appointed chief executive or director—I forget the exact title—of the local primary care group. As a result there has been a problem back at the practice. She spends two days back at the practice and three days trying to set up the primary care group and is at her wits' end knowing that she is running out of time. We know that primary care groups are to be introduced and we accept that—at least I do—but I am sure that none of us in this Chamber wants the process to go off at half-cock so it is in a mess right from the start. Is it not better to ensure that the organisation, staffing levels and liaison with practices are correct before the scheme comes into being? For that reason and for many others I support my noble friend's amendment.

I ask my noble friend to reject this amendment. I believe that the noble Baroness, Lady O'Cathain, has just given my noble friend a very good reason for rejecting it. Her argument points to getting on with it rather than delaying it. PCGs are a very important part of the Bill. If we delay that, we would be delaying all aspects of the Bill. I advise my noble friend to reject the amendment and to get on with it.

Perhaps I have misled the noble Lord. It takes a lot longer than five weeks, or whatever the period is, to do it. I suggest that there should be a longer running-in period. We should not get on with it now when there is still a state of confusion and in effect people are doing two jobs.

We do not seek to delay. This is an important part of the Bill. Having listened to the argument and knowing a little about this, I believe that as laymen most people deal with the problems that have been spoken to during their lives. The noble Baroness, Lady Hayman, must be perfectly well aware of this, too. The point that has been put in so many ways is that this should not go off half-cocked. Why cannot this be dealt with? The case that has been put is genuine. To say that we seek to delay is a totally meretricious intervention. We do not seek to delay. We do not challenge the principle, but as a matter of common sense we want to try to make it work. The noble Baroness and the Secretary of State can deal with this matter in a perfectly sensible, proper way. Clause 52 states:

"(1) The preceding provisions of this Act are to come into force on such day as the Secretary of State may by order appoint.
(2) Different days may be appointed under this section for different purposes".
Cannot the noble Baroness give the Committee an assurance that the Secretary of State will look at this with an open mind and not commit himself in advance to bringing in these provisions before it is right, proper and reasonable to do so? That is all I ask. Amendments to Clause 52 have been tabled but this is not one of them. I have only just thought of it while listening to the debate.

I support the amendment. Only a fortnight ago I spoke to my trust which told me of the difficulties that it was experiencing. Yes, it has known of this in advance and is working to try to get it to work, but the mere fact that it must be done in such a short time is causing no end of problems. I can assure the Committee that the pressures and the anxieties are very great.

As a matter of principle, I am intrigued to hear the case put by noble Lords opposite. This is one of the great breakthroughs as far as concerns the future of the health service. My experience is that, when you have made up your mind to do something that is both sensible and will help to solve problems, the best thing to do is to go ahead and do it. I am not quite clear how the running of an economics department comes into this. When I ran such a department I never encountered any problem. I simply decided what needed to be done and it was done. I entirely accept that this is more complicated than that. But the fact remains that many of us regard this as an important step forward. As I understand it, the noble Earl, Lord Howe, is at least willing to consider that this may be an important step forward and does not oppose it. It follows that the best course to take is to go ahead and do it. The notion that somehow one should not do anything until Parliament has passed the relevant Bill into law is an entirely new one to me. I have attended here only a dozen years, but it is the first time I have heard it enunciated that the provisions of a Bill should never start to come into practice until the legislation has become law because it would be an insult to Parliament.

I attended on the Benches opposite for a great many years. I often did not like what I heard. However, on the whole when governments said that they were going to do something, one generally took the view that they would do it and we should prepare for it to happen. I am at a loss to know where the doctrine comes from that it would be unfair and insulting to Parliament to ask people to act before the Bill became law.

I know how reasonable and moderate the Minister is. She will be listening carefully to all the amendments. However, on this occasion, despite her desire to be helpful, I would advise her not to accept the amendment.

4 p.m.

The noble Lord speaks from another dimension. He is an economics don. He can say, "This is this. Let's get on and do it". Whether or not it works does not really matter. I read economics some time ago. Economists get it wrong anyway. But the one thing about which they do not care is whether it will work in practice. It is theory.

We are concerned here with making the provision work. We are not in the dimensions of erudite economic theory. It is a practical problem. Delay it only to make it work.

Since we are in Committee, I am allowed to intervene. Logically I do not see how one discovers whether something works in practice until one puts it into practice. The position is the exact reverse of what the noble Lord said. It may well be theory now but it is very good theory.

What I hope the Government wish—it is certainly what I wish—is that we put the provision into practice and make it work. I have a higher opinion of the medical people involved. I am firmly convinced that they will make it work. I hope that they will be willing to make it work—without having their mouths stuffed with money—because it is the right thing to do.

Surely we need the assurance that we have the people on the ground to make it work. One of my great fears is that we do not have them.

The noble Baroness, Lady O'Cathain, seems to argue for our making the change, and as quickly as possible. She cited a case of a practice manager also being employed as a primary care group manager. Presumably within that primary care group there are other practices with practice managers. When the primary care group is set up, those managers will be redundant. They will no longer need to he paid by the National Health Service to provide that management function at the doctor practice level. The management function will be provided by one person at the primary care group level.

I exaggerate, but the system set in place by previous governments required a superfluity of managers for small groups. It is proposed that a smaller group of managers covers a larger number of people. Effectively, the money that we spend on the National Health Service will go into patient services, not management functions. The sooner we do that, the better for everyone involved.

We have now had the second red herring of the afternoon in debate on an amendment which my noble friend Lord Howe wished to be brief.

Yes, the management decision has been made. The Government want to get on with it but they do not want it to end in a mess. My noble friend Lord Campbell of Alloway is absolutely right. I readily understand that the Government will not accept the suggestion of a year's time, or 13 months. We want to know what date it will be introduced. Will it be introduced properly? Will it work? That is the only thing that matters.

The noble Lord, Lord Monkswell, does not seem to understand that a practice with, say, five doctors will still require a very active practice manager on the premises. The practice will also have someone running a much larger group of practices. The practice manager on the premises of the five-doctor surgery cannot be paid at the same rate as previously where he or she has had a much bigger role. Many of those practice managers will either want the job of the overall practice manager (there will be only one) or they will become redundant. Very few will wish to see their salary halved or greatly reduced. That is where the redundancy money comes in. I hope that the Minister will reassure us that every effort will be made to ensure that the money required for the changes is available. The story I hear from general practitioners is that they are having great trouble obtaining the necessary funding to bring in the changes.

I hope that I can be of some help to the Committee on this. I thank the noble Earl, Lord Howe, for the tenor of his introduction of the first amendment. I undertake to try to emulate his desire to be brisk and to the point. But this may not be the best amendment on which to start that process because I think that there has been some confusion in what the amendment would achieve on three separate issues.

One issue is the setting up of primary care groups which is outwith the scope of this Bill. That is going on at this moment. I shall return to some of the other issues raised. Perhaps I may say to the noble Baroness, Lady Carnegy, that, as sub-committees of health authorities, primary care groups do not need any form of primary legislation. Therefore there is no question of taking powers in anticipation of legislation. Those primary care groups will be up and functioning by 1st April. I shall return to some of the issues raised by the Committee on ensuring that they function effectively and efficiently.

I refer to the implementation date for what will be set up within the Bill. The noble Lord, Lord Campbell of Alloway, referred to Clause 1. Perhaps I can reassure him that the terms for the setting up of primary care trusts—we shall address the Committee's attention to that in a moment—have been made quite clear. We want to spend time getting this right. They will not be set up before April 2000, so there is adequate time to undertake that task.

I believe that confusion has arisen on this issue. If the Committee were to agree to the amendment, it would not delay the introduction of either primary care groups or trusts. It would delay the abolition of fund-holding. We need primary legislation for the abolition of fund-holding. The reason why an interim and residual scheme has been introduced from 1st April of this year is precisely that we recognise that need. We cannot anticipate the legislation and we have to have a residual scheme available to those GPs who wish to avail themselves of the proposal until the Bill becomes law.

The issue is simply whether extending the existence of GP fundholding until April 2000 would assist in the process with which the Committee is concerned: to ensure an orderly and effective transition to primary care groups. I suggest that it would not. In essence it would be looking backwards rather than forwards. Our responsibility is to ensure that the change which has been agreed, which no one is questioning, works well.

I pay tribute to the large number of professionals and managers who have been working extremely hard to get primary care groups off the ground by 1st April of this year. I do not recognise the noble Earl's gloomy description of what is going on on the ground in primary care groups.

Obviously, it is a major undertaking, but already boundaries and governing arrangements have been agreed around the country. The pace of change is sensible; we do not expect everything to be achieved overnight. This year, £31 million have been allocated to health authorities to help them fund the preparations. The allowances paid to PCG hoard members are reasonable and consistent with those paid to other members of NHS bodies. A revised model of standing orders and SFIs were issued to health authorities last week.

There is an issue around redundancies, to which the noble Baroness, Lady Gardner, referred, and there have been concerns about the transition of staff. Our aim is to avoid redundancies. We have set in place clear in-house arrangements to help achieve that. We have also required all health authorities to appoint an individual to co-ordinate this and other fundholder closure work. It is too early to predict exact numbers, but we are confident that most who formerly managed a fundholding scheme will secure posts in the NHS. The noble Baroness, Lady O'Cathain, said that that was happening on the ground. Our policy is that redundancy costs chargeable to the fundholder, the allotted sum for fundholding staff, should be the same as those which can be reimbursed to GPs for GMS staff under the Red Book rules. This is equitable, but it does not preclude GPs offering enhanced redundancy terms. However, if they were enhanced that would have to be a practice expense.

I return to what the amendment would achieve. It would delay the abolition of fundholding; there would be a minority fundholding rump scheme. We believe that in recognising the achievements which fundholding GPs gained for some of their patients, and looking at the way in which many of them have taken the lead in setting up primary care groups, we will serve no purpose whatever in extending a scheme for a small minority of GP fundholders. If the Committee is concerned about ensuring that primary care groups from 1st April this year, and primary care trusts as they appear from April 2000 onwards, work effectively, we need an orderly and proper parliamentary approved end to the fundholding scheme as soon as possible so that everyone can divert their attention to the future. That is the reason why within the Bill we have made clear that as soon as it receives Royal Assent and becomes law we will wind up the scheme that has been put in place simply to cover a brief transitional period. I hope that on that basis the noble Earl will not press the amendment.

I am grateful to the noble Baroness, although I am disappointed by her reply. The main point that I seek to make to her and to her noble friends Lord Haskel and Lord Peston is that the Government have not yet put in place arrangements for the orderly winding up of fundholding. That is the central issue. If they are unable to do so, it would be irresponsible to force the demise of fundholding with no safeguards for fundholder GPs and their staff.

With just over a month to go, PCGs have a vast agenda to complete in order to ensure that they are properly up and running. They must establish management structures and cost agreements; staff recruitment; accountability agreements with the health authorities; service agreements; develop investment plans; establish links with social services; design IT structures; and a whole lot more. Many PCG boards and health authorities are finding that an almost impossible hill to climb by 1st April. I believe that we need to be more sensible about it. My amendment does not mean that all fundholders must wait until March 2000 before winding up; it means that they do not have to wind up their fundholding arrangements by 1st April this year.

I am grateful to Members of the Committee who have supported my amendment and I believe that it is appropriate that we should test the opinion of the Committee.

4.15 p.m.

On Question, Whether the said amendment (No. 1) shall be agreed to?

Their Lordships divided: Contents, 72; Not-Contents, 137.

Division No. 1

CONTENTS

Aberdare, L.Howe, E.
Annaly, L.Hylton-Foster, B.
Astor of Hever, L.Kinnoull, E.
Berners, B.Lang of Monkton, L.
Bethell, L.Leigh, L.
Blaker, L.Long, V.
Blatch, B.Lucas of Chilworth, L.
Boardman, L.Lyell, L.
Broadbridge, L.McColl of Dulwich, L.
Burnham, L. [Teller.]Mancroft, L.
Buterworth, L.Merrivale, L.
Cadman, L.Milverton, L.
Caithness, E.Monson, L.
Campbell of Alloway, L.Morris, L.
Carnegy of Lour, B.Murton of Lindisfarne, L.
Chandlington, L.Naseby, L.
Clanwilliam, E.Noel-Buxton, L.
Clark of Kempston, L.Norrie, L.
Cullen of Ashbourne, L.Nunburnholme, L.
Dacre of Glanton, L.O'Cathain, B.
Davindson, V.Pilkington of Oxenford, L.
De Freyne, L.Platt of Writtle, B.
Dean of Harptree, L.Reay, L.
Dundee, E.Rees, L.
Elles, B.Renton, L.
Erne, E.Renwick, L.
Foley, L.Rowallan, L.
Fookes, B.St. John of Fawsley, L.
Gardner of Parkes, B.Simon of Glaisdale, L.
Glanusk, L.Soulsby of Swaffham Prior, L.
Haddington, E.Sudeley, L.
Harding of Petherton, L.Swinfen, L
Hayhoe, L.Teviot, L.
Hemphill, L.Wise, L.
Henley, L.[Teller.]Wynford, L.
Higgins, L.Young, B.
NOT-CONTENTS
Acton, L.Calverley, L.
Addington, L.Carlisle, E.
Ahmed, L.Carmichael of Kelvingrove, L.
Alderdice, L.Carter, L.[Teller]
Allenby of Megiddo, V.Charteris of Amisfield, L.
Alli, L.Christopher, L.
Alton of Liverpool, L.Clarke of Hampstead, L.
Ampthill, L.Clement-Jones, L.
Annan, L.Clinton-Davis, L.
Archer of Sandwell, L.Cocks of Hartcliffe, L.
Avebury, L.Craigavon, V.
Bach, L.Crawley, B.
Beaumont of Whitley, L.Currie of Marylebone, L.
Berkeley, L.David, B.
Blyth, L.Davies of Oldham, L.
Borrie, L.Dean of Thornton-le-Fylde, B.
Brightman, L.Desai, L.
Brooke of Alverthorpe, L.Dholakia, L.
Brookman, L.Donoghue, L.

Dormand of Easington, L.McIntosh of Haringey, L.
Dubs, L.

[Teller.]

Dunleath, L.McNally, L.
Eatwell, L.Maddock, B.
Elis-Thomas, L.Mar and Kellie, E.
Emerton, B.Methuen, L.
Evans of Watford, L.Milner of Leeds, L.
Ezra, L.Molloy, L.
Falconer of Thoronton, L.Monkswell, L.
Farrington of Ribbleton, B.Montague of Oxford, L.
Gainsborough, E.Morris of Manchester, L.
Gallacher, L.Murray of Epping Forest, L.
Geraint, L.Peston, L.
Gilbert, L.Pitkeathley, B.
Gladwin of Clee, L.Ponsonby of Shulbrede, L.
Goudie, B.Ramsay of Cartvale, B.
Graham of Edmonton, L.Rea, L.
Grenfell, L.Redesdale, L.
Hacking, L.Rendell of Babergh, B.
Hardie, L.Rix, L.
Hardy of Wath, L.Rodgers of Quarry Bank, L.
Harris of Greenwich, L.Rogers of Riverside, L.
Harris of Haringey, L.Sainsbury of Turville, L.
Haskel, L.St. John of Bletso, L.
Hayman, B.Scotland of Asthal, B.
Hilton of Eggardon, B.Sharp of Guildford, B.
Hollis of Heigham, B.Shepherd, L.
Howie of Troon, L.Shore of Stepney, L.
Hoyle, L.Simon, V.
Huges, L.Stallard, L.
Huges of Woddside, L.Steel of Aikwood, L.
Hunt of Kings Heath, L.Strabolgi, L.
Hylton, L.Symons of Vemham Dean, B.
Ilchester, E.Tenby, V.
Irvine of Lairg, L. [Lord Chancellor.]Thomas of Gresford, L.
Janner of Braunstone, L.Thomas of Macclesfield, L.
Jendins of Putney, L.Thomas of Walliswood, B.
Judd, L.Thornton, B.
Kennet, L.Thurso, V.
Kintore, E.Tordoff, L.
Kirkhill, L.Turner of Camden, B.
Laming, L.Uddin, B.
Linklater of Butterstone, B.Wallace of Coslany, L.
Lockwood, B.Walton of Detchant, L.
Ludford, B.Warner, L.
Macdonald of Tradeston, L.Waverley, V.
McFarlane of Llandaff, B.Weatherill, L.
Wigoder, L.
Williams of Crosby, B.
Willams of Elvel, L.
Williams of Mostyn, L.
Young of Old Scone, B.

Resolved in the negative, and amendment disagreed to accordingly.

4.24 p.m.

Clause 1 agreed to.

After Clause 1, insert the following new clause—

DIRECT FUNDHOLDING PRACTICES

(".—(1) The Secretary of State may, at his discretion—
  • (a) grant individual general practitioners leave to withdraw from any established Primary Care Trust;
  • (b) grant individual general practitioners leave to withdraw from the direct budgetary control of a Health Authority, or sub-committee thereof.
  • (2) Any general practitioner given leave under subsection (1) above shall take on powers, functions, and a budget as directed by the Secretary of State.").

    The noble Earl said: The Committee stage of a Bill gives us an opportunity to examine some of the broad conceptual underpinning of the Government's health reforms as distinct from the kind of matters we have just been considering; that is, structure and practice which flow from the policies. The high hopes that all supporters of the health service must share for PCGs and PCTs are, for many of us, counterbalanced by deep doubts.

    It is worth looking at a few aspects of the new arrangements. The Conservative government introduced reforms into primary care which were significant; but at the same time they were voluntary. GPs were able to choose whether or not to become fundholders; there was never any question of forcing them to do so. The present Government have adopted a different course. There is no longer a question of choice. Doctors must become part of a primary care group, and that PCG will be an entity which represents the interests of a great many more patients, doctors, nurses and clinicians than even the largest fundholding practice ever did.

    Doctors were previously given a choice, and if they wished to be fundholders they were given their own budgets and a great deal of freedom in which to develop primary care services for their local area. The benefits of that freedom, as I said at Second Reading, have been clear and tangible. Now, GP fundholders' budgets are to be taken away from them and their freedom of action within a PCG will be largely governed by the policy of the PCG itself, together with the health authority.

    The Government's stated aim in abolishing fundholding is to reduce inequalities in the delivery of primary care and to cut bureaucracy. Of course, those are laudable objectives. But will they be achieved? My first question to the Minister is: where is the much trumpeted figure of £1 billion of savings in bureaucracy to come from? As far as I can make out the only thing that the Government have done in that context is to cut the number of commissioning bodies. I accept that less paper is likely to flow in the form of invoices and so forth, but the PCGs and PCTs will still need managing and administering. That will be a much more complex task than fundholding and is bound to generate paper rather than the opposite.

    Devolved budgets gave fundholder GPs an incentive to make savings and plough that money back into primary care services. Can the Minister say what incentive GPs will have in a PCG to make savings, knowing that any such savings will be swallowed up by less efficient practices within the same group? What are the levers that will encourage them to do that? I do not see them. Indeed, how robust will the accountability mechanisms be in level one and level two PCGs? Why, in the final analysis, should a GP do as he is told by the health authority?

    Is the intention to withhold funding from any GP or practice which does not conform? Non-conforming GPs are bound to be a feature of the new arrangements. The sheer size of a PCG, let alone a PCT, which is likely to be much bigger, will make for unwieldiness in decision making. It will also make for much less of a facility to cater for local needs than has been the case under fundholding. The "accountability model"—as it is called—is weak. Meanwhile, at levels one and two it is the health authority's neck that is on the block.

    If the Government really believed in flexibility, they would have set up flexible structures to match that aspiration. Instead, they have gone the other way. That is what lies behind my amendment; a power to leave a future Secretary of State with the flexibility, if he so chose, to introduce devolved budgets for groups of GPs, should that seem to be a sensible course in a particular health authority area. Such a provision would, of course, keep a power in reserve without the need for further primary legislation in the future.

    That is the long and the short of it. It is, I hope, a modest proposal and not an offensive one. I look forward to the Minister's reply. I beg to move.

    4.30 p.m.

    Before my noble friend sits down—he has sat down but perhaps I may ask him a question. As we are in Committee, he will be free to answer. If a general practitioner is granted leave to withdraw from the PCT, would he, nevertheless, still be under an obligation to work within the National Health Service?

    Most certainly. The object of my proposal is to enable that to happen but to grant the GPs concerned more flexibility than they might otherwise have had. It would be a decision for the Secretary of State, though they would remain within the health service and subject to all the other disciplines of the health service.

    I am not sure whether a Bench can nail its colours to the mast. Be that as it may, whatever the appropriate metaphor, this seems to me the point at which I wish to indicate that, on these Benches, we support the broad thrust of the transition to PCTs. Indeed, the move towards PCGs that the Minister has indicated has already started.

    Of course, all change is uncomfortable and one recognises that the amount of work, management and sheer worrying general practitioners currently have to do is enormous. Nobody underestimates the amount of work taking place to prepare for when PCGs come into operation. In addition, nobody underestimates the amount of work which needs to be done with the Bill to improve the provisions in terms of the constitution of PCTs and in relation to accountability, transparency, partnership and consultation. We shall be seeking to ensure that a great many additions are made to the Bill in that respect.

    We do not support a command and control structure for the NHS as tight as perhaps the Government appear to he drawing it. I noticed in The Times the other day that the Secretary of State was talking about personally scrutinising the CVs of all trust chief executives. That is the route to a situation where the Secretary of State is responsible for every bedpan in the National Health Service. Quite frankly, I have no doubt that he does not wish to be responsible for every bedpan; it is bad enough being responsible for one!

    That said, there must be consent. Many of the amendments that we are considering today, which have been tabled by noble Lords of all parties, relate to the way in which the transition from PCGs to PCTs takes place. I believe that if that is run and constituted properly, the transition from, say, class 1 PCGs to class 2 PCGs and on into the PCT structure can be done in a proper, user-friendly way and mean that GPs are fully brought on board in the process. When I say GPs, I am not ignoring the other professions allied to medicine, a great many of whom have made a lot of representations on this Bill. However, I do not believe that trying to overturn this structure by a side-wind in this amendment is a sensible way to go. An opt-out for GPs by simply reconstituting fundholding by any other name is not in the interests of patients. It is certainly not the thrust of the proposals in the White Paper which we supported, and we do not believe that this amendment is the right way to go forward.

    I do not suppose one needs supernatural powers to imagine that the Minister's brief is marked "resist". Nonetheless, I support the amendment because I am sorry to see fundholding, as a concept, disappear. It has become clear to me over the years that all organisations are as much subject to fads and fashions as hemlines for ladies used to be. It is clear that fundholding is now last year's fashion. However, I would not wish the time to pass without saying that I believe this is a mistake on the part of the Government.

    I believe that fundholding was showing itself to be successful. If it had been given time, in the end, by voluntary means, all GPs would have joined in and we would have had a very satisfactory position, with none of the objections currently raised against it. However, it is clear that the Government are prepared to go on to another form, another fashion, and we are unlikely to see fundholding retained. That is regrettable. I support the amendment which seeks to leave a little loophole for it to return at some other time.

    I do not believe it is a matter of fashion. The noble Earl who moved the amendment did not address the main argument against fundholding; that is, that it makes for inequalities in the service. Patients want an equal service of a high level, not inequality of service according to where they live. That is why I believe that the move the Government are making is a desirable one to achieve that equality of service.

    I shall not pursue the "hemline" route pursued by the previous two speakers. However, I hope the Minister will recognise that this is a very unusual amendment indeed. Generally speaking oppositions resist like crazy giving extra powers to the Secretary of State, no matter what Bill is being discussed. In recent years they have been backed up by your Lordships' Select Committee on Delegated Powers and Deregulation. Indeed, we shall come to the arguments proposed by that committee a little later—probably not today, but on Monday.

    However, I would take issue with the noble Lord, Lord Clement-Jones. The amendment does not give GPs an "opt-out", which I believe was the phrase he used. As my noble friend Lord Howe stated, it allows a future Secretary of State to take account of a developing situation, and this is, of course, a developing situation. We go on from groups, through their various stages, to trusts. It may be that in some parts of the country things are not working quite as fast or as well as the Government apparently expect. I cannot see any good reason why there should not be a reserved power for the Secretary of State to take account of that. It may be that my noble friend does not have quite the right "account-taking" amendment—if I may put it in that way. Nonetheless, if we have to go back time and time again to primary legislation, that must be wrong. Therefore, I support my noble friend, certainly in the premise behind his amendment, if not in the amendment itself.

    It seems to me that the amendment is based on a good deal of optimism from those on the Benches opposite who feel, clearly, that they will be back in government at some stage and will be able to use it, if agreed, to put into effect yet another attempt to bring back a version of GP fundholding.

    It is perhaps worth recalling history. After all the efforts of the previous government to introduce GP fundholding and all the financial incentives given to GPs to become fundholders, we still ended up with only 50 per cent. or so of the population cared for by GP fundholders. Therefore, we still had a situation in which about 50 per cent. of the GPs in this country resisted those blandishments and were caring for their patients outside fundholding. Of those who had accepted fundholding, a good many did so with the greatest reluctance and felt that they were put under undue pressure to pursue that particular line. We must bear that in mind and the fact that fundholding was not the great triumph that it is presented as by those opposite. It was actually a very divisive approach to primary care for patients and it was rejected by very many of this country's GPs.

    I do not need to say, "Before the noble Lord sits down", because this is Committee. However, does he not accept that, by law, many GP practices were not allowed to become fundholders—I am referring to the smaller practices—and that therefore his figure of 50 per cent. is not terribly helpful in illustrating his case?

    The noble Earl said that this was a "modest" proposal and the noble Lord, Lord Skelmersdale, said that it was an "unusual" amendment. Perhaps we shall have a new concept in your Lordships' House—that of the modest and unusual wrecking amendment. This amendment, just like the previous amendment on which we have just voted, goes to the heart of a very firm manifesto commitment which was repeated in our White Paper on the NHS.

    I must advise the noble Baroness, Lady Fookes, that I did not need a brief marked "resist" to know that I should resist this amendment as the manifesto is dear to my heart—it is not quite written word for word on it—and I know absolutely what we said in it about ending GP fundholding—and I know that we have not wavered from that. Therefore, I echo the words of my noble friend Lord Warner.

    The noble Lord, Lord Skelmersdale, kindly offered the Secretary of State—unusually, as he said—additional powers. A Labour Secretary of State does not want to have additional powers to recreate fundholding because we do not believe that it is the right way forward for primary care within the NHS.

    As I have said, we have a clear commitment to abolish the internal market and GP fundholding in particular and to replace them with modern arrangements founded on the principles of co-operation and partnership. It is on those principles that our plans for primary care groups and primary care trusts are based.

    The fundholding system, in which individual GPs were allowed to take on powers, functions and a budget, was in fact a centrepiece of the old internal market. We recognise that although some GP fundholders used those arrangements to deliver benefits for their patients, that was done (almost by definition) because they were available only to some patients and were therefore achieved at the expense of others. Abolishing that system is crucial to the delivery of our commitment to improve the quality of healthcare overall and for all patients.

    Primary care groups, and in due course primary care trusts, will allow GPs and other professionals to work together to improve the health of, and to address the health inequalities in, their local communities. The arrangements will build on the experience not just of GP fundholders but of multi-funds, total purchasing and GP commissioning groups. They do so crucially without the competition embedded in the fundholding system and extend the influence of GPs and nurses across the full range of the health service.

    It has been argued that the amendment would provide an alternative for those GPs who feel that they have been in some way coerced into a primary care group or that they will be coerced into a primary care trust when the Bill has received Royal Assent and primary care trusts are first set up. It is absolutely true that all GPs are members of a primary care group. However, in practice, that is little different from what has been a long-established practice in the health service. I refer to GPs being on the list of a particular health authority, from which they could not opt out. They were, by definition, party to its commissioning arrangements if they were not fundholders. In both cases, they are essentially geographically based and, short of moving into other areas, GPs have only marginal choice about the group to which they are attached.

    However, GPs are, and will be, free to decide how actively they participate in the development of their primary care groups. We are looking to former fundholders to be among those leading the primary care groups forward. Many of them have demonstrated energy, enthusiasm and a commitment to patients in developing innovative services or commissioning arrangements. We want to harness those attributes. Many fundholders have responded to that challenge.

    However, it is not only fundholders who have something to contribute. I refer to the nurses who will lead primary care groups and to the other GPs who, for clear and committed reasons of principle, did not want to be fundholders but who have been leaders in developing services in their own authorities.

    We are convinced that we can extend good practice and innovation to all patients rather than start a process of levelling down. Success would be much more difficult to achieve if we were to allow the continuance or re-creation of islands of singleton fundholders. The new arrangements and the old systems are not compatible. Allowing the two to continue in parallel or, indeed, in competition for any substantial period would be a recipe for both confusion and bureaucratic excess.

    As the noble Earl pointed out, we are looking to reduce bureaucracy in order to make savings for the health service. That will be achieved not only by using across the board the funds that sustained GP fundholding for a minority of the population so that they provide the funding for primary care group management for the whole population, but also by other measures such as encouraging co-operation and benchmarking across the NHS which can save a great deal of money, by abolishing extra-contractual referrals (ECRs), by moving to longer-term service agreements and by doing away with some of the enormously wasteful and frustrating paper-chases which were the consequence of the internal market.

    The noble Earl also asked about the incentive framework to provide incentives for individual GPs within PCGs to make efficiency gains. Practices will be entitled to 50 per cent. of any savings they achieve against their indicative budgets. That entitlement will apply even if other practices in the PCG overspend in total. We have built into the system an incentive for the PCG as a whole as well as for the individual practices within it.

    Primary care trusts will be established by the Secretary of State. Progression to trust status will be locally determined, based on local views. The Secretary of State will be able to establish primary care trusts only after local consultation. The views of the primary care groups, the local GPs and other professionals, as well as those of the wider community and of the NHS locally, will clearly be key considerations for the Secretary of State in deciding whether to establish a primary care trust. It is our assumption that the support of the relative primary care group would be required—and GPs have a majority on PCGs.

    The Committee should note that this amendment would fundamentally undermine the changes which we are committed to deliver. Like the previous amendment, essentially it looks backwards and harks back to a discredited system rather than looking forward to making the new system work. I urge the Committee not to support it.

    4.45 p.m.

    I suppose that we should be thankful for some small mercies in that at least the Government are not wavering from one of their manifesto commitments. I put it to the Minister that she has been guilty of at least a little loose terminology. This is not a wrecking amendment. I deliberately have not tabled any wrecking amendments to this Bill. The amendment seeks to grant a reserved power to this or any future Secretary of State. It does not prevent the Government ending GP fundholding and fulfilling their manifesto commitment.

    I do not believe that the Minister covered my point about the Government's objective of saving £1 billion for the health service by cutting bureaucracy. I wonder whether she can comment on that and whether she still believes that that is an achievable target. It would be wonderful if it were, but I wonder whether the noble Baroness still believes that.

    Secondly and specifically, does the Minister believe that devolved budgets will be possible at practice level within the primary care groups and primary care trusts? Setting aside the amendment for a moment, does the noble Baroness believe that that is a realistic proposal for the new structures that will be put in place? Before I decide what to do with this amendment. I wonder whether the noble Baroness could answer that point.

    I can say to the Earl, Lord Howe, that there will have to be some element of devolution here in the sense that there will be indicative budgets, as I suggested in my reply about the savings and the incentives for efficiency gains. In order that people can make proper comparisons and assess their own practice on matters like prescribing, it will be necessary to know at practice level how an individual practice is doing and to be able to make comparisons. So in terms of information that kind of devolution will have to go on in order to make the situation work.

    It is very early in our deliberations to start bandying words and I would not wish to do so, but I have to say to the noble Earl that when we have a clear and unequivocal manifesto commitment to abolish fundholding and I see two successive amendments trying to recreate, either for a longer period or as a reserve power, that which we said in our manifesto we wanted to abolish and said very clearly that we were going to abolish—and we would be accused of ducking and weaving if we had put in some reserve power that we could pull back at a later time—it seems to me that we are undermining that fundamental manifesto commitment. I must make clear that we are not willing to do that. I do not quite understand what other manifesto commitments we were going back on, as mentioned by the noble Earl. Perhaps they will be listed later this evening, but I am not aware of any.

    So far as concerns the billion pounds of savings, we are still looking to that target as well as to the target reductions, including those for health authorities, NHS trusts and GP fundholder management costs that were set in May 1997, with 84 further targets of £73 million in 1998–99, which were announced in 1997, and for cumulative savings to date that are already around a quarter of a million pounds.

    Could I ask the Minister for a little clarification on what she has said? First, she says that the aim is to reduce bureaucracy—I am quite convinced that this proposal will not do that—and she is also looking for savings in financial terms. The noble Baroness said that practices would be able to keep 50 per cent. of any money that they saved. Would she confirm that that will be irrespective of whether every practice saves more than expected and will there be no ceiling at all on how much practices can save? Further, will practices be able to save, for example, by not prescribing in the same budget something like beta interfon—because that is just too expensive and certain GPs and their partners even now object to prescribing something very expensive because it affects the budget? Will GPs be able to prescribe quite freely or will they be losing their incentive if they prescribe these expensive treatments?

    The issue about GP prescribing and how we ensure equal access for patients to a variety of treatments is a much wider issue, which I am sure we will come to later. However, through the National Institute of Clinical Excellence, the national service framework and then through the clinical governance arrangements we are making sure that the best quality advice is going out to all those who are providing health services so that they can be publicly accountable through their clinical governance and in the course of clinical governance for the quality of the service which will include access to drugs, for example, to which the noble Baroness referred.

    As far as concerns the incentives for efficiency gains, practices will be entitled, as I said, to retain 50 per cent. of all savings they achieve against indicative budgets, but those savings are to be capped at £45,000, and they must be made through efficiency and not through reduction in services. I hope that is helpful.

    This has been a useful debate and I am grateful to the noble Baroness for answering the questions that I put to her. I would only say that if it had been my intention to wreck this Bill I would have given the Committee notice that I intended to resist Clause 1 as part of the Bill, and I would not dream of doing such a thing. With those comments, and reserving the right to bring this matter back at a later stage, I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    Clause 2 [ Primary care trusts]:

    Page 1, line 14, after ("may") insert (", only after a request from the doctors on the medical list of the Health Authority who would be covered by the specified area,").

    The noble Earl said: This amendment addresses an issue which is of great concern to GPs and other health professionals: namely, the fear that when a proposal is made to establish a PCT, that proposal could go out to consultation and be approved without any prior backing from those who are most affected by it, in other words, the PCGs. Unless the PCGs support the establishment of a PCT and unless the collective view of the PCGs is formally canvassed in advance of the consultation, then it is almost impossible to envisage how a PCT could successfully come into being. It would also be hard to justify spending valuable NHS resources in putting the proposals out for full consultation.

    Last Friday's circular from the Department of Health emphasised that progression to trust status would be locally driven and based on local views, but I believe we need to ask what that means. I do not think it is enough to say, as the circular goes on to do—and I am quoting here—

    "It is our assumption that the support of relevant primary groups would be required".

    I am not really sure what that means. The PCGs need to be actively in favour before the Secretary of State goes out to consultation, let alone takes a decision to give the green light to the PCT. Anything else would look very much like coercion, and we have had quite enough of that already. I beg to move.

    We seem to have two groups of amendments about consultation—am I right? I am not sure that they cover exactly the same ground, but I do not understand why there should be two groups. I noticed in the department's letter to the chairmen of health authorities, primary care groups and NHS trusts—and I was grateful to the Minister for sending a copy of that, because it was extremely helpful—that the department gives four criteria for the Government's arrangements for primary care trusts that need to be satisfied. The criteria are that they will have to put primary care professionals in the driving seat, that they will need to provide public accountability, support local public involvement and ensure probity regarding public funds and conflicts of interest.

    The question for all concerned in agreeing to proceed with a trust seems to me that they will have to decide that what the Bill proposes, in terms of accountability, public consultation and funding arrangements and indeed in conflicts of interest, will in fact enable primary health care professionals to be in the driving seat, whether or not they will stay there when all these arrangements are put into play.

    The move from primary care groups to trusts—the groups having been committed to health authorities and the trusts being self-standing—will be an enormous change and the relationship of GPs and others to the centre will change very much. It is a huge change and it seems to me extremely important that everybody concerned is happy about it. It is extraordinary that the Bill treats the matter of consultation is such a cursory way. Clause 2(4) says:
    "If any consultation requirements apply, they must be complied with before a PCT order is made",
    and swiftly sent through Parliament to set the whole thing in place. The Royal College of Nursing is very concerned about this, and rightly so. It wants to know what time will be allowed for consultation. However, I believe that we will deal with timing when we come to the next group of amendments, so the Minister may not wish to reply now in that respect. The universities are extremely concerned, especially those with medical schools and hospitals attached to them. I know one of them intimately and I am aware of the nature of the concerns. It seems to me that consultation of the sort suggested by my noble friend, or perhaps that proposed in the next group of amendments, is absolutely crucial.

    In passing, there is one matter about which I am not clear. The reason for this may be my own thick head, but I am still not clear whether the Government are convinced that GPs who are independent contractors will maintain the freedom that is legally theirs right through the story of a trust to what I believe is the fourth stage. If the Minister could reiterate precisely why they are convinced, I would be happier.

    This is not a party political discussion at all; we are trying to clarify the position and assess how we can get the system to work best for all those working in the health service. There are great questions about it and we really do need good answers from the Government.

    5 p.m.

    On the face of it, it would seem that this is quite an eminently reasonable amendment. However, the noble Earl seems to forget that general practitioners are not the only people who will play a part in the primary care groups. As someone who has spent most of his professional life working as a GP, I believe that the move from primary care group to primary care trust may be thought to be beneficial by many people who are working in the PCG or indeed in the health authority. There may be a few GPs who are not too keen to move on, but it would be for the benefit of the people living in the PCG area to do so. I am sure that many GPs in every case will want to move on to PCTs, but there is just a possibility that, in some cases, a majority of them want to stay put and not move forward. I believe that it would be wrong simply to have a ballot of GPs. Indeed, I might be more inclined to back the amendment if everyone concerned in the primary care group was balloted. I do not think that the Government should necessarily accept any rigid formula here.

    I rise briefly to oppose the amendments tabled in the name of the noble Earl, Lord Howe, and to speak to Amendment No. 16, which has been included in this group. The noble Lord, Lord Rea, has really made my main case for me; namely, that there are a large number of other health care professionals who should be involved in this process. I think it is a mistake to give individual doctors—or perhaps I should say GPs—such a pre-eminent role in determining whether or not you even begin to consider the formation or the institution of a PCT and whether or not it goes ahead.

    Amendment No. 16 follows more closely the circular in that it tries to put on the face of the Bill the necessity of having the agreement of,
    "the Primary Care Group or Groups",
    in the area which will form the PCT. Interestingly enough, it is our amendment in this grouping which has the support of the BMA.

    Several Members of the Committee have already spoken about the inadvisability of naming just one profession. Although we accept the importance of the role of general practitioners, they are not the only professionals in the primary health care team. In fact, the Government—and the Minister again, today—have made explicit commitments to include community nurses in the driving seat of the reforms. Therefore, in their present form, it would be difficult to support Amendments Nos. 6 and 12. I believe that any requirements for consultation should be inclusive of all these professions in order to be effective.

    We support Amendment No. 16. It is important not only to provide for the matters itemised therein but also to provide for the human resources element in which the professions work. That would include a human resource strategy for the whole of the National Health Service, including issues such as family-friendly employment and the issue of violence at work.

    I rise to oppose Amendments Nos. 3, 6 and 12 because, taken together, I believe that they are actually rather dangerous. Indeed, they would enable a smallish group of GPs to prevent the progression from primary care group to primary care trust, irrespective of whether most of the local health and social care professionals in the community in that particular area wanted to make such a progression. The good Benthamite principle of the greatest good for the greatest numbers is a very sound one and one upon which we should reject the amendments.

    I should also like to remind noble Lords opposite that when the previous government sought to merge family health service authorities with district health authorities, a good number of GPs were opposed to such a move. I do not recall a great deal of enthusiasm for consulting local GPs on that move. Indeed, the will of Parliament was regarded as sufficient at that time.

    We do not want to play political football with this matter. I hope that the noble Lord will not address those on the Benches opposite him as if they are always wanting one thing while he wants another. That is not what we are about when we are examining a Bill, and this is one that we want to work.

    Does the noble Lord really believe that you could proceed to form a trust with more than half of the GPs in the group being against operating within such a trust? The noble Lord, Lord Rea, was anxious about that and, therefore, thought that it was a pity to give them the chance to ballot on such a move. Does the noble Lord really feel it would not operate successfully?—because he knows about these things.

    The amendment does not put forward that particular proposition. This is all about health professionals at the local level working together on a co-operative basis. It takes a particular group of health professionals at that local level and almost encourages them to stand out against change if they choose to do so. In my view, that would not be a good contribution to the welfare of local people when we are talking about health professionals and social care professionals working together in the interests of their communities.

    I made some remarks about the Benches opposite. I should point out that the amendment was moved by the Front Bench opposite as part of a group. Therefore, I believe one is entitled to respond on the basis that the party opposite is actually supporting the amendments. I was merely reminding Members of the Committee opposite of the changes which they introduced when they were in government. There was no consultation and no right of veto as far as concerns GPs when the FHSAs were actually merged with district health authorities.

    Thus far in the debate a clear distinction has been made between, if you like, the balloting proposals in the first three amendments of the group and the proposal contained in Amendment No. 16, which—to use a word employed by the noble Lord, Lord Rea—is much more inclusive. It is certainly not our intention to have an unnecessary and artificial block on progress into PCTs. We are trying to avoid a situation which is theoretically possible. If one looks at the guidance notes, they state:

    "It is envisaged that proposals to establish a Primary Care Trust will be generated locally. The views of Primary Care Groups, NHS trusts and local communities will be taken into account in considering such a proposal".
    That does not give the PCG the primary role. In a sense, if one is going to undertake all the consultation that is proposed, it seems rather fruitless to find at the end of the day that the PCG is not favourably disposed to moving towards a PCT. That is why we on these Benches propose Amendment No. 16. We seek to make sure that the sine qua non of the whole process is the PCG itself, which includes not only GPs but also professions allied to medicine such as nurses, community nurses and so on. Therefore it is a much more inclusive proposal. What we want to avoid is the theoretical possibility that GPs and other health professionals could be delivered, bound and gagged, into the new PCT system. We think that would be highly undesirable. The foundation of proceeding to a PCT must be to obtain the consent of the PCG. Those are our motives. They are entirely distinct from those which underlie the other three amendments in the group. We hope that the Government will look favourably on this provision as a mechanism for making sure that there is full consent and that all parties moving into PCTs are part of a constructive process.

    Having heard the discussion, while I can understand and sympathise with some of the principles underlying Amendments Nos. 3, 6 and 12, I find it difficult to support those amendments. However, I believe that Amendment No. 16, to which the noble Lord, Lord Clement-Jones, has just referred, is one of considerable importance. I now pose the following question to the Minister. In her remarks a few moments ago the noble Baroness, Lady Carnegy, referred to wide consultation. That is an issue which I believe is mentioned in subsection (5) of this clause, to which I believe Amendment No. 17 refers. There are a number of important issues to which I should like to draw the attention of the Committee at a later stage. May I take it that it would be more relevant to discuss issues such as the interests of the universities and of other bodies when we reach Amendment No. 17?

    As I understand it, the principle underlying all these amendments, different though they may be, is that there should be agreement to participate in a primary care trust. It is absolutely vital that all those involved should be agreeable to this, and it should not be forced upon them. I am concerned that if the matter is left to consultation—which is a somewhat vague phrase—that could lead to something being imposed which is not welcome to the participants. I am rather taken with Amendment No. 6 because it provides for a secret ballot with a majority in favour of the proposal. I concede that perhaps it does not include the interests of others directly involved, but I think the principle of a secret ballot—perhaps involving all the people who will form the trust—is a wise and sensible proposal, rather than leaving the matter to the rather vague notion of consultation.

    Before the noble Lord, Lord Warner, spoke, I was about gently to chide my noble friend for being too prescriptive in his series of three amendments, Amendments Nos. 3, 6, and 12. As the noble Baroness, Lady McFarlane, and others have pointed out, there are many more people involved in the acceptance of all of these provisions than just GPs. I most certainly go along with that. I am not quite sure though why Amendment No. 16 is in this group, because I could support that straightaway without the slightest problem. The Secretary of State would make a grave error indeed if having slowly brought the PCGs through the various stages, he then enforced a trust upon them. I believe that would result in total and absolute chaos. I cannot go along with that.

    5.15 p.m.

    This has been a useful debate on this set of amendments. As the noble Lord, Lord Walton, said, I think it is a precursor for the debate that we shall have as regards some of the groups that we need to ensure are consulted. It has raised an issue that we shall deal with—to which the noble Lord, Lord Skelmersdale, has just referred—namely, exactly how prescriptive one is on the face of the Bill in an area where there are a large number of different groups and interests who need to be consulted, and where the list in one geographical area and circumstance may not apply to another geographical area and circumstance. By listing everything, one runs the risk either of having legislation that goes on for pages and pages and pages, or leaving out important bodies that may need to be consulted. I refer to local circumstances in this regard. However, that is a general issue to which we can return. I shall deal with the specific amendment of the noble Lord. Lord Clement-Jones, in a moment because that is much more precise.

    I wonder whether the noble Baroness can answer a question. What she seems to be saying is that the whole consultation process has a large agenda and PCGs are simply part of that. But does she accept that the requirement for the consent of a PCG comprises something other than purely consulting with the wider community, the voluntary sector, carers and so on, all of which we shall debate when we reach the later amendments?

    The noble Lord is quite right to chide me on the relationship between a PCG and progression to PCT status. I shall certainly discuss that in a moment. I was just trying to deal with the more general issue which I believe will concern us at various stages in the passage of the Bill.

    Perhaps it would be helpful to respond to the noble Baroness, Lady Carnegy. It is sometimes genuinely difficult to disentangle the role that GPs will play as commissioners of services, as providers of services as part of a level four PCT, and their services as general practitioners in the traditional sense and as independent contractors. I make it clear that in their role as general practitioners providing general medical services, the status of independent contractor will not be affected at all by primary care trusts. We recognise that it is the bedrock of general practice and that it is a major force for improving primary care. It is not the intention of the Government or of this legislation that it should be affected by the creation of PCGs or PCTs.

    I turn to the amendments in the group. As has been acknowledged, the first three deal particularly with general practitioners in relation to the progression to primary care trust status. We have made it clear all along that GPs and community nurses have a key role in developing local services and in rebuilding some of the public confidence in the NHS as a public service accountable to patients and open to the public and shaped by their views. We recognise the important part that GPs have to play in the progress of primary care groups to primary care trusts and in developing and shaping the delivery of healthcare to meet the needs of whole populations. However, that needs to involve the whole community.

    The Government's aim is for an establishment process that is locally driven and that takes into account all local views. We envisage proposals to establish a PCT being generated locally and any decision whether or not to establish a PCT will take into account the range of local views. Local doctors will, of course, have a view on that, but as has been pointed out by both the doctors who have contributed to the debate, they are not the only group of professionals or group within the community who will have a particular interest in the matter. Local PCGs will have a view on the matter—that is the issue which the amendment of the noble Lord, Lord Clement-Jones, addresses—but so too will local NHS trusts providing community services and many others, including (this is important) professional and patient representative groups.

    The PCG has a pivotal role in this process, to which I will return in a moment when I deal with Amendment No. 16. It is our assumption that the support of the primary care group would be required by the Secretary of State before he approved a primary care trust. Not all proposals will go forward for consultation. It is proposed that health authorities will select which proposals are to proceed to consultation, and then to consideration by the Secretary of State. The Government intend to provide in directions that the health authority must select proposals made or endorsed by a PCG or NHS trust providing community services locally. So there is a power for ensuring that locally generated proposals from PCGs go ahead.

    The issue we are addressing in these amendments is whether there is a veto in either body. But, on the positive and proactive side, there is some assurance that at least one of the local NHS bodies is signed up to a proposal before it triggers formal consultation.

    It is argued that these arrangements will provide GPs with a significant opportunity to influence whether or not the PCG initiates proposals and if so, the scope of such proposals, and whether or not to support others put together independently. The amendments proposed put GPs—and this was illustrated in the debate—in a uniquely preferential position. It effectively gives them the right of veto over primary care trusts. That is not the way to go forward. For those reasons I suggest to the Committee that this group of amendments should not be taken forward.

    I turn now to the wider proposal that a primary care trust should only be approved if it has the support of the primary care group. It is important to say at the start that it is no part of the Government's agenda to impose primary care trusts on the service. We believe that primary care trusts will bring benefits to patients, NHS professionals and local communities—and we are confident that people will recognise the opportunities they offer and will want them established—but we do not intend rushing headlong into primary care trusts. We want measured change, progression to trust status, driven locally, based on local views. That is why the Secretary of State will be able to establish a trust only after local consultation.

    There is clear provision in Clause 2, inserting the new Section 16A(4) and (5), for the Secretary of State to impose consultation requirements in relation to the establishment of primary care trusts. The detailed arrangements for that consultation are rightly matters for secondary legislation. Comparable orders for establishing NHS trusts are set out in the 1990 Act.

    The views of primary care groups, local GPs and other professions, as well as those of the wider community and the NHS locally, will be key considerations for the Secretary of State in deciding whether to establish a primary care trust. It is our assumption that the support of the relevant primary care group will be required. My honourable friend the Minister of State for Health made this clear to the chairs of primary care groups, health authorities and NHS trusts in a letter to them on the 19th February—which has been referred to by some Members of the Committee—a copy of which has been placed in the Library. We intend to establish PCTs in a way that is sensitive to local views, and primary care groups are key to that.

    We believe that the amendment is unnecessary and that if it was inserted in the Bill it would be unnecessarily restrictive. For example, it is possible that if two PCGs join to form one PCT, one PCG with a non-GP majority might oppose, even though the great majority of GPs in both PCG areas want to go ahead. Clearly that is a complex and difficult situation to handle—and one which we would have to be very careful and sensitive about—but to put a restriction on the face of the Bill would be overly restrictive. I hope that the explanation I have given—that we would not envisage circumstances in which proposals would go ahead without the support of PCGs—is such as to reassure the noble Lord, Lord Clement-Jones.

    Before the noble Baroness sits down, did I understand her to say that the Government would be quite happy if a primary care trust was set up in an area where the majority of GPs in that area did not want it; that it would be imposed on the GPs. Did she say that?

    If I did, it was an error. It was not what I intended to say. We would have no intention of doing that. The example I was giving was the possibility of a majority of GPs wanting a primary care trust, but the organisation of the primary care group—or one of the groups which would be involved in creating the trust—might not be supportive and therefore stand in the way of the majority of GPs. I was trying to reassure the Committee that we look for local support for these organisations. A key to local support would be local professional groups, like GPs—but not exclusively—and primary care groups would have an important role. The noble Lord, Lord Clement-Jones, is right to say that they will be key players and that their views would be a key consideration. My point is that writing that into the Bill may, in very rare circumstances, be unnecessarily restrictive.

    I thank the noble Baroness for that response. It seemed to warm up as it went along; the language became stronger and more reassuring as we proceeded. It may be that the language at the end was added later—I do not know—but certainly something like "we would not envisage circumstances" is useful language. But it is slightly contradicted—I obviously need to read Hansard—by the point the Minister made about the possibility of it being overridden. She gave the example of two PCGs going into a PCT, and so on. Therefore, I shall need to reflect on what the Minster has said.

    It is probably necessary—not only in terms of the Committee stage of the Bill but in terms of reassurance to PCG chairs and members—to amplify the letter of the 19th February. There are gaps in it and there has been some unhappiness concerning the language about,
    "It is our assumption that the support of the relevant Primary Care Group would be required".
    The Minister's current language of "We do not envisage circumstances where the consent of the PCGs concerned will not be required" is stronger and better.

    It was my honourable friend's language rather than my own which was written down in the advice. I was not trying to draw a distinction. I was trying to rephrase for him, in a way that the noble Lord might find more comforting, the assumption that is clearly set out in that letter. I take the noble Lord's point about the need to in some way clarify exactly what is involved in this. Perhaps he and I can both reflect upon this in the days to come.

    I thank the Minister for that reply. That is certainly the case. I do not think that I am alone in interpreting what she has said as more reassuring about PCGs than the wording in the letter. We need to reflect and come back to it. The Minister has given various reasons as to why it should not be on the face of the Bill—that it might create circumstances where that could not be overridden where that might be desirable, and so on. We need to think about it and come back to it on Report.

    This has been a useful debate. I realise that, when I introduced Amendment No. 3, I was guilty of not making it clear that I was speaking also to my other Amendments Nos. 6 and 12.

    I take the point made by the noble Lord, Lord Rea, and the noble Baroness, Lady McFarlane of Llandaff, among others, about inclusivity. It is, I am sure, the Government's intention, and indeed the wish of most of the Committee, that in the consultation arrangements there should be that inclusivity. There is no question about that. My purpose in putting down the amendments was to test the Government's receptiveness to the idea that there should be prior approval from a key group of professionals who would be most affected by a move to PCT status.

    The issue for GPs, as distinct from any other group of professionals, however important their role may be, is that, by moving from a PCG to a PCT, they are deprived of one very important factor, which is hands on control of the PCG under the current arrangements. Those current arrangements are ones which the Government have themselves granted to GPs. It is not as if they inherited those arrangements or anything else. They have quite consciously given GPs control of PCGs if they want it. No other group of professionals is similarly affected.

    With respect to the noble Lord, Lord Clement-Jones, it seems to me that under his amendment, Amendment No. 16, GPs could be delivered bound and gagged into a PCT unless there were some kind of formula in the voting arrangements. But that is a matter of detail.

    I am grateful to all noble Lords who have spoken. This has been a useful debate and no doubt we shall return to these matters at a later stage. In the meantime, I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    5.30 p.m.

    Page 1, line 15, at end insert ("to provide goods and services for the purposes of the health service.").

    The noble Lord said: I wish to repeat the declaration of interest I made during the Second Reading debate. I was formerly director of the Association of Community Health Councils and am currently a non-executive director of an ambulance service trust. In the interests of brevity, to which the noble Earl, Lord Howe, referred earlier, I intend to speak briefly. I will not repeat my declaration of interest at subsequent stages.

    We are now dealing with Clause 2. I wish to raise the issue of defining clearly the functions of primary care trusts. The Bill does not contain any details of the functions and it does not provide for regulations to define what the functions should be. Therefore, the only way these functions can be specified will be by the establishment orders which will be in the hands of the Secretary of State for Health.

    I am conscious that primary care trusts will be publicly funded, as is set out in Clause 3(1). It is also intended to transfer NHS properties and facilities to them, under Schedule 5A, paragraph 1(4) and paragraph 21. Furthermore, under Schedule 5A, primary care trusts will have powers to dispose of land and property and, under Clause 4(1), they will be permitted to treat private patients and to charge for those services. It is critically important that we build into the Bill safeguards to ensure that public moneys and NHS properties are utilised primarily for the benefit of the NHS. I therefore submit that limits on functions are necessary.

    It is arguable that the Secretary of State would not have powers to detail proper limits and safeguards in an establishment order, as by so doing the Secretary of State would be detracting from the functions permitted in primary legislation without there being an express power in primary legislation to permit the Secretary of State to do so. In any event, it would be more open to have these details in primary legislation than in individual establishment orders.

    What I am suggesting in the amendment is that it would be helpful to have functions specifically detailed in the Act along with safeguards to ensure that the primary care trusts operate for the benefit of the health service. Furthermore, it will be important to ensure that they do not operate in such a way as to disadvantage NHS patients or other bodies providing health or social services. It is also clear in this context that consultation issues will be important. No doubt we will return to that point when we come to discuss other clauses. I beg to move.

    I rise to speak to Amendments Nos. 5 and 24 and to Amendment No. 7 which stands in the name of the noble Earl, Lord Howe. Our amendments seek to put on the face of the Bill some description of what a PCT will actually do. They seek to set out not its powers but its functions. Amendment No. 5 amends Clause 2 and Amendment No. 24 amends Schedule 1. The two amendments are mutually supportive. Before I go any further, I should like to thank the Public Bill Office for ensuring that Amendment No. 24 was put in the right place.

    Our objective is to make the purpose of primary care trusts plain on the face of the Bill. There is a prima facie case for doing that in such an important Bill which gives a totally new structure to the purchasing of care in the National Health Service. There is also the matter of transparency. Bills are there not only so that legislators and lawyers can understand what they are about. More and more ordinary folk and the people who stand in their interests want to know what Bills are about. Perhaps I may remind the Committee that the Bill is a series of amendments to an Act which is already almost 300 pages long. Every one of those pages has at least one explanatory note. Some of them have four or five. We are in very complicated territory. That is another reason for wanting to make the purpose of this new development clear on the face of the Bill.

    Many pressure groups have seen the amendments and have written to support them for the reasons I have put forward. Perhaps I may also draw attention to the fact that in paragraph 15 of its report the Select Committee on Delegated Powers and Deregulation states:
    "If the House is of the opinion that Parliament does not have sufficient control over the creation of Primary Care Trusts, it may wish to consider amending the bill to include a statement of the purposes and objectives of PCTs".
    The formula we have chosen is not the only formula one could choose. The noble Earl, Lord Howe, has approached this issue in a different way. We could have done so. We could have taken a number of different formulae in order to get the same point across. The formula is not what we are most interested in. We want to get a description of the purpose of a PCT on the face of the Bill. I very much hope that the Minister will be able to indicate that she has some sympathy for the purpose of the amendment, even if she does not think that the formula is the one we should have chosen.

    At Second Reading the Minister argued that to include a definition of primary care trusts on the face of the Bill was unnecessary and inappropriate. She argued that on two main grounds. The first was that it was inconsistent with previous legislation. The second was that it was undesirable because what the Government wanted to achieve was maximum flexibility in the way that PCTs could operate and develop in the future. I totally understand the argument about flexibility. But what I tried to convey at Second Reading was the simple point that it was right as a matter of principle for the House to be able to comprehend directly from the face of the Bill the broad structure of what it was debating; namely, primary care trusts. I still do not think that that is an unreasonable expectation for a measure of this importance.

    Indeed, it is a view that is shared by the Delegated Powers and Deregulation Committee of this House, which suggested that,
    "the House may wish to explore whether the primary legislation might provide a general framework for PCTs which will provide a statement of the purposes and objectives within which the regulation-making powers can be exercised".
    That was a more than usually gentle hint from the committee. We should do well to take note of it. The amendment that I have tabled attempts to achieve that objective. I am not wedded to the wording, but I hope that the Government will not be dismissive of the principle behind it.

    It is worth reflecting on the background. As the Delegated Powers and Deregulation Committee said, this part of the Bill contains a wide set of powers. We shall debate their scope later. It is important for the primary legislation to place the order-making powers into a properly defined context.

    The Government have made it clear that they wish to see PCTs develop in imaginative new ways. One cannot possibly take issue with that. I do not believe that the presence in the Bill of what is by any standards a basic definition would inhibit the development of PCTs in any way whatever. So the scope for flexibility is still there.

    The enclosure with the Minister's letter of 19th February contains a whole page on the role of primary care trusts. Then the document immediately goes on to talk about their benefits. It is rather like a sales pitch. It speaks of better support to practices, better support to individual clinicians, better integrated services and better access. You then ask yourself where it relates to the role of PCTs. I mention this point merely to illustrate the necessity of being much more explicit in relation to functions. You have to turn another three pages before reaching the point where the letter states, in rather runic terms,

    "The functions of level 3 Primary Care Trusts are similar to level 2 Primary Care Groups, although with more extensive powers and responsibilities".
    We then refer back to the circular. My noble friend's amendment was drafted with reference to the circular, although in slightly more friendly and not such detailed language. It is that kind of issue that one is grappling with.

    A provision is needed on the face of the Bill. The functions of the commission for health improvement are included in the Bill; surely it would be relatively straightforward to include the functions of the PCTs. The PCTs will have a far bigger impact on the lives of ordinary people than will the commission for health improvement, so there must be a double reason for including the functions of the PCTs.

    I am sure that the noble Baroness, Lady Thomas of Walliswood, and the noble Lord, Lord Clement-Jones, were surprised when they arrived today and found that I had added my name to Amendment No. 24. I hope that they will accept my apology for not informing them beforehand. The functions of primary care trusts have particular relevance to people with a learning disability. I therefore stress the importance of heading (e) in the suggested new draft. It introduces a new function for primary care trusts to develop,

    "particular services to improve the access to health of disadvantaged or vulnerable residents".
    That function is important for two reasons. First, there is presently great confusion about responsibilities for local health services for people with learning disabilities. There is a danger that services may fall between primary care groups and mental health trusts. To that end I should welcome confirmation from the Minister as to where services for people with learning disabilities will be located in this tidal wave of reform. The foreseeable state of flux and uncertainty is a fragile basis for effective management of consultation, accountability and quality management over the next decade. This amendment would give greater priority to effective partnerships in services for people with learning disabilities, and indeed others who are disadvantaged by virtue of age, disability, ethnic origin or social factors.

    5.45 p.m.

    I am agnostic about how these functions are to be spelt out. However, I too wish to speak in support of Amendment No. 24, and particularly heading (f), which refers to,

    "The shaping of local health services to reflect local needs … which ensures the support of users and carers".
    It reflects the absolute necessity of spelling out information in what is to be a major change in health services. It will have the utmost effect on users of the health service. How we do it is of less concern to me, but we must be sure that it is done.

    I strongly support the principles underlying the reasons for tabling Amendment No. 24. One of my concerns, however, relates to the extent to which it is proper in primary legislation to lay down a whole series of individual clauses when it may subsequently become apparent that a number of points of considerable importance have been omitted. For example, heading (c) refers to,

    "the promotion of healthier lifestyles".
    Otherwise, however, the amendment says very little about preventive medicine and a whole series of other issues which might well be enshrined in such a statute.

    Is it, therefore, right that such a complicated and detailed series of proposals should be on the face of the Bill? Or might not these definitions preferably be subject to secondary legislation? If I may be pedantic, in sub-paragraph (g) the phrase "best clinical practise" should have a "c" not an "s".

    Like the noble Lord, Lord Walton, I was wondering whether the Liberal Democrat Benches had perhaps been taking lessons from the Americans, but we shall leave that aside.

    I wish to make three brief comments on this series of amendments. First, I am sorry that we have lost our two professorial economists. When I was learning economics at a very junior level, one of the first things I was taught was to define the terms before mounting the argument. I therefore go along with the noble Lord, Lord Harris, in his amendment, and indeed the other amendments which seek to define exactly what we mean by primary health groups and primary health trusts on the face of the Bill as soon as we decently can.

    However, one can go over the top. Ten years on the Front Bench opposite taught me to be very wary indeed of shopping lists; and what Amendment No. 24 provides is a shopping list. I am sure that, even if the Minister does not use those words, that is exactly what she will to tell the Committee.

    Thirdly, I have the honour to be a member of the Joint Committee on Statutory Instruments. I like to think that I do my homework fairly well and I pore over the various instruments that come before the Committee before each Tuesday's discussion. The idea of including a purpose clause in every statutory instrument pertaining to trusts fills me with total horror. It would be far better to have the provision on the face of the primary legislation; then we could all take it as read.

    A detailed list such that in Amendment No. 24 is not desirable. It would be even worse were it to include heading (j), which refers to,

    "any other activities and functions which, from time to time".
    It is already wide-ranging. Having provided a long list from (a) to (i), the amendment then adds anything else that we might like to name. I cannot support it.

    The noble Baroness has given my reply for me on Amendment No. 24. Perhaps I should try to be helpful to the Committee. The amendments propose in different ways to set out on the face of the Bill the purpose or the functions of primary care trusts. The amendment in the name of my noble friend Lord Harris of Haringey and that in the name of the noble Earl, Lord Howe, attempt to define the purpose in broad terms. In contrast, the amendments proposed by the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Thomas, define the functions in more detail. In the contributions from the noble Baroness, Lady Gardner, and the noble Lords, Lord Skelmersdale and Lord Walton, we had illustrations of the difficulties of putting down lists.

    On the broad principle of a statement of overall purpose of primary care trusts, I have some sympathy with the arguments put forward. We will have to try to define them in fairly broad terms, but we ought to try to ascertain whether we can bring forward a suitable government amendment at Report stage. It would allow the face of the Bill to show what we see as the broad purpose and role of primary care trusts. I believe we can do that.

    However, we get into more difficult territory when we try to define the functions in primary legislation rather than in secondary legislation. There was a commendable effort from the Liberal Democrat Front Bench and it broadly reflects the role that we envisage primary care trusts exercising. However, at the same time it illustrates the problems inherent in trying to define functions of that nature by primary legislation. For example, subparagraph (b) in Amendment No. 24 refers to hospital services "other than specialised services". We envisage that PCTs will be debarred through directions from commissioning some highly specialised services such as those for HIV/AIDS, or cystic fibrosis, or a number of tertiary services for children such as paediatric intensive care.

    However, there are other services such as blue light ambulance services and population screening services where we may want to direct PCTs on how they exercise their commissioning function. We might require them to commission services through joint arrangements with other PCTs or PCGs.

    Clause 2 allows PCTs to enter into such arrangements. The problem of definition has been referred to: what is a specialised service? Another problem of definition is that we all know exactly what is meant by "disadvantaged or vulnerable resident", but if we put it into the hands of the lawyers, after enacting it in primary legislation, we might all find NHS money going down the drain.

    I am not doing this in any way to try to nit-pick or challenge a very good statement of what primary care trusts will do. I suggest to the Committee that it might be a wiser course if we try to bring forward an amendment at Report stage that deals with the broad role that we envisage PCTs taking on. I hope that the Committee will find it useful.

    Reference was made to this being an issue raised by the Select Committee on Delegated Powers and Deregulation in its report on the Bill. At Second Reading I indicated that we would want to look carefully and constructively at what the committee suggested. I welcome the committee's conclusion that the argument referred to by the noble Earl, Lord Howe, whereby I proposed that the approach we had taken mirrored that in earlier NHS legislation was appropriate for the Bill and that in some ways the broad divide was acceptable. I intend to try to bring forward something that meets the points made by both the Select Committee and the Committee today.

    It might be helpful if I referred to two other broad areas on which the Select Committee on Delegated Powers and Deregulation made recommendations. One was in relation to pharmaceutical prices and profits. It stated that it would like to see an appeals procedure and also an affirmative rather than negative procedure for the powers in paragraph 36. We accept the underlying intention of that recommendation and will attempt to respond positively to it at a later stage in the Bill.

    On the issue of self-regulation of the healthcare professionals, there was the comment that there might be a statement of criteria for the exercise of the power, and in addition to the arrangements already set out in the Bill for consultation, a summary of representations received on a draft order laid before the House before that order was considered. That is another recommendation that is positive and helpful. I hope I shall be able to bring forward government amendments on those two areas, as well as on the specific one at Report stage.

    While on these points, if we look at paragraph 15 of the recommendations of the report of the Select Committee on Delegated Powers and Deregulation and the preceding paragraph, paragraph 14, they state that Part II of the Bill makes similar provisions to those that we have just been discussing for Scotland.

    I wonder whether the Government read it as the committee's intention that there should be a definition of the different primary care trusts for Scotland. I also wonder whether, in making the addition to the Bill which the Minister has just outlined, she would do likewise for Part II of the Bill. Perhaps the noble Baroness would consider it. I see the Minister sitting beside her. He may be able to help her in the matter.

    I will undertake to look at it. There is a parallel, as the noble Baroness rightly pointed out. If that parallel is one that ought to meet with an equal response, we will undertake to try to do so. Perhaps I may take it away and consider it in detail.

    Before the noble Lord, Lord Harris, decides what to do with his amendment, perhaps I may take this opportunity to thank the noble Baroness for giving constructive consideration to our debate at Second Reading and again in Committee today. I also thank her for offering to bring a government amendment forward at a later stage in the Bill. It is most helpful and I believe that the whole Committee will be extremely appreciative of the trouble she has taken to address the issues we have raised.

    I add my voice to that of the noble Earl. I thank the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Rix. We were delighted to see his signature on our amendment. It is always a great honour in this Chamber.

    We accept absolutely that the solution put forward by the noble Baroness is correct. I am grateful to her for her compliment on our drafting. We are not entirely surprised because we did our best to ground it on papers provided by Her Majesty's Government so as to make it difficult to oppose. However, we accept the solution she offered and look forward to the forthcoming government amendment.

    I am grateful to the Committee for a helpful discussion. It was clear that a consensus was emerging from all sides about the need to see something on the face of the Bill defining the role and functions of primary care trusts. It was interesting that no Member of the Committee who spoke seemed wedded to the forms of words before us in the group of amendments.

    I am a novice at all this. I understand that if my noble friend Lady Hayman says that she has some sympathy for the proposal, it should be regarded as good news. I look forward to seeing the amendment that she hopes to bring forward at Report stage. On those terms, I beg leave to withdraw the amendment in my name.

    Amendment, by leave, withdrawn.

    [ Amendments Nos. 5 to 7 not moved.]

    6 p.m.

    Page 2, line 1, leave out ("If any").

    The noble Lord said: I beg to move Amendment No. 8 which is inextricably linked with Amendments Nos. 10, 11, 14, 46, 47 and 48. Earlier today I had a conversation with my noble friend Lord Desai who was concerned to give me a lecture on grammar in case I did not make clear that all of these points were closely linked. This amendment brings us back to a discussion a few minutes ago about consultation. Clause 2 and Schedule 1 allow the Secretary of State to determine through regulation any consultation requirements on the creation of a primary care trust. The amendments in this group mean that clearer and more robust consultation requirements are written into the legislation to ensure that a thorough consultation process is followed whenever a primary care trust is created or—of equal importance—dissolved.

    There may well be circumstances in which in a few years' time primary care trusts merge. That may turn out to be a controversial matter. It is important that the circumstances in which a trust is dissolved are also subject to proper consultation. The purpose of these amendments is to ensure that there is always a consultation requirement, and that consultations are thorough, inclusive and effective prior to the creation or dissolution of any primary care trust. In each area different local communities will contain different organisations with relevant interests. Despite the need for local flexibility, there is perhaps a core group of organisations which should be consulted in all circumstances: certainly, all NHS bodies whose areas fall wholly or partly within or adjacent to an area specified in the primary care trust order; all bodies who represent patients and NHS users within the specified area, including community health councils; all local authorities whose areas fall partly or wholly within or adjacent to the specified area; and relevant professional organisations and other bodies.

    It is important to have greater clarity about the length of the consultation process. My experience over the years is that it is very difficult for local communities and organisations to be consulted properly unless there is adequate time for that consultation to take place. In particular, it is not simply a matter of small community organisations receiving a document and being able to respond very rapidly. They need time to consult their members. They may not meet very frequently. There must be an opportunity for proper discussion and understanding of the issues involved. This group of amendments provides that there should be a minimum of six months' consultation and that the outcome of that consultation should be published in all cases. The purpose is to ensure that there are equally robust consultation requirements in the event of both the creation and dissolution of a primary care trust. I hope that the Committee will accept the amendment.

    As the noble Lord, Lord Harris, points out, the Bill contains a provision for the Secretary of State to initiate consultation before a PCT order is made. What it does not do is make that consultation mandatory, unless I have misread the Bill; nor does it list those bodies which have to be consulted on a statutory basis. That is a cause for concern. In discussions that led up to the publication of the Bill complaints were made that significant bodies were not consulted at all or were simply informed of what would happen with no opportunity for participation.

    I speak now to my Amendment No. 13 in conjunction with Amendment No. 25. The Committee will note that Amendment No. 25 contains a list of those bodies which appear to be right and proper statutory consultees. I accept the strictures of my noble friend Lord Skelmersdale (who is not in his place at the moment) that there is an antipathy to lists in any piece of legislation. But the list in Amendment No. 25 is not exclusive and contains those very major bodies which are unlikely ever to become superfluous to the consultation process. The key point is that the consultation process should be thorough and effective. Amendment No. 13 in my name will ensure that there must always be consultation. But other questions arise, one of which has been posed by the noble Lord, Lord Harris: how long should the consultation period last? That is an extremely important question. Will the outcome of the consultation be published? My amendment proposes that it should be.

    I rise to support the amendment moved by the noble Lord, Lord Harris, and speak also to Amendments Nos. 15 and 17 to which I have put my name together with those of my noble friends Lord Clement-Jones and Baroness Thomas of Walliswood and the noble Lord, Lord Rix. We support the amendments that impose an obligation to consult. We very much support the amendment of the noble Lord, Lord Harris, which ensures that there is a minimum consultation period and that the outcome is published.

    As to Amendment No. 25, we have some reservations about the listing. We do not see why bodies such as the BMA and the RCN at national level should be consulted on what is essentially a very local change, although it is important that their representatives at local level are consulted. We certainly believe that to be the case. Amendment No. 15 is linked to the earlier discussion about the process of transition from primary care groups to primary care trusts. We believe that it is vitally important that the Secretary of State is satisfied that the primary care group is ready both in terms of the medical provision that it makes within the area and in terms of its financial capabilities to take over the very much wider necessary responsibilities of a primary care trust. It is also important that it has sufficient maturity to take on the necessary accountability for that status.

    Amendment No. 17 makes clear that primary care trusts belong to their communities and should include other key partners in the consultation process in the delivery of health care services, such as universities which frequently train GPs and are also involved in the training of nurses and other professionals in the medical field. It is extremely important that they are part of the consultation process. Further, dentists appear to get only a very small look in. We believe that they should be consulted to a much greater extent than they are. As to other professionals allied to medicine, such as physiotherapists and pharmacists, it is important that when setting up a community body they are consulted. Finally, patients, carers and voluntary organisations should also be consulted. This underlies the rationale of our amendments. But in broad terms this is very much a question of whether, when one does something that affects the local community so intensely, there should be an obligation to consult widely within the area.

    I rise to support Amendment No. 17, and in particular paragraph (d) which seeks to involve patient and carer associations and voluntary organisations which are involved in health care delivery. As president of MENCAP I am concerned to ensure that people with learning disabilities are adequately represented on the boards of local healthcare bodies so that their needs are not overlooked in the planning, commissioning and delivery of services and the development of strategies to improve public health.

    At MENCAP's conference last September the then Under-Secretary for Health Paul Boateng gave MENCAP assurances that people with learning disabilities would, with appropriate support, be represented on health authority boards throughout England and Wales. I shall therefore welcome today assurances from the Minister that this commitment will be honoured when the new structures are put in place, and that all the relevant consultation processes will be accessible to members of the community with a learning disability.

    On a matter of information, in December, in conjunction with the Royal Society of Medicine, we are holding a major conference of universities, schools of medicine, the dental profession and allied professions—nursing and so on—to look at the delivery of healthcare for people with learning disabilities. I am happy to say that the response from all the bodies taking part has been encouraging.

    While sharing the reservations of many Members of the Committee about lists, I add my support for the general principles of consultation. As we have heard, the consultation must be thorough and real and the outcomes reported back.

    I remind noble Lords that consultation with user, carer, patient and consumer groups is different from consultation with well established statutory organisations. The requisite support in the form of proper information, through radio programmes, respite care or expenses, must be considered if the consultation is to be meaningful.

    I rise to ask a question which I suspect will not be answered until we reach Clause 51. However, it seems appropriate to ask it now.

    I confess that I have only recently considered the Bill in detail. I was abroad at Second Reading. I cannot see that the issue was addressed at that stage. I am genuinely puzzled as to why the transfer of responsibilities to the Welsh Assembly starts only at Section 13. It is a little strange that the power to set up trusts, and for consultation, is given to the Secretary of State and not to the Assembly. If one sets out a list—I refer to Amendment No. 25—one would be bound to add the Welsh Assembly. If the Assembly is not to set up the trust and organise the consultation, clearly it will have to be consulted.

    It seems curious that we are in this situation. I may be wrong, but I do not believe that an explanation has been given on the selection of those powers which go to the Assembly and those which do not. They do not appear in the Explanatory Notes. I pose the question now in the knowledge that I may receive some brief indication. I shall return to the matter on discussion of Clause 51.

    Having been critical of lists a few moments ago, I believe that the list set out in Amendment No. 17 is wholly appropriate. It seems to me crucial that those bodies should be consulted on decisions about primary care trusts.

    The quality of general practice in this country has risen steadily since the institution of vocational training for GPs many years ago. While there is inevitably some unevenness in the quality of provision, the standard of general practice, I believe, is now the highest of any country in the world. I pay tribute to those who have been involved in this transformation.

    The universities play a crucial part in the training of doctors. Through the academic departments of general practice, they play a crucial part in training future GPs, in contributing to vocational training and to the postgraduate and continuing training of those in general practice. The medical schools have become increasingly aware of the crucial importance of teaching medical students in the community in association with general practitioners and not just in the hospital environment. For that reason alone, I believe that it is absolutely vital that university participation should be written on the face of the Bill.

    At Second Reading I referred to the parlous state of clinical academic medicine. That embraces the problems that are being encountered by academic departments of general practice. For that reason, I strongly support Amendment No. 17.

    The same problems relate to Amendment No. 25 as to the list which attempted nobly to define the functions of primary care trusts. If the BMA is to be consulted, why not, for instance, the Medical Women's Federation? If the Royal College of Nursing is to be consulted, why not the Royal College of General Practitioners? One could add infinitely to the list.

    Having given us an assurance that on the functions of primary care trusts she will come back with a government amendment at Report stage, I believe that the Minister and her colleagues are equal to the task of producing a satisfactory amendment to embrace the principles set out in Amendment No. 25. I hope that it is a matter she may be able to concede.

    6.15 p.m.

    Before the Minister rises, perhaps I may say to the noble Lord, Lord Walton, that I deliberately made the list non-exclusive. He will note that the amendment refers to,

    "such other relevant bodies as the Secretary of State shall determine".
    Therefore it does not exclude other bodies.

    I have difficulty with Amendments Nos. 17 and 25. Although I agree with the intent of Amendment No. 17, I believe that there are a number of important omissions. For instance, where would nursing be classed in the list which refers to,

    "key partners in the delivery of NHS health care"?
    Nursing is not technically classed as a profession allied to medicine. The listing in Amendment No. 25 falls into the trap that we have so often mentioned.

    A robust requirement for consultation to take place would be preferable. Bodies such as the Royal College of Nursing are asking how long the consultation process will last and how local communities and organisations should be informed about the outcomes. They suggest a six-month period for consultation. That may seem somewhat long. They also suggest a requirement for the outcome to be published in all cases. They also inquire about the consultation before a PCT is dissolved.

    We must have a requirement on the face of the Bill that the voluntary sector is consulted before any PCT is set up. They were not involved in the setting up of PCGs.

    I speak on behalf of the mentally ill. I declare an interest. I am a director of SANE and patron of Depression Alliance. I am concerned that only 33 per cent. of GPs have mental health training, and much of that is brief. The voluntary bodies do an enormous job in this field. Whatever else happens, we must make certain that they are involved in the setting up of a PCT.

    I apologise to the Committee that when I raised the subject of universities I had muddled my groupings. I had not realised that the subject would be raised now. The noble Lord, Lord Walton of Detchant, has introduced the matter in a more authoritative and able manner than I can.

    Perhaps I may add what the Committee of Vice-Chancellors and Principals has said; I expect that other noble Lords have received the information. It points out that in addition to their teaching responsibilities, university staff, including senior clinical academics, contribute substantially to patient care. It is university employees who provide 30 to 40 per cent. of consultant patient care in teaching hospitals. That is an important additional point, with which the noble Lord, Lord Walton, would probably agree. Those people do most of the science of clinical research which is essential to improvements in healthcare, as well as being major contributors to postgraduate training and continuing professional development.

    I therefore believe that an amendment such as No. 17 is important, although I do not know whether that is the way in which the Government would wish to include the provision in the Bill. The CVCP points out that major implications for medical education and research arise from changes in service delivery. The way in which the trust will operate will be different and that will affect universities enormously. I do not believe that the committee should be regarded as just another group of people to be consulted. It is part of the system and I hope that the Government will take that on board, regardless of whatever they wish to do about Amendment No. 17.

    It is sad that my noble friend's amendment does not mention the dentists, but that Amendment No. 17 does. I am pleased that Amendment No. 17 specifies dentists. For too long there has been too big a division between the British Dental Association and the General Dental Practitioners Association, which represents many National Health Service dentists and should be consulted on a more regular basis. I was pleased that the noble Baroness, Lady Sharp, made that point about dentists.

    I was impressed by the comment made by the noble Baroness, Lady McFarlane, that nursing is a huge omission from Amendment No. 17. I believe that that must be corrected.

    I am all for consultation, but I believe that a general power for consultation should be built into the Bill. The noble Baroness, Lady Pitkeathley, said that consumer groups are the most important, but everyone considers their interest to be the most important. Everyone is important. The noble Baroness stated that some authorities are well geared to sending their replies quickly. I believe that consumer groups and voluntary organisations must become better geared so that the consultation process does not take so long as to hold everything up. I heard six months mentioned, and I would be horrified by that. When I had a position with a regional health authority, I saw years wasted in consultation, after consultation, after consultation. I should like to see a general obligation for consultation and to have a time limit. I do not know whether that should he set by regulation or appear on the face of the Bill, but procedures should not be held up for ever.

    I was interested in the comment made by the noble Lord, Lord Rix—we are always interested in his comments—because dental healthcare for people with learning difficulties is a major issue. It is even more so now that dentists are not allowed to give general anaesthetics. Many of the patients he described are suitable only for treatment under general anaesthesia. They do not understand the treatment and that can be upsetting and frightening. There is therefore a requirement for consultation and for all special needs to be taken into account. I should like to see a more general power rather than it being spelt out in individual lists.

    I thank the noble Baroness for her kind words which are singularly appropriate. However, perhaps I may ask her a question. When I was young I was told that dentists wanted to be called "dental surgeons". I was told that "dentists" were people who just pulled out teeth—that was before the requisite qualifications were introduced. Perhaps the noble Baroness will clarify that point.

    A new Act was passed in 1921, after which dentists had to be qualified. Therefore, people wanted to call themselves "dental surgeons" in order to differentiate them from those who just put up a barber's pole and practised. I do not believe that any survive—certainly none still practises as far as I know! For that reason, we are all now proud to be called "dentists". The fact that dentists are also allowed to use the title "Doctor" has added a great deal to the professional standing.

    I am tempted to share with the Committee the fact that my grandfather was a dentist, but I am sure that he was properly trained. He changed his name by deed poll not when he first came to this country as an immigrant, but as a result of the 1921 Act when he had to register in order to give proof of the name under which he practised as a dentist. I am sure that such people have passed with the passage of time and no longer account for any difficulties.

    We have had an interesting and useful debate which has highlighted some of the difficulties in drawing up, particularly in primary legislation, lists of those who must be consulted in any circumstances. If we added to the list the Welsh Assembly, as suggested by the noble Lord, Lord Crickhowell, we would go even more broadly than the RCN or the BMA as consultees on what are essentially local proposals.

    As regards the Welsh Assembly, I understand that Clauses 2 to 12 amend the 1977 and the 1990 Acts. The Secretary of State's powers under those Acts will therefore be transferred to the assembly under the Transfer of Functions Order made under the Government of Wales Act. Therefore, the only provision which will be required in this Bill is one to the effect that the references in the Transfer of Functions Order to relevant provisions of the 1977 and 1990 Acts must be read as amended by the Bill. We will be introducing appropriate provisions to ensure that. Oh goodness, the noble Lord is going to ask me for even more detail!

    I wish merely to express gratitude to the Minister. It shows the importance of such explanations being included in the ExplanatoryNotes because the situation is not otherwise obvious. It is the kind of explanation we will need in Bill, after Bill, after Bill, so perhaps a precedent can be set.

    I am grateful to the noble Lord. I thought that he was going to ask a supplementary question that I would be quite incapable of answering. We are on the case, so to speak, and the appropriate provisions will be introduced at a later stage.

    In terms of the establishment of PCTs, consultation is mandatory. Clauses 16(4) and (5) have that effect. We must pay attention to two separate issues in tonight's debate. The first is the exception to consultation in certain cases of dissolution rather than establishment. Those are paralleled in other legislation. It will be undertaken only in cases where patient safety is at risk and would not be invoked in normal circumstances around merger or dissolution. It is important.

    Although we want to have local consultation in the case of a dissolution, it would be wrong not to allow for exceptional circumstances, say, to vary an order. It might be amended, for example, from being a commissioning only Level 3 PCT to a commissioning and providing Level 4 PCT. We will make clear regulations as regards the responsibilities of the PCT if it proposed any significant change in the provision of services. Those would mirror the responsibility for the consultation which takes place when a significant variation of service is proposed for other NHS bodies.

    We intend that the regulations will provide for exceptional circumstances when the requirements for consultation may need to be waived. It might, for example. appear to the Secretary of State to be necessary to dissolve a PCT as a matter of urgency. A similar power exists in connection with NHS trusts and is designed as a safeguard if patient safety is at risk. On the other hand, where a proposed change of a PCT order is a minor change—for example, a name or boundary change—we feel that full consultation is not necessary either.

    We would not like to have an absolute requirement on the face of the Bill; it would limit the flexibility. It is argued that placing a requirement for consultation on the face of the Bill is too prescriptive. And specifying the bodies which may be consulted neither takes account of the fact that those who must be consulted may change over time nor that different bodies may need to be consulted for different PCTs, depending on the functions they propose to exercise. Requirements go beyond even who must be consulted, to the period of consultation and a requirement to publish results.

    Clearly, we want there to be an adequate period of consultation—no one is suggesting that it should be a rushed and underhand process. However, as the noble Baroness, Lady Gardner, pointed out, we cannot extend that period ad infinitum. The current usual period is three months and I suggest to my noble friend that that may be more satisfactory than six months. It is also another reason why setting out in regulations the requirements for consultation is the most appropriate and practical approach. It mirrors the approach for NHS trusts. It avoids raising a large amount of procedural and administrative detail on the face of the Bill. And it allows for some flexibility for consultation procedures to develop and change over time in response to changing circumstances.

    The other amendments grouped with Amendment No. 8 indicate equal difficulties. I should like to make clear to my noble friend that we recognise the importance of patient and carer groups in terms of the consultation that should surround the creation of primary care trusts and the fact that they may not be geared up to respond as some of the professional bodies are that have full-time staff. But their views are crucial if these bodies are to respond appropriately to the needs of the communities. It is exactly the same argument put forward by the noble Lord, Lord Rowallan, in regard to voluntary organisations and their specific role and interest in seeing the proposals go forward.

    Equally, I recognise the fear that dentists are sometimes left out of the consideration when the contributions that they make—for example, to the care of those with learning disabilities—are considerable. I apologise to the noble Lord, Lord Rix, that I did not pick up his question earlier. There is no simple answer. Depending on the pattern of service locally and the services required by an individual, they may be of a specialist nature and therefore be regionally commissioned because there are regional specialist services available, or they may be at a primary care level, in which case a primary care trust that provided community services would do exactly that. We must look to the pattern of service being locally determined. I take the noble Lord's point that somebody at the commissioning level must make sure that the full range of provision is available for those with learning disabilities.

    Perhaps I can say also that the contribution and importance of the interest of academic medicine and the universities is well acknowledged. We are not suggesting that, by omitting their names from the face of the Bill and the list of people who have to be consulted, they are not key players; that they do not have an important contribution to make. From my experience in central London, it would be inconceivable not to look to the academic perspective.

    With the leave of the Committee, perhaps I can ask the noble Baroness a question which is of relevance to the universities. We had a great deal of debate when the National Health Service and Community Care Bill was under consideration in this Chamber. Eventually the government of the day conceded the right of universities to nominate members of health authorities and trusts. Do I take it that there is no such provision, following the repeal of certain sections, for university representation on primary care trusts?

    My understanding is that we are not talking about representation in terms of membership of trust boards. There is a recognition that not all the appropriate professional interests will be able to be represented at board level. It is important that at the executive committee level of the trusts and in their wider interactions with the local health community, account should be taken of other health service and academic bodies which are crucially important in the provision of both healthcare directly and in the training and education of staff. My understanding is that, because we are not talking about representatives on the boards, we are not in an analogous position to NHS trusts.

    A significant number of interests need to be considered and balanced when we look at the consultation that will take place before the setting up of a primary care trust. We talked earlier about the negative possibilities of people being able to stop a primary care trust from going forward. Here we are looking at the positives and how we ensure that there has been proper consultation. Nothing that has been said in the course of our debate runs counter to the views of the Government as to how this should be approached locally. Our difference lies in the fact that we do not feel that it is helpful or possibly satisfactorily to put all the variations on the face of the Bill; that those are best left to regulations that will be laid. That is the established way in which this has been done in the past and I suggest that it is an appropriate way to go forward.

    With the leave of the Committee, perhaps I may interrupt the Minister. One question that has not been answered is when the regulations will be published. The Minister's thesis is that these matters are best left to regulation, but the content and timing of the publication of the draft is of crucial importance if people are to accept that as a substitution for primary legislation.

    I am grateful to the noble Lord. Perhaps he will allow me to take some advice and soundings on that. I do not have the answer immediately. It is an issue to which we could return at a later stage, at which time I can give him a better idea about the timetable for regulations.

    Before the Minister sits down, perhaps I can say that, unfortunately, when the noble Baroness speaks "off-mike" the tinnitus from which I suffer drowns out the drop in the voice level. If my question has been answered, I apologise. It related to representation of people with learning disabilities on health authority boards and so forth. That was the promise given to us at our conference by the then Under-Secretary of State, Paul Boateng. MENCAP is in correspondence with the department and I would be glad if the Minister would look at that correspondence and write to me at some time in the near future.

    I am happy to give that assurance to the noble Lord, Lord Rix. I am aware that there has been correspondence; I am not aware as to exactly what stage it has reached. But I would rather deal with the matter by writing to the noble Lord than chance my arm at the Dispatch Box. I apologise for going "off-mike". One is always torn between trying to be courteous and look at people when replying and the knowledge that in so doing one may stop them hearing what one is saying. I shall try to address the microphone in future.

    I thank the Minister for her response to our amendments. I also thank noble Lords who have supported us, particularly as regards Amendment No. 17. We are disappointed that she does not see a way of including in the Bill some broad obligation to consult which we, from these Benches, should like to see. However, we take courage from the fact that the Minister has given us an assurance that such an obligation will be mandatory within the regulations. I believe it is important that the regulations are published quite quickly. As the Minister has assured my noble friend Lord Clement-Jones, of that, we hope that it will be the case.

    Amendment No. 15 was not covered in the Minister's response. I wonder whether she could deal with that now. That amendment concerns the process of transition between PCGs and PCTs and the readiness of PCGs to become PCTs. We should be grateful for a response.

    I shall attempt to do so. Perhaps the noble Baroness will let me flannel for a moment as I am trying to find the precise detail on Amendment No. 15. This is the issue about placing on the face of the Bill the criteria upon which the Secretary of State will base his decision of whether or not to establish a primary care trust.

    We recognise the need for criteria for assessing the suitability of PCGs to progress to PCTs. We want a measured transition with proposals developed and taken forward in partnership with key stakeholders. We want to ensure that people progress to PCT status when they are ready to do so.

    The amendment identifies suitable elements that we would clearly want to take into account when assessing the suitability of proposals for PCT status. They are all important issues. However, there may well be other factors which will need to be considered. We would expect to see, for example, a clear vision of how proposals to set up a PCT will benefit patients. The impact on existing services, both those that come within the remit of the PCT and wider services, would also be an important consideration.

    Again, this is not a case of us trying to undermine the importance of the issues to which the amendment draws attention; but rather that we wish to retain a degree of flexibility. It may be, for example, that in the light of experience, over time, we shall need to bring in other criteria. It is for that reason that we suggest that we do not put the provisions on the face of the Bill.

    I thank the noble Baroness for that response. Again, we are somewhat sorry that she does not see her way to include in the Bill something slightly more specific. By this amendment, and Amendment No. 17, we aim to give the Bill some teeth. I am sorry that the Minister cannot see her way to include them in the Bill.

    I welcome my noble friend's comments about the importance of consultation with users, carers, and patients. It is important, in considering such arrangements, that there is a tendency not simply to consider consultation with the professional groups and the established organisations in an area, but also to recognise the need to have discussions with users' and carers' organisations. I am slightly disappointed by my noble friend's suggestion that it would be inappropriate to put such provisions on the face of the Bill.

    I should like to comment on the point made by the noble Lord, Lord Clement-Jones, concerning publication of regulations. It would be helpful if we were able to see such regulations before the Bill finally leaves your Lordships' House. Again, I am learning the code words. "Advice" and "soundings" do not seem quite as strong as "some sympathy". However, I certainly hope that it will be possible for us to have sight of the regulations to enable us to understand exactly how the Government's thinking is developing on this matter.

    I was concerned by some of the comments made by the noble Baroness, Lady Gardner of Parkes, regarding the speed with which consumer groups respond to consultation, and the fact that perhaps they need to get their act together in that respect. I believe it needs to be recognised that we are talking of small groups of people, who may be fairly vulnerable, operating in the community. It is simply not realistic to expect them to respond at the speed with which professional organisations or statutory bodies can, and expect to, respond.

    Organisations of carers or patients may not meet more frequently than once every two months. It may be a complicated process for people to attend such meetings. Specialist care support and specialist transport may need to be arranged. It is simply not feasible for them to turn things round rapidly. Some of your Lordships may feel that three months is a fairly generous timespan in that respect, but it will not be adequate in some circumstances. I am conscious that the current Department of Health expectation, on many issues, is three months. It is remarkable how frequently those three months happen to cover the month of August or the Christmas period. That clearly makes it difficult for any organisation—even the more well-developed ones—to respond within the timescale concerned. I hope that my noble friend will be able to consider some of these matters again. However, in that context, and given the fact that perhaps we may be able to have sight of the draft regulations before we proceed much further, I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    [ Amendments Nos. 9 to 18 not moved.]

    Page 2, line 12, at end insert—

    ("( ) Every Primary Care Trust, or other body exercising functions on behalf of the Primary Care Trust, shall make arrangements for securing that they receive from—
  • (a) medical practitioners, registered nurses and registered midwives, and
  • (b) other persons with professional expertise in and experience of health care,
  • advice appropriate for enabling the Primary Care Trust effectively to exercise the functions conferred or imposed on it under or by virtue of this or any other Act.").

    The noble Lord said: The purpose of the amendment is to ensure that there is a statutory basis to require primary care trusts, or indeed other bodies acting on their behalf, to take advice from doctors, nurses, midwives and other healthcare professionals before commissioning decisions are taken. Under Section 12 of the National Health Service Act 1977, health authorities have a clear duty to involve healthcare professionals in decision-making. The wording of the amendment reflects the wording in that section.

    It is not clear in the Bill what mechanisms will be used to ensure that primary care trusts seek professional advice when they are deciding on the commissioning of medical services. Doctors, nurses, and other healthcare professionals have, of course, the kind of detailed knowledge necessary to advise on the clinical elements of the service. Their guidance and support is essential if the NHS is to work properly.

    A nursing sister, who has been running a busy ward for some years, really knows what she is talking about. To fail to collect the advice of these professionals would be a great mistake. One splendid ward sister noticed that the paper towels available in her ward were so rough that the only way they dried the hands was to knock the skin off and take the water with it. She started to investigate and found that if paper towels which actually absorb fluid were used, only one towel would be required as opposed to three of the rough variety. That saved a great deal of money. She did not have a degree in economics, but she did have sound commonsense.

    Primary care trusts will need to seek advice from experts on many issues, including on the public health services which are provided by clinicians, and on pharmacy services and services provided by the professions allied to medicine and many others. Primary care trusts will be charged in particular with building relationships with local social service departments. In the area of public health, primary care trusts will have a duty to contribute to the health improvement programme and to commission services for the benefit of the public health of their populations as well as for the health of individual patients. It will therefore be of great importance for primary care trusts to have access to high quality public health services at all stages of the commissioning process. I beg to move.

    I am afraid that I must tell my noble friend Lord McColl that I resisted the temptation to put my name to this amendment because of the shopping list phenomenon about which I have already chided the Liberal Democrats this afternoon. If my noble friend had left out paragraph (a) and the word "other" from paragraph (b), I could certainly have gone along with the amendment for all the reasons that he gave. However, as the amendment currently stands, I am afraid that I cannot support it.

    Perhaps I may find a "third way" between the two noble Lords!

    One of the key principles underlying the development of primary care trusts is to have stronger professional input. That will be achieved partly through professional representation on PCT boards and partly through the professional-led trust executive. My honourable friend the Minister of State for Health recently published the arrangements for the governance of PCTs.

    However, that is not the be-all and end-all. There will be a need for wider professional involvement in shaping and reviewing local commissioning policy and service agreements. We recognise that that is slightly different from the shopping list of consultees on the face of the Bill. It is an on-going task and it is important to have appropriate professional advice. We must recognise the key role to be played by secondary care clinicians in that work and by those in academic medicine. We would expect PCTs to ensure their involvement through, for example, membership of project teams. Similarly, the wider constituency of professional and other stakeholders will be engaged through the process of health improvement programmes, reinforced and underpinned by the new duty of partnership.

    I have some sympathy with this amendment, especially because I acknowledge that the 1977 Act contains a similar provision in respect of health authorities. Therefore, with the leave of the Committee, I should like to take the amendment away and to consider it with a view possibly to returning at a later stage with a similar amendment, perhaps slightly altered in form, which may appease the noble Lord, Lord Skelmersdale.

    I did not realise that my noble friend Lady Gardner of Parkes had left her place in the Chamber. I must take up her cudgel and agree with my noble friend Lord Skelmersdale because I should like dentists also to be mentioned in the list.

    I thank the Minister very much for her reply and I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    Page 2, line 27, at end insert—

    ("( ) Appropriate arrangements shall be made with a view to securing that a Primary Care Trust's functions are exercised with due regard to the principle that there should be equality of opportunity for all people."").

    The noble Lord said: I do not want to disguise the provenance of this amendment and I am pleased that the noble Earl, Lord Howe, and the noble Lord, Lord Astor of Hever, have put their names to it and to the linked amendment, Amendment No. 41, which relates to reporting on equal opportunities promotion.

    Amendment No. 20 is fairly straightforward. It is clearly aimed at encouraging positive action in this area by PCTs. It is very much in the context of something commendable which has happened since this Government took office. I refer to the fact that they have placed much greater emphasis on reducing inequalities in health. That is reflected in their consultation paper on public health which explicitly recognised ethnicity as a factor associated with poorer health outcomes. Since then, the action report has been helpful in plotting some of the key areas for action. I have no doubt that that will be reflected in the Government's White Paper on public health, to which we all look forward greatly.

    Surveys conducted by the Commission for Racial Equality, which in a sense is the provenance of this group of amendments, show that the ethnic minorities are concerned about access, outcomes and a variety of other matters related to inequality. We believe—this is particularly important and we have seen it only recently in other public services—that it is not good enough simply to be colour-blind; we must go out there and take positive action to eliminate inequalities. That is the only way to tackle some of these issues.

    In 1992 the Commission for Racial Equality published a code of practice for primary healthcare services. However, it felt that the level of take-up by, and interest from, practitioners was not adequate and that there needed to be a statutory duty to promote equality if real action was to be taken by those working in the area, such as the primary care trusts. These provisions fall very much within the overall general principles of the CRE as enunciated in its proposals for reform of the Race Relations Act. Public bodies should have a general duty to work for the elimination of racial discrimination and for the promotion of equal opportunities. This amendment is clearly in line with the CRE's existing proposals. In a sense, the CRE has now followed up that long-standing set of proposals with its leadership challenge—an interesting challenge to all of us in public life—on the active promotion of equality. The CRE expects political parties, public bodies and others to promote that challenge. The health service should be no different. Indeed, it should be better than other institutions at doing that.

    I strongly commend the approach set out in the amendments, which simply seek to impose a general duty to promote equality of opportunity. There is, in fact, a parallel. The Welsh Assembly has such a duty. That is provided for in the Government of Wales Act. There is, therefore, a precedent for this. It is with great pleasure that I recite precedent because we often hear from the Government Front Bench the argument, "Oh no, we have done this for years", so I say, "Well, we've done this for a year", so I very much commend this approach.

    It is often very easy to insert words into Bills but I really believe that inserting such a provision into this Bill would kick-start something at local level. It would be absolutely four-square with the duties of a PCT and it would be a valuable signal, particularly in the current climate. I beg to move.

    I rise to support Amendment No. 20. The needs of ethnic minorities must he addressed. The primary care trusts must ensure equality of access to patient care for all those who need it. An equitable service requires sufficient information, training and resources to cater for all sections of society. The Royal National Institute for the Blind has collated clear evidence that people of African descent have a higher risk of developing glaucoma. The primary care trusts will need to recruit, train and retain staff who are able to communicate effectively with ethnic minorities and those who do not have English as their first language. Such appropriate arrangements should ensure that access to high quality patient care is equitable for all.

    7 p.m.

    I am wondering whether the wording is right. Of course I go along with what the noble Lord, Lord Clement-Jones, has said: the principle should be equality of opportunity for all people. In this case, is he talking about all patients? Obviously the opportunities for staff and patients are different. It is a bit bland and sounds rather like a formula. I wonder whether it could be made more precise.

    I thank the noble Baroness for that intervention. Of course it is fairly general and of course it applies not only to employees. Indeed the principle itself applies not just to ethnic minorities but also to gender balance and other aspects. If one started writing a more detailed principle, one might then be accused of making lists, I suspect. One has to he careful about this. This is a commonly accepted formula. If there is a better way of putting it I would very much welcome that. This is, as I say, a general formula, but it puts the onus on the trust to act in a positive way. It is not simply a passive approach.

    I am grateful to those Members of the Committee who have spoken and to the noble Lords who tabled these amendments which, importantly, raise the issue of equal opportunities within the National Health Service. I would say to the noble Baroness, Lady Carnegy, that we have to tackle within the health service both the issue of equality of access to services, to which these amendments were predominantly directed, and the issue of equal opportunities for staff members within the NHS. Although the amendments to this Bill may not be the appropriate way forward for ensuring that, and we must have a much wider programme to tackle both issues, both are important. Perhaps on the latter I might say, because it is important to make absolutely explicit the commitment in public services in these areas, that we are committed to rooting out all racism within the NHS and to ensuring that both patients and staff are treated with respect and fairness.

    In December of last year we launched a campaign to tackle racism and set existing NHS bodies tough targets in order to stamp out racist behaviour. We have also, very importantly, increased the representation of non-executive directors who come from an ethnic minority background on the boards of NHS trusts and authorities. We have also signed up the NHS to the Commission for Racial Equality's Leadership Challenge. So there is a programme of progress in those areas.

    In introducing his amendment the noble Lord, Lord Clement-Jones, put it firmly in the context of addressing inequalities in healthcare, and the noble Lord, Lord Astor, also referred to these areas. I think it is important that we identify within our new framework for measuring NHS performance fair access to services as one of the key dimensions against which the NHS will be assessed. We made clear in A First Class Service that all NHS bodies will be reporting annually on clinical governance, and within the ambit of clinical governance delivering on that commitment for fair access to services is very important. It is another opportunity to pursue that theme.

    We intend to extend to primary care trusts the same drive to ensure that patients and staff are treated with fairness and respect, and we will need to look carefully to ensure that this permeates throughout the new arrangements. I am sure we shall expect to see it reflected in primary care trusts' annual reports, just as we see it now reflected, although there is no statutory obligation to do so, in the reports from NHS trusts.

    It is an absolutely key theme of the Government that we should reduce health inequalities, and within the national priorities guidance issued for the NHS and for social services we made that absolutely clear. We have to make clear too that we recognise the diverse and sometimes differing health needs of different populations, to which the noble Lord, Lord Astor of Hever, referred. Yesterday I was launching a campaign to encourage organ donation among the South Asian community, where the rates of kidney disease linked to diabetes and high blood pressure are much higher than among the ethnically European population but where in fact the rates of donation are much lower. It is important that we recognise the health needs of particular ethnic groups and make sure that they are addressed. Often at primary group or trust care level that will be the absolutely appropriate place so to do.

    I should like the opportunity to consider further these amendments. We want to take forward a shared agenda with both Front Benches opposite on these issues. If I may, I should like to look at the best way to take the points forward and whether they can be accommodated in terms of amendments to the Bill. I am happy to give that assurance, if the Committee agrees.

    Just on the wording, I have a dislike of bland expressions that do not mean anything and, with the greatest respect, I think that,

    "equality of opportunity for all people",
    is not a description of anything. Someone who is a surgeon may have an opportunity to become a promoted surgeon or whatever, but a patient does not necessarily have the opportunity to become a surgeon. If the wording simply said "equality of opportunity", that is what we are all talking about. I just wanted to justify my little intervention.

    I entirely agree with my noble friend. There is something not quite right about the phraseology, although I agree that the concept and principle behind it are fine. Are we not dealing with the patients, or the people in the community which the trust will serve, and will not staff already be covered by general legislation on equal opportunities?

    I hesitate to intervene, but I should declare that I am chairman of the sex equality group in the Houses of Parliament. I wonder whether the description given by the Minister of an equal opportunities policy within the health service actually came up to the target of being an equal opportunities employer, which is a good deal more than just showing respect to all different sorts of employees. There is a strict code attached to the designation.

    In her substantive response just now to the noble Lord, Lord Clement-Jones, the noble Baroness said she would like to take this away and look at it. Given that the beginning of the Bill amends the National Health Service Act 1977, in her consideration will she think about amending that Act to make it much more general than just primary care trusts?

    We have had a variety of helpful suggestions about what areas we should consider as regards amendment. I absolutely take the noble Baroness's point; I was trying to make the same point in a rather different way. We need a whole raft of actions if we are to behave satisfactorily in this respect. One small piece of legislation, as the noble Lord, Lord Skelmersdale, points out, in a very narrow field may be an important point at which to start, but certainly not an end point. With the leave of the Committee, I shall take away all the suggestions that have been made and perhaps come back at a later stage.

    I thank the Minister for her replies. I understand that there could well be other, wider formulations which could usefully be introduced. However, I hope that we do not reach a situation where in a sense the best is the enemy of the good and that we do not try to invent some rocket when actually a bicycle would do. We are talking about primary care trusts and ensuring equality of opportunity, especially as regards access. But that should also encompass other matters.

    It would be a shame if we were to spend hours labouring over a formula that would cover every single aspect when it could quite simply be determined for primary care trusts, which, after all, are the key component that we are talking about in this part of the Bill. Of course, it is essentially "access" that we are considering. I accept that a great deal is being done on the ground, but the issue about primary care trusts in particular is that there are many more of them. Indeed, you can reach down in a fairly controlling way into the NHS trusts, into health authorities and so on; but it will be more difficult to get into the practices of PCGs and PCTs. Therefore, my argument would be that it is more important to have this statutory duty for PCTs than it is for any other part of the health service simply because of the issue of management and control. I am delighted that the Minister has agreed to consider the amendment further. I look forward to the Report stage in that respect. I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    7.15 p.m.

    Page 2, line 27, at end insert—

    ("( ) Upon approval of proposals under subsection (2) in respect of a particular local authority area the local authority shall be entitled to exercise all the powers of the Secretary of State under section 97D of this Act.").

    The noble Lord said: We are getting very close—I hope—to the witching hour of 7.30 when we may perhaps be able to take some refreshment. But I have considerable enthusiasm in moving this amendment. In doing so, I shall speak also to Amendment No. 22, as they fall into the same grouping. This is essentially about taking forward the report of the Health Select Committee of another place, which many noble Lords will have read with considerable interest before Christmas. The committee effectively argued—I thought extremely cogently—for greater integration than is currently envisaged in the Government's proposals as set out in the original White Paper. I quoted from the report on Second Reading, and make no apology for doing so again. The quality of the work being done by that Select Committee is of a very high standard. In paragraph 65 of its conclusions the committee said:

    "We consider the current system for continuing health and social care to be very confused. Responsibilities are blurred, professionals face unnecessary problems, and users and carers are suffering because of barriers created by a structural division which is based on a ill-defined and arguably non-existent boundary".

    Later, at paragraph 68, it said:

    "The [Department of Health's] proposals in Partnership in Action to allow a lead commissioner and integrated provision are a step in the right direction. However we consider that the problems of collaboration between Health and Social Services will not be properly resolved until there is an integrated health and social care system, whether this is within the NHS, within local government or within some new, separate organisation".

    It is interesting to note how the Select Committee came to its conclusions. At the end of the day, members of that committee felt that the professions—and, indeed, the managerial evidence—were rather cautious. Their experience on the ground, especially when they went to Northern Ireland and saw how the system operates in practice there in a very integrated fashion—something that the NHS in England does not have—led them to think that it was highly desirable.

    I recognise that this would be quite a challenge to an organisation which is already undergoing considerable change. But the former Minister of State was permanently talking about the "Berlin Wall" between social services and health services. If we are to have an effective integration, it seems to us that it cannot be done just by joint working and pooled budgets; indeed, we will actually have to go a step further. What we have tried to do—and, in a sense, this is perhaps a bit of a balloon debate on the subject—is allow for a situation, which may not be perfect, where, once PCTs come into operation for the whole of a local authority area, that local authority effectively assumes the powers of the health authority. Indeed, if a PCT gets to stage four or partially to stage three, it will be in the process of withering away in any event. Matters like public health would then rest alongside social services within the local authority.

    I suspect that the Royal Commission on the long-term care of the elderly will also propel that movement. No doubt it will recognise that joint working, pooled budgets, and so on, will all help but that at the end of the day in order to get a coherent system of care, especially for the elderly, there will have to be a much greater level of integration than is envisaged in the Bill. Our contention is that there needs to be some mechanism whereby a local authority can take over the function of the health authority in those circumstances.

    One of the issues that was addressed quite strongly in the report of the Select Committee was the democratic deficit. It is not just a question of the actual integration of care and the quality of care between social services and the health service; it is also a question of the democratic deficit in terms of the accountability of the health service. In the pre-1990 days there was an element of representation from the local community on health authorities. That accountability disappeared, and this is also an attempt to try to inject a much greater element of democratic accountability into the process. That was one of the aims of the Select Committee as set out in its recommendations. I commend the latter to the Committee.

    It might be considered initially as quite a bold step. But when we consider the amount of work which will need to be done in any event over joint working, pooled budgets, and so on, why should we not take it a step further? This is only conditional; indeed, it is conditional on PCTs covering the whole of a geographical area and does not involve a rushing of the gate in any sense, because the PCTs will need to be formed and people will have to have fairly sophisticated management systems in those circumstances. Therefore, I hope that the Committee will carefully consider this proposal. It is not so outlandish. It is something which will inevitably happen, so why should we have to wait for another few years for further recommendations from perhaps a distinguished Royal Commission, or indeed a review or a report from another Select Committee, before we actually institute such changes? Such changes could be of huge benefit to those receiving a mixture of both social and healthcare at local level; indeed, let us face it, it often is a mixture. I beg to move.

    I rise with some reluctance because, from these Benches, I do not feel that we can support the amendments proposed by the noble Lord, Lord Clement-Jones. I shall not go into too much detail in the interests of brevity, but I believe the kind of path that the noble Lord is inviting us to go down would lead to a lack of clarity in responsibilities. Indeed, it could lead to confusion in the rules surrounding propriety in the use of public money. In general, I think it is undesirable to transfer health functions to bodies which are not concerned with the management of health as a full-time business. Therefore, I am afraid I cannot support the amendments.

    I warmly support what my noble friend Lord Howe has just said. It would be very dangerous to pass responsibility and power to local authorities in these circumstances. With the health authorities, we are going to get a good deal of consistency across the country as regards administration of this scheme, just as we had under the former National Health Service. But if we are going to give overburdened local authorities these specialised responsibilities we shall not get an even pattern across the country. We could get a serious variation. I hope that the Minister will also resist these amendments.

    I touched on this matter on Second Reading—as the Committee will recall—speaking from my experience as a former health Minister in Northern Ireland. The system we are discussing only works there because you have one body, a health and social services board. There is a good argument for rolling the four boards into one, but I shall not go into that at this moment. However, if one side or the other is dominant—which is what I think these two amendments propose—one is in danger of coming across all the difficulties that my noble friend Lord Renton has foreseen, and has just stated.

    I wish to make a couple of brief points in support of my noble friend. It seems to me to be quite sensible—this is a direction in which I feel we are bound to move at some point—that the commissioning of healthcare (that is, how the money is spent) is, as it were, united with the commissioning of social care under one authority. My noble friend has suggested that that should come under the local authority. I find that satisfactory for the following reason; namely, that in that way a democratic accountability would be introduced.

    I was a member of a local authority and of a hospital trust at the same time. The most uncomfortable element of membership of the trust board was that I had no standing vis-à-vis the people to whom that health trust delivered services. There was no way in which I could go to them and ask, "What do you think about this?", because that is not the way it works. Had I done that, I would simply have been removed from the health board, as I am sure my fellow members would not have thought that that was a proper thing for a member of a board to do. The difficulties involved in the relationship between hospital trust boards and their surrounding communities should be an example to us of the advantages of placing the health service within a democratic context.

    I believe that the health service is in a democratic context, but it is within a national democratic context. Some of the contributions that have been made to the debate have recognised the importance of that point and of the maintenance of a devolved structure. They have recognised the importance of establishing mechanisms through local boards and through some of the provisions we have discussed today for ensuring that local decisions reflect the views of local communities. I have tried to be helpful to the Committee as far as possible. However, I shall adopt the strictures of those on the Benches opposite who have spoken against this provision and be firm in my rejection of the amendment.

    I do not do so because we in any way wish to downgrade the issue to which the noble Lord, Lord Clement-Jones, spoke in detail; namely, to ensure that we dovetail services for individual patients, and that there is not some false divide between the care that is given by social services departments and the care that is given by the health service. Indeed the provisions that we shall discuss later in the Committee's deliberations under the partnership section of the Bill are designed to do just that and to go wider than a consideration merely of social services. We should consider the whole of local authorities' functions in order to achieve more effective co-operation between the NHS and local authorities. Those provisions have been widely welcomed.

    However, the amendment we are discussing would have a much more far-reaching effect. It would allow local authorities to assume the functions of health authorities, effectively bringing local health services under local authority control. That is quite simply not the Government's policy for the health service. I recognise the point that the noble Lord, Lord Clement-Jones, made regarding the recommendations of the Health Select Committee. I shall discuss those in detail shortly. However, it is worth noting that that committee recognised in its report that its proposals had received little support from those who gave evidence to it. That included the Secretary of State, who made it clear in his evidence that he felt major structural reorganisation was both unnecessary and would be highly disruptive. Earlier in the afternoon we debated how disruptive change can be, even measured change in limited areas.

    What we are trying to do is to allow an approach that does what both local authorities and the NHS have asked for; namely, to remove the longstanding legal barriers to joint working without imposing the turmoil of major upheaval. Provisions in the Bill will allow for integrated working where that would lead to better outcomes for patients and for clients. However, as regards the evidence that was given to the Select Committee, and the responses that we received to our Partnership in Action discussion document, it was made quite clear to us that the kind of major structural change that this amendment would involve would not be helpful. We can achieve the ends that we seek to achieve through the partnership arrangements. I urge the Committee not to pursue this amendment.

    I thank the noble Baroness for that not unexpected reply. I am not surprised at that response. When I introduced the amendment I did not seek to minimise the lack of support for the provision among those who gave evidence to the Select Committee. I believe that the Select Committee is composed of some pretty far-sighted people. I say that because I agree with them! They have looked several years ahead to consider the impact of joint working arrangements and pooled budgets. Some of them have had a long involvement in the health service. After taking evidence—even the negative evidence, as the noble Baroness has mentioned—it was their considered view that the provision would not be sufficient.

    I make my next point with all due deference to the noble Lord, Lord Skelmersdale. I appreciate his experience of the Northern Ireland situation, but he did not say whether he thinks that the standard of integrated care is higher in Northern Ireland as a result of the system that is adopted there. One can have this one way or the other. One can have the health service undertaking all these functions or local authorities undertaking them. We propose that they should be undertaken by local authorities. Our view is that after a period of time it will become quite clear that the mechanisms that are being set up under the banner of partnership, with the best of intentions—we fully support that intent—will not be sufficient to provide healthcare in the seamless way in which everyone in the voluntary and the health sectors is striving to achieve. Clearly, however, we have some way to go in the persuasion stakes. No doubt the campaign will continue—"la lutta continua". This is an area of considerable importance, and will continue to be so. I beg leave to withdraw the amendment.

    Amendment, by leave, withdrawn.

    [ Amendments Nos. 22 and 23 not moved.]

    Clause 2 agreed to.

    Schedule 1 [ Primary Care Trusts]:

    [ Amendments Nos. 24 and 25 not moved.]

    This may be a convenient moment to break for dinner. I suggest that we reconvene at eight o'clock.

    [ The Sitting was suspended from 7.28 to 8 p. m.]

    Page 42, leave out line 3.

    The noble Baroness said: In moving Amendment No. 26, I wish to speak also to Amendments Nos. 27, 28, 30, 31, 32, 33, 34, 35 and 36. Amendment No. 29 will be spoken to from the Official Opposition Benches.

    These amendments concern the governance of the primary care trusts, In particular they are intended, first, to make the membership of the board of the primary care trusts more representative, both in terms of the healthcare professions and in terms of local voluntary organisations, carers and lay members of the community; and, secondly, to make selection of the chairman more democratic, so that the body chooses its own chairman rather than the Secretary of State.

    We on these Benches are most anxious that the boards of the primary care trusts are not run by the medical profession for the medical profession but that they represent the broader community in which they are located. In particular we are anxious that they represent both those who are providing care and those who are receiving care. It is vital that the professions allied to medicine are included, as well as the voluntary bodies and the carers.

    I shall run quickly through the different amendments. Amendments Nos. 26 and 30 are allied to Amendments Nos. 33 and 34. They make it clear that we would like to see the members of the trust choose their own chairman from among their own members, rather than having the chairman chosen by the Secretary of State. Amendment No. 27 argues that a majority of the members of the trust should not be officers of the trust. Amendment No. 28 lays down that the various members of the trust shall include lay members representing the local community. Amendment No. 31 lays down that, in addition to lay members, there shall be representation from members of the other healthcare professions and not just general practitioners. Such professions would include community and practice nurses, social services, dentists, pharmacists, physiotherapists and opticians. Amendment No. 32 concerns the range of skills that we would like to see represented within the primary care trust. It is especially important that patients and carers, and those who have been patients and carers, are represented on the primary care trusts as consumers of primary care. Amendment No. 35 again makes it clear that the regulations shall include not only representatives from the medical professions but also representatives from the professions allied to medicine and from the nursing and midwifery professions. Amendment No. 36 places an obligation on the Secretary of State to consult widely within the community about appointments to the primary care trusts. We are anxious to ensure that those selected are widely known and respected within their communities.

    As I have said, Amendment No. 29 comes from the Official Opposition Benches. As far as we are concerned, it goes in the opposite direction. By laying down that a majority should come from the medical profession, the amendment does not exclude the possibility that the medical profession could dominate the PCTs, which we would be unwilling to see. I beg to move.

    I rise to support Amendment No. 28. There is real concern that older people are often discriminated against in the NHS because of their age. I hope that the Minister will see the wisdom of having at least one lay member on trust boards representing the interests of older people. Organisations working with older people are told time and again of instances where older people are suffering in certain conditions because they are old. As a result, old people are often too frightened to complain. PCTs will have responsibility for a greater number of treatments which primarily affect older people. I therefore hope that the Minister will support the amendment.

    Due to the rushed nature of our eating requirements, I did not appreciate that marshalled in this group of amendments was the one concerning older people, which is of considerable importance.

    As many of us know—not only from our own experience but from the representations made to us—there is an increasing concern that people are being discriminated against in the NHS because of their age. Amendment No. 28, which was referred to by the noble Lord, Lord Astor, is, in our view, of considerable importance as regards ensuring that discrimination does not continue. It is specifically important that there should be older people on primary care trust boards. We shall be talking later about amendments which relate to old people, but there is no doubt that there is an enormous degree of concern, not only about access but about treatment. There exists, in a sense, a kind of rationing. In order to tackle that kind of problem, we should be very conscious of the kind of representation we have on the primary care trust boards. That representation should specifically include older people, who will well be able to appreciate the problems that older people face.

    One could argue that there should be representation for every one of every type among the lay members, but I seek to make a special case for older people. They are massive consumers of healthcare—they face almost unique problems in the way in which they interface with primary care—and it is very important that they are not just, in a sense, passive users, but people who are able to drive forward primary care provision in a positive way by their representation on trust boards.

    I rise to support Amendment No. 28 because old people and children take an enormous amount of the budget of any national health service.

    I am concerned about Amendment No. 31, which is grouped with Amendment No. 26. It contains another list and, as we have already discovered, anything containing lists is extremely dangerous. We should remember that there is a huge body of people in professions in the NHS which used to be laughed at. I refer to the alternative medicine brigade. There are now very large clinics in some areas which practise medicines such as acupuncture, osteopathy, reflexology, kinesiology and so on. It is beholden on us to remember that an enormous number of people want to go to alternative medicine practitioners as opposed to using the National Health Service proper. We must take some of those large practices into account as well. Therefore, I do not support Amendment No. 31, but Amendment No. 28 is good.

    I support Amendment No. 28. I do so because the Government's claim that there is no age limit on appointments to any NHS body is a complete fiction. I meet people who tell me all the time that an invisible barrier is definitely there. I understand that there may be a problem with older people if there is a risk that they may develop senile dementia. None of us is immune to that. But to get round that, the appointments of older people could be made for a limited time and would be renewable only if the people were suitable. By that I mean that they remained mentally alert.

    It is wrong and hypocritical when we hear that age is irrelevant that the first thing one puts on any application form for a National Health Service position is one's date of birth. Those looking at those forms then sift through them. I should like to know how many older people will be on NICE and so on. This amendment is required on the face of the Bill to make it clear that there should be an obligation to consider older people.

    I support Amendment No. 28 but I should like to look at the issue in another way. The amendment states:

    "including lay members representing all sections of the community including older people".
    Enough has been said about older people and I will certainly support that. But let us not forget people at the other end of the spectrum. I refer to younger people.

    In our area we have a local patient support group. It has representatives who include a 17 year-old, a single mother with two children and a disabled person. It also includes several elderly people because that reflects the demographics of the area. It has worked like a charm, particularly for the 17 year-old and the 23 year-old. They have now had experience of working on a committee, of listening to people's views and of going to their sections of the community and feeding back information to the doctors and to the practice manager. It has revitalised the involvement of the community with the practice and has made people realise exactly how much work doctors do and how they need to he safeguarded against people who do not turn up for appointments. The young people are going to their friends and saying, "You can't make a doctor's appointment and not turn up". It is not the older ones who are doing that. The older ones represent people's needs in terms of access for disabled people, the requirement for hearing tests and so on. But it is the youngsters who are coming forward and stating the problems. I suppose they could even alert the doctors to where the drugs scene is becoming serious in the area.

    If the Government really want to be an inclusive government, they ought to start now and consider including quite young people in these groups, if only for a limited period of time—perhaps three years or so. They will benefit, the groups will benefit and certainly the young people will benefit. Young people generally will feel that their views are taken into account. I do not want to put on the face of the Bill the words "including young people", but I hope that the Minister will take the point on board.

    8.15 p.m.

    I rise to speak to Amendment No. 29 which ventures to take an opposite path to amendments tabled by the Liberal Democrat Benches in that it relates to the question of who should constitute the majority on the PCT board and proposes that that majority should rest with those who are professionally qualified. I do not think it is a contentious statement to make that if the NHS is to be asked to tolerate yet another period of adjustment, as it is, it is important that the changes are soundly based. A sound base involves our being very careful indeed that we take the doctors with us; indeed, not just doctors—of course not—but I single out doctors because, unless GPs feel that they own the new system, they will not respect it. Doctors will not want to feel dragooned into PCTs.

    Let us suppose that there is a proposal to convert a PCG into a PCT. What everyone understood from the original White Paper was that progress up the PCG ladder would be entirely voluntary, but it appears that that is not so. A proposal can he initiated by anyone in the PCG, by the local community health services or by a health authority. Let us suppose that the proposal goes out to consultation and the Secretary of State decides. If GPs do not like it there is no veto for them. A PCT is then established. The one thing that doctors will want to feel once they are in it is that they have a real measure of control and real responsibility for what the PCT does. If GPs see in PCTs a structure of decision making that erodes the degree of influence and responsibility that they enjoyed in a PCG, there is a risk that confidence in the system will evaporate. GPs will see it as an attempt to impose line management on them.

    We have to remember that a general practitioner is an independent contractor. A doctor will not accept a system that threatens to interfere with the one relationship above all which counts for him—the relationship with his patient. Nor will he embrace a structure which lacks a sense of corporate feeling and identity. I believe that the Government's proposals for PCTs, which originally, it has to be said, looked like manna from heaven to many doctors, have had the gloss decidedly knocked off them by fears of this erosion of influence at management level. It is perfectly true that expressions of interest in PCT status have been quite numerous, but I wonder how many of those will develop into firm applications once people have reflected more deeply on the Government's proposals.

    At Second Reading the Minister said that the Government wanted to build on what was best in the NHS that they inherited. But putting aside for one moment our disagreements about the merits or demerits of fundholding, one of its undisputed benefits was the way in which it put GPs in the driving seat and in so doing drove up standards of healthcare. That is the broad principle the Government say they want to preserve and carry forward in the new arrangements. I sincerely hope that they know what they need to do to make that objective a reality for doctors. If they do not achieve it, the risk to the NHS is substantial.

    I have considerable sympathy with the objectives underlying both Amendments Nos. 28 and 29. On Monday last I spoke in your Lordships' House on trying to persuade the Royal Commission to oppose any principle that there should be a mandatory age of retirement for life Peers. It is seven years since I received a letter from the Oxfordshire health authority thanking me for my services and saying that, now I had reached a certain age and my honorary clinical contract had expired, I could visit the hospital for social reasons but could not use the clinical facilities.

    We may bear in mind, for instance, the attitude of the United States Government. They have now decided that discrimination on grounds of age is illegal and is contrary to the US constitution. It is right that the Government should seriously consider the possibility of involving not only younger people but older people in many of the bodies concerned with the management of the National Health Service. As the noble Earl said, we should recognise the crucial importance of having a majority of members of the healthcare professions on these bodies. Therefore in a sense both of these amendments can be supported.

    I oppose Amendment No. 29. In the past I spent some time as a member of an executive council and of a family health service authority. I can still remember the rather gruesome meetings of the executive council, which were heavily dominated by healthcare professionals. It is to the credit of the previous government that they introduced a far stronger lay element into family health service authorities and other health authorities.

    Having sat through debates in those health authorities, I have seen the major contribution that lay members have made to those bodies and how they have influenced the thinking of healthcare professionals. A proper balance is necessary in those kinds of bodies if the best interests of the public are to be served. Now, many health professionals would take the view that they prefer a situation in which there is a good balance and an even spread of committed people from the lay communities who contribute to healthcare policy and its delivery at local level. We should reflect on the experience of the past 10 to 15 years, when there has been a much stronger injection of the lay element into healthcare bodies.

    I wish to make a slightly narrower point relating to the balance among professionals. Today I have received a rather angry letter from the Chartered Society of Physiotherapy, expressing disappointment that the professions allied to medicine are once again not specified in the Bill as being desirable members for trusts.

    It is relevant to remember that among those other professionals physiotherapists are experienced in community healthcare, not merely in the delivery of services at GPs' surgeries. Therefore, along with those of a similar professional background, they make a large input in terms of the improvement of community services, which is likely to become part of the responsibilities of most PCTs. The point is that it is not until the most superior stage, as it were, of the development of a PCT that it apparently becomes possible for those professions to be represented on the board. I hope that the Minister can offer some reassurance on that matter.

    I support the remarks of the noble Lord, Lord Warner. I, too, remember the Inner London Executive Council, of which I was a dental member. At least 50 per cent. of its members were professionals. The dentists were told: "Unless you vote to support the doctors, we shall vote against you". It was worse than any trade union—not that I have ever been a member of a trade union. It was as closed a shop as anything that existed. Many of the London boroughs took an active part in telling Sir Keith Joseph that, whatever happened, he must do away with that built-in majority that was so wrong. I therefore support the view that there should be a balance. No one group should have a built-in majority so that it can pressure others into supporting a proposal that they would otherwise oppose.

    I should find it easier to evaluate all these amendments if I had some idea of the size of the body of which all these people would be members. Is it possible for the Minister to give us some better indication as to the likely range of sizes? All these matters are to be included in regulations of which, as yet, we have no sight.

    On the last point, I think I can help the noble Baroness. As I said earlier, the proposals for the Government's arrangements for primary care trusts were published at the end of last week. Copies have been placed in the Library. I shall go into more detail later as I realise there has been only a short period of time for Members of the Committee to examine the proposals and the balance that we are attempting to strike in membership of the hoards and primary care trusts.

    The contributions to the debate indicate the need to strike a balance and some of the difficulties in so doing. We have heard cogently argued the reasons for maintaining a professional majority; there have been equally strong representations that a professional majority is not appropriate and that there ought, for reasons of probity and responsiveness, to be a lay majority. Later in my remarks I shall go into the detail of how we attempt to reconcile and achieve what we believe to be an appropriate balance, and also to see that there is the right balance between the professional groups and bodies concerned. Although GPs must be extremely important—and the PCG governing arrangements place GPs and nurses firmly at the forefront—when it comes to primary care trusts we are talking about a different animal, and different governance arrangements are appropriate.

    Perhaps I may deal first with Amendment No. 26 and the linked Amendment No. 30, removing the power of the Secretary of State to appoint the chairman of the PCT board and putting in place election between the members of the board. That is not an appropriate way forward. It is a well-established principle that the Secretary of State appoints the chairmen of NHS bodies. It is a way of ensuring that those bodies can be held to account by the Secretary of State. I see no reason that that should be different for primary care trusts. As with other NHS bodies, the Secretary of State will ultimately be able to dismiss the chairmen if necessary. Not to have that arrangement would mean not having a proper chain of accountability from primary care trusts upwards to the Secretary of State and, via him, ultimately to Parliament.

    We must bear in mind that each primary care trust will be responsible for large sums of money—at least £60 million. They will need to help achieve national priorities and develop and deliver local health improvement programmes. There has to be public confidence in the accountability.

    We have found that the system of chairmen being appointed by the Secretary of State and being accountable to him has worked well with other NHS bodies. There is no reason why it should not do so with primary care trusts.

    We want those trusts to be firmly rooted in their local community, and responsive to the health needs and wishes of local people. That is very much in line with existing NHS bodies. However, it is why, in selecting a chairman, the Secretary of State will consider a range of factors, including experience, knowledge and the level of confidence that is commanded by the individual within the community. That gives us some reassurance that the arrangements will provide a sensible balance between accountability upwards to the Secretary of State and the involvement of local people, not just as chairmen but as non-executive members of the trust board in running PCTs. I urge the Committee to agree that we should maintain those arrangements.

    I now deal with the issue of who should be included; who should he the lay members. I shall then come to the major issue of the balance on the board. It is important that we recognise the need to represent all sections of the community. Once we start specifying a particular group with needs, such as the elderly, who are major users of the health service, their needs are important and must be taken into account. The noble Baroness, Lady O'Cathain, pointed out that there are other users at the other end of the age scale who also need to be represented. Representing the needs of children is not easy in an automatically representative way. The noble Lord, Lord Rix, talked earlier about the possibilities of people with learning disabilities being involved in the governance of trusts that provide services for that group.

    I do not believe anyone would dissent from the broad aim of the amendment. We certainly wish lay members to be drawn from all sections of the community. However, we also want them to be not only from different age groups but also from different ethnic and racial groups and to represent different walks of life. As it stands, the provision allows lay members to be appointed who ensure that.

    At present we make the appointments in line with the principles of the Commission for Public Appointments. In doing so, we have made clear that we have been trying to increase the representation of people from the locality of the NHS body concerned. We have published goals on the appointment of women chairmen and members of NHS boards and those from ethnic minorities and that a guaranteed interview scheme is operated for people with disabilities. Those are all measures to try to ensure that we have a wide spread of people.

    Equally, there is no age limit to those who can become members. I heard what the noble Baroness said in relation to that. I have seen appointments of elderly members of the community to trusts within the department. Perhaps I could give the breakdown by age at present. Of those appointed at the moment, 7.5 per cent. are aged up to 39—not many representing the younger end of the spectrum. I remember that when I was younger I was always being asked to come onto boards because there were too many old people and they were trying to make the board younger. Pendulums swing and perhaps I shall now come into fashion in my later years to redress the balance in the other direction. Of those appointed at the moment, 66.5 per cent. are aged 40 to 59 and 26 per cent. are aged 60 and over. That is a substantial group already there.

    8.30 p.m.

    Can the Minister tell us of those aged 60 and upwards, up to what age? How many are over 70 and how many are over 75?