Health and Social Care (Community Health and Standards) Bill

House of Commons, 8 July 2003.

Clause 1 — NHS Foundation Trusts

David Hinchliffe (Labour, Wakefield)

I beg to move amendment No. 164, in page 1, line 4, leave out clause 1.

Alan Haselhurst (Deputy Speaker, Saffron Walden)

With this it will be convenient to discuss the following:

Amendment No. 60, in page 1, line 7, at end insert 'and Wales'.

Amendment No. 166, in page 1, line 10, leave out clause 2.

Amendment No. 96, in clause 2, page 1, line 12, after 'Foundation', insert 'and Community'.

Amendment No. 168, in page 2, line 3, leave out clause 3.

Amendment No. 169, in page 2, line 9, leave out clause 4.

Amendment No. 154, in clause 4, page 2, line 10, after 'trust', insert

'or combination of NHS trusts'.

Amendment No. 321, in page 2, line 10, after 'trust', insert

'or a Primary Care Trust'.

Amendment No. 65, in page 2, leave out line 12 and insert 'appropriate Minister'.

Amendment No. 322, in clause 4, page 2, line 12, at end insert—

'(1A) The Secretary of State may not support more than six applications make by NHS trusts and more than six applications made by Primary Care Trusts during the pilot test period.'.

Amendment No. 155, in page 2, line 14, after 'trust', insert 'or trusts'.

Amendment No. 323, in page 2, line 14, after 'trust', insert 'or Primary Care Trust'.

Amendment No. 156, in page 2, line 18, after 'trust', insert 'or trusts'.

Amendment No. 324, in page 2, line 18, after 'trust', insert 'or Primary Care Trust'.

Amendment No. 157, in page 2, line 19, after 'applicant', insert 'or applicants'.

Amendment No. 158, in page 2, line 21, after 'has', insert 'or NHS trusts have'.

Amendment No. 325, in page 2, line 21, after 'trust', insert

'or a Primary Care Trust'.

Amendment No. 159, in page 2, line 26, after 'trust', insert 'or trusts'.

Amendment No. 326, in page 2, line 26, after 'trust', insert 'or Primary Care Trust'.

Amendment No. 160, in page 2, line 28, at end insert 'or them'.

Amendment No. 161, in page 2, line 29, after 'it', insert 'or them'.

Amendment No. 170, in page 2, line 31, leave out clause 5.

Amendment No. 328, in clause 5, page 2, line 32, after 'trust', insert

'or a Primary Care Trust'.

Amendment No. 66, in page 2, leave out line 35 and insert 'appropriate Minister'.

Government amendment No. 245.

Amendment No. 171, in page 3, line 20, leave out clause 6.

Amendment No. 329, in clause 6, page 3, line 22, after 'trust', insert

'or a Primary Care Trust'.

Amendment No. 233, in page 3, line 27, at end insert—

'( ) taken as a whole the actual membership of the applicant's public constituency will be representative of those eligible for such membership,'.

Amendment No. 402, in page 3, line 37, leave out subsection (4) and insert—

'(4) In deciding whether or not to give an authorisation in response to an application under section 4 or 5, the regulator shall have regard to the outcome of a public consultation under section [public consultation relating to applications for foundation status].'.

Amendment No. 403, in page 3, line 39, at end insert—

'(4A) The regulator shall not give an authorisation under section 7(1)(a) or (b) unless and until the Secretary of State confirms support for the application to which such authorisation may relate after responding to—

(a) any recommendations made to him by virtue of section 21(2)(f) of the Local Government Act 2000 (Overview and Scrutiny Committees) in relation to the application, or

(b) any referrals or representations made to him by any Patients Forum by virtue of section 15(6) of the NHS Reform and Healthcare Professions Act 2002 in relation to the application.'.

Amendment No. 172, in page 4, line 1, leave out clause 7.

Amendment No. 330, in clause 7, page 4, line 2, after 'trust', insert

'or a Primary Care Trust'.

Amendment No. 331, in page 4, line 3 after 'trust', insert

'or a Primary Care Trust as the case may be'.

Amendment No. 100, in page 4, line 4, at end insert—

'(1A) On an authorisation being given to a Primary Care Trust—

(a) it ceases to be a Primary Care Trust and becomes an NHS community trust,

(b) the proposed constitution has effect.'.

Amendment No. 101, in page 4, line 10, at end insert

'or community trust as the case may be'.

Amendment No. 102, in page 4, line 13, after 'trust, insert 'or community trust'.

Amendment No. 173, in page 4, line 17, leave out clause 8.

Amendment No. 103, in clause 8, page 4, line 18, after 'trust', insert 'or community trust'.

Amendment No. 104, in page 4, line 20, after 'trust, insert 'or community trust'.

Amendment No. 174, in page 4, line 22, leave out clause 9.

Amendment No. 175, in page 4, line 35, leave out clause 10.

Amendment No. 105, in clause 10, page 4, line 37, at end insert 'and community trusts'.

Amendment No. 106, in page 4, line 38, at end insert 'and community trust'.

Amendment No. 107, in page 5, line 6, after 'trust', insert 'or community trust'.

Government amendment No. 355.

Amendment No. 67, in page 5, line 14, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 176, in page 5, line 17, leave out Clause 11.

Amendment No. 68, in clause 11, page 5, line 18, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 108, in page 5, line 19, after 'trust', insert 'or community trust'.

Government amendment No. 356.

Amendment No. 177, in page 5, line 22, leave out clause 12.

Amendment No. 109, in clause 12, page 5, line 24, at end insert 'or community trust'.

Government amendment No. 246.

Amendment No. 69, in page 5, line 29, at end insert—

'(aa) the Assembly,'.

Amendment No. 332, in page 5, line 30, after 'trust', insert 'and Primary Care Trust'.

Amendment No. 110, in page 5, line 31, at end insert—

'(bb) every Primary Care Trust intending to make an application to become an NHS community trust,'.

Amendment No. 70, in page 5, line 33, at end insert

'and send a copy to the Assembly'.

Amendment No. 111, in page 5, line 36, at end insert 'and community trust'.

Amendment No. 178, in page 5, line 37, leave out clause 13.

Amendment No. 333, in clause 13, page 5, line 38, after first 'trust', insert

'or a Primary Care Trust'.

Amendment No. 112, in page 5, line 38, after second 'trust', insert

'or a Primary Care Trust becomes an NHS community trust'.

Amendment No. 113, in page 5, line 40, at end insert 'or community trust'.

Amendment No. 114, in page 6, line 3, after 'trust', insert 'or community trust'.

Amendment No. 71, in page 6, line 6, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 72, in page 6, line 10, after 'England', insert

'or (as the case may be) in Wales'.

Amendment No. 73, in page 6, line 12, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 74, in page 6, line 14, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 115, in page 6, line 14, after 'trust', insert 'or community trust'.

Amendment No. 179, in page 6, line 18, leave out clause 14.

Amendment No. 75, in clause 14, page 6, line 23, at end insert 'and Wales'.

Amendment No. 76, in page 6, line 28, after 'England', insert 'and Wales'.

Amendment No. 77, in page 6, line 37, after 'England', insert 'and Wales'.

Amendment No. 180, in page 7, line 13, leave out clause 15.

Amendment No. 397, in clause 15, page 7, line 14, leave out 'may' and insert 'must'.

Amendment No. 78, in page 7, line 15, after 'England', insert 'and Wales'.

Government amendment No. 247.

Amendment No. 398, in page 7, line 17, leave out 'power' and insert 'duty'.

Government amendment No. 248.

Amendment No. 400, in page 7, line 23, at end insert—

'(3A) An authorisation must state that no services be provided to a patient, other than an NHS patient, by an NHS foundation trust, other than in circumstances prescribed by subsection (3B).

(3B) These circumstances are that a certificate issued by the lead clinician in that specialty states that the services so provided are not needed by an NHS patient with equal or greater clinical need.'.

Amendment No. 181, in page 7, line 28, leave out clause 16.

Amendment No. 116, in clause 16, page 7, line 29, after 'trust', insert 'or community trust'.

Amendment No. 79, in page 7, line 38, at end insert 'and Wales'.

Amendment No. 117, in page 7, line 41, after 'trust', insert 'or community trust'.

Amendment No. 182, in page 8, line 1, leave out clause 17.

Amendment No. 118, in clause 17, page 8, line 2, after 'trust', insert 'or community trust'.

Amendment No. 119, in page 8, line 7, after 'trust', insert 'or community trust'.

Amendment No. 120, in page 8, line 12, after 'trust', insert 'or community trust'.

Amendment No. 183, in page 8, line 15, leave out clause 18.

Amendment No. 121, in clause 18, page 8, line 16, after 'trust', insert 'or community trust'.

Amendment No. 122, in page 8, line 22, after 'trust', insert 'or community trust'.

Amendment No. 184, in page 8, line 29, leave out clause 19.

Amendment No. 123, in clause 19, page 8, line 31, after 'trust', insert 'or community trust'.

Amendment No. 80, in page 8, line 32, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 124, in page 8, line 33, after 'trust', insert 'or community trust'.

Amendment No. 185, in page 8, line 37, leave out clause 20.

Amendment No. 125, in clause 20, page 8, line 38, after 'trust', insert 'or community trust'.

Amendment No. 186, in page 9, line 1, leave out clause 21.

Amendment No. 126, in clause 21, page 9, line 2, after 'trust', insert 'or community trust'.

Amendment No. 187, in page 9, line 4, leave out clause 22.

Amendment No. 81, in clause 22, page 9, line 5, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 127, in page 9, line 6, after first 'trust', insert 'or community trust'.

Amendment No. 128, in page 9, line 7, after 'trust', insert 'or community trust'.

Amendment No. 82, in page 9, line 13, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 83, in page 9, line 17, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 129, in page 9, line 21, after 'trust', insert 'or community trust'.

Amendment No. 84, in page 9, line 22, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 130, in page 9, line 23, after 'trust', insert 'or community trust'.

Amendment No. 188, in page 9, line 28, leave out clause 23.

Amendment No. 131, in clause 23, page 9, line 30, after 'trust', insert 'or community trust'.

Amendment No. 132, in page 9, line 34, after 'trust', insert 'or community trust'.

Amendment No. 189, in page 10, line 7, leave out clause 24.

Amendment No. 133, in clause 24, page 10, line 9, after 'trust', insert 'or community trust'.

Amendment No. 134, in page 10, line 14, after 'trusts', insert 'or community trusts'.

Amendment No. 190, in page 10, line 17, leave out clause 25.

Amendment No. 135, in clause 25, page 10, line 19, after 'trust', insert 'or community trust'.

Amendment No. 136, in page 10, line 32, at end insert 'or community trust'.

Amendment No. 85, in page 10, line 33, at end insert—

'(bb) a Local Health Board,'.

Amendment No. 86, in page 10, line 35, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 137, in page 10, line 42, at end insert 'or organisation'.

Amendment No. 138, in page 11, line 1, after 'trust', insert 'or community trust'.

Amendment No. 139, in page 11, line 2, at end insert 'or organisation'.

Amendment No. 192, in page 11, line 3, leave out clause 26.

Amendment No. 87, in clause 26, page 11, line 5, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 193, in page 11, line 18, leave out clause 27.

Amendment No. 140, in clause 27, page 11, line 20, leave out 'and NHS foundation trusts' and insert

', NHS foundation trusts and NHS community trusts'.

Amendment No. 194, in page 11, line 23, leave out clause 28.

Amendment No. 141, in clause 28, page 11, line 26, at end insert—

'(e) NHS community trusts'.

Amendment No. 195, in page 11, line 27, leave out clause 29.

Amendment No. 142, in clause 29, page 11, line 36, at end insert—

'(fb) NHS community trusts;'.

Amendment No. 143, in page 12, line 3, after 'trust', insert 'or community trust'.

Amendment No. 196, in page 12, line 5, leave out clause 30.

Amendment No. 145, in clause 30, page 12, line 9, leave out 'and NHS foundation trusts' and insert

', NHS foundation trusts and NHS community trusts'.

Amendment No. 197, in page 12, line 11, leave out clause 31.

Amendment No. 146, in clause 31, page 12, line 15, at end insert—

'(bc) an NHS community trust;'.

Amendment No. 198, in page 12, line 21, leave out clause 32.

Amendment No. 200, in page 12, line 24, leave out clause 33.

Amendment No. 147, in clause 33, page 12, line 26, after 'trust', insert 'or community trust'.

Government amendments Nos. 249 to 251.

Amendment No. 201, in page 13, line 3, leave out clause 34.

Amendment No. 148, in clause 34, page 13, line 4, after 'trust', insert 'or community trust'.

Amendment No. 202, in page 13, line 7, leave out clause 35.

Amendment No. 91, in clause 35, page 13, line 10, at end insert—

'"the appropriate Minister" means—

(a) in relation to England, the Secretary of State; and

(b) in relation to Wales, the Assembly,

"the Assembly" means the National Assembly for Wales,'.

Government amendment No. 357.

Amendment No. 92, in page 13, line 13, leave out

'or a Primary Care Trust'

and insert

', a Primary Care Trust or a Local Health Board'.

Amendment No. 320, in page 13, line 14, at end insert—

'"parliamentary constituency" has the meaning given in section 1 of the Parliamentary Constituencies Act 1986 (c.56) (parliamentary constituencies);

"the pilot test period" means the period that—

(a) begins with the day on which the first order is made under section 184 which brings into force a provision of this Part, and

(b) ends three years after the day referred to in paragraph (a);'.

Government new clause 25—Audit.

Government new clause 36—Mergers.

Government new clause 37—Section (Mergers): supplementary.

New clause 1—Review of democratically accountable governance—

'(1) It shall be the duty of the Secretary of State to establish an independent review body to carry out the functions specified in subsections (4) to (6).

(2) The Secretary of State shall appoint at least nine members to the independent review body.

(3) The independent review body shall elect a Chairman from amongst its members.

(4) The independent review body shall prepare reports containing proposals relating to the establishment of a local, democratically accountable system of governance for NHS foundation trusts and Primary Care Trusts.

(5) The independent review body may in particular make proposals in accordance with the provisions of subsection (4) relating to—

(a) methods of securing wider public participation in the governance of NHS foundation trusts and Primary Care Trusts;

(b) methods of increasing public awareness and access to information about the governance of NHS foundation trusts and Primary Care Trusts; and

(6) The independent review body must—

(a) lay a copy of any report prepared in accordance with the provisions of this section before Parliament, and

(b) once they have done so, send a copy of it to—

(i) the Secretary of State, and

(ii) the regulator.'.

New clause 9—Foundation patients' fora—

'(1) The Secretary of State shall establish a body to be known as a Foundation Patients' Forum—

(a) for each NHS Trust which has made an application under section 4(2);

(b) for each person who has been incorporated as a public benefit corporation under section 5(5).

(2) The members of the Foundation Patients' Forum are to be appointed by the Commission for Patient and Public Involvement in Health.

(3) Once the Foundation Patients' Forum has been established, it may do anything (including the things mentioned in subsection (4) below) which appears to it to be necessary or desirable for the purpose of preparing for effective patient and public involvement in the NHS Trust or public benefit corporation once it becomes a Foundation Trust.

(4) A Foundation Patients' Forum must—

(a) monitor and review the range and operation of services provided by, or under arrangements made by, the trust for which it is established,

(b) obtain the views of patients' and their carers about those matters and report on those views to the trust,

(c) provide advice, and make reports and recommendations, about matters relating to the range and operation of those services to the trust,

(d) make available to patients and their carers advice and information about those services,

(e) in prescribed circumstances, perform any prescribed function of the trust with respect to the provision of a service affording assistance to patients and their families and carers,

(f) carry out such other functions as may be prescribed.

(5) In providing advice or making recommendations under subsection (4)(c), a Foundation Patients' Forum must have regard to the views of patients and their carers.

(6) If, in the course of exercising its functions, a Foundation Patients' Forum becomes aware of any matter which in its view—

(a) should be considered by a relevant overview and scrutiny committee, the Forum may refer that matter to the committee,

(b) should be brought to the attention of the Commission for Patient and Public Involvement in Health, it may refer that matter to the Commission.

(7) Subsection (6) does not prejudice the power of a Foundation Patients' Forum to make such other representations or referrals as it thinks fit, to such persons or bodies as it thinks fit about matters arising in the course of its exercising its functions.

(8) An NHS Trust or public benefit corporation exercising its powers under sections 4(4)(b) or 5(7)(b) as the case may be shall be obliged to have regard to and take account of the reports and recommendations of the Foundation Patients' Forum.

(9) The governors and non-executive directors of the Foundation Trust shall be obliged to respond in writing to the reports and recommendations of the Foundation Patients' Forum.

(10) All the members, governors and directors of a Foundation Trust shall be obliged to have regard to and take account of the reports and recommendations of the Foundation Patients' Forum in exercising their functions within the Foundation Trust.

(11) The terms in this section shall be construed in accordance with the provisions of section 15(8) and (9) of the National Health Service Reform and Health Care Professions Act 2002 (c.17).'.

New clause 18—Community Health Councils and NHS foundation trusts in Wales—

'(1) Schedule 7A of the 1977 Act is amended as follows.

(2) In paragraph 2 (general provisions)—

(a) in subparagraph (f), for "and NHS trusts" there is substituted ", NHS trusts and NHS foundation trusts";

(b) in subparagraph (g), for "and NHS trusts" there is substituted ", NHS trusts and NHS foundation trusts";

(d) in subparagraph (k), for "or NHS trusts" there is substituted ", NHS trusts or NHS foundation trusts".

(3) In paragraph 3 (entry and inspection of premises), in subparagraph (1), after sub-subparagraph (f) there is inserted—

"(fa) NHS foundation trusts;".

New clause 19—NHS community trusts—

'(1) An NHS community trust is a public benefit organisation which is authorised to commission goods and services for the purposes of the health service in England.

(2) A public benefit organisation is a body corporate which, in pursuance of an application, is constituted in accordance with Schedule [constitution of public benefit organisations].'.

New clause 20—Applications by Primary Care Trusts—

'(1) A Primary Care Trust may make an application to the regulator for authorisation to become an NHS community trust if the application is supported by the Secretary of State.

(2) The application must—

(a) describe the goods and services which the applicants propose should be commissioned by the NHS community trust,

(b) describe the goods and services which the applicants propose should be provided by the NHS community trust, and

and must give any further information which the regulator requires the Primary Care Trust to give.

(3) The applicant may modify the application with the agreement of the regulator at any time before authorisation is given under section [authorisation of NHS community trusts].

(4) Once a Primary Care Trust has made the application—

(a) the provisions of the proposed constitution which give effect to paragraphs 3 to 16 of Schedule [constitution of public benefit organisations] have effect, but only for the purpose of electing a shadow board of governors and appointing a shadow board of directors,

(b) the Primary Care Trust may do anything (including the things mentioned in paragraph 16 of Schedule 2 to the National Health Service and Community Care Act 1990 (c.19) (general powers)) which appears to it to be necessary or desirable for the purpose of preparing it for NHS community trust status.'.

New clause 21—Authorisation of NHS community trusts—

'(1) The regulator may give an authorisation under this section to a Primary Care Trust which has applied under section [applications by Primary Care Trusts] if he is satisfied as to the matters specified in subsection (2).

(2) The matters are that—

(a) the applicant's constitution will be in accordance with Schedule [constitution of public benefit organisations] and will otherwise be appropriate,

(b) there will be a board of governors, and a board of directors, constituted in accordance with the constitution,

(d) the applicant will be able to commission or the goods and services or to provide the goods and services which the authorisation is to require it to commission or to provide, and

(e) any other requirements which he considers appropriate are met.

(3) Subject to the provisions of subsection (4), the authorisation may be given on any terms the regulator considers appropriate.

(4) An authorisation must authorise the NHS community trust to commission goods and services for the purposes of the health service in England.

(5) If regulations require the applicant to consult prescribed persons about the application, the regulator may not give an authorisation unless he is satisfied that the applicant has complied with the regulations.'.

New clause 24—Representative membership—

'An authorisation may require an NHS foundation trust to take steps to secure that (taken as a whole) the actual membership of its public constituency is representative of those eligible for such membership.'.

New clause 34—Extension of provisions of Part 1 following pilot tests—

'(1) Within three months of the conclusion of the pilot test period—

(a) the Secretary of State,

(b) the regulator,

(d) the Comptroller and Auditor General

shall lay before each House of Parliament a report on the operation of the provisions of Part 1 of this Act during the pilot test period.

(2) After all of the reports under subsection (1) have been laid before Parliament, the Secretary of State may by order—

(a) amend the provisions of Part 1 so as to extend the application to other NHS trusts and Primary Care Trusts, and

(b) make such other amendments of Part 1 as arise from the reports.

(3) No order may be made under subsection (2) unless a draft of the order has been laid before and approved by a resolution of each House of Parliament.'.

New clause 39—Public consultation relating to applications for foundation status—

'(1) The Secretary of State shall—

(a) by regulations require that an NHS Trust proposing to make an application under section 4(1) or any person proposing to apply under section 5(1) shall first consult prescribed persons, and

(b) by regulations prescribe persons to be consulted which shall include the Patients Forums for the NHS Trusts and Primary Care Trusts in the area in which are resident all or any of the persons to whom the applicant NHS Trust has provided goods or services for the purposes of healthcare or to whom the applicant or person (as the case may be) intends to provide such services if its application is successful.

(2) In section 7(3) of the Health and Social Care Act 2001 (functions of Overview and Scrutiny Committees)—

(a) at the beginning of subsection (3) (matters to be covered by regulations) for "may" there is substituted "shall";

(b) at the end of subsection (3)(b) there is inserted "which shall include all matters prescribed under subsection 7(3)(c) below,";

(c) at the end of subsection (3)(c) there is inserted "which shall include any application or proposed application under section 4 of the Health and Social Care (Community Health and Standards) Act 2003".'.

Government new schedule 2—Audit of accounts of NHS foundation trusts.

New schedule 1—Constitution of public benefit organisations—

Requirement for a constitution

1 (1) A public benefit organisation is to have a constitution.

(2) As well as any provision authorised or required to be made by this Schedule, the constitution may make further provision (other than provision as to the powers of the organisation) consistent with this Schedule.

2 The constitution is to name the organisation and, if the organisation is an NHS community trust, its name must include the words "NHS community trust".

Members

3 (1) The members of a public benefit organisation are to be individuals who—

(a) live in the area specified for the purpose in the constitution ("the public constituency"), or

(b) are employed by the organisation ("the staff constituency").

(2) The constitution may also provide for the public constituency to comprise individuals who have received goods or services commissioned or provided by the Primary Care Trust as patients (including individuals attending as the carer of a patient).

(3) The constitution may also provide for the staff constituency to comprise NHS professionals who provide services to the Primary Care Trust or who a self-employed contractor or in a self-employed contract with the Primary Care Trust.

(4) Subparagraph (1)(a) does not apply to a person who is eligible for membership of the staff constituency.

4 The constitution is to require a minimum number of members of each constituency.

5 (1) A person may not be a member of a public benefit organisation unless he has agreed to pay a sum not exceeding £1 to the organisation.

(2) A person may not be a member of a public benefit organisation if—

(a) he has been adjudged bankrupt or has made a composition or arrangement with his creditors,

(b) he has within the preceding five years been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed on him.

(3) The constitution may make further provision as to the circumstances in which a person may not be a member.

Board of Governors

6 (1) A public benefit organisation is to have a board of governors.

(2) Only the following may be members of the board—

(a) members of the organisation, and

(b) individuals appointed under the following provisions who do not fall within paragraph 5(2)(a) or (b).

(3) The members of the board other than the appointed members are to be chosen by election.

(4) Members of the public constituency or the staff constituency may elect any of their number to be a member of the board.

(5) If contested, the election must be by postal ballot.

7 (1) More than half of the members of the board of governors are to be elected by the public constituency.

(2) Not fewer than one third of the members of the board are to be elected by the staff constituency.

8 (1) A member of the board of governors elected by the public constituency or the staff constituency may hold office for a period of three years.

(2) Such a member is to be eligible for re-election at the end of that period.

(3) But a person elected to membership of the board ceases to hold office if he ceases to be a member of the relevant constituency.

9 The organisation may pay travelling and other expenses to members of the board of governors at rates decided by the organisation.

10 The constitution is to provide for the chairman of the organisation or (in his absence) another person to preside at meetings of the board of governors.

11 (1) The constitution is to provide for meetings of the board of governors to be open to members of the public.

(2) But the constitution may provide for members of the public to be excluded from a meeting for special reasons.

12 (1) The constitution is to make provision as to—

(a) the conduct of elections for membership of the board,

(b) the appointment of persons to membership,

(d) the removal of a member from office.

(2) The constitution may make further provision about the board.

Directors

13 (1) A public benefit organisation is to have a board of directors.

(2) The constitution is to provide for all the powers of the organisation to be exercisable by the board of directors on its behalf.

(3) But the constitution may provide for any of those powers to be delegated to a committee of directors or to an executive director.

14 (1) The board is to consist of—

(a) executive directors, one of whom is to be the chief executive and another the finance director,

(b) non-executive directors, one of whom is to be the chairman.

(2) Only a member of the public constituency is eligible for appointment as a non-executive director.

15 (1) It is for the board of governors at a general meeting to appoint or remove the non-executive directors.

Removal of a non-executive director under this subparagraph requires the approval of three-quarters of the members of the board.

(2) It is for the non-executive directors to appoint or remove the chief executive.

(3) It is for the chief executive to appoint or remove the executive directors.

(4) An appointment or removal under subparagraph (2) or (3) requires the approval of a majority of the board of governors voting at a general meeting.

16 (1) It is for the board of governors at a general meeting to decide the remuneration and allowances, and the other terms and conditions of office, of the non-executive directors.

(2) The organisation is to establish a committee of non-executive directors to decide the remuneration and allowances, and the other terms and conditions of office, of the executive directors.

17 (1) A public benefit organisation is to have—

(a) a register of members showing, in respect of each member, the constituency to which he belongs,

(b) a register of members of the board of governors,

(2) The constitution may make further provision about the registers including, in particular, admission to, and removal from, the registers.

18 (1) The following documents of a public benefit organisation are to be available for inspection by members of the public free of charge at all reasonable times—

(a) a copy of the current constitution,

(b) a copy of the current authorisation,

(d) a copy of the latest annual accounts and of any report of the auditor on them,

(e) a copy of the latest annual report,

(f) a copy of the latest information as to its forward planning.

(2) Any person who requests it is to be provided with a copy of or extract from any of the above documents.

(3) If the person requesting the copy or extract is not a member of the organisation, the organisation may impose a reasonable charge for doing so.

Auditor

19 (1) A public benefit organisation is to have an auditor.

(2) It is for the board of governors to appoint or remove the auditor at a general meeting of the board.

(3) But a person may not be appointed as auditor unless he (or, in the case of a firm, each of its members) is a member of one or more of the following bodies—

(a) the bodies mentioned in section 3(7)(a) to (e) of the Audit Commission Act 1998 (c.18),

(b) any other body of accountants established in the United Kingdom and for the time being approved by the Secretary of State for the purposes of this paragraph.

(4) The organisation is to establish a committee of non-executive directors to monitor the exercise of the auditor's functions.

Accounts

20 (1) A public benefit organisation is to keep accounts in such form as the Secretary of State may with the approval of the Treasury direct.

(2) The accounts are to be audited by the organisation's auditor.

(3) But the Comptroller and Auditor General may examine—

(a) the accounts,

(b) any records relating to them, and

21 (1) A public benefit organisation is to prepare in respect of each financial year annual accounts in such form as the Secretary of State may with the approval of the Treasury direct.

(2) In preparing its annual accounts, the organisation is to comply with any directions given by the Secretary of State with the approval of the Treasury as to—

(a) the methods and principles according to which the accounts are to be prepared,

(b) the information to be given in the accounts.

(3) In determining the form and content of the annual accounts the Secretary of State is to aim to ensure that the accounts present a true and fair view.

(4) The organisation must—

(a) lay a copy of the annual accounts, and any report of the auditor on them, before Parliament, and

(b) once it has done so, send copies of those documents to the Secretary of State.

(5) In this paragraph and paragraph 23 "financial year" means—

(a) the period beginning with the date on which the organisation is authorised under section [authorisation of NHS community trusts] and ending with the next 31st March, and

(b) each successive period of twelve months beginning with 1st April.

Annual reports and forward plans

22 (1) A public benefit organisation is to prepare annual reports and send them to the Secretary of State.

(2) The reports are to give any information the Secretary of State requires.

(3) It is for the Secretary of State to decide—

(a) the form of the reports,

(b) when the reports are to be sent to him,

23 (1) A public benefit organisation is to give information as to its forward planning in respect of each financial year to the Secretary of State.

(2) The information is to be prepared by the directors after consulting the board of governors.

Meeting of board of governors to consider annual accounts and reports

24 The following documents are to be presented to the board of governors of a public benefit organisation at a general meeting—

(a) the annual accounts,

(b) any report of the auditor on them,

Instruments etc.

25 (1) The constitution is to make provision for the authentication of the fixing of the organisation's seal.

(2) A document purporting to be duly executed under the organisation's seal or to be signed on its behalf is to be received in evidence and, unless the contrary is proved, taken to be so executed or signed.'.

Amendment No. 165, in page 99, line 2, leave out schedule 1.

Government amendment No. 253.

Amendment No. 228, in schedule 1, page 99, line 18, at end insert

'other than those attending accident and emergency who have been treated and discharged within one hour of being medically examined'.

Government amendment No. 254.

Amendment No. 229, in page 99, line 25, at end insert—

'(2) The minimum number of members required in the public constituency shall not be less than 15 per cent. of those registered to vote in local government elections in the area specified for the purpose in the constitution.'.

Amendment No. 334, in page 99, line 26, leave out paragraph 5 and insert—

'5(1) All persons who are entitled to vote in parliamentary elections in parliamentary constituencies which fall (partly or wholly) within the area specified for the purposes of paragraph 3(1) in respect of a public benefit corporation shall be members of that corporation.

(2) For the purposes of this paragraph, entitlement to vote shall be determined in accordance with the provisions of section 1 of the Representation of the People Act 1983 (c.2) (parliamentary electors).'.

Government amendments Nos. 255 to 257.

Amendment No. 335, in page 100, line 2, at end insert

'comprising twelve members, eight of whom are to be elected and four of whom are to be co-opted'.

Amendment No. 404, in page 100, line 2, at end insert

'members of which are to be appointed from the constituencies set out in paragraph 7'.

Government amendment No. 258.

Amendment No. 336, in page 100, line 5, leave out 'appointed' and insert 'co-opted'.

Amendment No. 337, in page 100, line 5, leave out from 'provisions' to end of line 6.

Amendment No. 405, in page 100, line 7, leave out subparagraph (3).

Amendment No. 338, in page 100, line 7, leave out 'appointed' and insert 'co-opted'.

Amendment No. 339, in page 100, line 8, at end insert—

'(3A) Members of the public constituency may elect any of their number to be a member of the board.

(3B) To be eligible to stand for election a member must—

(a) have been nominated by at least 50 other members of the public constituency in accordance with the provisions of Schedule 1 of the Representation of the People Act 1983 (c.2), and

(b) have his main residence within the area specified for the purposes of paragraph 3(1) in respect of the public benefit corporation.

(3C) The provisions of Part 1 of the Representation of the People Act 1983 shall apply to elections under this paragraph in respect of the public constituency as they apply to parliamentary elections, subject to such modifications as the Secretary of State may by order specify.'.

Amendment No. 406, in page 100, line 9, leave out subparagraph (4).

Amendment No. 340, in page 100, line 9, leave out 'public constituency or the'.

Amendment No. 407, in page 100, line 11, leave out subparagraph (5).

Amendment No. 341, in page 100, line 11, after 'election', insert

'in respect of the staff constituency'.

Government amendment No. 259.

Amendment No. 230, in page 100, line 11, at end insert—

'(6) The board of governors shall not be properly constituted unless at least 20 per cent. of members of the relevant constituency have voted in the election.'.

Government amendment No. 260.

Amendment No. 408, in page 100, line 12, leave out subparagraph (1) and insert—

'(1) The trust will propose a scheme for approval by the Secretary of State for the constitution of the board of governors, which must include the following constituencies—

(a) elected members of the local authority;

(b) groups representing the local community;

(d) persons representing local Primary Care Trusts;

(e) a university, if the hospital includes a medical or dental school provided by the university; and

(f) any other groups the Board identifies as appropriate.

(1A) The balance of membership will be decided by individual boards.'.

Amendment No. 342, in page 100, line 12, leave out 'More than half' and insert 'Seven'.

Amendment No. 343, in page 100, line 14, leave out 'At least'.

Amendment No. 344, in page 100, line 15, leave out 'appointed by' and insert 'co-opted to represent'.

Amendment No. 61, in page 100, line 15, at end insert

'(in England) or a Local Health Board (in Wales)'.

Amendment No. 345, in page 100, line 15, at end insert

'in the case of a public benefit corporation primarily providing hospital services and an NHS hospital in the case of a public benefit corporation primarily providing primary care services'.

Amendment No. 354, in page 100, line 16, at end insert—

'( ) At least one member of the board is to be appointed by one or more qualifying local authorities.

A qualifying local authority is a local authority for an area which includes the whole or part of the area specified under paragraph 3(1)(a).'.

Amendment No. 346, in page 100, line 18, leave out 'appointed by' and insert 'co-opted to represent'.

Government amendment No. 261.

Amendment No. 347, in page 100, line 19, at end insert—

'(5) The co-opted members shall be so co-opted by a decision of the elected members of the board.

(6) The chairman may (with the agreement of the majority of the board) remove any of the co-opted members.'.

Amendment No. 348, in page 101, line 6, at end insert—

'(1A) The chairman shall be one of the members of the board of governors elected in respect of the public constituency.'.

Government amendments Nos. 262 and 263.

Amendment No. 242, in page 101, line 28, at end insert—

'(d) a register of interests of the directors.'.

Amendment No. 243, in page 101, line 30, at end insert—

'17A The constitution is to make provision for dealing with conflicts of interest of the directors.'.

Amendment No. 244, in page 101, line 36, leave out paragraph (c) and insert—

'(c) the registers mentioned in paragraph 17,'.

Amendment No. 349, in page 102, line 5, leave out subparagraphs (2) and (3) and insert—

'(2) The auditor is to be the Comptroller and Auditor General.'.

Amendment No. 350, in page 102, line 20, leave out 'corporation's auditor' and insert 'Comptroller and Auditor General'.

Amendment No. 351, in page 102, line 21, leave out subparagraphs (3) and (4).

Amendment No. 352, in page 102, line 39, leave out from 'and' to 'before' in line 40 and insert

'the report of the Comptroller and Auditor General thereon'.

Amendment No. 353, in page 103, line 6, at end insert—

'(1A) The report shall contain a breakdown of the costs incurred by the public benefit corporation running elections and managing the membership.'.

Amendment No. 234, in page 103, line 7, leave out 'any' and insert—

'(a) information on any steps taken by the corporation to secure that (taken as a whole) the actual membership of its public constituency is representative of those eligible for such membership,

(b) any other'.

Amendment No. 167, in page 103, line 28, leave out schedule 2.

Amendment No. 62, in schedule 2, page 104, line 13, at end insert—

'Consultation with the Assembly

2A The Secretary of State must consult the Assembly before exercising any of his functions under paragraphs 1 and 2 at any time after the day on which the Assembly notifies the Secretary of State of the Assembly's intention to make an order under section 184 in relation to Part 1.'.

Government amendments Nos. 264 and 265.

Amendment No. 63, in page 105, line 3, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 64, in page 105, line 4, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 97, in page 105, line 24, at end insert 'and Community'.

Amendment No. 98, in page 105, line 28, after 'Foundation', insert 'and Community'.

Amendment No. 99, in page 105, line 32, after 'Foundation', insert 'and Community'.

Amendment No. 191, in page 105, line 33, leave out schedule 3.

Amendment No. 199, in page 106, line 22, leave out schedule 4.

Amendment No. 88, in schedule 4, page 110, line 10, leave out 'Secretary of State' and insert 'appropriate Minister'.

Amendment No. 89, in page 110, line 15, leave out 'Secretary of State' and insert 'appropriate Minister'.

Government amendment No. 266.

Amendment No. 90, in page 113, line 38, leave out 'Secretary of State' and insert 'appropriate Minister'.

Government amendments Nos. 358 and 267.

Amendment No. 203, in clause 48, page 18, line 9, leave out subsections (6) and (7).

Government amendment No. 371.

Amendment No. 204, in page 19, line 1, leave out clause 50.

Amendment No. 205, in clause 54, page 20, line 10, leave out subsection (2).

Amendment No. 206, in page 21, line 1, leave out subsection (2).

Government amendment No. 378.

Amendment No. 207, in clause 116, page 51, line 32, leave out subsection (2).

Amendment No. 149, in clause 139, page 60, line 20, at end insert—

'(aa) an NHS community trust;'.

Amendment No. 208, in page 60, leave out line 24.

Amendment No. 93, in page 60, line 24, at end insert

'all or most of whose hospitals, establishments or facilities are situated in England'.

Amendment No. 209, in page 60, leave out line 47.

Amendment No. 94, in page 61, line 17, at end insert—

'(bb) an NHS foundation trust all or most of whose hospitals, establishments or facilities are situated in Wales;'.

Amendment No. 219, in schedule 10, page 135, line 30, leave out sub-subparagraph (a).

Amendment No. 220, in page 135, line 35, leave out 'an NHS foundation trust'.

Amendment No. 221, in page 143, line 29, leave out sub-subparagraph (a).

Amendment No. 222, in page 143, line 35, leave out 'NHS foundation trust or'.

Amendment No. 223, in page 144, line 2, leave out 'or NHS foundation trust'.

Amendment No. 224, in page 144, leave out line 20.

Amendment No. 210, in clause 141, page 62, line 36, leave out paragraph (b).

Government amendment No. 252.

Amendment No. 211, in clause 151, page 73, line 29, leave out subparagraph (ii).

Amendment No. 212, in clause 153, page 75, line 34, leave out subparagraph (ii).

Amendment No. 213, in clause 156, page 77, line 29, at end insert 'or'.

Amendment No. 214, in page 77, line 31, leave out from 'Act' to end of line 32.

Amendment No. 215, in clause 175, page 94, leave out line 6.

Amendment No. 216, in page 95 leave out line 31.

Amendment No. 217, in clause 184, page 96, line 13, leave out '1' and insert '2'.

Amendment No. 218, in page 96, line 18, leave out paragraph (a).

Amendment No. 95, in page 96, line 18, leave out from 'Part 1' to end of line 19 and insert—

'(i) for sections 2, 29 and 30, the Secretary of State;

(ii) for section [Community Health Councils and NHS foundation trusts in Wales], the Assembly; and

(iii) for the other provisions of the Part, and section 182 and Schedule 13 so far as relating to those provisions—

(a) in relation to England, the Secretary of State; and

(b) in relation to Wales, the Assembly;'.

Amendment No. 225, in schedule 13, page 151, leave out lines 3 to 26.

David Hinchliffe (Labour, Wakefield)

The purpose of the amendments tabled by my hon. Friends and I is to delete the foundation trust proposals from the Bill. I certainly support most of the remainder the Bill. It could be carried forward without part 1, which is the controversial element that many Labour Members oppose.

There are three key reasons why I am a member of the Labour party: my party has traditionally stood for redistribution of wealth and a fairer society; it has traditionally stood for comprehensive education and equal opportunities; and it introduced a national health service based on sound socialist principles. I emphasise the word "national" in national health service because the concept of the national health service is fundamental to the debate.

There was no national system before 1948. It was hit and miss as to whether local provision existed. There was a geographical lottery and people sometimes suffered as a direct consequence of that. Such a diversity of provision seems to be the aim now and I am worried that it will hit at the heart of much of what my party has achieved by bringing about the national health service.

The current Government have a proud record on health. I pay tribute to my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) and the Health Ministers who are in the Chamber. I also pay tribute to my right hon. Friend the Member for Darlington (Mr. Milburn), who is not in the Chamber, for his contribution to many of the Government's health achievements.

There is record investment in the national health service and record staff recruitment and training. We have a record capital programme to address hospitals that have been falling down for years and that suffered from gross under-investment. Pinderfields hospital, which is in my constituency, is such a hospital, and I am proud that we will soon have a new hospital. I am proud of the quality measures that the Government have introduced for our health care system. I am especially proud that we ended the Conservative internal market because my area experienced the two-tier system that was at the heart of our concerns about that. People living in the same street had different access to key health services, as I have said on many occasions in the House. I am proud that we set about getting rid of competition in a service that is essentially based on collectivism and co-operation.

Angela Eagle (Labour, Wallasey)

I am looking in astonishment at the Conservative Benches, which are completely devoid of any Back Benchers except for one high-quality Member. The Labour Benches are packed with people who will debate passionately the future of our health service. Is that not the most telling thing that we have seen today?

David Hinchliffe (Labour, Wakefield)

In defence of the hon. Member for South Cambridgeshire (Mr. Lansley), who is sitting on the Conservative Benches, he probably knows more about the health service than the rest of his colleagues put together.

For the first time in the history of the health service, we have a Government who are committed to the empowerment of primary care. That is probably the most crucial policy development that they have achieved. The history of the health service has been dominated by the concerns of the acute hospital sector and by hospital consultants. We have never before exploited the potential of primary care, but primary care trusts are starting to achieve that. I strongly commend the steps that the Government have taken.

Howard Stoate (Labour, Dartford)

Does my hon. Friend agree that the ballot of general practitioners in which 80 per cent. voted in favour of the new GP contract shows that primary care physicians are committed to leading the NHS toward the modernisation that we so richly deserve in this century?

David Hinchliffe (Labour, Wakefield)

I was delighted by the result of the GP ballot. It is also worth placing on record that the Royal College of General Practitioners, which represents GPs, including my hon. Friend, has come out strongly against foundation hospitals. No doubt he will take note of that point.

I shall outline the key concerns that many of us have. One lesson that I learned through my work on the Select Committee on Health is that the last thing that our health care system needs is further restructuring and change, especially ill-considered change that has not had its potential consequences worked through. As I said on Second Reading, there have been 18 significant restructurings of our health care system during the past 20 years. People ask me where all the money has gone—it has gone on many of those restructurings.

I have examined redundancy costs of staff who have gone down the road and early retirement costs. It is worth considering the possible salaries of the people who will be chief executives of the new foundation trusts. Some are campaigning enthusiastically for foundation status in the full knowledge that they are guaranteed to receive a huge salary hike. When we consider the use of scarce resources, we should be aware of how resources that should be used for patient care are being used—they are being used for ill-thought-out restructurings. I bet that there will be at least three more restructurings before the end of the proposed five-year roll-out of foundation hospitals. We should listen carefully to the many in the health service who say, "Enough is enough." We should let reforms bed down and let investment take effect so that we deliver on patient care.

I mentioned my pride that the Labour Government have moved away from the internal market that the Tories introduced. One of my central worries about the principles that underpin foundation status is that the policy will mark a return to a market-oriented approach to health care. It will undoubtedly restore a competitive ethos, putting hospital against hospital and doctor against doctor. I know from talking to managers that they are looking over their shoulders at their rivals in their localities and elsewhere in the regions in which they are based.

The policy is about winners and losers. It is clear from the Government's response to the Health Committee report on foundation trusts that capital spend by foundations will have an impact on the wider NHS. So when I talk to colleagues about their position on the issue and they say to me, "David, I'm going to have a foundation hospital in my constituency", I say, "That's all well and good, but have you thought about the impact on your neighbours?" There will be a foundation hospital near my constituency and I am aware of the serious impact that it will have on the health economy elsewhere in the west Yorkshire area. We have to consider that issue because it is fundamental to concerns about foundation status.

Louise Ellman (Labour/Co-operative, Liverpool, Riverside)

Does my hon. Friend share my concerns that the new system could lead to fragmentation and competing trading organisations—some in the public sector, some in the private sector—without us fully debating the implications of that concept in the Chamber?

David Hinchliffe (Labour, Wakefield)

I do. In a sense, my hon. Friend takes me to my next point. A number of organisations that have lobbied against foundation status have said that it is a step towards privatisation. I have never said that. I did not make that claim on Second Reading and I do not think any of my hon. Friends who oppose foundation status made it either. However, a briefing document states:

"a series of amendments were put down"

in Committee

"that open the doors to foundation hospitals actually being able to increase the amount of private work they undertake. Clause 15 of the Bill used to say that the regulator 'must' restrict the private work of the foundation hospitals; it now only says that the regulator 'may' restrict this work."

Before my hon. Friend the Member for Lewisham, West (Jim Dowd), who will probably be in the Chamber later, accuses me of reading from a Unison briefing, the document was issued by the Independent Healthcare Association. It is a briefing from the private sector. The association fears that foundation hospitals will lead to more privatisation—more private work in those hospitals—and the impact that that will have on private hospitals. We have to take serious note of that. I have not raised the issue before, but I think that it is relevant in view of the association's comments.

Kevin Hughes (Labour, Doncaster North)

Does my hon. Friend recall campaigning against trust status, in particular the self-appointed quangos introduced by the Tories? We pledged that, when we got into government, we would do away with those. The Bill does that and installs local democracy. Does he not think that that will act as a check on the problem that he raises? I think that it will.

David Hinchliffe (Labour, Wakefield)

If my hon. Friend looks at the Health Committee report, he will see that we calculated that, rather than getting rid of bureaucracy, the new system would increase it. I remember speaking in support of my hon. Friend's candidature when he stood in Doncaster and I argued against the Tory internal market. He was with me on that. He may not be with me at the moment, but the principles are the same. I hope that he understands that we are talking about the internal market, which he opposed before he became a Labour MP.

Kevin Hughes (Labour, Doncaster North)

Will my hon. Friend give way again?

David Hinchliffe (Labour, Wakefield)

No. I want to make progress. My hon. Friend will have an opportunity to respond. I am conscious that other colleagues want to participate and I have some points to make before I conclude.

A key consideration, which relates to my pride in the way in which the Government moved towards a primary care NHS, is that the policy on foundation hospitals runs directly contrary to that. It is a return to the dominance of certain acute hospitals. It does not make sense to talk about the new GP contract enhancing the role of primary care if we are suddenly to return to the empowerment of a small number of acute hospitals. That will be to the detriment of primary care and community care.

I have argued many times in the Chamber for local governance of health. I have made all sorts of arguments over the years, including when I was on the Front Bench, about how we would achieve local governance, but it has been resisted up to now by the Labour party and its Front-Bench spokesmen. I welcome the commitment to move towards local governance, but I do not think that it has been properly thought through. We should consult on and think about some of the issues that it raises.

I was interested to read the Health Service Journal this week, which reported the discussions at the NHS Confederation conference last week. It publishes the comments of two chairs of trusts that hope to receive foundation trust status. John Charlton, the chair of University hospital Birmingham, said:

"We are only a matter of months away from foundation trusts and it doesn't seem to me that anybody has thought the governance through."

He went on to say:

"Yes, let's have autonomy, let's have accountability, but for goodness sake don't expect us to have a 5,000-strong membership. That would be an absolute nightmare."

Frankly, if that is what a chair of an applicant trust is saying, I wonder where we are coming from because I would have thought that 5,000 would be a minimum.

Gordon Prentice (Labour, Pendle)

Will my hon. Friend give way?

David Hinchliffe (Labour, Wakefield)

I want to carry on.

Peter Dixon, the chair of University college London, another foundation trust applicant, remained concerned that those with an interest in governance might not represent the wider needs of the public. He said:

"We will be choosing between the Hampstead Heath Conservation Society and the local Trotskyists. The Marsden"—

the Royal Marsden in London—

"is worried about animal-rights protesters because of their research . . . There is a danger of disenfranchising those who don't have sharp elbows."

That sums up my concerns.

David Hinchliffe (Labour, Wakefield)

With the greatest of respect, I want to conclude. I have given way several times and many hon. Members want to speak.

I am concerned that the policy is part of a growing trend of policy making on the hoof. I raised that with the Prime Minister in the Liaison Committee this morning. The policy has not been properly thought through and there has been no proper consultation. Where is our manifesto commitment on it? I was not elected on the basis of foundation trusts; I was elected to get rid of the ethos that is behind foundation trusts. Where is the policy formulation in the party? I discussed the matter with my general management committee and it has not come through for discussion in the policy forums or at conference. Where is the Green Paper? Where is the White Paper?

We are bouncing to policies that are not fully thought through. The number of Government amendments tabled gives the impression of a policy that has been made on the back of an envelope. I hope that the Government will remove the part of the Bill on foundation trusts and not force us to go against them. They should go back to the drawing board and leave the rest of the Bill to go through the House unchallenged.

Liam Fox (Conservative, Woodspring)

The debate is important. Quite how important depends on which Government view of it we take. The Prime Minister tells us that the reforms are of monumental, historic importance, but the new Secretary of State told Back Benchers this week that the reforms are of little importance so they need not be worried about the amount of change that is being introduced. Both those views cannot be true, unless one is part of the Prime Minister's closest coterie and lives in the Alice in Wonderland world where it is possible to believe two opposites at the same time.

We have never made a secret of the fact that we favour the principle of foundation hospitals, especially the way in which they have been established in Spain and Sweden. Early in the debate on the Bill, we laid out what we wanted: foundation hospitals that can borrow according to their own plans outwith the limits set by Government; that are free from political interference; that are free from central targets and bureaucracy; and that are free to set the pay and conditions that they think appropriate to attract staff in their locality and with different clinical specialties.

I realise that that puts me in a diametrically opposed position to the hon. Member for Wakefield (Mr. Hinchliffe), but I have to admit that there is much truth in what he says. The policy is a move back towards an internal market-type system, which we support and would like extended. Indeed, the Government are not moving as far in that direction as we would like. Some people say that we could build on the Bill—were we to inherit it in its current form, we could use it as a prototype to take our plans much further. Indeed, we could and almost certainly would do that, but we believe that there are a number of practical reasons why the system as it has been set out in the Bill is so flawed that it will lead to a much worse system of health care than we have at present.

What are our major objections? First, there is freedom, but only for a few. Instead of a gradual roll-out for everybody, there is to be a total roll-out for some and none for others, which seems to maximise the potential for instability in the system. If one tried to design a system to give greater instability, it would be difficult to do.

There is borrowing, but only within the limitation of the NHS budget, which by definition means that if any foundation hospital gets more investment, there will be less investment in another hospital in the NHS. That is different from the case being advanced. The Government will tell us that at present hospitals must compete for a share of the budget, and the proportionate effect will occur anyway. Under the proposals, however, some will be dealt a stronger hand than others vying for the same budget. The whole point of foundation hospitals in other countries was to allow them the freedom not to have to borrow within the state budget, but to borrow from outside, therefore not affecting the total amount available in the public system. The Government seem to have missed the point of the system in Spain and Sweden.

Another issue is the independence of the system. Great play was made on Second Reading about the independence of the regulator. The term "independence" was not used in a sense that any of us would recognise. The regulator is appointed by the Secretary of State, he can be dismissed by the Secretary of State, his pay and conditions and pension are determined by the Secretary of State, he has to report to the Secretary of State on anything the Secretary of State deems fit, and he cannot grant foundation status except with the prior agreement of the Secretary of State. The system is to be run by the Secretary of State in all but name.

I have a number of questions that I would like the Minister to deal with when he speaks. The first is about pay. The previous Secretary of State said that managers should have

"freedom and flexibility within the new NHS pay systems to reward staff appropriately".

What does "appropriately" mean, in the context of foundation hospitals? Secondly, what does it mean in terms of the Chancellor's new plan, as laid out in the Budget, to introduce regional pay throughout the public services? How would that impact on the proposals for foundation hospitals, and how does it fit with the Prime Minister's pledge last week that all NHS staff will continue, as long as the Government are in office, to have above-inflation pay settlements? How does that relate to the independence of foundation hospitals?

Angela Eagle (Labour, Wallasey)

I am listening to the hon. Gentleman's comments with interest. Could he tell the House which way his party will vote on the amendment?

Liam Fox (Conservative, Woodspring)

Unless we hear something quite unexpected from the Minister, we will almost certainly vote with the hon. Member for Wakefield in support of the amendment. As I said, there are strong reservations about this part of the Bill.

We have concerns about governance. Where is the logic in applying any democratic leverage in the system not to the commissioners of health care, but to the providers? If there is a place for local democracy to be involved in the determination of the spending of health funds, it would have been far more logical to bring in election at the level of primary care trusts, where decisions about the commissioning of services, and therefore the spending of funds, will be taken. What is the point of introducing a democratic element into the providers—the hospitals? At that point, they cannot determine what the balance of the provision of services will be, because those decisions will already have been taken by the PCTs in charge of the funding. I find the proposal utterly illogical. It seems to invert the Government's intention.

John Mann (Labour, Bassetlaw)

In my area, local people want a say about the future of accident and emergency services. The one hospital in Bassetlaw is part of a larger trust, Doncaster and Bassetlaw. When the decision was made to downgrade Bassetlaw hospital under the current rules, not only were people not allowed to have a formal say, but they were not even allowed to find out about it until decisions were being made. I called a ballot on that and 35,000 people voted—a 60 per cent. turnout. That was not within primary care. What is wrong with that principle?

Liam Fox (Conservative, Woodspring)

That makes the point. The provision and maintenance of services is dependent on the funding of the services. It is the primary care trust that is responsible for the funding of accident and emergency services. There seems to be a dislocation between what the Government said they intended to do, and what they are doing through the Bill. There is no logic in the Government's approach.

I have a huge problem with the way in which the Government propose to take governance forward. Members of the foundation hospital board will be drawn from the public and the staff. The public members may be those who have attended an NHS foundation hospital as a patient or a carer. On the last two occasions on which we have had Health questions, the right hon. Member for Manchester, Withington (Mr. Bradley) asked about the Christie hospital. At a large hospital with regional and national status, where patients may come from all parts of the country, what will be the constituency if such a hospital became a foundation hospital? Twice Ministers failed to come up with an answer to one of the most fundamental questions about the practical application of the Bill.

Are we to have a foundation hospital which, because it can draw patients from anywhere in the country, can have hundreds of thousands, and possibly millions, of potential members, and what will the legal requirements be for the hospital trust to ask each of those members whether they want to be elected to the board? The system is supposed to reduce bureaucracy and red tape, according to the Government. It will create a nightmare of bureaucracy and red tape, without even considering the cost.

Let us consider a simple example—a foundation hospital with a patient catchment of 500,000 patients. Let us assume that one in 10 of the patients in the catchment area might want to be a member of the foundation hospital board at a servicing of between £4 and £5 a year, which is the cost estimated by trusts that have indicated that they might want foundation hospital status. If we add to that the cost of advertising and running the elections, we are speaking of a cost of £240,000 per year per trust simply to maintain and run the electoral arrangements and the foundation hospital board.

That cannot be what Ministers meant when they said that the public were willing to pay higher taxes to get better quality health care. The public will pay higher taxes, only to see the money diverted on a huge scale into an unnecessary bureaucracy that does not even exist yet. The hon. Member for Wakefield mentioned one of the trust chairmen, who also said that far too much of the time of his management would be taken up preparing and running the consultation process, rather than managing the hospital. All hon. Members must surely have deep reservations about the practical implications, if not the principle, of the proposal.

Gary Streeter (Conservative, South West Devon)

My hon. Friend has spent a great deal of time in the past couple of years speaking to people who run hospitals. How many NHS trust chief executives, consultants, doctors and nurses have said that the real problem with the health service and with our acute hospitals is some kind of democratic deficit? Are not the Government introducing measures that will not improve the health service, and should they not think again?

Liam Fox (Conservative, Woodspring)

Without going into the concept of the democratic deficit, I can say that as a doctor I have never had a patient and as an MP I have never had a constituent coming to complain that they had a real problem with the democratic deficit in the NHS. They usually complain about access to health care. There are arguments to be made about how a system of publicly financed health care is to be made accountable to those who use and pay for the system through their taxes, but the Government's proposals are not a reasonable solution, for the reasons that I have set out.

I want to mention just one or two other practical implications, as I know that many hon. Members wish to speak. The hon. Member for Wakefield referred to the problem in respect of private income. We believe that what Ministers are proposing has an enormous unintended consequence, as trusts will effectively be limited to the private income that they currently have and will not be allowed to increase it. I have raised the issue with the Minister before and we have still not received a proper answer. The provision will mean that when the new opportunities fund or a charity provides an MRI scanner for a national health service hospital, the foundation trust is prevented from selling to the private sector any spare time when that equipment is not being used to raise greater income. However, the private sector will be able to sell extra time on an MRI scanner to the NHS. Surely, that cannot be what the Government intended. Only a very badly thought out set of provisions would allow that to happen.

I have one other major reservation. Foundation hospitals are supposed to be set free from central regulation, yet they will be subjected to one of the forms of regulation that I find most ineffective and which is most resented in the health service—the star-rating system. In my constituency in north Somerset, we have five hospitals around us: the Weston hospital, the Royal United hospital in Bath and the three main Bristol hospitals. All those hospitals are officially no-star hospitals. In itself, that is deeply insulting and demoralising to staff, who would like to think that at least some of the services that they offer are high-class services and who resent hugely being rated across the board as having no stars. If there were one thing that might have attracted hospitals out of the current set-up and into the foundation hospital arrangement, it is that they would be freed from that deeply demoralising way of labelling our hospitals. Yet, that one opportunity is going to be denied. In almost every respect, the opportunities that the Government could have taken have been missed. Instead, they have misunderstood what could have been offered and introduced a new series of complexities, bureaucracies and costs that do not exist in the current system.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I was interested in what the hon. Gentleman said about private income. I think that he has a good point. Does he agree that one approach in tackling the issue is not to set an artificial maximum, but to ensure that the only restriction is that no NHS patient with greater clinical need should wait for a slot that might be given to private, paying patients? Amendment No. 400 deals with that point.

Liam Fox (Conservative, Woodspring)

There are a number of ways of dealing with the practical problem; indeed, some were mentioned in Committee and raised in amendments. I was simply pointing out that there is a perverse consequence in what the Government propose. It cannot be what Ministers intended and such provision will be unworkable.

Finally, the Office for National Statistics has said:

"NHS Foundation Trusts are a new type of organisation called a 'public benefit corporation'. . . This set-up has similarities with the model adopted for Network Rail.

However, the trusts' ability to determine its general corporate policy will be restricted by government's involvement via legislation and regulation. These regulations are many and significant, leaving very little scope for changing the corporate policy of each hospital. The ONS has judged that this involvement is sufficient to determine that the trusts are government controlled."

It seems that the Government have managed to get the worst of both worlds. What we are going to get is the triumph of Network Rail, augmented by central Whitehall control. And this is progress.

John Hutton (Labour, Barrow and Furness)

I should like to begin by speaking to the amendment moved by my hon. Friend the Member for Wakefield (Mr. Hinchliffe) and to set out one or two observations about other amendments.

Liam Fox (Conservative, Woodspring)

On a point of order, Mr. Deputy Speaker. As a large number of hon. Members intend to speak, may I ask whether it is normal for the Minister to speak before hon. Members have had a chance to make their voices heard?

Alan Haselhurst (Deputy Speaker, Saffron Walden)

The Minister will be speaking in support of amendments to a Government Bill and it is usual for the occupant of the Chair to call the Minister to speak at this stage if he seeks to rise. Under the Standing Orders, that will not preclude his making a short winding-up speech at the end of the debate.

John Hutton (Labour, Barrow and Furness)

Thank you, Mr. Deputy Speaker. I genuinely want to be helpful to the House, which is why I thought that it would be useful for me to speak now. If it is more helpful to hon. Members on both sides of the House, I shall confine my remarks to amendment No. 164 and the Government amendments. In the short winding-up speech that I might look forward, if that is the right phrase, to making if I catch your eye, I shall confine my comments to the other amendments.

I respect the sincerity of my hon. Friend the Member for Wakefield and the strongly held views that he and many other hon. Friends have expressed about NHS foundation trusts, but I believe profoundly that he is wrong in his analysis of the Government's policy and his description of the impact that the reforms will have on our national health service. I shall explain in a moment why I believe that he is wrong, but one thing needs to be made clear at the outset: the Government have listened to the concerns that have been expressed about that part of the Bill, and we have acted on those concerns. We tabled amendments in Committee, for example, to strengthen the accountability to this House of the new independent regulator of NHS foundation trusts. We are seeking to amend and improve the Government's arrangements in schedule 1 to make them fairer and more effective. The hon. Member for Woodspring (Dr. Fox) referred to his concerns, which I shall deal with in a moment. We have ensured that the new national health service pay arrangements will apply to NHS foundation trusts.

Judy Mallaber (Labour, Amber Valley)

I thank my right hon. Friend for giving way. He will know that the anxiety about the issue that he raises is that foundation hospitals could poach NHS staff from other hospitals by offering better pay and conditions. To avoid such an outcome, will he ensure that the newly negotiated "Agenda for Change" applies on the same timetable and basis for foundation hospitals as for non-foundation hospitals and consider further ways of locking in an assurance that hospitals will continue to abide by "Agenda for Change" and national pay rates in future?

John Hutton (Labour, Barrow and Furness)

I am grateful to my hon. Friend for her remarks. I shall make a few more comments about "Agenda for Change" in a moment, but I understand the point that she makes and have every sympathy with it. That is why I believe that it is important that all NHS foundation trust applicants agree to sign up to "Agenda for Change" as part of the approval process. My right hon. Friend the Secretary of State will not approve for submission to the independent regulator any application from an NHS trust that does not contain that clear and express provision.

We have made it very clear that the timetable that we envisage for implementation of "Agenda for Change" should be broadly coterminous with the arrangements in the other early implementer sites. I have also made that clear to the trade unions. We recently told trade unions that the NHS foundation trusts will start to apply the new "Agenda for Change" arrangements from this April, should they be set up at that time, but it will be done on the basis of a rolling programme between now and October, so that we can learn the lessons from what is happening in the early implementer sites. If any modifications are needed, they can be made in the NHS foundation trusts as well as other early implementer sites. I hope that my hon. Friend the Member for Amber Valley (Judy Mallaber) will take it from that that my answer to her question is broadly yes, which is what we have said to the trade unions.

We have also strengthened the audit rules to ensure greater financial transparency. The rules have been the subject of extensive comment both in Standing Committee and elsewhere. We have introduced a cap on the income that NHS foundation trusts can earn from private patients, so that NHS patients will always come first. We have also moved to ensure that the NHS in England will not become a two-tier service, as all trusts will have an opportunity to become NHS foundation trusts in the next few years.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The Minister says that he insisted on a cap, but did he not table in Committee amendments that weakened the regulator's role in enforcing the cap by transforming it from a duty into a power? The changes also made it clear that the regulator need not enforce the cap in some cases. As far as any concessions were made in Committee, they were made in reverse on the important issue of pay beds and private income.

John Hutton (Labour, Barrow and Furness)

No, that is completely not the case. In case any hon. Member is confused, let me just deal with that point, because my hon. Friend the Member for Wakefield and others have expressed concern to me about it. The amendments that we tabled in Committee were purely and simply designed to ensure that the ability of NHS foundation trusts to treat patients from Scotland, Wales and Northern Ireland was not compromised by the Bill. That is the sole extent of the changes. Let me make it clear that under clause 15(2) the regulator must impose such a restriction on the amount of private business that an NHS foundation trust can undertake. There is no question at all about that: he must exercise that provision.

George Stevenson (Labour, Stoke-on-Trent South)

As my right hon. Friend suggests, this is an extremely important matter. Clause 15(1) says that an authorisation "may" restrict. As I understand it, that "may" was inserted in place of "must". How does that strengthen regulation?

John Hutton (Labour, Barrow and Furness)

As I have tried to explain, we changed the word from "must" to "may" to deal with the issue of whether the trust is treating patients from Scotland, Wales or Northern Ireland; it may not be. I give my hon. Friend this absolute assurance—

Alan Haselhurst (Deputy Speaker, Saffron Walden)

Order. I am sorry to interrupt the Minister, but it would be helpful if he addressed his remarks to the Chair, not behind him.

John Hutton (Labour, Barrow and Furness)

I am sorry, Mr. Deputy Speaker. It is always nice to look into the eyes of my hon. Friends when trying to be reassuring and tell them how it is. My only other choice is to look at that lot over there. [Interruption.] Well, one or two of them are not too bad, but some of them really do suck.

The point that I am trying to make to my hon. Friend the Member for Stoke-on-Trent, South (Mr. Stevenson) is that he, like others, has confused the amendments that were made to clause 15(1) with the requirement in clause 15(2) that the regulator shall exercise his powers to impose such a cap. I recognise that it looks on first reading as though there has been a change, but I give my hon. Friend an absolute assurance that the regulator must impose a cap on the volume of private patient activity that an NHS foundation trust is to undertake.

Patsy Calton (Liberal Democrat, Cheadle)

Will the Minister give way?

John Hutton (Labour, Barrow and Furness)

With the greatest of respect, I am conscious that many other hon. Members want to speak, and I am trying to get through my points as quickly as I can.

These are all significant movements. We have tried to reach a sensible set of positions. The Tories say—we have heard it again from the hon. Member for Woodspring—that we have not gone far enough, and some of my hon. Friends say that we have gone too far. That probably means that we have got it about right.

In putting forward his arguments against part 1 of the Bill, my hon. Friend the Member for Wakefield made a number of claims. Let me deal with those. First, the claim that NHS foundation trusts will reintroduce the old internal market is not true. That system was based on two-tier commissioning and price competition. Primary care trusts will do all the commissioning in the NHS and, as my hon. Friend well knows, there will be a new national tariff for all hospital services as part of our reforms to NHS finances. NHS organisations will all be paid the same for the same procedures, whether they are NHS foundation trusts or not. Those reforms to NHS finances are all about ensuring that NHS assets are used to maximum effectiveness for the benefit of NHS patients. They are not designed to, nor will they have the effect of, reintroducing the damaging effects of the old internal market.

In the old internal market, there were no national standards and no independent inspection and audit arrangements. That has all changed. In the old internal market, there was no statutory duty of co-operation between NHS bodies. That has changed, too. The very same statutory duty of co-operation that is contained in the Health Act 1999, and which my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) rightly said would bring the internal market to an end when he introduced the debate on that legislation on Second Reading, is now being extended to NHS foundation trusts. I profoundly believe that it is a myth that these proposals reintroduce the internal market: they do not.

Secondly, it is wrong to suggest that NHS foundation trusts can gain only at the expense of everyone else. As I have said, there will not be one set of rules on revenue for NHS foundation trusts and another set of rules for NHS trusts; there will be one set of rules for everyone. On capital, we have made several things repeatedly clear. First, there will be proper limits on how much NHS foundation trusts can borrow, which will be determined according to the terms of a prudential borrowing code and their ability to service debt.

Andrew Lansley (Conservative, South Cambridgeshire)

Will the Minister give way?

John Hutton (Labour, Barrow and Furness)

I greatly respect the hon. Gentleman, but I really do want to make my points. Perhaps I will get round to him, although I suspect that he intends to make his own speech.

Secondly, the independent regulator must take into account the impact of NHS foundation trust borrowing on the wider NHS when he sets their individual borrowing limits. Thirdly, NHS capital budgets are sufficient over the next few years, until every trust becomes an NHS foundation trust, to provide the necessary capital requirements for both foundation trusts and NHS trusts; in fact, there will be a 144 per cent. increase in capital for the NHS in the next five years. So it is not the case that foundation trusts can borrow whatever they like and thereby ensure that every other trust has to go without. NHS foundation trusts will be able to take advantage of a new approach to lending, which means that they can borrow up to their limit without the need to obtain approval from the centre for each investment decision. The new arrangements will be less bureaucratic and less burdensome. It is true that foundation trusts will be able to access capital from public as well as private sources, but these are sensible and reasonable reforms—they are not about robbing Peter to pay Paul.

Thirdly, foundation trusts are not about a super elite. Over the next four to five years, all NHS trusts will have the opportunity to become foundation trusts. In the meantime, we are investing a further £200 million to improve performance in poorly performing trusts, so no one will be left behind.

Clive Efford (Labour, Eltham)

If NHS hospitals are allowed to borrow up to an overall envelope limit, will any additional spending by a foundation trust, whether it comes from the private sector or not, count against other NHS hospitals and therefore limit their scope? If so, foundation trusts will have an advantage over other NHS trusts.

John Hutton (Labour, Barrow and Furness)

My hon. Friend must take into account one fundamental issue: namely, that foundation trusts are not at liberty to borrow whatever they would like to borrow irrespective of their ability to service the debt. They must be able to service the debt. That, in turn, must be related to the revenue that they have secured through primary care trust commissioning to provide services to NHS patients. As I said, the independent regulator of NHS foundation trusts must, in approving and setting the borrowing limit, take into account the impact of foundation trusts' borrowing on the wider NHS. As elsewhere, we have tried to balance those important new freedoms with some essential safeguards. That is essentially the point that I am trying to make to my hon. Friend the Member for Wakefield.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Will the Minister give way?

John Hutton (Labour, Barrow and Furness)

No, I will not.

Fourthly, my hon. Friend suggested that the proposals will undermine primary care and its emerging role in the NHS. That, too, is simply not true. It is not the case that there is no need for further reforms in the acute secondary care sector of the NHS; and it is possible to implement those changes without compromising on the key role that primary care trusts will have in the NHS in future. The Bill does not change commissioning arrangements: primary care trusts will still lead the development of the NHS.

Finally, as I said to my hon. Friend the Member for Eltham (Clive Efford), we have tried to balance operational and financial freedoms with the right safeguards, so that the NHS continues to operate as an effective, comprehensive and universal service. All trusts wishing to become foundation trusts will operate the new national pay system—we do not want any unfair poaching of staff—and foundation trusts' actions will be subject to the new arrangements on local public consultation.

NHS foundation trusts embody a new form of social ownership that provides a much stronger means whereby health services can become more responsive to local needs because local people will have more say over them, as will local staff. We have developed in this country a form of public ownership in which the public frequently feel that they own nothing at all, and in which public ownership has become synonymous with state control. Those are significant problems for all of us who believe in the public service; the Bill provides a solution to both those deficiencies.

Gordon Prentice (Labour, Pendle)

Will my right hon. Friend tell me whether individuals who want to become a voting member of a foundation trust will have to pay £1, as specified in the Bill, or merely pledge to do so?

John Hutton (Labour, Barrow and Furness)

They have to agree to pay up to £1. The provisions of individual constitutions of NHS trusts will be determined and agreed locally through consultation.

Keith Bradley (Labour, Manchester, Withington)

I shall ask a question about which my right hon. Friend may have notice, since I have already asked it on several occasions. What will be the electorate for a specialist hospital such as Christie in my constituency? Who will be eligible to vote on the governance of that hospital?

John Hutton (Labour, Barrow and Furness)

I am happy to try to answer my right hon. Friend's concerns, because they are perfectly reasonable and many other hon. Members have raised them. The Christie hospital is a unique asset to the NHS. It is a regional—indeed, national—centre of expertise for cancer services. The Bill requires a public constituency for the NHS foundation trusts, and that must include representatives who are elected from the area in which the hospital provides services. However, in the case of NHS foundation trusts such as Christie's—if it became one—we assume that the majority of the public constituency, especially those elected to the board of governors, would be chosen from the patient constituency, for which the hospital predominantly provides services. That group comprises many people, and we want to work with local foundation trusts to develop the proper mechanism for reaching out to members of the patient constituency and inviting them to become members of the foundation trust.

Conservative Members today expressed their disdain for the democratic process. They do not want a democratic model of governance for NHS foundation trusts.

Tony Lloyd (Labour, Manchester Central)

Will my right hon. Friend give way?

John Hutton (Labour, Barrow and Furness)

No, I shall not.

The hon. Member for Woodspring tried to pooh-pooh suggestions that there was anything commendable in the proposal for patients to have a say in the governance of their local hospitals. He is wrong. It is a fundamental principle of democracy to extend patient choice and involvement in the NHS.

Liam Fox (Conservative, Woodspring)

Before the Minister leaves the subject, what is the answer to the question? What is the patient constituency for a hospital such as Christie? The Minister says that the Government would like to consult about that in future. That pinpoints the weakness of the Bill: it is being made up as we go along.

John Hutton (Labour, Barrow and Furness)

I note that some of my hon. Friends support the Conservative spokesman on that point.

Liam Fox (Conservative, Woodspring)

They are entitled to disagree with you.

John Hutton (Labour, Barrow and Furness)

Of course they are all entitled to their views. I have made it clear that I respect my hon. Friends' views. However, the hon. Gentleman sits here day after day, berating the Government for being a command-and-control Administration. He claims that we dictate everything from the centre. In the Bill, we are trying to set a broad structure for local governance, which should be determined and agreed locally, but in a structure of basic guarantees.

In response to the point of my right hon. Friend the Member for Manchester, Withington (Mr. Bradley) about the governance at Christie hospital, I have made it clear that the majority of the board of governors will be elected from the patient constituency.

George Stevenson (Labour, Stoke-on-Trent South)

Will my right hon. Friend give way?

John Hutton (Labour, Barrow and Furness)

No, I shall not.

For example, patients that the hospital treated in the past three years are eligible. The guide for applications to become an NHS foundation trust sets that out clearly.

George Stevenson (Labour, Stoke-on-Trent South)

Will my right hon. Friend give way?

John Hutton (Labour, Barrow and Furness)

I have great respect for my hon. Friend, but I have given way to him once and I must make progress.

Local consultation will take place and agreement will be reached on the governance issues for each applicant for foundation trust status. We have strengthened schedule 1 today as the result of points that my hon. Friends the Members for West Bromwich, West (Mr. Bailey) and for Ealing, North (Mr. Pound) made in Committee. It provides for an improved framework for local accountability and engagement, and the governance arrangements are clearer and more transparent. The Government have listened and acted on the concerns to which hon. Members rightly drew our attention. The Bill is therefore better and stronger. The Government will accept the relevant amendments that my hon. Friends tabled.

I believe that the aspects of the Bill that we are considering fully reflect the basic principles of the NHS, and are based on the values of public service. They are not about two tiers, markets, competition or privatisation. Nor are they about change for change's sake or simply another round of NHS reorganisation. The measure is fundamentally about how we can best improve local health services so that the patient benefits.

Howard Stoate (Labour, Dartford)

The purpose of the Bill is to give patients more say, flexibility and control over local services. Surely foundation hospitals are merely one mechanism for doing that. We are making a huge amount of fuss about a relatively small reorganisation to allow more flexibility in the running and provision of services.

John Hutton (Labour, Barrow and Furness)

I agree with my hon. Friend in many respects. The reforms are important but basic, and I hoped that my hon. Friends could support them, especially since they apply to the democratic governance arrangements. Labour Members have always argued that there is a democratic deficit and the Bill tries to remedy that.

As my hon. Friend said, the measure gives patients a stronger say about what happens in their local NHS and allows local staff to get on with the job of sustaining improvements in the quality of local services. It will take Whitehall out of the daily management of NHS hospitals and help to deal with health inequalities more effectively than the current "one size fits all" model. Local needs and priorities can be better reflected. Giving foundation trusts greater freedom to do the job must be matched by new forms of local accountability, otherwise we could disfranchise rather than empower local people.

The measures on NHS foundation trusts are based firmly on Labour's traditional values and applying them to today's new world, where people rightly want more personally tailored health care, where their needs should always come first and where everything that we do is judged by one simple yardstick: how will matters be improved for patients? That is why we are introducing the Bill.

I simply say to all my hon. Friends: do not vote in the same Lobby as the Tories when the future of the NHS is at stake. The Tories want only one simple thing—they want the NHS to fail so that they can peddle their solutions of spending cuts, subsidised private medical insurance and top-up vouchers for those who can afford to go private. It is a policy for the few, not the many. Labour Members should be in the Government Lobby this afternoon, supporting NHS principles and values.

Let me briefly consider the Government amendments, especially No. 253. It would require NHS foundation trusts to use electoral wards to define their public constituencies. The amendment would provide further clarity in defining boundaries for public constituencies.

In Committee, concerns were raised that those whom the trust did not directly employ could not become staff members. Government amendment No. 254 would ensure that those people, who have an interest in the organisation because they work there and contribute to its services, could also be members of the staff constituency. That will include, for example, those who work for cleaning contractors when that work has been passed to a private, independent operator. The amendment would also affect our stated intention to ensure that staff on rolling contracts who are continuously employed by the trust for at least 12 months are eligible to become members of the staff constituency.

Government amendments Nos. 255, 256, 257, 258, 260 and 262 would remove the bankruptcy and criminal conviction exclusion criteria for members and apply them solely to governors and directors. As I said earlier, we shall accept new clause 24 and amendments Nos. 233 and 234, which my hon. Friend the Member for West Bromwich, West tabled. I pay tribute to him for his work to strengthen the Bill.

Clearly, the process for selecting the representatives of the local community who serve on the board of governors must be fair and transparent. The Bill therefore requires governors who represent patients, the public and staff to be chosen by election. Provided that there is a requirement for contested ballots to be secret, foundation trusts could be allowed to use different forms of voting, such as voting electronically or in person, as set out in Government amendment No. 259.

Government amendment No. 261 clarifies that representatives of local partner organisations can be appointed to the boards of governors of NHS foundation trusts, as set out in a guide to NHS foundation trusts. Government amendment No. 263 deals with the appointment of a chair, to put the matter beyond doubt.

The Government will also accept amendments Nos. 242 to 244, which my hon. Friend the Member for Ealing, North tabled. They deal with conflicts of interest. We shall also accept amendment No. 354 on local authority representation on the board of governors of NHS foundation trusts. I am grateful to my hon. Friend the Member for Milton Keynes, North-East (Brian White) for tabling it.

Opposition Members and some of my hon. Friends intend to move other amendments later. I shall deal with those shortly. Government amendments Nos. 247 and 248 deal with the private patient cap. Earlier, we discussed private patient provisions. I should like hon. Members to accept amendments Nos. 247 and 248. The regulator has powers to set any terms that he considers appropriate to the terms of authorisation under clause 6(3). However, the amendments would make it explicit that the regulator can restrict the provision of non-NHS health care in all NHS foundation trusts, not only those that were previously NHS trusts.

New clauses 36 and 37 and amendments Nos. 355, 357 and 358 concern mergers. I shall be happy to deal with that issue in my winding-up speech. In Committee, Members drew attention to a deficiency in the Bill, and these technical amendments seek to close the gap.

In amendment No. 378, the Government propose a change in respect of Wales. Although the Bill provides for the Welsh Assembly to inspect care provided for Welsh patients by foundation trusts, it includes no requirement for it to report matters of concern to the independent regulator. The amendment will allow the Assembly, like the Commission for Healthcare Audit and Inspection, to report failings in trusts to the regulator.

Part 1 sets out a new direction for the national health service, but it is the right direction. Our proposals are based firmly on traditional NHS values. These reforms are sensible and reasonable. They will help to sustain improvements in the NHS that are now under way. They will give patients and local staff more say over what happens to their local NHS. They will result in a better and more responsive service, so NHS patients will be the winners.

For all those reasons, I ask my right hon. and hon. Friends to support the Government's proposals.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

When the Government first proposed the establishment of foundation trusts, we examined their plans carefully and compared them with our own policies for NHS reform before considering the likely consequences. For reasons that I will give, we believe that the foundation trust policy is deeply flawed, and, having failed to secure key amendments in Committee, my colleagues and I will vote against it. That contrasts with the position of the Conservatives, who will vote against foundation trusts although, as they themselves say, they support the principle. Some may consider that approach opportunistic—[Interruption.] I believe that it is opportunistic to vote against a proposal when one supports the principle behind it. We have always made clear where we stand, and what our principles are.

Because of the opportunistic nature of the Conservatives' support for the amendment, Labour Members need not be deterred from supporting it by a fear of being identified with their approach. We will certainly resist that.

I intend to identify the respects in which the Government's proposals fail to deal with our concerns, and the problems inherent in foundation trusts. I shall then say a little about pay beds. The key flaw in the Government's initiative is its failure to address the issue of NHS commissioning. NHS commissioners—largely primary care trusts—are charged with a duty to plan, organise and purchase NHS care for the populations that they serve by making contracts with those who provide services, mainly hospitals and clinics. There is a desperate need for decentralisation, democratisation and empowerment on the commissioning side of the health service, even more than on the providing side. Primary care trusts are run by doctors and other health care professionals, with a sprinkling of local people on the board. They are not democratically accountable, and have very little discretion because of excessive interference from Whitehall and from Ministers. They cannot raise extra resources from their local populations to expand or improve services, even when there is local consent.

The best way of protecting and promoting the interests of patients is to give more power to those who are responsible for planning and buying services on their behalf, rather than to those who provide care. We would prefer an approach that created reform by tackling restrictions on the power and freedom of health and social care commissioners.

We would have liked the Bill to free local commissioners from central political diktat. While retaining evidence-based clinical outcome national standards and tough quality inspections, we would abandon the politically based targets that distort resource allocation and clinical decision making, replacing them with clinical decisions driven by clinical needs. We would introduce light-touch performance monitoring and the auditing of performance against standards. The Government's proposals include no such provision.

We wanted the Government to replace strategic health authorities and primary care trust commissioning roles with democratically accountable elected commissioners of health and social care at regional and local level, advised by primary care trusts and with a reinvigorated public health function. They would have a legal duty in regard to equity, effectiveness, quality and cost-effectiveness, but would be able to make local decisions. The efficiency involved in electing the same people who are currently elected has already been noted indirectly by the hon. Member for Woodspring (Dr. Fox).

The empowerment of commissioners would allow them to raise resources locally through a progressive taxation to meet the demands of the local population for a more responsive, comprehensive and high-capacity NHS.

Sadly, the Government propose no such changes for commissioners, who will consequently have little control over the services that they can develop, despite the rhetoric of "increased devolution to the front line". Indeed, the Bill actually bars commissioners from ever sharing in any of the reforms.

As for the possibility of a diversity of providers of NHS care, we are committed to a mixed market in provision including the private and voluntary sectors, NHS hospitals and other providers, as long as the care is free at the point of delivery and access is based on need rather than ability to pay. In the not-for-profit sector, we are keen to see the development of mutuals. Although aspects of foundation hospitals are similar to aspects of mutuals, we would allow them greater financial freedoms, and would not allow the freedoms that are given to be exercised at the direct expense of non-mutual NHS hospitals. We would not impose mutual status on a few hospitals, or "award" it to them; we would allow all hospitals to consider whether they wanted such status. We would consider it to be different from, not better than, the status of other NHS hospitals.

The way in which the Government propose to award foundation status to three-star hospitals is extremely divisive—especially given that the star rating system does not measure good clinical care, higher quality or meaningful patient outcomes. It measures performance, or statistical massage, against a series of political targets which, if anything, threaten good patient care by distorting resource allocation to areas that are outcome-measured and distorting clinical decision-making.

Gordon Prentice (Labour, Pendle)

In what respect are foundation trusts mutual organisations? Having asked the Minister about that, I was told in a parliamentary answer yesterday that he would write to me as soon as possible.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

It is in the context of staff representation on governing boards that we consider the Government's proposals vaguely similar to our proposals for mutuals. I think there is merit in those proposals, regardless of what happens on the commissioning side. If that were all that the Government were proposing, without some of the other problems, we would be minded to support it—and in Committee we did not oppose such measures. When the Government announced amendments to extend the franchise of the staff side to people in ancillary roles, often low-paid, who have worked for a hospital all their lives but whose service has been contracted out, we tabled our own amendment in Committee and the Government accepted it. We have worked to make these hospitals more like the mutuals that we want to see, but unfortunately we are still not satisfied.

Andy King (Labour, Rugby and Kenilworth)

Surely it is possible to put staff representatives on the hospital boards without creating a huge two-tier economy.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I agree. That would have been an alternative approach for the Government and for us. We still think that providers should be allowed to seek mutual status, but we do not think that it should be imposed or awarded, or that there should be electoral nonsenses.

I hope that the Secretary of State or the Minister will tell us why, despite our many attempts to establish the facts, the Government have still not provided a shred of proper evidence that the high-level targets or performance indicators—such as the numbers on waiting lists, or the two-week wait—on which they base their award, or reward, of three-star status have any basis in clinical outcomes. I ask the Minister to provide that answer, because he has never done so before. The "Panorama" programme that focused on my local hospital in Oxford identified exactly how patients are put at risk by the imposition on managers of the need to meet these targets. The trauma surgeon Keith Willett, who works at the John Radcliffe hospital, showed how the need to treat the least urgent patients within a maximum time limit often means that treatment of patients whose needs are more urgent is postponed, to their detriment. The Government have not responded to that point; indeed, they refused to address the questions raised in the "Panorama" programme. Until they ditch such politically based performance indicators, their approach will have no support from health care professionals or, even more important, from patients and those who represent them.

The Government propose a sham democracy for foundation hospital trusts, in which local members will elect a few people to the board of governors. This is clearly a far less effective method of ensuring proper democratic accountability than our proposal properly to democratise, through the electoral roll franchise, the commissioning side of the NHS. Although there is certainly merit in the public's having a stake in major local providers, this should not be seen as an alternative to, or rival to, proper, democratically accountable commissioning. A pseudo-democracy like that proposed in this measure creates the real problem of a parallel franchise, rivalling local, democratically elected councillors. The resulting confusion would actually damage accountability.

We would prefer—we proposed amendments in Committee to this effect—a stakeholder-type board for mutual hospitals, representing staff and the community. The interests of patients and the public are more powerfully represented by elected commissioners and by patients forums. The Government proposed to set up patients forums as a replacement for community health councils, but they now propose to ditch them in respect of foundation hospitals, and, in due course, in respect of all hospitals, because all hospitals will be foundation hospitals.

Patrick Hall (Labour, Bedford)

Will the hon. Gentleman give way?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Yes, I will give way to the hon. Gentleman, who chairs the all-party group on community health councils and may well be keen to catch your eye, Mr. Deputy Speaker.

Patrick Hall (Labour, Bedford)

I thank the hon. Gentleman for giving way. Does he not agree that not having a patients forum on a foundation hospital trust would remove that element of independence that is crucial to the new system of patient and public involvement in the NHS?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

The hon. Gentleman is right, and given his experience of talking to the people involved in patient and public representation, the Government would do well to listen. I invite him and others to look at new clause 9, on page 2,489 of the amendment paper, which is tabled in my name. When this issue was debated in Committee, there was support for the proposal from both sides of the House, and the hon. Gentleman makes a very good point. It is impossible to secure the interests of patients simply through the efforts of those who run hospitals. That creates a conflict of interest, and with the best will in the world, those who try to exercise the dual roles of defending and supporting hospital management and representing the views of patients would find it impossible to juggle them.

I urge the Government, even at this late stage, to say that they will support new clause 9. After all, when they abolished CHCs—in itself a highly controversial measure—their defence was that patients forums would roam further than CHCs, not only examining the commissioning side but being active on the provider side. Now, the Government propose that there be no patients forums in any hospital. The hon. Member for Wakefield (Mr. Hinchliffe) strove hard with many of us to secure amendments to initial Government proposals during the previous Parliament, and to secure amendments to an earlier Bill in this Parliament under which the Government proposed to abolish CHCs. He must share my disappointment that the Government intend that if foundation hospital measures are adopted—I accept that he hopes they are not—there will no longer be patients forums in hospitals. That raises questions about the Government's good faith in making the concessions that they claim to make in abolishing CHCs.

Liam Fox (Conservative, Woodspring)

Are the hon. Gentleman's anxieties about the lack of patients forums diminished or heightened by the fact that the Government, through one of their own amendments, are moving away from the concept of postal votes and potentially towards electronic voting, which might further disfranchise patients?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

That may well be a problem. The electoral arrangements are likely to be not only a parallel franchise, as I said, but a dog's breakfast. The Government's saying that they are simply going to leave the matter to the constitution of foundation trusts gives no comfort to those of us who think that it will be impossible to find a clear way out of this mess.

In terms of foundation trust status, it seems that the Government's motto is: "To those who have, more shall be given, and from those who have not, it shall be taken." In Committee, the Government effectively admitted that because any borrowing by foundation trusts, using their greater licence to do so from the private sector, would be set against the total amount of capital available to the NHS, any extra ability to borrow—and any extra borrowing achieved from the private sector for foundation trusts—will by definition reduce the pot of money available for non-foundation trusts. If the Minister looks at the record, he will see that the Government simply did not address that point, either in answer to me or to the hon. Member for Birmingham, Hall Green (Mr. McCabe), who is no longer in his place.

I invite the Minister to explain this at the Dispatch Box today: if the total amount of NHS capital is limited and any borrowing by foundation trusts through their increased licence to do so will be taken from that total, how will that not by definition reduce the amount of capital available for the second wave of borrowers—those with less power than non-foundation NHS trusts? [Interruption.] The Dispatch Box remains empty, and as happened in Committee, no answer is given, for the reason that there is no answer to that problem. It is the inevitable consequence of the decision to ensure that such borrowing is against the pot available.

There was an alternative, which was not to go down this path at all, or even to allow such borrowing to be set against expenditure limits. Unfortunately, the Government chose not to do so, and the result is a policy that robs Peter to pay Paul. Our proposals for mutuals would have allowed additional private borrowing without its counting against Treasury limits for borrowing in the health service. In addition, we would not have proposed that the sale of assets by foundation trusts—those that are allowed because they are not necessary for core service—be available only to foundation trusts, rather than to the NHS as a whole. I suspect that other Members will make that point in more detail.

We are not opposed to foundation trusts because we think that everything has to be the same; there can be a mixed market in provision. In the Liberal Democrats' opinion, the NHS should be free at the point of delivery, as comprehensive and universal as possible, and based on need rather than the ability to pay. In that respect, who owns or runs hospitals is not important, so long as they guarantee equity, quality and other essential factors. We are not opposed to foundation trusts because we think that they amount to quasi-privatisation of the NHS. Such privatisation is far more likely to happen through a version of the patient passport policy proposed by the Conservatives. Although we do not consider foundation trusts to be a direct route to privatisation, private care issues do arise, particularly in relation to pay-beds.

As has been pointed out, in Committee the Government weakened the provision relating to the cap on private income. The Minister may say that it was not his intention to do that in changing "must" to "may" and "duty" to "power", but on an issue as important as this the phrasing should have put the matter beyond doubt. I invite him to do so, and if he is unable to give such reassurance, those of us who are concerned that that cap guarantee is not worth the paper that it is written on will not be reassured by his approach.

Amendments Nos. 397 and 398 seek to reverse the changes made in Committee, and amendment No. 400 makes it clear that there should not be arbitrary limits on pay-beds. People should not occupy pay-beds in the NHS if there are NHS patients with greater clinical need. We know that NHS waiting lists are far longer than private waiting lists, and that beds and precious capacity in the health service are given over to private patients. I urge hon. Members to consider amendment No. 400, which would ensure that, regardless of any arbitrary limit on private income, NHS patients are not badly treated.

New clause 39, also tabled by the Liberal Democrats, urges the Government to accept a proposal whereby overview and scrutiny committees and patients forums have to be consulted before approval is given.

Finally, the Government did not deal with Government amendment No. 356. As far as I know, the Minister did not mention it as he rattled through the list. That amendment proposes that the Government underwrite external loans taken on by foundation trusts. Will that not give even more power to foundation trusts to loan against the limit that is shared by non-foundation trusts? I invite the Minister to tackle that issue now.

John Hutton (Labour, Barrow and Furness)

I do not wish to detain the House, but the hon. Gentleman is barking up the wrong tree. [Hon. Members: "Barking?"] In line 1, page 1, before "up the wrong tree" leave out "barking". The amendment to which the hon. Gentleman refers deals with the private finance initiative. We need to find an appropriate mechanism to support PFI deals in NHS foundation trusts. That is all that the amendment does, and that PFI borrowing does not score against the prudential borrowing limit.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

This is the amendment that dare not speak its name—[Interruption.] The Minister conveniently forgot to mention an amendment that approves the ability of foundation trusts to close PFI deals.

In summary, for the reasons that I have given, we oppose the Government's proposals for foundation trusts. I hope that they fail today and I urge hon. Members to join me and my colleagues in opposing them. I also urge them to consider the need, if foundation trusts are approved, to secure adequate means of patient representation through patients forums. If I have the opportunity to move new clause 9, I hope to preserve patients forums on the provision side of the health service.

Frank Dobson (Labour, Holborn and St Pancras)

Out of courtesy to anyone who wants to intervene on my speech, may I use a clinical expression that I picked up as Secretary of State for Health? I have done my back in, so if I give way and sit down, I may not be able to stand up again.

The Government's various concessions do not deal with most people's fundamental objections to the concept of foundation hospitals. Those hospitals will impose an unwelcome and unnecessary reorganisation of the NHS, which will consume much money and a great deal of senior management time. Advantages will be given to one group of hospitals at the expense of another. Foundation hospitals will be allowed to set their own strategy and priority, taking that role away from local primary care trusts. Competition and the spirit of competition will be reintroduced to the NHS. All that is being done, we are told, in the name of less Government interference.

We do not need to reorganise the NHS or change the law in order to reduce the amount of ministerial interference. All my right hon. Friends need do is stop interfering—[Hon. Members: "Hear, hear"]—and they should stop interfering in all hospitals, not just a limited number of them. I confess that I did some interfering myself as Secretary of State, but by the time I resigned, I believed that there was too much interference and too much earmarking of funds. I am afraid, however, that that development has continued rather than being reduced, and we need to reverse that.

It is also said that the proposals will give local people a sense of ownership of their local hospital because they will be able to vote for the governors. We have to recognise, first, that the NHS is the most popular institution in this country. If we ask people about their local hospital, local town hall or local MP, I know which is most popular with my electorate—let alone anyone else's. They have a higher opinion of the hospitals that serve them than they do of my excellent council, or even of me. The fact of election will not necessarily give local people a sense of ownership or increase the popularity of the health care that they receive.

I know that the Government would never be swayed by anything to do with opinion polls, but they may be aware of the work carried out for the Audit Commission, which asked people whether they would like a bigger say in the running of their local hospital. In that survey, 22 per cent. said yes, and more than 50 per cent. said no, so it is not even popular with the people who are going to be enfranchised.

We are told that hospitals will receive more money, more beds and more staff. That is right, but all hospitals are getting more money, most will increase the number of beds and most will increase the number of staff. That is the crucial change that the health service needs, because for decades we have expected the service to go on with too few doctors, nurses, midwives, therapists and everyone else. That is the fundamental problem. The Government's 40 per cent. increase in the intake of students to medical schools is a huge step in the right direction, but it will be a long time before it produces great benefits.

In the absence of sufficient staff, the NHS has been exposed to reorganisation after reorganisation until the people working in it are sick to death of reorganisation. They know that every process of reorganisation distracts the people working in the health service from their proper and chosen job of looking after patients. It takes up money and, above all, it takes up time. It is safe to say that as we debate this proposal, the 32 applicant foundation trusts will be having one of their innumerable and endless meetings about how to progress their application for foundation status. We know that every hour they spend on that aspect of reorganisation is one less hour spent on helping clinicians to help patients.

As my hon. Friend the Member for Wakefield (Mr. Hinchliffe) said, we have had 18 reorganisations in the last 20 years. Some people are now saying that extra money, extra staff and extra beds are not delivering the improvements that we want. Well, I can tell them this: the 18 reorganisations certainly did not deliver the improvements that were wanted. Given some time and the opportunity to let the changes bed down and to make good use of the additional resources, the NHS will improve, as it is already improving.

It is suggested that those who are opposed to the structural reorganisation are opposed to change and improvement in the health service. I do not use the word reform. Reform is a word that gets up the nose of virtually everyone who works in the health service and it does not impress the public. People working in the health service want to improve it. They want to improve what is happening in their clinics, their operating theatres and their surgeries—and they are getting on with it. However, if we introduce foundation hospitals, some of them will find it easier to get on with it than others, because those hospitals will be given advantages over the others. That fact cannot be denied.

I think of my own constituency. University College hospital, a wonderful hospital in my constituency, is going for foundation status. If it gets that status, it will get more money. If it has more money, what is it going to spend its money on except improving the pay and working conditions of its staff? There is nothing else for it to spend the money on. If it improves the pay and working conditions—by working conditions, I include acquiring new equipment that does not go on the blink as the existing equipment does—it is bound to attract staff from the Royal Free, the Whittington, St. Bartholomew's or Great Ormond Street: other hospitals that also serve my constituency. They will be put at a disadvantage, so University College hospital will get better at the expense of the rest.

Nothing that Ministers have said will prevent that happening. They tell us that "Agenda for Change" will apply to all hospitals, but that needs money, and those with more money will be able to implement the agenda quicker. If they feel like it, they will be able to upgrade a post—they have the money to do it—and then attract someone to fill it. That is made clear—unless the Government were being misleading originally—in the Green Paper, which says that the extra funds would allow hospitals to offer new rewards and incentives to staff. That means more money and better working conditions.

I am also concerned about the registers of electors to the boards. Some of the big teaching hospitals will have more than 2.5 million people on their register of electors—if they can put one together. Who will qualify? We are told that it will be people living in the locality, and anyone else who has made use of the hospital. However, we know that the hospitals will get it wrong. Compiling a register is a very complex process and it is a safe bet that within a few months the hospitals will have 20 old ladies who regularly visit a clinic saying that they have been left off, and someone from Doncaster who went into A and E on a once-in-a-lifetime visit will be entitled to vote. We know that that is bound to happen.

In addition, compiling the register will be astonishingly expensive. Local authorities annually spend £50 million making the minor incremental changes to their existing registers, even though they employ staff who are familiar with the problem and know how to do it. It costs another £20 million to organise local elections. Do most people think that that is the best use of the next lot of money for the NHS? Or would it be better spent on patients?

Patient confidentiality is another issue. Most hospitals do not put their name on the envelope when they send people letters, because many people do not want anybody to know that they are going to hospital. They do not like their employer knowing and often do not even like another member of their family knowing. However, if someone is on the register, everyone will know. The British National party will have access to the register and know who has gone to hospital. How will Asian people—for example—fancy the idea of the BNP trying to exploit their hospital attendance in some racist way, such as claiming disproportionate use of hospital services?

What will happen to the primary care trusts? They were established, with the full agreement of the professions, to involve the GPs, community services, local nurses and social services in laying down the priorities and strategies for health care in their area, based on an analysis of their day-to-day experience. That would assist in placing proper demands on the local hospitals. However, that role will now be taken back by the foundation hospitals. All the documents say that the foundation hospital governors will establish the strategy and priorities for their hospital. So foundation hospitals will be the cuckoo in the nest, and that is why the Royal College of General Practitioners joins the BMA and virtually every other health service organisation—including the main health service unions—to oppose the proposition.

I cannot agree with my right hon. Friend the Minister of State, Department of Health—and he is my good friend—that this proposal does not reintroduce competition and will not set hospital against hospital. It will. Its whole philosophy is to get hospitals competing with other hospitals down the road. That was a disaster when the Tories introduced it, because co-operation came to an end. I remember going with my hon. Friends the Members for Hampstead and Highgate (Glenda Jackson) and for Islington, North (Jeremy Corbyn) and my right hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) to talk to the chief executives in our area when the internal market was at its height. We pleaded with them to co-operate on something—I cannot remember exactly what—but one of the chief executives said, "Oh, we can't co-operate now, Mr. Dobson. It's dog eat dog in the health service now." We do not want that atmosphere back.

We know that competition increased bureaucratic costs and that waiting lists went above 1 million for the first time. The only serious academic study of the impact of competition of the quality of care was done by Bristol university, which looked at figures from all over the country for recovery rates for people who had gone into hospital following a heart attack. The summary of their findings stated:

"Our central finding is that competition is associated with high death rates: in other words competition is associated with lower quality."

We do not want competition or lower quality.

I have addressed the damage that foundation hospitals are likely to do to the health service. I confess that, as a Labour party member, the damage that the policy will do to the Labour party bothers me just as much. Almost everybody in the labour movement is opposed to this proposition, and their instincts are right. It was suggested to me on the radio the other day that perhaps the leadership of our party did not want us to speak up against foundation hospitals because it looked as though we were the party of the producer. If the producers are the doctors, nurses, midwives and therapists—the people who actually provide the care for the patients—I would rather be on their side than on that of faceless think-tanks and advisers, who seem to think that the world can be transformed with the click of a laptop button. If I must choose between the laptoppers and the producers, I am with the producers.

Andrew Lansley (Conservative, South Cambridgeshire)

I have two groups of amendments in this gargantuan group, and I shall refer to them briefly and to the general proposition, as advanced by the hon. Member for Wakefield (Mr. Hinchliffe). I am grateful to him for his kind comments. If I know anything about the NHS, it is in part due to serving under his chairmanship of the Health Committee, and in part to my father. On the day on which the NHS was created, my father was working for London county council, running a health service laboratory. He worked for the NHS for the next 35 years and became chairman of the Institute of Medical Laboratory Sciences.

There are Conservatives—including my hon. Friend the Member for Woodspring (Dr. Fox)—who have worked for the NHS, and who would resent the way in which the Minister referred to our intentions. Our intentions are to try to create an NHS that delivers more and better quality health care for the people of this country. We may have different views on how to achieve that, but I hope that the Minister will not dispute that that is our intention.

Some of us will also join the hon. Member for Wakefield in resisting the structure of foundation hospital status, as the Government propose it, for different reasons, but with the same intentions. We will not have many opportunities in the next year or so to discuss the structure of the legislative framework for hospitals, so we have to get it right. Behind some of my amendments is the desire to get the structure right this time.

My first group of amendments runs from No. 154 to No. 161 and relates to the possibility that a combination of NHS trusts might wish to apply for NHS foundation status. The Minister mentioned Government amendment No. 357 and new clauses 36 and 37. I am grateful to the Government for tabling those provisions, because they will allow foundation trusts and NHS trusts to apply for authorisation as NHS foundation trusts by way of a merger. The previous structure of the legislation implied that one NHS trust equalled one NHS foundation trust. We discussed the issue on Second Reading and again in Committee, and Government amendment No. 357 and new clauses 36 and 37 remedy that deficiency, so I am happy that the Government have tabled them.

The other group of amendments that I wish to speak to begins with amendment No. 96, but its essence is contained in new clauses 19, 20 and 21, which would introduce the concept of NHS community trusts alongside the foundation trusts.

Siobhain McDonagh (Labour, Mitcham and Morden)

Will the hon. Gentleman support the application of Addenbrooke's hospital in his constituency for foundation status? If so, why would he vote against them today?

Andrew Lansley (Conservative, South Cambridgeshire)

The hon. Lady anticipates a subject that I was about to discuss. I have already said that I would support the applications by the Addenbrooke's NHS Trust and Papworth Hospital NHS Trust, both of which are in my constituency and both of which are applying for NHS foundation status. Whether there is a foundation trust status in the form proposed available for them to apply for will, of course, depend on the decisions of the House.

Claire Ward (Labour, Watford)

But the hon. Gentleman is voting against the Bill.

Andrew Lansley (Conservative, South Cambridgeshire)

I am answering the hon. Member for Mitcham and Morden (Siobhain McDonagh). If the hon. Member for Watford (Claire Ward) wishes to intervene as well, I will gladly give way.

I will support Addenbrooke's because it is an excellent hospital at the leading edge of medical research, clinical practice and innovation in the NHS. The view of the trust, with which I agree, is that it wants to be at the leading edge of innovation within the NHS, wherever the NHS is going. If the Government tell Addenbrooke's that NHS foundation trust status is the way forward for the NHS, Addenbrooke's will go along with that, and I will support it. On each occasion that it has acted in a similar manner, resources have tended to flow from that decision. The word that we have not yet heard is "capacity". Addenbrooke's NHS Trust is running at about 95 per cent. bed occupancy now, and if it is to be able to increase capacity to serve my constituents, it will have to be at the leading edge of the NHS.

Papworth Hospital NHS Trust is a complementary case. It is a heart and lung hospital, and the fastest growing hospital in the country. It, too, needs to increase capacity. It did not succeed with a private finance initiative bid in 1998, shortly after the Government came to power. I want that trust to be able to undertake its necessary capital projects. As things stand, it could do that in one of two ways: through PFI or by borrowing the money from the Department's facility. This has not previously proved an easy bid to finance through PFI, but it might well be able to arrange that borrowing through the departmental financing facility as extended in the Bill. It might also be able to do so on better terms, given that it would be doing so at the national loan fund rate.

I am a practical person. If the legislation is in place, I will support my hospitals in using it to their best advantage. I would like to be able to persuade the Government to introduce legislation that offers genuine freedoms to NHS hospitals, providers and commissioners. My purpose in voting with my Front-Bench colleagues today will be to tell the Government that they need to introduce such legislation. I shall give way to the hon. Member for Stoke-on-Trent, South (Mr. Stevenson), who has previously been denied that opportunity by his Front-Bench colleagues.

George Stevenson (Labour, Stoke-on-Trent South)

The hon. Gentleman says that if foundation hospitals become a reality, he will support Addenbrooke's because the resources would flow from that decision, but will he have a care for my constituents, who will not benefit from the first wave of foundation hospitals and are likely to lose out as a result?

Andrew Lansley (Conservative, South Cambridgeshire)

I am not sure that the hon. Gentleman's constituents will necessarily lose out in that way. The Minister would not give way to me earlier, but I wanted to make the point to him that he is trying to tell the House that NHS foundation trusts and NHS trusts are on all fours. They are not. For example, he has not yet told us what he is going to do about year-end surpluses in relation to NHS trusts. I want Addenbrooke's, which has resolved its deficit problems and which, with the national tariff, will be able to generate a surplus, to be able to carry over that surplus at the year end. As an NHS foundation trust, it would be able to do so. The hon. Gentleman's constituents would not necessarily lose out as a result of that flexibility, however. It is in the Minister's gift to get up now and tell us that he will offer year-end surplus transfers to all NHS trusts. If he does so, fine. We would then be nearer to the point at which every trust would be the same.

So far as borrowing is concerned, there could be a difference between NHS trusts and NHS foundation trusts. That will entirely depend on the Minister making an assertion that, during the years that foundation trust status is available only to some hospitals, the Department's ability to finance their borrowing will not constrain the availability of capital for the others.

I have departed from my main point, and want to return to the amendments. In the event that the House decides to proceed with NHS foundation trust status, and not to reject it at the instigation of the hon. Member for Wakefield, an important second question will arise. Should foundation status—the mutualisation and local ownership of decision making in the NHS—be confined to hospitals, or should it be provided to the commissioning bodies, the primary care trusts? My hon. Friend the Member for Woodspring and the hon. Member for Oxford, West and Abingdon (Dr. Harris) both said that the latter proposal was entirely desirable. The Select Committee report referred to the evidence of many witnesses who suggested that it was not only desirable but arguably the logical place to start with such measures.

The Government responded to the Select Committee report yesterday, and their attitude seems to be "Make us virtuous, O Lord, but not yet." They say:

"the Government is open minded about the possibility of a wider democratic option for Primary Care Trusts, but remains of the view that Primary Care Trusts must be given time to mature as organisations before this option is explored further."

We know what that means. It could be many years before new primary legislation is introduced to give primary care trusts, as commissioners, the opportunity to be locally owned.

The purpose of new clauses 19 to 21 is to introduce a community trust status that would apply to primary care trusts and enable them to become locally owned. I hope that the proposals are carefully drafted, and they incorporate certain safeguards. As with NHS foundation trusts, PCTs would not be able to apply for community trust status until the Secretary of State had given his approval for them to do so. He would, therefore, still have a block on the speed at which they could apply.

It is not possible simply to add PCTs into foundation trust status, because the form of the constitution is not precisely right for that. The way in which the community trusts are written into the amendments and new clauses would stress to a greater extent the proper role of the staff constituency and set a minimum of one third of the membership of the board of governors for the staff constituency. In making this transfer, we would be asking general practitioners and other primary care professionals to hand over a significant part of their current control over primary care trusts to the local public. We would therefore put in place a mechanism, which I hope the House will accept, to offer that choice. It is vital that we do so, otherwise it may be many years before PCTs have the chance of local ownership, and during that time the balance will shift dramatically in the NHS. It is important that that balance continues to be geared towards primary care, as we are seeking a primary care-led NHS. I shall use my locality as an example.

If there is a dominant hospital in Addenbrooke's NHS Trust with a multiplicity of primary care trusts acting as commissioners and if, at the same time, the NHS trust has a large local membership that believes that it owns Addenbrooke's hospital, not only does the PCT have less power in relation to the NHS trust than it used to, but it will be perceived locally as being less locally owned than Addenbrooke's hospital. When questions of priority come to the fore, people will expect the hospital, rather than the PCT, to be their voice which, to me, seems the wrong way round.

If amendment No. 164 is not accepted, I urge Members to support my amendment. I hope that my colleagues will do so, as well as Liberal Democrats, in the light of the speech of the hon. Member for Oxford, West and Abingdon. I believe that the right hon. Member for Birkenhead (Mr. Field) and the hon. Member for Hornchurch (John Cryer) tabled amendments with a similar aim to mine. I hope that all hon. Members will regard amendment No. 96 and the linked amendments as a way of injecting such proposals into the legislation.

I answered the question of the hon. Member for Mitcham and Morden about the two hospitals in my constituency, but I wish to deal in more detail with the principle of NHS foundation trusts. Essentially, my objection to the Government's proposals is not about the principle of such trusts; as my hon. Friend the Member for Woodspring said, we support the principle of foundation trust status. We favour freedom for NHS providers to manage themselves and respond to local priorities, rather than being subject to central control. The problem is that the Bill simply does not offer that. We know that NHS trusts will be tied to the "Agenda for Change" on pay and conditions. Addenbrooke's is happy with that but, in principle, managers should be free to vary them. Trusts will be subject to a national tariff but, if they want to maximise the utilisation of capacity, they ought to be able to discount the cost of capacity so that they can use spare capacity.

Nobody has mentioned the NHS information technology strategy. Most providers, including hospitals, are clients of IT companies. NHS foundation trusts will be subject to the entire NHS IT strategy, but will not be direct clients of IT companies. Instead, regional bodies will be the clients of IT providers. Trusts will be subject to PFI. The Minister reminded us that Government amendment No. 356 reinforces the fact that PFI will operate in exactly the same way for foundation trusts as for NHS trusts. Foundation trusts will also be subject to the same overall departmental expenditure limit as other NHS trusts. The freedoms that I seek, including the freedom from bureaucracy, are simply not present in the Bill, so I cannot support the introduction of foundation trusts, because the rhetoric is simply not matched by the reality. I shall therefore press amendment No. 96 to a vote.

Adrian Bailey (Labour/Co-operative, West Bromwich West)

I shall speak in support of new clause 24 and amendments Nos. 233 and 234, which I tabled. First, however, I should like to declare the fact that I am vice-chairman of the Co-operative group in Parliament, and a lifelong supporter of the principles of mutuality and co-operation in the delivery of our public services.

Before I discuss the substance of the amendments, I should like to pick up a couple of points. First, many Members have spoken about the running costs of any form of democratic involvement in foundation hospitals. Various mutual and co-operative organisations have developed low-cost, effective means of communicating with their members, and I know that the movement would be happy to make its expertise available to any prospective foundation trust. Secondly, there is nothing intrinsically socialist about the present Whitehall-driven NHS. The debate about local control and mutuality in the health service went on for many years before the NHS was founded in the 1940s. The current model was not arrived at because it was intrinsically egalitarian or socialist—it was the result of horse-trading between the Labour Government and health professionals in the 1940s.

I have tabled these amendments because I recognise that legitimate concerns were expressed on Second Reading and in Standing Committee about the commitment of foundation hospital trusts to democratic participation, and because the provisions in the Bill appear a little vague. New clause 24 would place a legal duty on foundation hospital trusts to take steps to secure a membership that is truly representative of the local community. Amendment No. 233 stipulates that, to obtain authorisation, a foundation hospital trust must be representative, and amendment No. 234 would place an obligation on trusts to report annually on the steps taken to achieve that.

My prime objective with the amendments is to ensure that the full potential offered by this new form of governance is realised. I believe that the democratic responsibilities of the trusts must not be subordinated to the other freedoms that foundation status will bring. The amendments define more clearly the obligations of applicant trusts to democratic ownership and control. To achieve foundation status, an applicant trust must demonstrate that it is as committed to local accountability as it is to gaining freedom from Whitehall.

In the debates on Second Reading and in Standing Committee, concern was expressed that the proposed membership arrangements could be open to abuse. One fear was that a highly organised religious group might hijack a governing body to demand that the clinical priorities of the hospital be changed in accordance with its religious beliefs, irrespective of the views or needs of the local community.

Another concern was that the governing body would be dominated by representatives of the so-called sharp-elbowed middle classes. It was feared that the professional, better educated and more self-confident members of the local community would be more skilled at using the democratic machinery, and that the views and principles that they expressed would take precedence over the interests of the less educated and more inarticulate members of the community.

The amendments are designed to stop that. However, they are not just defensive: they are also designed to promote social inclusion. My constituency is fairly representative of a large number of inner-city areas. It has a high percentage of elderly people on low incomes who do not have cars. They spent their lives in local industry and suffer from a range of conditions related to a hard working life. We also have a substantial ethnic minority population. Many of them are first-generation immigrants, with limited language skills but considerable health needs.

Such people could be excluded from participation by hidden barriers that are not directly or deliberately erected by a hospital trust. Those barriers could exist because the trust's governors are not sufficiently representative, or because their understanding of the measures that need to be taken to ensure full participation is incomplete. Ironically, it is the elderly and disabled—the ones with the most pressing health care needs—who could be the ones least able to play a part in a service on which their quality of life might crucially depend.

My amendments would ensure that the elderly, the disabled and the disadvantaged are heard. As a condition of the granting of foundation hospital status, credible steps must be taken to ensure that all views are incorporated into hospital governance.

The Bill's provisions represent a dramatic change from the centralised, Whitehall-driven control of local hospitals that has developed since the formation of the NHS. I accept that they pose an enormous challenge for management and represent a change in working culture.

The current management trusts appointed from local applicants are a recognition of the need for local input into hospital management. Many of the trusts are staffed by able and dedicated people, but they are not directly accountable to the local public. They amount to little more than a genuflection in the direction of local participation.

Currently, hospital management has no track record of democratic involvement. That lack of experience means that there is a danger that the mechanism of member involvement will not achieve its full potential. The last thing that we want is an incomplete and rudimentary form of member participation that enables a coalition of the great and the good in the local community to perpetuate its control of the trust by a form of mutated democracy. That would be no more than a sort of quango with votes on.

Siobhain McDonagh (Labour, Mitcham and Morden)

Is my hon. Friend aware that my constituency is not represented on the board of either St. George's hospital or St. Helier hospital, both of which serve my community? It is not represented on the primary care trust and, so far, it has been excluded from all centres of power and the limited democracy in the health service. Does he agree that foundation hospitals will give some of my constituents a chance to be represented on those boards?

Adrian Bailey (Labour/Co-operative, West Bromwich West)

My hon. Friend raises a valuable point. Local membership would give the opportunity to elect people to the governing board, which would effectively represent their interests.

I believe that Ministers share with me the intention that foundation hospitals should be genuinely mutual. The amendments detail the obligations of the trust, and provide a mechanism by which the means and level of membership recruitment can be measured to ensure that the boards are truly democratic.

The amendments are positive; they are designed to extend and promote the principles already incorporated in the Bill. They will provide a record of best practice and achievement that can be shared by everyone and passed on to subsequent generations of applicants. Furthermore, as democracy develops and becomes more successful, the model could be transplanted to other NHS services.

I take the point that has been made about PCTs. However, if we are to pioneer a new form of democratic participation in the health service, it makes sense to do so where the local community has the strongest identity and interest, which is undoubtedly at the local hospital.

The proposals offer the opportunity for a whole new constituency to engage in the running of our most valued public service. Few institutions arouse more justifiable loyalty and regard than the local hospital. By giving local residents, patients and employees a say in the running of their hospital we are both pioneering new forms of public participation and providing a means of educating people about the structures, policies and priorities of the service. We shall also be educating administrators on the wishes and aspirations of the local communities, and making them accountable in a way that might lead to a refinement of established practices better to meet the needs of their constituents.

Developing the bond between the public and their local hospital opens new possibilities for voluntary support and recruitment to add value to the hospital's existing work. In his Second Reading speech, my right hon. Friend the Member for Birkenhead (Mr. Field) talked of the potential that could be unlocked. Once people feel that they own and control their local hospital, who knows what extra efforts they will make to support it? Above all—

Glenda Jackson (Labour, Hampstead and Highgate)

Will my hon. Friend give way?

Adrian Bailey (Labour/Co-operative, West Bromwich West)

I am about to conclude my speech; I am conscious that other Members want to speak.

Above all, that bond will make it much more difficult for enemies of the NHS to privatise our hospitals in the future.

The only alternative to the proposals is to continue to invest more money in a structure run by local quangos and regulated by Whitehall. Giving local people a say in how the vast sums of money invested in their local services should be used is infinitely preferable.

We should be radical. It is time that we matched our financial investment to our commitment to local democracy. My amendments are designed to do just that.

Richard Taylor (Independent, Wyre Forest)

May I pay very sincere tribute to the right hon. Member for Holborn and St. Pancras (Mr. Dobson), who put the case in favour of his amendments so intensely clearly and has spoken up so strongly for all NHS staff, who do not want more interference?

I shall be very brief because time is short, but I want to ask the Minister to clarify new clauses 36 and 37, which, to my amazement, were welcomed by the hon. Member for South Cambridgeshire (Mr. Lansley). As hon. Members will know I am extremely sensitive to mergers and closures, and those new clauses seem to provide draconian powers.

The trusts interested in merger have to apply to the regulator, who at least, I am relieved to hear, will be accountable to the House, but new clause 36(3) says:

"applicants may modify the application with the agreement of the regulator at any time before authorisation is given".

The only mention of public consultation is in subsection (6):

"If regulations require the applicants to consult prescribed persons about the application, the regulator"

has to be satisfied that the applicants have complied. Which regulations may be relevant? Who are the prescribed persons who might be consulted? Are they just the management boards, the PCT patient forums, or the overview and scrutiny committees?

Without its own patient forum, a foundation trust has no one to refer matters to overview and scrutiny committees and, in turn, no one to refer to the independent reconfiguration panel, unless I have got that wrong, and I should be delighted to hear from the Minister about that. Mergers will inevitably become more likely because of the European working time directive. If those new clauses are accepted, proper open consultation will be bypassed and people will be unable to stop closures because of the unlimited powers in the Bill. I fear that MPs may find their seats at risk.

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

I am pleased to be called to take part in the debate. Before I speak to amendment No. 60, which is in my name and the names of several of my hon. Friends, and a number of consequential amendments, I should like briefly to mention the right of Welsh MPs to speak in the debate, because my hon. Friend the Member for Wakefield (Mr. Hinchliffe) has indicated that other hon. Members and I should keep our noses out. He may not have noticed, but this is an England and Wales Bill—that will become clear when I speak to amendment No. 60, which is about foundation hospitals. Moreover, other parts of the Bill will be voted on by hon. Members from England in overwhelming numbers compared with the number of Members from Wales.

I am not sure whether my hon. Friend is interested in those constitutional matters, but if he is, he will have noticed that on every England and Wales Bill in the past I have expressed my frustration that the time available to debate matters of extreme importance to Wales—primary legislation for Wales still rests with the House—is completely inadequate when we are also debating English matters, and I have suggested other routes so that we could have those debates. If we had other routes—if Welsh matters could be referred to a Grand Committee—I would be sympathetic to the argument that I should not participate in English affairs, but we do not, so I shall take part in the debate and I hope that my voice will be respected.

The problem emerges from the first sentence in the Bill:

"An NHS foundation trust is a public benefit corporation which is authorised under this Part to provide goods and services for the purposes of the health service in England."

Hon. Members may not know it, but there is a great deal of cross-border movement for treatment in Welsh hospitals and English hospitals. Overwhelmingly, however, it is for the treatment of Welsh patients in English hospitals. Last year, 43,000 Welsh patients were treated in English hospitals. Some of those hospitals—particularly the one that treats the greatest number of Welsh patients, Countess of Chester hospital—are in the first wave of applications for foundation hospital status. Therefore, whether they have foundation status and whether it works properly is clearly an issue of importance to Welsh Members.

Chris Grayling (Conservative, Epsom and Ewell)

The hon. Gentleman is making extremely important points, and I hope that Ministers will listen. Is he aware that not only is there a cross-border flow of patients but, in the Welsh border areas, the hospital in Chester is the prime referral point for the majority of local GPs?

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

Yes. The issue is even more important for people from mid-Wales, where the only acute services available are on the other side of the border in Shrewsbury, Hereford and other hospitals. For many Welsh patients, therefore, English hospitals provide the only available acute services. How they are run is therefore extremely important.

This Bill provides a legal duty and responsibility to treat English patients, but does not provide such a duty and responsibility to treat Welsh patients.

Ian Lucas (Labour, Wrexham)

Has my hon. Friend, like me, received a letter from the Secretary of State for Health, which talks about the fact that health care should be provided equally to those who need it, free at the point of need? Does he agree that this Bill runs directly contrary to that principle, in that it provides preferential treatment to patients from England over and above those from Wales?

Jon Owen Jones (Labour/Co-operative, Cardiff Central)

It certainly does. A pattern already exists, even prior to foundation hospitals being established, of Welsh patients finding it difficult to get access to the hospitals to which they would traditionally be sent from their catchment. An article in the Shropshire Star only yesterday stated:

"A patient from Mid Wales has been refused a vital hip operation at a specialist orthopaedic hospital in Shropshire—because he is from Wales, a letter revealed . . . GP Dr Hywel Lloyd in Llanidloes received the . . . letter from a consultant orthopaedic surgeon at the Robert Jones and Agnes Hunt orthopaedic and district hospital in Gobowen."

I could cite a number of examples of Welsh patients who are already having difficulty getting into English hospitals, even though those English hospitals do not have the additional power that they would have under foundation trust status to restrict the growing demand for their services from Welsh patients.

I raised these matters at the Committee's first sitting and the answers given by the Minister, which were repeated by the Secretary of State for Wales, other Ministers and the Health Minister in the Welsh Assembly, were all to the effect that, to paraphrase, nothing in the Bill precluded or prevented Welsh patients from getting treatment. But that was never the question that I had asked. I asked why it was necessary to give Welsh and English patients a different legal status and to put Welsh patients in a disadvantageous position?

The Government claim that they have amended the Bill to answer that point. They amended clause 14(1) in Committee, and at first glance it appears that the amendment meets the purpose. The original Bill said:

"An authorisation must authorise the NHS foundation trust to provide goods and services for the purposes of the health service in England."

The amended Bill now says:

"An authorisation must authorise the NHS foundation trust to provide goods and services for purposes related to the provision of health care. "

All well and good—it appears to answer the problem. However, the very next subsection says:

"But the authorisation must secure that the principle purpose of the trust is the provision of goods and services for the purposes of the health service in England."

How can one read that and not conclude that the Bill and the establishment of foundation hospitals will put Welsh patients in an inferior position?

On Second Reading, I spoke in support of foundation hospitals, much to the annoyance of several of my hon. Friends, because I am in favour of reform in the health service. However, I must tell my hon. Friends on the Front Bench that the Government amendments tabled so far do not address the central point that I am making. I do not believe that they do not want to respond to the argument that I have made. Indeed, I am fairly convinced that privately they would like to agree to my amendments. They must stand up and make that point, because other hon. Members who support my proposals might think that if the Government cannot guarantee equal provision of services for people in Wales after the establishment of foundation hospitals, perhaps they should vote against establishing foundation hospitals. I do not hold that view because I support the principle of modernisation, but others might be less convinced.

Several hon. Members, especially Liberal Democrat and Plaid Cymru Members, have made a point about devolution. They are reluctant to support my amendments because they would empower the Welsh Assembly to create foundation hospitals if it wished. Provisions giving the Assembly the choice to do something exist in many other Bills. I do not understand—I have received no explanation—why the Welsh Assembly would want to put Welsh patients at a disadvantage in the way in which I described simply in order to make a gesture by saying that it would not create foundation hospitals or take up the power to introduce them at a later date. That puts ideology in front of any practical benefit and protection for Welsh patients.

Hywel Williams (Plaid Cymru, Caernarfon)

My party's standpoint is abundantly clear, as is that of the Scottish National party: we do not want foundation hospitals in Wales or Scotland and we are worried about cross-border effects. As was said earlier, the standpoint of the newly democratically elected Labour Government in the National Assembly for Wales is clear: they are against foundation hospitals.

As the hon. Member for Cardiff, Central (Mr. Jones) said, clause 1 contains no reference to Wales, and he tabled amendment No. 60 to add such a reference. I take it from his remarks that he is in favour of establishing foundation hospitals throughout Wales, but that would be against the expressed wishes of my party and the Labour Government in Cardiff.

The hon. Gentleman says that adding a reference to Wales in clause 1 would address the problems of cross-border treatment. We are certainly worried about those problems. We are concerned that three tiers of treatment will be available in England: treatment available in foundation hospitals, treatment available in other hospitals and treatment available for Welsh patients. As my hon. Friend the Member for Angus (Mr. Weir) said, there are potential consequences for the Barnett formula if hospitals in England lever in large amounts of private money. Will the Minister explain the consequences that that would have on the proportion of money available for Scotland and Wales?

We accept the force of some of the arguments made by the hon. Member for Cardiff, Central about cross-border treatments, but we note the Government's assurances that the issues are properly addressed. Presumably, the logical conclusion for the hon. Gentleman is that if his amendments are not adopted, the Bill is flawed. In that case, is he prepared to vote against it? I understand from his remarks that he will support it even if it is flawed. Should he undertake to vote against the Bill, Plaid Cymru will be prepared to consider our position on his amendments.

Frank Field (Labour, Birkenhead)

I want to speak to amendment No. 321, the 25 associated amendments and new clause 34, which stand in my name and those of my hon. Friends.

I begin where my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) began, by reminding the House that we are debating the one institution about which this country cares. He was right to say that, but it was only a partial truth. If we look back over the past 20 years, the respect that the NHS has commanded among our voters has declined. Just because most of our constituents willingly vote for extra taxes to pay for improvements in the NHS, we cannot sit back and think that that state of affairs will continue. If any of my hon. Friends doubt me, they need only look at that other popular institution of 20 years ago—the monarchy—which was more popular than the NHS. The fact that something commands public favour at one point in time does not of itself mean that that favour will continue.

So the Government are right to take a twofold approach to NHS reform. The first approach is to commit record sums of taxpayers' money to improving services. The second is to consider institutional changes. I want to dwell on the size of the extra moneys that our constituents are willingly putting towards the NHS. We are approaching the mid-point of the Parliament. Even if our minds are not concentrated on the next election, our voters are increasingly thinking about it and the Government's record and performance. They will want improvement, over and above what they already expect, from the very large sums of money that they have willingly donated to improve the NHS. So my right hon. Friend was correct in saying that there are huge dangers in the Government playing around with the structure again at this time in the Parliament.

I am glad that my hon. Friend the Member for Wakefield (Mr. Hinchliffe) is in the Chamber. No one was more favourable to the Bill's principles when we discussed it on Second Reading than I was. The direction that the Government wish to take—the ownership of the NHS—is right. I just question whether they have had sufficient time to listen enough or think enough about the structure that they will not only impose on many people, but roll out before the next election.

Before hon. Members vote, I beg them to acquaint themselves with what is in the Bill on the register of electors. My right hon. Friend the Member for Holborn and St. Pancras was rather gentle with the Government. He talked about the additional cost each year for local authorities to keep their register of electors up to date—some £50 million. But we will not be asking foundation hospitals to use an existing body of electors. They have to start from scratch, so mega resources will go into trying to understand the legislation which we may or may not pass today, and building up that body of electors.

The amendments and new clause in my name and that of my hon. Friends recognise that the Government are right to consider ways of changing from a producer-run to a consumer-run organisation. I do not accept that, as my right hon. Friend the Member for Holborn and St. Pancras said, there was a choice only between a producer-run body and a laptop. If that were the only choice, we would be with him. The Government are trying to feel a new way as they in effect denationalise the last nationalised industry in this country and the only nationalised industry about which people care.

Geoffrey Robinson (Labour, Coventry North West)

The amendments in my right hon. Friend's name, mine and that of several other hon. Members, all make the simple point that there is no use in planning for a roll-out of a major reorganisation that has not been pilot-tested first. The proposals embody some good and bold aspirations. Is not the answer to try them first, involve the new foundation hospitals together with primary care trusts on a limited geographical scale, and let them iron out the difficulties without another massive disruptive reorganisation?

Frank Field (Labour, Birkenhead)

My speech can now be even briefer. That was the next point that I wanted to make, and I agree with every word my hon. Friend said. Our large group of amendments is intended to say to the Government, "Well done. We think you are moving in the right direction, but we are worried about any possible disruption in the delivery of services between now and the next election." The amendments therefore propose the establishment of six foundation hospitals and six primary care trusts. New clause 34 lists who would carry out the evaluation and how they would report back to the Secretary of State and to us before there was any further roll-out.

The simplest form of election would be to use the roll of electors who elect us. That would entail no extra administrative cost, and the people who act as returning officers in parliamentary elections would return the board members in the 12 pilots that the amendments propose. [Interruption.] My hon. Friend the Member for Pendle (Mr. Prentice) asks whether it would be a mutual organisation. No, of course not. I do not understand why the term "mutual" is being used. Most of my constituents think they own the health service. When one considers the difficulties that we place on our hospitals now, the idea of asking them to collect the quids or parts of quids and to deal with more administrative detail is a nightmare. My constituents are willingly paying to try and own the health services that they have. The Bill should be designed to give that effective form.

The amendments set out the procedure for nominations. When we want to stand for Parliament, we have to get, say, 50 members of our local electorate to support us, and the same should apply to the election of board members. The returning officer would be the same as for parliamentary elections, as I said, and the Comptroller and Auditor General would carefully examine the key pilot experiments.

We were told by the Minister of State, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), that we must not go into the Lobby with the Tories on any of the amendments today. Our fear is that if we rush headlong into reforms that are almost open-ended, we will deliver the NHS up to their reforms. What we want to do more than anything is to make sure that the extra resources being put through the NHS are shown to be effective, and that our constituents are allowed to experiment. The NHS has survived for 60 years because everybody in the country knew that it had a cast-iron guarantee, a security, a fall-back position. We could all say to our electorates, "Don't worry, the NHS would perform better if only it had more money," but the Government have bravely stripped away that defence. We cannot go into the next election saying, "The service would be better if only you were prepared to cough up more taxes," as our constituents are already doing that. I beg the Government to draw back a little in their proposed pace of reform, to concede that we need an array of pilots to deal with PCTs and foundation hospitals and to ensure that the vast majority of hospitals do what they are meant to do—deliver improved services—particularly before we have to meet our paymasters, the electorate, at the next election.

Patsy Calton (Liberal Democrat, Cheadle)

Time is short, so I shall be brief and confine my remarks to two areas about which I am especially concerned. They have been raised by other hon. Members and, to that extent, I shall seek to labour them, as I think they are important.

Amendments Nos. 397 and 398 seek to reverse the Government amendments made in Committee that changed the sense of clause 15 and, in particular, the severity of the cap on private treatment. My hon. Friends and I regard it as imperative that the clause should be made clearer. Unfortunately, the Government have tabled yet another amendment, Government amendment No. 248, which makes it even less clear. It has become a dog's breakfast of a clause and, as a provision that deals with privatisation and the supposed cap on privatisation, it needs to be reconsidered to ensure that there is a cap on the amount of private treatment that can be given in a foundation hospital.

The second area about which I am very concerned again relates to a Government proposal—Government new clause 36, relating to mergers. The hon. Member for Wyre Forest (Dr. Taylor) mentioned that issue, which goes beyond an attempt by the Government simply to ensure that there is not another hon. Member for Wyre Forest waiting out there. What is really important is that there should be transparency and honesty about the situation into which we are moving. If a foundation hospital can effectively become merged or closed and if its authorisation can be changed so that it can involve itself with more private treatment, and if all that can happen right up to the point at which authorisation is given, there will be no time whatever for public consultation. People will see their local hospital whipped away from them with no chance for them, their local politicians or anyone else to make any difference whatever.

I ask the Government to reconsider new clause 36 and especially proposed subsection (3), which allows changes to be made to the application right up to the point at which authorisation is given. That is not right. The public need to know whether their hospital can be changed, closed, merged or privatised. There has been a reduction in transparency as the Bill has passed through the House.

John Hutton (Labour, Barrow and Furness)

I should like briefly to respond to some of the points made in the debate after I made my initial speech.

I pay a very warm tribute to every hon. Member who has spoken in the past three hours or so. All debates about the national health service are high-quality debates. We in this place care about the national health service. I know that that is true of all my hon. Friends, but I ask them to recognise that it is true of Ministers too. We care about the national health service, which is why are making proposals to help improve and sustain the direction of travel that we have set in the NHS plan and beyond. Let us be clear about that.

It is deeply depressing to see some of the Lib Dem amendments to which the hon. Member for Oxford, West and Abingdon (Dr. Harris) spoke tabled by someone occupying his space on the political spectrum. He wants to remove the provisions about direct elections to the boards of governors of NHS foundation trusts. I know that some of my hon. Friends would also like that to happen, but I have to say to him and to them that it would be entirely contrary to the spirit and intent of these proposals. A model of governance and representation that involves people being appointed to NHS trusts is no longer acceptable in the society in which we live. Let us have some democracy, but let us have some effective accountability as well.

New clause 9 deals with patients forums. I fully understand the concerns expressed by the hon. Member for Oxford, West and Abingdon and others—for example, by my hon. Friend the Member for Bedford (Mr. Hall), who has played a distinguished role in this House in championing the cause of community health councils and the role of patients. However, the Government's arrangements for NHS foundation trusts extend beyond the current requirements for consultation and involvement. Primary care trust patients forums and the Commission for Patient and Public Involvement in Health will provide an additional means for independent patient involvement in the work of NHS foundation trusts. It is not the case that there will be no independent voice or opportunity for patients to be involved in the work of NHS foundation trusts. The patients forums established for primary care trusts will have that overview role. Nor is it the case, in relation to the comments of the hon. Member for Wyre Forest (Dr. Taylor), that there is no role for the overview and scrutiny committees of local authorities, whose role is protected in the Bill. I am afraid that those arguments have little or no substance.

Let us also be clear about amendment No. 400, which would remove the cap on private charges altogether, replacing it with a system that would at best be a woolly attempt to give priority to the needs of NHS patients, but is clearly not a mechanism that is capable of being applied to any extent in the practical environment of the NHS. It is impractical, impossible to operate and riddled with contradictions—no change there as regards the Liberal Democrats.

On new clause 36, the points made by the hon. Member for South Cambridgeshire (Mr. Lansley), which were picked up by the hon. Member for Cheadle (Mrs. Calton) and the hon. Member for Wyre Forest, suggest that there has been some misunderstanding of the Government's proposals. Under the new clause, an NHS foundation trust and another NHS foundation trust or an NHS trust may make a joint application to the regulator for authorisation as a new NHS foundation trust. In every other sense, we have simply mirrored the current provisions in the Bill on the principal application to become an NHS foundation trust. There is nothing different about the process at all.

On the group of amendments, including new clause 60, that were moved by my hon. Friend the Member for Cardiff, Central (Mr. Jones), I am confident that nothing in the Bill changes or adversely affects the way in which Welsh patients are treated in NHS foundation trusts established in England. I say this to my hon. Friend, because I respect and value his counsel: my colleagues and I are prepared to have another look at the Bill to make absolutely sure that the assurances that we gave in Committee and on the Floor of the House are fully honoured. I hope that my hon. Friend will be satisfied with that.

We are reaching the conclusion of this debate—which by common consent represents an important and seminal moment in this Parliament—as regards how we take forward improvements in the national health service. We have set out a clear prospectus today. This is not about competition, privatisation or two tiers: it is about taking forward traditional NHS values and applying them in the new world and new society in which we live. No one who is treated at an NHS foundation trust will be charged for that treatment. The standards that are set will be national: my right hon. Friend the Secretary of State will ensure that that is so. These are sensible reforms that will take forward a better basis and a more solid foundation on which we can build genuine and strong public support for public services. I urge my hon. Friends to support the Government in the Lobby.

Liam Fox (Conservative, Woodspring)

On a point of order, Madam Deputy Speaker. Could you use your offices to get a quick breakdown of the vote, so that the House can see how many Scottish Members were used to force through legislation that does not apply to their constituencies?

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

Order. The normal procedures will apply to this vote as to any other vote in the Chamber.

It being more than three and a quarter hours after the commencement of proceedings on the programme motion, Madam Deputy Speaker proceeded to put forthwith the Questions necessary for the disposal of the business to be concluded at that hour, pursuant to Order [this day].

Amendment proposed: No. 96, in clause 2, page 1, line 12, after 'Foundation', insert 'and Community'.—[Mr. Lansley.]

New Clause 9 — Foundation Patients' Fora

Simon Burns (Conservative, West Chelmsford)

On a point of order, Madam Deputy Speaker. As you will be aware, after the Division on amendment No. 164, the Government had their lowest majority in this Session—35. It might help the House to know that 40 Labour Scottish MPs voted with the Government to ensure that England did not have—[Interruption.]

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

Order. That is not a point of order for the Chair. I ruled on a similar matter earlier this afternoon.

I understand that the Minister is prepared to move amendments Nos. 233, 354, 242 to 244 and 234 and new clause 24, so I shall include them in the groups that I am about to call him to move.

Clause 5 — Other Applications

Clause 6 — Authorisation of NHS Foundation Trusts

Clause 10 — Register of NHS Foundation Trusts

Clause 11 — Power of Secretary of State to Give Financial Assistance

Clause 12 — Prudential Borrowing Code

Clause 15 — Private Health Care

Clause 33 — Offence

Clause 35 — Interpretation of Part 1

New Clause 25 — Audit

New Clause 36 — Mergers

New Clause 37 — Section (Mergers): Supplementary

New Clause 24 — Representative Membership

New Schedule 2 — 'Audit of Accounts of NHS Foundation Trusts — General duty

Schedule 1 — Constitution of Public Benefit Corporations

Schedule 2 — Independent Regulator of NHS Foundation Trusts

Schedule 4 — Amendments Relating to NHS Foundation Trusts

Patrick Cormack (Conservative, South Staffordshire)

On a point of order, Madam Deputy Speaker. Can you confirm that that extraordinary list of amendments, which was not read out by Mr. Deputy Speaker for understandable reasons, will be printed in Hansard, so that people know how many amendments were tabled for this short period?

More important, Madam Deputy Speaker, would you ask Mr. Speaker whether he will refer the whole question of programming to the Procedure Committee so that, in future, the time taken for votes is not counted in the programme motion? As it is, we have exactly half an hour left to debate what we were given an hour and a half to debate. I hope that you agree, Madam Deputy Speaker—[Interruption]—and I hope that those who are protesting would agree that this adds to the insult to Parliament.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

Order. In response to the first part of the point of order, I can assure the hon. Member for South Staffordshire (Sir Patrick Cormack) that all those amendments and new clauses will be included in Hansard tomorrow.

On the second point, as the present occupant of the Chair, I am very mindful both that time is proceeding and of the time that is left for the debate. I shall certainly make sure that Mr. Speaker is aware of that. The Procedure Committee or the Modernisation Committee may already be considering the point raised by the hon. Gentleman.

New Clause 30 — Complaints About Health Care

Stephen Ladyman (Labour, South Thanet)

I beg to move, That the clause be read a Second time.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

With this it will be convenient to discuss the following:

Government new clause 31—Complaints about social services.

Government new clause 32—Complaints regulations: supplementary.

Government new clause 33—Representations relating to special guardianship support services.

Government amendment No. 301.

Amendment No. 40, in clause 107, page 44, line 7, leave out subsection (1) and insert—

'(1) Complaints under this Act may be made by an individual or a body of persons, whether incorporated or not.

(1A) A complaint may be submitted in respect of—

(a) the exercise by an NHS body of any of its functions,

(b) the provision by any person of health care for which the body is responsible.

(c) the provision of services by the body or any other person in pursuance of arrangements made by the body under section 31 of the Health Act 1999 in relation to the exercise of the health-related functions of a local authority.

(1B) A complaint may be initiated by—

(a) the person aggrieved,

(b) his personal representative,

(d) an independent advocate, or

(e) some body or individual suitable to represent him.'.

Amendment No. 41, in page 44, line 7, leave out 'may' and insert 'shall'.

Amendment No. 42, in page 44, line 17, leave out 'may in particular make' and insert 'shall make further'.

Amendment No. 43, in page 44, line 17, leave out 'may' and insert 'shall'.

Amendment No. 44, in page 44, line 18, leave out paragraph (a).

Amendment No. 45, in page 44, line 20, at end insert

', including timescales for completion of each stage'.

Amendment No. 46, in page 44, line 26, at end insert—

'(h) for a specific complaint and redress procedure for challenging the refusal of NHS-funded continuing care'.

Amendment No. 47, in page 44, line 27, leave out subsection (3).

Amendment No. 48, in page 44, line 29, leave out

'and within the prescribed period'.

Amendment No. 49, in page 44, line 37, leave out paragraph (d).

Amendment No. 50, in page 44, line 37, at end insert—

'(e) primary care practices providing NHS services under contract, and other private providers treating patients under contract with an NHS body'.

Amendment No. 51, in page 44, line 37, at end insert—

'(4A) The provision that may be made under subsection (2)(f) includes the provision for a report about a complaint to recommend the making of an ex-gratia payment in respect of injuries sustained, loss of earnings or expenses incurred as a consequence of the incident or incidents complained about.'.

Amendment No. 52, in page 45, line 4, leave out 'may' and insert 'shall'.

Amendment No. 53, in page 45, line 6, at end insert—

'(6A) Provision under subsection (2)(g) will include provision for a complaint to be referred to either the CHAI or the Health Service Commissioner if the complaints procedure has not been completed at the relevant stage within a reasonable timeframe.'.

Amendment No. 54, in page 45, line 16, at end insert—

'(8A) Regulations under this section shall include provisions for the right to an oral hearing with the investigating officers of the relevant body where appropriate.'.

Amendment No. 26, in page 45, line 19, at end insert—

'(10) No regulations may be made under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendments Nos. 302 and 303.

Amendment No. 55, in clause 109, page 46, line 43, at end insert—

'( ) for circumstances in which a complaint may be considered, including—

(i) the breach of any duty under Part IV of the Care Standards Act 2000, and

(ii) the breach of any duty to provide services under Part III of the Health Service and Community Care Act 1990 (c.19).'.

Amendment No. 27, in page 47, line 41, at end insert—

'(10) No regulations may be made under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendments Nos. 304 to 312 and 316 to 318.

Amendment No. 28, in clause 181, page 95, line 35, after 'from', insert

'regulations under section 107 or 109 or'.

Government amendments Nos. 313 to 315 and 319.

Stephen Ladyman (Labour, South Thanet)

We now come to the part of the Bill that everyone is really interested in. I wish to speak to Government new clauses 30, 31 and 32, and I will comment on the other new clauses and amendments in this group. I shall try to be as brief as possible so that other hon. Members can speak.

Government new clauses 30 to 32 will replace clauses 107 to 110 on health and social services complaints in England and Wales, so removing a large amount of repetition of common provisions by combining those clauses into a supplementary clause. I apologise to the House for tabling replacement clauses on Report, but I hope that hon. Members will agree that that approach is preferable to tabling a large number of drafting amendments. I took that decision because I thought it preferable to introduce the new clauses on Report, rather than waiting for the Bill to reach the Lords. Time constraints did not allow a debate on the complaints clauses in Committee, so time has not been wasted debating those clauses that we now propose to replace.

Patrick Cormack (Conservative, South Staffordshire)

rose—

Stephen Ladyman (Labour, South Thanet)

New clause 30 will allow regulations to be made setting out the procedure to be followed when considering complaints received by an NHS body in England and Wales about the exercise of its functions.

Stephen Ladyman (Labour, South Thanet)

I shall give way, but then I want to make progress.

Patrick Cormack (Conservative, South Staffordshire)

I am grateful to the hon. Gentleman for giving way, but that is the very point that I am making. Does he truly and sincerely think that the House now has adequate time to debate what was not debated in Committee? Can he give a straight answer to that question?

Stephen Ladyman (Labour, South Thanet)

The House has voted on the programme motion; the House clearly believes that it has adequate time.

Lynne Jones (Labour, Birmingham, Selly Oak)

Will my hon. Friend give way?

Stephen Ladyman (Labour, South Thanet)

Yes, but this is the last time.

Lynne Jones (Labour, Birmingham, Selly Oak)

My hon. Friend says that he took that decision. May I ask whether he personally took the decision?

Stephen Ladyman (Labour, South Thanet)

Of course not; I made a recommendation to the Secretary of State for Health and he made the decision.

New clause 31 will allow regulations to be made setting out the procedure to be followed when considering complaints received by a local authority in England or Wales about the discharge of its social services functions.

New clause 30(1) and (2), and new clause 31(1) and (3) will allow regulations to be made setting out the procedure for handling and considering complaints where a complaint is made about the exercise of an NHS body's functions or health care provided by or for such a body, or where a complaint is made to a local authority in England or Wales respectively. The regulations made under those clauses can specify in what circumstances a complaint will trigger the formal complaints procedures, as prescribed in the regulations.

NHS bodies or local authorities may often be able to address concerns expressed or issues raised by service users, or their relatives or carers, without the formal complaints procedures being used. We want people to have access to the formal procedures when they want them, but we do not want to force people to undertake the whole process if they prefer a less formal approach.

There are also a number of drafting amendments to provide for consistency and clarity of wording between the various complaints clauses. The new clauses make it clear that, if the Commission for Healthcare Audit and Inspection, the Commission for Social Care Inspection or, in Wales, the independent panel, refer a complaint to the health service commissioner or local government ombudsman, the commissioner or ombudsman will have discretion about the action that they might take in response and are not obliged to investigate every case. A further amendment aims to clarify the intention of clause 109(8) and reconcile it with the language used in the Children Act 1989 in respect of representations and complaints.

The purpose of new clause 32 is to combine all common provisions that exist for the handling and consideration of health care and social services complaints for both England and Wales into one new clause. It has been drafted to clarify the policy intentions and any procedural differences between health care and social services in both England and Wales. Subsection (2) combines common provisions in clauses 107 to 110, and specifies the persons who may make a complaint, the complaints which may or may not be made, complaints which need not be considered, the period within which complaints must be made and the procedures for making and considering a complaint. It also allows for regulations to be made about which complaints may be heard, about the making of a report about the complaint and the action to be taken once a complaint is made.

Subsection (3) is intended to provide for the body considering a complaint to be able to recover its costs from the body complained about if it wishes, depending on precisely how it decides to execute the functions being bestowed on it to investigate and resolve complaints. The new wording of subsection (3) is intended to clarify the position on who makes the payment and to whom the payment is made. It also replaces the word "fee", which implies a service rendered, with "payment", which more accurately reflects the position that the payment is to cover costs incurred in considering the complaint.

The new clause also contains a consequential amendment to ensure consistency of wording in the Bill in relation to disclosure of information to third parties. As currently drafted, clauses 107(9), 108(9), 109(9) and 110(10) may be interpreted as applying to unspecified obligations of confidence, which would mean that they would override obligations arising under statute as well as common law. The clause does not override the specific protections from disclosure for individuals set out in the Data Protection Act 1998: information relating to individuals must not be disclosed without the consent of that individual unless it is necessary to do so for any of the reasons specified in the Act. Personal data will still need to be processed lawfully in accordance with the provisions of the Act, and it is not the intention that information relating to individuals will be disclosed without their consent unless the Data Protection Act provides that that may be done.

Subsection (5) allows for regulations to provide for cross-cutting complaints, not all of which could be considered under one set of regulations. The intention is that when a complaint would fall to be considered under two different schemes, the regulations enable the complaint to be considered in parallel. A single complaint of this kind would trigger action under both sets of regulations, each working in parallel, so that for the complainant, it appears as one system.

New clause 33 tidies up the legislation by revoking section 14G of the Children Act 1989 and inserting a new subsection into section 26 of that Act, which brings complaints about such special guardianship support services functions as may be specified in regulations within the ambit of the complaints procedure established under section 26. Section 14G was inserted into the Children Act 1989 by section 115 of the Adoption and Children Act 2002. The policy intention was always that complaints about special guardianship support services in relation to children should be considered under the Children Act complaints procedure.

The Bill preserves a separate procedure for the consideration of complaints that are capable of being considered under section 24D or section 26 of the Children Act, and we therefore need to make it possible for some complaints about special guardianship support services to be considered under this procedure. We also want such complaints to come within the provisions for further consideration by the Commission for Social Care Inspection under clause 111. The most effective way of achieving that is to revoke section 14G of the Children Act, and to extend the coverage of section 26 to include those complaints, which is what the new clause does.

Work is still to be done on defining the precise nature of special guardianship support services. During the passage of the Adoption and Children Bill, the Government promised that we would consult stakeholders extensively on the development of support services for special guardianship. The definitive range of support services will be finalised only after a public consultation. We will then wish to consider which complaints about which services will be considered under the Children Act procedure because we envisage that only complaints relating to the provision of services that are directly for the benefit of a child should be considered under that procedure. That explains why we need to be able to specify the functions that will be considered under the Children Act procedure in regulations. That is consistent with the system for complaints from people provided by the adoption service. There should be parity for special guardianship.

Amendments Nos. 301 to 304 are necessary because they remove clauses 107 to 110—the current complaint clauses—so that they may be replaced by new clauses 30 to 32.

I shall briefly touch on the other amendments in the group and explain why the House would be well advised to resist them. Clause 107(1) sets out in general terms what a complaint may be about. However, amendment No. 40 would broaden that provision by detailing who may make a complaint. The amendment is unnecessary and would put too great a level of detail in the Bill.

Amendments Nos. 41 to 43 and 52 should also be resisted. I understand the effect that they would have but they are unnecessary. I assure the House that we have every intention of using the regulation-making power provided by clause 107 and the other clauses relating to complaints procedures.

Amendments Nos. 44 and 47 should be resisted. They would remove the ability to make regulations to set parameters for the complaints procedure in terms of what, who, how and when, which is not sensible. It is right that the procedure has always allowed patients, or a person acting on their behalf, the right to complain if they are not happy with the service or treatment received from the NHS. Of course, other people who use or are in NHS facilities, such as visitors and contractors, should be able to raise concerns, but not necessarily under the NHS complaints procedure.

Amendment No. 45 is unnecessary because the existing wording of the Bill is sufficient to provide for the time scales and deadlines that it would create. Amendment No. 46 should be resisted because the powers in the Bill and Government new clauses 30 and 32 are sufficient to ensure that the complaints procedure will apply to all manner of services and treatment provided, subject to any exceptions thought necessary. The amendment would add too much detail to the Bill.

I understand the motives behind amendment No. 48. However, it is important for there to be a time limit so that people are encouraged to make complaints as quickly as possible while events are fresh in the memories of those involved. I appreciate that there might be extenuating circumstances if people suffer trauma or distress, so it is right and proper that there should be discretion to waive the time limit, if appropriate. Sensitivity must be used and I promise that we will consider the matter carefully when drawing up the regulations.

Hon. Members should resist amendment No. 49. I do not understand the point of accepting an amendment that would restrict the range of options available for the successful resolution of a complaint. Amendment No. 50 should be resisted and although I understand the thinking behind it, the Bill adequately covers the proposed provision.

Amendment No. 51 is unnecessary. NHS bodies are already allowed to make ex-gratia payments if a claimant has suffered a financial loss, such as expenses incurred as a result of a complaint. NHS organisations will continue to have such flexibility after we have made regulations under the Bill. Again, I understand the thinking behind amendment No. 53, but it would add too much detail to the Bill.

The provisions suggested by amendment No. 54 are already covered by the Bill. Amendments Nos. 26 and 27 are undesirable because they would provide that regulations would be subject to affirmative resolution. Opposition amendment No. 28 deals with things that are usually addressed under the negative procedure. Amendment No. 55 should be resisted because clause 111 provides for an effective, speedy and fair process. The clause, and other provisions, also cover the measures proposed in the amendment. Finally, I recommend amendments Nos. 305 to 319. They are technical, clean up the wording and are consequential on other amendments.

Simon Burns (Conservative, West Chelmsford)

I assure the House that I shall not speak for long. As my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack) rightly explained, the vagaries of the Government's programme motion mean that we have only 45 minutes to discuss a key part of the Bill, bearing it in mind that we were unable to debate 50 clauses in Committee because of the programme motion Upstairs. In addition, the Government have tabled four new clauses and 18 amendments, which have eaten into that time.

I shall concentrate on amendments Nos. 26 to 28. It is clear from the Government new clauses that they will once again rely on regulations to flesh out the fine detail of how the Bill will operate in practice. That has happened with many of their measures and reflects their approach to the crucial subject of social care. We all know that negative procedures are about as relevant as an ex-MP. It is difficult to find opportunities to hold the Government to account and debate such measures in detail. We can pray against them, but that is not the same as insisting on affirmative resolution, which triggers an automatic debate before measures become law.

Imitation is apparently the greatest form of flattery. My amendments try to imitate what the Labour Opposition did for 18 years when they sought to hold the Government of the day to greater account by insisting on secondary legislation that was subject to affirmative resolution. On reflection, we were probably wrong to use the negative rather than the affirmative procedure. However, having researched primary health legislation during the Thatcher-Major years, it is clear that we were prepared to make far more of the secondary legislation in our primary legislation subject to affirmative resolution rather than to negative resolution.

The Minister is new, so my speech will be novel to him. It would not be novel to the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton), and I must apologise to my hon. Friends who heard it numerous times when we discussed three primary health Bills in Committee. I think that it gains in stature with the telling, and I am pleased that the Minister is hearing it for the first time. He kindly and uniquely for a Minister in this Government assured us in a Standing Committee last week that he was the sort of thinking man—again, unusual for this Government—who was prepared to consider the Opposition's valid points. To the utter horror of his Whip, he said that if the Opposition had a good point, he would be prepared to change the legislation.

I challenge the new Minister—a so-called thinking Minister, if that is not a contradiction in terms for this Government—to give an instant response to my concerns. I know that that is unlikely because he responded to my amendments before I had a chance to explain what they would do. However, there is time in another place for him to show how reflective—the word he used last week—and intelligent he is. He should realise that it is right that we hold the Government more to account and save them from themselves if they make mistakes in secondary legislation. He can table amendments in another place to include affirmative resolution. Much of the detail is important because it fleshes out the Bill.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I shall speak briefly to the principles behind the amendments, without elaborating on the detail, as the Minister kindly outlined the purpose of our amendments for us. I entirely subscribe to the view expressed by the hon. Member for West Chelmsford (Mr. Burns) about the need for the affirmative procedure in respect of this important subject, not least because the House will not have the opportunity adequately to scrutinise this part of the Bill. We did not debate it at all in Committee and we have a minuscule amount of time in which to try to do it justice today, yet there is no doubt that independent complaints procedures that are transparent and easily accessible, and which ensure a good flow of communication between the body that is the subject of the complaint and the complainant, are an important part of improving patients' experience and the quality of care that they receive.

I shall raise a couple of points with the Minister. Can he say whether, in the regulations that the Government plan to introduce, they will stipulate training requirements for NHS and social services staff to make them aware of the complaints procedures that they have to operate, and to enable them to provide the informality that he mentioned, before a more formal complaints process begins?

Amendments No. 41 to 43 deal with whether there should be a discretionary power to make regulations, as implied by the use of the word "may", or an explicit mandatory duty for the Secretary of State to introduce regulations to establish clear complaints procedures. The Liberal Democrat view is that that should not be at the discretion of Secretaries of State, but a requirement. There should be a complaints procedure. That should not need the assurance of a Minister that powers will be exercised. It should be for the House to write into the Bill that we expect Ministers to exercise those powers, consult and introduce regulations.

The Minister says that our amendments to deal with time scales are a level of detail too far. That argument is regularly deployed by Ministers to rebut any amendments to regulation-making powers, but can he explain to me and perhaps to those outside, why it is appropriate to impose a time limit on complainants for making a complaint, but reasonable for the Government not to set time scales for each stage of the complaints process? Amendments Nos. 45 and 53 try to concentrate the minds of NHS bodies and social services departments to ensure that they do not just hit their target by responding by letter within 20 days and say that they have dealt with the complaint, but go about dealing with it meaningfully.

That brings me to a couple of questions that I raised in Committee but which, because of the vagaries of the process, never received a reply from the Minister with responsibility for these matters at the time. Where a complaint has been made—for example, where a poor assessment is made in an acute trust, which leads to an inappropriate discharge to intermediate care provided by a primary care trust, which itself fails to realise that the discharge is inappropriate and fails to readmit the person to the acute trust—is it for the complainant to navigate their way round the system, complain to the PCT and the acute trust, and work out where the complaint should be directed? Should it not be for the bodies that are the subject of the complaint to work together co-operatively so that they provide a seamless approach to dealing with complaints? Should there not be regulations to that effect?

The same applies in respect of health and social care. Increasingly, where services are integrated and provided seamlessly, it becomes less clear whether complaints should be addressed to social services or health departments. The regulations need to clarify that. I hope the Minister can give us some reassurance on those matters. We shall return to some of the amendments at later stages of the Bill. Hopefully, in the other place, there will be sufficient time to ensure that we get adequate responses to our concerns.

Patrick Cormack (Conservative, South Staffordshire)

There may indeed be some time in the other place, but that is no answer to those of us who are concerned about this place. While I welcome the Minister to his portfolio—he comes to it with a reputation as a thoughtful and hard-working man and I wish him every success—he must be ashamed of himself for what he had to do today. He had to gabble through, reading every last word, not only on the details of what the Government are proposing, but prepared replies on all the amendments that had not yet been spoken to by my hon. Friend the Member for West Chelmsford (Mr. Burns) or the hon. Member for Sutton and Cheam (Mr. Burstow). That is not only an insult to Parliament, but an insult through Parliament to every constituent who sent us here.

I do not blame the Minister individually. He is working to orders, as he made plain in replying to an intervention. He cannot yet make the decisions, but no self-respecting parliamentarian, whatever his or her views and whatever party he or she belongs to, could be anything but ashamed that this is how Parliament deals with a Bill of extreme importance.

I do not make these remarks merely as somebody who is opposing the Government. Indeed, I did not oppose them in the first Division. Neither do I speak having never opposed my own Government. Although the guillotine was generous in comparison with today's, I remember throwing down my papers and refusing to vote on Third Reading of the NHS reform Bill introduced by my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), as I felt that Parliament was being badly treated. However, if Parliament was being badly treated then, it is being totally abused now, and Ministers should be thoroughly ashamed of themselves.

When we look at the selection list, we see that there are four new clauses and about 40 amendments relating to the crucial subject of complaints procedures, which affect so many of our constituents. There are issues such as guardianship, but the Minister gabbled through that bit at such a rate of knots that, quite honestly, I could not understand what he was saying and I shall have to read it in Hansard tomorrow. Of course, I shall do so, but that is not good enough. When we have dealt with the current group of amendments, and although we have to finish at 5.50 pm, we must still deal with standards for health and social care, provision of health and social care in cross-border areas and registration and regulation of social care services and other services for children—and this Government are supposed to be child-friendly.

Madam Deputy Speaker, this is really not good enough. I was grateful to you for the thoughtful and considerate manner in which you replied to my point of order, but unless the voting time can be taken out of such programme motions, we may as well all pack up and go home, and show people out there how little care, concern, consideration and deliberation we give to issues that affect their daily lives.

I sit down in total disgust at the way in which this matter has been handled.

Stephen Ladyman (Labour, South Thanet)

I shall be very brief in answering the points that have been raised. I hear what the hon. Member for South Staffordshire (Sir Patrick Cormack) is saying and I shall certainly reflect on his thoughts and his admonition to me.

The hon. Member for West Chelmsford (Mr. Burns) pointed out that a prayer against could be used to secure the negative procedure, which puts in the hands of the House the decision on whether these matters are debated. He also noted my assurance that I would reflect on points made by the Opposition and be prepared to change the legislation if they made a good point. He will recollect that I said that I thought it highly unlikely that they would come up with any such points that we had not thought of. None the less, I confirm that I shall reflect on everything that the Opposition say to me.

I can assure the hon. Member for Sutton and Cheam (Mr. Burstow) that we will consider the possibility of training in the regulations. We are determined that the two organisations will review complaints and carry out reviews in a seamless fashion. Indeed, the legislation requires them to work closely together, so I hope that people who complain will get such an assurance. We will also consider time limits for each stage of the procedure during consultation on the regulations.

Question put and agreed to.

Clause read a Second time, and added to the Bill.

New Clause 31 — Complaints About Social Services

New Clause 32 — Complaints Regulations: Supplementary

New Clause 33 — Representations Relating to Special Guardianship Support Services

New Clause38 — Joint Annual Reviews

Stephen Ladyman (Labour, South Thanet)

I beg to move, That the clause be read a Second time.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

With this it will be convenient to discuss the following:

New clause 2—Duty of the CHAI to prepare standards guidance relating to health care—

'(1) It shall be the duty of the CHAI to prepare guidance to assist in securing the raising of standards in health care.

(2) In preparing guidance for the purposes of subsection (1), the CHAI shall have regard to performance indicators relating to—

(a) the availability of, and access to, health care;

(b) the quality and effectiveness of the health care provided to patients; and

(3) The CHAI must—

(a) lay a copy of any guidance prepared in accordance with the provisions of this section before Parliament, and

(b) once they have done so, send a copy of it to the Secretary of State.'.

New clause 3—Duty of the CSCI to prepare standards guidance relating to social care—

'(1) It shall be the duty of the CSCI to prepare guidance to assist in securing the raising of standards in social care.

(2) In preparing guidance for the purposes of subsection (1), the CSCI shall have regard to performance indicators relating to—

(a) the availability of, and access to, social care services;

(b) the quality and effectiveness of the social care services provided to the public; and

(3) The CSCI must—

(a) lay a copy of any guidance prepared in accordance with the provisions of this section before Parliament, and

(b) once they have done so, send a copy of it to the Secretary of State.'.

New clause 4—Duty of the CHAI to prepare standards guidance relating to health care in Wales—

'(1) It shall be the duty of the CHAI to prepare guidance to assist in securing the raising of standards in health care in Wales.

(2) In preparing guidance for the purposes of subsection (1), the CHAI shall have regard to performance indicators relating to—

(a) the availability of, and access to, health care;

(b) the quality and effectiveness of the health care provided to patients; and

(3) The CHAI must—

(a) lay a copy of any guidance prepared in accordance with the provisions of this section before Parliament, and

(b) once they have done so, send a copy of it to the Secretary of State and the Assembly.'.

New clause 5—Duty of the CSCI to prepare standards guidance relating to social care in Wales—

'(1) It shall be the duty of the CSCI to prepare guidance to assist in securing the raising of standards in social care in Wales.

(2) In preparing guidance for the purposes of subsection (1), the CSCI shall have regard to performance indicators relating to—

(a) the availability of, and access to, social care services;

(b) the quality and effectiveness of the social care services provided to the public; and

(3) The CSCI must—

(a) lay a copy of any guidance prepared in accordance with the provisions of this section before Parliament, and

(b) once they have done so, send a copy of it to the Secretary of State and the Assembly.'.

Amendment No. 38, in clause 41, page 14, line 23, at end insert—

'(1A) The Secretary of State must publish all such statements and must publish a statement of the evidence-base upon which these standards are set'.'.

Amendment No. 39, in page 14, line 24, leave out from 'may' to end of line 25 and insert

'amend the standards whenever he considers it appropriate.

(2A) The Secretary of State must publish amended statements, and must publish a statement of the evidence-base of the statements.'.

Government amendment No. 359.

Amendment No. 1, in clause 45, page 15, line 34, leave out from 'must' to end of line and insert

'undertake an assessment of the performance of each such body in relation to the guidance issued under section [duty of the CHAI to prepare standards guidance relating to health care]'.

Government amendments Nos. 360 to 370 and 372 to 377.

Amendment No. 226, in clause 70, page 28, line 20, at end insert

'of vulnerable adults and of people with disability'.

Government amendments Nos. 379 and 380.

Amendment No. 2, in clause 73, page 29, line 14, leave out from 'must' to end of line and insert

'undertake an assessment of the performance of that authority in relation to the guidance issued under section [duty of the CSCI to prepare standards guidance relating to social care]'.

Government amendments Nos. 381 and 382.

Amendment No. 3, in clause 75, page 30, line 24, leave out from 'CSCI' to 'a' and insert

'concludes as a result of an assessment that there is significant cause for concern about the effectiveness of the performance of'.

Government amendment No. 383.

Amendment No. 23, in clause 88, page 35, line 33, leave out paragraph (b) and insert—

'(b) undertake an assessment of the performance of each such body in relation to the guidance issued under section [duty of the CHAI to prepare standards guidance relating to health care in Wales]'.

Government amendments Nos. 384 to 386.

Amendment No. 56, in clause 114, page 51, line 5 at end insert—

'(5) Regulations may make further provision—

(a) for prescribed functions of the CSCI to be exercised by CHAI on behalf of the CSCI;

(b) for prescribed functions of the CHAI, so far as exercisable in relation to England, to be exercised by the CSCI on behalf of the CHAI.'.

Government amendments Nos. 387 to 396.

Amendment No. 57, in schedule 5, page 117, line 36, at end insert—

'(4) The CHAI must consult and have regard to the advice of the Children's Rights Director under Schedule 6(5)(2) in discharging its functions under section 43(2)(d).'.

Amendment No. 58, in page 119, line 14, at end insert

'and is to be responsible to it for the general exercise of its functions'.

Amendment No. 59, in page 122, line 12, at end insert

'and is to be responsible to it for the general exercise of its functions'.

Stephen Ladyman (Labour, South Thanet)

New clause 38 allows CHAI and CSCI to conduct jointly a review of services of a prescribed description provided under section 31 of the Health Act 1999, including reviews of care trusts. The aim of the new clause is to seek maximum flexibility to enable CHAI and CSCI to carry out, where appropriate, a joint review of services provided to the NHS and local authorities in partnership. We recognise and welcome the fact that the number and type of services provided under section 31 partnerships are constantly growing. We wish to allow for the possibility that in future it might be appropriate for CHAI and CSCI to carry out a joint review of certain services provided under a partnership and to award a performance rating in respect of those joint services.

Patrick Cormack (Conservative, South Staffordshire)

On a point of order, Madam Deputy Speaker. Could we have English spoken in this Chamber, not these extraordinary mnemonics and so on? Can the Minister explain what he is saying?

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

Order. Perhaps Dr. Ladyman can respond to that point of order.

Stephen Ladyman (Labour, South Thanet)

I certainly can. The Commission for Healthcare Audit and Inspection and the Commission for Social Care Inspection are often referred to as CHAI and CSCI for the sake of speed.

We wish to allow for the growth of organisations where those two services will have joint responsibilities. We want them to have the flexibility to be able to work together. For example, we may choose to provide in regulations that all adult mental health services provided under a section 31 partnership should be subject to a joint performance review under the clause. The Commission for Healthcare Audit and Inspection and the Commission for Social Care Inspection would be responsible for drawing up criteria under that section, which might include aspects such as how joined up and seamless was the provision of services under the partnership. The services provided under the partnership would still receive separate performance ratings for their health and social care elements, but we felt that it would be useful to have a separate rating to be able to judge the added value that the partnership had given to the service provision. We will consult all relevant stakeholders closely before drawing up any regulations under the provision and prescribing the services that will be subject to a joint review. I hope that that goes some way towards tackling the anxieties that the hon. Member for Sutton and Cheam (Mr. Burstow) expressed earlier about our determination that both organisations should work closely together.

Government amendment No. 359 has been tabled in response to a commitment that the former Under-Secretary of State for Health, my hon. Friend the Member for Tottenham (Mr. Lammy) made in Committee. That shows the hon. Member for West Chelmsford (Mr. Burns), who has unfortunately left his place, that my hon. Friend listened in Committee and was prepared to respond to good points.

The amendment makes it clear that the Commission for Healthcare Audit and Inspection will be concerned with all the factors in clause 43(2) when it exercises any of its functions that relate to NHS health care, not only the functions to which that provision currently refers.

The list of the Commission for Healthcare Audit and Inspection's functions in clause 43(2) will be extended to include giving advice and information under clauses 49 to 50 to the appropriate authority—my right hon. Friend the Secretary of State, the Assembly or the regulator—reviewing data obtained by others in relation to providing health care and any conclusions drawn from such analysis under clause 51; and promoting the effective co-ordination of reviews or assessments that other bodies undertake under clause 52.

The amendment will therefore ensure that, in discharging those functions, as well as the functions under clauses 44 to 48, the commission will pay particular attention to availability and access; quality and effectiveness; and the economy and efficiency of providing health care. In discharging those functions, the commission, as specified in clause 43(2)(d) and (e), will also concern itself with the need to safeguard and promote the rights and welfare of children and the effectiveness of NHS bodies or persons who provide—or are to provide—health care.

We gave assurances in Committee that we would consider further the application of the clause and I therefore hope that Opposition Members will support amendment No. 359.

Government amendments Nos. 360 and 361 are among the cluster of amendments that we are considering. Amendment No. 360 amends clause 46 to ensure that the Commission for Healthcare Audit and Inspection can undertake a review of the overall provision of health care by and for NHS bodies in England and Wales. We are taking the opportunity to clarify the function because the clause as currently drafted technically enables the commission to review only health care of a specific description. Without the amendment, the commission might carry out a review of cancer services in England and Wales but not of NHS care more generally.

Amendment No. 360 aligns clause 46 with clause 47 when amended by amendment No. 363 expressly to enable the commission to review the overall provision of health care by or for English NHS bodies and cross-border strategic health authorities.

Amendment No. 361 would ensure that my right hon. Friend the Secretary of State could request the commission to undertake such a review, should he consider one necessary. That will enable my right hon. Friend to ensure that the commission undertakes such necessary work so that issues of interest to the public or Parliament will receive the required attention from the inspectorate.

I shall not speak in detail about the other Government amendments, but, if I get the opportunity to do so, I shall happily respond to any points later in the debate.

Chris Grayling (Conservative, Epsom and Ewell)

In the few moments available, I want to concentrate on new clause 2 and amendment No. 1. Before I do that, I emphasise that it is a shame that the Government did not see fit to include in new clause 38, which deals with joint annual reviews, provision for joint reviews between England and Wales to avoid the huge duplication that the measure will cause across borders.

New clause 2 gives CHAI the right to participate in the process of setting standards. Under the Bill, it is the duty of the Secretary of State alone to prepare standards for health care. Conservative Members believe that that is unacceptable. That is doubly true when the Bill gives the new Secretary of State, who, by his own admission, has limited knowledge and experience of health care, the power to frame standards. There is no involvement of the Commission for Healthcare Audit and Improvement, which has the job of monitoring and tracking the performance of our health care system and understanding when it is and is not doing well. We believe that CHAI should be formally involved in the process, and new clause 2 would enable that to happen. I intend—with your consent, Madam Deputy Speaker—to press new clause 2 to a vote.

Amendment No. 1 returns the debate to what is, in our view, one of the big handicaps and impediments confronting the health service: the star-rating system, an ill-judged, ill-thought-out process that sets hospital against hospital, causes confusion in both clinical and management sectors, and throws up extraordinary anomalies.

Let me, in the few minutes available to me, give a clear explanation and a clear example of the problem, with reference to the Audit Commission's recently published report "Achieving the NHS Plan". Three hospitals are cited. Of the first it is said:

"This Acute Trust performed poorly in relation to NHS Plan targets, and was rated as poor managerially".

According to the second case study,

"This Specialist Acute Trust achieved most NHS Plan targets, and was rated as 'very good' on the majority of measures of financial and performance management".

Pretty good, really. As for the third example,

"This Acute Trust has performed poorly in relation to NHS Plan targets, and the auditor noted significant financial management failings, without identifying any substantial signs of imminent improvement."

What do those three hospitals have in common? The first, which performed poorly in relation to NHS plan targets, was awarded two stars by the Department of Health. The second, which performed well, was awarded two stars. The third, which performed poorly and showed no substantial signs of imminent improvement, was awarded two stars.

The current star-rating system is a disgrace, which is founded on poor statistics and bears no relation to the true clinical performance of hospital trusts. As my hon. Friend the Member for Woodspring (Dr. Fox) said this afternoon, there are good hospitals in this country that are stuck with zero star ratings and all the handicaps that that entails. The star-rating system should go. It should be replaced by a system shaped by CHAI, on the basis of its experience of what is good and what is bad in our health service. CHAI should be given an active role in helping to shape the standards for health care.

I want to press new clause 2 and amendment No. 1 to the vote, because I believe that they would make a real and positive difference to health care, and would help to get the politicians out of the health service.

Paul Burstow (Liberal Democrat, Sutton and Cheam)

I want to speak, exceedingly briefly, on amendments Nos. 38, 39, 56 and 59. In all of them the key issues are who decides standards, the process for setting them, and whether that should be entirely within the Secretary of State's remit or the commissions should play a role. That goes to the heart of the question whether the commissions are genuinely independent from the Secretary of State, or independent only at the pleasure of the Secretary of State. At present the Bill is inadequate, because the commissions are beholden to the Secretary of State in regard to much of what they must do.

Amendments Nos. 38 and 39 would require the Secretary of State or indeed the commissions, when publishing standards, to have an evidence base and to refer specifically to the evidence. That strikes me as a sensible proposition, on which a thinking Minister might wish to reflect.

We will support both the amendments that will shortly be put to the vote, not least because we believe that the star-rating system is deeply corrosive of the national health service. It misleads patients, and does not provide an adequate or reliable measure of what NHS performance actually is. It should be swept aside, and replaced by something that is more objective and more independent. We presented that argument in Committee in rather greater detail than I can present it now, but I hope that there will be more time to discuss it in the other place.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

Order. Time is up.

Patrick Cormack (Conservative, South Staffordshire)

On a point of order, Madam Deputy Speaker. May I put on record that the debate has not been concluded, and that two subjects of great importance to your constituents and mine, and everyone else's, have not even been touched on? Will you please report that to Mr. Speaker when you ask him about taking Division time out of programme time?

Andrew Lansley (Conservative, South Cambridgeshire)

Further to that point of order, Madam Deputy Speaker. Would it be appropriate also to note that I sought to discuss new clause 22, which stands in my name, in Committee, but it was not reached by virtue of the time limitations imposed in Committee? So this is the second time that it has not been debated.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

I am very mindful of what Members have said, but as I am sure that they will appreciate, I am bound by the programme order.

It being more than four and three quarter hours after the commencement of proceedings on the programme motion, Madam Deputy Speaker proceeded to put forthwith the Questions necessary for the disposal of the business to be concluded at that hour, pursuant to Order [this day].

Question put and agreed to.

Clause read a Second time, and added to the Bill.

New Clause 2 — Duty of The CHAI to Prepare Standards Guidance Relating to Health Care

Clause 43 — Introductory

Clause 46 — General Reviews

Clause 47 — Other Reviews and Investigations

Clause 48 — Failings

Clause 51 — Reviews of Data

Clause 53 — Studies as to Economy, Efficiency Etc

Clause 64 — Reviews and Investigations Relating to Wales

Clause 65 — Reporting to Secretary of State

Clause 71 — Information and Advice

Clause 72 — Review of Studies and Research

Clause 73 — Annual Reviews

Clause 74 — Other Reviews and Investigations

Clause 76 — Studies as to Economy, Efficiency etc

Clause 88 — Reviews and Investigations

Clause 92 — Right of Entry

Clause 105 — Boarding Schools and Colleges: Reports

Clause 107 — Complaints About Health Care: English and Cross-Border Bodies

Clause 108 — Complaints About Health Care: Welsh Bodies

Clause 109 — Complaints About Social Services: England

Clause 110 — Complaints About Social Services: Wales

Clause 111 — Complaints Under The Children Act 1989

Clause 112 — Complaints About Handling of Complaints

Clause 113 — Complaints: Data Protection

Clause 121 — Annual Reports: CHAI

Clause 127 — Inquiries: CHAI

Clause 130 — Section 129: Defence

Clause 131 — Information Obtained by CHAI: Supplementary

Clause 139 — Interpretation of Part 2

Schedule 8 — Part 2: Minor and Consequential Amendments

New Clause 26 — Provision of Primary Medical Services

John Hutton (Labour, Barrow and Furness)

I beg to move, That the clause be read a Second time.

Sylvia Heal (Deputy Speaker, Halesowen and Rowley Regis)

With this it will be convenient to discuss the following:

Government new clause 27—General medical services contracts.

And the following amendment thereto: (a), after 'appropriate', insert—

'(4A) No direction issued under subsection (1) shall involve payment based on rewarding contractors for reaching a target number or target proportion of treatments given.'.

Government new clause 28—Government medical services: transitional.

Government new clause 29—Abolition of pilot schemes.

New clause 40—Definition of personal medical service—

'In the 1977 Act, in section 29(2), leave out "adequate" and, after "attendance", insert "to meet their clinical needs".'.

Government amendments Nos. 270 to 299, 268, 269 and 300.

John Hutton (Labour, Barrow and Furness)

Following the recent decision by doctors in the British Medical Association to approve the new general medical services contract for family practitioners, the Government are taking the earliest possible opportunity to legislate for the necessary implementation. These clauses were not laid during earlier stages of the Bill's passage because we did not want to prejudge the outcome of the BMA ballot. As it turned out, 79.4 per cent. chose to support the new contract: 31,945 GPs cast a vote, which was a 70 per cent. turnout. That indicates the strength of support for the change.

Andrew Lansley (Conservative, South Cambridgeshire)

Will the Minister tell the House when the clauses and amendments were drafted? It may not necessarily have pre-empted the ballot, but it would have informed the House—notwithstanding the requirement for a positive vote in the ballot—if the clauses and amendments had been available for scrutiny earlier.

John Hutton (Labour, Barrow and Furness)

As the hon. Gentleman will understand, these amendments have been through several iterations in the Department and were not finally ready to be tabled until we were satisfied—as the BMA and the NHS Confederation were—that they provided the right legal framework to deliver the new contract. That was not until Thursday. I apologise to hon. Members and the House for the fact that the documentation that we sent out on Thursday did not reach them until Monday. That is regrettable and I apologise to the hon. Gentleman and other right hon. and hon. Members who take a close interest in these matters. We were genuinely trying to be helpful in that regard. I am sorry if it did not end up like that. To help Members understand the clauses, I wrote to them with an explanatory note last week. I hope that, despite the delays in reaching them, it has turned out to be at least some help for this afternoon's debate.

In general terms, the new clauses are designed to achieve two things: first, to implement the new GMS contract as agreed overwhelmingly by general practitioners; and, secondly, to make provision for putting personal medical services arrangements on to a permanent basis, as originally envisaged in the 1997 Act, in order to reflect the success of PMS as a means of providing primary care services.

In order to effect these changes, we need to give primary care trusts additional powers to commission primary medical services. In the process, our objectives have been to simplify the existing legal framework, to minimise the volume of secondary legislation—an inevitable by-product, I am afraid—and to make the new arrangements more straightforward for family doctors, patients and NHS organisations.

New clause 26 replaces the existing duty on PCTs and local health boards to make arrangements for the provision of general medical services with a new duty to provide or to secure the provision of primary medical services. The primary care trust or the local health board can meet this duty by entering into general medical services contracts, personal medical services arrangements, through providing the service itself, or by commissioning services from other health care suppliers. New clauses 27 and 28 provide for the making of the new GMS contract and for the necessary transitional regulations.

New clause 29 and amendments Nos. 278 to 282 will remove the pilot status of personal medical services arrangements and place PMS in the mainstream of delivering primary care services in the NHS. To do that, the power to make pilot schemes will be repealed, and sections 28C to 28E of the National Health Service Act 1977 will be commenced. As part of that process, several amendments will be introduced to sections 28C to 28E, simply to bring them up to date and, in particular, to reflect the changes made to the GMS provisions.

Amendments Nos. 284 to 291 will amend clause 166 to provide for a single list of performers in primary medical services to be held by primary care trusts, replacing the existing three-list structure set out in the Health and Social Care Act 2001. It is a helpful streamlining of those arrangements.

Amendments Nos. 292 to 295 will amend clause 167 to extend the assistance and support provisions to general medical services and personal medical services. Remaining amendments cover minor and consequential amendments and list the associated repeals.

That is what each new clause and amendment does in a nutshell. I would now briefly like to explain that while the new clauses make significant and important changes to the old GMS arrangements, the new GMS contract will retain many of the features of traditional general practice. For example, primary care trusts and local health boards will be under a duty to secure or provide within their areas the provision of primary medical services, to the extent that the trusts or boards consider that necessary to meet all reasonable requirements. It is that legal responsibility to ensure a comprehensive package of commissioning arrangements in respect of primary medical services that underpins the very important patient services guarantee described in chapter 6 of the agreement. We have made copies of the framework agreement available in the Vote Office for right hon. and hon. Members to consult.

Patients need to be assured that the new contractual arrangements do not deny them access to services, and they will not. The new arrangements do not envisage any diminution of the services currently provided under GMS contracts. Indeed, it is envisaged that most practices will continue to deliver the full range of additional services. Where they do not, the PCT must step in, and it is in those cases that a patient might need to go to another provider for certain services. The PCT will therefore have a power to commission services through other arrangements, including providing the services itself, if necessary. However, patients can expect the PCT to ensure that they continue to be offered at least the range of services that they currently enjoy under the existing GMS arrangements. That is the patient services guarantee.

All GMS contracts must include a duty to provide essential services, including the management of patients who are ill, or believe themselves to be ill, for the duration of that condition; care for those who are terminally ill; and the management of chronic disease. Where additional services such as minor surgery are provided for patients—that will be the case in all PCT areas, albeit that every practice may not provide such services—existing practices in the PCT or local health board area will start off with a preferential right to provide such services and will normally be expected to do so.

We are also retaining list-based general practice. In future, a patient will not be registered with an individual GP but will still be registered with a practice. A practice-based contract, rather than an individually based contract, will provide much more flexibility for the practice to decide how it delivers services. That will be a helpful degree of flexibility that we will provide for busy family doctors. For example, it will enable nurses to be contracting partners in the practice, which is not possible at the moment.

Once registered with a practice, the patient will continue to have the right to request to be seen by the doctor of their choice. That is important for patients who value seeing their own GP, and I certainly count myself among that number. The PCT will also retain its ability to help patients who, for whatever reason, cannot register with a general practice. It will retain the ability to assign patients to general practice but can additionally, for example, arrange to provide primary medical services itself where that is an appropriate solution.

Patrick Cormack (Conservative, South Staffordshire)

My constituency has only two practices in which the doctors themselves provide all the out-of-hours services. All the rest contract out that provision. Will that situation change as a result of the Bill? I know from experience that patients prefer to see a doctor from the practice to which they are assigned, rather than some locum from far away.

John Hutton (Labour, Barrow and Furness)

I agree with the hon. Gentleman that those are important issues, and patients value that provision highly. The situation will change under the new contract that we have agreed with the BMA and the NHS Confederation. Essentially, it will be for GPs to choose whether to provide an out-of-hours service directly. The new contract will not remove the requirement to provide out-of-hours services, but it will change who has the responsibility to organise the delivery of that service. At the moment, GPs must provide it, and some provide it directly themselves. They will continue to be able to do so if they wish to, but increasingly, for a variety of reasons—including work-life balance and other lifestyle issues—GPs do not want that onerous responsibility to fall entirely on their practices. They are happy for the service to be delegated, which is what happens with GP co-ops and other providers. The agreement provides for the PCTs to take on the principal responsibility for organising local out-of-hours services. I hope that they will be provided by patients' own GPs in many cases, but that will have to be decided locally.

Andrew Murrison (Conservative, Westbury)

Does the Minister agree that the Government are putting several new duties on primary medical care providers, which makes the out-of-hours provision mentioned by my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack) impossible, if GPs are to achieve a work-life balance?

John Hutton (Labour, Barrow and Furness)

I have significant sympathy with that view, which is why the new agreement reached with the BMA and the NHS Confederation provides for the solution that I have just described. GPs will be able to opt out of the responsibility of providing out-of-hours services, mainly for the reasons that the hon. Gentleman suggests. It is important that we do not lose sight of the fact that family doctors voted overwhelmingly for the new contract. It is the right contract for the future of primary care and it strikes the right balance between the need to ensure that patients have access to effective services and that doctors have the chance to lead their own lives and balance their work with their family and other responsibilities. That is our aim.

There has been some misunderstanding about the out-of-hours aspect of the agreement. Headlines in some newspapers claimed that there would be no 24-hour family doctor service. That is not what the new contract is all about. Such provision in the future will be the responsibility of the PCT or local health board, and that is where the responsibility should be located, not—as at present—with the busy family doctor.

Patrick Cormack (Conservative, South Staffordshire)

How will patients be affected? I presume that as far as they are concerned, the service will continue to be provided through the general practice.

John Hutton (Labour, Barrow and Furness)

Yes, that is how it is likely to be arranged. The usual arrangement of providing a telephone number for out-of-hours services will continue. One of the clauses that we shall discuss later provides for a new obligation on PCTs to provide such information to everyone in the area they serve. I would expect PCTs and local health boards to send out notes reminding people that the 24-hour services still exist and providing the telephone number. Some practices will decide to provide those services themselves and some will use other out-of-hours services providers, such as GP co-ops or private companies, which provide such services to many GPs now. Whatever the arrangements are, the maximum amount of information must be available to people locally, so that they know when and who to ring. That will be the responsibility of the PCTs.

We will also retain PCTs' ability to make decisions about the suitability of general practitioners to provide primary medical services. We are simplifying the legislative process, but retaining all the effective and necessary controls, by merging the current multiple list system into a single list of primary care performers. The detail of the new contract is set out in the agreement document, called "Investing in General Practice", which was published on 26 February. Copies of it have been placed in the Library and the Vote Office.

The new contract will be accompanied by a substantial additional investment of nearly £2 billion for primary care services across the UK. Funding will increase from £6.1 billion this year to £8 billion by 2005–06. That is 11 per cent. per year, each year, for the next three years.

To implement the contract, it has been necessary to make significant amendments to the legislative basis on which general medical services are presently provided, and to repeal a significant amount of primary as well as secondary legislation. It is intended that, after the implementation and commencement of these provisions, the volume of delegated legislation will be less extensive and more transparent than at present. Subsections (5) and (6) of proposed new section 16CC, as inserted by new clause 26, provide regulation powers to clarify what should and should not be considered to be primary medical services. This power could be used, if necessary, to maintain a national range of primary medical services across all PCTs and local health boards.

New clause 40, tabled by the hon. Member for Oxford, West and Abingdon (Dr. Harris), seeks to amend a primary care trust's duty to secure primary medical services and to require PCTs to meet the clinical needs of patients. His new clause removes the reference to "adequate" care. The existing duty set out in section 29 of the 1977 Act requires every primary care trust to make arrangements with individual medical practitioners to provide personal medical services, and for the recipients of those services to receive

"adequate personal care and attendance".

The PCT duty in proposed new section 16CC replaces that duty, and is intended to be no less stringent than the duty in the existing legislation.

The duty on PCTs is to provide services to the extent that they consider necessary to meet all reasonable requirements. There was some discussion about this issue in Committee, as I am sure the hon. Member for Oxford, West and Abingdon, and the hon. Member for West Chelmsford (Mr. Burns) and the other Conservative Members on the Committee, will remember. They will probably not recall every nuance of the debate—I certainly do not—but I remember that this was registered as a problem. There was, for example, concern that the duty to commission primary dental services was not properly aligned with the duty to provide primary medical services. We have tried to deal with that particular problem in a subsequent amendment, which I shall come to in a moment.

I had hoped that the wording of the duty in respect of primary medical services would provide a more direct read-across, which would satisfy the hon. Member for Oxford, West and Abingdon, following our discussions in Committee. As I said, we have tried to take on board the concerns that were expressed at that time. The similarity in wording for medical and dental services is appropriate because the provision of services by the PCT goes towards the fulfilment of the Secretary of State's duty under section 3 of the 1977 Act with regard to primary medical services.

The problem with the new clause tabled by the hon. Member for Oxford, West and Abingdon is that it seeks to amend a section of the 1977 Act that we are about to repeal, so it would be difficult for me to accept it.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

We tabled that new clause at what we reasonably thought was the last minute, but it became clear yesterday when the Minister tabled his new clause that this was going to be the case. I accept what he has just said.

John Hutton (Labour, Barrow and Furness)

I am grateful to the hon. Gentleman for that, because we have taken away the comments that he and other hon. Members made and tried to amend the Bill to reflect their concerns. There is a problem with new clause 40 and I am grateful to him for clarifying that point. I assume that that means that he will not want to press the matter to a vote.

Sadly, I also have a problem with the hon. Gentleman's amendment (a) to new clause 27, because it seeks to remove the ability of the Secretary of State to issue payments based on rewarding contractors for reaching a target or

"target proportion of treatments given".

The United Kingdom has one of the most successful vaccine programmes in the world, with high levels of uptake. It has been achieved by the hard work of general practitioners and enforced by the system of targeted financial incentives. The target payment scheme incentivises levels of uptake that protect children not only individually but collectively in the wider community, especially those for whom immunisation is contra-indicated. Removing the target payments could have a negative effect on vaccine uptake, and could perpetuate coverage that is insufficient for the protection of the wider community.

I understand the hon. Gentleman's wider objections to targets; he and I have debated the matter extensively across the Floor of the House and elsewhere. I believe, however, that he is pursuing the wrong issue here. This particular method of incentivising achievement in primary care and general practice has worked; it has helped to protect the health and safety of children. On this issue, therefore, he might not have chosen the strongest ground on which to fight his battle.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I accept the Minister's invitation not to go into the whole issue of targets in this debate, but in my speech I shall go into the reasons why, even if this system worked, it would give rise to major problems. Can he provide any evidence that the incentive payments for those vaccination targets have provided the cover that exists—questionable and dodgy though it is, because of other factors—or does he simply think that the system must be working because the incentive scheme exists and we have reasonable coverage? Is there any evidence?

John Hutton (Labour, Barrow and Furness)

I think that there is, and I should be happy to write to the hon. Gentleman setting out some of the trends involved in immunisation so that he can form his own view on the matter.

On the future of this type of payment, the new contract makes it clear that we will be discussing with the BMA how we can use the target payments more effectively in a way that meets general practitioners' concerns—I acknowledge that such concerns exist—and encourages even higher uptake, protecting children from potentially life-threatening diseases.

Andrew Lansley (Conservative, South Cambridgeshire)

The Minister's exchange with the hon. Member for Oxford, West and Abingdon (Dr. Harris) did not touch on a particularly difficult issue relating to the contract and the target payments. The Minister will be aware that, in respect of this particular set of targets, exception reporting for informed dissent does not apply. The effect of that is that GPs are operating under a financial incentive to raise their level of compliance, regardless of the fact that parents might choose for their children not to have a particular vaccination. I have been consistent in my support of the childhood immunisation programme—including vaccinations for measles, mumps and rubella—but there is a serious question mark over this practice, as perceived by patients.

John Hutton (Labour, Barrow and Furness)

I certainly accept that, and I have taken part in some of the discussions with the BMA on precisely that issue. In the light of the new agreement, we clearly need to continue to discuss it with the association. I am talking here about the general principle, however, rather than about how the details of the payment mechanisms are working.

Andrew Lansley (Conservative, South Cambridgeshire)

It is in the contract, on page 8.

John Hutton (Labour, Barrow and Furness)

It is, but it is also clear from paragraph 2.11 of the agreement that we shall continue to discuss the detail of those arrangements with the BMA. That is the only point that I am trying to make.

The second of the two principal purposes of these amendments is to make changes to the legislation on personal medical services—the alternative to general medical services. We have already considered the amendments necessary to implement the agreement between the BMA and the NHS Confederation for a new GMS contract. We have also looked at the new duty on PCTs to provide or secure the provision of primary medical services as set out in proposed new section 16CC. This will have an impact on other areas of primary care, including PMS schemes. The intention of new clause 29 and amendments Nos. 278 to 283 is, therefore, to provide the legal basis for changes to PMS that are, in the main, consequential to the new GMS contract.

We are taking the opportunity to bring local PMS contracts into the mainstream of primary medical services. It is our intention that all existing PMS pilots will become mainstream with effect from 1 April 2004. The National Health Service (Primary Care) Act 1997, which was introduced by the previous Conservative Administration and supported by the then Labour Opposition, introduced the concept of personal medical and dental services, and inserted new sections 28C, 28D and 28E into the 1977 Act. However, the concept was considered at the time to be very different from the traditional national GMS agreements, so a period of piloting was provided for in part 1 of the 1997 Act.

Personal medical service pilot schemes are voluntary—rightly so—and are intended to give GPs, nurses and primary care trusts the flexibility and opportunity to innovate by offering different options for addressing primary care needs that have to be met locally. It was always the intention, however, that, provided that PMS proved successful, the system would be made permanent. It has proved to be successful and we are therefore repealing part 1 of 1997 Act in respect of England and Wales. PMS will continue under the permanency arrangements that were set out in the 1997 Act. In other words, the legal basis of PMS switches to sections 28C to 28E of the 1977 Act. This also applies to personal dental service arrangements.

This means that decisions can be made locally rather than nationally about individual schemes, now that we have moved beyond the pilot phase. The House will be aware that individual PMS schemes need to be approved by Ministers, but I believe that that is no longer necessary, and that we can move beyond that sort of centralism. The intention is that under the general transitional powers in the Bill we will issue an order that allows existing PMS agreements to continue, but automatically changes the legislative basis of those contracts to the 1977 legislation. All things being equal, that will have no impact at all on PMS providers unless there are variations to their PMS agreements. We are also making a number of other changes to the provisions in sections 28C, 28D and 28E, which are largely technical and reflect some of the changes brought about by the new general medical services contract provisions.

That concludes the formal substance of my remarks, but I think that this is an important moment for primary care. We have had a strong, positive endorsement of the new contract from family doctors, and the House now has the means to give effect to it. I hope that Members on both sides of the House will support our new clauses, which command the support of the BMA and the NHS Confederation.

Simon Burns (Conservative, West Chelmsford)

May I begin by thanking the Minister? In Standing Committee, it emerged that large parts of the Bill relied heavily on the Government's regulation-making powers. We did not know how the Government intended to use regulations to build on the nuts and bolts of the Bill—this is not a criticism—because they were not yet in a position to share their views with Opposition parties or anyone else. However, towards the end of proceedings in Committee, the Minister said that he would seek to introduce new clauses and amendments on Report to incorporate the GP contract in the Bill, and gave a commitment to make available to Committee members explanatory notes and a briefing on the Government's proposals. That commitment was honoured, and the briefing and notes arrived yesterday morning. Of course, it would have been better and more convenient to have them over the weekend, but not getting them then was not the end of the world. In the first post yesterday we received an extensive briefing from the Minister, which will certainly assist us during today's proceedings. I thank the Minister for going to the bother of keeping us informed.

As the Minister will be aware, five new clauses and 32 amendments have been tabled on the GP contract, so incorporating it in primary legislation constitutes an extensive addition to the Bill. The Minister was factually correct when he said that it had taken two years to get a GP contract, but he did not say that it had had a chequered history. The Government have had to make significant changes to the initial contract that they hoped to persuade GPs to accept. Dr. John Chisholm, chairman of the BMA's general practitioners committee said:

"The profession has given a clear mandate for change. A large majority of general practitioners—eight out of ten—want the new contract to be introduced".

Significantly, Dr. Chisholm continued:

"While I am delighted by the overwhelmingly supportive vote in favour of the new contract, I am in no way complacent. The negotiations have been difficult and there are GPs who do not have confidence in parts of the new contract. The negotiating team is in no doubt what their concerns are and there is much work to be done during the implementation phase of the contract. This will begin immediately."

Dr. Chisholm summed it up 100 per cent. accurately. A number of GPs have misgivings, and those who supported the contract despite their misgivings probably did so because they thought that it was important to resolve the issue. I hope that during the implementation of the contract, everyone will work together to seek to iron out any problems, concerns and difficulties that arise.

I do not want to detain the House for long, but I should like to raise a number of matters with the Minister. If he catches Madam Deputy Speaker's eye and responds to my questions later in the debate, I shall be grateful; equally, given the time pressure on our proceedings, I shall fully understand if he thinks it better to write to me rather than using up time that other hon. Members could use to contribute to the debate.

First, as the Minister's briefing and the amendments demonstrate, the proposals, like other proposals that we debated earlier, will involve considerable regulation-making powers. I suspect that I will get the same old answer, to the effect that those powers will be subject to the negative procedure rather than the affirmative, but I would appreciate it if the Minister confirmed that my assessment is right. I will not repeat the speech that I made a little earlier about the affirmative procedure, save to say that, as, sadly, the sadly was not here for my contribution, I would immodestly recommend for once that he read it tomorrow—[Interruption.] I am grateful to my hon. Friend the Member for Tatton (Mr. Osborne), who obviously enjoyed my speech and understood the wisdom of it, but I shall spare the House a repetition—the Minister can read it.

The Minister has said that the measures before us will simplify the legislative base—despite the new delegated powers, the overall volume of delegated legislation after implementation will be less than it is now. I would welcome confirmation that that is the case, but I am intrigued to learn how regulation will be reduced. I am old enough to have heard Governments of all political persuasions claim that there will be less regulation, and that less regulation means better government. I am cynical about those claims because, when it comes to the crunch, they are never realised. I would appreciate the Minister's comments on that.

I should now like to deal with one or two specific issues arising from new clause 26. Subsection (4) of proposed new section 16CC, as the Minister will know, specifies that a PCT or a local health board must

"co-operate with any other such body in the discharge of their respective functions".

The explanatory notes state that that subsection imposes a duty on PCTs and local health boards in Wales to co-operate with other bodies. If the provision is intended specifically to deal with cross-border co-operation, why has it been drafted so widely? Is it intended to cover other instances in which co-operation is required? If that is the case, can the Minister explain what those instances will be, and in what sort of situations he envisages a need for such co-operation? Finally, will he confirm that the provision will mean that English PCTs and Welsh bodies have a reciprocal duty to co-operate with one another?

Turning to enhanced services, new clause 27 inserts a number of new sections into the National Health Service Act 1977. The Minister referred to the changes that the Government will make to that Act through their amendments. However, the explanatory notes state that under proposed new section 28Q, a general medical services contract is a contract for primary medical services, as specified in paragraph 2.8 of the new GMS contract. However, it may also include enhanced services on the boundary of primary and secondary care such as specialised services in areas like drug and alcohol misuse, sexual health and depression. Where the new GMS contract does not provide for enhanced services, will the Minister confirm how and by what mechanism those services will be available to patients? I am sure that he will agree that this is a matter of critical importance. From the outset, there must be no misunderstanding about how the Government envisage this part of the Bill working.

On the question of pay, proposed new section 28T allows the Secretary of State or the Welsh Assembly to make directions regarding payments to be made under the new contract. Will those directions provide for the minimum income guarantee? Can the Minister confirm that the Government do not intend to place a time limit on the minimum practice guarantee? Again, if the Minister can give some more information on that point, it will go a long way towards satisfying our quest for knowledge and will send a message beyond this Chamber to those who may have some concerns or uncertainty about what is a very important matter and a crucial part of the contract.

Finally, proposed new section 28T(3) states that the payments will be made

"by reference to compliance with standards or the achievement of levels of performance".

Will the Minister provide more detail about the standards and performance targets intended under the regulations?

The Minister will be relieved to hear that I do not intend to reopen the debate pursued with such skill in our Opposition day debate yesterday by my right hon. and learned Friend the Member for Folkestone and Hythe (Mr. Howard), the shadow Chancellor, and by my hon. Friend the Member for Woodspring (Dr. Fox), the shadow Secretary of State for Health. I do not want to cause the Government embarrassment for a second day running, but I should be grateful if the Minister would expand on the question of targets.

In his concluding remarks, the Minister said that he hoped that hon. Members on both sides of the House would accept the Government amendments and, in effect, the new GP contract. I assure him that the Opposition broadly accept the GP contract. I have no intention of asking Opposition Members to divide the House on this matter. However, I should be grateful if the Minister will provide me, when it is practicable and sensible to do so, with answers to my questions.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I begin by offering my apologies to you, Madam Deputy Speaker, and to the Minister, for my slightly delayed arrival. There was a lobby of social services users—appropriately enough—from my county this afternoon. They are waiting for me to lodge a petition this evening, which I shall do if I am able to catch your eye when the time comes. I was detained with them, and I regret missing the beginning of the Minister's speech. However, I understand that, in the bit I missed, he set out in general terms the issues relating to the background of the new clauses.

I am keen to speak to amendment (a), tabled in my name. The Minister began to deal with that, and the hon. Member for South Cambridgeshire (Mr. Lansley), in his perceptive style, also made a substantial part of the contribution that I was going to make. However, I also have a number of questions with which I hope that the Minister will deal, given the Committee style of our proceedings today. I should be grateful if he ensures that he is able to cover them. By way of advance notice, I can tell him that he will find some of the matters that I want to raise among the questions that I placed on the Order Paper yesterday. They were not selected for debate, but I am grateful that a starred amendment was selected, given its late submission.

I share the gratitude expressed by the hon. Member for West Chelmsford (Mr. Burns) for the fact that we have some explanatory notes, even if we did not get much warning that they were coming and had little time to read them before the deadline for tabling amendments. As I said in respect of the programme motion, it is not very satisfactory that a large chunk of new clauses and amendments should be presented with so little time to consider them before the debate. Even so, like the hon. Gentleman, we must do what we can with what we are given.

With regard to amendment (a), the Minister rightly recognised that it raises concerns about incentive payments in general terms. However, he—and the hon. Member for South Cambridgeshire—were both right to recognise that it relates specifically to incentive payments for vaccinations and immunisations, especially childhood immunisations.

The problem is that, if the system works, it will be of questionable ethics. If it does not work, it will be unnecessary. The Minister has argued that, if GPs were not paid to meet a target, some people would not receive the vaccination that they needed, even after a consultation. Effectively, therefore, there is a third person in the consultation room with the doctor and the patient, or the patient's parents. That third person is the doctor's accountant.

In general terms, I do not think that that is how a doctor-patient relationship should be conducted. It seems to me entirely wrong that GPs should entertain the notion that, if seven out of the next 10 patients do not end up with being immunised after their consultation, they—the GPs—will miss out on a significant amount of money. It is not an item of service payment, or a payment per immunisation, as the payment kicks in once a threshold is reached. If a doctor is on the cusp of achieving that incentive, the risk is that that factor will creep into the consultation.

The Minister would consider that to be a success. Like me, he believes that immunisation, where clinically inappropriate and in the absence of contraindications, is a good thing. Even so, it is not appropriate for a GP's recommendation to be backed up—in force or in any other way—by the promise of payment for reaching a particular target. That is not the relationship of equipoise that ought to exist. Doctors and patients should not have these incentive payments and targets in mind.

If the Minister is arguing that the system works and that doctors are right to chase payment in the consultations, that is not an ethical basis for giving treatment. If the system does not work—if it is not a relevant factor in increasing the number of immunisations—then what is the point in having it? Indeed, I would go further and state that not only is the system pointless, it is damaging. Even if a GP is not influenced by the equation that states that, to reach the threshold, he needs to get seven of the next 10 patients immunised, the perception that he is being influenced still exists. To a great extent, that will undermine the doctor-patient relationship.

Informed patients—and patients in general—may well be concerned that their doctors will be influenced by the incentive payment. That is especially the case in an area such as immunisation, where the recommendation is being given not to a competent patient—that is a patient with capacity—or even to a Gillick-competent patient, but to a patient without capacity, whose parents must make a decision.

That is an especially sensitive area. We are talking about treatments that are given to healthy people, and it is understandable that some parents may feel that an unnecessary intervention is being made in respect of a healthy child. It is always more difficult to see the need for such an intervention than for treatment for a person who is symptomatic.

In addition, many parents and patients may be aware that they benefit from herd immunity and consider that they do not need the immunisation because they can rely on others. That is not an approach that I recommend, but it is a serious concern.

Andrew Lansley (Conservative, South Cambridgeshire)

Before the hon. Gentleman moves off this point, does he share my concern about the incentive payment mechanism? The mechanism is not specified in the contract, which states only that it will be the subject of further discussion and that exception reporting does not apply. Moreover, under the new contract, GP practices will be able to opt out from providing additional services, at a cost of just over £1,000 of the global sum. Does the hon. Gentleman agree that there is a risk that practices that are unhappy with the ethical position presented in the contract may simply choose to opt out of the arrangement? Would not that undermine our ability to deliver this additional service?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Quite so. Immunisation levels are so marginal that we cannot run that risk. The Minister may say that he cannot run the risk of removing incentive payments, but I hope that he will give me some comfort by assuring us that if the system is pursued, it will be changed. There is less of an argument against having a threshold for the number of consultations, so that GPs will be incentivised to consult patients. However, if patients refuse or reject standard immunisation, even with no good clinical reason, that should not penalise the doctor. The Minister could achieve the improvement of access to immunisation that he wants and ensure that there is a proper call and recall system by setting incentive payments—if they have to happen—at a proportion of the eligible population receiving those consultations.

In fact, that should be the default position and the Minister should have to justify his current position on two grounds. First, there should be clear evidence that a threshold for immunisation payments given works. It is not good enough to look at trends without having an adequate control group to determine what would happen over time if the threshold payment system did not apply. Indeed, the Minister might consider a test whereby in some parts of the country some practices did not operate an incentive scheme for immunisations given, so they would not be penalised when people without good clinical reasons refused immunisation. Simply to cite trends coincident with the introduction of incentive payments is the same sort of logic as he and I both reject when people cite increases in the incidence of autism at the time the MMR vaccine was introduced. If the test is not controlled, such arguments do not have a rational scientific basis. Where there is better evidence—as there was in that case—it should be cited. I urge the Government to show convincingly that there is evidence that the scheme works.

Secondly, the Minister needs to show that he can overcome the ethical objection that I identified and the public relations problem—people who have lost confidence in the system—before he proceeds with the incentive scheme.

In Committee, the Minister said that it would be unwise to try to amend these provisions because GPs had just come to an agreement, so any amendments would undermine that agreement. That cannot be right. First, it is the right of the House to make amendments to legislation. Secondly, GPs are still not happy about some aspects. As we know from the recent BMA meeting, incentive payments are one such matter. I should be grateful if the Minister provided some explanation and a defence of his position in response to those charges.

I have a few more questions that relate to the Liberal Democrat amendments that were not selected. Can the Minister explain why subsection 28U (2) of the new clause states "may" rather than "must"? One would have thought that regulations were definitely needed to make provision for all the points listed under subsection (2). Indeed, a series of questions flows from that and we should try to deal with them if we had time.

Subsection (3) refers to regulation of the circumstances in which a contractor or contractors

"may decline to accept a person as such a patient; or . . . may terminate his or their responsibility for a patient".

Will the Minister explain how that will work? Can he confirm whether the provisions are merely a translation of the existing arrangements? If so, he will know from representations made to him and from the health ombudsman's report that that is not satisfactory. Like many other Members, I certainly know of patients in my constituency who have been struck off their GP's list with no reason, even where—as is true in the majority of circumstances—there is no question that it would damage the patient's interests to know the reason.

Often the reason is that the patient has made a complaint. The Minister knows that that is an unacceptable basis for striking off. He knows that the BMA guidelines sent out by family health services authorities, health authorities or whatever they are called nowadays make it clear that the practice is unacceptable. I have an example from my constituency. In a conciliation meeting, a GP told a patient that they should not have complained to their GP if they wanted to stay in the practice. That is unacceptable.

The Minister has an opportunity to toughen up the regulations. There is an argument that the reasons for which patients can have their relationship with their GP terminated should be limited. That is not just on the ground of natural justice but because it can be so damaging for a patient to be treated in that way, especially when they do not receive a good reason or even any reason at all. Unfortunately, that is a problem in the culture—I speak as someone who has practised as a doctor. It is on the wane, but it still exists; GPs and other doctors still find it hard to adjust to having their treatments questioned. However, that is part and parcel of a modern NHS with empowered patients, and the regulations must keep pace.

Will there be provision for an appeals process that is open and transparent? It should allow the patient to be reinstated in the practice without GPs automatically saying that they cannot possibly have the patient back because the termination process means that the GP-patient relationship is irrevocably broken. That is a circular argument and such a fallback position cannot be right. I should be grateful if the Minister explained his thinking about that.

Subsection 28U (6) states that a GMS contract

"must contain provision requiring the contractor or contractors to comply with any directions given by the appropriate authority"—

which, as we know from reading the regulations, is the Secretary of State in England—

"for the purposes of this section as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the contract".

At short notice, it is difficult for me to determine whether that is a brand new provision or a translation of existing provisions. Can the Minister clarify that point?

John Hutton (Labour, Barrow and Furness)

There is a risk that I might forget that point in my summing up. The provision is a continuation of the existing legislative arrangements; it is not new.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I checked in the table provided by the Minister to determine whether that was the case. It states that the provision replaces schedules 10 and 11, which are, as we know from our debates on Sildenafil, infamous. Is the provision a direct translation? Sildenafil, or Viagra, probably offers a good example, although I do not want to go too far down that path.

Patrick Cormack (Conservative, South Staffordshire)

Why not?

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Because I know that other Members want to speak and I do not want to provoke Members into reopening that debate.

Can the Minister tell us whether it would be a breach of contract, or a breach of the terms and conditions of a general practitioner under a GMS contract, for a GP providing primary care services under a GMS contract to prescribe something that the Secretary of State has put under schedules 10 or 11? At present, that is not a breach of terms and conditions because GPs can provide such drugs privately; indeed, they have to do so if they are not to be out of pocket, because they are not reimbursed. In effect, that is rationing. I do not object to rationing itself, but it should be explicit. Normally, if rationing is an issue, it is possible for prescribing freedoms not to be limited and the GP has to explain, within the reimbursement process, what is going on. There may be exceptions, where reimbursement for such a prescription is appropriate, but the blanket provision in the regulations that the subsection may herald could go further than schedules 10 and 11.

I accept that the matter is technical and that the Minister may not be able to address it at present. If we were in Committee, I should ask him to write to me before Report. However, perhaps he can address that point, as several practitioners have raised it.

Proposed section 28R deals with the power to set out in regulations the primary medical services that a GP must provide under a GMS contract. In the third column—headed "replaces"—of that very useful table in the explanatory notes, the Minister explains that proposed new section 28R will replace a description in section 29 of the National Health Service Act 1977. The explanatory notes do not specify any provision; they refer to the agreement on essential services in paragraph 2.8. However, among other things, section 29 of the 1977 Act states:

"Regulations may provide for . . . securing that the arrangements will be such that all persons availing themselves of those services will receive adequate personal care and attendance, and the regulations shall include provision".

It goes on to provide further specifications. 7 pm

New clause 26 has been written in very vague terms, so it waters down the obligation in the Bill to ensure that patients can refer to something when protesting that the essential services are insufficient to fall within the remit of the primary legislation. I should be grateful to the Minister if he reassured me about the absence of any description in primary legislation in respect of what must be provided to meet reasonable needs.

Why are such things not still defined in the new arrangements? If they were defined, future negotiations could allow something that patients have a right to expect beyond the current definition of adequate personal care and attendance to be moved from paragraph 2.8 of the GP contract, which deals with essential services. Does the Minister accept that removing section 29 of the 1977 Act without replacing it with a similar duty represents a dilution, unless I have missed something? That brings me to the Government's amendments on primary dental contracts.

Patrick Cormack (Conservative, South Staffordshire)

The hon. Gentleman has been speaking for 20 minutes now.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I have got amendments in this group, and it is reasonable to speak for 20 minutes. The hon. Gentleman made the point earlier that we did not have enough time in Committee. I will ensure that I end my speech shortly, so that he has a chance to speak, but I have a specific question on the Government's amendment on dentistry.

The Minister has chosen to accept some of the arguments made in Committee about the fact that the definitions in clause 161 were inadequate. He now proposes to delete from clause 161 the words

"it is reasonable to do so"

and insert,

"necessary to meet all reasonable requirements, exercise its powers so as to."

I should be grateful to the Minister if he clarified whether that addresses the point made in Committee about the language used. Is the word "necessary" the significant addition? If it is, I should like to thank him for making that concession. I should like him to deal with the description of services set out in clause 161 for primary dental services and identify—I may have missed it—where the similar general description of the reasonable requirements that it is felt necessary to meet for primary medical services appears in the new provisions.

My last point relates to proposed new section 28U(3), where the Government's description refers to a power to make regulations setting out the relationship between contractors and their patients. Those relationships are covered in chapter 6 of the NHS Confederation/General Practitioners Committee agreement. The legislation refers to issues relating to termination of the relationship between patients and GPs. I have mentioned patients being the struck off the list. However, I am a bit concerned whether chapter 6 of that agreement is the way by which the proposals that the Government floated in the Labour party about a contract between the patient and the GP may be enforced.

I should like the Minister to clarify whether chapter 6 of that agreement could be used, if amended in future, to make patients agree to stop smoking, stop eating or start exercising before they can continue to get services. Perhaps the Minister will welcome the opportunity to put that idea to rest, because a number of people have read into the consultation that the Minister is undertaking in the Labour party that that may be the result.

We recognise that, overall, the contract represents a good deal for GPs, especially in financial and work load terms, but that is not the same as saying that it represents a good deal for patients because, especially in respect of the number of hours that GPs have to work, there is a zero sum gain. If GP work load is reduced, the services that patients can get from their GPs at a one-stop shop, holistically, are inevitably reduced.

The Government say that GPs will no longer have to provide out-of-hours services if they choose not to do so. Indeed, they will be paid for their other services even if they choose to drop that responsibility. GPs will be paid more, even if they do less, so patients will get less of a service from their own GPs. I understand that there are not enough GPs and that there are not enough hours in the day for GPs, but I hope that the Government will accept that patients would not have voted for the new contract, even if GPs thought that accepting it was the only thing that would allow them to cope with their work load. Until there is a significant number of new GPs, patients and GPs will not benefit from the new contract.

Patrick Cormack (Conservative, South Staffordshire)

I will certainly be briefer than the hon. Member for Oxford, West and Abingdon (Dr. Harris). I do not dispute for a moment that all the points that he raised were very pertinent and should be addressed. Again, the terrible time constraints under which we have to debate this very important Bill have been underlined.

I regard the Minister as a very honourable and extremely decent man, and I know that he has the interests of patients very much at heart. That is not in dispute, but I am very concerned about one aspect of the contract in particular. I touched on it in an intervention, as did the hon. Member for Oxford, West and Abingdon towards the end of his speech. What concerns me is the service that patients will receive.

I fully understand the need for the contract. I completely support my hon. Friend the Member for West Chelmsford (Mr. Burns), who spoke eloquently from the Opposition Front Bench. He said that he supported the Minister and that he would not seek to divide the House. I am glad about that, and I certainly would not wish to do so. I hope that no one will do so on this issue. However, while it is possible to go through life without going into hospital, it is virtually impossible to go through life without needing the services of a doctor, so we are dealing with a part of the Bill that affects every man, woman and child in this country. I believe in the NHS. If we are to have a national health service worthy of the 21st century, it is crucial that the services provided by GPs—family doctors—are of the highest possible excellence.

I am surprised that no Labour Back Bencher is present for this important debate, but I do not wish to make too much of that. Let me just say that, when the right hon. Gentleman answered my questions most courteously, he did so with a disturbing imprecision. When I asked him about the relationship between the patient and the practice and where the PCT kicked in, he did not give me a terribly clear answer. It is crucial that the patient looks to the practice with which the patient is registered for all services, both those within and without hours.

If there is a contractual arrangement that the practice does not provide out-of-hours services, that should be fixed up between the PCT and the practice, so that the patient has absolutely clear information. We have to remember that, although there are some hoaxers and malingerers, most patients who need a doctor out of hours are genuine people who are alarmed and need a service. The last thing that they want is a plethora of telephone numbers or a sheaf of papers. Those people are often elderly. They are sometimes old, distressed and even confused. A doctor is needed for the husband, the wife or the child in the middle of the night, but how is that doctor obtained? I should be most grateful to the Minister if he addressed that point and told us how such things will work.

I have a rural constituency—not as large as some of my colleagues' rural constituencies, but quite large. I have had experience of patients who are registered with practices that rely for virtually all their out-of-hours services on agencies. If the patient gets a doctor who has no idea of the geography of the area, who takes a long time to reach them, who does not know the patient and knows nothing of his or her medical history, it is hardly reassuring. Any agency that provides an out-of-hours service for a practice should have all their cars equipped with satellite navigation, which is simple these days—I have it myself, and I find it helpful when I am driving around an area that I do not know. It would be most reassuring if when people made a telephone call they knew that the doctor would arrive on their doorstep in pretty sharp time.

This aspect of the contract worries me. It is underlined by something that was said to me by the wife of a GP in my constituency a little while ago. I was shocked—perhaps I am too old-fashioned—that she said, "Of course, medicine is not a vocation any more. It's just a job." I am naive and idealistic enough to believe that the element of vocation is terribly important and should still exist. Of course doctors deserve private lives as much as anybody else, and of course they have great pressures on them—many of them work in practices whose lists contain thousands of names. Of course it is incumbent on us to ensure that they have a contract that allows them to have decent private time and decent private lives. Nobody makes a man or woman become a doctor, however, and the element of vocation is important. When somebody has a sense of vocation, as most of us in this place do, hours sometimes have to be forgotten.

I trust that the Minister's answer will reassure me satisfactorily—because this would also reassure my constituents—that however the new arrangement works, the patient will still feel registered with a practice, that if illness strikes in the dark hours of a winter's night a doctor can be summoned, will be summoned and will appear in reasonable time, and that the quality of care will be commensurate with that given by the doctor who regularly sees the patient at the surgery. That is what I and my constituents are concerned about, and I am sure that the same applies to the constituents of every Member in every part of the House.

I thank the Minister for what he has done. I appreciate the information that he got to us—albeit a little late, but that was not his fault—and, I have absolutely no doubt about his personal integrity or desire to ensure that the quality of medicine is the highest possible. I have these worries, however, and I hope that he can reassure me. When he winds up this all-too-brief debate, I hope that he will be able to give me that reassurance, so that I can pass it on to my constituents.

Andrew Lansley (Conservative, South Cambridgeshire)

I am grateful for the opportunity to contribute to this short debate on an important subject. I feel confident that the Minister will have a few minutes in which to reply fully to the points raised. I thought that my hon. Friend the Member for West Chelmsford (Mr. Burns) was generous to the Minister in contemplating that he might respond to some of the questions asked subsequently. It seems to me that the Minister has lived with the subject of the general medical services contract for some time, and I would be surprised were we to raise issues to which it was not within his competence to reply. I hope that he will reply in substance to our points.

My purpose is not to speak about the construction of the legislation and the new clauses and amendments, but about what lies beneath them: the new contract and how that it is to be framed. The debate gives us an opportunity for such discussion. It does not depend on the documents sent to us by the Minister, which I received on Friday in the House, but on the "Investing in General Practice" document, which, as the Minister rightly told us, was published in February. There has therefore been scope to think about these issues, but none to raise them. That is why I am disappointed that we did not get an opportunity prior to this to do so. It seems rather last-minute.

Let me run through my points, some of which have already been mentioned. The first was rightly raised by my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack). Much as we might be putting into legislative effect the framework for the contract negotiated between the NHS Confederation on the one hand and the GPs committee of the British Medical Association on the other, we are the guardians of the interests of the public, and, in that respect, of the interests of patients. I hope that my remarks will not be interpreted wrongly—both those organisations have the interests of patients at heart, too, but the final responsibility rests with us.

My hon. Friend expressed the concerns that have been raised in the right way, and I do not want to add to them, except to say that this is not simply about out-of-hours cover. The out-of-hours issue is terribly important, and I know that the Government will have thought long and hard about the extent to which practices can opt out of it; offering a timetable of 31 December 2004 for opting out is bold. I hope, however, that we will not find in the latter stages of next year or the early part of 2005 that, in practice, primary care organisations are seeking to provide out-of-hours cover for a high proportion of practices that are not willing to take it up, or a high proportion in rural areas in particular that are not willing to take it up, and that the alternative service models that are being developed simply cannot cope. I hope that we do not arrive at that, and I am sure that the Minister will give us some comfort that he feels confident about the scale—and the relative modesty of the scale—of opting out by practices, as it will be very difficult if it is much more than Ministers anticipate.

The second point, particularly in relation to rural areas, is the patient services guarantee. The patient services guarantee to which the Minister referred, I understand, is a guarantee for the primary care organisation to have a continuing responsibility for the provision of services under the existing contract. It is not, however, a guarantee that those services will be provided by the existing practice, because, of course, the practice in question has the ability to opt out of additional services. Therefore—this is particularly relevant in rural areas—if the service is being provided by other practices, other primary care providers or by the primary care organisation itself, provision may be in a number of different places. A considerable difference of substance exists between receiving one's essential services from a single practice, and, in respect of additional services, perhaps having to go to a more remote town or city to access a range of different services. In relation to provision for rurality, sparsity and special allocations of funds to reflect the costs of travel and the like in rural areas, I hope that the Minister will think hard and keep a weather eye on the extent to which the patient services guarantee leads to deterioration in the level of service or access to service for patients, whether in rural areas or anywhere else, and that he will be willing to intervene if necessary to boost some of the enhancements to practices, particularly in rural areas, if it proves that the incentives are not sufficient.

I want to echo two points made by the hon. Member for Oxford, West and Abingdon (Dr. Harris). I have been concerned about a case in my constituency, as other Members will be, involving the circumstances under which practices have the right to remove patients from their lists. He referred to that in the text of new clauses, but, of course, it reflects paragraph 6.29 in the contract. Of course, we know that patients may be removed if they are violent and that primary care organisations have to take responsibility in such circumstances. Paragraph 6.29 clearly says:

"Removal from a list will follow a transparent process that normally would include a warning to the patient before removal".

That is quite right. The subsequent sentence is less clear and gives rise to a specific concern. It says:

"When a patient is removed, practices will be required to give specific reasons to the patient as to why the removal has occurred, though it is accepted that, in certain specific circumstances, a statement to the effect that the relationship between the patient and the practice has irrevocably broken down will suffice."

What are the "certain specific circumstances" in which such a situation could occur? I suspect that they applied when my constituent was removed from a list. That process affected not only him but his wife and family because the practice's decision that the relationship with him had broken down meant that the whole family were effectively treated as though their relationship had broken down. The family live in a rural area, so the distance that they must travel to an alternative practice is substantial. My constituent believed that there was no underlying reason behind his removal from the practice. I suspect that it happened because he made a complaint, as the hon. Member for Oxford, West and Abingdon mentioned. That should not be sufficient to allow removal because there should be a formal and transparent process. I want to know the specific circumstances in which patients may be removed.

On immunisation, I have said that it is surprising that exception reporting for informed dissent will not be applied to the target payments. I have a technical question. Amendment No. 299 will disapply section 53 of the National Health Service Act 1977 under which every practitioner who is under contract to provide personal medical services should be enabled to offer child vaccination and immunisation services. Will the Minister explain why that provision must be removed?

I want to make a further point about the structure of the contract itself, although perhaps I should have raised it with the British Medical Association because it worries about such things. I earlier expressed concern about the extent to which information technology systems in the NHS are being centralised and said that the responsiveness of the IT system to individual customers was being removed. I fear that the same will be true of information management and technology systems for practices. The BMA and general practitioners might feel comfortable at the moment that they will enjoy the benefits of centralised standardisation, purchasing and funding for the provision of IT systems and the telecommunications to support that, but GPs will not be the customers. I wonder whether the BMA is entirely confident that GP practices will be able to exercise the same control over their service providers that they do at present. They currently spend their own money and obtain their systems from a range of competing providers that meet the necessary protocols of standardisation—the systems need to be able to talk to each other. There should be a customer-contractor relationship between a practice and its service provider, but that will not exist in future.

I am worried by paragraph 5.16 of the contract. It is an obtuse, yet important, part of the structure of remuneration and it relates to the adjustment of the list size for list inflation. Up until now, the registered population has tended to exceed the population estimates of the Office for National Statistics. In future, primary care organisations will rely on new census population estimates. It will come as no surprise to the Minister that there are places throughout the country—the most prominent are Westminster and central London, but the same can be said of the city of Cambridge—in which there are significant discrepancies between population estimates from the 2001 census and the figures anticipated. If those statistics affect the allocation of resources to primary care organisations and their practices under the contract, I am worried that structural problems with census population data will lead to problems with the contract. I hope that the Minister understands that caveats might need to be entered against that.

I asked the Minister earlier about order-making powers. He said that the negative procedure would be used; I assume that he meant in all cases. I imagine that many orders that arise from the Bill would not need to be considered using the affirmative procedure, but I urge the Government and those in another place who care deeply about the structure of legislation to look hard at Government new clause 26. It contains order-making powers to prescribe services that

"are, or are not, to be regarded as primary medical services"

and to define how they should be delivered. That is one of the central issues behind the new structure of contracts for personal medical services and general medical services. It would not be excessive for Ministers to give an undertaking that such orders at least would be considered under affirmative resolution. It would be undesirable if Opposition parties had to pray against orders so that something so central to the contract's structure could be debated.

John Hutton (Labour, Barrow and Furness)

I warmly thank hon. Members who contributed to the debate for their remarks. I am grateful to the official Opposition and the hon. Member for Oxford, West and Abingdon (Dr. Harris) for their general support for the new contract. However, I am afraid that I shall lower the tone by saying that the hon. Gentleman's reluctance to express anything like enthusiasm for the decision taken by 80 per cent. of GPs to embrace the new contract was typically curmudgeonly. Although it has nothing to do with the amendments, it is not the case that patients would not have voted for the new contract, although neither the hon. Gentleman nor I can prove that.

The new contract represents a significant development for primary care that will allow us to provide a better range of primary care services than at present. The arrangement is good for GPs and everyone who works in primary care but it has been exclusively driven by our one simple desire to improve the range of primary care services available to the people of this country. I think that people would overwhelmingly vote for that if they were given the opportunity, but I hope that the hon. Gentleman understands from our previous debates that we do not suggest extending the democratic franchise quite that far—we have enough on our plate with NHS foundation trusts.

It is important to bear in mind one or two basic facts and figures about primary care. Much of the debate has been focused on the importance of out-of-hours services, and I agree that they are central to many people's perception of the comprehensive nature of NHS services. GPs and practice staff in primary care deal with about 250 million consultations each year, and 90 per cent. of all patient journeys in the NHS begin and end in a family doctor's surgery. The work done in primary care will certainly be central to the success of the national health service well into the future. I do not question the commitment of the hon. Member for South Staffordshire (Sir Patrick Cormack) to the national health service because he, like me, wants it to be a success. It is important that the issues raised by the hon. Members for South Staffordshire, for South Cambridgeshire (Mr. Lansley) and for Oxford, West and Abingdon are addressed properly as we move toward implementing the new agreement.

There is no doubt that there are risks. Perhaps the most difficult aspects of the agreement were the out-of-hours provisions. I know from my work as a constituency MP that our constituents place a high premium on around-the-clock access to a GP, 24 hours a day, seven days a week. It is a defining characteristic of our primary care services. I can give the hon. Member for South Staffordshire the assurances he seeks: we will implement the agreement to ensure that there is no loss of access to out-of-hours services. That is intrinsic in the agreement that we reached with the NHS Confederation and the British Medical Association. They recognise the importance of the service, too.

I have had the benefit of talking to many GPs about the new contract. Without exception, they all want the out-of-hours services, and the quality of those services, maintained because doctors care deeply about the well-being of their patients. They will not accept for a second a diminution in the quality of out-of-hours services. I am sorry if my answer was not to the hon. Gentleman's satisfaction, but it will be the responsibility of primary care trusts, in discussions with their local practices, to finalise, over the course of the next year or so, the arrangements that will need to be put in place locally to provide comprehensive out-of-hours services. That will include a proper setting of standards to be met. The arrangements governing accessibility of the service, who comes out to deal with a call and how quickly he or she arrives are important and will need to be put in place. It is a big job, but we have worked actively with primary care trusts to ensure that the hon. Gentleman's constituents, like mine, are not put at risk or disadvantaged. I am sorry if my original answers were not precise enough, but I assure him that that is how we intend to proceed. We would not accept anything less.

The hon. Member for West Chelmsford (Mr. Burns) mentioned the technical aspects and asked me to give an example of how we are reducing the burden or the volume of secondary legislation. I gave him one example and am happy to give him others in due course. He asked how enhanced services will be provided if not through GMS or PMS. They can be provided through the additional third route of directly commissioned PCT services and the services of additional providers can also be used. He also asked whether the minimum practice income guarantee would be covered by directions under proposed new section 28T. It will be. The minimum income guarantee will continue beyond 2006. It is not time limited.

On subsection (4) of proposed new section 16CC, I can assure the hon. Gentleman that the duties are reciprocal. It is not one-way traffic. The duties are broadly designed to deal with some of the cross-border issues that he mentioned, including the need to move to single commissioning of primary care services in those areas if possible.

The hon. Member for Oxford, West and Abingdon asked a number of questions. I am afraid that I shall have to write to him. I hope that he does not mind. He did invite me to go down that path and I intend to take advantage of that get-out. He kept referring to "U2", which is one of my favourite bands. I did not realise we were debating that today, and I am happy to discuss it with him another time.

The hon. Member for South Cambridgeshire asked pertinent questions. Given the time left, I shall have to write to him with further details. I am more than happy to meet hon. Members who contributed to the debate to discuss primary care services at any time in the future. I am also happy to arrange for them to be briefed by my officials, if they would find that helpful. The hon. Gentleman referred to the difficult issue of removing patients from practice lists and how we could deal with that. He is right to refer to sections of the February agreement that attempt to deal with the problem. We intend to use the regulatory powers to set out some of those issues in secondary legislation. It is not an entirely satisfactory state of affairs for any patient to be declined registration or to be removed from a practice. As the hon. Member for Oxford, West and Abingdon said, professional practice guidelines have been set out and we hope people will follow them.

The debate has been helpful. I am grateful for the support expressed for the Government new clauses. I look forward to discussing related issues in due course.

It being six and a half hours after the commencement of proceedings on the programme motion, Mr. Deputy Speaker proceeded to put forthwith the Questions necessary for the disposal of business to be concluded at that hour, pursuant to Order [this day].

Question put and agreed to.

Clause read a Second time, and added to the Bill.

New Clause 27 — General medical services contracts

New Clause 28 — General Medical Services: Transitional

New Clause 29 — Abolition of Pilot Schemes

Clause 161 — Provision of Primary Dental Services

Clause 163 — General Dental Services Contracts

Clause 165 — Arrangements Under Section 28C of the 1977 Act

Clause 166 — Persons Performing Primary Dental Services

Clause 167 — Assistance and Support

Clause 169 — Special Health Authorities

Clause 170 — Charges for Dental Services

Schedule 10 — Part 4: Minor and Consequential Amendments

Clause 141 — Liability to Pay NHS Charges

Rosie Winterton (Labour, Doncaster Central)

I beg to move amendment No. 235, in page 61, line 36, after 'injury' insert

', whether physical or psychological,'.

Michael Lord (Deputy Speaker, Central Suffolk and North Ipswich)

With this it will be convenient to discuss the following:Government amendments Nos. 236 and 237.

Amendment No. 29, in page 63, line 15, at end insert—

'(9A) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendment No. 238.

Amendment No. 30, in clause 144, page 67, line 22, at end insert—

'(11) No regulations may be made under by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendment No. 239.

Amendment No. 31, in clause 148, page 71, line 22, at end insert—

'(8) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendment No. 240.

Amendment No. 32, in clause 151, page 73, line 22, at end insert—

'(3A) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Amendment No. 33, in clause 153, page 75, line 21, at end insert—

'(3A) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Amendment No. 34, in clause 154, page 76, line 23, at end insert—

'(4) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Amendment No. 35, in clause 155, page 76, line 40, at end insert—

'(4A) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Government amendment No. 241.

Amendment No. 36, in clause 156, page 77, line 16, at end insert—

'(1A) No regulations may be made by the Secretary of State under this section unless a draft of the regulations has been laid before Parliament and approved by a resolution of each House.'.

Amendment No. 37, in clause 181, page 95, line 35, after 'from', insert

'regulations under sections 141, 144, 148, 151 or 153 to 156 or'.

Rosie Winterton (Labour, Doncaster Central)

This part of the Bill was discussed in some depth in Committee. I hope that I will be able to show that the Government have listened and have responded positively to the concerns raised.

Government amendments Nos. 235, 236 and 237 amend clause 141 and are intended to put an end to any concerns about the scope of the NHS costs recovery scheme. Our policy intention in relation to the scope of the NHS costs recovery scheme has always been clear. As my right hon. Friend the Minister of State said when this was discussed in Committee, free-standing diseases, particularly industrial diseases, are not covered by the scheme. It is our intention that both physical and psychological injury are covered. Nevertheless, some Committee members expressed genuine concerns about whether the Bill as then drafted left room for other interpretations, and my right hon. Friend agreed to reconsider the issue. We have decided to put the matter beyond doubt and the amendments seek to achieve that.

Government amendment No. 235 confirms that psychological injury as well as physical injury is included in the scheme. That would cover, for example, the case of someone who received NHS treatment for post-traumatic stress disorder following a particularly harrowing incident for which they received compensation. The compensator would also be liable for NHS charges relating to the treatment.

Government amendment No. 237 deals with questions that arose on the issue of disease itself. It makes it clear that free-standing disease, which would include, for example, asbestosis or mesothelioma, will not be within the scope of the scheme. There will be cases in which someone suffers an injury that leads to the development of a disease as a consequence of the injury. An example might be someone who suffers a broken leg that becomes infected and results in septicaemia. In such cases, if the disease is directly attributable to the original injury, it is clearly right that treatment of it should be included as part of the overall treatment of the injury for costs recovery purposes. The amendment makes that distinction clear.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

Committee members asked how that arrangement would work, even in a policy that we did not particularly like. I am grateful that the Government have tabled an amendment to clarify that. The remaining problem is whose decision it is, and on what basis they decide, that the disease in question is attributable to the injury suffered. One can usually tell when an injury is caused by an incident, and that would be covered. It is much harder to say whether a disease is attributable to an injury. Has the Minister given any thought to how that might be decided?

Rosie Winterton (Labour, Doncaster Central)

Obviously, such cases would be linked to decisions made about personal injury claims, and there are two ways in which the decision might be forthcoming. One way would be through a court case where that had been established, and secondly, where an insurance company was settling a claim, there would be discussion about that and agreement would be reached. Clearly, if that gave rise to an appeal, the mechanism to deal with it exists.

Government amendment No. 236 is the first of five minor drafting changes. Government amendment No. 237 specifies that only disease attributable to an injury should be taken into account for the recovery scheme, on the basis that treatment for such a disease is received as a result of the injury. Having used the words "as a result" in that amendment, we have been advised that the same wording should be used in clause 141 (1)(b)(i) and at various other places in this part of the Bill, in place of the original reference to treatment "in respect" of the injury. That ensures clarity and consistency in the test to be used in assessing whether treatment received is within the scope of the scheme. Government amendment No. 236 is the first of those technical changes.

Opposition amendment No.29 seeks to amend clause 141 by making the regulation-making powers in that clause subject to the affirmative resolution procedure. Indeed, all the Opposition amendments—Nos. 29 to 37—try to do the same thing.

With only one or two exceptions, the regulation-making powers in part 3 are not new. Rather, they mirror—sometimes word for word—powers that already exist in the Road Traffic (NHS) Charges Act 1999. Regulations made under the terms of that Act are all subject to the negative resolution procedure, and I see no reason why regulations made under the Bill, which will largely be concerned with the detailed and technical administration of the scheme, should be treated any differently.

Simon Burns (Conservative, West Chelmsford)

The Minister sees no reason why regulations made under the Bill should be treated any differently. Why does she think the original decision was taken to use the negative, not the affirmative, resolution procedure?

Rosie Winterton (Labour, Doncaster Central)

For reasons of consistency, which we believe should continue in the Bill. The regulation-making powers are concerned largely with the administration of the scheme, and we believe that the time of the House would be better spent dealing with them through negative rather than affirmative resolution, especially as all the regulations are set out. I appreciate that the Opposition would prefer regulations to be made by affirmative resolution, but given the amount of time available to the House to discuss such matters, we believe that the negative procedure will be sufficient. Of course, the Opposition are free to pray against those regulations if they wish to do so.

Government amendment No. 238 is one of a small number of minor technical drafting amendments, like amendment No. 236 which I have already covered, consequential on the wording of amendment No. 237. The intention is simply to ensure that references are consistent throughout this part of the Bill. Government amendment No. 239 is another minor drafting amendment consequential on the wording of amendment No. 237, as is Government amendment No. 240. Government amendment No. 241 is the last of the minor amendments designed to ensure consistency.

I hope that hon. Members will accept that the Government amendments have been tabled in response to concerns raised in Committee and are intended to clarify the position, or are largely technical. I hope that hon. Members will also accept that the Opposition amendments are not only unnecessary, but would take up valuable time of the House, particularly when they repeat what already exists in legislation. I ask the House to accept the Government amendments and reject those of the Opposition.

Chris Grayling (Conservative, Epsom and Ewell)

It is clear from the Minister's last remarks that she does not understand the importance of this part of the Bill to many outside groups, small businesses, GPs and organisations that provide insurance to GPs. If this part were implemented wrongly, it could have a significant effect on the welfare and possibly even the survival of a number of smaller businesses. I shall therefore challenge what the Minister said about the negative and affirmative approach to future statutory instruments, and attempt to convince her that she is wrong about that aspect of the measure.

It is true that we have received from the Government some clarification of their intentions in the Bill. In Committee we debated a number of provisions that were vague and confusing, and the Minister has gone some way to clarifying the Government's intentions, but in doing so, she has created additional confusion. I shall deal with some elements of the confusion that arises from the changes that she has made.

It was clear from the comments of the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton), in Committee that the measure was intended to apply solely to injury. As the hon. Lady rightly said, we raised the issue of long-term chronic conditions and the fact that it was impossible for the insurance industry to plan for those, as such conditions sometimes emerge years after the event. The Government's focus on injury specifically was welcome and helped to clarify their intentions.

However, I remain uncertain, as do my hon. Friends, about some aspects of what is proposed in the Government's amendments. The Minister spoke about psychological injury. It is appropriate that we should recognise that injury is not always physical and that it is sometimes psychological. The hon. Lady set out a good example in which this aspect of the Bill might be applied—the case of a substantial and distressing public event, following which a large number of people were treated for shock, post-traumatic stress disorder and other psychological conditions that resulted from experiencing or being an eye-witness to the incident.

In the case of a major sporting event, the impact on the organisers could be substantial. We need only think back to some of the more terrible incidents that we have experienced in this country in recent years, such as the Bradford City fire and the Hillsborough disaster, in which large numbers of people were affected by direct experience of an appalling situation. Sports clubs that must insure against the risks to them could face huge problems. [Interruption.]

Michael Lord (Deputy Speaker, Central Suffolk and North Ipswich)

Order. I am being distracted by conversations while the hon. Member for Epsom and Ewell (Chris Grayling) is addressing the Chamber.

Chris Grayling (Conservative, Epsom and Ewell)

In assessing the risk associated with large-scale sporting events or public events of any variety, including rock concerts or open-air classical concerts, the insurance industry will have to take into account the possibility of reimbursing to the national health service the cost of treating people who have suffered shock and other psychological aftermaths as a result of a major incident of the sort that we hope will not occur too often. That will be factored into insurance premiums in future.

What discussions has the Minister had with the insurance industry about that issue? Has she made any assessment of how the Government could limit the measures? In Committee, the Minister of State, the right hon. Member for Barrow and Furness, said that he would cap the payout that an insurance company could have to make in an individual case. Of course, as a large number of payouts could be made in relation to an individual incident, insurance organisations and event organisers could face substantial payouts, as a single incident might affect not only one person but a range of people. Will the Minister clarify that point?

I should also like clarification in respect of disease acquired from injury. The Minister cited the example of septicaemia. We can all understand how that would feature in a case for personal injury. She will be aware, however, of the very widespread incidence of MRSA, a hospital-acquired infection. She and her colleagues have indicated that health care providers will not be exempt from the provisions. What is the position in respect of infection acquired as a consequence of having an injury, rather than as a direct result of the injury itself? Where will she draw the dividing line, especially in respect of claims against the national health service? Treatment for an injury and an adverse incident of the sort that many people experience when they pick up MRSA in a hospital might be indistinguishable in that context. What about somebody who falls out of a bed in a hospital because they have not been properly protected with barriers at the side of the bed? That happened to an elderly gentleman in my constituency a few weeks ago and he contracted a hospital-acquired infection. How will the distinction be made in law?

Our amendments need to be seen in the light of the substantial number of unanswered questions in the Bill. We received a number of assurances from the Minister of State, the right hon. Member for Barrow and Furness, that various limitations would be put in place. For example, he said that a maximum amount would be retrievable by the national health service under the Bill. Of course, the Bill does not specify that maximum amount, which will be subject to regulations. Various provisions in clauses 144 and 141 give the Government the freedom to modify the scheme, whether to withdraw eligible circumstances in which payments can be made to the NHS or to add to them. Frankly, I do not accept what the Minister said about the road traffic measure and the negative procedure. I suspect that the argument that we are having tonight about the affirmative and negative procedures also occurred when that measure was debated.

As was amply demonstrated by the very good piece of work done by the Department for Work and Pensions on the problems that employers are facing because of the rising cost of compulsory employers liability insurance, if the Government get this measure wrong, it will have a significant adverse effect on smaller businesses in particular. Therefore, it is not good enough to send the Government forth from this place with a free hand and the ability to make regulations and push them through with the negative procedure. I know that business groups are less than satisfied with what the Government are doing and do not feel that they understand the consequences of even a limited scheme for the cost of liability insurance in respect of smaller employers who already face a substantial increase in costs as a result of circumstances in recent years. They will pay more at a time when they can ill afford to do so.

I am grateful to the Minister and her colleague, the Minister of State, the right hon. Member for Barrow and Furness, for saying that the Government would wait at least until the Department for Work and Pensions review is completed before implementing the measure. I find it surprising that it was drafted in separation from that process, but it is welcome that they have agreed to delay it. None the less, when the Government come to frame the regulations off the back of that DWP work and the measures set out in the Bill, they should come back to the House and seek its consent. They should not hope that hon. Members will spot the regulations when they have been tabled and pray against them. The issue is too significant for the small businesses of this country. There is no reason why the regulations should not be made a matter of mandatory debate in this House. The issue is important and it is a shame that the Government do not feel it appropriate to tell the House that it will automatically have a chance to debate this issue and to challenge them over it. That is to be regretted. I hope that, even at this stage, the Government may change their mind and that the Minister will accept that the affirmative rather than the negative route is the right one.

Evan Harris (Liberal Democrat, Oxford West and Abingdon)

I have two brief questions for the Minister. First, does the provision that she has made to distinguish between injury and illness and to provide for illness directly resulting from injury mirror the equivalent road traffic measure? Does she intend it to do so for consistency?

Secondly, I mentioned that the only problem that I envisaged was working out what illnesses were attributable to an injury, but I have a further question about that issue, which was prompted by the remarks of the hon. Member for Epsom and Ewell (Chris Grayling). The Minister argues that injury may be "physical or psychological". The amendment does not refer to physical and/or psychological injuries or to physical and psychological injuries, but allows for psychological injuries alone. I imagine that she may have in mind post-traumatic stress disorder, but it is hard to argue that that is not an illness rather than an injury. As an illness, it would not be countered by virtue of Government amendment No. 237, which seeks to introduce into clause 141 a new subsection (4A):

"'Injury' does not include any disease."

One might argue that post-traumatic stress disorder is more like a disease or condition than an injury. In the absence of any physical trauma—I think that that is the distinction on which she and her draftsmen are relying, which is logical—it is hard to see how post-traumatic distress disorder and other purely psychological injuries might be considered injuries, as they are more likely to be considered illnesses when push comes to shove, such as in the event of an appeal, as the trauma causing the condition will not exist in that instance. I should be grateful for clarification.

Rosie Winterton (Labour, Doncaster Central)

I take on board the points made by the hon. Member for Epsom and Ewell (Chris Grayling) about businesses feeling that they have to bear an added weight as a result of the Bill. We need to be clear, however: if an employer did not have proper health and safety measures in place and their negligence resulted in injury to an individual who was subsequently awarded compensation through a personal injury claim, surely it is only right that the employer should pay back to the NHS the costs of the treatment. That principle is embodied in the part of the Bill under discussion and I think that we should all welcome it.

The hon. Gentleman referred to the fact that the Minister of State, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), said that we would not implement the provisions until the Department for Work and Pensions had finished its review of liability insurance and so on. However, the principles are very clear. Given that background, I turn to the specific points raised by the hon. Member for Epsom and Ewell. On sporting events, if negligence on the part of an organiser results in personal injury claims, those provisions will apply. 8 pm

On the setting of caps, that will be done by regulations, but our intention is that it will be in line with the current road traffic tariffs—that is, £452 for an out-patient charge and £556 for an in-patient daily rate fee, with a £33,000 cap.

Chris Grayling (Conservative, Epsom and Ewell)

Taking the Minister back to sporting events, one of the bodies that will be affected is the police. If she thinks back to the Hillsborough disaster, the police were ultimately held responsible for operational mistakes made on the ground. Financially speaking, the police face a potentially huge challenge in catering for such an eventuality, given that, tragically, mistakes are sometimes made.

Rosie Winterton (Labour, Doncaster Central)

That would follow on from the winning of personal injury claims; the same point was made about the national health service. We think that it is right that the provisions have to apply across the public bodies, not just in the private sector. If a personal injury claim is made and settled, it is only right that the appropriate body pays for the care.

MRSA would not be covered in the way that the hon. Gentleman suggests, because there would be a separate intervening cause that was not part of the original injury. Obviously, there are other mechanisms for redress in those circumstances.

On post-traumatic stress disorder, the scheme will apply only if a person has been able to sue someone for damages. Several of the cases that the hon. Gentleman raised would not concern a personal injury claim; that may well apply to the major sporting events that he talked about.

The distinction in the Bill does not mirror the Road Traffic (NHS Charges) Act 1999, which will be repealed when the Bill takes effect. It does not apply solely in relation to those provisions, which focus on injuries caused by the use of a motor vehicle on a road.

I shall be more than happy to write to hon. Members about any matters that I have been unable to cover. Having given those assurances and further explanations, I hope that hon. Members will feel able to support the Government amendments and reject those of the Opposition.

Amendment agreed to.

Amendments made: No. 236, in page 61, line 39, leave out 'in respect' and insert 'as a result'.

No. 237, in page 62, line 28, at end insert—

'(4A) "Injury" does not include any disease.

(4B) Nothing in subsection (4A) prevents this Part from applying to—

(a) treatment received as a result of any disease suffered by the injured person, or

(b) ambulance services provided as a result of any disease suffered by him,

if the disease in question is attributable to the injury suffered by the injured person (and accordingly that treatment is received or those services are provided as a result of the injury).'.

No. 252, in page 62, line 36, leave out from beginning to 'an' and insert 'other treatment provided by'.

No. 268, in page 62, line 44, leave out from 'section 16CA' to end of line 45 and insert

', 16CC, 28C, 28K or 28Q of the 1977 Act (primary medical and dental services), or'.

No. 269, in page 63, line 4, at end insert—

'( ) In relation to any time before sections (provision of primary medical services) and (general medical services contracts) come into force, the references in subsection (5)(d)(i) to sections 16CC and 28Q of the 1977 Act are to be taken as a reference to section 29 of that Act (arrangements for general medical services).'.—[Ms Rosie Winterton.]

Clause 144 — Information Contained in Certificates

Clause 148 — Appeal Against a Certificate or a Waiver Decision

Clause 151 — Provision of Information

Clause 156 — Power to Apply Part 3 to Treatment at Non-Health Service Hospitals

New Clause 23 — Replacement of the Welfare Food Schemes: Northern Ireland

Clause 184 — Commencement

Clause 187 — Extent

Schedule 13 — Repeals and Revocations

John Reid (Labour, Hamilton North and Bellshill)

As several speakers have said, there is never sufficient time to examine and debate a subject as important as this, but today's has been a long debate that is the culmination of previous long discussions.

Patrick McLoughlin (Conservative, West Derbyshire)

Will the Secretary of State give way?

John Reid (Labour, Hamilton North and Bellshill)

It looks as though the debate is going to be even longer.

Patrick McLoughlin (Conservative, West Derbyshire)

The Secretary of State said that there can never be sufficient time to deal with this subject, but the other place will not have a time restraint put on it. Does the right hon. Gentleman not find it rather odd that the elected House is timetabled, yet the unelected House can speak on the Bill for as long as it likes?

John Reid (Labour, Hamilton North and Bellshill)

Of course the other House is constrained by its own conventions. I do not know whether the hon. Gentleman was making a threat; I suspect that he was. If so, I remind him that this House—specifically the majority of this House who form the Government—has a mandate from the people of this country, especially when it comes to decentralising power and modernising the national health service.

Simon Burns (Conservative, West Chelmsford)

Not on foundation hospitals.

John Reid (Labour, Hamilton North and Bellshill)

Let me tell the hon. Gentleman that if the Labour Government have one mandate it is to defend and modernise the national health service. Since we have done that successfully for six decades, I do not see any reason why we should change now.

Liam Fox (Conservative, Woodspring)

Purely on a technicality, can the Secretary of State tell us which part of the Labour party manifesto mentioned foundation hospitals?

John Reid (Labour, Hamilton North and Bellshill)

The manifesto contains several references to the defence of the national health service, to putting patients first and to decentralising decision making. Once again, the hon. Gentleman is wrong. It has not been a particularly good week for foxes, and that has not changed tonight.

Howard Stoate (Labour, Dartford)

Does my right hon. Friend agree that the real issue surrounding the Bill is that people deserve a modern health service that is accountable to the people and gives them more flexibility, more control over local services and more choice? That is what this Government are trying to do. The Opposition are trying to get rid of the health service and privatise it, while we want to modernise it and bring it into the 21st century to provide the level of care that people deserve.

John Reid (Labour, Hamilton North and Bellshill)

Even though I am well used to the articulacy of my hon. Friends, I am sometimes astounded by just how articulate and on the mark their comments can be. I could not have put it better myself.

I begin by paying a courteous tribute to my predecessor, my right hon. Friend the Member for Darlington (Mr. Milburn) for all his work, and to my Ministers, especially the Minister of State, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), who has performed so admirably today. I say with total modesty that he has carried the weight of the Bill. He is a great asset to me, my team and the Government.

The Government have a proud record of investing in and developing the national health service. That is not only because politically it is a child of the movement, but because morally it has long been at the centre of our values that no one in this country should be deprived, through lack of finance or station in life. of health care when needed, free at the point of need. Such a national health service, through collective provision, is increasingly not only a moral but a circumstantial imperative. As our health becomes more predictable through advances in genetics—they may not become definitive for some considerable time but they must be taken into account—the NHS becomes more, not less relevant. That is especially true when the health service is compared with private health insurance. Any health insurance actuary who is doing his job will give the minimum coverage to those who need it most. Actuaries are paid to do that. [Interruption.]

Michael Lord (Deputy Speaker, Central Suffolk and North Ipswich)

Order. The Chair frowns on electronic devices in the Chamber. I wish hon. Members would ensure that they were turned off before they came into the Chamber.

John Reid (Labour, Hamilton North and Bellshill)

I was explaining why the NHS is so important to us and why we are intent on ensuring that it will be as effective and well supported in future as it has been in the past.

We introduced the Bill because the same strong belief in the values that drove the architects of the NHS endure to persuade me, the Government and, I hope, all other Labour Members to support the measure.

Simon Burns (Conservative, West Chelmsford)

Not all of them.

John Reid (Labour, Hamilton North and Bellshill)

The hon. Gentleman may point to differences in the Labour party, and I would be the last to deny them, but they are as nothing compared with the yawning chasm between all Labour Members and the hon. Gentleman over the real dividing line: our insistence that everyone in this country has health care when it is needed, free at the point of need. I shall refer to that later.

The Bill and the changes in it are intended to ensure that the NHS survives and thrives for future generations as it has done for the past six decades—three or four generations. We intend it to serve our children and grandchildren as it served our parents and grandparents: as a national health service free at the point of need, without regard to background or station in life.

Our challenge, the response to which is enshrined in the Bill, is to ensure that the same values that underpinned the NHS remain in a service that fulfils the rising expectations and ambitions of current and succeeding generations. The Labour party, which forms the Government, can claim to have been a central dynamo over the past century in ensuring that the influence as well as the affluence of working people in this country increased with each generation. We rejoice that one of the effects is that their expectations and ambitions increase with every generation. Our job is not only to provide a socially just system of Government and public service but to develop that system and service for each generation.

It is the job of those of us who believe in the NHS to ensure that people's desired choice and increased expectations can be fulfilled in the NHS. Otherwise, we will do the NHS a great disservice. As people in this country become better off, they will make choices, fulfil their ambitions and have their expectations met. They will do that because, as their expectations rise, increasing financial affluence allows them to make choices. It is our job to ensure that we develop a national health service in which expectations can be met rather than forcing those who wish to fulfil their ambitions to go outside the NHS.

Graham Allen (Labour, Nottingham North)

Will my right hon. Friend consider that a key factor in providing such a health service and such choices might be a period of stability, not least for him and his new, welcome Front-Bench team, thus allowing people a year or possibly two in which the many changes that have been introduced in recent years can bed in, and letting staff and patients use the NHS in the way he outlined?

John Reid (Labour, Hamilton North and Bellshill)

I have discussed the matter with my hon. Friend. We do not agree about everything but I take the sense of his point. However, I cannot say to any organisation—my party, Parliament or the services that serve the people of this country—that it can exist in a world that does not change. As one old philosopher said, the only constant is change. I cannot promise that the NHS will be isolated from the necessity to change. I take my hon. Friend's point that sudden lurches and changes in direction, pulling back and stopping and starting are most debilitating for a service that wants to use the increased capacity that we are providing to the best effect. I was therefore pleased to tell the NHS Confederation last week that, although in a sense the big challenge is that change occurs, the good news is that the direction of change will not shift. In partnership, we want to work out how we can increase the momentum of that change, but I take my hon. Friend's point that we do not want yet another road map, road sign and direction for everyone.

It is important to recognise that, whatever our differences over introducing change, they are minuscule compared with the big debate about the essential nature of the health care system that future generations will inherit. Not everyone wants us to succeed in the task of modernisation because not everyone shares the values on which the NHS is based. Those values are under attack from the Opposition who want to introduce finance into the relationship between doctor and patient. The Conservative party is capable of reducing the highest moral values to the cash nexus. It has a genius for that, despite the fact that we know from experience how that affects the human condition. For example, the United States has a health system that the Opposition greatly admire, and no less than 40 per cent. of all personal bankruptcies are attributable to people's inability to find the money to pay for their health care.

Liam Fox (Conservative, Woodspring)

I hope I can save the Secretary of State time by stopping him peddling the myth that Conservative Members are attracted by the American system. We have gone out of our way to say that we are not attracted by it. But we are very attracted by the social insurance systems of other European countries. Why do the Chancellor and the Secretary of State insist, Don Quixote-like, on chasing monsters that they have imagined?

John Reid (Labour, Hamilton North and Bellshill)

That is an interesting intervention. I believed that the hon. Gentleman was pledged to a system of patient passports, as he calls them—vouchers that are equal to approximately 60 per cent. of the cost of an NHS operation. That would be given to individuals at the same time as the Conservatives would cut—

Liam Fox (Conservative, Woodspring)

Finland. The Netherlands.

John Reid (Labour, Hamilton North and Bellshill)

The hon. Gentleman mentions Finland and the Netherlands. I like the British NHS. It has served us well. The idea of eager little Tory Front-Bench spokesmen scuttling around Finland doing a little fishing and trying to pick up an NHS that is better than ours is mind-boggling. However, the Opposition plough ahead with a plan that would mean that patients, including pensioners, have to pay up to £4,000 or £6,000 for a hip operation and £1,000 to £2,000 for a cataract operation. That is their PPP—poor pensioners paying for Tory health policy.

The rest of the debate is in Hansard.