The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a timely debate. I thank the noble Baroness, Lady Wheeler, for calling it and all noble Lords who have spoken and contributed so eloquently. To pick up the baton handed to me by the noble Baroness, Lady Donaghy, who remarked what big plans my colleagues and I have in the Government's programme of modernisation of the NHS, the debate has indeed covered a great deal of ground. I will do my best to cover most of the key issues in my speech. To the extent that I do not, I will of course follow up those points in writing.
The noble Baroness, Lady Wheeler, asked why we needed to legislate at all. The Health and Social Care Bill seeks to create a stronger, more responsive and more innovative NHS—an NHS led by clinicians, with patients in control of their own care and with a resolute and unflinching focus on results. We must streamline the architecture of the health service to improve its efficiency.
My noble friend Lord Ribeiro directed us towards exactly the right starting point by referring to the core principles underpinning the Bill. Despite widespread support for these principles—and there has been such support—some thought that the detail of the Bill could be improved to better support those principles. So we took the unprecedented step of asking a group of independent health experts, the Future Forum, to recommend changes to the Bill. I would like once again to thank Professor Steve Field, the members of the NHS Future Forum, the hundreds of organisations and thousands of people who contributed to the listening exercise. We accepted all of the forum’s core recommendations and we have since made significant changes during the Bill’s Second Committee stage. I cannot accept the criticism of the noble Baroness, Lady Thornton, of the process. Stakeholders have in fact welcomed how the forum conducted itself—for example, Mike Farrar of the NHS Confederation and Hamish Meldrum of the BMA. I believe that the process has been hugely positive and has helped us to improve a number of our plans in different ways.
First, I would like to run briefly through some of the key changes that the Government are making. My noble friend Lord Ribeiro, as might have been expected of him, referred to clinical leadership. Some were concerned that too narrow a group of clinicians would be charged with designing services, so we have amended the Bill to place stronger duties on commissioners to ensure that all relevant health professionals are involved in the design and commissioning of services at every level—including clinical networks in relation to specific conditions and new clinical senates for broader areas. The governing bodies of clinical commissioning groups will need to appoint at least one registered nurse and one secondary care specialist.
The noble Lord, Lord Rea, questioned whether there would be public health input into the commissioning process. The Bill should require commissioning consortia or groups to obtain all relevant multiprofessional advice to inform their commissioning decisions, including public health but also other types of advice. The authorisation and annual assessment process should be used to assure this. We will make sure that a range of professionals plays an integral part in clinical commissioning of patient care and we have amended the Bill to place stronger duties on commissioners to obtain that advice.
We are committed to harnessing the benefits that competition and choice bring for patient care but let me make it clear, particularly to the noble Lords, Lord Rea and Lord Sawyer, that competition will never be about serving the interests of corporations. It will be about serving only the interests of patients and we have made changes to the Bill to reflect this. We have removed Monitor’s duty to promote competition as though it were an end in itself. Instead, it will be under a duty to support services integrated around the needs of patients and the continuous improvement of quality. The choice of “any qualified provider” will be limited to those areas where there is a national or local tariff, ensuring that competition is only ever based on quality, not price. That will also ensure that there can be no cherry picking. I will come back to that point in a moment. There will be and can be no privatisation of the NHS. In fact, it will be illegal for current or future Ministers, the NHS Commissioning Board or Monitor to favour the private sector over the public sector, or indeed vice versa. While some will undoubtedly disagree, what matters is the outcome of care provided and the end results for patients, not the nature of the provider—public, private or otherwise.
The noble Baroness, Lady Wheeler, suggested that we had not implemented the Future Forum’s recommendations on board meetings being held in public. It is not correct to say that we have not amended the Bill in regard to that, as we have made it a requirement for every clinical commissioning group to have a governing body with decision-making powers. To enhance transparency and accountability, governing bodies will be required to meet in public and publish their minutes, while clinical commissioning groups will have to publish details of contracts with health services. Openness and transparency will be the bedrock of a new, more patient-centred, outcome-focused and accountable NHS. We have amended the Bill in the way that I have described but, in addition, we have said that the governing bodies of commissioning groups must have at least two lay members: one to champion patient and public involvement, the other focused on overseeing key elements of governance such as audit, remuneration and managing conflicts of interest. Foundation trust governing boards will also need to meet in public.
The theme of integration loomed quite large in a number of noble Lords’ contributions. Excellent care often means integrated care. We have strengthened the NHS Commissioning Board’s duty to integrate services and introduced an equivalent duty for clinical commissioning groups. Health and well-being boards will be required to involve the public when identifying local needs and developing the joint health and well-being strategy. In future, I think there will be far more effective arrangements than exist currently for ensuring joined-up working across the NHS, public health and social care—a theme picked up by the noble Baroness, Lady Pitkeathley. We will have an NHS Commissioning Board setting common frameworks in which clinical commissioning groups commission services, a regulator to ensure that standards in care are met and greater transparency of outcomes, which will drive up efficiency and quality. I add that we have asked the NHS Future Forum to look at integration as part of its continued conversations with patients, service users and professionals. The forum will report back to Ministers later this year on what it has heard.
The pace of change has also caused concern for some people, so in a number of areas we have made the timetable for change more flexible. No one will be forced to take on new responsibilities before they are ready to do so. However, those who wish to progress more quickly will not be prevented from doing so.
Let me now turn to some of the specific concerns which have been raised during the debate. The noble Baroness, Lady Wheeler, and my noble friend Lady Jolly referred to the Secretary of State’s duties—concerns that were echoed by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Sawyer. At present, the Secretary of State has a duty to provide or secure services himself but delegates that responsibility to strategic health authorities or primary care trusts by directions. Generally, he delegates nearly all his commissioning responsibilities to SHAs or PCTs, but he has the powers to alter that and vary the extent of delegations. Under the new system, the function of arranging the provision of services—that is to say, commissioning—will be conferred directly on the board and clinical commissioning groups by Parliament, providing stability for the system and removing the Secretary of State’s ability to intervene arbitrarily in the day-to-day management of the commissioning process. That will free up those with the relevant expertise to focus on commissioning the best possible services for patients, free from political micromanagement.
Ministers are accountable for the NHS and will remain so. The Bill does not change the Secretary of State's overarching duty to promote a comprehensive health service, which has underpinned the NHS since it was founded. The Bill simply makes it clear that it should not be the responsibility of Ministers to provide or commission services directly. That should be the job of front-line organisations, free from interference. We are putting patients and professionals in the driving seat in order to create better quality care and better value for taxpayers.
The noble Lord, Lord Sawyer, said that there was not enough in the Bill to provide clarity. I understand why he makes that point. Every Bill that we scrutinise in this House needs to get the balance right between what is on its face and what is in regulations. We have republished our delegated powers memorandum, which sets out our justification for taking the delegated powers that the Bill proposes, and I hope that memorandum is well read and scrutinised.
The noble Baroness, Lady Wheeler, and others including the noble Lords, Lord Warner and Lord Sawyer, suggested that we were adding layers of bureaucracy. I think the noble Baroness said that the number of bodies would be increasing from 163 to 521, if I did not mishear her. I simply cannot accept that; it is not true that we are creating additional bureaucracy. The changes we made to the Bill as a result of the listening exercise do not create any extra statutory organisations at all and I do not recognise the figure that she cited. We remain absolutely committed to our promise to cut bureaucracy. We are removing layers of management by abolishing 151 PCTs, 10 strategic health authorities and half of the national health quangos. Administration costs across the health system will be cut by a third in real terms by 2014-15.
The noble Baroness, Lady Wheeler, spoke generally about the Future Forum recommendations, particularly about some that in her eyes the Government did not accept. We accept all the core recommendations of the Future Forum report but there are some areas that need further work before the final decision is taken. Those include further work on the feasibility of a citizens’ right to challenge poor quality services and lack of choice, and work to improve how continuing professional development is provided.
Some but not all of the forum’s core recommendations to the Bill require amendments to the Bill. For example, clinical networks and clinical senates will be hosted by the commissioning board, and will not need to be provided for by amendments to the Bill.
The noble Lord, Lord Warner, asked about phase 2 of the Future Forum’s activities. We announced in August that the forum will provide further independent advice on four themes: information, education and training, integrated care and public health. While the first phase of the forum’s work focused largely on the Bill, the second is focusing on non-legislative aspects of the reforms. It will report back to the Government later this year and publish its advice, as I indicated earlier, and we will draw on that advice as we work to implement the reforms across the piece.
My noble friend Lady Jolly took up the subject of education and training, which was also the theme of a number of other noble Lords’ contributions. It is vital that any changes to the funding of education and training have to be introduced in a careful phased way that does not create instability. We are therefore going to take our time to develop the proposals, working with our health and social care partners, and through further consultation. We will be publishing more details about that in the autumn and will bring forward an amendment in due course.
We think that individual employers with appropriate professional input and leadership are best placed to plan and develop their own workforce and assess what workforce and skills are needed on the front line to provide affordable, safe and high-quality care. Health Education England is being established to support healthcare providers and provide national oversight of workforce planning, education and training. It will be a lean and expert organisation and will provide leadership for effective workforce planning and the provision of high-quality education and training that supports innovation, value for money and better skills. We have also been working closely with strategic health authorities, which are managing the transition to the new system.
I turn to specific questions about the subject of competition, an issue raised by the noble Baronesses, Lady Wheeler and Lady Donaghy, and the noble Lord, Lord Rea, among others. “Promoting competition”, which was the original wording in the Bill, could have been interpreted in a number of ways. It could have been interpreted as proactively encouraging new providers of NHS-funded services to come forward or existing suppliers to compete for more services, irrespective of what was in the best interests of patients. Addressing anti-competitive behaviour is about preventing potential abuses by providers and commissioners to ensure that the system works in the best interests of patients. “Promoting competition” might also have been interpreted as requiring action where Monitor felt that there was insufficient competition in place, such as where there was a single dominant supplier of a particular service. The Bill now provides that Monitor should consider acting in such cases only if the provision of services is not economic, efficient or effective, or if a provider is abusing its market position to the detriment of patients.
A number of noble Lords were worried about cherry picking, especially the noble Lord, Lord Rea, and the noble Baroness, Lady Thornton. Those two noble Lords in particular were mistaken in their analysis of the position. We have consistently said that we would prevent private companies from cherry picking easy, profitable NHS services. We fully agree with the Future Forum’s call for additional safeguards against private providers being able to cherry pick profitable NHS business. We have made changes to the Bill to ensure that competition is about quality, not price; for example, there will now be a specific duty on Monitor to ensure that providers are paid in line with the complexity of the cases that they treat. Providers will have to set and apply transparent eligibility and selection criteria.
In her wide-ranging speech, the noble Baroness, Lady Wheeler, also covered the subject of the private patient income cap. Professor Field told the Commons committee in June that the Future Forum heard a wide range of views on that subject. He expressed the personal view that, because of the mixed views on this area, the forum could not make a strong recommendation as a body. In the eyes of many, the current cap is arbitrary and unfair. Foundation trusts tell us that the private income cap is unnecessary and restricts their ability to innovate and maximise income to deliver improved NHS services. We are confident that, as and when the cap is lifted, private income will benefit NHS patients. We are determined that that should be seen to happen. However, we will explore whether and how to amend the Bill to ensure that foundation trusts explain how their non-NHS income is benefiting NHS patients.
My noble friends Lady Jolly and Lord Ribeiro and the noble Lord, Lord Warner, spoke about reconfiguration. Although I have extensive notes on that important subject, I suspect that there is not time to cover it now. However, we will no doubt return to it, as we will to the many questions asked of me by the noble Baroness, Lady Pitkeathley.
I shall cover a couple of smaller issues. My noble friend Lady Jolly asked whether directors of public health would report directly to the chief executive of a local authority. We expect directors of public health to be of chief officer status and to report directly to the chief executives of local authorities. We are engaging with local government and public health stakeholders about how best to ensure that they have appropriate status.
Now that the Bill has passed to this House, I look forward to the debates that we will have in the weeks and months ahead. In preparation for those, my office will be in touch with interested Peers to arrange briefings with the Bill team and Library officials about any of the issues that we have been debating today and indeed any others that are troubling noble Lords. Those are likely to take place between Second Reading and Committee.
On the question of organigrams, I refer the noble Baroness to the original White Paper that we published, which contains a rather good one. We will also shortly be publishing a statement of accountabilities in the NHS, which will set out the roles and responsibilities of each organisation in the system.
Thanks to the excellent work of members of the Future Forum, the Bill has the potential to free clinicians to lead, to enable patients to take control and to focus the NHS on improving the quality of outcomes—principles that I hope we can all agree upon as we move forward to the next very interesting stage of the parliamentary process.