NHS: Annual Report and Care Objectives

Baroness Barker Excerpts

Wednesday 4th July 2012 Lords Chamber

[Baroness Barker]

My Lords, I thank the Minister for introducing a highly innovative document. This is the first time that the NHS has ever been treated in this way, with a document of this kind brought to Parliament and put out to consultation. I am delighted that in such a milestone document mental health has not been forgotten and is included alongside physical health.

I wish to ask the Minister three quick questions, because this document is important and the process of consultation about it is important for the future of the NHS. First, in the section on commissioning, will the Minister tell us whether he believes that the document fully reflects the decision taken in this House during the passage of the Health and Social Care Act that commissioners should not be under any obligation to put services out to tender when there is a justifiable case not to do so in the best interests of patient care? I want to make sure that he believes, as I do, that that point needs to be stressed during this period of consultation.

Secondly, with reference to the Public Administration Committee report in 2011 about the need for government to have robust accountability and audit trails as services are increasingly delivered by other providers, will the noble Lord reassure the House what the processes will be, given all the work that was done by my noble friend Lady Williams of Crosby about the capacity of Parliament and the Secretary of State to have sufficient information to judge whether or not the aims and aspirations of the document have been met in practice? How will it be evaluated and what data will be made available to Parliament to make that judgment?

Finally, I welcome the part of the mandate about the NHS in its broader context, but does the Minister agree that the omission of any mention of housing is a serious one—in particular aids and adaptations, which are so important to prevention of ill health and for the reablement of people who have been in acute care?

[Earl Howe]

My Lords, I am grateful to my noble friend. On her first question about commissioning and the matter that we discussed during the passage of the Health and Social Care Act, she will remember that the cardinal principle of “any qualified provider” is that it is for commissioners to judge whether putting a service out to tender is in the best interests of patients. If there is no need to bring in competition, there is no obligation on a commissioner to do so. Why should they wish to? On the other hand, a service may be failing. The classic example that I always give is that of children’s wheelchair services. In some parts of the country it is appalling. There is every reason in the world for a community service like that to be put out to tender. Nobody argues with that, if it delivers a better service at the same or roughly equivalent price. So I can reassure her on that point.

On accountability and audit trails, the way in which the board will hold the service to account will be based on the commissioning outcomes framework very largely, but of course there will be very tight financial controls through the accounting officer of every CCG. Broadly speaking, the service will be held to account through the results achieved for patients, the quality of care and the outcomes. There will be metrics attached to those—the indicators that I referred to, which fall below the NHS outcomes framework, as it were.

My noble friend will notice in the mandate that we have quite consciously not articulated umpteen sets of targets or indicators for particular disease areas, such as cancer or coronary heart disease. Once we started to do that, we would produce a volume 500 pages long; nobody wants that—the clear message that we had was that the mandate should be brief, succinct and to the point. That is what we have produced in draft, and we would be very interested to hear what noble Lords think about that. I encourage all noble Lords to feed in their views as to whether we have got the balance right.

On housing aids, I do not think there is anything specifically in the mandate on that. On the other hand, one of the features of the integration of services will be for the health service to work much more closely with social care. We believe that the health and well-being boards will provide the best forum to do that. I hope that through mechanisms such as pooled budgets—and indeed the support that my department is already giving local authorities to bolster their social care budget—such housing aids can be maintained as we move into the future.

Dementia

Baroness Barker Excerpts

Thursday 28th June 2012 Lords Chamber

[Baroness Barker]

My Lords, I thank the noble Lord, Lord Touhig, for enabling us to hold this debate and for his eloquent and moving introduction. I confess that I am a veteran of pretty much every one of our debates in this House over the past 10 years. We have had dementia strategies and dementia plans, and I congratulate the previous Government on their work on those important documents, which have moved us forward. Dementia is something that affected my family until last December, when my mum died having, in her words, “kind of lost the place a little bit”. That was her euphemistic way of talking about dementia. It is a subject that for the past 20 years I have followed with a great deal of interest because, as noble Lords know, I work with older people.

I want to sound a somewhat more hopeful note than did the noble Lord, Lord Touhig, and I do so because two or three things have happened that give cause for optimism. Building on the work of people like the noble Baroness, Lady Greengross, and the all-party parliamentary group, as well as on important reports from Alzheimer’s bodies, the Prime Minister’s Challenge on Dementia and the updated dementia strategy are extremely good documents because they move us forward. Not only are they forward-looking, they are quite detailed. The strategy talks not just in broad terms about the need for more research and support, but it begins to draw down different areas in order to achieve a series of things which, over the next five years, will bring about real and actual change in both communities and the health service. They will be of benefit to people who have dementia and their carers.

The Prime Minister’s Challenge on Dementia is based on three things: raising awareness and understanding, early diagnosis and support, and enabling people to live well. There is a commitment to increase research funding to the unprecedented level of £66 million, some of which is to be spent in social care, which is extremely helpful. Some of the money will be spent on redesigning services in the health service, but some will also go to the Medical Research Council for further research into brain scanning. We are beginning to move away from broad strategies into more targeted and focused areas. I was pleased to see that resources are to be devoted to developing dementia-friendly communities. That is not jargon. People are starting to work towards a definition of what that is all about.

For more than 20 years I have followed the work of the Dementia Services Development Centre at Stirling University, both under its previous director and now under Professor June Andrews. It has contributed more than any other organisation to the understanding of dementia as an illness, to understanding the needs of carers, and to enabling academics and healthcare professionals to move forward. Recently, Professor Andrews gave a talk about design. She and her colleagues had been involved in a community pilot study in the Forth Valley. People from various disciplines worked for a year to see how, within their existing resources, they could manage things differently. I was pleased to see that not just the health service but organisations like the police, libraries, churches and the general public felt more confident in their ability to deal and interact with people who have dementia. We are getting close to the point where a diagnosis of dementia is not going to lead to older people and their carers automatically being cut off from the life they enjoyed previously and which, for many years to come, may still have some meaning for them.

Professor Andrews talked about the issue of design, and particularly design in people’s homes. I am very pleased that some of the people involved in the Prime Minister’s challenge are designers and private companies, looking at how they can respond in practical ways to the challenge of dementia. Professor Andrews also talked about the need to develop things like glass-fronted fridges so that people know that they have food. I look forward to the time when homes have glass-fronted freezers because I stopped counting the times that I had to throw away a freezer’s worth of food because my mum forgot about it and it went bad. Design, lighting and so on in people’s homes can make a tremendous difference to their ability to remember.

I want to focus on one particular area that has not been mentioned so far. Many older people with dementia also have other disabilities. If you are a carer supporting somebody and you try to find out about adaptations, they will be designed for a particular physical disability and not for someone who has a physical disability and also dementia. In this hopeful time, designers could look at the potential to design appliances for the home for people who have the multiple disabilities that most older people will develop.

One particular area we should focus on is telecommunications. It is great that there is enormous change going on in the world of telecommunications and that, for example, phones can now be used by people with hearing disabilities who could not use one before. Yet there is absolutely no point in having a phone that has wonderful functionality if you cannot learn to use it. Professor Andrews made an important point about the ability of people to design things in future that will have new functionality but will look like the objects that people with dementia remember—retro-designing things so that people can continue to use them.

I am also pleased that in the dementia challenge we are finally recognising that in future all health and social care professionals, whatever their discipline, will deal with people who have dementia. That will include dentists, pharmacists and others. We are now moving to a point where basic pre-qualification training for all health and social care professionals has to include dementia, whatever the area of specialism.

In the short time available, I will raise one more point. Last December, the Alzheimer’s Society produced a report, Short Changed, about the experiences of older people with dementia, and their carers, with banking and financial services. Older people with dementia are particularly vulnerable to financial abuse. We have known that for years. We knew it 15 years ago when the noble Baroness, Lady Greengross, set up Action on Elder Abuse. It is now more than five years since the passage of the Mental Capacity Act. At that time, the Office of Fair Trading and the British Bankers’ Association produced guidelines about tightening up procedures in relation to people who lack mental capacity, but we still have problems. Anybody who listens to “Money Box” will regularly hear reports of irresponsible lending to people with dementia.

I make one particular suggestion: will the Government, with the Office of Fair Trading and the British Bankers’ Association, now do some further work on banking services for people who lack capacity? Will that work draw a difference between people who have learning disabilities, people who have mental health problems which may be episodic and people who have dementia? All three have different issues but at the moment the banks treat them all the same. That is causing a problem, not least for carers of people who have dementia, who are worried and trying desperately to enable their relatives to keep control of their finances for as long as they can. They want a backstop for when the time comes when their loved ones can no longer manage.

Dementia is a terrible thing, and it is going to happen to more and more people as we live longer. It is going to become a part of life for more of us. I am not a Pollyanna, but having read the dementia strategy and the Prime Minister’s Challenge on Dementia, I think we now have reason to be much more hopeful than we have ever been that we will be able to see people living well with this terrible disease.

Care Homes

Baroness Barker Excerpts

Wednesday 27th June 2012 Lords Chamber

[Earl Howe]

The noble Baroness’s remarks will resonate with many noble Lords. We have been here before. One of the emerging issues from the review is around poor practice on the use of restraint, as she rightly mentioned. CQC inspectors found that only 73% of locations met requirements on physical intervention or restraint. There was ineffective monitoring of restraint data and learning from incidents. Staff were not always trained and restraint was not always delivered in line with the care plan. There are real lessons to be learnt by providers about the use of restraint. We have flagged this up as one of the actions that we will take in the department to work with the Department for Education, the Care Quality Commission and others to drive up standards and promote best practice in the use of positive behavioural support and ensure that physical restraint is only ever used as a last resort. The report published on Monday is an interim report and we will be publishing a final report later in the year.

[Baroness Barker]

My Lords, does the Minister agree that this report calls into question the role of local safeguarding adult bodies? What are they doing now while people are being mistreated in a way that the CQC has uncovered? Does the Minister think that it is time to revisit the legal bases of those organisations?

[Earl Howe]

My Lords, my noble friend is right to call that matter into question. My department will be working with the NHS Commissioning Board Authority to agree by January next year how best to embed quality of health principles in the system using NHS contracting and guidance. Those principles will set out the expectations of service users in relation to their experience. We are taking a range of other action—the 14 national actions to which I referred in my initial Answer—which I would suggest my noble friend looks at. We are clear that there is a need not just for providers but for everybody in the system to focus on their responsibilities and to work together to drive up standards in the way that we all wish to see.

Social Care: Legislation

Baroness Barker Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

The noble Baroness raises the key issue of transition, which will be covered in the forthcoming White Paper.

[Baroness Barker]

My Lords, the Government will be aware of the report, Reforming Social Care: Options for Funding, published by the Nuffield Foundation in May. What is their response to the proposal that some universal benefits that currently go to wealthy pensioners should be restricted to enable the implementation of the Dilnot report?

[Earl Howe]

My Lords, my noble friend raises an issue that has been very much in our sights as we have prepared the progress report on funding. I can only ask her to be patient a little longer until the report is published.

Health: Clinical Commissioning Groups

Baroness Barker Excerpts

Thursday 26th April 2012 Lords Chamber

[Earl Howe]

My Lords, the watchword in this context is transparency in that the governing body of a clinical commissioning group will usually meet in public. There will be provision for the health and well-being board of a local authority to challenge decisions made by the clinical commissioning group in its annual commissioning plans. In general, if anyone has a concern about a conflict of interest, or indeed a perceived one, it is open to them to refer the matter, first to the CCG and, secondly, to the NHS Commissioning Board itself.

[Baroness Barker]

My Lords, have the BMA and the royal colleges been involved in drawing up the guidance? And if a member of a CCG believes that there is no conflict of interest but a member of the public believes that there is, what mechanisms are available to resolve such a dispute?

[Earl Howe]

My Lords, we are involving all relevant stakeholders in drawing up the precise rules that we expect the NHS Commissioning Board to follow. As I mentioned in my initial Answer, part of that has resulted in guidance that has already been issued and the rest will follow shortly. As regards the second part of my noble friend’s question, the key is for CCGs to make arrangements to make sure that actual and potential conflicts of interest do not affect the integrity of the group’s decision-making process and do not appear to do so. Therefore, the CCG must not only be fair and open and honest, it must also be seen to be all those things, because a perceived conflict of interest which is not managed appropriately would be as damaging to the reputation of a CCG as an actual conflict.

Health and Social Care Bill

Baroness Barker Excerpts

Thursday 8th March 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, my noble friend has made a powerful case for having a champion for older people to look not just at the impact of decisions made in the NHS but going much wider. She is right to refer to pejorative remarks such as bed-blocking being very insensitive to old people. We face a considerable challenge within the health service to ensure that we are sensitive and reflect that there is huge demand from frail older people which is not being met as effectively as we would wish.

My noble friend said that the amendment may not be perfectly formed but that we have to start somewhere. I wonder whether the noble Earl, late on this Thursday afternoon, might give some comfort. After all, it would not be impossible within HealthWatch England to have a designated person with responsibility for overseeing—or, if you like, monitoring—services for older people. It could be well worth exploring whether the thought behind my noble friend's amendment is worth pursuing.

[Baroness Barker]

I just make two or three simple points. I have enormous sympathy with the amendment of the noble Baroness, Lady Bakewell. My party's policy is in favour of the establishment of an older people's commissioner in England, building on the interesting work that has been done in Wales. I have a great deal of sympathy with what she is trying to do. She made the argument that one has to start somewhere. I disagree with her that this is the right place to start. If one had to start somewhere, it should be in social care. The deficiencies in social care matter more to more older people than those in health.

Having said that, the noble Lord, Lord Hunt of Kings Heath, is right. Given that older people are by far the biggest users of NHS services, it would be remarkable if healthwatch were not to include people with the expertise to follow up older people's issues.

My deep resistance stems from two things. First, I think that the biggest challenge set out in the Bill, which has been overlooked, which is why I take the opportunity to mention it again, is the challenge for the NHS to get to grips with social care and enabling older people—all people, but, by definition, older people—to live healthier lives for longer and not to wait until they turn up in the NHS.

However, my fundamental point is that I have talked to lots of older people over the years and I believe that old age has to be about more than the health service. If the only government recognition that older people have is the right to have someone to complain about the health service, I think we will be in danger of medicalising old age and inadvertently removing the full experience, wealth creativity and knowledge that older people bring to many aspects of life. I know that, given her former role, the noble Baroness, Lady Bakewell, would not intend that. Therefore, I hope that she will accept my support for what she is trying to do and my reservations about the way that she is trying to do it with this amendment.

Health and Social Care Bill

Baroness Barker Excerpts

Tuesday 6th March 2012 Lords Chamber

[Baroness Murphy]

My Lords, I think that the noble Lord, Lord Warner, is having us on. There is an urgent need to press the Government on bringing forward their White Paper on social care reform, which is the pressing economic and social care issue of our day—more important than this Bill. But we have to get it right. We are expecting a White Paper, and there are many arguments to be had about the recommendations from the Dilnot commission, although there is quite a consensus of opinion, and about the right and wrong and who will pay and when. I hope that we can have those debates in this House. But this issue requires a full Bill. This amendment gives a new Bill inside the Health and Social Care Bill on Report, and I do not really think that it will fly. I can imagine what the noble Lord, Lord Warner, would have done if it had been proposed when he was Health Minister. He would have given it very short shrift—and I urge the Government to do so again. We need a proper recommendation and discussion in the White Paper.

I also remind the House that last year the Law Commission came out with a report on adult care social services that said that we had had endless piecemeal bits of legislation over and over—and this amendment does it all over again. Let us not make the mistake of supporting this amendment. I am very sympathetic to what the noble Lord wants to do, and we all feel very impatient about it, but let us have a proper Bill and proper debates and get it right for the next generation. Frankly, it is our generation and the next one that will benefit from a proper social care reform Bill. Let us get it right and not do it this way.

[Baroness Barker]

The noble Lord, Lord Warner, asked what was to disagree with—what was not to like—and the answer is nothing at all. However, that is not to say that this amendment is not deficient and there are not an awful lot of questions that it begs.

The noble Lord is right that my party, along with others, has agreed with the Law Commission review and supported the efforts to see the Dilnot commission brought into law. However, he will know as well as I do that the history of social care law reform is littered with failed attempts to deal with one of the biggest issues that our society faces—the Royal Commission on long-term care. The Wanless report was largely about the NHS, but a significant chunk of it was about the need to reform social care to drive down future demands on the health service. Noble Lords have been critical of this Bill, and many of their criticisms are justified, but they overstate the extent to which the latter parts of the Bill, with the placing of public health into local government and the creation of health and well-being boards, attempt to deal with that agenda, decrease health inequalities and raise levels of preventive health promotion. I, too, think that this is an inadequate response, particularly to the Law Commission report, which was a good and detailed piece of work. It deserves extensive scrutiny and to be brought forward in law in a way that is far more comprehensive than this.

I will not have a go at the noble Lord, Lord Warner, for keeping the issue on the agenda, but I say to him that the Care Services Minister, Paul Burstow, has made it clear throughout his tenure that he is doing all in his power to keep social care to the fore. I come back to the £2 billion that was invested in social care at the beginning of the Government’s term. The Government are mindful of the need to deal with this, not least because the noble Baroness, Lady Murphy, is right to say that, as she often reminds this House, no one has a social care need unless they have a healthcare need—the two things are indivisible—and if the Bill is about anything, it is about tackling the health needs of the population as a whole over time.

I do not disagree with the noble Lord, Lord Warner, but I do not think that this is quite the way to go forward. I hope that all Members of this House will continue to uphold the consensus that there has been over the past two years behind the work of the Law Commission and the Dilnot report to bring this issue forward in a way that means that it can be determined successfully once and for all.

[Lord Campbell of Alloway]

My Lords, I would like to raise the matter of the process of putting in statute what in the ordinary course of events should be put in subordinate legislation by regulations or whatever. If you read the amendment carefully, it is a very wide command involving four assessments of individuals’ needs. I am not at all criticising what is sought, but I ask for it to be considered that the amendment would open a large gateway of legal challenge to the Secretary of State that would not exist if this were not put into statute. This question is concerned with finance at a time when finance need not be referred to again.

--- Later in debate ---

[Lord Walton of Detchant]

My Lords, I will briefly speak to Amendment 167 in this group, which has been tabled in the name of the noble Lord, Lord Hunt of Kings Heath. I understand entirely why he has tabled this amendment but, with respect, I do not believe that it is necessary.

All medical bodies, including the BMA and the General Medical Council and others, now agree that the days of doctor’s orders are long past. The practice of medicine is a partnership in which it is up to the doctor to recommend to the patient what course of action is most appropriate in the patient’s best interests; what it is appropriate to do in order to reach a diagnosis; what tests are appropriate in order to achieve that diagnosis; and what course of treatment would then be necessary. However, it is up to the patient to decide whether or not to accept that advice and it is not possible for a doctor to carry out a test without the informed consent of the patient.

It is also well agreed by these medical bodies that if a doctor has given full and detailed information to a patient about the course of action that is appropriate, and if the doctor recommends a particular course of treatment that he regards as being necessary in the patient’s best interests, the patient may nevertheless have the right to refuse that advice even if refusal of that advice ends in the patient’s death. For that reason, as all of these issues have been dealt with repeatedly in the advice given by the GMC, the BMA and other bodies, I do not believe that this amendment is necessary.

[Baroness Barker]

My Lords, the noble Lord, Lord Walton, will be aware of many occasions in this house—when the noble Lord, Lord Hunt, was Minister and some of us were in opposition—when we listened to Lord Weatherill speaking on behalf of Christian Scientists, who often wish to refuse treatment. I understand that this amendment originated from the Christian Scientists, who merely wish to draw again to the attention of the medical authorities the fact that they have a belief system that deserves the same amount of dignity and respect as any other. Perhaps he might view the amendment in that light.

[Lord Hunt of Kings Heath]

My Lords, I do indeed recall the debates that we had during one of the many health and social care Bills that have gone through your Lordships’ House in the past few years. It was indeed Lord Weatherill who raised the issue with me. Essentially, it was about standards in nursing homes where there was some concern that an insensitive regulator would take action against a home that was actually respecting the wishes of a member of the Christian Science religion. We were able to reach a satisfactory solution. An appropriate amendment was put forward and I think the noble Earl, Lord Howe, was also part of what I like to think of as the “second Weatherill agreement”. We may need another one in a couple of years’ time—who knows? I ask the Government for an assurance that the position that we then agreed will continue under the new Bill.

Health and Social Care Bill

Baroness Barker Excerpts

Wednesday 29th February 2012 Lords Chamber

Moved by

[Baroness Barker]

79A: Clause 24, page 36, line 1, at end insert—
“14NA Registers of interests and management of conflicts of interest
(1) Each clinical commissioning group must maintain one or more registers of the interests of—
(a) the members of the group,(b) the members of its governing body,(c) the members of its committees or sub-committees or of committees or sub-committees of its governing body, and(d) its employees.(2) Each clinical commissioning group must publish the registers maintained under subsection (1) or make arrangements to ensure that members of the public have access to the registers on request.
(3) Each clinical commissioning group must make arrangements to ensure—
(a) that a person mentioned in subsection (1) declares any conflict or potential conflict of interest that the person has in relation to a decision to be made in the exercise of the commissioning functions of the group,(b) that any such declaration is made as soon as practicable after the person becomes aware of the conflict or potential conflict and, in any event, within 28 days, and(c) that any such declaration is included in the registers maintained under subsection (1).(4) Each clinical commissioning group must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the group’s decision-making processes.
(5) The Board must publish guidance for clinical commissioning groups on the discharge of their functions under this section.
(6) Each clinical commissioning group must have regard to guidance published under subsection (5).
(7) For the purposes of this section, the commissioning functions of a clinical commissioning group are the functions of the group in arranging for the provision of services as part of the health service.”

--- Later in debate ---

Moved by

[Baroness Barker]

82A: Schedule 2, page 281, leave out lines 32 to 34

--- Later in debate ---

Moved by

[Baroness Barker]

86A: Schedule 2, page 281, line 38, at end insert—
“( ) The constitution must specify the arrangements made by the clinical commissioning group for discharging its duties under section 14NA(1) to (4).”

Organ Transplantation

Baroness Barker Excerpts

Monday 27th February 2012 Lords Chamber

[Earl Howe]

The noble Lord makes a good point. It is generally the practice that the relatives are consulted even where someone has expressed a wish to donate an organ after death. Doctors will normally respect the wishes of the relatives; however, it is equally true that that person’s wishes will be emphasised to the relatives. There is a delicate balance to be struck here. The moment that action by medical teams is seen to be high-handed, it risks damaging the credibility of the transplant service.

[Baroness Barker]

My Lords, what is the Government’s response to the recent BMA report on increasing donation, particularly regarding the obligation introduced last year on individuals who apply or reapply for documents such as driving licences and passports to answer a question about donation of organs?

[Earl Howe]

My Lords, the report from the BMA was very useful and we are looking at it extremely carefully. It made some useful suggestions about how we might expand the number of donor organs. A number of initiatives have already been taken: for example, there is a prompt when you apply for a driving licence online as to whether you wish to donate an organ. In general, public awareness is being raised in a number of useful ways, which has led to the increase in the number of people donating organs.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, we return to one of the most important matters in the Bill: clinical commissioning groups and their effective corporate governance, or lack of it—specifically, the question of how conflicts of interest are to be dealt with. In his letter of 16 February to putative clinical commissioning groups, the Secretary of State spoke enthusiastically of the freedoms that they were to receive. There can be little doubt that they are one of the most important features of this Bill. They are to be given a huge amount of money. They are to be given freedom to commission services. They are to be given freedom to decide when and how competition should be used. Because clinical commissioning groups will exercise such important roles, I would have thought that public interest demands that the principles of good corporate governance should apply as much to them as to any other public body.

In Committee, the noble Lord, Lord Kakkar, drew attention to the seven principles of public life and asked whether they applied to clinical commissioning groups. I asked the noble Earl, Lord Howe, whether independently appointed non-executives would be on the board of clinical commissioning groups. I also asked how conflicts of interest were to be dealt with. He said that the Bill places a duty on the Secretary of State,

“to publish a code of conduct for CCGs, incorporating the Nolan principles on public life”.—[Official Report, 14/11/11; col. 564.]

To my suggestion that each clinical commissioning group board should have on it a majority of non-executives and be independently appointed, he said—disappointingly—that each group must only have at least two lay members and that one must be either the chair or deputy chair of the governing body.

On the conflicts of interest, the noble Earl said that the Bill had three safeguards: statutory requirements on clinical commissioning groups to make arrangements to manage conflicts of interest, governance arrangements, and specific regulations on good practice in the procurement and commissioning of healthcare services. Is that sufficient? I do not think that it is. These groups are unique. In essence they represent groupings of small businesses which have had handed over to them billions of pounds, a proportion of which they can spend on primary care services. Sometimes these are to be provided in the surgeries of GPs who are members of the clinical commissioning group, or perhaps are to be provided by companies in which GPs within a clinical commissioning group may have a financial interest. The potential conflict of interest is so obvious that it surely begs the question as to why the Government are not putting safeguards on this matter in the Bill.

My amendment is a lengthy one, but I hope comprehensive. It sets up a register of pecuniary and non-pecuniary interests. It places an obligation on clinical commissioning groups to register. It prevents any arrangements being entered into between a clinical commissioning group and a party with whom a member has an interest. It provides for an exemption procedure whereby the board could approve the arrangement if it was open and transparent. It prohibits a member of a clinical commissioning group taking part in discussions with any business in which he or she has an interest. It also provides a process under which an adjudicator appointed by the Secretary of State can adjudicate on complaints about members of clinical commissioning groups breaching the code of conduct, which is provided for in my proposed new subsection (8C). The sanctions include removing the individual as a member of the clinical commissioning group and the termination of any contract which has been put in place between the group and anyone with whom the member has a registerable interest.

A clinical commissioning group board will have a majority of GPs sitting on it. They are involved in running businesses which are largely dependent on the NHS for their income. The role of a clinical commissioning group will be to commission services, some of which will be commissioned from those GPs who are members of that group or, as I said earlier, from companies in which some of those GPs may well have an interest. Independent lay members will be in a minority and we have yet to receive assurance that they will be independently appointed. We have not even been assured that the chairman of the clinical commissioning group will be an independent lay member. It will have the weakest corporate governance of any public body in this country.

We know that over the past 20 or 30 years any number of inquiries have shown the problems of poor corporate governance. After all, the Nolan commission was started because of such problems. This will explode in the Government’s face unless they strengthen the corporate governance of clinical commissioning groups. If you combine these weak corporate governance arrangements with the ability of a clinical commissioning group to make decisions that could be to the financial advantage of GPs who are members of that group, you are heading for trouble. We need robust safeguards and they ought to be in the Bill. I beg to move.

[Baroness Barker]

My Lords, noble Lords will recall that in Committee I too highlighted the issue of conflicts of interest. I did so because, like many other noble Lords, I had listened to and read the briefings sent by the professional bodies, many of which raised fears and concerns about conflicts of interest. Like many other noble Lords, I believe it is important not only that members of the public have faith in the integrity of the decisions being made by CCGs but that members of the professions believe in those decision-making processes and feel able to participate in them. They should also have the protection of good governance and good conflict-of-interest policies to enable them to carry out what will be a difficult role.

Before we look at the detail of this, it is important to remind ourselves a little of the context. There are conflicts of interest in the National Health Service now. There always have been, as anyone who has ever sat around the table at a joint finance meeting at which every single person has an interest in the discussion will know. It may not be a direct financial interest; it could be about a post, a project or money. Managing conflicts of interest is something that the NHS and PCTs do now. That is not to say that we should not take the opportunity of the Bill to make the principles according to which the NHS should act more overt. They should be the highest of principles.

It is for that reason that my colleagues and I raised the matter in Committee. We then drafted a set of amendments that are in this group—Amendments 84, 89, 91, 92, 93 and 116. I am very grateful to several noble Lords, including the noble Lord, Lord Newton of Braintree, who looked at those amendments with the seasoned eye of an ex-Health Minister. His response was, “Very good but an awful lot of this needs to be in regulation, not in the Bill”. I took his comments to heart, which is why my colleagues and I withdrew those amendments on Friday and noble Lords now have Amendments 79A, 82A, 86A and 86B before them on the Marshalled List.

It is also important that noble Lords understand one particular point about the interpretation of the Bill. A great deal of anxiety has been expressed by some of the professional bodies about the role of commissioning support organisations. Noble Lords may recall that I raised that in Committee. I have been in discussion with several members of the professions to try to understand the source of that concern. As far as I can understand, there is a view within some of the professional bodies that commissioning support and the commissioning of services are one and the same thing, whereas the Minister was at great pains in Committee to stress that they are two different processes that go side by side.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Baroness. Could she clarify what happens in the situation that she has laid out in these amendments if a member of a CCG does not do the right thing? Are there any sanctions in her amendment?

[Baroness Barker]

The noble Lord is quite right and I will come on to that.

These amendments also refer to the board publishing guidance and what that guidance would include. As I understand it, members of CCGs who are in material or consistent breach of a conflict-of-interest policy might be referred to their professional body. Amendment 86A is a regulation-making power. It is under that power that many of the important details could be included. They would, I imagine, include issues such as the ones which the noble Lord has just raised about the sorts of sanctions which CCGs should include in their guidance and policy.

[Lord Hunt of Kings Heath]

My Lords, with respect to the noble Baroness, she has withdrawn some amendments and put in some substitutes, so I think it is fair to ask her these questions. Without sanctions, this is not going to have any teeth. There is a major concern about corporate governance in CCGs. Surely it would be better to put it on the face of the Bill rather than, as it seems to me she is doing, leaving it up to CCGs to do the necessary.

[Baroness Barker]

Not entirely, my Lords. As I was coming on to say, an important piece of work is that the GMC is updating its guidance on how its members should work in the new setup. It is important that members of bodies such as the GMC, the BMA and other professional bodies are involved, should they wish to be, in setting out the detail of what those sanctions should be. We should end up with something that is effective and workable, as well as principled. The noble Lord’s argument does not therefore stand up. Nothing in these amendments would preclude that sort of sanction being put into regulations or guidance.

Our amendments are, admittedly, not as detailed as the amendment of the noble Lord, Lord Hunt, nor do they—as his amendment does—incorporate language from the world of commercial legislation. The terminology of conflicted arrangements and exemption procedures comes from commercial law, and I am not sure that that is appropriate for what we are seeking to do. At the end of this debate we should achieve the objective that all noble Lords are seeking—transparency and accountability around the decision-making processes of CCGs, and the legislation and regulations around them should be sufficiently robust so that not only can members of the public have faith in those procedures but the procedures should be workable. I accept that our previous amendments included provisions that were so draconian that they would not work in practice. We could have ended up in a position whereby the very people who should be making decisions on CCGs would not have been eligible to do so, particularly at the precise moment at which their expertise would be necessary.

Our amendments are not by any means the end of the matter; they are the beginning of a process that should move on further in the discussion on regulations and guidance. That is where much of the detail of this should come to the fore, but the principles that we have set out in these amendments are robust and workable, and I hope that in his reply the Minister will accept them.

[Lord Patel]

My Lords, I support the amendments relating to conflict of interest and I agree that there needs to be something in the Bill. I will give an example to indicate why I believe that more strongly following a seminar that we attended before the Recess. For those noble Lords who were not there, we had a presentation from a GP who told us, first, that he was salaried, and I therefore presume he did not have a standard general medical services contract, and that his salary came from somewhere else—it may well have come from another general practitioner. He said, secondly, that he was involved in commissioning and, thirdly, that the commissioners had found that the provision of some services in his area was not satisfactory or of the quality that they had asked for—particularly, in relation to hand surgery. They therefore set up an independent provider of surgical services, of which the GP was a non-executive director. The conflicts of interest are quite obvious: here is a commissioner who is a salaried doctor, and that raises a question. If the commissioning board is to hold the contracts of primary care providers, will they not include those who have a general medical services contract, or will they include those who are salaried? More and more primary care providers are salaried GPs employed by other practitioners. We therefore also need to clarify who will be asked to be a member of the commissioning group: will it be only those who hold the general medical services contract, or will it be all those who provide primary care services? The conflict of interest here is many-fold, and therefore we need to address how it is to be resolved.

While I was, and still am, very attracted to the amendments of the noble Baroness, Lady Barker, because I had not seen those of the noble Lord, Lord Hunt, the question of sanctions needs to be addressed more clearly. I agree with the noble Lord, Lord Hunt, on the need for this question of sanctions to be clarified so that those who may be involved in conflict know from the very beginning how those sanctions will apply to them.