Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Greaves

Monday 19th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, it is with a very heavy heart that I feel I must stand up and record that many of the voices outside, who are very scared about this Bill and what it means, are people who are of no particular political persuasion. Yet they are worried about the problem of lack of financial transparency, about the number of private healthcare companies incorporated in offshore jurisdictions—which they see may evade taxes of various types—and about the commissioning process. They are also concerned that the use of public money in the healthcare system will slowly be obscured like a great iceberg wrapped in fog. They will work to deliver whatever is needed for the patients in front of them. The vast majority of them stand to gain nothing by this Bill passing, but to gain nothing either if it does not pass. They want to improve the standards for their patients, and indeed they argue for change.

The noble Earl has worked tirelessly and has confidence across the whole House. Everybody, however much they have been concerned about this Bill, owes him an enormous debt of gratitude for the way that he has listened to every single one of us, at all times of the day and night, and weekends and so on. But we should not let this Bill pass without recognising the enormous concerns there are outside this House among those who will be delivering healthcare, now and into the future, in whatever form it takes.

[Lord Greaves]

My Lords, this has been an extraordinary parliamentary process. When this Bill was introduced, I said at Second Reading that it was a bad Bill. It was a bad Bill when it came here; there has been a growing tide of opposition to it and concern throughout the process while it was in the Commons and the Lords. There was the pause in the Commons and the Future Forum, which resulted in a large number of changes, and at that time Nick Clegg said that no Bill is better than a bad Bill. What we all individually have to do now—I speak very much for myself and not my party—is to assess whether it has now moved over from being a bad Bill to perhaps being, as Nick Clegg said last week, a much better Bill.

There is no doubt at all that on a spectrum of bad to good, it has shifted very considerably. It shifted in the Commons; it shifted far more here in the House of Lords. I believe that the process in your Lordships’ House has been the House of Lords at its best. This House can be proud of the work that it has done throughout the gruelling Committee stage, then during Report and again today. I regret that I could not take a detailed part in much of that, because I was then spending time as a patient of the NHS, but I have been watching it all and I believe that the work this House has done has been absolutely superb.

If I can make a party political point here for a moment, the work that our team has done on the Bill, led by my noble friend Lady Jolly with all my other noble friends who have taken part, has contributed well. I refer not only to the Liberal Democrats but to Cross Benchers and everybody around the House. Tribute has been paid to the Minister. I pay particular tribute as a Liberal Democrat to our person on the ministerial team, my noble friend Lady Northover, who from our point of view has played a very important part by being a link into the Government and getting many of the changes which have taken place.

It is about not just the changes to the Bill but the implementation—the work that starts after this Bill has been passed, as no doubt it will be today. A huge number of ministerial assurances have been made, which may or may not be put upon people’s bedroom walls as the noble Baroness, Lady Cumberlege, wants to do with hers. Nevertheless, this is a Bill which has had more outside scrutiny and involvement from people out there, as far as the House of Lords is concerned, than any other Bill I can remember in 12 years in your Lordships’ House. That will continue with the implementation, and it is absolutely crucial how the Government now implement this Bill. Will it be gung-ho privatisation, which is what people were very frightened of when the Bill was first introduced and many are still frightened about, or will it be implemented in a cautious and careful way to allow the health service to breathe and to cope with the changes? This will be absolutely crucial, and we will know the answer to that in a year or two’s time.

The noble Earl, Lord Howe, said that we have had debates of unparalleled length and scope, and that is true. However, as I have just said, the public interest and lobbying on this from outside has been unprecedented. One of the lessons that we all have to learn is that we—whether the House of Lords, members of the Government or our party—have not coped with that very well. I do not think that the Opposition coped with it terribly well either because, even this morning, I was getting e-mails telling me what the Bill did, some of which was absolutely untrue. They were still telling me that the Bill removes the duty on the Secretary of State to provide health services. We are still getting that, and the amount of education or information which goes out from debates within this Chamber to the outside world is pretty poor.

Several people have said, “We have been trying to follow this Bill. We have been trying to follow your Marshalled Lists, having discovered where to find them on the internet. We have been trying to follow the parliament channel, and we haven’t understood a word of it. It is interesting, but we can’t understand it”. I have to tell them that that applies to quite a lot of Members of your Lordships’ House while the Bill is going through.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Greaves

Wednesday 30th November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I certainly support the amendments tabled by the noble Baroness, Lady Williams, who has just spoken, and they go further than the amendments to which I have added my name. I would just draw the attention of the House to the conflicts of interest guidance from the General Medical Council, which makes it quite clear that doctors,

“must be honest in financial and commercial dealings with employers, insurers or other organisations or individuals”.

It goes on to say:

“If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest”.

I would also remind the House that the ultimate sanction is to be struck off, and that if you are struck off, you lose your livelihood. I have a concern that when it comes to the implementation, warnings may actually be issued rather than stronger sanctions taken against those who might breach such guidance, because this is guidance, and it is therefore subject to interpretation.

This whole group of amendments has really gone to the heart of the problem of conflicts of interest, both for the individual general practitioner, who would be on a clinical commissioning group, but also their families and all those others around. It may be friends of theirs, who they know really well, with whom they are inclined to place some commissioning contract, or enter into some arrangement. There is a really fine line between having a personal interest, and going to that person because professionally you think that they are the best person to do the job.

Of course, I will say as a doctor, we all know the doctors that we would like to be referred to, and we all know the people who we want to work with in our teams. That is human nature. It is a mixture of competence and attitude, but there is also something about having a shared set of values, and so on, because you tend to gravitate towards people who share the same set of values as yourself. The highest principles and values would of course fall, I would hope, outside of the conflicts of interest, but financial interest is a really difficult one.

While I would suggest that none of these amendments are absolutely perfect, this group of amendments illustrates the fact that we need to come back to this at Report with a definitive amendment that really crystallises the whole problem around conflict of interest in commissioning.

[Lord Greaves]

My Lords, I spoke on an earlier amendment this afternoon about issues that come round and round, and this one comes round across Bills. We had a great deal of quite difficult discussion on these matters in the Localism Bill—now the Localism Act—and achieved what we hoped will be a satisfactory compromise in the Bill.

It is all about standards in public life and the importance of all bodies that deal with public funds and public functions being part of the regime of standards in public life. I assume that clinical commissioning groups, while not part of local government, are certainly part of local governance, or they will be part of local governance as far as the health service is concerned. They will deal with a lot of authorities that have the standards of public life regime as part of their own practice. I wanted to go very quickly through the basic principles that need to be established in my view before this Bill is finished. First of all there have to be clear rules. In The Localism Act they are set out in Part 1, Chapter 7, across 11 pages and in parts of the schedules. There need to be set out on the face of the Bill so that everybody knows where we are.

There needs to be a code of conduct, whatever it is called, which is based on the Nolan principles. We came to the view in the Localism Bill, now the Act, that those principles needed to be set out again on the face of the Act: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. In my view they ought to be set out on the face of this Bill.

There needs to be a system which members of commissioning groups have to register appropriate interests and again in the Localism Act some of these were pecuniary interests, going back to the old wording which is now on the face of the new Act. There are interests other than pecuniary interests which also need to be registered even if they do not debar people from taking part in decisions. If we are going to be open about what interests people have, then they ought to be there on record. There needs to be a register of interests—there is no point in registering if there is not an open public register. Then there needs to be a system in which people taking decisions and taking part in decision-making meetings have to declare interests at the point of that decision, as in the system that we have in your Lordships’ House. As the noble Baroness said, it needs to involve close families and partners as well as the individuals concerned.

Then there is no point in having that unless you have a system of dealing with complaints. It needs to be very clear what the system is, how such complaints are investigated and what penalties there are for breaching the rules. There may be different penalties for different rules. Clearly breaching the system in relation to financial pecuniary interests is much more serious than breaching one for non-pecuniary interests.

The penalties need to be clear and understood and the system for judging on them needs to be clear. The whole system has to be in the public domain. The system itself has to be open and transparent and all the actions taken under the system, whether it is just registering an interest or dealing with a complaint and the results of that complaint, have to be open, transparent and in the public domain. It seems to me that those are the principles. The details will quite rightly differ according to different organisations and different contexts. I am not suggesting the details of the local government scheme, although the amendment of my noble friend Lady Williams picks up some of the wording from the Localism Act, I think. Clearly CCGs are different from local authorities, but they are not sufficiently different that the basic principles should not apply, or the basic rules and regulations about avoiding conflicts of interest and declaring those interests when they exist and enforcing those interests within the framework of a broad code of conduct. That in my view has to apply and I hope that when the Bill leaves this House, it will incorporate sufficient detail to give those assurances.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, there is an additional area which I think means that the provisions in this Bill have to be different from other previous legislation. We face a huge financial challenge across the whole of healthcare, with budgets squeezed in a way they have not been squeezed before. So the potential for conflict of interest will go up as very difficult decisions are made. One can envisage the situation where somebody on the governing body of a clinical commissioning group will have a relative with a certain condition—and I refer back to the example I used previously, motor neurone disease. Say that person needs end-of-life care, and say that is a clinical commissioning group that has decided that it is not commissioning it in its area. There would be a direct personal conflict of interest, because that person would obviously want that care for their relative, but they would need to stand back. With the financial stringencies, the proposed amendments become even more important. While they are probing amendments, I hope the Minister in responding will recognise the importance of this area and agree to come back to it—hopefully, with a Government amendment—at a later stage.

[Lord Greaves]

My Lords, in brief response to the noble Lord, Lord Warner, I am not suggesting in any way that the regime should be identical to the local government regime, but that the decision-making body in clinical commissioning groups will be the board. Under the new Section 14A, the board will include lay members and possibly other people. So merely relying upon professional standards and professional systems of discipline will not be sufficient.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Greaves

Monday 28th November 2011 Lords Chamber

[Lord Greaves]

My Lords, this has been a useful discussion. This clause takes a bit of reading but its meaning is quite clear and it was explained very carefully by the Minister and my noble friend Lady Williams. However, there is one point that I want to raise. I have an old fashioned, perhaps rather simple, view of legislation. When you read it, you should be able to understand what it means. The bit of this clause that is not good in this respect is new paragraph (b). New paragraph (a) very clearly says that the Secretary of State and these bodies cannot discriminate for ideological, dogmatic or general policy reasons in favour of either the public sector or the private sector. That is clearly there because of the concerns that the whole purpose of this legislation is to discriminate in favour of the private sector, as the Minister has explained very carefully.

However, new paragraph (b), which refers to what the Minister described as charities, voluntary organisations and social enterprises, refers to,

“some other aspect of their status”.

That is not clear and understandable legislation. I suggest that the Minister thinks seriously about coming back at a later stage and replacing those words with a clear explanation of what the Bill is referring to, which appears to be charities, voluntary organisations and social enterprises. If nobody else does so, I shall table an amendment on Report to replace the current wording with those words. However, I would prefer the Government to put into legislation words that ordinary people—or even the sort of extraordinary people who might want to read this legislation when it has been passed—can read and understand, rather than vague words such as,

“some other aspect of their status”.

[Baroness Finlay of Llandaff]

The Minister’s comments have been most helpful, so far as they have gone. Taking on board the comments made by the noble Lord, Lord Greaves, it will be helpful, when the Minister writes in response to this evening’s debate, to stipulate how the new arrangements will differ from what is currently available to commissioning by PCTs or by other groups. The voluntary sector works very well, by and large, with the current commissioning bodies and finds that it is viewed as good quality and value for money, by and large, though not all the time. The difference in the arrangements needs to be clarified in that letter so that people can really understand if there is a difference and where it is, and also to allay the fears which are quite widespread in the voluntary sector, as was stated so clearly by the noble Baroness, Lady Armstrong.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Greaves

Wednesday 16th November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.

When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.

[Lord Greaves]

I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase “public health” has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.

In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases “environmental health” and “environmental health officers” were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.

The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours’ time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.

As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.