Health and Social Care Bill
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hennessy of Nympsfield
I shall speak also to Amendment 150, which is in my name on the Marshalled List. These amendments are a product of the conversations chaired by my noble friend Lord Laming, designed to bring the highest possible level of consensus to what the noble Earl, Lord Howe, calls the suite of clauses dealing with the accountability of the Secretary of State. I am very grateful to my noble friend for his sensitive chairmanship of the discussions and to the Minister for generously accepting the argument—that the special essence of the National Health Service as distilled in the NHS constitution be enshrined in the Bill.
With this new status, the NHS constitution will shine even more, both as a beacon for all involved in healthcare, whatever their place in the proposed new mixed economy of service provision, and as a statement of enduring values, which occupy such a central place in how we wish our services to be undertaken and how we conceive of ourselves as a people.
I shall not detain your Lordships long, as I am confident that these amendments, for all the friction and division that other clauses have generated, are ones that embrace the views of the vast majority of your Lordships as they do the country they serve. But I must also express my gratitude to the noble Lord, Lord Darzi, and his colleagues in the last Labour Government, for commissioning the wide consultation whose streams of thought fed into the NHS constitution when it first appeared in January 2009. It managed to contain the key principles in seven well worded paragraphs, which I shall not recite as your Lordships have the text to hand and will be familiar with its ingredients.
The Bill, when an Act, will take a great deal of bedding down, and it will take the second coming for the rifts between the political parties and the anxieties expressed by so many health professionals to be assuaged—and perhaps not even then. However, with the NHS constitution in its prominent place towards the top of the statute, we shall have a touchstone, not just for aspiration and inspiration but for behaviour and conduct, a shared talisman for the tougher moments when the implementation of this Bill throws up its inevitable problems and controversies. When we find a lustrous patch of consensus on the NHS’s road from 1948, as represented by the NHS constitution, we should cherish it through thick and thin, for we are never better as a country than when we concentrate on those things that unite us rather than divide us. I beg to move.
Baroness Thornton
My Lords, I am very pleased to put my name to this amendment and I congratulate the noble Lord, Lord Hennessy, on his tact and diplomacy in getting us to this point, and in getting agreement to have the constitution mentioned in the Bill, and in such a prominent part of it. In preparing a few supportive remarks, I had a look at the constitution because I was working for my noble friend Lord Darzi in a similar role to the one the noble Baroness, Lady Northover, has—as his support and his Whip—when we were working towards the constitution, and when it was discussed and adopted across government and Parliament.
The importance of having it in the Bill is there in various key parts of the constitution, which are worth mentioning on the record here because we need to remember them as we move forward to discuss this Bill in all its glory in the next five or six weeks, or however long it takes us. The constitution says:
“The NHS is founded on a common set of principles and values that bind together the communities and people it serves—patients and public—and the staff who work for it”.
It goes on to say that it,
“establishes the principles and values of the NHS in England. It sets out rights … and pledges which the NHS is committed to achieve”.
It says:
“All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this Constitution in their decisions and actions”.
That is a very important part of why this needs to be in the Bill.
The final part which I would like to draw to your Lordships’ attention is point 6 of the guiding principles in the constitution, which is a commitment,
“to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves”.
That is exactly right. It is not the shareholders of companies and not individuals who might seek to make a profit but the people whom the NHS serves, and the taxpayer.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am very grateful to the noble Lord, Lord Hennessy, for tabling these important amendments and for the eloquent way in which he introduced them. As he said, they seek to require the Secretary of State to have regard to the NHS constitution when exercising his functions in relation to the health service. I say to him in all sincerity that I very much welcome his contribution throughout this debate. I identify myself entirely with the enthusiastic remarks that he addressed towards the constitution itself, which is a most succinct and inspiring document, and I agree with him that we have reached a very workable and satisfactory outcome to the question that he originally posed to me and to the House.
I fully support these amendments. It is right that we continue our commitment to the principles set out in the NHS constitution. I hope that these amendments together provide noble Lords with reassurance of the Government’s continued commitment to the core principles and values to which the noble Lord and the noble Baroness have referred. I commend them to the House.
Baroness Thornton
My Lords, when we were having our negotiations on this part—on which I was very happy to take part, even if I was regarded on some issues more as grit in the oyster than as co-operative help—they were about these issues, including autonomy. I have not changed my view. I shall speak to Amendments 10, 36 and 52.
We have no problem with the concept of autonomy. In principle our position is that autonomy has to be earned, and that it should be able to be taken away as well. That formed the principle and the basis on which the foundation trusts were established. However, we part company with the Government on their view of autonomy, and we are not completely convinced by the point made by the noble Lord, Lord Marks of Henley-on-Thames. On first sight of the Bill it seemed that autonomy was to be presumed and that each part of the service would be subject to less interference from the other parts in a way which could be detrimental. There would therefore be less performance management, and giving various bodies more powers with less need to sign off an agreement could mean that there would be less co-operation. Bodies acting in their own interests via a market process will mean that the motivation could be something that does not have the NHS and patients at its heart, and that there is less planning and system management, which sometimes actually is required. That is how you deal with things like postcode lotteries. You have to collect the information, compare it between different parts of the country experiencing different levels of deprivation, and then you have to take decisions which are about planning how to use your resources to ensure that people are not disadvantaged. So there are some very good reasons why planning and systems need to be in place.
The original briefing on the Bill stated that CCGs would not have PCTs or SHAs above them to performance manage them and that the commissioning bodies were not meant to performance manage but only to step in if there was a danger of failure. Again, that was the original briefing. It is not surprising that when we first discussed this in Committee there was general agreement across the House that the Bill would be better off without Clause 4 and what was then Clause 10 but is now Clause 12.
Since then the Constitution Committee has done what I think is really rather a good job. Although I was not deliriously happy about it, I was prepared to live with the draft produced by the committee. However, I do have problems with the draft that the noble Lord, Lord Marks, and the Minister have brought to the House. The provisions are not strong enough and some of the dangers that we originally expressed about problems with the autonomy clauses still exist. Furthermore, I take very much to heart the questions that both of my noble friends have raised. From different points of view they have asked pertinent questions and shown up the problems with the autonomy clauses. That is why, certainly in the process of our negotiations on Clause 4, I reserved my position to come to the House and explore whether what we actually wanted to do was delete it completely at this stage. On Clause 12, for the sake of consistency we feel that it should also be deleted. However, I have to say that because of the amendments that were accepted in the process of our negotiations, we feel less strongly about it.
I am not any more convinced as a result of this debate that our original position is not the right one—that if we cannot have the Constitution Committee’s version of Clause 4, we should delete the whole clause. Obviously I will listen to the Minister’s summing up of the debate, but at the moment I remain convinced that our position is indeed the correct one.
Earl Howe
My Lords, the noble Baroness, Lady Thornton, has spoken to Amendments 10 and 52, which, as she has said, would remove altogether the autonomy duties on the Secretary of State and the board. The noble Lord, Lord Harris, asked me what the problem is that the Bill is trying to solve in this regard. The duty is intended to promote a culture of fostering local autonomy rather than to outlaw specific practices; but without a focus on autonomy, it is possible that the mandate from the Secretary of State to the board or the framework document from the board to CCGs could impose disproportionately burdensome requirements on the system. The Government believe that local operational autonomy is essential to enable the health service to improve the outcomes of care for patients, provided that autonomy is within the framework of clear ministerial accountability.
The noble Baroness will be aware, because I have said it before, that we are aiming to free those closest to services to take decisions that are right for patients, free from central micromanagement by either the Department of Health or the NHS Commissioning Board. The amended duties, with the caveat that the interests of the health service take priority, achieve the right balance between autonomy and accountability. Without the clause, a future Secretary of State could choose to ignore one of the fundamental principles of the Bill, which is that those closest to patients are best placed to take clinical decisions. Without the clause, a future Secretary of State would be free to use his extensive powers to micromanage the NHS. The autonomy duty is a necessary part of the Bill, placing a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances—
Earl Howe
I challenge the noble Lord to think of one Secretary of State, with the distinguished exception of my right honourable friend Mr Lansley, who has not succumbed to the temptation of micromanaging the NHS. No Secretary of State has been able to resist that temptation because, frankly, Parliament expects them to do it. That is what the system has expected of the Secretary of State. This is a burden on commissioners and clinicians, and, in the end, it does not well serve the interests of patients. It is all very well for the noble Lord to say, “Well, just stop”, but the system encourages it and the duties on the Secretary of State are there to encourage it.
Baroness Thornton
I cannot resist saying that the noble Earl’s right honourable friend Mr Lansley has dabbled and intervened on at least 12 occasions since the Bill started. He is on the record as saying on one of those occasions that certain managers should be sacked. Is the noble Earl saying that that will cease when this Bill is on the statute book?
Earl Howe
I am saying that the Secretary of State will not have the ability to micromanage the health service as he does at the moment. Whether the examples cited by the noble Baroness constitute micromanagement, if my right honourable friend is just expressing a view, I rather question.
The autonomy duty is a necessary part of the Bill because it places a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances in which they must be able to step in to protect the interests of health service patients. That is the balance that we are trying to strike.
The noble Baroness, Lady Finlay, asked whether the autonomy duty would allow a clinical commissioning group to justify not commissioning the full range of services. The autonomy duty does not apply to CCGs; it is a requirement on the board and the Secretary of State. If a CCG chooses not to commission services and the board considers that this is not consistent with the interests of the health service, the board can intervene to direct a CCG. If the board fails to intervene when necessary, the Secretary of State has power to intervene. Finally, the Secretary of State can set out services which CCGs must commission, and he can do that in the standing rules if he considers it necessary. The CCG’s key duty is to arrange services as it considers necessary to meet all reasonable requirements of the population that it is responsible for, and the amendments do not change that in the slightest.
Health: Children and Young People
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, accident and emergency services will be commissioned at a local level. I am afraid that I do not have in front of me detailed information on the split between adult and children's services in an emergency context. If I can get the information, I will be happy to write to my noble friend.
Baroness Thornton
My Lords, given that responsibility for commissioning for 0 to five year-olds will be at a national level, and commissioning for six to 19 year-olds will be the responsibility of local arrangements, as the noble Earl described, what are the risks for the continuing responsibility for safeguarding the health of the most vulnerable children in our society?
Earl Howe
My Lords, the two main outcomes frameworks relevant to this are the NHS and the public health outcomes frameworks, which we are trying to align as far as possible. They set a clear direction for the health and healthcare of children and young people, but there is more to do. As our data improve, we need to ensure that the outcomes measured are the ones that matter most to children and young people. That is why we are developing a health outcomes strategy for children. This will be the first example of an outcomes strategy as part of the health reforms model.
Tobacco
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Thornton
My Lords, it was as a direct result of the evidence of the underhand tactics of the tobacco industry that the UK very wisely adopted Article 5(3) of the Framework Convention on Tobacco Control. In 2008-09, the noble Earl’s noble friend Lady Northover successfully asked the then Secretary of State Alan Johnson to write to all his ministerial colleagues drawing attention to and outlining the importance of Article 5(3) and asking for their assurance that they were abiding by the article in their dealings with the tobacco industry. I invite the Minister to agree to ask his right honourable friend the Secretary of State to do the same with this Government.
Health: Stroke Care
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Thornton
My Lords, I congratulate my noble friend Lady Wheeler on being patient enough to allow this debate to take place tonight. I thank all noble Lords who have taken part in this debate.
When Andrew Lansley was appointed to the Cabinet by David Cameron in May 2010, we might have expected that the new Health Secretary would take the trouble to introduce himself to the leading players in his department. I have to say that this was not the case. Sir Roger Boyle, who had been toiling away as the Government’s national director for heart disease and stroke for more than a decade, did not actually meet the Secretary of State until just before he parted company with the department. As someone who judges the success of something by the action that is taken, not by the rhetoric, I think that that is decidedly unimpressive.
Sir Roger Boyle was appointed as national director for heart disease in March 2000. He led the implementation of the National Service Framework for Coronary Heart Disease, which led to a 50 per cent cut in deaths from heart attacks. That has been in the news very recently. He published the National Stroke Strategy in December 2007, and indeed was working on the implementation of that stroke strategy when he left the department last summer. My question to the Minister is this: I understand that Sir Roger Boyle has not been replaced. If he has not been, why not? Indeed, what does that say about the priorities of the department on the issue of stroke?
It is a pity that Mr Lansley did not make more of an effort to find out what Sir Roger was up to. He would have learnt some important lessons about the NHS and what it had achieved without the benefit of the market revolution that is being ushered in under the NHS reforms before the House.
The second question I would like to ask the Minister is what future, therefore, will the national stroke strategy have in a reformed NHS, and who will be responsible for its implementation under the proposed new system?
My third question picks up the points made by my noble friend Lady Wall. It concerns whether something as successful as the London stroke strategy could be replicated and how that would be achieved. I make no apology for repeating the question that I have been asking, on and off, at every opportunity over the last year or so, because I think that so far we have not received a satisfactory answer. The London stroke strategy was achieved through a London-wide strategic plan driven by clinical co-operation. I would like to know how, and in what timeframe, such a strategy would be possible under the new levels of decision-making bureaucracy and, some might even say, fragmentation that are being proposed by the new Bill.
Would there be a great risk that the clinical competition that allowed the London strategy to move forward, if it were to be an economic or financial competition, would have to be based on the failure of some centres, to allow others to emerge as winners? That is my understanding of how things would have to move forward. I hate to say this to my noble friend Lady Wall, but it seems at present to be less rather than more likely under the new regime.
I thank all noble Lords who have covered what seem to be all conceivable questions about the matter of stroke, and I look forward to the Minister’s reply.
Health and Social Care Bill
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Thornton
To ask Her Majesty’s Government what were the estimated costs of implementing the Health and Social Care Bill when it was originally introduced to the House of Commons one year ago, and whether they have changed.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in January 2011, we estimated the costs of implementing the Health and Social Care Bill at £1.4 billion. When we published the revised impact assessment in September, we estimated the costs of implementing the Bill to be between £1.2 billion and £1.3 billion. This will reduce administrative costs across the system by one-third by the end of this Parliament, saving £1.5 billion per year from 2014-15 onwards.
Baroness Thornton
My Lords, I thank the Minister for that Answer. Many people in the medical world believe that the cost is mounting and that the cost which the Minister cites is not accurate. It is safe to say that this upheaval is costly both in money and in the risk to patient care. As well as the cost, at a time when the NHS has to find £20 billion of efficiencies, today the nurses and midwives have asked for the Bill to be dropped, arguing that their concerns have not been answered. Can the Minister give the nation and the NHS a first birthday present by listening to what is said and advising his right honourable friends Mr Lansley and the Prime Minister that it is time to pull back—
Noble Lords
Baroness Thornton
I am asking a question; I am in the middle of asking it. You may not care about the NHS but, on these Benches, we do. When the medical professions and nurses say that the Government should think again, it would be wise for the Government to do so. My question is whether the noble Earl will ask his colleagues to do so, and whether we can then move together, with consensus, as my right honourable friend Andy Burnham has now twice asked the Secretary of State to do.
Earl Howe
My Lords, I understand that the noble Baroness is asking me to deliver a certain message to my right honourable friend. I am not quite sure what that message was, but if it is to do with the Health and Social Care Bill, I have to say that we need that Bill. We believe that reform of the NHS is essential if it is to be sustainable in the future. Every penny saved from this reform will be reinvested in front-line patient care. The previous Government had, as we do, an ambition to save £20 billion—the so-called Nicholson challenge—over the next three or four years. This reorganisation will enable us to contribute to that total. The modernisation will also move the NHS to a much more patient-centred system where good providers are rewarded for high-quality services. We are spending money on redundancy now to gain in the future.
NHS: Transition Risk Register
Baroness Thornton Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, this issue turns on a disagreement between ourselves and the Information Commissioner about where the balance of public interest lies. Our view is that the balance of public interest does not lie in disclosure, and his view is the opposite. It would be likely, if we gave the Information Commissioner a second opportunity to look at this, that he would come to the same conclusion as before, so we have to let due process occur.
Baroness Thornton
My Lords, the strategic health body in London was perfectly content to make the register of risks on the health Bill available, so the House needs to know, first, what the difference is—except in terms of size—in the national Department of Health making its risk register available. Secondly, I realise that in appealing the Information Commissioner’s decision the Government have said, in effect, that this decision has cross-government implications. Does the Minister accept that it also has wider implications for Parliament? In this House, our ability to scrutinise legislation effectively must be in doubt if any Government withhold important information from us, so what course of action does the Minister suggest that noble Lords in this House should take under these circumstances?
Earl Howe
My Lords, to answer the second part of the question first, a substantial number of the risks pertaining to the Bill are already in the public domain and we are considering whether there is scope to draw these sources of information together in a single place, so that noble Lords can look at them more easily. To answer the first part of the noble Baroness’s question, I made inquiries about NHS London. Its situation is very interesting and quite different from that of the Department of Health. NHS London developed its risk management strategy with a view to it being visible to stakeholders and the public, as its document says. It is therefore a reasonable assumption that officials will have worded their risks for inclusion in the register in the knowledge that that wording would be likely to form part of a document placed in the public domain, so there is a very real difference between the two situations.
Health: Pathfinders
Baroness Thornton Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My noble friend is right. We were very pleased to see the NHS Future Forum says that running right through the Health and Social Care Bill is the desire and aim to integrate services. That is certainly right. We recognise that there is a balance to be struck between allowing local ideas to spring up and people to progress their own ideas and having the necessary support from the centre to do that. We have established a national learning network for pathfinders to complement the support given to them by strategic health authorities and PCTs. Those learning networks will ensure that best practice is spread and, specifically, that pathfinders support other local groups which are less developed.
Baroness Thornton
My Lords, perhaps I may ask a question concerning clinical commissioning groups and the legal advice and support they might be receiving. Has the Minister taken advice on the impact of EU procurement law as regards the tension in commissioning and delivering integrated services and the legal requirements concerning procurement of services which are integral to the Health and Social Care Bill that is before the House? Will the Minister make any such advice available to us?
Earl Howe
My Lords, my understanding is that procurement law, which already applies in the NHS, is certainly part of the learning sets that clinical commissioning groups have been provided with. I would be delighted to supply the noble Baroness with further information but I do not have it in front of me.
Health: Breast Cancer
Baroness Thornton Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
I could not disagree more with the noble Lord. He refers to the policy of “any qualified provider”. That policy gives absolute assurance to every NHS patient about the quality of the treatment that they get if they are treated by the NHS, whatever the provider setting. Therefore, the idea that this incident has any bearing on the provisions of the Health and Social Care Bill is absolutely misplaced. I cannot emphasise that more.
Baroness Thornton
The noble Lord, Lord Low, asked a legitimate question. Any qualified provider goes through a process of approval in which the CQC is responsible for regulating clinics and services. That is exactly what the CQC has done for these private clinics. They have all been given a stamp of approval to carry out these operations by the CQC. That, surely, was the point of the noble Lord’s question. Therefore, what are the implications for “any qualified provider” under the fragmentation and increased marketisation of the NHS by the Bill?
Earl Howe
The “any qualified provider” policy was instigated by the Government of the noble Baroness. There is no suggestion that these clinics have been carrying out procedures badly; the issue is around the quality of the implant, which they could not be expected to know about. Nevertheless, the CQC is conducting inspections, some of them unannounced, on cosmetic clinics to assure itself that everything is being done properly. I will not stand here and say that any of these clinics have carried out the procedures badly. We have no evidence to show that they have.
Health and Social Care Bill
Baroness Thornton Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Thornton
My Lords, I return for the last time in 2011 to the issue of the risk register in the Health and Social Care Bill—a sort of Secret Santa for the Minister. During the course of the debate on the Motion to Regret on 7 December, several noble Lords referred to the start point of Report being timed so that the appeal on the Information Commissioner’s report would be complete and the House would know the result. The Minister himself—
Baroness Anelay of St Johns
My Lords, may I first ask Members to leave quietly so that we may hear from the noble Baroness, Lady Thornton. May we establish on what basis, on what Motion, the noble Baroness is making her point? She has not interrupted the House going into Committee. I believe that perhaps the most appropriate way forward would be for the first amendment to be called. The noble Baroness may then speak as part of her contribution to that amendment, but I believe she would be out of order to continue at this stage.
Clause 247 : Powers to publish information standards
Baroness Thornton
My Lords, I agree with the noble Baroness, Lady Williams. This question brings us right back to the Secretary of State’s powers. I also agree that the procedure in the Bill is complex and I am not sure that it will work. It is not clear at all who will be the arbiter. It seems strange that Monitor has powers to intervene on failure but there does not seem to be the same structure around co-operation and when co-operation fails. This part of the Bill feels like it does not work properly. It is too complex and probably needs another look.
Earl Howe
My Lords, I have listened with great interest to the points that have been made. I feel it would be useful if I first set out how this clause would work and the series of events that it would allow. Then I will try to explain why we believe that the powers it provides are an appropriate and constructive lever within the new system.
The method of intervention set out in Clause 285 needs to be considered as one of a range of intervention powers and levers available to the Secretary of State in order to ensure that the system operates in the best interests of patients and that he complies with his duties in relation to the health service. These include the proactive setting of objectives for the health service through the annual mandate to the board and setting requirements through the standing rules. The Secretary of State also will have a duty to keep the effectiveness of arm’s-length bodies under review.
In addition, the Secretary of State will have more extreme intervention powers such as the ability to remove the chair of an organisation, where they have failed adequately to perform their functions, and the ability, under specified circumstances, to give directions to an arm’s-length body where the Secretary of State considers it has failed to discharge those functions, or has failed to discharge them properly. Clause 285 should be viewed as an additional power alongside the others conferred on the Secretary of State by the NHS Act and this Bill. Of course, should the Secretary of State employ his powers as set out in Clause 285 and the problem persists, then where he considers that one of the bodies is failing to discharge its functions properly, he would be able to exercise his powers of direction.
The Bill places new duties to co-operate, in addition to modifying existing duties, so as to ensure that all of the arm’s-length bodies in the system, such as the Commissioning Board and Monitor, are required to co-operate with one another. We wanted to do more to encourage co-operation in the new system, partly out of recognition that the current system would benefit significantly from greater co-operation, but also because the new arrangements will create an even greater need for co-operation given the strongly autonomous and interdependent arm’s-length bodies that will be created.
The clause sets out powers for the Secretary of State to take action in response to a breach of the relevant duties of co-operation. It provides a mechanism for pressing organisations to resolve disputes in the unlikely event—we hope and trust that it will be unlikely—that two or more organisations covered by the clause fail to co-operate. If the Secretary of State believes that the duties of co-operation listed in this clause have been or are being breached, or are at significant risk of being breached, he will have a new ability to write formally and publicly to the organisation in question. If the bodies continue to breach the duty following the notice and the breach is having a detrimental effect on the performance of the health service, as the noble Baroness, Lady Finlay, pointed out, then the Secretary of State will have a further ability to lay an order, specifying that each body could take certain actions only with the approval of the other body. This measure would be subject to affirmative approval by both Houses of Parliament and could last for up to a year. That means that organisations in dispute would be strongly reminded of their interdependence as part of a national system. As a matter of last resort, if agreement could not be reached, either party would be able to invoke independent arbitration under Arbitration Act arrangements. In this way, the organisations in question will be pressed to resolve their difference without recourse to the Secretary of State and the Department of Health.
This is an important element of our policy. We want arm’s-length bodies to focus on the functions conferred on them by Parliament, the objectives set for them by Government and the relationships with other organisations that will help them to achieve their goals. We do not want them placed in a position where they are trying to secure relative advantage in the system by using the Secretary of State as a means of determining the outcome of disputes. The existence of the order-making power will both help to preserve the autonomy of organisations and encourage them to work constructively with one another.
I emphasise that this is a precautionary power and we expect it to be used only in very exceptional circumstances. It is also important to note that the powers and duties described in this clause are about co-operative behaviours. They do not in any way undermine the independence of Monitor or the CQC to make specific regulatory decisions in relation to another arm’s-length body. For example, the Secretary of State could not use the provisions to constrain Monitor from taking action against anticompetitive purchasing by the NHS Commissioning Board.
Baroness Thornton
My Lords, if these bodies are strongly autonomous, as the Minister has said, can they not just tell the Secretary of State to get lost?
Earl Howe
My Lords, that is the whole point of this clause. The Secretary of State must have levers at his disposal. Even if he does not use them, the fact that he has them will be a clear signal to bodies that they must co-operate in the way that Parliament—if the Bill is approved by Parliament—intends. As I said, we have identified gaps in the current system that need to be resolved because it is important that arm’s-length bodies that have functions directly conferred upon them take those functions seriously and do not resort constantly to arbitration by the Secretary of State or the department.
We expect that the vast majority of differences between organisations will be resolved by the organisations themselves and that this power will be used rarely, if at all. Nevertheless, it is important that the power exists. The fact that failure to co-operate could have public and highly embarrassing consequences will strengthen the incentive for organisations to co-operate effectively in the interests of patients.
We believe that this approach strikes the right balance between the need for the Secretary of State to fulfil his stewardship role within the system, being able to intervene to ensure that disputes are resolved, with the need to ensure that organisations are responsible and accountable for their own decisions and actions. These powers allow the Secretary of State to ensure that solutions to problems are found in a timely manner, without him or her stepping in to specify and micromanage what those solutions should look like.
The noble Baroness, Lady Finlay, asked me a number of specific and detailed questions. I will take up her invitation to write to her on those and copy other noble Lords in. With those assurances, I hope that she will feel able to allow the clause to stand part of the Bill.
Baroness Finlay of Llandaff
My Lords, I really am not trying to prevent Christmas starting for Members of this Committee. I feel as though most of today’s amendments have concerned me. These are probing amendments, which relate to NHS capital assets. They are designed to explore what happens to the current offices and clinical premises of an NHS body at the time of transition and afterwards. If these premises are occupied by a clinical commissioning group or a company that is advising a clinical commissioning group on its commissioning, who will become the owner of the property?
This is important because GPs are themselves independent contractors, not NHS employees. For many—not all but a significant number—the premises from which they work are owned by their practice. They, not the NHS, jointly own them, even though the building will usually have been subject to a range of capital improvement schemes from the NHS over many years. Such schemes allow a GP to purchase a practice and invest in it over the years. The capital gained then forms a significant additional pension pot for that GP.
My question for the Government concerns whether the deeds of the property will be transferred to the general practitioners of the clinical commissioning group. Will they be able to sell it for profit that would then be their personal profit? Will the profit revert to the NHS and, if so, to which pot? If property is transferred, will the new owner be liable to put capital gained into the capital part of the commissioning pot to develop service premises and equipment for the health service itself, rather than be able to take whatever capital gain there is on that property? I beg to move.
Baroness Thornton
My Lords, I just wish to add two questions of my own to the list that the noble Baroness asked. Has the Department of Health now resolved the issues around future asset ownership in respect of PCT and SHA estates? Within that, does that include LIFT schemes and PFI?
Earl Howe
My Lords, I hope I can answer the question of the noble Baroness very quickly. Clinical commissioning groups will be statutory bodies. They will be legally and operationally separate from GP practices. As such, if a clinical commissioning group occupies property that is under the ownership of that group, it will be under statutory ownership. It will not be open to GPs to sell such property at a cut price, or at any other price, to GP practices to enable such practices to pocket the profits. What the noble Baroness outlined sounded to me very much like embezzlement from the state. It will be no more possible for what she envisages to happen than for a primary care trust to sell a property and have its officers pocket the proceeds. I am a little mystified by the scenario that she has painted.
Health and Social Care Bill
Baroness Thornton Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Warner
Could I just clarify for the noble Baroness that I do not claim that my wording is perfect? I brought the National Commissioning Board in—slightly against my better judgment, I have to admit—because it has the responsibility for, in a sense, approving the commissioning arrangements and spending the money. My instincts were that it would not support this unless it had been consulted and was satisfied with the commissioning arrangements.
Baroness Thornton
My Lords, I will be very brief because my noble friend and other noble Lords have pretty much covered the territory here. This small group of amendments is rather important and significantly improves the Bill. I realise that they are probing amendments, but they do three things. The first amendment is about changing culture. It talks about the manner of the integration of services, not just an integrated manner. The second one says that we need to define integration. This must be perhaps the third or fourth debate that we have had on integration in the past however many weeks. It seems quite clear that there needs to be some definition of integration in the Bill. My noble friend Lord Warner explained that. Given that many parts of the Bill offer a list of different ways in which things can be described and done, I see no reason why the same list on integration cannot be included. The third point in the amendment to which I was pleased to be able to put my name is about encouraging co-operation across the piece. Having the national Commissioning Board mentioned in that is rather important.
Those three points about changing the culture, defining what you mean and encouraging co-operation seem to me to be the type of message that any health and well-being board will look to as it starts up its work. It will look to what is in the Bill, what is in guidance and what is in statutory instruments to help it to work out what to do. To have something that defines the kind of culture that is expected, defines integration and the way the bodies should work, lists the bodies that should work together, if not in the Bill then certainly in guidance, and explains the manner in which they are expected to work seems to me to be a very helpful way forward.
Earl Howe
My Lords, these amendments from the noble Lord, Lord Warner, are primarily concerned with strengthening the role of health and well-being boards in promoting integration between health and social care and wider aspects. I completely understand why noble Lords have felt moved to support these amendments. They are undoubtedly well intentioned, but I am afraid that I have a problem with them.
Amendment 336, which I will speak about more fully in a second, could be seen to enable changes to be made to the fundamental responsibility for functions, which we are clear would not be right. Amendments 332 and 335 would also introduce a prescriptive definition of integration. I resist that idea not just because it would be counter to the principles of localism, which we believe are very important, but because it could act as a diversion from effective integrated working between commissioners. I do not see the need for a definition beyond what the clause already says, which seems quite clear.
We have a shared intent on the importance of integration, but I cannot agree that this cause would be aided by pinning down a definition in primary legislation. I see no need for that. Apart from anything else, having a definition set in primary legislation would risk creating inflexibility as times and practices change. We should focus on removing barriers on the ground to ensure integration. That is where the Government’s response to the Future Forum’s work will, I hope, make a difference. We aim to publish our response to the Future Forum’s report before the Report stage of this Bill.
I am sure that Amendment 336 is intended to be helpful, but it might create confusion between the arrangements mentioned in the amendment and those made under Section 75 of the NHS Act, which would enable local authorities and CCGs to enter into partnership arrangements such as lead commissioning and pooled budgets. Existing provisions in the Bill are designed to encourage and enable the NHS and local government to improve patient outcomes through more effective co-ordinated working. The Bill provides the basis for better collaboration, partnership working and integration across local government and the NHS at all levels. I hope that that, in part at least, answers the question posed by the noble Lord, Lord Patel.
Indeed, health and well-being boards will have a strong role in promoting joined-up commissioning between health, public health and social care. Through their duty to promote integrated working between commissioners, they will also be in a good position to promote more integrated provision for patients, social care service users and carers. They will also be able to encourage close working between the commissioning of social care, public health and NHS services and aspects of the wider local authority agenda that also influence health and well-being, such as housing, education and the environment. Through statutory guidance on preparing the joint health and well-being strategy, and the Government’s mandate to the NHS Commissioning Board, we will be encouraging lead commissioning and integrated provision.
There are enough levers and mechanisms in the system to encourage every part of the system to look for ways of joining up services, and the commissioning of those services. I hope that I have reassured noble Lords of our intentions, and that the noble Lord feels able to withdraw his amendment.
Baroness Thornton
If a new health and well-being board got in touch with the Minister, or perhaps with the Commissioning Board, and asked whether it would please say which form of integration it should be using or how it should be doing this, would he tell it to work it out for itself?
Earl Howe
My Lords, we have to give credit to people on the ground to be the professionals that we know them to be. Integrated working can take many forms, as we have discussed quite often in Committee. I will not rehearse the various manifestations of integration. Once we have mandated the duties in the Bill and issued statutory guidance on what good practice looks like, I really think that it will be up to people on the ground to decide how best to set about fulfilling the duties and expectations placed on them.
Baroness Masham of Ilton
My Lords, I shall add a few words because a pharmacist contacted me. Pharmacists are being encouraged to take on more and more, and the drugs are extremely difficult. Some drugs are the same but have different names. It is extremely difficult for patients too, and as they often go to pharmacies for advice it is really very important there this is openness and honesty when a mistake is made. However, I would not like this amendment to open a door for more mistakes to be made.
Baroness Thornton
My Lords, I support the amendment. I would have put my name to it, had I had the opportunity. However, in Committee those on the Liberal Democrat Benches have tended to block up their own amendments and have not sought support from across the House, which is a great pity.
My experience in dealing with the many drugs that my mother takes is that in fact pharmacists are often those who spot the doctor’s mistake. Our local pharmacists do an excellent job. My wider interest in this Bill and in pharmacists is that they play the proper, important role they need to play at local level in the health and well-being boards and with the planning at a local level of both preventive medicine and their jobs at dispensing.
This is also about a level playing field in regulation, which is very important. This Bill offers probably the only opportunity that there will be in the next few years to put right this wrong. I hope, therefore, that the Minister will support this amendment—and if not this one, then one like it at a later stage in the Bill—and rectify this error.