Health and Social Care Bill Debate
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Earl Howe
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Health and Social Care Bill
Earl Howe Excerpts(12 years, 9 months ago)
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“( ) Until section 8 comes into force, the references in this Part to the National Health Service Commissioning Board (other than the reference in section 95(11)(b)) are to be read as references to the NHS Commissioning Board Authority.
( ) Until the day specified by Secretary of State for the purposes of section 14A of the National Health Service Act 2006, the references in this Part to a clinical commissioning group (other than the reference in section 95(11)(a)) are to be read as references to a Primary Care Trust.
( ) Until section 180 comes into force, the following provisions in this Part are to be read as if the words “and its Healthwatch England committee” were omitted—
(a) section 84(4)(c);(b) section 85(5)(a)(iii);(c) section 96(2)(e);(d) section 100(2)(e).”
Baroness Murphy
My Lords, it is evident that everyone around this House who has participated in the discussions on the Bill in effect wants the private patient and other private income to be of benefit to and contribute to institutions whose primary focus, not just their duty, is to public patients. That is what we have all been trying to achieve and it is a matter of finding the right words. Actually, I was going to say to the noble Baroness, Lady Finlay, that I quite liked her Amendment 220. The amendment might not have the right wording but it encapsulates exactly the principle that we are trying to get into the Bill. The amendment is admirable.
I do not have any problem at all with Amendment 218A, which is about accounts, because foundation trusts already produce very detailed accounts in order to indicate to Monitor how near or far they are from meeting their existing private patient cap, which is carefully monitored. Those sorts of accounts are already there. The only difficulty is that accounts, being made up by accountants, do not always reflect which service line is supporting another service line. Therefore, I am not quite sure that requiring this great detail will do quite what the opposition Benches hope. However, in principle, I see nothing wrong with the amendment.
It is worth while remembering all the time during these debates that we are talking about a situation where the vast majority of hospitals—apart from a handful of internationally renowned specialist hospitals in London and the suburbs and in one or two other cities outside—have a private patient income of about 2 per cent. That is not likely to change very much. However, we need to add something that is reassuring because we all understand the anxieties out there. Amendment 220BZB, in the name of the noble Earl, Lord Howe, is an excellent solution. The change to a 5 per cent limit during the year means that there will be no great energy thrown at changing this area, which is the most important thing. We want the board of the hospital and the governors to focus on public patients. If they have some other income coming in from private activity, that is fine, but we do not want them suddenly to throw a lot of energy at it. Therefore, I think that 5 per cent is about right. I know that some foundation trusts have asked for 10 per cent, but 5 per cent is fine.
Requiring hospitals to warn everyone in advance what they are going to do is also helpful. I seek reassurance from the Government that that will still protect the confidentiality of plans, because I know that trusts have expressed anxiety about that. However, I cannot see any problem with it.
The reason that I prefer the amendment of the noble Earl, Lord Howe, to Amendment 220C is because his amendment involves the governors. Crucially, they are the people responsible for the institution, whereas Amendment 220C involves the much wider membership—often 10,000, 12,000 or 20,000 members. That is just too unwieldy a group to be seriously involved in the governance of an organisation. They are vital people in getting local communities to be involved in and have knowledge about the hospital but they would not be the right people when it comes to these sorts of changes.
I support much of what the noble Lord, Lord Marks of Henley-on-Thames, has said, but I am attracted to the Government’s amendment, which solves the problem that we are all looking for a solution to.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been a good and constructive debate on NHS foundation trusts. It is right that we should focus on the removal of the private patient income cap, as I am acutely aware that that is where the majority of noble Lords’ concerns lie.
We need to focus on one core point at the outset. Fears have been expressed that removal of the cap could see foundation trusts increasing private income at the expense of NHS patients—in other words, that it could create a two-tier NHS, with those who can afford to pay going to the front of the queue. That is wrong and, I believe, alarmist. There are robust safeguards in place to prevent that kind of outcome.
Allowing a foundation trust to generate more private income does not release it from its prime duty to its NHS patients. Foundation trusts will still have to meet their legally binding contractual obligations on waiting times and provide the highest standards of care for NHS patients. Foundation trusts themselves are very clear about that. Removing the private patient income cap would allow them to bring extra investment in infrastructure and leading-edge technology to benefit NHS patients. Today, foundation trusts can be prevented by the cap from treating private patients who wish to be treated at the trust even when the income that the trust would earn would support its NHS services. The point made by the noble Baroness, Lady Finlay, was absolutely spot on. The cap leads to the ridiculous situation where NHS consultants are forced to get into their cars to drive to independent providers to perform private patient work in their non-contracted hours. Removing the cap would improve clinical safety for all patients in NHS hospitals, because doctors would be more likely to remain on site for longer.
It may well be, as the noble Baroness, Lady Murphy, pointed out, that most foundation trusts will not be affected at all by the removal of the cap. Many of them are earning below their caps at the moment. It is worth noting that NHS trusts, as distinct from NHS foundation trusts, which are not subject to a cap at all, are not earning proportionately more than corresponding foundation trusts. The point is that removing the cap gives the most innovative organisations the opportunity to boost income for NHS services.
I can also assure the House that we have put in place substantial safeguards to protect NHS patients. NHS foundation trusts will remain first and foremost NHS providers. Their principal legal purpose, to treat NHS patients, has been in legislation since 2003. I tabled an amendment in Committee to clarify its legal meaning. A foundation trust’s principal purpose requires it to earn the majority of its income from the NHS. That is very different from saying that 49 per cent of the work of foundation trusts will be with private patients, as some have misinterpreted it. The Bill does not mention 49 per cent, as I hope the noble Baroness is aware. Amendment 220A would remove the clause. That would be most unfortunate, because its effect would be to leave governors and local communities unclear that foundation trusts must remain predominately NHS providers.
There have been worries that the internal governance of foundation trusts will not be strong enough to exercise the requisite control in that area. I hope that I can provide reassurance on that point. As the local community's representatives, it is the responsibility of the governors to hold the board to account for its management of the trust. The governors should also consider whether the level of private activity is in the best interests of their organisation. The Bill will ensure that governors are better able to do that. It strengthens their arm by giving them new powers to hold directors to account and, if necessary, to remove the chair and non-executives of the board of directors. It would be entirely appropriate for the governors to use these powers if they felt that non-NHS activity was not operating in the interests of NHS patients.
At this stage, I should like to thank my noble friend Lord Clement-Jones for setting out a very persuasive case for adding to governors’ powers to oversee a foundation trust’s private income. I have tabled an amendment, which I hope will address his concerns, requiring directors to detail in the trust’s annual plan—that is, the forward look—any proposals to earn private income and the income that they expect to receive. By law, directors already have to take into account governors’ views in preparing this plan, but this amendment would place an explicit duty on governors to consider the plan and be satisfied that any proposals to increase private income would not significantly interfere with their foundation trust’s principal legal purpose to treat NHS patients.
With regard to the point raised by the noble Lord, Lord Campbell-Savours, a plan to increase private income substantially—that is, to increase by 5 percentage points or more the proportion of total income earned from non-NHS activity—must secure agreement by a majority of governors in a vote. For example, governors would be required to vote where a foundation trust planned an increase in non-NHS income from 2 per cent to 7 per cent or more of its total income, or from 3 per cent to 8 per cent or more. To make it quite clear, the vote would be triggered by plans for large increases in non-NHS income. Other matters, such as significant transactions, are for foundation trusts to decide. These proposals would complement the amendment that we introduced in Committee to require directors to explain in a foundation trust’s annual report how private income had benefited NHS patients.
Lord Campbell-Savours
We all know of cases where in the real world GPs have said to their patients, “Go private and go early. Effectively, jump the queue”. That is going on all over the country and in certain parts it is happening on a great scale. If that is the case, what is to stop GPs working with governors and consultants to try to move patient activity more towards the development of private operations within National Health Service facilities? Will the impetus not come from GPs working in conjunction with consultants and governors who might be sympathetic to the cause?
Earl Howe
With respect to the noble Lord, perhaps I may point to a later group of amendments in the name of my noble friend Lord Phillips, which gets to the heart of that question. I do not think that the noble Lord’s question is directly related to the private patient income cap but, if I may, I should like to cover the answer to it when we reach the later group.
Baroness Thornton
This goes back to the maths, which partly relates to the question that I asked the noble Earl earlier. I think that the Minister and his colleagues may need to look at what his proposals actually say about the proportion. His amendment refers to 5 per cent, and I am not sure that that is not a very tiny amount. I do not want it to be a particularly big amount but I am not sure that the Bill says what the noble Earl says it says. That is the clarification that I need.
Earl Howe
I shall gladly seek clarification and, if I have misled the noble Baroness, I apologise. By the time we reach the end of the debate, I shall have made doubly certain that what I said was correct. I hope that the approach that I have just laid out will allay noble Lords’ concerns, subject to any clarification that I am able to offer the noble Baroness. I am now told that I was absolutely right in what I said.
One thing that these arrangements may well do is nurture the working relationship between directors and governors. I think that they would help to ensure that directors worked collaboratively with their governors to develop non-NHS activity in the best interests of NHS patients. A planned increase of 5 percentage points or more in one year would be a very significant increase in non-NHS income for any foundation trust. Such an increase would certainly be due to a major development becoming operational, such as a new private patient facility. Requiring governors to vote on such a significant development strengthens directors' accountability to their local communities. However, I take the point made by the noble Baroness, Lady Murphy, about confidentiality. In all of this, we should be aware that the strengthening of the governors' oversight in this way places increased responsibility on the governors to maintain an appropriate level of confidentiality while a new project is initially developed. I would expect the directors and governors to ensure that a foundation trust's constitution would protect that.
Lord Avebury
I am sorry if I am a little late in raising this point. The Minister was talking about the burden that would be placed on the accounting system by having separate accounts for the private sector when it was a small proportion of the total. How will the person scrutinising these accounts know what the profitability of that private work is when that small amount of the total is not separately itemised in the accounts?
Earl Howe
We would certainly expect boards of directors to satisfy themselves on that point through management accounting systems and, if necessary, produce the relevant evidence to governors, if a question were asked about that. I think that the point that we were alive to was the cost involved in compelling all foundation trusts—some of them hardly have any private income at all—to go to the trouble of producing statutory accounts and separating out those two income streams. Although my noble friend’s question is well placed, it is perhaps a different question from the one that I was addressing.
We can allay all these anxieties in this area through one simple principle, and that is transparency. Today, I have tried to set out an open and transparent regime for the oversight of a foundation trust’s planned increase to non-NHS income. The governors, as representatives of local communities, would hold the directors to account for ensuring that non-NHS activity does not significantly interfere with their foundation trust’s principal legal purpose to provide NHS services. I think our proposals strike the right balance between the powers of the directors—
Earl Howe
My only frustration was that I was getting to what my noble friend wanted me to cover but she did not give me the chance to do it. Otherwise, I am more than happy to take questions from noble Lords on points of clarification.
I was explaining that governors, as representatives of local communities, will hold directors to account for ensuring that non-NHS activity does not significantly interfere with the foundation trust’s principal legal purpose, which is to provide NHS services. Our proposals strike the right balance between the powers of the directors and the responsibility of the governors.
The answer to my noble friend’s point, and that of my noble friend Lady Williams, is that Monitor will publish guidance for NHS providers on the requirements it sets for them to maintain the continuity of NHS services. We fully expect this guidance to cover conditions for foundation trusts relating to the need to ensure that the continued provision of NHS services is not put at risk by non-NHS activity. As the House will know, foundation trusts will be required to demonstrate how non-NHS income contributes to the foundation trust’s delivery of improved NHS services. In particular, if a foundation trust is increasing its non-NHS income by more than 5 per cent of its total income in a year, we will expect Monitor in every instance to review whether there is any cause to intervene in order to safeguard the ongoing provision of NHS services. This will be in addition to the required scrutiny and approval by the foundation trust’s governors. I hope that fully reassures my noble friends that this matter is not just a question that will be looked at within the confines of a foundation trust. It will have wider exposure than that.
I am afraid I am going to disappoint the noble Baroness, Lady Finlay, not as regards her amendment, which she did not speak to, but as regards Amendment 220C. The problem with it is that it would give Monitor the discretion to agree private income caps for foundation trusts. It would also retain the current cap and, as I have indicated, we think that the cap is unfair and has definitional complexities. That is an undesirable road to go down. It would burden foundation trusts with a governance regime that would be bureaucratic, costly and at odds with a foundation trust’s ability to manage itself.
Requiring governors to vote on any increase to their trust’s private patient cap, and therefore any increase to non-NHS income, would unreasonably inhibit the board of directors’ ability to manage its organisation. We surely do not want foundation trusts being run by boards that are constantly requiring votes by governors. The proposal in Amendment 220C would also require a majority vote by the members of a foundation trust for any increase to the trust’s private patient cap. That is a completely misguided approach. It would undermine the authority of the governors. Governors represent the members, the majority are elected by the members, and they should be allowed to get on and fulfil their responsibilities.
Securing a majority vote by members would also be very expensive. Many foundation trusts have several thousand members. Do we really want scarce NHS resources being spent on polling members about any increases to non-NHS income? I gently ask noble Lords opposite to think again about that.
Finally, Amendment 220C proposes that Monitor should be required to approve any increases to private patient caps beyond 5 per cent. My objection to that is that it would undermine foundation trusts’ autonomy to manage themselves. Directors and governors are better placed than Monitor to decide what is best for their organisation. Monitor’s involvement could also dissuade foundation trusts from pursuing innovative approaches if they are required to go through an external assessment and, in effect, a second approval process.
The central point is this: Part 4 has been built on the experience of what foundation trusts know will work. It represents the opportunity to realise what value foundation trusts can bring to the NHS. It will enable them to develop as responsive, transparent, autonomous and accountable bodies. Removal of the private patient income cap is about foundation trusts making the most of the opportunities they have to earn additional income for investment in the NHS. It is precisely why many NHS leaders and clinicians wrote an open letter to this House urging support to remove the cap. I hope that what I have said will reassure noble Lords that we have the right checks and balances in place while also giving foundation trusts the freedom that they need and have asked for. I also hope that the noble Baroness will feel able to withdraw her amendment.
Baroness Thornton
I thank the Minister for those remarks. I might be able to make him happy at least in one or two respects. This has been an interesting and useful debate, but I would like to start by making two comments. The first is about the remarks made by the noble Lord, Lord Marks. I know that he and his colleagues have been frustrated about the interpretation that has been put on the 49 per cent. The noble Lord spoke about that being there to mitigate risks. The only point that I would make to him and his colleagues is that the opportunity to mitigate those risks was there earlier this week, and they did not take it.
I would also like to apologise to colleagues on the Cross Benches if they have found the adversarial style in this part of the Bill unhelpful. On these Benches, it partly stems from our very grave disappointment that we have not managed on Report to protect the NHS in the way that we felt was necessary. I am afraid that those arguments are political arguments and the arguments that we have had to have. I put that on the record. I do not apologise for the fact that they have been political, but I apologise to my colleagues that sometimes they have not been entirely comfortable with that.
Lord Hunt of Kings Heath
My Lords, I refer to my chairmanship of a foundation trust. From the opposition Benches, we very much support this amendment and wish to reinforce the importance of education and training.
It is right that we should emphasise the importance of NHS foundation trusts recognising their responsibilities in relation to education and training. It is equally important that they have an influence over the architecture for education and training. As the noble Earl will know, there are going to be local boards responsible for commissioning the education and training of professional people. It is very important that the people who run hospitals should be very much involved in the selection of students and ensuring that the curriculum is effective. The noble Earl will know that the Future Forum paper chaired by the chief executive of University Hospitals Birmingham NHS Foundation Trust emphasised the importance of looking at these matters.
We will be debating the quality of nursing next week, but there is no doubt that there is a real problem with public perception of the quality of nursing in particular, and issues to do with nutrition and basic nursing skills. I am convinced that there is a real problem that the universities that train our nurses, in the end, are much more focused on academic practice, because that is what universities do. I am anxious that no one has been able to put their finger on the solution. One way of improving the quality is to involve the foundation trusts much more in these matters. My noble friend’s amendment is very helpful in that respect.
Earl Howe
My Lords, as noble Lords will know, we have had a number of earlier discussions about education and training and I welcome this new opportunity to return to the subject. As the noble Lord, Lord Turnberg, is aware, we are putting in place what we see as a strong national system for education and training, with a strengthened focus on quality outcomes.
In the Bill we have introduced a clear duty on the Secretary of State to ensure that such a system is in place. We are now making good progress in establishing Health Education England and the local education and training boards. We are acutely aware of the importance of a safe transition to the new system. We are proceeding with care and at a sensible pace to ensure that the new system is fully up and running by April 2013.
We have also introduced amendments to strengthen links with the wider system. Our Amendments 61 and 104, which were accepted in an earlier debate, place duties on the board and on clinical commissioning groups to have regard to the need to promote education and training. They are designed to ensure that commissioners of NHS services consider the planning, commissioning and delivery of education and training when carrying out their functions.
We also accepted an amendment tabled by the noble Lord, Lord Patel, to strengthen co-operation among providers of NHS-funded services, which would place a duty on commissioners to ensure that any person providing services as part of the health service would have to co-operate with the Secretary of State in the discharge of his education and training duty, or with any special health authority discharging that duty—that is, Health Education England. This aims to ensure that providers, too, play an active role in education and training.
The noble Lord, Lord Hunt, spoke with his customary authority on this subject and I agree with what he said. I particularly agree that employers best understand the workforce they employ and the kind of workforce they want to employ. They also understand the need to link service planning and workforce planning. They are able to focus on the whole workforce and to recognise the levels of contact with patients and service users, and the varying local needs. Evidence from other sectors and feedback from providers has been clear that in order to deliver successful and responsive world-class services, employers need to have clear ownership and involvement in the education and training and planning of their workforce. I am entirely at one with the noble Lord on that.
Employers have welcomed our plans for education and training. They believe that this approach should provide real opportunities so that healthcare providers have the right incentives to secure the skills that they wish to have, invest in training and innovate to improve the quality of services that they provide. They welcome the opportunity to have the incentives to align service, financial and workforce planning, and to have greater flexibility to respond to the strategic commissioning intentions of the NHS Commissioning Board and clinical commissioning groups.
The NHS Confederation, NHS Employers, Foundation Trust Network and the Association of UK University Hospitals all support a system that provides greater accountability for employers. Strategic health authorities are working with employers to support them in developing these local partnerships so that they can take full responsibility for workforce planning, education and training.
I hope that that is of reassurance to the noble Lord, Lord Turnberg. What is happening on the ground almost pre-empts the speech he so articulately made. We are rapidly moving towards the kind of system to which he and other noble Lords aspire. Having secured the amendments that are already in the Bill, we do not believe that it is necessary to build in any more. On the strength of what I have said, I hope that the noble Lord will feel comfortable in withdrawing his amendment.
Lord Turnberg
My Lords, I am well aware of the lengths to which the Government have gone to support education and training, for which I am truly grateful. I am also aware that earlier amendments might appear to have covered the points that I raised about the need for foundation trusts: there is a particular recommendation for them. I am a little disappointed that my amendment cannot be accepted but I understand the reasoning. The foundation trusts are key providers and, therefore, it should be clear to them that they have this responsibility. I know that they are willing providers of education and training but it should be in the Bill. However, I beg leave to withdraw the amendment.
“( ) for “The” substitute “An”,”
Earl Howe
My Lords, before I address the amendments in the name of my noble friend, I would like to come back to some of the comments made by the noble Baroness, Lady Finlay. She mentioned one of the most pernicious myths about the Bill. The paper that she quotes is not just factually inaccurate on a large scale but is also, frankly, scaremongering. As she herself knows, the Bill does not extend current arrangements for charging; indeed, the Government have committed to introducing no new charges for healthcare during this Parliament. I felt that I had to make that abundantly clear. I know that the noble Baroness realises that that is the case but it is important for the world out there to understand what the Bill does and does not do.
I agree completely with the sentiments behind the amendment that my noble friend has tabled. Patients’ access to essential clinical care and treatment should be on the basis of clinical need, not their ability to pay. That has been a fundamental principle of the NHS since its inception, and we fully support that. I understand that there is some concern that private healthcare by NHS providers might represent a better deal for patients in need of essential treatment. However, I hope that I can convince my noble friend and other noble Lords that there are already adequate safeguards in place, because that is what I firmly believe.
First, I shall cover the issue from the perspective of clinicians—I shall move on to hospital management in a moment. Ethically and professionally, clinicians are required to treat all their patients to the same standard and should not discriminate in any way. It would be wrong to suggest that the vast majority who provide an excellent standard of care would not do so, and I am sure that my noble friend would never suggest that. The General Medical Council’s Good Medical Practice states that the overriding duties for doctors include making the care of patients a doctor’s first concern and never discriminating unfairly against patients or colleagues. The Government also have in place a robust system of regulation on the quality of services. The Bill strengthens that system and makes it more accountable.
Secondly, Good Medical Practice ensures equality of access. It requires all doctors to treat their patients on the basis of clinical priority and to the same standard. Therefore, if a doctor did not treat a patient on the basis of clinical priority or was treating a private patient to a better clinical service, they could be in breach of the principles set out by the GMC and could be putting their registration at risk. In addition, the terms and conditions of service in NHS consultants’ contracts make it clear they are responsible for ensuring that their private work,
“does not result in detriment of NHS patients or services”.
That principle was reiterated in the department’s guidance on NHS patients who wish to pay for additional private care alongside their NHS treatment, which was published by the previous Government following a review by Professor Sir Mike Richards in 2008. The guidance makes it very clear that patients who choose to pay for additional private treatment,
“should not be put at any advantage or disadvantage in relation to the NHS care they receive. They are entitled to NHS services on exactly the same basis of clinical need as any other patient”.
The NHS consultant contract also binds them into adhering to the principles set out in a code of conduct for private practice. These are recommended standards of practice for NHS consultants published by the department. This says that,
“the provision of services for private patients should not prejudice the interests of NHS patients or disrupt NHS services”,
and that,
“with the exception of emergency care, agreed NHS commitments should take precedence over private work”.
It is important to note the point about NHS commitments taking precedence over private work. I strongly believe that professional regulation through the General Medical Council combined with guidance from the Department of Health is the best way to ensure equality of access for patients. It allows regulators to respond to changing circumstances and practice without departing form the central principle involved.
Putting the amendment into statute would risk endless arguments about what is and is not essential care and treatment. Perversely, it could prevent a foundation trust giving preferential treatment to its NHS patients because of the amendment’s reference to equality. The primary purpose of a foundation trust is to provide NHS services. A foundation trust may want to prioritise NHS patients where there is equal clinical need. The amendment might well prevent that; at the very least, it would create legal ambiguity and confusion.
Some noble Lords have voiced concerns that a foundation trust might pressurise its consultants into prioritising private healthcare ahead of its NHS patients. There are safeguards to prevent that as well. First, foundation trusts have a public service ethos; they are governed by the public and by NHS staff. They have a principal legal purpose to treat NHS patients. Secondly, the NHS Commissioning Board and clinical commissioning groups would be responsible for ensuring that NHS patients continued to be offered prompt and high-quality care. With regard to managers, my noble friend will wish to know that we have already commissioned the Council for Healthcare Regulatory Excellence to produce standards of conduct and competence for senior NHS leaders, and these are currently the subject of public consultation.
I remind noble Lords of the points that we debated earlier. If there appeared to be a trend or a significant increase in the level of a trust’s private income, not only would that be picked up by the governors but it would be seen by Monitor, which will have extensive powers to direct foundation trusts through the licence. Foundation trusts will also be required to explain in their annual reports what the impact will be of their non-NHS income on NHS services. One might say that there is going to be no hiding place in this regard.
The noble Lord, Lord Campbell-Savours, asked earlier about GPs channelling patients to NHS private patient units. GPs’ responsibility is to ensure the best care for their patients. They would have nothing to gain from trying to collude with foundation trust managers and commissions to increase a foundation trust’s private income. More to the point, they would risk being reported to the GMC for not serving their patients’ interests. If the noble Lord’s point is that clinical commissioning groups may try to do this, then it would clearly be unethical and would give grounds for the commissioning board to intervene. I hope that that provides the noble Lord with reassurance on that point.
I make a further point to my noble friend around any possible incentive that trust management might have to channel patients into a private wing, a concern raised by the noble Lord, Lord Kakkar. The Bill will establish a transparent and legally enforceable pricing system that will reward foundation trusts for treating NHS patients. In other words, money will genuinely follow the patient, and foundation trusts will be paid a fair price for treating complex cases. The current system has not always achieved these simple aims. An independent report into the current system published last month makes this clear; I have placed a copy of that report in the Library of the House for noble Lords who are interested. As the report makes clear, although foundation trusts should have been paid for every NHS patient treated, this has not always been happening. There have been unacceptable levels of cross-subsidy that have meant that the prices payable for complex cases have sometimes been woefully inadequate. One important facet of the reassurance that I can give my noble friend is that the pricing system proposed under the Bill will address those problems and ensure that foundation trust managers have the right incentives and rewards for prioritising NHS patients.
For some—although not, I think, for my noble friend—the amendment has been prompted by fears around the consequences of the private patient income cap for foundation trusts being removed; again, the noble Lord, Lord Campbell-Savours, voiced that fear. I suggest to him that those fears are misplaced. It is not, to my mind, a valid argument to suggest that removing the cap, a restriction that does not apply to NHS trusts, would lead to foundation trusts ignoring NHS patients as their prime concern and responsibility. Foundation trusts are the only NHS organisations which have never been subject to a cap on the amount of private income that they can earn. However, some foundation trusts can and do earn high levels of private patient income. There are also some NHS trusts which earn private incomes well in excess of many foundation trusts. There is no evidence that these NHS providers have ignored NHS patients as their main responsibility. The NHS constitution guarantees fair access to NHS treatment. The Government are putting in place a quality improvement framework that will improve outcomes for patients. Therefore, there is no scope for NHS patients to be harmed by private provision. Indeed, I say again that the extra income that the NHS would earn through the lifting of the private patient income cap would help to provide better quality care for all in the future.
I hope that my noble friend will accept that he and I are on the same page—on the same side—on this question. The difference between us lies in how to tackle it. As the noble Lord, Lord Warner, was right to remind us, privately funded and NHS healthcare have always co-existed in NHS hospitals. Governments of all parties have preferred to use professional regulation rather than statute to ensure equality of treatment. I am sure that that is right. It is unnecessary and, I think, a mistake to use primary legislation to establish the same principles. Of course, over the length of time for which the NHS has been in existence, professional regulation has, on the whole, been an effective safeguard of equality of access. On that basis, I hope that my noble friend will feel genuinely reassured and able to withdraw his amendment.
Baroness Finlay of Llandaff
Before the Minister sits down, I seek clarification. It is extremely reassuring to hear about the code of conduct that will be coming through for managers. I seek reassurance that the code of conduct will cover managers at every level. While there is clarity over consultants, consultants’ contracts and the GMC guidance which we have discussed at length, there are many others in the healthcare team who are not managerially answerable to the consultants. They are managerially answerable in other streams. There needs to be consistency across all those aspects of management. That includes other professional managers such as nurse managers, allied healthcare professional managers and so on, not just those who are caught, perhaps, by the council guidance because they are managers coming from a non-healthcare background. We were seeking that consistency of conduct with the amendment. I hope that the Minister can give me reassurance.
Lord Phillips of Sudbury
My Lords, I first thank the seven Peers who added their voices to the amendment. I thank my noble friend the Minister for an extremely thoughtful and comprehensive reply. None the less, it would be dishonest of me to say that he convinced me on all counts. It is perhaps asking too much on such a complicated business to have full satisfaction.
The one thing that I am bound to say is that the Minister’s interpretation of these various provisions in the various codes is different from mine. I am a lawyer extremely long in the tooth and I do not think that the provisions that he quoted, although they look helpful on the face of it, actually work in practice. That is evidenced by the total absence of any disciplinary measures—ever, as far as I can see—against doctors acting improperly in relation to queue-jumping. However, that is in the past.
I must quickly answer questions raised of me by the noble Baroness, Lady Murphy, and the noble Lords, Lord Warner and Lord Ribeiro. The noble Lord, Lord Ribeiro, is the easiest to answer: the amendment does not cover the existing NHS trusts, only the NHS foundation trusts. However, I think that the NHS trusts are going to be out of existence in a couple of years’ time. I saved the House by not including that; I would have had it at Third Reading if necessary. As to the noble Lord, Lord Warner, he can go to his private knacker any day, any place, any time and pay what he likes. To the noble Baroness, Lady Murphy, the answer is that, if you are having private treatment within an NHS hospital, the amendment would prevail, had it passed; namely, you could not then barge the queue because you were a private patient in respect of essential clinical care. It really is as simple as that.
I do not get the sense from the House that noble Lords want a Division on this matter. I do get the sense that they are impressed by what the Minister said, particularly in relation to the management code. That could make a very big difference. The only thing that I ask my noble friend the Minister—if he is with me—is that he just keeps an eye on the issue at the heart of this amendment and the debate, and, in the new regime that we are ushering in, on the concerns behind this amendment, shared by many in the country.
Earl Howe
Before my noble friend withdraws the amendment, I give him that reassurance. The NHS constitution will be monitored at every level in the system, from the Secretary of State downwards, as will the provisions within relating to access to healthcare for NHS patients. Of course, if there is any sign that that pledge in the constitution is being jeopardised in any way, appropriate action will of course be taken.
I am told that I should clarify what I said in answer to the noble Baroness, Lady Finlay, about to whom manager training will apply. It will apply to “leaders across the NHS”—it says here. It will primarily be aimed at very senior managers with a cascade of good practice down to more junior levels.
“( ) If, at any time before section 8 comes into force, Monitor obtains the approval of the NHS Commissioning Board Authority to publish guidance under section 65DA(4)(c) or (5) of the National Health Service Act 2006, that approval is to be treated for the purposes of subsection (6)(b) of that section as approval obtained from the National Health Service Commissioning Board.”
“(14) The Healthwatch England committee is to be treated for the purposes of section 2(1) of the Public Bodies (Admission to Meetings) Act 1960 as a body that includes all the members of the Care Quality Commission.”
Baroness Masham of Ilton
My Lords, perhaps I may ask a question following the speech of the noble Baroness, Lady Barker. Does healthwatch not cover health and social care? If it does, the noble Baroness, Lady Bakewell, has a strong point.
Earl Howe
My Lords, while, for reasons which I shall explain later, I do not feel able to accept this amendment, I say immediately to the noble Baroness that she has raised a very important issue with which the Government are in complete sympathy.
It is important for older people to have a strong voice to champion their interests and to ensure that their needs are addressed in public services. Both I and my honourable friend the Minister of State for Care Services have met the noble Baroness over recent months to discuss this issue and have been struck forcefully by the powerful case that she has made. As she is aware, my honourable friend would like to continue these discussions with her, as we are particularly grateful for the expertise that she brings to this area.
I am sure noble Lords will agree that older people are affected by a wide range of issues—not only health and social care but areas of policy such as housing and pensions. The Government recognise this. The UK Advisory Forum on Ageing, co-chaired by the Minister of State for Care Services and the Minister of State for Pensions, provides advice across government on the additional steps that they and their partners need to take to improve well-being and independence in later life.
In health, a range of functions in relation to older people are already carried out in this country. That should not surprise us because we all know that a very large proportion of the NHS budget is accounted for by healthcare delivered to the elderly. The Department of Health is pursuing a number of initiatives to improve the care of older people in hospitals, care homes and other settings. These initiatives cover all stages of the care pathway—from helping individuals to stay healthy and to stay in the community all the way through to end-of-life care. For example, the department already has a National Clinical Director for Older People, Professor David Oliver, whose remit is to promote the better care of older people across the NHS and social services, and to provide clinical leadership for cross-government work on older people.
My noble friend Lady Barker rightly stressed the key role of social care in relation to older people. Looking across the spectrum of health and social care, each health and well-being board will be required to develop a joint strategic needs assessment, identifying the current and future needs of the local population, and a joint health and well-being strategy to set out how those needs will be met. I can say to the noble Baroness, Lady Bakewell, that it is intended that health and well-being boards will bring together the key local commissioners to enable them, first, to consider the total resource available to improve their population’s health and well-being, and then to come to a joint understanding about how those resources can best be invested. This will undoubtedly help to encourage a more integrated local service which is better able to meet the needs of older people by joining up NHS and social care services. I hope that that offers some reassurance to the noble Baroness that the voice and needs of older people in health is absolutely a priority for this Government.
Amendment 231A proposes that the role of commissioner for older people should fall on a member of HealthWatch England. I am afraid that I cannot agree that that would be an effective approach. The first reason is the one that I mentioned earlier: the role of an old people's champion goes wider than health and social care. Equally importantly, the job of HealthWatch England will be to carry out functions in relation to people. The word “people” is a deliberately broad term and its ordinary meaning would include older people of course, so we do not feel that it would be appropriate to give a member of HealthWatch England a remit for older people, which would give additional weight to one group of people over another. It could also lead to calls for a commissioner for other groups like those with learning disabilities and it would be difficult to see where the list would stop.
Although I completely understand the concern that older people have often lacked a voice within the system, and the need to ensure that they are not overlooked, we do not agree that the singling out of this group over others, within the context of healthwatch, would be the best way to achieve that. We want to address the concerns of the noble Baroness but not in this way. In the light of that and on the basis that she will continue to have discussions with my honourable friend on the issue in a wider sense, I hope that she will feel sufficiently reassured to withdraw her amendment.
Baroness Bakewell
I thank the noble Earl for that engagement with the argument which I hope to start. Having a toe in the door, I hope that I can keep it open and perhaps prise it a little bit further open.
The noble Earl cites all the amazing institutions which are responsible for older people and one wonders why there is such a catalogue of misery across the country. Why are things going wrong? Why do they not answer the needs of older people? Why are there so many people catalogued as living wretched lives and writing letters of complaint, virtually with tear-stained ink? This is a major problem that the system is not answering. Therefore, I hope to take the issue further.
I very much agree with the noble Baroness, Lady Barker, that we should not medicalise the issue of being old. We have to keep old people fit so that they can enjoy old age. If this matter is to be referred to other government departments, I would include the DCMS so that access for older people to theatres and cinemas, help with hearing and so on can improve their quality of life. There is much to be improved, as we all know. I welcome the noble Earl’s commitment to making that so and I hope to follow it up in future. I beg leave to withdraw my amendment.
“( ) After subsection (3A) insert—
“(3B) Each local authority must ensure that only one set of arrangements under subsection (1) in relation to its area is in force at any one time.””
“(7) In the title to section 221, omit “: local involvement networks”
“(2) The arrangements must be made with a body corporate which—
(a) is a social enterprise, and(b) satisfies such criteria as may be prescribed by regulations made by the Secretary of State.(2A) For so long as the arrangements are in force, the body with which they are made—
(a) has the function of carrying on in A’s area the activities specified in section 221(2), and(b) is to be known as the “Local Healthwatch organisation” for A’s area.(2B) But the arrangements may authorise the Local Healthwatch organisation to make, in pursuance of those arrangements, arrangements (“Local Healthwatch arrangements”) with a person (other than A) for that person—
(a) to assist the organisation in carrying on in A’s area some or all of the activities, or (b) (subject to provision made under section 223(2)(e)) to carry on in A’s area some (but not all) of the activities on the organisation’s behalf.”
“(3) In subsection (3), for the words from the beginning to “who is not” substitute “None of the following is capable of being a Local Healthwatch organisation”.”
“Local arrangements: power to make further provision
(1) Section 223 (power to make further provision about local authority arrangements) is amended as follows.
(2) In subsection (1), for “require prescribed provision to be included in local involvement network arrangements” substitute “include prescribed provision”.
(3) After that subsection insert—
“(1A) The Secretary of State may make regulations which provide that local authority arrangements must require Local Healthwatch arrangements to include prescribed provision.”
(4) In subsection (2)—
(a) for “must require local involvement network arrangements to include” substitute “must include or (as the case may be) must require Local Healthwatch arrangements to include”,(b) in paragraphs (a), (c) and (d), for “a local involvement network” substitute “a Local Healthwatch organisation or a Local Healthwatch contractor”, and(c) after paragraph (d) insert “; (e) prescribed provision relating to the activities which a Local Healthwatch contractor may not carry on on a Local Healthwatch organisation’s behalf;(f) prescribed provision relating to the obtaining by a Local Healthwatch organisation of a licence under section 45C of the Health and Social Care Act 2008 and the grant by the organisation to a Local Healthwatch contractor of a sub-licence;(g) prescribed provision relating to the use by a Local Healthwatch organisation or a Local Healthwatch contractor of the trade mark to which a licence under that section relates;(h) prescribed provision relating to the infringement of the trade mark to which a licence under that section relates;(i) prescribed provision relating to the imposition of a requirement on a Local Healthwatch organisation to act with a view to securing that its Local Healthwatch contractors (taken together) are representative of—(i) people who live in the local authority’s area,(ii) people to whom care services are being or may be provided in that area, and(iii) people from that area to whom care services are being provided in any place.”(5) After subsection (2) insert—
“(2A) The provision which may be prescribed in relation to a Local Healthwatch contractor includes provision that relates to the contractor—
(a) only in so far as it assists the Local Healthwatch organisation in the carrying on of activities specified in section 221(2);(b) only in so far as it carries on such activities on the organisation’s behalf.(2B) Regulations under this section may make provision which applies to all descriptions of Local Healthwatch contractor, which applies to all those descriptions subject to specified exceptions or which applies only to such of those descriptions as are prescribed.”
(6) In subsection (3)—
(a) before the definition of “a local involvement network” insert—““care services” has the meaning given by section 221;”,
(b) omit the definition of “a local involvement network”,(c) for the definition of “local involvement network arrangements” substitute—““Local Healthwatch arrangements” has the meaning given by section 222;”
(d) after that definition insert—““Local Healthwatch contractor”, in relation to a Local Healthwatch organisation, means a person with whom the organisation makes Local Healthwatch arrangements;”, and
(e) after the definition of “prescribed provision” insert “;“trade mark”, and “use” and “infringement” in relation to a trade mark, each have the same meaning as in the Trade Marks Act 1994.””
“( ) a complaint under section 73C(1) of the National Health Service Act 2006; ( ) a complaint to a Local Commissioner under Part 3 of the Local Government Act 1974 about a matter which could be the subject of a complaint under section 73C(1) of the National Health Service Act 2006; or”
“(2) In subsection (2), omit “by a local authority with another person (“H”)”.”
“Consequential provision
(1) In the Schedule to the Public Bodies (Admission to Meetings) Act 1960, after paragraph (bk) (as inserted by paragraph 2 of Schedule 13) insert—
“(bl) Local Healthwatch organisations, as regards the carrying on of activities specified in section 221(1) of the Local Government and Public Involvement in Health Act 2007 (local care services);”.(2) In Part 3 of Schedule 1 to the House of Commons Disqualification Act 1975, at the appropriate place insert—
“Director of a Local Healthwatch organisation.”(3) In Part 3 of Schedule 1 to the Northern Ireland Assembly Disqualification Act 1975, at the appropriate place insert—
“Director of a Local Healthwatch organisation.”(4) In Part 2 of Schedule 1 to the Freedom of Information Act 2000 (local government), after paragraph 35D insert—
“35E A Local Healthwatch organisation, in respect of information held in connection with—
(a) arrangements made under section 221(1) of the Local Government and Public Involvement in Health Act 2007, or(b) arrangements made in pursuance of arrangements made under section 221(1) of that Act.” (5) In section 65H of the National Health Service Act 2006 (NHS foundation trust special administration provisions: consultation requirements), in subsection (8), for subsection (e) substitute—
“(e) a Local Healthwach organisation;”.(6) In section 4 of the Health and Social Care Act 2008 (matters to which the Care Quality Commission must have regard)—
(a) in subsection (1)(c)—(i) for “local involvement networks” substitute “Local Healthwatch organisations or Local Healthwatch contractors”, and(ii) omit “in their areas”.(b) for subsection (3) substitute—“(3) In subsection (1)(c), “Local Healthwatch contractor” has the meaning given by section 223 of the Local Government and Public Involvement in Health Act 2007.””
Earl Howe
My Lords, this group of amendments all relate to health and well-being boards and in particular their statutory minimum membership, responsibility for preparing both joint strategic needs assessments and joint health and well-being strategies, as well as their role in promoting integration.
Amendments from the noble Lord, Lord Ramsbotham, and my noble friend Lord Shipley, relate to changes to the statutory membership of health and well-being boards, which I know we have previously debated. As noble Lords will be aware, we have consulted extensively on the membership of health and well-being boards and one of the consistent messages we have heard is that local people want a balance between the flexibility to add members alongside some consistency in representation from key players, such as elected representatives and clinical commissioning groups.
The Future Forum looked at this and, following its report, we made a commitment that it will be for local authorities, or in some cases the leader or mayor, to determine the precise number of elected representatives on its board, although we have stipulated that there must be at least one. I would ask my noble friend Lord Shipley to note the words “at least one”. We believe that it is right for local areas to be able to have the flexibility to determine the wider membership of their boards based on local need. I am of course happy, however, to engage with my noble friend in further discussions.
The Bill allows local areas the flexibility to develop the arrangements that best work for them. It is important to be clear that the purpose of this policy is not primarily about setting up a committee but about stimulating effective joint working for and with local people and communities. The health and well-being board will be central to this joint working but must not represent its limit.
We can be encouraged by what is now happening on the ground. We know that a large number of local areas are already working with all the relevant stakeholders to explore and agree how they can work together in the future to make the biggest difference to local people. For instance, from our work with shadow health and well-being boards, we have had lots of feedback to suggest that two-tier county councils are working closely with district councils through the boards in a range of creative and positive ways based on local need and circumstances. In fact, I understand that in many two-tier areas, shadow boards are already operating with more than one district council representative ranging from the leader, the chief executive or a senior officer. However, developing these relationships and understanding how best everyone, whether it be district councils, health professionals, local providers or the voluntary sector, can contribute in the most appropriate way, is something that we feel strongly is best left to these conversations rather than being prescribed on the face of the Bill.
Amendments 238C, 238D and 238E, tabled in the names of the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Whitaker, relate to placing a particular emphasis on educational and children’s services. They would make explicit reference to education and children’s services in the Bill, in the context of the duty and powers of health and well-being boards, to encourage close working between the commissioners of health and social care services, with itself and with commissioners of health-related services in the area. I should like to take this opportunity to reiterate some of the points made during our previous debates on this topic. I fully agree that joining up health and social care services for children as well as for adults is crucial, but I believe that the existing provisions set out in the Bill are sufficient to ensure that the voices of children are heard. Indeed, I should like to remind noble Lords that in preparing the JSNA and joint health and well-being strategy, health and well-being boards will have a statutory duty to involve people who live or work in the area, and this will include within it young people. The director of children’s services will be a statutory member of the health and well-being board to ensure that the needs of children are taken into account, and local healthwatch will also be able to use its membership on the boards to help ensure that the voices of the whole community, including those of young people, are fed in.
In addition, the statutory guidance—I think this is a reassurance that the noble Lord, Lord Ramsbotham, wanted—we are producing on JSNAs and joint health and well-being strategies will emphasise the importance of understanding and addressing the needs of children and young people. We are also supporting the efforts of local partners by bringing together emerging health and well-being boards into a national learning network, which is developing ways to engage effectively with local people, including a focus on effective joint working to improve services for children and families.
Baroness Whitaker
I am sorry to interrupt the noble Earl, but before he moves off our amendments, I did not actually hear the words “education services” in his helpful remarks. Could he explain how they will come in?
Earl Howe
I was going to come on to that in replying to the noble Earl, Lord Listowel. If the noble Baroness will bear with me, I hope that I will cover the point.
Amendment 238A would require local authorities and CCGs to specifically consult relevant health professionals when preparing the JSNA. As I have said before, in preparing the JSNA and joint strategy, local authorities and CCGs will be under a duty, which the health and well-being boards will discharge, to involve people who live or work in the area. In practice this could well include health professionals. Indeed, I thought that the noble Baroness, Lady Finlay, made a powerful point in this regard, and I do feel that we are broadly accepting the spirit of the amendment.
In relation to Amendment 238AZA in the name of the noble Baroness, Lady Massey, and the noble Earl, Lord Listowel, I should like to reassure both of them that the health and well-being strategy will be a shared, overarching response addressing the health and social care needs of an area identified through the JSNA. In the joint strategy, the board will be able to consider how the commissioning of wider health-related services could be more closely integrated with health and social care commissioning. For example, the board could consider whether and how housing, education or local authority leisure services could affect health and, if they do, how commissioning could be more closely integrated with the commissioning of health and social care services. The model we have chosen for health and well-being boards is designed to enable those wider conversations to take place, and in answer specifically to the noble Earl, Lord Listowel, I genuinely believe that the arrangements in the Bill afford a much better chance of us having joined-up thinking and joined-up services than we have had before. Clinical commissioners will be best placed to work in the interests of children, especially when this requires working with other professionals. There are strong duties on commissioners as to promoting integration, as the noble Earl will be aware.
On Amendment 238H, in the name of the noble Lord, Lord Beecham, we believe that health and well-being boards will provide an opportunity to build strong relationships with an open culture of peer-to-peer challenge. The JSNA and joint strategy will provide all members with a common understanding of local needs and priorities. However, giving boards a power of veto over commissioning plans would undoubtedly undermine that relationship. I am afraid that we are firmly against that idea.
We are in agreement on that matter with the Future Forum and the Local Government Association, both of which recognise that placing a duty on CCGs to agree commissioning plans with the health and well-being boards would confuse lines of accountability and be unworkable—confusing and unworkable were the words of the Future Forum. CCGs are ultimately responsible for their budgets and to give the health and well-being boards the right to make decisions that might incur costs for commissioners without taking responsibility for expenditure would be wrong.
I hope that I have been able to reassure noble Lords adequately—although I know that I will not have reassured the noble Lord, Lord Beecham—and they feel able not to press their amendments.
Finally, I should like to speak to the government amendment in this group, Amendment 239, which is a minor technical amendment in relation to Clause 195. The purpose of this amendment is to clarify that a local authority may delegate any functions exercisable by it to the health and well-being board. I hope that it will receive the support of the House.
Lord Beecham
I remind the noble Earl of my question about whether that extends to general powers of competence rather than statutory functions. I invite him to communicate later as I suspect that he may not be in a position to do that immediately.
Lord Ramsbotham
I thank the noble Earl for his habitually courteous and balanced reply and I am reassured on some of the points that I raised. I am grateful to the noble Baroness, Lady Whitaker, and my noble friend Lady Finlay in particular for supporting the amendments and to the noble Lord, Lord Beecham, for mentioning them. Like the noble Baroness, Lady Whitaker, I have this nagging fear that education, education, education is something that will need to engage the health and well-being boards. The link between education and health, particularly in the assessment, which was the subject of the amendments, is absolutely crucial. During the passage of the then Education Bill, noble Lords described what they wanted but of course they could not have it because they were health matters funded by health. Therefore, it is terribly important that joint working happens.
I was very glad that the noble Earl mentioned “effective joint working”, because I am sure that that is what we all seek. That was what was behind each and every one of the amendments. On the basis of that and knowing the noble Earl and that if he says something it is usually likely to happen, I beg leave to withdraw the amendment.