Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Monday 19th March 2012 Lords Chamber

[Lord Owen]

Before the noble Earl continues on that path, I have never used the word “concealment” in any of the many speeches I have made on this Bill. I also do not believe that it is improper for the Government to appeal on both those points. I do not mind my argument being destroyed, but if there has been any lack of clarity, I have said neither of those propositions.

[Earl Howe]

I accept the first point. In his article yesterday in the Observer, he called it “constitutional outrage”— or words to that effect—which was the point of my second proposition. Other noble Lords have made the accusation that the Government have consciously set about concealing the risks associated with the NHS reform programme, but that allegation does not stand up to a moment’s scrutiny.

The Bill was published some 14 months ago. During that time it has been subjected to a level of analysis, both inside and outside Parliament, that is without recent precedent. I am not just referring to the Bill’s impact assessment, which runs to 200 pages and dissects the risks, costs and benefits of the Bill clearly and meticulously. Nor am I referring only to the two successive NHS operating frameworks of 2010 and 2011, which lay out for all to see the risks of putting the NHS reform programme into practice, and how the service can best mitigate those risks. Nor do I wish to highlight only the extensive oral and written evidence that we provided to two House of Commons Select Committees, whose reports took apart a very wide range of risks to which the reforms give rise and made recommendations on the back of that. As much as any of these documents, it is the debates that have taken place in Parliament that have aired the risks associated with the Bill. When added together across both Houses, those debates have been of unparalleled duration and scope.

Noble Lords may recall the statement that I made on 28 November 2011, in which I set out a list of nine headings, summarising the areas of risk contained in the transition risk register. Many of those areas of risk have been the subject of amendments and debates during the Bill’s passage through the House. For example, one of the risk areas was,

“how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively”.

Noble Lords will need no reminding of the amendments that we agreed across the House on the chain of accountability in the NHS or the lengthy debates that preceded them. A further risk area was,

“how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board”.

We have debated and passed amendments on health inequalities, conflicts of interest, research, education and training and a whole lot more, all of which will directly contribute to those worthwhile objectives. Another area was how,

“to ensure that the new system delivers future efficiencies”.— [Official Report, 28/11/11; col. 16.]

Our debates on integration, the tariff and many other topics have focused on that theme, and there are more such examples. Therefore, I cannot accept for one minute that without sight of the transition risk register the House has somehow been denied a deep insight into what the Bill means for the NHS. It is an absurd proposition.

Why, then, is there such an issue over the release of the risk register? We heard the answer to that from the noble Lord, Lord Wilson of Dinton. We are dealing here with something for which I make no apology—namely, a point of principle. It is very firmly the view of the Government—here I refer to departments right across Whitehall—that the release of departmental risk registers would seriously undermine the work of civil servants if it became an accepted practice. Civil servants need to be able to formulate policy advice for Ministers fully, frankly and without fear that what they say may be exposed to the public gaze. The moment that officials feel inhibited in setting out the possible risks attached to a course of action in worst-case terms, the process of policy formulation becomes weaker and good government inevitably suffers. It is our belief, as it has been the belief of successive Governments, that to agree to the release of a risk register such as the one associated with the Bill would be to cross a Rubicon. It would remove the safe space that Ministers and civil servants need to do their job thoroughly and properly.

The potential for making that judgment was explicitly recognised and allowed for in the Freedom of Information Act. Indeed, our decision to invoke the Act in order not to release the department’s strategic risk register was upheld by the First-tier Tribunal. We await the tribunal’s reasons for arriving at this conclusion, and for arriving at the opposite conclusion with regard to the transition risk register. When those reasons are before us, the Government will need to take a decision on whether there may be grounds for a further appeal. Until then, no one can tell what the legal basis of the judgment is.

--- Later in debate ---

[Earl Howe]

My Lords, I take that to be the meaning of the Motion; in fact, it presents the House will an either/or decision, which if passed, would leave us in an uncertain situation. However, I take it that the Motion of the noble Lord, Lord Owen, means that, failing the first alternative, the second applies.

I have discussed the parliamentary timetable at length with my noble friends, as might be supposed. I am advised that in reality there is little time left in this Session, but there is a great deal of business left to complete: the Legal Aid, Sentencing and Punishment of Offenders Bill is on Report; the Scotland Bill is still in Committee; and we await our amendments to other Bills to come back from the other place, whose own schedule is complicated by the Budget, Easter and the Finance Bill. The clear advice that I have received from the business managers is that to delay Third Reading to await the tribunal’s reasons and a government response would put into serious jeopardy all the excellent work that this House has done to make this a better Bill.

I put it firmly to the House that we need to get on with the Bill. Today is the 25th full day on which we have been discussing it, and during that time it has been greatly improved. There is no major issue in it to which the House has not done justice. Delaying Third Reading would, in my submission, be wrong and wholly unwarranted. We need to get on with it, and the NHS needs certainty—the certainty of the Bill being on the statute book. I therefore urge your Lordships in the strongest terms to reject the Motion of the noble Lord, Lord Owen, and allow Third Reading to proceed this afternoon.

[Lord Owen]

My Lords, we have heard a lot of speeches and I do not intend to take long, but I reiterate—if any noble Lord has come in late to this debate—that they should again read the amendment. It makes it clear that what we are trying to do is find enough time—a matter of a few weeks—to hear the opinion of the tribunal that has found against the Government on the disclosure of the risk register. That is a provision within the Freedom of Information Act and follows the earlier decision against the Government arguing for the disclosure of the transitional risk register by the commissioner.

It is pretty unusual for the Government to find two such rulings against them, and it seems perfectly legitimate, before making a final decision—which I readily concede has to be made before Prorogation—to give the courtesy, let alone anything else, of hearing the judgment. It is almost as if we are afraid of the judgment.

In fairness to Professor Angel, we heard from the former Lord Chancellor about his credentials. People do not sit on the tribunal for freedom of information just on one case. They have made many different judgments; they know the issues. With respect to the former Permanent Cabinet Secretaries who have spoken, those who sit on the tribunal know the issues—I do not say as well as former Cabinet Secretaries, but they were looking at it from one side of the equation, the well-being of the Civil Service and the service and information they gave to Ministers. The Freedom of Information Act looks at it from a wider perspective. It looks at it for the good governance of the country as a whole. It urges people to look at why we have open government and greater transparency: because people find it much easier then to accept democratic decisions. This is about a democratic process.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Wednesday 8th February 2012 Lords Chamber

[Earl Howe]

That the Report be now received.

[Lord Owen]

My Lords, before the House agrees that the Report should be received, I would like to raise some important constitutional questions. On 4 April, the day the Prime Minister and the Deputy Prime Minister embarked on their “listen and explain” experience and the legislation was paused, I wrote to the then Cabinet Secretary, Sir Gus O’Donnell—now of course the noble Lord, Lord O’Donnell—and raised with him the fear that, because of the long drawn-out legislative process, discussion of the Bill in this House could be pre-empted. I also told him that I had consulted the clerks in Parliament and it appeared that there was no written convention that guides the Government on what is or is not acceptable to take in advance of Royal Assent. Obviously they cannot implement the legislation in full.

Many of my concerns since then have been more than justified. I received a letter on 7 April from the then Cabinet Secretary that said:

“The Treasury guidance on ‘Managing Public Money’ sets out how, in some circumstances and if … conditions are fulfilled, departments can incur expenditure on the measures contained in a bill prior to Royal Assent. In addition, a department may take steps to prepare for implementation using existing statutory powers. I have therefore discussed your concerns with Una O’Brien, as Accounting Officer, in the light of this guidance. She has confirmed”—

this is important—

“that the work currently underway is taking place under the broad powers of the Secretary of State and NHS bodies under existing legislation. For example, the arrangement of PCTs into management clusters and the creation of pathfinder consortia are possible under existing powers in the National Health Service Act 2006. In addition, some of the changes currently taking place would be required regardless of the Health and Social Care Bill. For example redundancies in PCTs reflect the longstanding challenge, which pre-dates the Bill, to deliver up to £20bn of efficiencies across the NHS over the next four years for reinvestment in frontline services”.

As a result of that, there has been broad acceptance in this House that on these controversial questions, some of which are already agreed, the Government are proceeding under existing legislation.

On 16 September I was informed by the chairman of the Constitution Committee that that committee had briefly discussed the pre-legislative disappearance of PCTs, and had in front of it my correspondence with the Cabinet Secretary, which I had made available to Professor Tomkins, one of its advisers. I was asked whether I would provide more information about changes that had been introduced following Second Reading of the Health and Social Care Bill but prior to it coming to the House of Lords. I enclosed an up-to-date document in great detail that had been sent out for consultation by the Midlands and East Strategic Health Authority, which I thought gave a pretty clear indication of the anticipated massive changes to the whole architecture of the NHS, many of which seem as if they will be introduced despite the fact that the full legislative process was continuing.

I also drew attention to a speech that had been made in the other place by a Member of Parliament that had again raised the question of whether it was proper to stop the legislation when so much was already being done and so much pre-emption had occurred. Today I have written to the Constitution Committee on this question because an MP drew my attention to a letter that says that people,

“are absolutely terrified of the chaos that will apply if the Bill is dropped altogether now. Restructuring is a nightmare, un-restructuring could be even worse!”.

On today’s “World at One”, the chief executive of the Foundation Trust Network warned of a no-man’s land if the Bill did not go through.

This raises pretty big questions for legislation that is still to go through all its stages in this House, and it is a matter of great concern to this House when it considers reform. These conventions will become very much more important if we have an elected House of Commons—which of course we have—and an elected House of Lords, which I personally would like to see. There is no question that these conventions are important.

There are two important points here. First, the House should be aware of the fact that the Constitution Committee is seized of the problem and may well wish to make judgments on it. Secondly, we should not feed the idea that legislation can reach us but we cannot do anything about it because it has already been pre-empted. Whatever our views on the Bill, and it is controversial, it is important on democratic grounds that we maintain the position that legislation does not have full authority until it has gone through all its processes. That point needs to be reaffirmed. We should give no comfort to the opposite view in what we say in this House in the remaining stages of the legislative process.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, of course, the noble Lord, Lord Owen, had no obligation to give the Government advance notice of the issue that he has just raised. Nevertheless, I am sorry that he did not. I just say to him that everything that has happened to date in my department’s implementation of the transition programme has been done under the Secretary of State’s powers under the 2006 Act. This is all proper and lawful. However, this can go only so far. It is not a permanent solution, hence the need for the primary legislation that we are now debating.

It has been the practice of successive Governments, once a Bill has passed through the other place, to do as we have done and make preparations for that Bill’s implementation. The previous Government did it on a number of occasions and we are doing so as well. Furthermore, we are doing so in a measured and structured way. It is not an overnight process—it never could be. It is being done over a period of years. It in no way pre-empts the will of this House, which has made its views, to which the Government have listened very carefully, known on a number of issues.

While thanking the noble Lord for raising this concern, which I shall of course consider very carefully, as I always do, I hope the House will feel that it is unconstrained in how it presents amendments to the Government and how it argues for them. We, in our turn, will respond in a constructive manner, as I hope always to do.

NHS: Transition Risk Register

Debate between Earl Howe and Lord Owen

Wednesday 18th January 2012 Lords Chamber

[Earl Howe]

My Lords, with respect to the noble Lord, I do not think that is a matter for me. Obviously, if there is a committee that feels able and willing to look at this matter, we shall of course co-operate and comply with that committee to the fullest extent.

[Lord Owen]

My Lords, there is a Motion on this very subject before the House in my name, and I hope that there will be an opportunity well before we reach Report for it to be debated. Since public companies are under strict obligations to publish their risk assessments—they have to weigh very carefully what they say because they could be sued by shareholders in their companies—why is it so different for Her Majesty’s Government in the circumstances in which the Information Commissioner has expressed the view that this is a legitimate case that ought to be made available?

[Earl Howe]

The Freedom of Information Act was framed specifically in a way that would protect the process of policy-making within departments. Our view is that the risk register forms an integral part of policy-making and implementation; the Information Commissioner came to a different view. It is about the balance of public interest here: we wish to see this process adjudicated further.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Wednesday 21st December 2011 Lords Chamber

[Lord Owen]

May I just make a slight correction? I said that the debate on the impact of the European Union on healthcare in the United Kingdom in the name of the noble Lord, Lord Kakkar, will be held on 10 January. It will actually be held on 11 January, as the dinner-break business. I want to be quite clear about the timing of that important debate, which at the moment is limited to a maximum of one hour.

While I am on my feet, I want to stress that every word that the noble Baroness, Lady Williams, has said is wholly appropriate. This question of risk assessment is central to the judgments which will have to be made at Report. I hope very much that we do not proceed to Report until the tribunal's judgment has been heard.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, perhaps I could begin by addressing briefly the matter of the risk register. Arising from earlier debates on this subject, I have discussed the timetable for the appeal with my officials, and I say again that I recognise fully the strength of feeling on this issue and the desire for speedy resolution. As noble Lords are aware, the timetable for matters of this kind is a matter for the Information Commissioner and the legal process. In view of the noble Baroness’s very courteous suggestion that I should write to her and to the noble Baroness, Lady Thornton, about this, I undertake to do so straightaway. I will copy in my noble friend at the same time. In that letter, I undertake to give as much information as I can at the moment about what we see as the likely timetable for the process.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Tuesday 13th December 2011 Lords Chamber

[Lord Owen]

My Lords, I wish to draw attention to Clause 72(1)(b), which refers to,

“a power to investigate on its own initiative whether the National Health Service Commissioning Board or a clinical commissioning group has failed to comply with a requirement imposed by virtue of section 71(1)(c)”—

which we discussed earlier, the provision to,

“not engage in anti-competitive behaviour which is against the interests of people who use such services”.

I had understood that the decision not to have competition as one of the main functions of Monitor was a considered political decision, but the more one looks at Clause 71(1)(c), and now at Clause 72(1)(b), the more one realises that this has been got round, effectively, by ensuring that anti-competitiveness becomes a prime responsibility of Monitor.

There are a number of objections to this. The noble Lord, Lord Whitty, put his finger on it, that a good regulator does not also become a policeman in an anti sense to the people he is trying to regulate. There is a deep question as to whether you really want a situation where Monitor can be set against the National Health Service Commissioning Board and the commissioning groups. I am very doubtful that this is a sensible power to give to Monitor.

I know it is regulating the whole group, but if you look at the way Monitor is approaching its tasks, time and again it is going to be reliant on good will and an atmosphere of trust between Monitor, the NHS Commissioning Board and the commissioning groups, and now there is this question of anti-competitiveness. It is not as if nobody else is going to be looking at anti-competitive behaviour of the National Health Service Commissioning Board. The private sector wants to go into this whole area and will be looking very carefully at whether or not it is being given an even playing field. It will be taking, and threatening to take, the Commissioning Board to law—I am not even raising the issue of EU legislation, but just under British legislation.

I do not think it is fair to argue that there is unlimited freedom for the National Health Service Commissioning Board or the commissioning groups to operate in this area, particularly the board. You are really setting yourself up for a very difficult situation. Also, to do it “on its own initiative”—does that mean Monitor would not consult the board or a clinical commissioning group but just suddenly involve itself in an investigation? I would be grateful if the Minister could give some indication of how he sees this in practice.

Will some guidance be given not to develop an adversarial relationship? It is very easy for animosities to start coming in to this area. As I say, it is not as if it is free from legal challenge. Their actions can be challenged. However, for another NHS body to be able to question the judgment of the Commissioning Board that in this particular case it is best not to put something out to competitive tender, or to make a judgment when it has been done because somebody feels that it is anti-competitive, is a really dangerous power. In the wrong circumstances, where Monitor might be chaired by somebody who is getting into a bad relationship with the NHS Commissioning Board chairman, something not totally unknown in these areas, this is a tool which could be used in a destructive and adversarial fashion.

It would be very helpful, for future occasions, to hear from the Minister as to how he thinks this would actually work out in real life.

[Earl Howe]

The noble Lord, Lord Owen, has caught me napping, so to speak, because I was not expecting that intervention. I would be very happy to write to him to set it out, if he will allow.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Tuesday 13th December 2011 Lords Chamber

[Earl Howe]

They are there because this is the first time that any Government have attempted to bring together under one umbrella the disparate parts of our existing system for regulating and controlling competition. As I said earlier, we have that system in skeletal form, but there are lots of gaps and inconsistencies. By bringing them under one umbrella, as this Bill does—I am afraid that it inevitably occupies a goodly number of clauses—we will have a coherent system of regulation for the future.

Establishing concurrent powers for Monitor would not extend the scope of competition law or its applicability to the NHS; that is an important point for noble Lords to appreciate. Why have a sector-specific regulator? For me, the reason is that, instead of such matters being reserved for the Office of Fair Trading, Monitor will be able to lead on these issues in its capacity as a regulator with statutory duties to protect and promote patients’ interests and to enable integration, and as a body with much greater knowledge and expertise of healthcare compared with the Office of Fair Trading. That would include, for example, where arrangements such as clinical networks, which may restrict competition, deliver overriding benefits to patients. Just because there is no competition, that does not mean that the behaviour in question is anti-competitive.

That view was forcibly brought out by the NHS Future Forum. As I have said, competition is just one of the tools available to the commissioner in securing access and improving services, and it will be the commissioner, not Monitor, who will decide where and how to use it. That is not new. The use of competition—for example, through competitive tendering—is already well established in the NHS. A range of providers—NHS, voluntary, and independent—are contributing to improving services for patients.

Of course I understand the passion with which the noble Lord, Lord Owen, spoke; my concern is that his amendments would remove from the Bill a protection for patients in relation to the actions of commissioners. That is very important; if the noble Lord’s amendments were accepted we would have commissioners taking decisions that were not overseen or checked in any way, which would be very dangerous. It would also be a backwards step from the existing principles and rules that apply to primary care trusts and that were introduced by the previous Government. The noble Lord, Lord Owen, said very interestingly that according to his research the French railway system is not subject to EU competition law. I defer to his knowledge of French railway legislation but, as is made clear in the OFT’s recent guidance, the issue of whether competition law applies requires an analysis of the activity in question. To insert a clause into the Bill just to say that EU competition law shall not apply to the NHS would not achieve that aim. EU competition law is a fact, so we have to ensure that the system that we put in place protects patients against breaches of the law and that when breaches do occur they are remedied effectively.

[Lord Owen]

What about the issue of letting the House have the information that was produced for the previous Government before they came forward with their proposals? Is he prepared at least to look at that question, which is currently before the Information Commissioner?

[Earl Howe]

I shall indeed look very willingly at that question and I am grateful to the noble Lord for raising it. Although I might not appear to be at times, I am very keen to be as open as possible about as much as possible. Whatever I can do to facilitate this I will, although it is not a matter that I have been directly involved in.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Tuesday 22nd November 2011 Lords Chamber

[Earl Howe]

It could do. However, that is to be determined. I would welcome the views of the noble Lord on that, if he has particular examples in mind.

This brings us to the question the noble Lord, Lord Hunt, asked about the period which the mandate will cover. It will be a multi-year document, updated annually, which is intended to provide a stable policy context for the board. There may be circumstances which call for the mandate to be updated in-year, including after a general election, to ensure that an incoming Government could start to implement their manifesto commitments for the NHS in-year. Any revisions to the mandate will be open and transparent. If the mandate is revised, it must be published and laid before Parliament with an explanation of the changes.

I will now comment on Amendments 98 and 100, tabled by the noble Lord, Lord Warner, and Amendment 100A, tabled by the noble Lord, Lord Hunt. These rightly highlight the importance of transparency and parliamentary scrutiny of the mandate. I completely sign up to transparency as a principle. In the first place, there will be a public consultation. Alongside that, we will engage with stakeholders, including the board, to ensure that we set ambitious but achievable objectives. It is essential that the Government hold the board to account for objectives that are achievable. It is not in anybody’s interests to set the board up to fail. At the same time, where there is scope for improvement in the health service within the resources available, the mandate should and will ask the board to drive such improvements.

Ministers have a legitimate right to be ambitious on behalf of citizens and taxpayers, but we know that getting the balance right and setting objectives that are affordable and ambitious will not be straightforward. Much of the answer lies in transparency. There will be open public consultation on the Government’s objectives for the NHS. I can assure noble Lords that the process of developing the mandate will be open and consultative, including a formal 12-week public consultation. We intend to publish a consultation response as well as a summary of the responses we receive.

I point out that the Bill places a duty on the Secretary of State to consult the board and HealthWatch England before specifying the objectives and requirements in the mandate. We should be clear about how that changes the current arrangements. At present, decisions about the Secretary of State’s priorities for the NHS can be decided without reference to, or consultation with, anyone, as we saw under previous Governments. Top-down targets can be set without consultation. The priorities for the NHS are issued around this time every year through an operating framework without any need for consultation. Under the Bill, for the first time parliamentarians and the public will have the opportunity to consider and challenge the Government's objectives for the NHS every year. No previous Government have ever allowed this. It will highlight and reinforce, year by year, Ministers’ overarching responsibility for a comprehensive National Health Service free at the point of need.

The consultation will provide a period in which Parliament will be able to scrutinise the Government's proposals—as will the Health Select Committee if it chooses. It is appropriate that this consultation should take place before the mandate is published. We must provide clarity of purpose for the NHS. A period of additional parliamentary scrutiny after the mandate is published, which is what the amendment proposes, would be disproportionate and very disruptive. It would reduce the time the NHS has for planning and would create uncertainty in the service.

There will of course be formal parliamentary control over any legal requirements set for the NHS through the standing rules and any other regulations. The Bill not only gives Parliament an unprecedented role in setting out the roles and responsibilities in the NHS but increases parliamentary scrutiny by requiring detailed parameters and requirements to be set in regulations rather than in ministerial directions that have no scrutiny at all. I hope that noble Lords will give the Government credit for that package of proposals.

In addition, we have accepted the recommendation of the Delegated Powers and Regulatory Reform Committee that the requirements in the mandate should have the force of legislation and should be in an instrument subject to the negative procedure.

[Lord Owen]

It sounds very reasonable, but effectively the pre-consultation period will involve the board, HealthWatch England and such other persons as the Secretary of State allows. Parliament will not always be fobbed off with the answer that the Minister is still considering the issue. That is perfectly reasonable; we all know that a normal consultation period is required by all ministries, and certainly the Department of Health has observed this over many decades. It is when the Minister makes up his mind that Parliament will know what the policy is—and if it is in legislation it will be at that stage that there will be an intervention from Parliament with the right to challenge it. Therefore, it is perfectly reasonable to ask Parliament to come in after the consultation period because then it will know what the Secretary of State is proposing.

[Earl Howe]

Of course, Parliament is the sovereign body and can do whatever it chooses. Nothing will prevent it commenting on the mandate once it has been published. No doubt the Health Select Committee will wish to do this. My point is that to expect the process to feed into a regurgitation or reformulation of the mandate would be unfair on the NHS. The opportunity for Parliament to have its say should surely be during the normal consultation period. Parliament will be able to see the extent to which the Secretary of State has responded to whatever comments it has made.

--- Later in debate ---

[Earl Howe]

The noble Baroness knows that I have undertaken to engage in discussions outside this Chamber about Clauses 1 and 4 and their relationship with Clauses 10 and 20, and that is what I intend to do. There is a broader question here. My point to the noble Lord, Lord Owen, and the noble Lord, Lord Warner, who suggested in his opening speech that somehow the Secretary of State would detach himself and say, “Not me, guv” about anything that happened in the health service, is that they are mistaken because Clause 49 requires the Secretary of State to keep health service functions under review—in other words, not just the functions, but the effectiveness of the exercise by the bodies of those functions in relation to the health service. That is a very powerful duty. It is not a signal that the Secretary of State can just detach himself from what is going on in the health service. If he is holding the board to account, it involves him doing what Clause 49 requires, and I do not think that anything in the Bill negates that.

[Lord Owen]

The procedure in another place is deliberately very limited in terms of getting to a legislative change. This mandate has many of the qualities of legislation. It lasts for a year. It is going be a fixed statement. Is the Minister really telling us that the Secretary of State will not be saying that, because the mandate has been given, this is a question for the commission or the board—one which he would normally accept on the Floor of the House? Past experience is that he will pass that responsibility on the Floor of the House to, in this case, the commission. This is what concerns many people: there will be a change in procedure in how questions are answered in the House of Commons. The Minister has still not answered the question. This amendment allows a substantive change in the mandate that would stay for a year to be instituted by Parliament after it knows what is in the Minister’s mind, and he appears to be rejecting that. Is he rejecting that?

[Earl Howe]

I am surprised that the noble Lord, Lord Owen, thinks that the health service should be run in that way; that is, Parliament in effect mandating requirements to the health service whenever it chooses. I do not think that is a helpful idea. I think it is helpful for the Secretary of State, as now, to take responsibility for the health service but in the future to take direct responsibility for what lies in the mandate. Should events during a given year raise questions about the performance of the board, the Secretary of State would be answerable to Parliament for whatever the event was, and he would indeed have to take the necessary advice from the board. What he would not be saying is, “This is not my concern, guv”. He is answerable to Parliament in the ways that I have indicated. There is obviously a need for the board to take responsibility for the day-to-day management of the health service. However, we are seeking to achieve a balance between the Secretary of State taking responsibility in Parliament for what is in the mandate and the outcomes that he has set for the health service.

This is a shift of responsibility, it is not an abdication of responsibility—that is the distinction. Power is a zero sum game. If you shift power from the Secretary of State down to the health service, you cannot at the same time expect the Secretary of State to retain the same degree of power. We are transferring power in two directions; from the Secretary of State downwards, and from the Secretary of State upwards to Parliament. That is the picture that I hope noble Lords will keep in their minds.

Health and Social Care Bill

Debate between Earl Howe and Lord Owen

Tuesday 25th October 2011 Lords Chamber

[Earl Howe]

The Secretary of State could act if Health Education England was failing in its functions. Our vision is that we will be giving functions to Health Education England to oversee a national system. If it does its job properly, then the situation the noble Lord describes would, one hopes, be handled in a satisfactory way. If it fails in its functions, then, yes, of course it would be the duty of the Secretary of State to step in and oversee the process.

[Lord Owen]

This is a crucial question. The word failure is extreme. A lot of us worry that waiting for failure would be too late. We want to see an intervention capacity when the Secretary of State has anxieties or doubts about what it is doing and that he has a position to represent this Parliament—or any Parliament —on the issue.

[Earl Howe]

I know that is the noble Lord’s concern and of course I understand it. However, it is the policy of the Government to confer functions where they best sit. If the Secretary of State were to intervene at any whiff of trouble, it would run counter to that vision. I believe that there will be ample scope in the next set of amendments to talk about this very subject; but it is very important to understand that we have quite deliberately taken the view that functions, duties and responsibilities should sit with individual bodies and that the Secretary of State should be there to ensure, to the public and Parliament, that those bodies fulfil their duties and functions correctly.

I suggest that we defer the particular issue raised by the noble Lord, Lord Owen—about the degree of system failure that has to occur before the Secretary of State intervenes—to the next set of amendments. The amendment we are dealing with now has to do with the ultimate accountability of the Secretary of State for the education and training system—which I am saying to the Committee is there in our amendment.

NHS: Standards of Care and Commissioning

Debate between Earl Howe and Lord Owen

Thursday 31st March 2011 Lords Chamber

[Earl Howe]

Yes, my Lords. However, if the noble Lord will forgive me, I do not propose to take many interventions as the time is limited. As I say, the answer to his question is yes.

Those who question the effectiveness of these arrangements should focus on the new framework of accountability that we are proposing as it is central. The new NHS will be more directly accountable than it is now. Because of that our reforms introduce a stronger national framework for driving quality improvement than ever before. How will this accountability work? The Secretary of State will hold the NHS Commissioning Board to account for delivery against the NHS outcomes framework, published in December. The NHS Commissioning Board will then hold individual consortia to account for their performance against the indicators set out in the more locally focused commissioning outcomes framework. There was widespread and strong support for such a framework during our consultation.

The NHS Commissioning Board will decide on the shape and content of the commissioning outcomes framework over the next two years, working closely with emerging consortia and with professional and patient groups. To help maintain momentum, the department will shortly publish a discussion document, seeking more detailed views on possible features of the framework. The Health and Social Care Bill contains a new duty of quality. The NHS Commissioning Board and GP consortia will be required continually to improve the quality of NHS services. Underpinning that, the Care Quality Commission will regulate providers on safety and quality, with wide-ranging enforcement powers to protect patients should providers fail to meet requirements. Accountability works in its fullest sense only if there is transparency. We will publish clear, easy to understand information on the quality of healthcare services and the progress being made to reduce health inequalities. We also propose, subject to the passage of the Bill, that the NHS Commissioning Board be able to make payments to consortia in recognition of the outcomes they achieve collaboratively through commissioning and the effectiveness with which they manage their financial resources.

How will quality be driven through the commissioning system? Quality standards, prepared by NICE, will be at the centre of it. Quality standards bring clarity to quality, providing definitive and authoritative statements of high-quality care, based on evidence of what works best. Quality of care does not cover just the effectiveness of that care but also includes patient safety and patient experience. The three domains of quality are interconnected: they cannot exist in isolation. The Royal College of Physicians reflected on this point in its response to the consultation on the NHS outcomes framework and acknowledged that healthcare that is not safe could not be described as efficient, effective or sustainable.

Our reforms will allow a re-established NICE to produce a broad library of quality standards that will cover the majority of NHS services. NICE will also develop quality standards for social care and public health. The Secretary of State and the NHS Commissioning Board will be able to commission quality standards jointly, which will open up the opportunity for standards to cover the whole care pathway, from public health interventions in primary care through to rehabilitation and long-term support in social care, and will support the integration of health and social care services. It is important to understand that quality standards will do more than just bring clarity to quality: they will have real traction within the system, underpinning the duty of quality and linking with the new best practice tariffs that will see providers paid more for better care.

GP consortia will have a duty to support the NHS Commissioning Board in continuously improving the quality of primary medical care services. That does not alter the board's overarching responsibility for commissioning GP services and holding GP contracts. But it does mean that consortia will play a systematic role in helping to monitor, benchmark and improve the quality of GP services, including through clinical governance and clinical audit. It means also that consortia will have a core role in improving patient care across the system. That will include both the quality and accessibility of the care that GP practices provide and the wider services that consortia commission on behalf of patients.

Where does the Secretary of State sit in all this? The Health and Social Care Bill strengthens the accountability of the Secretary of State to Parliament for the provision of the comprehensive health service. For the first time, the Secretary of State will have to report each year on the performance of the health service, consult on the annual objectives set for the NHS through a mandate, and lay both documents before Parliament. The NHS Commissioning Board will be accountable to the Secretary of State for delivering against that mandate.

Nursing has been a strong theme in the debate. The noble Baroness, Lady Emerton, asked when the Government's response to the report of the commission on nursing will be published. I can assure her that the Government will respond soon to the commission's report and I apologise for not having given her an undertaking to that effect sooner. The noble Lord, Lord Turnberg, and the noble Lord, Lord Winston, raised concerns about nursing standards in hospitals. As they know, we now have matrons in post. They have a specific remit for quality of patient experience and should be accessible to patients and carers. Matrons are directly accountable to directors of nursing, who should present ward-to-board reports. We launched the Principles of Nursing Practice in November last year. This sets out an agreed set of standards and behaviours that were developed by the Royal College of Nursing in association with patient groups. These principles reinforce the NHS constitution.

The noble Lord, Lord Turnberg, asked about the duty of consortia to improve the quality of care for older people. There is no specific duty in the Bill relating to consortia and older people. However, we propose a new duty for consortia to seek continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. That extends to all aspects of care.

The noble Baroness, Lady Sherlock, spoke about the recent King's Fund report. The report highlights particular variation in relation to patient involvement in decision-making, and in co-ordination and continuity of care. It also highlights the need for changes in leadership and culture. We have a strong system of general practice in this country, but we agree absolutely with the report that there is too much variation in quality. This reinforces the case for GP decommissioning, because one of the key aims behind the development of GP commissioning is for consortia to play a central role in helping to reduce variation and drive up the quality of general practice. There will be strong incentives for GP consortia to want to tackle these variations, because with lower-quality primary care one achieves poorer outcomes for patients and one has greater pressure on more expensive secondary care services.

The noble Baroness, Lady Sherlock, questioned whether the Government were allowing enough time to see whether the changes would work. With the introduction of shadow bodies and early implementers, we are allowing almost three years to consult, to dry-run and to put our reforms into practice on the ground, so that by 2013 the new organisations will have had time to secure capability collectively. Therefore, it is wrong to say that the house is being demolished; in many senses, we are refashioning some parts of the existing edifice.

On that theme, the noble Baroness, Lady Pitkeathley, asked how consortia will be authorised, given their different states of readiness. The pathfinder programme is, I think, central to sharing learning across emerging consortia, and it is a crucial part of their development to take on full commissioning responsibilities. Consortia will not have statutory responsibility for commissioning until April 2013, so the intervening period will allow all consortia to be ready by that time.

We listened to an impassioned speech from the noble Lord, Lord Owen, who criticised the Health and Social Care Bill on a number of fronts. Time prevents me setting out a detailed set of counterarguments but perhaps I may just say to him that we have tabled amendments to the Bill that will put beyond doubt that competition will be on the basis of quality and not price. Far from challenging the principles of the NHS, we have consistently made it clear that we are absolutely committed to a comprehensive National Health Service which is free at the point of use and is based on need rather than ability to pay. Nothing in our plans changes that.

The noble Lord criticised the policy of “any willing provider”, or “any qualified provider” as we are now calling it, because we think that that is a better description of the policy. The noble Baroness, Lady Thornton, did the same. “Any qualified provider” is about empowering patients and carers, improving their outcomes and experience, enabling innovation, and freeing up clinicians to drive change and improve practice. Introducing a choice of any qualified provider will give patients more control. That is what all the research evidence tells us they want and increasingly expect from the NHS. Why should not someone with MS be able to choose the physiotherapist they want and be treated at the time and in the setting that best suits their need? Why should not a patient, at the end of their life, choose their hospice provider? Patients are already able to choose from any provider that meets NHS standards and prices when they are referred for a first out-patient appointment to a consultant-led team. That was an innovation brought in by the previous Government. “Any qualified provider” will extend that principle to more providers and more services, including social enterprises and charities, particularly in community care. For the life of me, I cannot see what is wrong with that. Money will follow the patient and the choices they make about where and by whom they are treated.

The noble Lord, Lord Owen, indicated his belief that the policies that the Government are advancing will damage clinical professionalism and remove the intimacy inherent in the doctor/patient relationship. I say to the noble Lord gently and with huge respect that I do not believe he has any basis whatever for suggesting that. I would argue, on the contrary, that clinically-led commissioning brings the design of services closer to patients.

[Lord Owen]

Will the Minister ensure that the phrase “any qualified provider” will not involve EU competition policy and the possibility of legal action being taken in a commissioning decision?