Health and Social Care Bill

Lord Beecham Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Warner]

My Lords, I want to say a few words about children in this group of amendments. I know and agree with the arguments put forward by the noble Baroness, Lady Cumberlege. We do not want this to become a huge talking shop. I sympathise with and support that idea, but I think that children are different in kind, in part for the reasons given by the noble Baroness, Lady Benjamin. If we are serious about investing in the future, we need to pick up some of the issues around children much earlier. Diabetes and obesity are big issues facing our society. Many of our services are not very good at picking up the needs of children and responding to them in a comprehensive manner. There are lots of organisations that speak on behalf of them, just as there are lots of organisations that speak up for other interest groups, but I would say that the investment issue on children is much more significant than the investment issue on 80 to 85 year- olds, or even 70 year-olds. That is not to say that those people do not need a good or compassionate set of services responding to their needs, but if we as a society neglect the voice and needs of children, we are just bringing a lot of problems upon ourselves as a society—more so than if we have less good care at much older age groups.

From my time as a Minister, I thought that the voice of the child in the NHS was really quite muted. The working across boundaries in the needs of children is often far less good than it should be. We need to put in the Bill a stronger requirement to listen to the voice of children and to have their representatives fully focused in the health and well-being boards. They are different in kind and their voice has not been heard enough. Too often, public services operate through parents rather than going straight to the child. That is particularly an issue with young carers and with adolescents. We need a bit of a wake-up call on the needs of children in our NHS and social services and across the spectrum of their needs. I hope that the Minister will look carefully at this issue in the particular circumstances of children.

[Lord Beecham]

My Lords, these few clauses relating to health and well-being boards are perhaps less politically exciting than many of those that we have spent days debating—days that are rapidly drawing to a close—but they are potentially highly significant and their importance will be realised over time. The purpose of these boards is to facilitate integration between local government and the National Health Service in the planning and provision of all services relevant to the health and well-being of the present and the future population. They should take a strategic view of a range of services—health in its conventional sense; public health, which is now effectively to be restored to local government; social care; children’s services; housing; environmental services; leisure; and the criminal justice system, all of which have been mentioned by various of your Lordships this morning.

In addition to that fundamental strategic role, these clauses provide for greater democratic accountability at local level and the engagement of the community and the voluntary sector. As we have heard, they also ought to provide for the engagement of staff with a range of professional skills to be brought to bear on the issues that communities face.

I listened with some care and, frankly, growing concern to the observations of the noble Baroness, Lady Cumberlege. If I may say so, she got it wrong about the purpose of the health and well-being boards. They are not operational boards. They are to produce a health and well-being strategy. They operate at that level. They will not be directly involved with implementing that strategy. They will not be responsible for the range of services which will be required both to work together and to work efficiently to impact on the health and well-being of an area.

The noble Baroness also perhaps misunderstands how influential bodies like local government can be. When I had responsibility in the area of social care in Newcastle, many years ago, I was able, with a committee of 15, to drive through a significant programme of change in our authority. We created one of the first welfare rights services, we trebled meals on wheels, we doubled the home help service and we made vast changes in the way that we provided for children’s services and adult services alike. It is perfectly possible to do that with a reasonably sized committee, provided that there are people on it with the kind of vision which is necessary, and people in the employ of whatever authority is providing those services who, equally, have drive, sensitivity and vision.

In looking at the role of the health and well-being boards, then, we have to have regard to that area of responsibility. Of course they will be working to an agenda which will actually be set rather separately, in a sense, because it is the local authority and the clinical commissioning groups which will be responsible for the preparation of the joint strategic needs assessment. That is the basis upon which matters will have to be carried forward.

I am afraid that the noble Baroness, Lady Jolly, joins the noble Baroness, Lady Cumberlege, in possibly having slightly misunderstood the nature of one of the problems that she touched upon. She is absolutely right that housing has to be an integral part of the programme to deal with health, both for communities and individuals, but her amendment is the wrong way around. It is not that the health and well-being board has to take into account the views of the planning authority. It is the other way around—the planning authorities and housing authorities should be drawing up their plans on the basis of the strategic needs assessment and the health and well-being strategy that follows it. We are not at odds about that, really; it is perhaps simply the wording of the amendment. I will have to make a confession about the wording of my amendments later, so I might also plead guilty to the charge that I have levied at noble Baronesses opposite.

Before coming on to the amendments as such, there are two or three questions upon which I would like to hear the Minister’s views. The first is in relation to the relationship between the national Commissioning Board, and its local outposts in particular, and the health and well-being boards. The Bill refers to the position of the national Commissioning Board, but I am interested to learn how he sees the role of the local outposts—I think that is the phrase—which will be established, because part of the agenda which will remain with the national Commissioning Board will impinge pretty directly upon the local strategy and will have very significant and very specific local implications.

Going beyond that, perhaps the Minister would comment upon whether the Government intend to replicate at national level the kind of joint working across departments that they are, perfectly properly, looking to create at local level. Will we see some ministerial committee or some forum for relevant government departments? I go beyond even those that have so far been mentioned. I am thinking in particular of the Department for Work and Pensions and the impact of the Welfare Reform Bill, as well as its general responsibility for benefits; and, bearing in mind the observations of many noble Lords about having regard for the needs of children and young people, but also adults and people with learning disabilities and so on, the Department for Business, Innovation and Skills clearly has a role. It would be interesting to learn whether the Government’s thinking has taken them beyond the local level to looking at how these matters might be addressed nationally.

In addition to that, there is the question of community budgeting, as the phrase now is: whether it is envisaged that it has a role in this context and whether some of the pilots being considered nationally could address those issues.

I will now speak to the amendments in my name and those of my colleagues, Amendments 330ZB, 330ZAB, 331A, 331AAA, 335A, 336A and 336AA. Amendment 330ZB requires the publication of an integrated commissioning plan to which all partners must have regard. That might go somewhat beyond the terms of the Bill as it stands at present, but it seems essential that there should be an integrated commissioning plan across the piece. We are, after all, talking about very considerable sums of public money being spent. Since most of the health budget as such is being devolved to clinical commissioning groups, we are talking about £80 billion nationally. That would be translated into smaller but nevertheless significant sums of money locally, to which would be added the local authority’s own contributions in any given area across its own responsibilities. For a large authority, we are probably talking of a budget of close to £1 billion —possibly more—which will be encompassed within, though not directly administered by, the health and well-being board.

Amendment 335A calls on the health and well-being board to have the responsibility of signing off the clinical commissioning group’s commissioning plan. This is to ensure consistency and a degree of accountability for the work undertaken by the clinical commissioning groups. That is backed up by another amendment which gives the health and well-being board the right to request information as to the progress in implementing the strategy, so that, in addition to the scrutiny committee of the local authority—it in any event has a wide range of possibilities to scrutinise what is happening—the board itself, having set the strategy, is able to see how it is being implemented.

We now come to the question of membership. This is certainly a somewhat difficult issue. There are a whole range of amendments, most of which I would agree with, setting out the wide range of organisations which should be included in membership of the board. They include representatives of education providers; pharmacies; the probation and police services, mentioned by the noble Lord, Lord Ramsbotham; allied health professionals, about whom the noble Baroness, Lady Finlay, spoke; and people from the field of alcohol and drug abuse and the field of safeguarding. It is a significant number.

The Bill at present constitutes the health and well-being board as a committee of the local authority, yet somewhat paradoxically, as the noble Baroness, Lady Jolly, pointed out, only requires a single member of a local authority to be appointed to a board. Admittedly, this is as a minimum, but it could hardly be less. Interestingly, my own authority in Newcastle recently agreed a shadow board, in my absence, which is 25 strong. That strikes me as slightly on the high side, but it includes two representatives from each of the two clinical commissioning groups in the city, from the three trusts that serve the city and from a range of other organisations —many of which reflect the bodies to which noble Lords have referred this morning in debate or in amendments—as well as just three councillors.

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[Lord Mawhinney]

I am most grateful to the noble Lord. I think he knows that I listen carefully to him when he is on his feet. The essence of a democracy is that people are elected to represent their community. I can see an argument for having some professionally trained people adding their expertise, because it might be a stretch to expect locally elected people to command the technicalities of a professional view, but given that commitment of democracy, why does the noble Lord think it necessary to have so many other people representing—in the best possible spirit, I hasten to add—specialist vocations or vested interests?

[Lord Beecham]

In the first place, I am grateful to the noble Lord, Lord Mawhinney, for recognising when I am on my feet, given that there is not much of me to be seen. In relation to his question, I am not suggesting that they should be voting members. That is the point. There is a difference. The voting members—I do not mean executive members—should be confined to elected councillors and those representing the other partners, the clinical commissioning groups and the trusts. It is a partnership arrangement. You have this sort of arrangement in care trusts and the like. It is an acceptable one, but at the very least there should be equality of arms between the elected members and those from other organisations.

[Baroness Murphy]

Can we be quite clear that the noble Lord, Lord Beecham, is asking for a health and well-being joint board on which the director of social services and the director of public health—two crucial people contributing to the board—have no vote?

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[Lord Beecham]

That is exactly right. They do not have a vote in the council, which determines a budget of several hundred million pounds and deals with huge issues of social care and public health. They are paid officers. That is a distinct, separate role. On this, the noble Lord, Lord Mawhinney, and I are entirely at one.

There are ways in which the current positions can be improved. I hope that the Minister may be able to give an indication today that there is some scope for change. However, there may be issues that we need to address on Report if what is basically a good plan cannot be further improved today.

[Baroness Cumberlege]

I do not really accept the noble Lord’s criticism of my thinking. Of course I understand that these health and well-being boards are essentially planning boards. I will read very carefully what he has said in Hansard, but I am sure he accepts that you cannot do the planning if you are totally ignorant of the implementation of what you are planning. Clearly, finance and other things come into this. The health and well-being boards that I have spoken to say that what is really important to the success of the board is the equality of members on it. If he is saying that only local government councillors have a vote, I think that people who also hold budgets—the clinical commissioning group people and the health people—would be very upset if decisions were made involving their finances without them having an opportunity to put their case in a vote, if it comes to that. Again, the boards that I have been speaking to and working with have said that they would always try very hard to avoid a vote.

When I came into the health service from local government, I found the whole culture very different. I enjoyed working as an equal partner with those who were advising me, such as the district or county medical officer and others. We really should leave this to the health and well-being boards to decide how they want to run their business. Why do we always think we know best? Every health and well-being board will be totally different, representing different areas of the country and all sorts of different interests. For once, let us have a light touch and trust the people who are going to be doing this business.

[Lord Beecham]

I think we need to set out a minimum requirement. That is all I am seeking to do. I am not seeking to circumscribe.

[Baroness Cumberlege]

It is in the Bill.

[Lord Beecham]

The minimum requirement in the Bill is the wrong requirement. That is the point for some of us, at any rate.

[A noble Lord]

Rubbish.

[Lord Beecham]

Rubbish is the responsibility of district councils, as the noble Baroness, Lady Jolly, would point out—at least its collection is.

We clearly do not agree about this. The Bill does not go sufficiently far to underpin democratic accountability. It goes too far to entrench professional and bureaucratic interests, whose voice should certainly be heard but who should not be able to vote on these decisions, just as they are not in central or local government.

[Earl Howe]

My Lords, this group of amendments has prompted a very worthwhile debate. They all relate to health and well-being boards, and in particular their statutory minimum membership, their responsibility for preparing joint strategic needs assessments and joint health and well-being strategies, as well as their role in promoting integration. On the first of these issues, concern has been expressed about the membership of health and well-being boards. I am sympathetic to the very important points that several noble Lords have raised. We are all keen to ensure that health and well-being boards access the best expertise and professional advice on the myriad complex challenges facing the health and well-being of their local populations. However, taken together these amendments would significantly increase the minimum membership of each health and well-being board, making the requirements substantially more prescriptive. We want to preserve local discretion and flexibility in these arrangements and the ability of boards to shape wider membership in a way that reflects local priorities. These amendments would severely limit that flexibility and discretion. Their other big downside is that they could lead to larger and somewhat unwieldy boards, making meaningful dialogue and decision-making more difficult. My noble friend Lady Cumberlege was absolutely right to sound the note of warning that she did.

In general, we want to avoid being too prescriptive. The Bill sets out a minimum membership for health and well-being boards, but members can be added by either the local authority or the health and well-being board. I would say to the noble Lord, Lord Beecham, in particular that following the Future Forum report, we made a commitment that it will be for local authorities to determine the precise number of elected representatives on their board. We fully recognise that health and well-being boards will want to draw from a range of expertise beyond the statutory membership, such as clinicians, allied health professionals, police, probation service and voluntary sector groups. However, in deciding who to invite, they will need to consider local needs and priorities and the delicate balance between having the right people and having too many to make it an effective board.

The noble Baroness, Lady Finlay, was quite right to emphasise that the right people needed to be there. It is perhaps worth highlighting in that context that we have retained the power for the Secretary of State to issue guidance on the preparation of joint strategic needs assessments, and there will be power to issue guidance on the preparation of joint health and well-being strategies, particularly when it comes to defining what best practice looks like.

The noble Lord, Lord Beecham, asked how the NHS Commissioning Board would fit in with health and well-being boards. The NHS Commissioning Board will be required to send a representative when asked by the health and well-being board and where the discussions touch on the proposed exercise of local commissioning functions of the commissioning board, for example when discussing primary care commissioning. It will also be required to send a representative to participate in the health and well-being board’s preparation of the JSNA and a health and well-being strategy. With the agreement of the health and well-being board, the Commissioning Board may appoint someone to represent it who is not its member or employee, such as a clinical commissioning group representative.

[Lord Beecham]

Does that mean that it will be the local outpost, if that is the correct phrase, of the national Commissioning Board that will have that relationship, or will this in effect be directed from London?

[Earl Howe]

It will almost certainly be the local outpost that will have direct responsibility for those matters.

A number of amendments would introduce specific requirements in relation to the JSNA, but before I move on to that I have been informed of something that I think I probably implied, if not stated. It would be up to the board to decide who would be most appropriate to attend at a particular health and well-being board meeting.

I agree that the JSNA must be a full analysis that covers the current and future health and social care needs of the local population. It will be a framework to examine inequalities and the factors that impact on health and well-being. This could include aspects such as deprivation. Its scope will naturally include health and social care needs that are related to a wide range of areas, such as alcohol harm, disability or older people.

Health and Social Care Bill

Lord Beecham Excerpts

Tuesday 13th December 2011 Lords Chamber

[Baroness Finlay of Llandaff]

I thank the noble Baroness. I am most grateful. That message had not reached me, although I may be a little deaf. I shall simply confine my remarks to the amendment in this group about Monitor reporting annually to the Secretary of State on how it discharges its duty to promote integration. I do not think that the comments that I made previously are annulled. They are relevant because, unless we have integrated services—however much they may be seen to be in competition with each other over different aspects—and attempt to have a seamless provision of care, at the end of the day it will be the patients who fall through the gaps.

Earlier today, we heard a lot about Monitor being light touch, not having a series of minimum criteria and being able to use its discretion in how it grants licences of all sorts. But I have a concern that there has to be a means by which the way in which Monitor functions is transparent and available to public scrutiny. That is why I have suggested that an annual report to the Secretary of State would allow such scrutiny to occur, particularly as regards promoting integration.

[Lord Beecham]

My Lords, in the first instance, I shall speak to Amendments 267ZDA and 269 in the names of my noble friend Lady Thornton and myself. Amendment 267ZDA refers to the need for integration. Indeed, there are a series of amendments on integration, with which I will try to deal as a group. Amendment 267ZDA gives an interpretation of integration which would,

“mean that health-related and social care services are provided in such a manner that individuals will experience services … as being independent of organisational barriers”—

which I suppose is the very definition of integration—and which offers patients,

“the most appropriate involvement in their care choices … which reduce … the need for separate assessments; and … which result in a care plan for the individual which covers all aspects of their care”.

Surely that aspiration would be shared by the Committee and widely within both the health and social care professions. It would seem to make sense to incorporate it in the Bill. However, Amendment 269 simply makes clear that it is unnecessary for a provision in the Bill to repeat a definition of anti-competitive behaviour since that already exists in existing legislation, although that is not a hugely important point.

In relation to other amendments in terms of integration, we certainly support Amendment 268B, which would provide the duty for Monitor to report annually as to how it has promoted integration. Amendment 274B seeks a requirement to publish a statement if conflicts between its functions arise which are likely to have a significant impact on integration of services. Amendments 278 and 278B impose requirements on the national Commissioning Board and clinical commissioning groups to extend the right of patients to make choices in respect of the integration of healthcare and to ensure the integration of services where that is in the public interest. Again, the aim is to drive the integration agenda. Then, as an overarching provision, Monitor would have under Amendment 278C the power to investigate whether the Commissioning Board and clinical commissioning groups are complying with those requirements. All of these seem to be perfectly sensible amendments to provide the right structure and one which Monitor could effectively supervise.

Still on the integration agenda, there are later amendments—Amendments 286A, 287 and 287B—which impact on integration. Amendment 286A allows a modification of Monitor’s powers to encourage integration, if that is in the interest of patients, as it usually will be, presumably. The amendments provide for modifications to licence conditions—again in the interest of integrated healthcare—to ensure that standing conditions of licences include requirements relating to or encouraging the integration of healthcare services. All that makes a sensible package to drive an important part of the underlying concept of the Bill and the too-long-deferred integration of services.

The other amendments in this group essentially relate to the issues of collaboration or competition. Here, it is slightly unfortunate that the noble Baroness, Lady Finlay—I am sorry, the noble Baroness, Lady Hollins—did not move Amendment 265ZA, which stresses that Monitor must exercise its functions with a view to promoting collaboration and preventing competitive behaviour. I think that is the other side of the coin that the noble Baroness, Lady Murphy, put on the table previously when she was complaining, perhaps rightly, about anti-competitive practices within the NHS. A more positive way of looking at that agenda is to say that NHS bodies should collaborate on the provision of services, rather than take a negative stance. That is, I suppose, a necessary fallback position, but the prime objective must be to ensure collaboration within and across health service provision and—having regard to what has just been indicated in relation to integration—with social services as well. That is probably the right approach.

Other amendments in this group relating to competition raise some other issues. For example, under Amendment 265C, there is a suggestion that Monitor’s duty to prevent anti-competitive behaviour should be qualified by requiring it to aim to improve the quality of services and outcomes and the efficacy of provision and reduce inequalities. These are listed separately; I take it that all of them—rather than any alternative—are intended to be part of Monitor’s duty. If the Minister were minded to accept the thrust of that argument, he would do so in that sense.

Again, there is the provision under Amendment 266, tabled by my noble friend Lord Warner, for Monitor to conduct and publish a review of anti-competitive barriers and their impacts within a year of Royal Assent. There may well be some sense in that, particularly in regard to the way in which he moved the amendment. There are similar duties on Monitor to look at impact assessments under Amendment 275. Government Amendment 278D, to be moved by the Minister later, refers to non-disclosure of the “business interests” of parties. Does that extend to the interests of, say, trusts or voluntary sector providers? Does “business” relate to their activities or would it be confined to commercial providers? It seems to me that it would be invidious if only one part of the provider sector had the protection of confidentiality; it should be applicable to all or none. There is of course no issue with the amendment that requires individual circumstances not to be subject to disclosure.

I have a question about Amendment 278J, which requires the Competition Commission to review the “occurrence” rather than the “development” of competition in the provision of healthcare services. It is not clear to me what the significance of the word “occurrence” is. This is not a government amendment and I do not know whether those who originally tabled it want to clarify the position. I understand the amendment if it requires the Competition Commission to review the impact of competition in the provision of healthcare services, but I do not know how the occurrence of competition would be reviewed. It does not actually make much sense to use the word in this context.

The thrust of most of these amendments makes sense and sets out a sensible role for Monitor. In what would have been the next group but for the leapfrogging, we will come on to look at the issue of conflicts, and I am sure that there will be some further discussion about that. However, I hope that the Minister will feel able broadly to support the amendments in this group and recognise that they should contribute to meeting the shared objectives that have emerged from today’s debate.

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[Lord Beecham]

My Lords, it saddens me to say that 41 years ago I became opposition spokesman on the Newcastle City Council health committee. Within two years, we had the Seebohm report and a change of structure, leading to the creation of a social services committee that embraced both children’s and adult social care and replaced two committees—the old health committee and the old children’s committee. That seemed to me then and, frankly, it seems to me now to have been the right approach, because I do not think that you can sensibly divide children’s and adults’ social services. We do not have that system now. My personal view—which is not necessarily the view of the Opposition—is that it may be time to look again at that division. To an extent, the group of amendments that the noble Baroness has spoken to seeks to secure that objective.

As a consequence of the way in which amendments are ordered, the actual order of the amendments in this group is not quite logical. I suppose one should start with Amendment 269B, which would give Monitor functions relating to children’s social care services. Earlier, we touched on the possibility of Monitor having a role in respect of adult care services. Presumably, one would look at both services coming under their auspices, or neither, rather than keeping a division. Amendment 269B sets out the basic role for Monitor in this context. I note that proposed new subsection (2) would include within the functions,

“inspection of, and reporting on, the potential impact of children’s social care services in a particular area on the potential need for adult social care in that area”.

I am tempted to say “and vice versa”, because so often problems of parents and adults impinge on the needs of the children, and that would make perhaps a more rational disposition of functions.

The other two amendments in this group are, in effect, consequential, and sensibly would require local authorities to ensure a smooth transfer and, as Amendment 270AA puts it, “a careful handover” for children moving into adult social care. All of those seem to me very sensible suggestions. Nevertheless, it is probably better to look at the whole context of where social services fall within the remit of the Bill.

I imagine that there will have been some discussions between this department and the Department for Education, although the way in which Whitehall and, for that matter, local government tend to work, it is not necessarily the case that the relevant organisations come together to discuss these issues. It may be, therefore, that the Minister would wish to consult colleagues in other departments before giving a measured response. Perhaps this matter might be best brought back at Report, because it raises significant issues. As I have indicated, I have felt for some time that the division of responsibilities at the moment is not terribly sensible, with children’s social services being, arguably, at best a sort of fifth wheel on an education coach. At the very least, that matter ought to be re-examined. Perhaps it is too late in the day for it to be part of this Bill, but at some point, I think, this issue certainly needs to be referred to. I congratulate the noble Baroness and the noble Lord, Lord Northbourne, on having put down this amendment, which gives us an opportunity at least to ventilate concerns about this issue.

[Earl Howe]

My Lords, I understand and well appreciate the concern of the noble Baroness to ensure a high standard of children’s social care services and, in particular, a smooth transfer for young people moving from children’s to adult social care services. I would, of course, be very happy to speak to her and indeed the noble Lord, Lord Northbourne, about this issue away from the Committee, if they consider that to be an appropriate way forward.

On the specific amendments that we are looking at, I really do not think that Monitor is the right organisation to ensure that local authorities are carrying out their responsibilities on these issues, or to act as a regulator of children’s social care services. I am confident that existing arrangements for the regulation and inspection of children’s social care are sufficient and robust. Joint working is important and I hope that the noble Baroness will be reassured that the relevant inspectorates are already working together to improve the arrangements for joint inspection, which will address the very important issue of child to adult transition that she has raised.

Children’s social care is regulated and inspected by Her Majesty’s Chief Inspector of Education, Children’s Services and Skills—Ofsted. Its inspection remit covers all local authority social services functions relating to children—that means services for children in need, safeguarding children, children in care and care leavers, as well as adoption and adoption support services. Local authority adoption and fostering functions must be inspected by Ofsted at a minimum of every three years. Ofsted can of course make unannounced inspections.

We are already working to improve these arrangements. Ofsted consulted over the summer on local authority child protection inspection arrangements that will be more child-centred and less bureaucratic. This new type of inspection will begin in May next year. In addition, all relevant inspectorates have agreed in principle to Professor Eileen Munro’s ideal model of joint inspection, which looks at the contribution all services make towards protecting children. Noble Lords may recall that Professor Munro last year conducted a thorough review of child protection arrangements for the Government. The Care Quality Commission is one of the inspectorates working with Ofsted to establish what those services will look like and when they will begin.

For children with special educational needs and disabilities, the recent Green Paper proposes a new education, health and care plan, covering support from birth to 25. The new plan will include a much clearer focus on the long-term outcomes for children and young people including independent living and employment. This should improve outcomes for young people with special educational needs and disabilities as they make the transition from school into employment or training.

I hope that the noble Baroness will appreciate that work in this area is ongoing. I sympathise with the tenor of all she said, but if she is content to wait for a discussion following these Committee proceedings, I hope that she will, in the mean time, withdraw the amendment.

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[Lord Nickson]

My Lords, I am afraid that I was not present at Second Reading but I am moved to support this amendment on a personal basis as my wife is in long-term social care in Scotland. It was a Southern Cross home that has now been taken over by Healthcare One. It would have been a comfort to me had I known that an organisation such as Monitor was supervising the very unhappy situation in Southern Cross, but I have to say that the communications from the local authority concerned in Scotland both with me and Southern Cross as it was in its death throes were absolutely first class in attempting to reassure and keep us in touch with what was happening. I am equally glad to say that all the information and everything coming now from Healthcare One is very reassuring and makes one full of confidence. It would have been reassuring had something like Monitor been in the background looking at this sort of situation well in advance. I support the amendment.

[Lord Beecham]

My Lords, I am happy to endorse all the amendments in this group, with the exception of Amendment 270. I particularly endorse Amendment 274ZZB tabled by my noble friend Lord Warner. He is 100 per cent right in this context. I have to say in confidence to the Committee that I do not always entirely agree with my noble friend, but he is exactly on the right lines today. The situation to which he referred clearly causes great concern. We heard from the noble Lord, Lord Nickson, that fortunately matters turned out reasonably well in his case and that of his wife, but who is to say that that would always be the case? I hope that the Minister will feel able to take on board the suggestion made by my noble friend Lord Warner. As he said, it is a probing amendment but it is one that I hope will lead to an outcome that will guarantee that problems of the kind generated and disclosed in the Southern Cross affair will not arise again so that those in residential care and their carers and families will have greater confidence in the system—a confidence that must have been shaken by events in recent months.

[Baroness Northover]

My Lords, this is the group of amendments that we almost came to earlier this afternoon. I hope that noble Lords who thought that their issues would be in that last group have now gathered them together, as they are back in this group. The amendments cover a number of issues, including patient and public involvement in Monitor’s work and the advice that it should take. The Government are clear that Monitor should involve patients and the public in its decisions and get appropriate clinical advice to enable it to carry out its functions. That is why in another place we introduced Clause 59(7), which creates a duty on patient and public involvement, and Clause 59(8), which creates a duty to obtain clinical advice. For Monitor to carry out effective patient involvement, it will almost certainly need help from people or organisations with expertise. Here I address in particular Amendment 267A, and Amendment 267B in the name of my noble friend Lord Clement-Jones and others.

However, setting this out in the Bill could constrain Monitor’s flexibility to decide how and when it sought such help. We do not want to create bureaucratic and potentially costly arrangements that would require Monitor to take such advice even when it was unnecessary. I hope that, over time, Monitor will develop expertise in how best to involve patients and the public in its decisions, reducing its dependence on professional advice in this area.

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[Baroness Williams of Crosby]

My Lords, I can address my Amendment 274ZB very quickly. I have to admit that it arises from a fog of misunderstanding. Frankly, I do not know what this subsection means. Under Clause 63(3), there can be a Monitor intervention in a situation where Sections 109 and 111, which address themselves to various aspects of foundation trusts, can be completely waived without any regard to the fact that they are looking at competition and pricing as regards profoundly sensitive subjects. I wish that I could say that I know what it means but I do not. Instead I have put down an amendment which simply proposes leaving out that subsection. If the Minister can enlighten me, perhaps I will put it back in again. At the moment, I simply do not know what I would be putting in or out. I apologise to the House for such absurd and detailed ignorance, to which I confess with great humility. But I hope that the Minister will be able to enlighten me because so far no one else has been able to do so.

[Lord Beecham]

My Lords, at Second Reading I made a jocular reference to Monitor, recalling that it is also the name of a carnivorous reptile. Having regard to the range of duties and responsibilities that the Bill seeks to impose on Monitor and the number of organisations with which it will have to work—ranging from the Competition Commission, the Office of Fair Trading, the national Commissioning Board, clinical commissioning groups to foundation trusts—carnivorous seems to be the wrong word. Omnivorous would appear to be a better term for the job which the Government seek to give to this unaccountable body.

We certainly accept the need for an organisation—Monitor is no doubt the appropriate one—to be responsible for the rigorous financial regulation of all providers to the National Health Service. We approve the concept of a licensing scheme. Where we part company from the Government is that we do not accept that the handing over of economic regulation of the whole of the health service to an unaccountable quango—it is unaccountable—is the right course of action. We think that oversight of the whole system should remain vested in the Secretary of State, as opposed to the detailed regulation of individual parts of that system. Therefore, we think that there are two distinct roles.

We are particularly reluctant to envisage the wider scope that the Bill seeks to confer on Monitor in the light of what its chairman, the noble Lord, Lord Owen, who is not now in his place, reminded us this morning. He was at pains to make it clear that there is an analogy between the health service and the utilities. He cited the railways, gas, water and electricity. The whole nation of course resounds with rejoicing from the users of the railways, and gas, electricity and water, who are thrilled with the services that they obtain and the prices that they have to pay. That, apparently, is the model which recommends itself to the chairman of Monitor.

Much has been said in some thoughtful, forceful and frankly brilliant expositions today by the noble Lords, Lord Clement-Jones and Lord Owen, the noble Baroness, Lady Meacher, and other noble Lords about the need to have a discrete function of dealing with the foundation trusts and the rest of Monitor’s responsibilities. Some of that is encompassed within amendments, such as Amendment 274ZB, that are before us this evening. That seems to be right: in particular, if the fears of the noble Lord, Lord Owen, about the position of foundation trusts in relation to European competition law are to be realised, then it is all the more necessary for a continuing role for Monitor in relation to foundation trusts. We certainly see this not merely as a transitional provision, but one for the longer term.

There is a job for Monitor to do, but there is a clear risk of conflict for the organisation in the terms that the Bill now provides. They may be so conflicted as to require the attentions of the noble Lord, Lord Alderdice, if they have to resolve these potential conflicts of interest, and that would not be in anybody’s interest. The Government really should think again about what they expect of Monitor and how it is to be rendered accountable, because there is clearly a widely shared view in the Committee and the House generally that the present prescription is simply not adequate for the purposes that the Government wish to see carried out.

[Earl Howe]

My Lords, Clause 63 sets out several provisions detailing how Monitor should deal with potential conflicts in relation to its general duties, and conflicts with regard to its functions. It would be helpful to cover each of these in turn. The noble Lord, Lord Davies of Stamford, will not be surprised to learn that I did not agree with much of what he said. We should not find it surprising, because it is not uncommon for bodies to have potential conflicts of interest. What matters is how they are dealt with, and the Bill sets out a robust framework for Monitor to operate effectively. In theory, there is a possibility that Monitor’s general duties, as set out in Clauses 59 and 62, might conflict—if, for example, the most economic, efficient and effective provision did not deliver fair access because that access was limited to certain days and times or locations. If a conflict did arise, we are clear that it would need to be resolved effectively.

In order to be a successful independent regulator, Monitor would need to be able to resolve any conflicts that may arise. It would be closest to these conflicts, and it would be best able to weigh up the potential risks and benefits. Balancing competing priorities is just a reality of life, and resolving such conflicts is a key function that all public bodies need to carry out. When considering how to resolve conflicts, we believe that Monitor should do so in the manner it considers best, in line with its overarching duty to protect and promote patients’ interests. I am not going to call patients “consumers”, but in response to the noble Lord, Lord Beecham, who has tempted me, it was Alan Milburn who said in 2004, when he was Secretary of State for Health:

“In the business world success today depends on being flexible enough to innovate and responsive enough to meet consumer demands. Public services have to apply the same lessons”.

I do not want to press that analogy too far, but we all know what we are talking about when we talk of patients as consumers who require the same kind of care in terms of centring priorities on their interests.

I want to reassure the Committee that when resolving any conflict, Monitor would have to take into account the need to maintain the safety of the people who use healthcare services. Indeed, Monitor would be able to take this and a range of other issues into account when resolving any conflict between its duties. However, Amendment 274ZA would go further. Its impact would be that, in resolving any conflicts between its general duties, Monitor would always act with a view to maximising safety—potentially at the expense of its other duties. This would be inappropriate: it could cut across the role of the CQC, not to mention potentially undermine the role of commissioners and the independence of clinicians. It could also undermine individual patient choice. I can elaborate on that if noble Lords would like me to.

Similarly, while I sympathise with the desire to ensure that providers do not face unnecessary burdens, there may be occasions where a conflict solution that imposes the least burden on providers is not the most effective. Amendment 274ZAA, in the name of the noble Baroness, Lady Finlay, would impose resolutions that prioritised the least burden on providers over all other considerations. I think that is a mistaken way to go. We believe that Monitor should be free to decide how best to resolve conflicts between its duties, and therefore I would encourage the noble Lords who tabled these amendments to withdraw them. Nevertheless, I will consider—as I indicated earlier—whether it would be appropriate for the Bill to rationalise within Clause 62 matters to which Monitor must have regard. This would help Monitor decide how to resolve any conflicts. Therefore, I hope noble Lords will appreciate that I am not impervious to their suggestions on this clause.

Let me turn now to potential conflicts between Monitor’s functions. For clarity, Monitor’s functions include those it has as sector regulator, which are: ensuring continued access to NHS services; setting and regulating prices; preventing anti-competitive behaviour and licensing providers of NHS services. In the short term, Monitor would also continue with specific oversight functions over foundation trusts. As with Monitor’s duties, we need to ensure that any conflict between these functions is resolved effectively. Clause 63(2) requires Monitor to make arrangements to avoid potential conflicts of interest between its specific functions as foundation trust regulator and its broader functions as sector regulator, which are provided for in this Bill. I think we are all clear that we need to have appropriate arrangements within Monitor to mitigate and manage potential conflicts of interest between its functions. The Bill does not prescribe exactly what arrangements Monitor should make for this; it gives Monitor flexibility to determine the most effective arrangements, but we would expect that this would necessarily involve some separation of decision-making. This may need to be underpinned by informational separation and other working arrangements at operational level.

[Lord Beecham]

Would such proposals by Monitor have to be approved by the Secretary of State or would it be left entirely to Monitor to decide without reference to the Secretary of State?

[Earl Howe]

My Lords, I think we will rely on Monitor to make its own arrangements and, as the Committee will appreciate, there are limits to how far it is sensible to prescribe in legislation what the arrangements should be. Nevertheless, picking up the noble Lord’s prompt, I am sympathetic to the concerns that have been raised in this general area and I undertake to discuss the matter further with Monitor.

To create legal certainty, Clause 63(3) clarifies Monitor’s arrangements to resolve conflicts further, so when preventing anti-competitive behaviour and setting and regulating prices, Monitor must ignore its transitional regulatory functions relating to foundation trusts. I hope that addresses Amendment 274ZB, tabled in the name of my noble friend Lady Williams. The meaning of this provision—

Health and Social Care Bill

Lord Beecham Excerpts

Wednesday 7th December 2011 Lords Chamber

[Lord Warner]

I was the Minister responsible for the MHRA and very much share the noble Baroness’s views on this. There are some slight differences, one of which is that a lot of the funding for the MHRA, in effect, comes from the pharmaceutical industry, in terms of licence fees. However, I was well aware of the MHRA experience, and my own experience of it, in trying to craft Amendment 257ZA, which does bear some resemblance to that. I certainly would not argue with the idea that the number of non-executives under my amendment should be larger than three—it does say “at least three”. I will certainly go along with her that some outside expertise, in quite substantial numbers among the non-executives, is an extremely good model.

[Lord Beecham]

My Lords, I am tempted to open by invoking, if not the Health Protection Agency, then perhaps the protection of the local environmental health department, because conditions in this Chamber, at this temperature, are hardly conducive to anyone’s good health. However, that is a matter perhaps for the House authorities to look at.

I rise to express the view that Clause 53 should not stand part of this Bill and to support my noble friend Lord Warner’s Amendment 260. I do the latter on the basis that that would be a fallback position, because I entirely concur with the view expressed in particular by the noble Lords, Lord Turnberg, Lord Patel and Lord Walton, and the noble Baroness, Lady Finlay, who have of course such a distinguished history as leading clinicians in these and other medical fields. Part of the thrust of the argument is the need to maintain not only a functioning organisation which has, as we have heard, an international reputation, but also to ensure that any such organisation has the requisite degree of independence from Government—that is, the right and in fact the duty, as the noble Lord, Lord Turnberg, made clear, to advise the Secretary of State and the Government generally without fear or favour.

Amendment 260 would create an executive agency for the Health Protection Agency. It is arguable that executive agency status would not of itself lead to the required or desired degree of independence whereas perhaps a special health authority would conceivably achieve that. There is a difference of view from the Government about the status of a special health authority. Their preference for Public Health England is that it should be an executive agency. They argue that a special health authority would not be appropriate. They point to analogous situations of agencies created for the Medicines and Healthcare products Regulatory Agency and curiously, by way of analogy, the Met Office, as organisations which are deemed to have sufficient independent status, albeit operating as executive agencies of their respective departments.

Neither of those arguments can be sustained. The role of Public Health England is a much wider one than either of the two bodies to which their document published earlier this year refers. A regulatory agency is not the same as an organisation which has to advocate and oversee a wide range of services, such as Public Health England would be required to do, and the Met Office is hardly an organisation which is required to be independent of Government in preparing its weather forecast. The analogy is somewhat ludicrous.

There is also, of course, the very important point made by noble Lords about the need for independent status in order to attract some of the funding, both charitable and contractual, on which in particular the Health Protection Agency is critically dependent and which might be endangered by its absorption into Public Health England in a way which would make it clear that it is no longer independent. That is not to say that the creation of Public Health England in the form of a special health authority would not of itself be desirable. The bringing together of a range of functions under the auspices of Public Health England, although not, I would argue, the Health Protection Agency, would be welcome.

A number of professional bodies have commended the principle but clearly have reservations about how the new structure would work. The Association of Directors of Public Health, for example, makes it clear that Public Health England should include health protection and emergency planning, health improvement and health services in its main areas of work and, in addition, provide an independent science base and advice to the Government and the devolved Governments. One of the arguments against creating a special health authority was that it would not be able to deal with devolved Governments. I would have thought that that is something that the Government could deal with relatively easily.

The role of Public Health England should also support the national Commissioning Board and provide support for local directors of public health. However, the association expressed concerns about the role and status of directors of public health. We recently discussed some of those in Committee. It also had concerns about the input into the national Commissioning Board and the lines of accountability. We will have Public Health England, the clinical commissioning groups, the directors of public health and various other functioning arms of the National Health Service, and it is not clear how the relationship would work and, in particular, what the role of Public Health England would be. The association has argued strongly for consolidating public health capacity into Public Health England with overall responsibility for improvement, protection and promotion of health care, and for public health intelligence and analysis.

Health and Social Care Bill

Lord Beecham Excerpts

Wednesday 7th December 2011 Lords Chamber

[Baroness Finlay of Llandaff]

I have my name on the amendments about setting up the authority. In his response to the questions posed, I hope that the Minister will address how exactly we are going to streamline the process, as has been outlined so eloquently, and whether mechanisms such as commencement orders could be used so that we do not delay the process of speeding up research, because some parts, such as the Human Tissue Authority and the HFEA, are not yet clarified. It would be very sad to go at the slowest pace rather than storm ahead. This Government have demonstrated an understanding of research as an important economic driver to the UK as a whole, but that infrastructure, as suggested in these amendments, has to be in place and cannot wait. I hope, therefore, that the Minister will also address the timetabling in detail when he replies.

[Lord Beecham]

My Lords, I come to this debate unencumbered by any particular knowledge or experience of the issues addressed by the amendment, but it is apparent that today’s debate is but the latest instalment in a long-running saga, which in a sense reached its peak almost exactly seven months ago on Report of the Public Bodies Bill; many of the arguments that we have heard today were rehearsed on that occasion. It is not without significance that the noble Baroness, Lady Deech, complained at that time that no full and impartial public review of the risks and benefits, including the financial risks, of the proposed abolition of the HTA and the HFEA had actually been undertaken. Members of this Committee are clearly of the same mind as most noble Lords have been.

At that time, the Minister set out his reflections on the points that had been made in that debate. He pointed out that there was a common theme: a desire for greater clarity on where the Government intended to transfer the functions of the HFEA and HTA, and concern that the dispersal of functions across a range of bodies would risk fragmenting regulation. Clearly, those matters are still in the air. The Minister said that he intended to consult in the late summer on the options for where certain functions would be most appropriately transferred, and intended to proceed on the basis that the preferred option was for the HFEA and HTA functions to be transferred to Care Quality Commission, except for certain research-related functions that would transfer to the health research regulatory agency. Consultation would therefore take place. It is now seven months since all that was said. The main justification for not proceeding with what was sought then, and indeed still is now, was that:

“We do not want to add to what is already a substantial Bill”.—[Official Report, 9/5/11; col. 699.]

It might be thought that there were matters of less importance in the Bill, and certainly matters that in many respects were more controversial, than the topic that we are addressing today.

Having said that, I have listened with interest to my noble friend Lady Warwick, who takes a somewhat different view of this. Without the in-depth knowledge that other noble Lords have exhibited on this I hesitate to disagree with her, but for my own part I am persuaded by the force of the arguments made by the noble Lord, Lord Willis, and those distinguished noble Lords who have supported him. It is not good enough, particularly in the light of the Government’s clearly confirmed intention to press on with giving greater emphasis to the role of research, specifically in this field, that we should be told, as I anticipate—perhaps wrongly—that further consultations will take place and at some time there will be a conclusion and then a Bill. Given that legislation must already be piling up for the next Session, which, presumably, unless the rules have changed again, will be a year long, it is unlikely, with pressure from other departments, that this department will obtain the space for a Bill of this kind, so the uncertainty will continue. Uncertainty is almost the worst feature of the present situation; it cannot be good for anyone concerned with the problems of research, from the point of view of either pure research or, more particularly, its development into industry and production. Equally, the ethical side clearly cannot be allowed to drift.

I hope the Minister will, if he cannot commit tonight to reviewing the position, undertake seriously to discuss matters again with the noble Lord, Lord Willis, and those who have supported him tonight, with a view to seeing whether, even at this stage, the Government can change their position and deal once and for all with a significant issue around which there seems to be a considerable degree of consensus in this Committee and in your Lordships’ House.

Health and Social Care Bill

Lord Beecham Excerpts

Wednesday 30th November 2011 Lords Chamber

[Lord Beecham]

My Lords, these amendments deal specifically with the national Commissioning Board, but of course the issue of costs and bureaucracy extends well beyond this particular creation of the Bill. In fact, the Bill establishes something like a new health solar system, at the centre of which of course will be the Secretary of State, a perhaps rather dimmer sun than we would like to see—some of us, at any rate—but nevertheless at the centre of a system in which he will circled by a veritable constellation of boards and bodies. Along with the national Commissioning Board and its wonderfully euphemistically named “field offices”, which, as we understand it, will effectively be local commissioning boards of some kind, there will be Monitor, the clinical commissioning groups, clinical senates, clinical networks, directors of public health embedded in local government, Public Health England with perhaps four regional hubs, and 25 local units of the Health Protection Agency. There will still be some special health authorities and of course NICE. All of this is a formidable complex of organisations and the risks to which my noble friend has referred of the escalating costs of bureaucracy are self-evident.

There are particular examples of that, and the noble Lord, Lord Warner, touched on the question of support for commissioning. The recent draft recommendations that the Government have produced about that raise concerns about how that will function and about the costs involved. My noble friend referred to the National Audit Office looking particularly at the national Commissioning Board, but it seems to me that the abolition of the Audit Commission is something that the Government and the public generally may come to regret. Its rather more extensive and comparative work in looking at the way the health service operates, and indeed the way local government operates, will not be entirely replicated by the National Audit Office, perhaps ultimately to the detriment of the service.

I want to look not just at the long-term future but at the immediate costs of the reorganisation envisaged by the Bill, because this week saw the publication of the aptly named Operating Framework for the NHS in England 2012-13, which contains a reference to a requirement for all primary care trusts to set aside 2 per cent of their recurrent funding for non-recurrent expenditure purposes. That has been the case for the last couple of years and that non-recurrent expenditure has been effectively devoted to the service itself. The current framework suggests that:

“The non-recurrent cost of organisational and system change … will need to be met from the 2 per cent”—

in effect, the cost of this Bill and its implementation. Is the Minister in a position to say how much of that 2 per cent, which is estimated to amount to some £3.4 billion, will be devoted to these non-recurrent costs of the system change? Can he also give an indication of the costs of working through the structures of the national Commissioning Board and other bodies that the amendments directly address?

I have sympathy with the aspirations of my noble friend in moving these amendments although, as he acknowledged, it would be somewhat unusual to place restrictions of this kind on the face of the Bill. It will be important to hear the Minister’s views about how the future finances can be managed.

[Baroness Tonge]

Before the noble Lord sits down, I would like to remind him and the House that several Committee sessions ago, I asked the Minister to find out how much it is going to cost to disband the primary care trusts and how much it will cost to set up the clinical commissioning groups. I think this is all very relevant in this question—that we have absolutely no idea at all how much the change in bureaucracy is going to cost.

[Lord Beecham]

The noble Baroness encapsulates in about two minutes the thrust of what I said in five; she is precisely right. There are clearly going to be costs—redundancy costs, relocation costs and property costs—which we have not yet seen clarified in the case of the Audit Commission which I mentioned despite the fact that the proposal has been around for 18 months. It would be enlightening if the Minister responded to my question and that of the noble Baroness.

[Lord Mawhinney]

I share the view expressed by the noble Lord, Lord Beecham, of extending appreciation to the noble Lord, Lord Warner, for raising this issue because it seems to me to be one of some significance. Those of us who strongly support my noble friend and what the Government are doing in establishing commissioning-led services do so because, first, we think patients are likely to get a better deal out of it than they get under the present bureaucratic system and, secondly, because we have concerns about the efficiencies of SHAs and PCTs; in my case, that relates particularly to the activities of the East of England Strategic Health Authority.

I hope my noble friend will not deem a probing amendment about cost to be antagonistic or inappropriate. My reaction to the amendment of the noble Lord, Lord Warner, in its present form is much the same as the reaction of the noble Lord, Lord Beecham. I like the idea, I think it is helpful to this Committee to have more information although I am not sure that this form is actually the way in which that should be done. I hope my noble friend will be as generous as he instinctively and normally is in giving us as much information about costs as he can. If 30 per cent seems very high to him, as it does to me given the realities of setting up a new system, perhaps he would indicate what savings he thinks might be achievable if there was a sufficiently stringent regime in place to control costs.

--- Later in debate ---

[Earl Howe]

This is one area where the Secretary of State has a direct interest to ensure that administrative costs are kept low. In answer to the noble Lord’s first question, of course I would be happy to write. There is already a great deal in the impact assessment, to which I would direct noble Lords’ attention. However, I shall be happy to write an individual letter to him and copy it to noble Lords in answer to the questions that he posed.

[Lord Beecham]

When the Minister writes to us about the risk register, would he indicate whether this topic of the cost will be referred to?

[Earl Howe]

My Lords, I am not sure what question the noble Lord is asking me.

--- Later in debate ---

[Lord Beecham]

Does the list of issues that are covered in the risk register include the question of the costs of transition and reorganisation?

[Earl Howe]

My Lords, the cost of transition was certainly very much an issue that was thought about when the risk register was put together.

Health and Social Care Bill

Lord Beecham Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Jolly]

I will be brief so perhaps we can make a little more progress this evening. These four amendments come as a group; originally they were in two groups of two, but actually they hang together as a suite. They are probing amendments, and I thank the Royal College of Paediatrics and Child Health for its help with them. These amendments are intended to arrange for the organisation of carer children and young people, particularly young people who are vulnerable, and are about guaranteeing their safety and well-being and safeguarding them. When I was rereading the amendments earlier and making my notes I realised that they are not in the context of children necessarily and thought that they might just as easily apply to vulnerable adults, but certainly the intention was around children.

Successive Governments have tried without an awful lot of visible success—or perhaps there have been successes, but with some high-level and visible failures—to integrate services for young people. From Victoria Climbié to Baby P, there are still issues around silos not talking to each other. We have not got integration absolutely right.

In many ways, the Bill does not help streamline services for young people: if you are under five and going to be looked after by health visitors it is the responsibility of the board; if you are over five, school nurses come under the auspices of the health and well-being boards; primary services, local services, mental health and acute services are all under clinical commissioning groups. Within the Bill there are several different organisations responsible for delivering services to young people.

I will very quickly go through the meaning of all the amendments. Amendment 135AA concerns the general duties of the board in promoting integration. The wording of the Bill encourages commissioning groups to enter into Section 75 arrangements with local authorities. The amendment suggests that we move to mandating—and it occurs to me that somebody really should produce for this House a sliding scale of verbs from “may” right up to “mandate” so that we can work out exactly where they all sit within the hierarchy. Certainly this is a probing amendment, however, so I am using the verb “to mandate”. We are talking about Section 75 arrangements involving pooled, shared budgets. Shared budgets will give you shared ownership and shared solutions to problems. With shared solutions one will get shared decision-making. For this vulnerable group, we need shared decision-making.

Amendment 197BA concerns the general duties of clinical commissioning groups. It covers the duty to obtain appropriate advice. The intention of the amendment is to add in experts in maltreatment. Nobody could gainsay that. Whether it needs to be in the Bill, I do not know. We would appreciate some indication from the Minister on this.

The third amendment in the group concerns the establishment of health and well-being boards. It would add to the board a representative who is a health professional, for safeguarding. The final amendment in the group, Amendment 331AB, concerns the function of health and well-being boards and the duty to encourage integrated working. Again, it uses the word “mandate”, which I appreciate is at the top of the scale. It mandates people who work in health and social care to work in an integrated manner.

I do not apologise for the verb, because the situation is very serious. Young people who need the most care run the risk of falling into holes where there is nothing joined up. We are saying that the Bill puts the patient first and we talk about integration running all the way through the Bill. Sadly, it does not look like this will happen in children's services. The amendments in the group try to make it happen. Perhaps the Minister will offer clarity on the level of detail—which clearly is not in the Bill—that will be in secondary legislation to help with this. Successive Governments have tried to get this right but it has not always worked on the ground. This is an opportunity to rectify that. I beg to move.

[Lord Beecham]

My Lords, I sympathise with the motives of the noble Baroness who tabled the amendments but I am not sure whether they are persuasive. Mandating is not necessarily the right approach. It is certainly not the correct approach for health and well-being boards, because they are not executive decision-making bodies. We hope that the boards will produce joint strategic needs assessments, to which the clinical commissioning groups will have to have regard. There will certainly be joint working there, but the boards will not be in a position to mandate anybody. Therefore, while the aspiration is noble—appropriately—the phraseology does not necessarily achieve what is intended.

I expect the Minister to say that he envisages that the precise object that the noble Baroness is pursuing will be taken into consideration and acted on by the relevant parties: in this case clinical commissioning groups in particular. Obviously these are probing amendments. They should not be reflected in a substantive amendment put to the vote—unless of course the noble Earl departs from his usual practice and accepts them.

[Earl Howe]

My Lords, the amendments concern the issues of integration and advice, and in particular the use of arrangements under Section 75 of the National Health Service Act 2006 between the authorities and clinical commissioning groups. Section 75 arrangements would effectively be a means for CCGs and local authorities to work together in an integrated manner, often to commission health and social care services. The Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors to improve patient outcomes through more effective co-ordinated working. It provides a basis for better collaboration, partnership working and integration across local government and the NHS at all levels.

Health and well-being boards will have a strong role in promoting joined-up commissioning between health, public health and social care. Through their duty to promote integrated working between commissioners, they will also be in a good position to be able to promote more integrated provision for patients, social care service users and carers. They will also be able to encourage close working between commissioning of social care, public health and NHS services and aspects of the wider local authority agenda that also influence health and well-being, such as housing, education and the environment.

--- Later in debate ---

[Lord Mawson]

My Lords, I am very sympathetic to the amendment of the noble Lord, Lord Rooker, for very practical reasons. I am building a street at the moment in Tower Hamlets, and part of that street is not only a new school but a new health centre, which has been under development for five years. The health centre proposals were begun in the previous Government’s time in office. It is true that the Bromley-by-Bow Centre, when competing for that practice, was not on a level playing field. It is very difficult to compete with a multinational company that could undercut the price per patient to £75 per head, when I, having run an integrated health centre for 20-odd years, knew that the real costs were probably around £119 per patient and that the £75 per patient was not sustainable. It was very interesting going through the whole of that process, of proper competition and then losing the competition, to three years later, when I was approached by that company which admitted that the business plan did not work and asked whether we could help rescue the situation, which we have now done, and the multinational business has now withdrawn. I know that there is a problem here that we need to get our heads round, and I know and believe that the Government are serious about wanting the social enterprise sector and the voluntary sector to play their full role. It is a practical problem that needs to be got hold of.

The other thing that I know from experience is that bureaucracies like to talk to bureaucracies. I know that large government departments often find it easier to talk to large businesses. Indeed, we have seen this happen over many years. I am in favour of the private sector. We work a lot with the private sector, and I do not think that it is a case of one of the other. However, I have noticed how easily civil servants translate across into large companies, with the bureaucracy carrying on under other names, and organisations that are leaner and more innovative sometimes find it very difficult to break in. Therefore, if the Government are really serious about allowing some of us who do this work but are smaller in scale to break into this market and grow in capacity, then something will need to happen here to help that.

I also know from experience that one way in which we have grown in capacity is by forming relationships with one or two businesses. They have got to know what we are about and we have got to know what they are about, and we have formed partnerships and grown opportunities together. As I mentioned earlier, a £35 million LIFT company has now built 10 health centres. When we formed that relationship, which is a bit like a marriage, we got to know about each other’s worlds. We are now in a social enterprise with that business carrying out landscape work on 26 school sites. Therefore, there are things that government can do.

In my experience, some businesses are becoming more intelligent about this, although some businesses are not. The Government should be using their muscle to encourage businesses to form these local partnerships. If they do not do that, the danger will be that the profits made in poorer communities will be sucked out of the area, rather than there being virtuous circles around the areas creating more jobs and opportunities in local contexts. Therefore, I am sympathetic to the amendment. I would encourage the Government to look again at some of the practical issues and how they work in practice on the ground.

[Lord Beecham]

My Lords, for centuries what is now termed the voluntary or charitable sector was the main provider of health services in this country. It is a common view across your Lordships’ House that the sector must be encouraged to play a growing part in the provision of services, partly because it has a track record of innovation, is less inhibited by cumbersome regulations, and perhaps, as I have said on a previous occasion, is a little less risk averse than public bodies tend to be and obviously less motivated by the profit motive than the private sector necessarily has to be.

Surely it is common ground that we want to see a thriving voluntary sector, and I credit the Minister with sharing that aspiration. The trouble is that the Bill does not help him to do that. At best, this clause is neutral in its attitude towards the voluntary sector and, at worst, it will conceivably endanger the realisation of that aspiration. The noble Lord, Lord Greaves, pointed to the curious phrase in paragraph (b), seeking some elucidation, which we may get. However, as it stands, that paragraph could easily be interpreted as referring to the charitable and voluntary sector and as placing that sector at a disadvantage because it would be brought within the scope of the provisions of the clause, which would prevent any positive discrimination—if I might put it in such terms—in favour of that sector. That may not be the intention but it would appear to be very likely to be deemed to be the outcome.

There are already significant inhibitions, as a number of your Lordships have pointed out. The noble Lord, Lord Rooker, referred to the central Surrey experience, where a £9 million performance bond was requested from a social enterprise which clearly was not able to provide it. Incidentally, I contrast that with the financial position of Circle, which had a £45 million pre-tax loss in the year prior to the award of a contract to it and apparently very little relevant experience in running a hospital facility. However, it was awarded a contract. It would be interesting to see what criteria would be applied in future cases of that kind, whether to social enterprises, enterprises purporting to be social enterprises, such as Circle, or other enterprises. Be that as it may, there are clearly considerable difficulties for the social enterprise sector. Social Enterprise UK in its briefing, which no doubt some of your Lordships will have had, points out that the clause could also prevent the continuation of policies such as the Social Enterprise Investment Fund, which helped to support social enterprises in their endeavours.

The noble Baroness, Lady Williams, bravely interposes herself between the raging Opposition and the beleaguered Minister—as he appears to deem himself—but for what purpose I really cannot quite understand. Nobody is doubting his bona fides; the question is whether the legislation reflects his intentions. The very best that can be said of the clause which the amendment of the noble Lord, Lord Rooker, seeks to improve is that it creates a neutral situation. However neutrality, like patriotism, is not enough in this context. If we want to support the sector then we have to recognise the disadvantages with which it starts and not go for a simple level playing field on the assumption that all parties on the field are equal. We have to prepare the ground to assist this particular sector. At the moment, I do not think that the Bill provides for that.

The amendment does not require the board to favour the sector. I might have gone along with it had it done so. It provides the option for the board to assist the sector in making its particular and distinctive contribution to the provision of health services and removes what would be a substantial obstacle to that happening. This clause reflects a positive attitude to a sector that needs that kind of support. I therefore hope that the noble Earl will accept the suggestion made by my noble friend Lady Thornton in the earlier debate and hold some kind of discussion with representative bodies such as ACEVO, which is clearly concerned. The chief executive of ACEVO was a member of the Future Forum and his views should be taken very seriously. There are other organisations, some of them already in the field providing services, which clearly have an interest in this. The hospice movement, which has been referred to, is a very good example. A meeting convened by the Minister would be very helpful in that respect.

Social enterprises are perhaps slightly different from traditional third sector organisations. They are essentially a new form of enterprise in this field and again they ought to be represented at such a discussion. At the very least, I cannot see what the Minister would have to lose by accepting the noble Lord’s amendment. It does not impose a positive requirement. It does not prevent other parties being involved in undertaking work or competing for the provision of services in this area, it merely provides for a third option. If that is consistent with the Minister’s approach I cannot see what the Government have to lose by accepting it. It certainly is no reflection on his intentions, as I am sure the noble Lord would confirm and as I have repeatedly said. I therefore hope that the Minister can respond positively—if not tonight by simply accepting the amendment, which would be the easiest and most preferred course for many of us, then at least by entering into discussion with a view to assessing the degree of difficulty that the sector fears would arise from this provision. We could then see on Report whether we might amend the clause something along the lines of—if not on the actual lines of—what the noble Lord, Lord Rooker, has proposed. That would meet the wishes of all Members of this House to see a thriving sector contributing in that mixed-economy provision to which we all subscribe.

Health and Social Care Bill

Lord Beecham Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Earl Howe]

I understand the noble Lord’s point; it is one that we have thought carefully about, as he might imagine we would. The trigger for local service reconfiguration is often a joint decision by commissioners and providers that the current configuration of services does not offer the highest quality care or that it does not meet current and modern clinical practice. It is usually a dialogue between commissioners and providers which identifies services as being, in some way, not optimal for patients, and that a reconfiguration is the most appropriate way to improve and modernise services, rather than smaller scale operational change.

We are proposing that commissioners should engage and consult on these changes in the normal way, working closely with providers and engaging with patients, the public and local authorities in developing their proposals. However, I agree that there are clear roles for the board, and for Monitor, in ensuring that this process is given a fair wind. They have an interest in ensuring that services are of high quality and sustainable and they will wish to add value to the process.

We talk as if all reconfigurations were long and drawn out—we all know of some that are like that—but the successful reconfigurations tend to be those that have involved more, rather than fewer, local stakeholders. That is why we are strengthening the powers provided by the Bill, so that reconfigurations can take place in a genuine spirit of local engagement and partnership.

[Lord Beecham]

What does the Minister mean by local consultation and local considerations? One can envisage a situation when hospitals serve just a particular locality. However, in many areas, there are trusts and hospitals serving a much wider community—a sub-regional or perhaps even a regional community—and who then is to lead the process? Who then is to take the decision? There could be several commissioning groups involved, looking at the facilities in question, rather than just the one or two in a particular town or county.

[Earl Howe]

The noble Lord is absolutely right. In that kind of situation the process would inevitably become more complex. I do not know whether the noble Lord noted the comments of Dr Jennifer Dixon of the Nuffield Trust when she gave evidence to the Commons committee, but she said:

“If you look at some of the more successful attempts at reconfiguration, more involvement of local groups was necessary in order to get change. Some of the unsuccessful ones have been those where they have communicated less and involved fewer people”.

So paradoxically, she said, having more local organisations involved,

“could have the opposite effect”.

I think that that was a very perceptive comment. We think that the Bill should strengthen and encourage these relationships, either within a local area, or within a larger one, where services are commissioned over a larger area, as very often they will be, and you will get a broader dialogue taking place. The main object for all of us is to ensure that the mechanisms for this kind of partnership-working and local engagement are in place.

I take the point of the noble Lord, Lord Warner, about the length of time that some reconfigurations have taken in the past. We are very conscious of that. Under our plans, local authority scrutiny functions will be required to publish a timescale for when they will make a decision on whether to refer proposals for substantial service reconfiguration. We intend to change the existing regulations so that, where scrutiny functions are delegated to joint committees of two or more councils, councils could not step in and exercise those functions. This should prevent proposals which have taken time to develop and agree through a joint overview and scrutiny committee from falling apart at the end of the process by one local authority choosing to refer.

I understand the noble Lord’s concerns and will of course reflect on his proposal. However, I think that we are creating what could be an effective framework that would allow commissioners and providers to work together to reconfigure services where that is needed to protect patients’ interests. To support that, the Bill sets out a commissioner-led framework. We think that it is right for patients that it should be framed in that way. With the prospect of continuing dialogue on this subject, which I think will rear its head on more than one occasion as we go through these Committee proceedings, I hope that the noble Lord will feel content for now to withdraw his amendment.

NHS: Waiting Times

Lord Beecham Excerpts

Tuesday 22nd November 2011 Lords Chamber

Asked By

[Lord Beecham]

To ask Her Majesty’s Government how many patients currently waiting more than 18 weeks for treatment will benefit from the recent directive on waiting times; and what are the most common conditions from which they suffer.

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

My Lords, we have introduced a strong performance measure in 2012-13 for patients still waiting to start treatment more than 18 weeks after referral. This, and the requirement to treat patients in order of clinical priority, will ensure that the NHS focuses on minimising waiting times for all patients. At the end of September 2011, 242,540 patients were waiting longer than 18 weeks to start treatment. The largest numbers of patients were waiting in trauma and orthopaedics specialties.

[Lord Beecham]

My Lords, does not this U-turn underline the folly of abandoning targets in the first place? Will the Minister say how, under the provisions of the Health and Social Care Bill, the Secretary of State will be able to intervene in similar circumstances should they arise in future?

[Earl Howe]

My Lords, this is not a U-turn. The Government have always been clear that the standards laid down in the NHS constitution should be adhered to. As the noble Lord will know, that includes the expectation that patients should not wait for longer than 18 weeks. It is also a condition built into the NHS standard contract. We have been absolutely consistent all the way along. Those things will continue to have to be measured after the Government’s modernisation proposals are put in place.

Health and Social Care Bill

Lord Beecham Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Greaves]

I am not saying that there are no counties where that might be the appropriate arrangement. I am saying that in very large counties which, first, have a large population and, secondly, cover a large geographical area it would be excessive. Indeed, the situation in those counties which I just referred to is that the primary care trusts do not cover the whole county. All I am asking for is a degree of flexibility to allow appropriately sized clinical commissioning groups where the counties themselves would be too large. I declare that my own county is one such example. Indeed, as I said earlier, the areas that people are looking at as being appropriate for CCGs in Lancashire do not cover the whole county but the principle is absolutely right.

More important is Amendment 60, which is linked with Amendment 92ZZA, which my noble friend spoke to. Amendment 60 is about the code of conduct and was spoken to by the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, who I am pleased to see in his place again to hear what I have to say. As far as I am concerned, there is a real sense of déjà vu here, since in debating the recent Localism Bill—I do not know whether it is now the Localism Act—we spent many hours agonising over codes and standards of conduct for members of local authorities. I assume that when the noble Lord, Lord Kakkar, talks about a code of conduct applying to clinical commissioning groups he actually means that it applies to the members of those groups.

I do not want to say a great deal more about this now, because if I start I will be difficult to put down. However, there was a great deal discussed during the Localism Bill since the Government started off with the position that they wanted to sweep away the existing regime in local government for local authority members, which is based on the Standards Boards for England and which they thought—and I agreed with them—was highly bureaucratic and expensive, very legalistic and over the top. They wanted effectively to remove the standards regime altogether. As a result of intensive discussions in your Lordships’ House in Committee, on Report and at Third Reading, a compromise was arrived at—a lighter touch regime, which regrettably does not involve a national code of conduct but requires local authorities to have a standards regime, to adopt a code of conduct based on the Nolan principles and a published system which is transparent and applies to local authority members in their area. The two noble Lords putting this amendment forward might profitably spend an hour or two reading Hansard from the Localism Bill—I am sure they will enjoy doing so—and looking at the way it might be applied to clinical commissioning groups, different bodies but with the same principles. If they come back on Report to say what regime would be appropriate I am sure those of us who have been involved in the Localism Bill would be pleased to discuss it.

Amendment 175CA is the first of what I believe to be extremely important amendments put forward by the noble Lord, Lord Hunt of Kings Heath. It refers to representatives of district councils in two-tier areas. This is important because district councils in two-tier areas have actually been written out of this Bill and not included under the various definitions of local authorities, despite having a very important role to play in public health; they are housing authorities, housing standards authorities and environmental health authorities, and they provide all sorts of public health facilities such as leisure services. At present they often work closely with their primary care trusts on local projects to improve public health. It is an important issue in this Bill that will come up again later so I will not say any more now.

Direct representation on CCGs is not necessarily the most important issue here. If you have five or six district authorities in one CCG, as it looks like we will have, the representation would not be very direct anyhow. It is a crucial issue and one which casts its shadow over discussions we shall have in coming days. The really important parts of the amendment tabled by the noble Lord, Lord Hunt, are about the governance structures, how many independent members there may be on the CCGs and what role they will have. This is absolutely fundamental and links with local accountability. Should local accountability be to the patients in the area? Should it be through GPs? Should there be an understanding of some kind of accountability to everybody who lives in the area covered by the CCG? It is becoming very clear indeed that they are going to be area-based organisations responsible for the health of people in their area, despite the fact that some of the GPs will have patients who cross boundaries.

I think it was the noble Lord, Lord Hunt, who said that if it is simply left to the groups themselves to appoint their members and successors they will run into trouble. There are going to be many countervailing forces within this new complex system that we are to have at local level. Bringing those countervailing forces together might result in integration, but if there is not sufficient integration and accountability built into the system it will result in conflict. There will be all sorts of different bodies involved. People will be out on the streets campaigning and collecting petitions, and the general culture within the local NHS will too easily become one of conflict rather than of people working together for the best of the area. The composition of the commissioning groups, the way in which they work and their accountability are going to be absolutely fundamental to this. If, with the assistance of this House, the Government get it right, it could be very successful. If they get it wrong, we will all be back in two or three years trying to get a new system, and we really do not want to see that happen.

[Lord Beecham]

My Lords, when I spoke to the amendments concerning the NHS Commissioning Board, I said that the arrangements for governance, membership and the like were skeletal. In the absence of the most reverend Primate, I am probably safe to say that these arrangements for clinical commissioning groups are, by comparison, words made flesh. There is currently virtually nothing in the Bill that indicates how these commissioning groups would be constructed, what their membership would be and indeed what they should do.

Clause 22 contains provisions to make changes to the 2006 Act to provide for regulations as to the governing bodies of clinical commissioning groups. It is disappointing that nearly a year after the Bill was first produced we are debating the formation of clinical commissioning groups without any clarity at all—for example, in the form of draft regulations, if they are to be prescribed by regulation rather than the Bill itself—about how these groups should be composed. It is quite unsatisfactory. Clearly tonight we are not going to be voting on anything—these are probing amendments—but I hope that before we get to Report we can have sight of draft regulations to see what is in the Government’s mind and what changes might be necessary for the composition of these bodies. I have some sympathy with Amendment 101A, tabled by the noble Baroness, Lady Williams, but that assumes that it would be the function of the NHS Commissioning Board to ensure the composition of the commissioning groups. That does not necessarily follow and presumably we will not know until we see what the draft regulations contain.

A number of your Lordships have referred to the issue of coterminosity. In principle, it sounds fairly straightforward although in practice it looks a little less straightforward. There are different types of coterminosity. As I have said before, in my home town of Newcastle we have two clinical commissioning groups. In one sense they are coterminous because they are within the boundary, but on the other hand there are two of them. What if they do not agree? What if there are competing, conflicting ideas about what should be commissioned from the service in Newcastle? That assumes that you can treat the services within the city as confined to the city, but of course that is not the case. There are facilities in the city that are widely used across the region. Some of them are specifically regional centres. It may be that some of these services would be commissioned by the NHS Commissioning Board, but others would not. In this era of patient choice and the like—and one understands and supports that—there will be interest from other commissioning groups around the region in what goes on in the city, so coterminosity takes on a different flavour in that respect. In some parts of the country geography could make it difficult to envisage coterminosity. In a county like Cornwall or Devon, commissioning groups based primarily on general practitioners would be less likely to find it easy to work on the basis of coterminosity across the county area.

Health and Social Care Bill

Lord Beecham Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Cormack]

My Lords, I thought that the noble Lord, Lord Patel of Bradford, moved an absolutely model probing amendment, and the complexity of the issue was very well illustrated by the brief contribution of the noble Baroness, Lady Barker. I came not to take part in this debate but to listen, but I just want to say, as someone who represented a constituency in Parliament for 40 years, that I saw the enormously valuable work that so many charities did, particularly hospices and organisations that provide support, such as the Macmillan nurses and, as the noble Lord, Lord Noon, mentioned, the Marie Curie nurses, who do a very similar job.

As we have this seminal opportunity to get it right, I hope that my noble friend the Minister, for whom I have enormous respect and regard, will be able to respond to this exemplary probing amendment in his customary exemplary way by indicating that the Government are indeed taking these matters exceptionally seriously. I hope that the Government are anxious to ensure, when this Bill emerges from Committee and goes to Report, that the Minister will have some remedies to meet the extremely important and pertinent points raised by the noble Lord, Lord Patel, when he moved this amendment and others who have supported him in this brief but, I think, important debate.

[Lord Beecham]

My Lords, like other noble Lords, I declare an interest in charitable organisations that are in the register. When it comes to the details of VAT and its complications, my expertise is roughly equivalent to that of Vince Cable. In the light of that, I took the very sensible advice of my noble friend Lady Wheeler and discussed matters with a charity here in London. It was quite an enlightening experience. I was told that the change in the world of voluntary organisations has made a significant difference to their position in relation to VAT. At one time, much of their income came from grants; now it is increasingly contracted. As contracting organisations, they become liable for the tax. For example, a new build for that particular organisation at one time would not have attracted VAT, but now it does; and as we have heard, there are other examples of that happening. Moreover, some of the services that it provides are exempt, as in education and social care, while others are not. As the noble Baroness, Lady Finlay, told us, smaller organisations in particular have to invest resources in getting the necessary advice to deal with their VAT problems. The organisation to which I spoke had an even more complicated position. It has a building, and because it is carrying out work that is both subject to VAT and not subject to VAT, it has effectively had to split the building into those parts that provide services that are exempt and others that are not; and there is a problem with mixed use in part of the building. It has to monitor and record everything scrupulously and file returns accordingly, so it is an extremely difficult position for such organisations.

I congratulate my noble friends Lord Patel of Bradford and Lord Noon on bringing this amendment to the House, as it throws light on a significant anomaly affecting very many voluntary organisations—the very sector that all of us, especially I suppose the Government, in the light of their proclaimed belief in the big society, would wish very much to encourage. The amendment does not require a change in the law at this stage; it merely seeks a report. It is time that this long-running matter, which has endured for many years under Governments of both political persuasions, should be resolved on the basis of a report. It is of growing importance, as the noble Baroness, Lady Finlay, again reminded us, because of the position of any qualified provider, which would now be open to a wider range of organisations.

--- Later in debate ---

[Baroness Hussein-Ece]

My Lords, I want to make a few brief comments on Amendments 50 and 52C. I listened to all of the arguments about the public health specialists being on the national board, and I think it is really important. If we are going to have, or aspire to, a national health service that is about prevention and improving health rather than just treating it, there needs to be somebody on the board who attends or has that specialism and brings in the local government perspective. I was involved nearly 10 years ago in appointing one of the early public health directors. It was a joint appointment between the PCT and the local authority that I represented. That person sat on the senior management board of both the local authority and the PCT and was able to bring that expertise to both of those boards. Importantly, in the local government setting, he was able to bring together the directorships of education, environment and social services and to ensure that, when we were trying to address issues such as teenage pregnancies—which is still a massive problem in this country—it was everyone’s responsibility. It was not just over there; it was not just a health problem: it was a borough-wide problem. In terms of bringing that thinking on to the national stage—as other noble Lords have mentioned in this and other debates—local government has to be seen to be a key member if we are to aspire to improving the health of the population. Someone experienced in public health should have a very strong voice on the national, as well as the local, CCGs .

I now turn to Amendment 52C in the name of my noble friend Lady Jolly, which aims to have as a board member someone who is also the chair of HealthWatch England. I support having the patient’s voice heard at a national level. I listened very carefully to what the noble Lord, Lord Harris of Haringey, was saying: the important thing is to have the voice there. Quite often, with a group of 11 or however many it will be of the “great and the good”, it is very important that we have somebody on that board who is going to represent the wider public as well—a lay person who can bring about some of the thinking that is going on locally around the country. The proposed chair of HealthWatch England might be bound in to some sort of collective decision-making which might sometimes make him or her quite unpopular with the other local HealthWatch organisations across the country. The most important thing we should be focusing on is that there is somebody on the board who has the authority, who can bring the voice of the patient and the public to this board.

[Lord Beecham]

My Lords, these are probing amendments: as the debate has shown, there is a great deal to probe. I hope that when the Minister replies, he will be able to answer some of the questions and give more details of the thinking that underlies the Bill as it stands, and how it might be carried out in practice.

The body that we are talking about will have—as the noble Lord, Lord Harris has pointed out—an enormous budget and enormous responsibilities, both nationally and extending to localities. It will be responsible not just—just!—for commissioning general practice throughout the country, as the noble Lord, Lord Hunt reminded us, but also for a range of other services which will effectively be delivered locally. Yet in terms of the structure, composition and governance of the board, this Bill is about as skeletal as I imagine is the specimen that will greet first-year medical students at their first anatomy lecture. It needs flesh on the bones. There are a number of suggestions here; I have rather too many suggestions and I plead guilty to having advanced only some of them, but we clearly need a view about how the board will work and who will serve on it. I concur with the views of the noble Lord, Lord Harris, in relation to the appointment of the chair of HealthWatch England as proposed by the noble Baroness, Lady Jolly, as a member of the board. That person is likely to be conflicted: part of the job of HealthWatch will be to look at the operation of the board in an objective way. It may be that an attendance, as he suggests, would suffice.

Although I put down the amendment about the Chief Medical Officer being a member of the board, I can see the logic of the suggestion of the noble Lord, Lord Harris, that the Chief Medical Officer should attend without necessarily being a member of the board. I am temperamentally averse to mixtures of executive and non-executive directors. In the local government sphere, I never felt very comfortable with chief officers voting alongside elected members, but I suppose that members of this board are not going to be elected: they are going to be selected. I therefore think that it is sensible to have the best advice possible available to the board in the way that the noble Lord, Lord Harris, has described.

In terms of public health specialism, I think there needs to be a public health specialist—but not necessarily a serving public health specialist. I see the noble Earl, Lord Listowel, has tabled an amendment calling for the appointment of a former director of children’s services. Without necessarily agreeing that that particular post should be designated, the concept of somebody with that experience—not necessarily being a serving member and therefore not conflicted—might well appeal. It is crucial—given that we are now going to have public health delivered in a very different way from what we had before, and basically rightly so, though in a complex structure that will involve the Secretary of State, the Commissioning Board and local government as well—that there should be a public health specialist of some kind serving on the board. I hope that the Minister may indicate a degree of sympathy with that.

As to the total size, I am a bit ambivalent about that, too. It clearly needs to be a working board and therefore cannot be too large; it cannot possibly reflect every conceivable interest. I agree with noble Lords who said perhaps it would be a mistake to prescribe the number in the legislation. That is a matter that could well be discussed later by the Secretary of State, no doubt having taken views and not least the views of the Health Select Committee in another place.

I hope that we can make some progress tonight in identifying issues which the Government will look at sympathetically and bring back on Report. If they do not, then at least those of us who want to press points will have an opportunity of doing so.

[Lord Greaves]

My Lords, I have for most of this Committee so far been listening to and reading what people have said and have been astonished, as I always am, by the immense amount of expertise and distinction there is in this House. There are all the professionals, and there seem to be more former Health Ministers in this House than in any other place that could be gathered together. Most of the debate so far has been about high-level, national-level principles and structures, and we are now moving on to the area that I have been trying to get my mind around since I first obtained a copy of this extraordinarily huge Bill. That is the new structures that are being set up at all levels and how they are all going to work together.

At Second Reading, I laid some claim for my party for some of the improvements that were made to this Bill after the pause in the House of Commons, but one thing that certainly happened to the Bill after that pause is that it became more complex as the number of different organisations and bodies became greater. The need for this House is to sort out how this new galaxy, or kaleidoscope, of new bodies within the health service are going to relate to each other and how it is going to work—I use the word “work” in a neutral sort of way—how it is going to happen in practice and how they are going to relate to those bodies which continue to exist, such as the hospital trusts, the PCTs, the strange clusters of PCTs that will stagger on for a certain amount of time and then disappear by some means that is not completely understood yet and, of course, local authorities and the whole of the voluntary and private sector involved in healthcare.