Health and Social Care Bill

Lord Sentamu Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Owen]

My Lords, I reiterate some of the comments that have already been made by many noble Lords on the sense of urgency about this issue. Above all, I feel rather like the man in the Bateman cartoon who mentions the words “party politics” in the Health and Social Care Bill in the House of Lords. There is here a very deep question. It is frankly inconceivable that there will be legislation in the next Session; I would think it would be almost inconceivable that there would be legislation on this before the next election, which is currently scheduled for 2015. Politicians simply do not usually go in for a repeat hiding, and this Bill has already had one hell of a political controversy. If we have legislation, it may be all on medical education, but it opens up a whole realm of party politics, which I just do not see being done.

Therefore, I want to make a practical suggestion to the Minister. There is a way through this if there could be bipartisan agreement. One only has to think of a situation in which there is no legislation until 2016 to realise that we are facing a real chasm in medical education and continuity. As I understand the legislation, the Secretary of State is empowered to create special health authorities. Whether he does that or removes the ones that are necessary, that power is there. If not, he could easily take it in the Bill.

There is so much cross-party agreement that doing something about health education is pretty urgent. I would have thought that it would be perfectly possible to meet most of the demands. The noble Lord, Lord Ribeiro, is completely right. We are not in a position to legislate now on anything other than a structure. That structure might be a temporary special health authority. It is not worth prejudging the question but, if it was a special health authority, it would need some form of regulation passed. As long as an agreement could be made—first on the clause that would be in the Bill, along the lines more of Amendment 47B than 47A; and, secondly, with the main substantive regulations for the special health authority done through an affirmative resolution—then it would be perfectly possible for us to move on the creation of this training authority, which has to embrace all the health professions and be pretty wide-ranging, some time at the end of 2012 or early 2013. That would meet the wishes of most people in the National Health Service.

It is really not enough to rest on the fact that there will be a Bill in the next Session of Parliament. I have already tried to convince my own college, the Royal College of Physicians, that it is highly unlikely that this will be fulfilled. As practical politicians, we should ask the Minister to take this away with a measure of real good will to see if there is some way through this issue which does not prejudice the long-term future but allows us to fill a very serious gap.

[The Archbishop of York]

My Lords, I too support the amendment of the noble Lord, Lord Warner. Proposed new subsection (2) simply says that:

“In discharging this duty, the Secretary of State must establish a body known as”.

It does not tell us the rest of the details. It puts a duty on him or her to establish a body responsible for,

“the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries”.

How will it deliver that? What is going to be its content? That is for the Secretary of State in the future. But we fail in our responsibility if we miss the opportunity right now in the Bill to flag that up as part of the duty of the Secretary of State.

Noble Lords may remember from Second Reading that I spoke against supporting the Motion of the noble Lords, Lord Owen and Lord Hennessey, because I wanted to ensure that the constitutional duty of the Secretary of State is to promote a comprehensive health service and improve the quality of that service. I told the House that I have recently spent time in three different NHS hospitals: University College, London; St Thomas’s Hospital; and York Hospital. These are teaching hospitals. I was more than content that whenever the doctors saw me they came with a large range of nurses, doctors and those in training of all kinds. I became a guinea pig. I did not mind because I knew that I was in a training hospital. How are we to ensure that our National Health Service has that responsibility of making sure they are training hospitals? We must not assume that our NHS delivery of clinical care is almost like the assembly line of a motor car where you fix it and it goes out okay. It is not that kind of thing. What distinguishes most of the best clinical practice is the fact that our National Health Service has these training hospitals. I would be unhappy to know that the Secretary of State had not established a body, known as Health Education England, with responsibility,

“for the oversight, supervision and management of all current functions”.

Where will those lie when the Bill has been passed?

Last time, when we debated other amendments, there was a worry about the diagram of the proposed structure of NHS reforms in the Bill. I drew one up for myself. Listen: the Secretary of State is on top, then there are other bodies—Public Health England, HealthWatch England, the Care Quality Commission, Monitor, NICE, clinical senates and networks, the NHS Commissioning Board, local Healthwatches, health and well-being boards, the community voluntary sector, local government social and public health, and multiple clinical commissioning groups. Where is education in all this? When the Minister replies, will he tell us where he thinks education is going to lie? If it does not lie within this Bill, with its already very complicated structure, the next time I am being treated in the NHS I will be crying, “Where are those learning as I am being treated?”.

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[Noble Lords]

Primate!

[The Archbishop of York]

Call me whatever you like.

[Lord Mawhinney]

I am a just a simple Belfast boy. Archbishop of York seems pretty good to me; most of the clergy I know can only fantasise.

The timing of this debate is important in that it reinforces the message that my noble friend got the last time this was debated in this Chamber. I hope that he will tell those who tabled the amendments that they are premature. If he does, he will need to tell them that he will take away the contents of this debate and the previous one and bring back, in whatever way the Government think is appropriate, a means to attach the principle of education and training to this Bill. He knows that I hope that he will do that, but I hope that he is encouraged that I share the views expressed that this is not yet the time.

The noble Lord, Lord Owen, has addressed particularly well the element of perplexity and perhaps confusion in the NHS about the Government’s intention. My noble friend and his colleagues keep going on about the Future Forum. I am sure that it is doing a fine job, and no word of criticism about it will cross my lips—except to say, as a simple Belfast boy, that in a democracy it seems to me that the role of this House is to try to persuade Ministers; it is not its role to try to persuade those who are going to try to persuade Ministers. The Future Forum may have an important role, but I would like us to discharge our role quite clearly. The noble Lord, Lord Owen, has the experience of having served in Cabinet, and I have been extremely fortunate and blessed to have had a similar experience. If my noble friend or the Secretary of State can go to the Dispatch Box and say, “I undertake that there will be legislation”, and specify the Session, we will all believe him. However, if that is not possible, it adds to the importance of bringing forward at least the principle to get this issue into this Bill.

Those of us who are in favour of education and training but want to support the Government are not entirely clear whether we should be tempted by Amendments 47A, 47B or 133, and I have to say to the noble Baroness, Lady Finlay, that I am not tempted by her Amendment 199A. But at some point this House has to make a decision, so I hope that my noble friend will stand up, look the noble Lords who tabled these amendments in the eye and say, “Thank you, it’s been very helpful and I’ve heard what you’ve said. I’ll take it away and I’ll bring something back on Report, which I hope will satisfy the whole House”. In the mean time, I hope that noble Lords will not press their amendments.

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[Lord Harris of Haringey]

My Lords, it is always a pleasure to follow the noble Baroness, Lady Cumberlege. She and I have sat opposite each other at meetings for more years than I care to remember.

However, her belief that the chair of the NHS Commissioning Board will only be able to manage a board of 11 is slightly misplaced. We already know that the person who holds this office will be able to walk on water, with due deference to the most reverend Primate. We know that this individual will have the most extraordinary qualities. Indeed, the Health Select Committee has demonstrated that by the overwhelming vote that it gave him on his appointment. Therefore, any person of such calibre who is able to manage a quango with such an enormous budget must surely be able to manage a board of more than 11 people. That goes without saying.

It is probably unhelpful for the Bill to specify precisely the number of people who will be appointed because circumstances will change. At different times it may be appropriate to have particular people or specialisms involved, but that will change over time. To lay down the numbers too specifically is probably a mistake. Indeed, I am not sure that 11 is a sensible number for the effectiveness of boards. It is too large for the most efficient and effective of boards but it is not quite large enough to bring together all the strands of opinion and expertise that you might wish to bring.

My main reason for intervening was not to pick up on that point but to question a couple of the amendments, in particular Amendment 52C in the name of the noble Baroness, Lady Jolly. The amendment refers to the board,

“including one member who is also the Chair of Healthwatch England”.

That is a misguided amendment. It is very important that the viewpoint of the patient is heard clearly by the NHS Commissioning Board, but it would be wrong to bind HealthWatch England into the collective decisions that will be taken by the NHS Commissioning Board. Had the amendment said something along the lines of, “The chair of HealthWatch England will be able to attend all meetings of the NHS Commissioning Board and to contribute to them fully” rather than talking about membership, it would have been much better.

There is already a concern that HealthWatch England will not be seen as a properly independent organisation, partly because in the Bill it is framed as a committee of the CQC and also because the local healthwatch organisations will be wholly owned subsidiaries of local councils around the country and the money for them will not even be ring-fenced. Under those circumstances, there is a real problem about the reality of the independence of HealthWatch England. Further, to put the chair of that body in the position of perhaps having collective responsibilities for NHS Commissioning Board decisions is potentially a serious mistake. I would like to see a position where the board has the chair of HealthWatch England as an adviser. His advice may or may not be accepted, but it will be on the record what advice has been given.

I hesitate to oppose an amendment moved by my noble friend Lord Hunt of Kings Heath but the same applies to the Chief Medical Officer. He should be there to advise the board—and that advice should be recorded—rather than being a member of the board and therefore being part of that collective responsibility. In framing the structure of the NHS Commissioning Board, there needs to be clarity of thought. There are a number of areas of expertise and interests that ought to be reflected in board membership—those individuals should bring their expertise to the table—but they cannot be there as representatives of those particular interests because they will have to take collective responsibility for the decisions of the board. However, it is also important that you have explicitly there a number of people to give advice. That should certainly include the chair of HealthWatch England and the Chief Medical Officer.

[The Archbishop of York]

My Lords, I was not going to speak to these probing amendments, but as I have been gratuitously referred to twice it is prudent that I should speak.

The noble Baroness referred to number 11. We should remember that Jesus had 12 disciples; the twelfth betrayed him and so there were eleven left. Then the disciples decided before Pentecost to choose Matthias, so they then had 12 again. They then ran into trouble once St Paul the Apostle came along and they had 13, but they did not know where to put him. Numbers are always dangerous.

I am with the noble Baroness, Lady Murphy. We may need all kinds of characters on the board but it would be wrong to specify them in the Bill. If we do, then we will not have the kind of liberty and freedom to be creative and to enable the Secretary of State to promote a comprehensive health service and improve the quality of service. He needs that to help him promote the health service and then improve it. The board needs to consist of people who have the calibre to do that.

I have sympathy with Amendment 54 but not in the precise form in which it is put. It states:

“The Secretary of State must ensure that a majority of the non-executive members of the Board appointed under subsection (1)(b) have relevant experience”.

Those members should have relevant experience but as to whether they should be a majority, again, the discretion should be left to the Secretary of State and the board. If that is specified, they will all be there in big numbers but might end up not delivering or promoting whatever is required. Yes, the people appointed should clearly have relevant experience of either working in the NHS or serving on an NHS body—the NHS is not the same as Rover cars, Marks & Spencer or Tesco and you need people with relevant experience who are able to deliver properly—but I would go for the Secretary of State having people with relevant experience of working in the NHS or serving on a body without necessarily saying that they must be in the majority.

As these are probing amendments, I shall be interested to hear what the Minister has to say about that.

[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.

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[Lord Greaves]

I am not quite sure why the noble Lord is asking me that question. He is tempting me to make provocative statements in relation to the coalition Government of which my party is a member. I think that it is an open question and the answer can remain open. I am not in the mood to make provocative statements today. I might be tomorrow, and the noble Lord can come back to me then.

The point that I am trying to make before I finish, if the Labour Benches will not interrupt me just one more time—

[The Archbishop of York]

The Benches opposite are probably provoking you into some kind of statement because of your earlier comment that you were reputed to have influenced the Bill during the pause. Given that influence, why did you not go back to what was working?

[Lord Greaves]

It is our view that the original proposals were not working at all, and the proposals that we have now are better than the original ones. That does not mean to say that they are perfect, and it is the job of the House of Lords to check that the imperfections in them are removed before the Bill leaves your Lordships’ House.

The point that I was trying to make, which I will finally make once more, is that there is a real difference between the two meanings of “commissioning”. If you are a GP, you can commission services from an existing, static landscape or system of provision for your patients. However, commissioning services on a wider scale, commissioning the very landscape of services and the series of organisations that exist, whether it is deciding to put more money overall on a wide scale into one area of medicine and pulling back on others or just keeping the others going as they are, or whether it is financing capital projects—where to build new hospitals, new health centres or whatever it is—is very different indeed. You need bodies on a larger scale to do that. The idea that practices on their own or small groups of practices could commission that kind of undertaking on a wider scale is nonsense. You cannot rely on the market to provide them all because that will produce chaos and a lack of provision in many areas. That is why the original proposal for GP commissioning groups, which were to be quite small, simply would not have delivered at that level. The original proposals did not indicate in any way how that wider capital commissioning would take place.