Health and Social Care Bill
Lord Warner Excerpts(13 years ago)
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Lord Turnberg
My Lords, I rise to lend my support for this amendment. I speak here as a trustee of the Wolfson Foundation, which has a programme of support for hospices and care homes and over the years has given many millions of pounds, largely for capital projects. VAT is a constant source of unhappiness to the trustees, and, in fact, they have reached the conclusion that they will no longer pay VAT for capital projects. This means, of course, that the hospices and care homes themselves will have to find that money, which is unfortunate. Therefore, I hope that the Minister will take this amendment seriously.
Lord Warner
My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a source of grievance. It often goes with another grievance—one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs—the management costs—of local authorities. If one takes the two together—a meanness about meeting management costs and being treated unfairly on VAT—this is a barrier to entry.
I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government’s own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.
Baroness Armstrong of Hill Top
My Lords, I rise briefly to lend support to the amendment. I work with charities for the homeless and for children. If the Government’s ambition is to enable the NHS to work with the patient on the full pathway—rather than work being done in little bits by different organisations—then making the playing field level for the voluntary sector is absolutely critical to developing those pathways. In my experience, the voluntary organisation is frequently the glue in making sure that the pathway for the patient works for the patient.
I remind the Minister that when this works well there are often savings for the National Health Service. I have experienced that in homelessness, where we have been able to work with the PCT to get a community matron. That has reduced the number of expensive admissions to hospital and A&E for the most disadvantaged—the homeless. I have also seen that work well with, for example, children with disabilities and children who are very ill. They have been enabled to remain at home with the proper support instead of being frequently admitted to hospital.
It is to the advantage of the NHS that we get this right. What will the Government do to bring forward in the Bill comfort and encouragement for the voluntary sector? After the pause, that sector has been left with a rather large amount of confusion.
Lord Warner
My Lords, I rise to speak to Amendment 47B, which to some extent overlaps with Amendment 47A, which the noble Lord, Lord Kakkar, has moved so eloquently. I fully support the remarks that he made, particularly in relation to medical deaneries.
I want to start from the position in which we find ourselves. This Bill contains a major reorganisation, which affects 1.4 million employees. As David Nicholson has said, the size of this reorganisation can be seen from space. I can remember making these rather trite speeches as a Minister about the NHS being the largest organisation alongside Indian Railways and the Red Army. Ministers before me made the same speeches just to emphasise the sheer scale of the NHS and the number of employees working in it. Therefore, it seems extraordinary that the Government could have considered for a long time reorganising this organisation in such a way without taking into account the education and training of probably the most labour-intensive and largest workforce in the country. It is not surprising that, in these circumstances, people in the NHS are very concerned about what is going to happen to education and training in this brave new world that the Government are taking us into.
That is why some of us want to move amendments that go a good deal further than did the Government’s amendment in this area, which seemed to me not unlike those Russian dolls—once you open one doll, another is inside and a smaller doll is inside that—in its endless reference back to other bits of legislation. We need something much clearer than that if we are to reassure the people working in the NHS that education and training are going to be safeguarded and looked after in a period of major disruption to the way we run our health service.
Amendment 47B imposes a clear duty on the Secretary of State,
“to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size … to discharge his duties under this Act”.
That seems to me to be the focus that we should have in our discussions in this particular area. It tries to produce a clearer duty on the Secretary of State than the Government’s Amendment 43, but goes further by requiring the establishment of a new body, Health Education England, to oversee, supervise and manage the current functions and national budget relating to multidisciplinary training.
As we take the Bill through this House, it is not enough simply to say, “Oh dear, we are waiting on the Future Forum”. I am sure that the Future Forum will have something good to say, but before this Bill leaves this House as an Act we need to produce much more certainty about how this service is to be continued and how the money is to be safeguarded. The size of the budget involved is considerable—somewhere in excess of £5 billion a year. Much of that money is looked after and spent by the rather maligned strategic health authorities, which will disappear in 2013 as I understand it. That money passes through them to the end-users of the money that deliver education and training. There is great uncertainty and concern about how national and regional planning of education and training, including the medical deaneries, will actually work, how they will be funded and how the current budget will be safeguarded.
I recognise that employers need to play a full part in education and training, as the noble Lord, Lord Kakkar, has said, but I have seen the briefing by NHS Employers on this issue. That briefing makes pretty clear that there is huge uncertainty below the national level about how education and training will be managed when the strategic health authorities are abolished in 2013. People seem to be fumbling their way around, searching for a way forward when the SHAs go. We know that some activities cannot be left to local employers alone. A prime example of this is the specialist training that has to go on in securing placements for younger doctors coming through the early stages of their training and needing to have specialist postings to ensure that they can progress along the specialist route to fill the consultant posts of tomorrow.
At the national level we need to achieve greater clarity on how the Secretary of State will discharge his responsibilities in relation to education and training. The Government seem to think that this can be left to legislation in the next Session but as far as I can see they can give no assurances, other than resting on good will and the Future Forum, to say clearly what this system would encompass, what it would look like and how it would work. The more sceptical among us have doubts about whether the Government will have the appetite for another Health and Social Care Bill in the next Session. If one was Prime Minister for a day, it would not be surprising to doubt whether one would entrust another Bill in this territory to the team that gave us this Bill. That thought must have occurred to the Prime Minister at some time in his busy life.
In closing, I would like to say a few words about the third subsection in this amendment. This is in response to the concerns that have been expressed that many current functions and their budgets will be passed to the national Commissioning Board almost by default, and at the very time when the crisis on meeting the Nicholson challenge of saving £20 billion in four years will be moving to crunch time. I suppose there is a kind of poetic justice that David Nicholson should be asked to consider his own challenge and deal with it as chief executive of the national Commissioning Board, but people are concerned that temptation should not be put in his way in the form of the £5 billion or so of the budget for education and training work of the NHS. To help him resist that temptation, should it arise, this amendment includes a formula for preserving the education and training budget. It may not be the perfect formula—I am sure that noble Lords across the House would be willing to discuss a better one—but some kind of formula and ring-fencing which protect the budget for education and training is a sine qua non if we are to carry with us staff up and down the country working in the NHS whom we expect to continue to deliver a highly effective NHS at a time of great organisational change.
Of course, the Minister may be able to reassure us all and give us some guarantees, and I look forward to hearing them. These need to be guarantees about how the amount currently spent on education and training will be safeguarded. We will also want to know: what is to happen to the money when the SHAs are abolished? What division of responsibility between Health Education England and employers are the Government planning? Do the Government envisage a role in this sphere for the national Commissioning Board? I hope the Minister will not simply say that the Government are waiting for the Future Forum to report.
Lord Warner
“Secretary of State’s duty relating to education and training
(1) The Secretary of State has a duty to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size and competence to discharge his duties under this Act to ensure a comprehensive health service.
(2) In discharging this duty, the Secretary of State must establish a body known as Health Education England and this body will be responsible for the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries.
(3) The budget for this body and its functions should be calculated on the basis of a formula related to the total health service expenditure and initially should be no less than the level of expenditure on education and training at the time of Royal Assent.”
Lord Warner
My Lords, I am grateful to everybody who has spoken in this debate. I particularly welcome the support given by the most reverend Primate and by the noble Lord, Lord Owen. I share the scepticism of the noble Lord, Lord Owen, about next-Session legislation and we would all do well to think carefully about his remarks.
I am still rather puzzled about why, if the Government are prepared to set up Health Education England as a special health authority, they cannot put it in the Bill along the lines of Amendment 47B. By all means doctor Amendment 47B. It was not the purpose of Amendment 47B to unreasonably tie the hands of the Government but I am still struggling with the question of why, if the Minister is prepared to produce a detailed paper before Report in which he agrees to set up a special health authority by next September, we cannot have a sensible cross-party discussion about setting up Health Education England in this Bill and giving the Government the necessary powers to make regulations to fill in the details.
My ears pricked up on the subject of money when the noble Earl said that there would be a “robust analysis”. I am willing to open a book on how far south of £4.9 billion the Government end up with on the robust analysis on education and training. I am available at all hours to discuss the odds a little further on this issue.
I will study the noble Earl’s remarks carefully. I listened carefully to what he said. He has moved some way. Whether he has moved sufficiently far to stop us bringing forth an amendment on Report is in doubt.
Lord Mawhinney
My Lords, I too want to focus on line 27 of Clause 6:
“The Board is subject to the duty under section 1(1) concurrently with the Secretary of State”.
This raises all the issues that we have debated at length. I know that the Minister has taken away Clauses 1, 4 and 10, but, as the noble Lord, Lord Hunt, said, it would be extremely helpful to the Committee if he agreed to take away Clause 6 as part of the package on which to consult. Otherwise, those words in the Bill continue to provide a fault line that at some point will need to be addressed. I hope that my noble friend feels that it would be more productive to address this point in the spirit of co-operation and cross-party support that he has engendered for Clauses 1, 4 and 10 and include Clause 6 as well.
Lord Warner
My Lords, I rise to speak on this amendment, mainly because of my puzzlement over why the Government want to give the national Commissioning Board a concurrent duty with the Secretary of State under new Section 1(1), given all the other provisions in the Bill which try to shape—if I may put it that way—the relationship of the Secretary of State with the national Commissioning Board. This is especially the case with Clause 20, the mandation clause. One interpretation of this concurrency is that the Secretary of State can pick and choose how he interprets his responsibility.
My noble friend Lord Hunt has mentioned, as delicately as he could, what has happened in the Home Office recently about the sometimes rather strange boundary between policy responsibility and management responsibility and the confusions that could arise. This is not the first time that the Home Office has got into this kind of territory. Your Lordships will remember the difficulties that Michael Howard, when he was Home Secretary, had with the chief executive of the Prison Service, Derek Lewis. It boiled down to this problem of uncertainty about where the remit of Ministers ended and where responsibility began, in this case with the Prison Service, an executive agency. Equally, though, I suggest it could have been a non-departmental public body.
There is a lot of history in this area where one should be extremely wary about passing legislation in particularly high-profile areas and giving concurrency of responsibility to a Secretary of State and to a powerful arm’s-length body, in this case a non-departmental public body, the national Commissioning Board. It is fraught with difficulties. I thought that the Government were trying to clarify this with Clause 20. I think the clause has been misunderstood a little bit by the new chairman of the national Commissioning Board, but the wording as it stands gives the Secretary of State the right, before the beginning of each financial year, to set out a mandate for the board.
There are a lot of safeguards in Clause 20, on both sides of that discussion and agreement. The national Commissioning Board has a lot of safeguards. The Secretary of State cannot keep coming back and adding bits and pieces as the year progresses. The Secretary of State also has quite a lot of safeguards. He or she can expect the national Commissioning Board to stick to what has been agreed in that mandate. There is no doubt about the Secretary of State’s ability to give instruction to the board and there is no doubt about his ability to change those instructions on an annual basis after proper discussion and consultation. That is very clear. One of the strengths of Clause 20 is that it does make the relationship clear between the Secretary of State and the national Commissioning Board.
I have tabled an amendment that tries to restrict the number of requirements that the Secretary of State can place on the national Commissioning Board. I can well remember the time when the noble Lord, Lord Mawhinney, was a Minister with responsibilities for health, along with his colleague the noble Baroness, Lady Bottomley, who is not now in her place. We had somewhere in excess of 50 priorities in the NHS that we were required to deliver each year. In practice, we had no priorities, because no one could hold 50 priorities in their head, so there is an issue about how far you go on mandation. Nevertheless, the structure of Clause 20 clearly states what that relationship is, on an annual basis, between the Secretary of State and the national Commissioning Board.
We would do well to stick with that kind of relationship rather than muddy the waters with a concurrency of responsibility. I will be interested to hear what the Minister has to say on this issue.
Earl Howe
My Lords, as has been pointed out, this amendment returns us to the topic of the comprehensive health service. We have had a wide-ranging debate on that issue. I appreciate the concerns held by some noble Lords about the extent to which the Secretary of State will be genuinely accountable for the health service under the new arrangements introduced by the Bill. I have outlined the reasons why I believe accountability will be maintained and how accountability to Parliament and the public will be increased by our proposals. We have indicated our intention to look further at what could be done to put the Secretary of State’s ultimate accountability for the health service beyond doubt. We will do that.
However, it is a core principle of our reforms that politicians should step back from day-to-day interference in the NHS to allow clinicians to take the lead in developing services that are built around the needs of patients. That would simply not be possible if the Secretary of State retained broad powers of direction over the NHS Commissioning Board. As I have previously described, the role of the Secretary of State in future should be to set the legislative and regulatory framework; to set the strategic direction for the NHS through the mandate, as the noble Lord, Lord Warner, has rightly reminded us; and to hold the national bodies in the system to account for fulfilling their responsibilities effectively.
I also understand the argument that the Secretary of State alone should be responsible for promoting a comprehensive health service. However, I believe that there are strong arguments that, in the interests of accountability, the NHS Commissioning Board should share this duty as far as it relates to NHS services. The NHS Commissioning Board will be the body responsible for ensuring that there is a comprehensive coverage of clinical commissioning groups covering every area of the country. It will be responsible for authorising and assessing clinical commissioning groups, providing support and guidance to them, and intervening if they run into difficulties. It falls to the NHS Commissioning Board to ensure that the continuity and quality of service provision is maintained at all times.
I am afraid that the arguments of the noble Lord, Lord Hunt, expose a clear fault line between the Government and the Opposition. We believe it is important that the board should be under the same obligation as the Secretary of State to promote a comprehensive health service in so far as this relates to the health services that the board and clinical commissioning groups will be responsible for. Let me be clear: the Bill’s provisions would in no way dilute the Secretary of State’s overarching duty. Indeed, they are intended further to reinforce the promotion of a comprehensive health service rather than to undermine it. With the general desire of noble Lords to strengthen accountability in the Bill, it seems odd that the noble Lord, Lord Hunt, should want to weaken accountability in this way, for that is what his amendment would do.
I listened to the point made by my noble friend Lord Mawhinney that this is another facet of the issues that we are going to consider in relation to Clauses 1, 4 and 10. He made a good point. Therefore, I suggest that, in the light of our intention to consider together how we approach the duty on the Secretary of State and return to this on Report, the amendment should also be withdrawn and that any consequential changes to the functions of the board or clinical commissioning groups are considered as part of those deliberations.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for his response. I am, of course, very happy for this to be considered in the light of the debate in relation to the other clauses around the Secretary of State’s powers. I may not have convinced the noble Earl but he has convinced me that a “train crash” will inevitably occur given the ambiguity and confusion built into the Bill on the role of the Secretary of State and the national Commissioning Board. The more the noble Earl spoke about that, the more evident the ambiguity became. As regards the mandate, my noble friend’s amendment suggests that only five functions should be given to the national Commissioning Board with five other objectives. I think that he is supported in that by other noble Lords. He has probably forgotten about the innate ability of the wonderful civil servants at the Department of Health to write very long functions which could probably embrace the world. However, I understand where he is coming from.
Lord Warner
I well understand the Civil Service’s ability to use the semicolon to extend a sentence for a very long period.
Lord Hunt of Kings Heath
My Lords, my noble friend should refine his amendment by limiting the number of grammatical devices that can be used.
I raised this matter because of what the noble Earl said. I raised the reported intervention by the Secretary of State in relation to primary care trusts and the concern that because of their financial issues they are essentially putting in some artificial barriers in relation to patient treatment such as having a rule that on non-urgent treatment you have to wait a certain length of time before you can be treated, and other such mechanisms. When I asked the noble Earl how this would work in the future, he told me that it would be put in the mandate. Clearly, what will happen—
Lord Warner
“( ) must include at least one member who is a registered public health specialist and who has a broad range of professional expertise in public health”
Lord Warner
My Lords, in the unavoidable absence of my noble friend Lord Rooker, he has asked me to move Amendment 50 standing in his name and those of a number of colleagues. This amendment is very simple in intent. It seeks to ensure that the national Commissioning Board has at least one member who is a public health specialist. Much of the work of the board and, indeed, of the clinical commissioning groups, is to commission services that arise from failures of public health, or the associated issue of the absence of clinical intervention at an early stage in a person’s condition. Later we will discuss a raft of amendments for strengthening the Bill’s provisions on public health itself. This group of amendments is concerned with the membership of the national Commissioning Board and the disclosure of information.
This amendment is intended to help the board in its deliberations. It is essential that it has ready access to public health expertise. I very much support Amendments 153ZA and 153B in this group, standing in the names of my noble friends Lord Hunt of Kings Heath and Lady Thornton, which seek to curb the administrative costs of clinical commissioning groups. I have degrouped my amendments on controlling the overheads and management costs of the board. I have also tabled amendments that try to curb clinical commissioning group management costs. I tabled these amendments because I wanted to ensure that we had a fuller discussion on the two linked issues of overheads and administrative costs at a later stage. I will not speak on that issue at length today but I want to flag up to the Minister that this is an extremely important issue in this very difficult financial climate. Rather unusually, we may need to put in a Bill establishing new bodies a curb on the extent to which they can grow their administrative budgets in the future. My noble friends are doing the House a service in giving us a chance to have a debate on this issue.
I return to Amendment 50. It may not be directed at the right place in the Bill—I leave the Minister to think about that—but its substance should be in the Bill. I hope that the Minister will reconsider the Government’s position on this issue. I beg to move.
Baroness Finlay of Llandaff
My Lords, I rise to speak to this amendment, which is also in my name, and to support the other amendments in this group. They have the effect of ensuring that public health considerations and public health expertise are given due weight in the new arrangements set out in the Bill.
Public health covers three main domains: health improvement; health protection; and health service delivery. Public health specialists are trained and skilled in interpreting data and information about populations, understanding health needs and securing the services required to meet those needs. That expertise is vital to having effective commissioning at every level, particularly that of the NHS Commissioning Board, which will have the overarching responsibility for commissioning health services, so as to ensure that the services are effective, appropriate, equitable, accessible and cost-effective. It therefore seems only sensible to make sure that that expertise is incorporated at board level.
The Commissioning Board exists to secure and improve the health of the population through the NHS services it commissions, and indeed through the services which are not NHS-provided, if I have understood this Bill correctly. To do this, the board would benefit from public health input. Public health specialists have an unparalleled overview of a community's need for health services and how they are best commissioned, including changing, adapting or even decommissioning services which could work better in other ways. The role of a public health specialist would also be to provide the essential expertise needed to commission preventive services, such as screening and immunisation, and to look at the evidence relating to those services. The board may need the courage to decommission some of those services as well, or to substantially alter the way that they are delivered.
It would be inappropriate to say that this is going to be too expensive, because a public health specialist should pay for themselves many times over with their presence on the board. It is only by having such an expert at board level that we can ensure their expertise is incorporated into decision-making, rather than only feeding into the process in an advisory capacity.
Lord Warner
I think that the noble Baroness is experienced enough, like me, to remember the 1974 reorganisation of the NHS, where we ended up debating whether area gymnasts should be appointed. Therefore, I have every sympathy with her particular line of argument.
Baroness Cumberlege
My Lords, I am very grateful for that intervention. I have no experience of gymnasts and, sadly, I cannot remember that particular time. However, I have chaired very big boards. I have chaired a board of 26 and it was a nightmare. It was a nightmare because we are such a lovely nation and we always try to get consensus. Trying to do that takes time and tough and speedy decisions are not taken. In the end, the board loses the grip necessary to manage the service, the organisation or whatever it is in charge of. Therefore, I strongly support my noble friend on the issue of having 11 members on the board. When one has a very large board, a clique forms; one gets a few people who in the end run the board. They run it outside board meetings. They make the decisions before they come to the board. One gets a body of people who are responsible on the board but are actually disenfranchised—they are accountable but disenfranchised—and I think that that makes the board totally dysfunctional. Therefore, we should resist the temptation to have representatives on the board. We need a chairman with considerable leadership skills; a chief executive of proven management expertise; executives who know the business; and non-executives who bring a breadth of experience.
I have some sympathy with the arguments that have been put on the issue of the Director of Public Health but I wish to reserve my position on that, as I do on the suggestion put forward by my noble friend Lady Jolly on HealthWatch England, because it could be that the board, or whoever, might decide that there is a non-executive who has wider experience and possibly could be more effective on the board than the chairman of HealthWatch England. This needs discretion and we should leave it in the hands of the board and the Bill and not try to make it representative.
In an earlier debate the noble Lord, Lord Davies of Stamford, who is not in his place today, referred to the “fatal tendency” of the NHS to be bureaucratic and exercise producer catch-up. He said that:
“the tendency of any organisation that is in a monopolistic position [is] to be run for the convenience and in the interests of those who are providing the service, whether doctors, nurses, managers or whatever”.—[Official Report, 9/11/11; col. 251.].
We have to be very careful that we do not fall into that situation and we must try to address that “fatal tendency”, as he described it.
I wish to make one comment on the seductive amendment on limiting the numbers to be employed to 500. That again is a mistake. If we set a number, it is very likely that that number will be reached where possibly only 100 are required. It needs a great deal of scrutiny by the Secretary of State and others, through the mandate, to see what the board is doing and whether it is effective and keeping to its budget, which I am sure will be closely watched. I would like to keep the number on the board to 11.
Lord Greaves
There is a great deal of truth in what the noble Lord says. Looking at this from afar, I think that the Government have had to struggle with this tension. In order for the bodies to be serious commissioning bodies, commissioning not just for their patients individually or collectively but for the health needs of their area, they have to be sufficiently large. What will happen is that the GPs who sit on these new commissioning groups almost certainly will represent the GPs in the whole of that area, and they will have to be appointed by some democratic process representing the whole area—perhaps one from each area. I do not know how they will do it but that will have to happen at a local, practical level.
In my view, one thing that has bedevilled this debate is that the word “commissioning” has been used in two quite separate senses. One has been the idea of a GP commissioning services for his particular—
Lord Warner
I am sorry to interrupt the noble Lord’s flow, but I would like to press him a little further to give us some clue as to his thinking on this. My noble friend Lord Hunt gave us a snippet of history, but there is quite a lot more. We have been through a process where we have come down since 2002 from 300 PCTs to 50 or so PCT clusters. We have been on that journey because we found it extremely difficult to commission services effectively when there are very large numbers of PCTs covering small geographical and population areas. There is simply not the expertise to do that. Could he give the House some clue about where he thinks this is all going to end up? At the moment, in terms of starters for 10, we have about 250 of these clinical commissioning groups. I think it would be helpful to know where the members of his party and others who have argued for this stand on where the journey may end.
Lord Greaves
I am extremely flattered that the noble Lord, Lord Warner, thinks that I have the slightest idea where it is going to end up. I am doing exactly what the noble Lord, Lord Warner, and other noble Lords are doing—trying to get the Minister to give us some idea of that. We will be interested to see whether he gives that. Over the political lifetime of this subject, we have had constant changes. We started with bigger area health authorities and smaller district health authorities, going down to district level, and then going back to the area level, with the regional level having a greater or lesser influence. The fact is that this is a fundamental administrative difficulty—not a philosophical difficulty—for an organisation like the health service.
Lord Warner
Can I press the noble Earl a little further on that? If a chairman has been appointed for this body who has a level of experience to enable him or her to function at that level, then requiring the Secretary of State to approve the appointment of the chief executive seems to throw into doubt whether the Government have confidence in that chairman running that kind of body—they need to be able to appoint an accountable officer as their chief executive. I find this a pretty considerable vote of no confidence in the kind of people who are being appointed as chairmen.
Earl Howe
Not at all, my Lords. Of course we have confidence in the chairman. However, it is a little strange to hear from the noble Lord that he suddenlythinks the Secretary of State should not be involved in an area where he has a legitimate interest to make sure, on behalf of the taxpayer and indeed patients, that we have somebody who is capable of fulfilling the role of accounting officer. This is an important role for the Secretary of State to have.
Turning now to Amendments 57, 153ZA and 153B, let me assure the Committee, and especially the noble Lord, Lord Hunt, that we want to reduce the amount of NHS funding spent on back-office bureaucracy. That is why have made a commitment to reduce administration costs across the health system by one-third in real terms, saving £1.5 billion annually by 2014-15. All that money will be put back into patient care.
Clause 21 provides powers for the Secretary of State to impose certain limits on the overall expenditure and use of resources by the board and clinical commissioning groups, including in relation to administrative matters defined through parliamentary regulations, for the first time. The board has the power to set similar limits for individual CCGs. I see no reason to change this to a duty to do so, as Amendment 153B suggests. As the board will itself be responsible for overall administrative spending, I am sure it will want to use this power carefully. Within those limits, it should be for the board to determine how best to use the resources available to it, and to decide on its own structures and ways of working, and the number of staff that it needs to perform its functions effectively. It is not appropriate to set a staffing cap on an arm’s-length body.
How big will the board be? In a document called Developing the NHS Commissioning Board, Sir David Nicholson, chief executive-designate of the board, estimated that the board was likely to have 3,500 staff, carrying out the functions currently exercised by around 8,000 staff in the Department of Health, strategic health authorities, PCTs and a number of arm’s-length bodies that are being abolished, along with its own new functions. It will deliver these in a much more streamlined way.
Likewise, setting an arbitrary cap in the Bill on the number of clinical commissioning groups or on their expenditure on administration in comparison to PCTs is not, in our view, an appropriate means of controlling administrative costs. CCGs will be different from PCTs. They put local clinicians in charge and align clinical decisions with the financial and quality consequences. It is a little unfair of the noble Lord, Lord Hunt, to say that we are creating a complicated and bureaucratic system, and citing clinical senates and networks and health and well-being boards. Clinical senates and networks are not new organisations in their own right: they will be hosted by the board. Clinical networks already exist. Health and well-being boards are also not separate statutory organisations: they will be hosted by local authorities. We are abolishing a whole raft of bodies under this Bill, as I have said on previous occasions. It is important to bear that in mind.
I appreciate the concerns underlying Amendments 58 and 59. It is important that there should be transparency in all the workings of the board. This is why Schedule 5 to the Bill was amended in another place to include the board in paragraph 7 as a body to which the duty in Section 1 of the Public Bodies (Admission to Meetings) Act 1960 applies. This would include any annual meeting that the board may decide to hold. I say “may decide” because the Bill is clear, in new paragraph 12 in Schedule 1, that:
“The Board may regulate its own procedure”.
This would also apply to determining when it is quorate.
However, the Bill does include clear procedures around the publication of the board’s annual accounts and annual reports, to ensure transparency. The board must send its annual accounts to the Secretary of State and the Comptroller and Auditor-General. The latter must examine, certify and report on the accounts and then lay copies of the accounts and the report before Parliament. The Comptroller and Auditor-General is responsible for the audit of the accounts of all arm’s-length bodies. The board must publish an annual report and lay it before Parliament. The Secretary of State must then write to the board, providing an assessment of the board’s performance of its functions, publish the letter and lay it before Parliament. That gives an indication that there will be maximum transparency here.
Turning to Amendments 145A, 146A, 147ZA and 147C, I am afraid that I do not agree that it would be worth while to add the unusual burden of an explicit duty of consulting on a draft business plan. The board is already required in new Section 13P(2)(a) to involve and consult the public in planning its commissioning arrangements. Under a duty in new Section 13J, it is required to obtain appropriate advice to enable it effectively to discharge its functions, including the planning of how it will exercise its functions.
I hope I can reassure noble Lords that Amendments 147A and 147B are also not necessary. First, the duty to produce a business plan already provides for transparency by obliging the board to publish its plan. Secondly, while the Bill requires that the board’s annual report and annual accounts are laid before Parliament, that is part of specific processes for scrutiny of the board’s performance against the objectives it was set and the outcomes it has achieved. It is right and proper that the board should be held to account in such a way. Another clear recommendation by the NHS Future Forum was that the autonomy of the board needs to be respected. With this in mind, although it is right that the board should be required to produce a plan and for that plan to be published for all—including Parliament—to see, I am not convinced that it would be appropriate to have parliamentary scrutiny of the board’s plans or draft plans. The Bill places certain functions on the board, and it should be for the board to determine how it will seek to exercise these.
With regard to the questions asked by my noble friend Lord Greaves concerning the size of clinical commissioning groups, I respectfully suggest to him that we defer them to a later group of amendments, where this issue will come up and I shall be able to talk more about it. For now, I hope that the noble Lords are sufficiently reassured to be able to withdraw the amendment.
Earl Howe
I apologise to my noble friend. The national Commissioning Board will, we envisage, be tasked with commissioning a number of public health functions by Public Health England. There will be a close relationship between Public Health England and the board. Much of the work of the board will straddle both public health and the provision of NHS services. There will be an intimate symbiosis between the two bodies.
Lord Warner
My Lords, on Amendment 50, which I seem to have moved quite a long time ago, I will consider the noble Earl’s remarks. I am grateful to noble Lords who spoke in support of Amendment 50. Public health is a rather special case and I would want to reflect, in a later debate, on the public health amendments. In the mean time, I beg leave to withdraw the amendment.
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Baroness Murphy
Even the psychiatrists were not. I can remember this group of people being pretty darn useless. You would send up a proposal; they would look at it; they did not like it because it was not in their best interests as a specialty and they would send it back again. I can see that my colleague, the noble Baroness, Lady Emerton, agrees with my every word.
I am a little concerned about what these people are going to do. Will they provide cutting-edge, evidence-based expertise of the best kind to local commissioners? Will they be a talking shop? Will they be a regional medical advisory group?
Lord Warner
My Lords, I rise to reassure the noble Baroness, Lady Murphy, and restore her confidence in the Labour Benches on the subject of senates. If the Conservative side can have the Mawhinney-Howe dialogue, why should we not have the Hunt-Warner dialogue on senates?
I can well understand why people would like to be a senator. It sounds very grand. It would be good to put on your CV that you are a member of the senate of wherever—even if it is Birmingham. To some extent, I can understand why the Future Forum thought it would be a good idea to have senates. I can imagine it received a lot of representations from specialists in various parts of the country that perhaps these GP commissioners, as they were then known, were getting a little uppity and needed to be curbed a little and put in their place. Why, then, not give a little more space to the people who really know about these things—the specialists—and bring them together in senates? Yet, since 2006, thanks to the helpful report by Sir David Carter on specialist commissioning, we have gone a long way in putting in place a sensible way for dealing with regional specialties and, on top of that for very rarefied stuff, a national commissioning capability. That has not been around for long. It would not be a bad idea to try to keep some of that learning experience together as we move into this brave new world.
I do not have any problem with networks. Networks have been a proven success. They have done a lot of good and there is a lot to be said for trying to reinforce them, even to put some wording about them in the Bill. But I struggle with senates. We need a really good explanation of what they are out to do. The noble Baroness, Lady Murphy, put her finger right on the button: it is a very good solution but what is it a solution to? I hope we can have some enlightenment on that from the Minister.
The Archbishop of York
In my day-to-day life, I have to do what they call “oversight”. The trouble with oversight is that it is always remote. The person who comes on the round is the parish priest or the diocesan bishop. The moment you begin to take oversight seriously from a distance, you are in real trouble. How do you know that the delivery of what you want will work? I am not so certain that I want this Commissioning Board to have oversight of both clinical issues and the senates. That would lie somewhere else, not with the board. It is to the board that Monitor, NICE, clinical senates and networks, and the Care Quality Commission actually report. I can understand the other factors in the Bill but the moment you include the business of,
“overseeing sub-national clinical senates and networks”,
you are in real trouble. What is that, by the way? I remain uncertain. We certainly need a clear spelling out of what senates are for. That is a separate question from whether the board should oversee their work, let alone if we understood it.
I am not one to suggest that this amendment is helpful. What would be most helpful would be to hear from the noble Earl what are the senates, what are these networks, and where you would locate the whole question of accountability and responsibility. I do not think it is the board; otherwise you are giving it a much bigger function when it already has five functions; and there are further provisions in the schedule. If you really want the board to fail, add on more work. So my view is that it should not have oversight of the sub-national groups. However, I am still confused. Will the noble Earl tell us what the senates are for? Networks I can understand; but what are the senates for? If he explains, we may actually see that this amendment is redundant.
Earl Howe
The noble Lord could be proved right. As I have said, we will see how the functions of senates are defined. That work is ongoing. The initial proposals for the design and implementation of senates are currently being developed and initial straw-man proposals are being tested with the intention of presenting a clear set of recommendations to the top team of the special health authority later this year, so—
Lord Warner
I am sorry to interrupt the noble Earl but I am still puzzled about where he and the department are taking this concept of the senate and how it fits in with the regional specialist commissioning set-up, which already exists and which has 10 regional commissioning capabilities aligned with the SHA areas. I am not clear about whether that work is to be folded into the senates. Is it free-standing? Are the lessons all to be lost, and what are the costs of this? What does hosting the senate mean in terms of costs, because there are costs to these regional bodies that are undertaking the work on specialist commissioning? I am at a loss to understand how these two elements—the senates and the regional commissioning capability that is there now—coexist and what the cost implication is of hosting senates alongside those.
Earl Howe
I will talk in a moment about specialised commissioning and I hope the answer to the noble Lord’s question will emerge. Amendment 84, tabled by the noble Lord, Lord Patel, would require the board to commission highly specialised services, in collaboration with the sub-national clinical senates that are accountable to it.
I will not rehash my arguments around Amendments 51 and 224A, but many of the same points will apply to this amendment. Specialised services are challenging to commission; they involve complex care pathways, small numbers of providers and very small numbers of patients with rare conditions. The new NHS Commissioning Board authority will be considering options as to how it does this, including the best form for its substructures. There will be the freedom to adapt these over time and, to ensure that progress is not lost, the board will be required under existing provisions to maintain the necessary focus of clinical expertise in these highly specialised areas.
The noble Lord, Lord Hunt, asked how we ensure that clinical senates are not ignored; this is precisely why we do not want to prescribe their role in the Bill. We want senates to be enabling bodies, which is why we are inviting views on the type of advice they could provide to identify the functions of the board and CCGs where they would add value.
The noble Lord, Lord Patel, indicated that he thought the clinicians on the senate would have to come from outside the clinical commissioning group area. That is not the case; he is not correct in that assumption. There may be slight confusion with the rules we set for secondary care doctors on CCG governing bodies, who must avoid conflicts of interest, hence the need for area restrictions in that context. Experts on clinical senates can come from, in theory, all or any areas of the country. The difference between the senates and regional specialist commissioning is that the latter focuses on specialised services and nothing else. The senates could, in theory, work across all services; the two are not designed to do the same thing. The senates will be quite high level. It is expected they will be about only 15 in number, and while they may be established in a certain form they can evolve over the years to conform to the requirements that are placed upon them.
My noble friend Lady Jolly pressed me on the role of the board with regard to specialised commissioning, and I have already indicated in outline part of that role. The key point is that the board will maintain the necessary focus of clinical expertise and it will be under specific duties to obtain professional advice in the exercise of its functions. Under the regulations, the types of service the board will be required to commission will be kept under regular review. Work is going on at the moment to define what those services should be in the first instance, and I fully expect them to conform broadly to the specialised services national definition set. As my noble friend knows, the list of those services has historically changed over time and I expect the same will apply in the future.
The noble Baroness, Lady Finlay, asked about the long promised organigram. In fact, our fact sheet on the overall health and care system does have an organigram in it. It includes the NHS Commissioning Board and describes how senates and networks will be hosted by the board. I refer the noble Baroness to that sheet. The noble Lord, Lord Kakkar, asked how senates will be different to academic health science centres in their focus. In short, AHSCs are partnerships of local academic and health bodies to support innovation and excellence in that area. However, they will not be impartial; they are by definition a vested interest. Therefore, they would not be the right bodies to offer the broader perspective on how services should best be configured across a region.
I hope that noble Lords will be at least somewhat enlightened by the details I have been able to give about clinical networks and senates. As I say, this is work in progress. I make no apology for that. This was very much a recommendation that emerged from the Future Forum report. We have got on with the work needed to flesh out what these bodies should be, but we have a broad and, I hope, helpful idea of their role across the wider NHS system. I hope the noble Lord will feel able to withdraw his amendment.
Lord Warner
My Lords, I shall speak to Amendments 169, 171 and 174 in my name and that of the noble Lord, Lord Patel. I very much endorse the remarks made earlier by the noble Lords, Lord Kakkar and Lord Patel, and my noble friend Lord Hunt. There has been a huge amount of concern about the governance and accountability of clinical commissioning groups since they were launched upon a slightly unsuspecting world. That is not to say that it was a bad idea to have them, but a large number of questions have been legitimately asked about how they will be held to account for large sums of public money and how they will govern themselves, given in particular that they are a new type of public body. We have been unsure from the beginning precisely how many of them will emerge. It seems that there are now in the order of 200, or 250 or something like that, but we are not quite sure how many there will be eventually. Some of them are quite small and some will be quite big, so they are quite variable in their scale of operation.
The conflict of interest issue has come up repeatedly. I cannot remember how many events I have been to where that issue has been expressed. There is also the fact that these bodies are untested. They are different in kind from many other public bodies that there have been. The theme running through my three amendments is about trying to improve the governance and accountability of clinical commissioning groups, given the large amount of public money that they will be spending—the collective expenditure of these particular groups runs into tens of billions a year.
Lord Greaves
My Lords, this is a very mixed bag of amendments. It is all about clinical commissioning groups but the issues behind such a mixed group are varied and it is quite difficult to get a coherent debate about them—although I do not criticise the Government Whips’ Office for attempting to push this Bill along a bit, given the speed it is going. I shall speak to three or four of these amendments. I totally agree with everything that my noble friend Lady Barker said, so I will say no more about that.
The noble Lord, Lord Whitty, started us all off with Amendment 59A, suggesting that,
“clinical commissioning groups … coincide with local authority boundaries”.
In his speech, the noble Lord modified it a bit further than his amendment seems to go but the basic principle behind it is extremely important, except that where there are large, sprawling counties in two-tier areas those counties are clearly far too big to be the areas of the commissioning groups. In a county such as my own, Lancashire, or North Yorkshire it would seem sensible for the clinical commissioning groups to be smaller than the county, although I would argue strongly that the county boundaries and the top-tier or the unitary authority boundaries should not be crossed.
Lord Warner
Is the noble Lord aware that some of the most effective clinical commissioning in the existing arrangements has been done by primary care trusts which are based on county boundaries?
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 Warner
I am sorry to interrupt the noble Earl, but I was aware of that. My concern was that it seemed to leave to clinical commissioning groups the decision on what type of information they put in that. They could put in a whole load of information that was not comparable with any other clinical commissioning group. The whole point of my amendment was that there should be a level of standardisation so that we could see the different levels of performance in different CCGs.
Earl Howe
My Lords, I take that point on board. It is my understanding that the NHS Commissioning Board will wish to set common standards for CCGs to follow. However, I will follow up that point with the noble Lord. As I said, the Bill requires each CCG to prepare annual accounts, independently audited. The board may, with the approval of the Secretary of State, direct CCGs as to the methods and principles according to which their accounts must be prepared, and the form and content of such accounts. Therefore, there will be scope for the board to drive consistency in the area the noble Lord mentions.
I turn now to Amendments 169, 175BA, 175C and 101A, which concern membership of, and appointments to, CCG governing bodies. In response to amendment 169, as the Bill stands, under new Section 14N, regulations may already provide that members of governing bodies must include the accountable officer of the CCG. Paragraph 11 of Schedule 1A also specifies that the accountable officer may be one of the following: a member of the CCG, or an employee of the CCG or any member of the group. Restricting the accountable officer to being the “most suitable senior employee” of the group, as Amendment 169 also proposes, would narrow who the officer could be and ignore other able candidates, so I am not attracted to that amendment.
Amendment 175BA, and Amendments 175A and 175B, which we will be discussing in more detail in a future group, clearly intend to ensure CCGs have access to professional or other expertise to advise on all areas of their work. This is undoubtedly important, but the governing body is not the route to achieve this. As the Future Forum advised, a clear distinction should be made between governance of CCGs and clinical involvement in designing care pathways and shaping local services.
Clinical involvement in designing pathways or shaping services is exactly what a CCG will need to ensure in exercising its duty in new Section 14V, which requires a CCG to obtain advice appropriate for enabling it effectively to discharge its functions from individuals, who, taken together, have a broad range of professional expertise.
Clinical senates and networks will, of course, be crucial to effectively meeting this duty and to ensuring that CCGs can access specialised advice, as will the local knowledge and public health knowledge held by health and well-being boards. We believe there is a case for ensuring that governing bodies include the voices of some other professionals—at least one registered nurse and a secondary care specialist—but it would be unhelpful, as the Future Forum also acknowledged, for governing bodies to be representative of each group. That could lead to bodies that are too large and slow to do their job well. CCGs should have the flexibility to determine the professional input into their governance arrangements.
Amendment 175C would provide for regulations to be made setting out how lay members are recruited and remunerated. Subsection (3) of new Section 14N already makes provisions as to the appointment of members, including lay members, to the governing body. Paragraph 12 of Schedule 1A allows the CCG to pay members of its governing body such remuneration and other expenses as it considers appropriate. These existing provisions cover the intent of Amendment 175C.
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Lord Warner
My Lords, in the absence of the noble Lord, Lord Patel, I should like to speak to Amendment 37 as my name has been added to it.
Before getting down to the precise wording of the amendment, I want to give some context to my remarks by talking about what I regard as the total incoherence of Clause 4. I note from the letter of 7 November from the noble Earl, Lord Howe, to my noble friend Lady Thornton that the Government now seem to want to treat Clause 4 in the same way as Clause 1. I have to say that that is hardly a ringing endorsement of the drafting of Clause 4. I wonder, privately, how many other clauses we will have this problem with as we progress through the Bill. In effect, the Government are seeking to take these clauses out of the normal consideration of a Bill in Committee. We are getting into rather strange territory where, as we wander through the Bill, we find that, when the Government find themselves under pressure with regard to bits of the Bill, they sweep those bits aside to have another go in some procedure, which is less than clear to the House, and promise to come back later. Before I go any further on the amendment, as I am already unclear as to how the Government are going to handle Clause 1—and, it now seems, Clause 4—procedurally, I would welcome any light that the Minister can shed on how we are going to deal with these clauses and have a proper discussion of them in Committee.
I turn now to Amendment 37. I am completely supportive of reducing or even stopping ministerial and Department of Health micromanagement of the NHS.
Lord Mawhinney
I am extremely grateful to the noble Lord. Is he aware that the concern which he has just expressed is held by other noble Lords as well?
Lord Warner
I am grateful to the noble Lord for that intervention. The more the merrier, I say, on this theme and I hope that noble Lords will speak out about this issue in our debate today.
As I was saying, I am completely supportive of reducing or stopping ministerial and Department of Health micromanagement of the NHS, which, as I understand it, is the Government’s purpose in framing Clause 4. However, I struggle with reconciling the clause in its present form with the other duties and powers that the Secretary of State has taken unto himself in the Bill. I do not mean just the relationship between Clauses 1 and 4, which itself seems to have produced a hefty dose of confusion and uncertainty, not to mention, in the case of Clause 1, many attempts at drafting alternatives. How will Clause 4, for example, fit with Clause 3, which most of us in the previous session in Committee—except, perhaps the Minister—seemed to favour strengthening in terms of the duty on inequalities? How will it fit with Clauses 16 and 17, with their very extensive regulation-making powers for the Secretary of State, or indeed Clause 18 or Clause 20, which gives the Secretary of State extensive mandating powers, which seem to me to be rather stronger than the new chairman of the NHS Commissioning Board seems to think?
Many people who have looked at the Bill do not understand what the Secretary of State is trying to do in relation to the issue of central control, central powers and autonomy and delegation. Is he trying to let go or to tighten his grip? I do not see, at present, how the Government can retain in the Bill a clause as loosely drafted as Clause 4 and, at the same time, retain all the other powers of the Secretary of State that we will be discussing later. Apart from anything else, this is a recipe for confusion in the minds of many local decision-makers.
Are people to take Clause 4 as drafted at face value? If they do, will they not be wondering whether the Secretary of State or his henchmen and henchwomen in the Department of Health or the NHS Commissioning Board will come down on them like a ton of bricks using other powers in the Bill if they think that they are not acting in the interests of the NHS? What will the courts make of all this? If people do not like a decision taken higher up the line, as the Royal Brompton and Harefield NHS Foundation Trust is demonstrating now over paediatric surgery changes, do they seek judicial review of the central decisions, praying in aid Clause 4 as drafted? Will not Clause 4 in its present form simply encourage legal challenge and create local uncertainty?
I turn to the wording of the clause and why Amendment 37 is at least an improvement. It is an attempt to improve what is a highly defective clause. As I read Clause 4, it seems to place little inhibition on local decision-makers,
“exercising functions … or providing services”,
in any manner that they consider appropriate. If that means what it says in the dictionary, if people want, for example, to provide a wide range of alternative therapies for which there is no scientific evidence of clinical benefit, they can do so, praying in aid the powers under Clause 4. If they want to remove tattoos or do a bit of cosmetic surgery, I cannot see that there is very much to stop them. Under the clause as drafted, the Secretary of State can intervene only after the event. If he finds out what has been going on, he can, in effect, try to stop it happening again, but that is ex post facto. He cannot intervene earlier, as I understand the drafting of the clause. I am happy to be corrected by the noble Earl, but I am not the only one who thinks that these powers will have that effect.
Amendment 37 is an attempt to require those behaving autonomously locally to apply the test that their actions are in the interests of the NHS before they take their decisions rather than relying on the Secretary of State deciding that they were not in the interests of the NHS after the event. I see that my colleague, the noble Lord, Lord Patel, is now with us. I suspect that we both agree that it is a far from perfect solution, but it is better than the way that the clause is currently drafted. I know that some noble Lords are very attached to the clause—like me, they are attached to the idea of autonomy—but I hope that they will consider whether in its present form it is really in the best interests of the NHS. I suggest that the Government rethink the form of Clause 4 if they want to proceed with it. As I see it, what would get nearer to their intentions but not create some of the loopholes that I have identified is a kind of drafting that gives a commitment that the Secretary of State would not exceed the powers provided elsewhere in the Bill, would impose only burdens that are totally consistent with those powers and would maximise operational freedoms for those delivering NHS services consistent with public accountability. That seems to me to be the direction in which the Government are trying to go, but the way the clause is drafted does not do that.
I would prefer the Minister to accept that the clause is seriously deficient and either abandon it altogether or take it away for a serious makeover. In the mean time, on behalf of the noble Lord, Lord Patel, and myself, I move Amendment 37, which goes a modest way to improve the shape and drafting of the clause. I beg to move.
Lord Patel
My Lords, first, I offer my sincere apologies to the House for being delayed. I was also thrown by the fact that that the first two amendments were not moved. I am sorry about that. I am grateful to my friend, the noble Lord, Lord Warner, for moving the amendment in my absence, and I join absolutely in his comments. I shall try to cover some other points. My name is also on the amendment tabled by the noble Baroness, Lady Williams, and I support that too.
As I interpret it, under the clause, as long as the Secretary of State does not think that it is inconsistent with the interests of the NHS, he or she must act positively to allow any other person exercising health service functions to do so in a way that that person thinks appropriate. Although the Secretary of State keeps some form of oversight, it is the views of other persons and bodies delivering health services on how those services are to be delivered that are important.
This duty would therefore require the Secretary of State, when considering whether to place requirements on the NHS, to make a judgment. The challenge for the Secretary of State would be to justify why these requirements were necessary. Does this mean that the Secretary of State has the power to act only when the steps to be taken are really needed or essential, rather than because he or she thinks that something is desirable or appropriate? He or she would have to demonstrate why no other course of action will be followed. Is that a high test to meet on the part of the Secretary of State?
Baroness Cumberlege
My Lords, I very strongly support the spirit of Clause 4, and I oppose the amendment that the clause should no longer stand part of the Bill. I accept that it could be amended and could be clearer, but I want to hold to its spirit.
In the past I have put down six amendments to two major health Bills in an attempt to achieve something similar to what is in Clause 4. I have to say that my attempts, although I was supported by the King’s Fund, were puny compared with the weight of this mighty Bill. I hoped that my time had almost come. I say almost, because I know that the Minister, in his letter dated 7 November to the noble Baroness, Lady Thornton, which the noble Lord, Lord Warner, mentioned, is suggesting a strategy. I understand that the noble Lord, Lord Warner, does not like this strategy. In contrast, I do. One of the real hallmarks of this House is that we try to negotiate and accommodate what we, as a whole in this House, feel is appropriate.
In revising and amending the Bill, I appreciate that an enormous amount of time and care—
Lord Warner
I am not opposed to having a strategy, if I may say so to the noble Baroness, and I thank her for giving way. However, when a Bill reaches this House with a major clause in it, it has been through the other place and has been subject to a lot of scrutiny by Professor Field and his group, the Future Forum, it is reasonable to assume that the drafting does not have the kind of loopholes that this clause has. I am not the only one raising this; other people are raising the same issue. There is a lot of concern outside. We are not opposed to having a strategy, but it is reasonable to expect the Government to have got the Bill into a better shape than it was in before it came here.
Baroness Cumberlege
My Lords, I thought that that was the whole purpose of Committee stage. This stage is intended to question some of these concerns and to see whether a resolution can be achieved.
Lord Warner
The noble Earl is taking this clause out of the Committee stage, so far as I understand his proposal. If the strategy is to take clauses out when the going gets rough, that does not seem to be in keeping with the spirit and behaviour of this House.
Earl Howe
My Lords, I have no desire to take this clause out of the Committee proceedings. These proceedings are continuing. We have heard the noble Lord and his views, and I look forward to hearing other noble Lords. I am not in the least desirous of inhibiting debate on this clause, which I think is very valuable. However, perhaps noble Lords will consider that, in view of the undertaking that I gave on 2 November, there is a certain amount that need not be said today because I have undertaken to look at this clause on a cross-party basis and with an open mind. It is a clause that the Government were and are satisfied with and they believe that it can stand as worded without amendment. However, I appear to be accused of being too concessionary on this. It is a case of the Government being damned if we do one thing and damned if we do the opposite.
I felt that my offer to the Committee was helpful. I think that there is concern around the Chamber about this matter and I can only repeat my offer to look at that concern and, if we can reach an agreement, to put beyond doubt the fact that these clauses do what I believe many noble Lords wish them to do. I hope that in that spirit the noble Lord, Lord Warner, will agree that, while we can debate the clause today for as long as we wish, the offer is there on the table from the Government to engage in cross-party discussions with a view to reaching consensus.
Lord Mawhinney
Moving on, I remind my noble friend of the times we sat with a cup of coffee and a private secretary or two—just to make her feel better—and we wrestled over some fairly difficult and complex issues. Either she or I would say, “We need a bit more information about that”, the civil servant would say, “Yes, Minister”, and in due course, when diaries permitted, we would sit down again with a bit more information. That can be said to be good ministerial governance—or it could be said to be politically motivated delay when others in the health service knew better, and if only we had got out of the way they would have done what they wanted, but they would do what those in power at the time happened to want, ignoring the contrary views of those who did not happen to hold the management positions at that moment.
I want my noble friend to accept that I still hold her in as high regard as I did before this debate started, but we part company fairly fundamentally on the issue of the accountability on a spend of £128 billion a year. As I said in an earlier debate—I have expressed this privately to the Minister, and my noble friend had the grace to say that he understood—my difficulty is that if you are spending £128 billion of public money, the public whose money are spending are simply not going to say when big problems arise, “Well, that’s okay, we’ll listen to him or her because he or she is chairman of a quango”—even a quango as highly thought of as my noble friend no doubt hopes the national Commissioning Board will be.
There is no debate in this House about the fact that the Secretary of State must be held accountable by Parliament. My noble friend Lord Marks of Henley-on-Thames made the point, which has to be right, that the Secretary of State must also be held accountable by the courts. However, the Secretary of State also needs to be held accountable by the public and the patients, who have not had a huge showing in our debates thus far. I have concerns about this clause because I am not at all clear how the Secretary of State is going to satisfy X billion people by putting in £128 billion that he is accountable to them for if they are absolutely determined that they want him to be accountable to them.
To help the Minister when he takes this clause away and thinks about it, I say to the noble Lord, Lord Warner, that I was not convinced by the amendment. I am happy that he has made that part of his contribution to the review that my noble friend will conduct, but I hope that he does not press it to a vote because I for one would not be able to support it.
There are parts of the clause that the Minister really needs to look at, such as the phrasing in new Section 1C(a):
“any … person exercising functions … or providing services … is free to exercise those functions or provide those services in the manner that it considers most appropriate”.
From that, I am not clear—I do not necessarily want the Minister to tell me this today, but I ask him to think about this—at what point these actions start to become health service policy in their own right. We quote precedent in here. If someone takes an action because they think it is right in the circumstances, does that become a policy or a guideline? Where does the Secretary of State play any role in developing a policy for the NHS?
New Section 1C(b) goes on to say,
“unnecessary burdens are not imposed”.
I have to say to my noble friend that I do not understand what that means. Who decides whether it is a burden? Who decides whether the burden is unnecessary, and where can you challenge the decision whether a burden is a burden and when it becomes unnecessary? It is okay if you consider your action to be the most appropriate in the circumstances. My party occasionally gets criticised for being inclined to being a bit too individualistic, but you cannot run a health service in which everybody can make the decision that they think is most appropriate in the circumstances without a well defined political framework within which they would be expected to act.
I will tell my noble friend something that I have said to him in private but do not mind sharing in public. I spent 26 years at the other end of the Corridor. In all that time I never once voted against my party. Some in this House will see that as wimpish and craven, and some will see it as a fine expression of loyalty. Frankly, I do not mind how you see it. It is how I see it that is important to me.
I have not done a Committee stage of a Bill since I left the Cabinet in 1997, so I want Members of your Lordships’ House to understand that I am not having much fun in these Committee sittings. This is not something that comes naturally to me, and I have tried to reassure my noble friend that my participation in these debates is because of my commitment to the health service and my desire that it should be as excellent as possible. This is for the sake of my former constituents, who are patients. In that spirit, I hope my noble friend will take away Clauses 1 and 4 and think about them again.
Lord Warner
My Lords, I compliment the noble Lord on his speech and say that we hope to see him every day of this Committee.
Baroness Murphy
My Lords, could I try to cheer up the Committee? We are getting very gloomy about this topic. To me, this is one of the most important clauses in the Bill and we must support it. I hope that we can reassure colleagues on the opposition Benches that there is no intention, as far as I can see, to withdraw any accountability, which we have discussed at great length. Nor is there any intention to interfere with the ability of the Secretary of State to intervene when necessary. It is clearly written in the Bill that the Secretary of State has a mandate and a multi-year setting of objectives, but he has to stay clear of interfering until something is really at crisis point, is going wrong or is urgent. There is plenty of opportunity for him to interfere.
I want to intervene because we have gone into the stratosphere with ideological and constitutional issues. We have certainly talked about political interference, and I agree wholeheartedly with the noble Baroness, Lady Cumberlege, about this. As a senior manager, I have a little list of Ministers around this Chamber who I can tell noble Lords did or did not interfere. I am delighted to say that the noble Baroness, Lady Cumberlege, was one of the least interfering of Ministers. Others around this Committee must wait for my judgment elsewhere.
Earl Howe
I am grateful to the noble Baroness. As she has indicated, there is certainly a read-across from Clause 4 into Clause 20, and I readily accept the suggestion that we should factor in issues that emerge from Clause 10.
I am clear that a successful process will be one that can take account of views from all political parties and the Cross Benches. As well as hearing in full from those Peers, many of whom have put their names to amendments and have become particular experts on this issue, there is also an implicit legal perspective to this and I believe that an important building block will be to engage with the Constitution Committee of your Lordships’ House and other legal experts in this House on these points. To start that dialogue, I propose to meet next week with a number of noble Lords, if they are willing, to explore the process for going forward. Following that, I will write again to all Peers setting out the proposed process in more detail. I hope that that is helpful.
I have very clear answers for the noble Lords, Lord Patel and Lord Warner, and other noble Lords to the concerns that they have raised. However, for the reasons that I have set out, if they will bear with me, I shall refrain now from providing a detailed commentary on the amendments in this group. I hope that, with the prospect of future discussions that will factor in the valuable points in this debate, the noble Lord will feel able, for the time being, to withdraw his amendment.
Lord Warner
My Lords, there is a film showing in local cinemas called “We Need to Talk About Kevin”; I think that this excellent debate has shown that we do indeed need to talk about Clause 4. I do not intend to comment on all the excellent contributions that have been made. I just want to say two things in conclusion.
I think that the noble Lord, Lord Marks, has provided an excellent forensic analysis of what is wrong with this clause. My personal view is that he has holed this clause below the water-line. I hope that the Minister, in conducting these cross-party discussions, will really keep in the front of his mind the easy solution that the noble Lord, Lord Marks, has helpfully given to the Committee, which is that we simply drop the clause.
Secondly, I would say to the noble Baroness, Lady Cumberlege, that I do not disagree with her about many of the issues that she raised. However, if she is really concerned about reducing political interference in decisions on service reconfiguration, I would direct her towards Amendment 304 in the names of myself, the noble Lord, Lord Patel, and the noble Baroness, Lady Murphy. There is room for another name on that amendment, which will indeed actually reduce political interference in this area. So I commend it to her. In the mean time, I beg leave to withdraw the amendment.
Lord Warner
My Lords, I shall speak to Amendments 40 and 42 in my name and those of other noble Lords. I also support Amendments 39, 40A, 41, 74, 89E and 199ZA in the names of other noble Lords and to many of which I have added my own name.
The noble Lord, Lord Willis, did us a great service in setting out the argument for strengthening these provisions regarding the Secretary of State’s duties on research. There is a bit of a conundrum, as he put it very well, about how a Secretary of State and indeed the NHS protects research and development in a devolved NHS. That is a difficult issue, and it is not good enough simply to have a general duty on the Secretary of State. As the noble Lord, Lord Walton, says, we need more flesh on the bone that gives some comfort to the idea that the Secretary of State, whoever he or she is, will actually take an interest and pursue some other aspects around the duty of promoting R&D. It is difficult to see how that duty could be protected without some degree of capability to intervene and ensure that the NHS pulls its weight in co-operating with R&D.
I turn to Amendments 40 and 42 in my name. I speak from the background of having been for two years the Minister responsible for NHS R&D when we started the reforms of the structure of R&D in the Department of Health and the NHS to produce much more focus to the R&D programme, to streamline some of its approval processes and to improve the translation of research to clinical care—the so-called movement from the lab to the bedside.
I, too, pay tribute to the work done by Dame Sally Davies—she was just plain Sally Davies in those days—and the leadership and persistence that she has shown in this area. The ideas that we were putting forward then for a National Institute of Health Research, which to some extent was based on the NIH model in the US, were not uniformly welcomed, if I may put it that way, by everyone across the NHS. It was deemed to be a bit too interventionist in some of the activities that were going on in the name of research and development in some of the dusty corners of the NHS. We have come a long way in that period. That is the background from which I speak, because I am keen to ensure that we do not go backwards in this area as we devolve more autonomy to the NHS.
It is relevant that I was also a member of this House’s Science and Technology Committee, where I had the privilege of working on the inquiry into genomic medicine under the extremely skilful chairmanship of the noble Lord, Lord Patel. That experience has convinced me that we need to feature R&D much more prominently in the Bill, particularly the issue of translating R&D findings into clinical practice that benefits NHS patients. That is what Amendment 40 attempts to do.
However, Amendment 40 goes further in two other aspects of successful development of research findings and their application in clinical practice: the back-up of information technology and the informatics skills, which are often inadequate to back up basic scientific discoveries. One of the things that the—in my view much maligned—national programme for IT did was to make it easier for researchers to access the very important patient database that the NHS provides for them, and it makes it easier for them to collect the kind of patient samples, if I may put it as crudely as that, that they need for their research. However, the genomic medicine report also showed that we have some serious problems in this country about informatics skills in carrying forward R&D in the health and life sciences area. That is why those parts of the back-up services get a special mention in Amendment 40.
I turn to Amendment 42. The noble Lord, Lord Willis, put his finger on it: if the NIHR disappears into the maw of the National Commissioning Board, how will its budget be protected? Will there not be a temptation, if times are hard, to dip into that pot and use it for operational matters such as the delivery of services? As a Minister and a civil servant who has worked in this field for many years, I can say that there is a great temptation when the going gets rough financially to—I shall put this as kindly as I can—reach into the pot of R&D, and indeed the pot of education and training, which we will be coming to later. I have watched people, who shall remain nameless, find themselves unable to resist that temptation. That is why I feel strongly that we should put something in the Bill along the lines of Amendment 42 to try to ensure good conduct.
Sometimes R&D is a bit slow in spending its budget. That is quite convenient if you are running into a bit of financial difficulty during the financial year. What happens is that money gets held back because of some pressing need and it will not really matter if we take a bit longer to get on with this bit of R&D. I assure the House that I have observed a Chancellor who managed to announce the same NHS R&D budget increase in two successive Budgets, and he was not spotted by anyone in the media. It is possible for some of this “peas under the pot” manoeuvring to take place. We are talking about political temptation, and Amendment 42 would provide some encouragement to resist it. The temptation to dip into R&D budgets is of course not confined to the NHS, but we have an opportunity with the Bill to ensure better behaviour in the NHS regarding R&D.
Lord Ribeiro
I rather suspected that the noble Lord did. That is why I felt able to make that reference. None the less, I launched a big campaign at the time because here was a budget—part of the NPEC budget—for nurses, doctors and so on that was being raided. It should have been a ring-fenced budget for training, yet the money was taken out of that budget to meet the NHS deficit. There is a real danger for the present Government if a situation should occur whereby the £1 billion budget—and there is no reason why it should be more than that—that has been set aside for research, particularly as the Secretary of State has taken responsibility to promote research, was found to come under the auspices of the chief executive of the NHS Commissioning Board, and that at times of trouble and trial that that money could be used.
I wanted to speak in line with what I said yesterday, although some noble Lords may doubt that I have spoken briefly. However, I speak in strong support of Amendments 40 and 42.
Lord Hunt of Kings Heath
Yes my Lords, but so was the overriding duty of Ofgem to the customer. The problem is how a regulator defines that responsibility. Since the Government are intent on this very foolish drive into competition, I believe that the risk is that the regulator will also be driven into thinking that that is its most important aim.
There are some real questions here, which I put to the noble Earl, about ensuring that there is sufficient concern, investment and leadership on the question of research. I would also ask the noble Earl how we protect and ring-fence the research budget. I ask him to think of the national Commissioning Board, faced with a hard winter, huge public concern and political pressure about funding, and the temptation to dip into the research budget. We all know that that happens. My noble friend Lord Warner and I were debating earlier who was responsible when there was real pressure on the training commissions. I thought it was my noble friend, actually, but we can continue to debate that.
Lord Hunt of Kings Heath
My Lords, with the greatest respect, I will not go into who left me the junior hospital doctors issue. He will recall that my first day as a Minister was actually the first day of Committee on the glorious Mental Health Bill, and that was a blessed memory, I must say.
My experience was that the health service let us down on training commissions, because at the time they were facing a financial difficulty and it was all too easy to cut those commissions. The result was that Ministers essentially took it upon themselves to put central controls back into the system. My concern is that if the NCB simply has research in its budgetary responsibility and there are severe pressures, it is just too easy to dip into it. The problem is also, as my noble friend Lord Warner said, that, as we know, sometimes research budgets take a little time to kick in, but once you do it you are funding for three, five, seven years. Again, in each financial year, an amount is probably available in the winter that had not been spent. The problem is that you will never get that resource back again.
The second point that I would like to put to the noble Earl is about clinical commissioning groups. How do we ensure that their commissioning decisions support research? My noble friend Lord Turnberg said that research is no cottage industry, but clinical commissioning groups are the epitome of a cottage industry. He also referred to the fact that GPs have little history of undertaking research and commitment to it. Yet we are handing them billions and billions of pounds, quite remarkably, on the basis of no evidence whatever that I can see that they are fitted to discharge that responsibility. I ask the noble Earl where we can have assurance that clinical commissioning groups will be prepared to invest in services where there is a strong research base.
The third challenge is to NHS trusts and NHS foundation trusts. The noble Lord, Lord Ribeiro, put his hand on it when he talked about the reduction in the number of clinical academic posts. I believe that NHS trusts have a great role to play in encouraging their clinicians and in encouraging joint posts with universities. Again, I worry that the focus on job plans and the productivity of clinicians will discourage research because the emphasis will be on patient throughput. How are we going to ensure that that does not happen?
Earl Howe
I hope that I am not putting my neck on the block, but within a month the noble Lord should hear news that may cheer him on this front.
A great many noble Lords have asked me questions, some of which I have covered, but I suggest that in the interests of time it might be helpful if I followed up this debate in writing and in a way that will enable me to answer the questions in greater detail than I would now in any event.
Lord Warner
My Lords, in doing that will the Minister clarify what “health service” means? As I read the Bill, it sometimes looks as though public health is not included in that definition. It would be helpful if the Minister could give us some clarity on that and point us in the direction of an authoritative definition.
Earl Howe
I should be very glad to do so. The noble Lord may not be surprised to hear that, when I was being briefed for this Bill, I had to ask myself that very same question. The definition is there, but I think that it would be helpful if I set out the import of that phrase in its fullest sense.
I hope that I have said enough to encourage noble Lords not to press their amendments, but, in doing so, I reiterate my thanks to all noble Lords who have made such an excellent contribution to this debate.
Lord Willis of Knaresborough
My Lords, I thank the Minister for, as ever, a very courteous and thoughtful response to many of the issues which have been raised, in particular his response to Amendment 39 and his undertaking to reconsider “have regard to the need to”, which appears to be a little bit of clumsy draftsmanship that would be unworthy of the Minister himself.
The Minister raised a number of important issues, including that to which the noble Lord, Lord Warner, referred. We have now had a definition of “health service” which includes public health. That means that public health research could lie within some local authorities, because a significant amount of public health will be devolved to local authorities. While I was pleased to hear the Minister say today that those people moving from the National Health Service to local authorities for public health matters would retain National Health Service terms and conditions, the reality is that they will be working under a local authority aegis and that research would therefore be an issue for local authorities rather than Public Health England—or so I understand, but we will probe that later.
On protecting funding, I was particularly grateful for the way in which my noble friend the Minister responded to the idea of ring-fencing. He spoke not of ring-fencing, but said that there had been an increase in budget. It would have been good if he could have made that comment. However, he did say that NIHR would remain a stand-alone organisation. That was news to me; I thought that it was going to move into other organisations. Quite frankly, that is good news. It has a reputation which demonstrates that research is very important and we can track how it is used and when. I thank the Minister for that.
I apologise profusely to the noble Baroness, Lady Emerton, for indicating that “research” meant the work that is coming out of universities and being translated for use at the bedside. She was quite right to remind us that “research” for the purposes of this Bill was all research, and that what should underpin all public policy, in the NHS or anywhere else, is research which gives you evidence to inform policy decisions. I thank her for that rebuke.
Lord Warner
I do not want to prolong this debate. I will read very carefully what the Minister said about protection of finance. We may want to come back to this issue to be reassured that all is well.
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Lord Warner
My Lords, I support the amendments of the noble Lord, Lord Patel. I draw the Minister’s attention to the noble Lord’s great expertise, of which I am sure he is aware, in the area of setting standards for good clinical outcomes. He has done this in Scotland and the Committee should take careful note of the amendments that he has proposed and which I strongly support. I shall not go over again the ground that the noble Lord has covered, but he has made a compelling case for tidying up the wording of the 2006 Act in the areas that he has suggested.
Amendment 109 is in my name and that of the noble Lord. The words that it would add to new Section 13E(3) are very important to patients. Good and speedy access to services is essential to good outcomes, but it is an issue with which the Conservative Party has played fast and loose in its efforts to distance itself from targets. In doing so, it may have made itself popular with the NHS but it has rather lost sight of the importance that access to services has for patients in terms of their view of the way in which the NHS treats them.
Good and speedy access is critical to good outcomes, and nowhere is that more apparent than in cancer services, which is why a lot of effort was put in by the previous Government, with experts in cancer, to devise the targets that were produced in this area. I am not trying to make a party political broadcast on the success of Labour’s access targets, although the temptation is enormous, but to bring out the key difference in approach to access between many parts of the Chamber and the Government Front Bench. I suspect that when the Minister comes to reply, I will get a little lesson on the lines that access is a process and what we should concentrate on is outcomes. I suspect that his brief will tell us a lot about that particular issue.
I suggest that there is a different way of looking at this. Access is not just a process issue because it incorporates one of the requirements for good outcomes. Of course, no one, least of all me, is suggesting that we should be against trying to define outcomes or measuring performance in achieving those outcomes. Some of us have spent the best part of our working lives trying to deal with the subject of outcomes in a whole range of public services. But we usually struggle, as I suspect this Government will, to define the outcome appropriately and to find an appropriate measure. Often we have to wait an indecently long time for the outcome to become apparent. We are often forced back onto proxies, which usually look much more like outputs than outcomes. Performance measures on access are a good example, not least because without speedy access patients are unlikely to get good outcomes.
It is also important that we have speedy access in order to ensure that diagnosis takes place, particularly in areas such as cancer. That is why targets were used by the previous Government to drive improvements to access. One reason why they got involved in the issue of targets and access was the great public concern in the 1990s about the length of time people had to wait before they could get access to services. I am not making a party political point, but trying to get across to the Benches opposite that patients take this very seriously. They judge the NHS to a great extent on whether they can get access to services in a timely way. It is worth bearing in mind that the previous Government's targets were actually less demanding than some of the views that patients had on how long they should wait to get services. Patients were much more demanding than the NHS targets that the previous Government set for the NHS in this area.
A Nuffield Trust comparative study of access targets in north-east England and the lack of them in Scotland revealed that the English experience was better for patients both in terms of speedier access and of efficiency and cost. It also showed that targets were indeed often unpopular with NHS staff. But if we are to make a choice between popularity with NHS staff and popularity with patients, I know which side of that argument I would prefer to be on.
I know that the Government have begun to retreat, to some extent, on the issue of abolition of targets, but we need to keep speedy access to services high on the NHS agenda, particularly as the NHS moves through a period of considerable challenge. Our five little words in Amendment 109 would help to do that, and I hope that the noble Earl will feel able to accept them.
Baroness Bakewell
I support Amendment 18B, which is also included under the heading,
“Duty as to improvement in quality of services”,
of the proposed new Section 1A to the 2006 Act.
I speak on behalf of particular interest group: the old. I declare an interest. I was for 18 months the government-appointed Voice of Older People. The interest group for which I speak is large and growing larger. Some 10 million people are now over 65 in the UK. In 2034, 23 per cent of the population will be over 65 of whom 3.5 million will be of the older old—over 85. That age, 85, is significant to the amendment. The amendment is to new Section 1A(3), proposed in Clause 2, dealing with the Secretary of State’s duty to seek continuous improvement in the outcomes, and it lists the relevant outcomes to be measured: effectiveness, safety and quality. We have already heard from the noble Lord, Lord Patel, and others about the important amendments to that.
Amendment 18B seeks to add a fourth consideration—and a rather odd one—which is that,
“These outcomes should not exclude sections of the population due to age”.
That phrase sits uneasily here—it would sit uneasily anywhere—because it is not of a kind like any other. However, it is important for the many people who will be numbered in the data on which outcomes are based—or, rather, not listed in the data.
The NHS Outcomes Framework 2011/12, which sets out outcomes and corresponding indicators, states:
“Where indicators are included which can be compared internationally, levels of ambition will work towards the goal of achieving outcomes which are among the best in the world”—
a laudable aim indeed. However, the document goes on later to state:
“Current data collections are limited in the extent to which this is possible … We recognise that there are certain groups or areas which the framework may not effectively capture at present, simply because the data and data collections available do not allow outcomes for these groups to be identified”.
In the document’s charts that show the overarching indicators, it is clear that many of the indicators stop at the age of 75. The indicators specify the mortality rates from cardiovascular disease, respiratory disease and liver disease. Thus, the data on deaths from such causes over the age of 75 are not monitored under the outcomes framework, despite the fact that life expectancy is far higher than 75.
It is also clear that many of the data are under development. I understand that, and there is work to be done. As the document states:
“This is the first NHS Outcomes Framework and … it is intended to signal the direction of travel for the NHS”.
The direction of travel for the population of this country is to have a much higher percentage of older old people. We already have more than 12,000 centenarians. Throughout debates on this Bill, I will be pressing for considerations of age to be written specifically into its provisions.
Why do we need to be so explicit? Surely we are all citizens, we are all taxpayers and, in the end, we are all patients. That is of course the reasonable case, but that is not how care is experienced. A recent report commissioned by the Department of Health concluded:
“Evidence of the under-investigation and under-treatment of older people in cancer care, cardiology and stroke is so widespread and strong that, even taking into account confounding factors such as frailty, co-morbidity and polypharmacy we must conclude that ageist attitudes are having an effect on overall investigation and treatment levels”.
That was in a report published for the Department of Health. To give just a simple anecdotal example from broader practice, although the risk of breast cancer increases with age, the general-practice reminders that are sent out to women to invite them to mammograms stop once a woman reaches the age of 70.
My amendment seeks to make clear, and even overemphasise, that all outcomes include all sections of the population. Prevailing attitudes to the old require that to be spelled out in the Bill.
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Baroness Hollins
I absolutely agree with the comment of the noble Lord, Lord Winston. Commenting on another practitioner’s practice and making judgments is fraught with error. That is why it is important when looking at the duty of candour to understand the role that whistleblowing plays. A great deal more could be said but it is extremely dangerous to make assumptions about another person’s practice.
Lord Warner
My Lords, I was not intending to intervene in this debate, but after listening to the discussion I want to remind the Minister of the many happy hours that we spent taking the NHS Redress Bill through this House six or seven years ago. Can he tell us the extent to which some of the measures in that Act may or may not have helped to deal with some of the concerns that have been expressed in this debate, because that legislation was an attempt to give patients more satisfaction without going to court and to encourage a greater culture of openness and apology on the part of the NHS when it made mistakes?
Lord Warner
Lord Warner
My Lords, my name is on this amendment along with that of my noble friend Lord Rooker, who cannot be with us this evening. I also support many of the other amendments in the group aimed at strengthening the Bill's provisions relating to reducing inequalities.
The problem of health inequalities has bedevilled the NHS since its inception. There are very considerable variations in health outcomes around the country and even in the same area between different groups. That variation was graphically illustrated by my noble friend Lord Darzi in his excellent report on London's health services in 2007, just before he became a Health Minister. That report showed that, as you travelled the seven stops on the Jubilee line between Westminster and Canning Town, so male mortality worsened by seven years. Of course, some of this deterioration is to do with income, housing, education and environmental issues. However, good access to services, good health education and good-quality treatment can have a strong mitigating effect. Therefore, we should be unequivocal in the duty we place on the Secretary of State to work to reduce inequalities. The wording that the noble Lord, Lord Rooker, and I propose is—if I may put it as gently as I can—much less weaselly than the Bill’s current wording in proposed new Section 1B. Our wording effectively strengthens the impact of the other more detailed provisions in this group. I hope, therefore, the Minister will look sympathetically on our more dirigiste wording. I beg to move.
Lord Warner
My Lords, this has been an interesting debate. I do not want to prolong it. The mood of the House was to strengthen the wording in Clause 3 on the Secretary of State's duties on reducing inequalities. A key factor that the noble Earl may have overlooked is the relationship of that duty to the Secretary of State being more active on the subject of access, which is a key part of securing inequalities. In the mean time, I will withdraw my amendment, but I must tell the noble Earl that we may return to this at a later stage.
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Lord Newton of Braintree
My Lords, I say gently to the noble Baroness that I had understood that the whole purpose of the proposal made this afternoon by the noble Baroness, Lady Williams, was to give us a chance to look at all the practical issues in the Bill before returning to this umbrella of principles. I can see that one could argue it either way. I have no more right to speak on behalf of my Benches than my noble friend but I share his views entirely and, indeed, I expressed them last week. What is being proposed must be the right way to proceed. It has consensus support around the Committee and I think that we should get on with it and let the Minister explain how he will conduct the discussions. Let us just leave it there.
Lord Warner
My Lords, perhaps I may intervene briefly not in any way to damage this positive outbreak of peace but to make a practical suggestion. Much of the Constitution Committee’s report turned on the judgment of the noble and learned Lord, Lord Woolf, in the Coughlan case.
Baroness Jay of Paddington
My Lords, I must intervene on that point. That is only the secondary point of the report.
Lord Warner
Perhaps I may be allowed to deal with it, whether it is the first or secondary point—I do not have the report with me. The point that I wish to make is that we have the noble and learned Lord available to us in this House. If we are to have some arrangement to consider how we go forward on this, I think that it would be sensible to discuss the matter with him because he has sat on cases where the role of the Secretary of State has been a key factor in the courts.
Lord Greaves
My Lords, I discovered at the end of last week that it is possible to table an amendment as part of a group if the debate on that group has been adjourned and the first item in the group has not been put to the House. I did not know that that was possible until I asked. We can all do something new every day in your Lordships’ House. Therefore, I put forward a small amendment to question the use of the word “ultimate” in relation to the Secretary of State’s powers. My noble and learned friend Lord Mackay very kindly responded to that before I had a chance to speak to it.
I picked up this issue following comments made last week by the noble Lord, Lord Harris of Haringey, concerning “ultimate”. I went home, looked at dictionaries and did my own research, as did my noble and learned friend. I looked in the most recent and biggest dictionary that I could find, which was the Shorter Oxford English Dictionary. I also looked online, as one does nowadays, and spent a happy time looking at what online dictionaries say. If I can gently tease the noble Baroness, Lady Thornton, it is a much better exercise than looking at Twitter, if I may say so.
Lord Walton of Detchant
My Lords, my noble friend has, as always, been extraordinarily persuasive in her detailed argument in support of her Amendment 10A. I apologise to her and to the Committee for not having discussed it in detail with her beforehand. The intention underlying the amendment is in every way admirable. Amendment 10B, to which she spoke more briefly, deserves a great deal of attention and would greatly improve Clause 2 of the Bill. My only concern with her remarks about area-based populations relates to the definition that would be attached to the clause. New Section 1A(1), as inserted by Clause 2, is defective in my opinion in that it refers to,
“securing continuous improvement in the quality of services provided to individuals”.
The provision of services in the National Health Service does not relate simply to the treatment and improvement of the health of individuals. As the term “public health” implies, it deals also with the improvement of the health of communities. After all, public health doctors were called community physicians until quite recently. In many ways I would have preferred to see the clause include, after the word “individuals”, “and/or communities” to make that position entirely clear. I warmly support the principles underlying my noble friend’s amendment but the wording requires a little attention as throughout my professional career I have been very familiar with the hazards that arise in attempting to draft and redraft documents in committees, large and small. I do believe that this matter needs to be given attention by the Minister.
Lord Warner
My Lords, I am not altogether sure whether I rise to support these amendments or not. I promise the noble Lord, Lord Mawhinney, that the phrase “area-based populations” will not pass my lips after this utterance. There is a question which it is apposite that I raise with the Minister under this group of amendments as it has puzzled me for some time. Under the present arrangements, we have a public body called a primary care trust which can cope with a set of circumstances in which people are thrown off a GP’s list, have not got onto a GP’s list or have a lifestyle which means that they are disinclined to join a GP’s list. There is a mixed bag of people. This group of people live in a particular area, however that is defined. It is an area for which, somewhere in the country, a primary care trust is responsible. In the world of clinical group commissioning which is based on practice lists, I am not altogether clear how this group of people are safeguarded.
I am sure that the brilliant minds of the officials in the Department of Health have thought of this and have a cunning plan that, no doubt, the noble Earl will divulge to us. However, it is an issue that has caused concern, and I do not feel equipped to answer that concern because I am not clear as to how the Government will cope with that group of people.
Earl Howe
My Lords, I will address that question in a moment, if I may. The noble Lord, Lord Warner, asked how clinical commissioning groups will deal with the non-registered population in practice. Individual clinical commissioning groups will have responsibility for ensuring that patients resident in their area who are not registered with a GP have the same access to the care for which the clinical commissioning group has commissioning responsibility as a patient registered with a GP. Individual clinical commissioning groups will need to ensure that they have sufficient geographical focus to be able to commission emergency care services for anyone who needs them when in their area. The National Health Service Commissioning Board will be responsible for establishing a comprehensive system of clinical commissioning groups covering the whole of England, and the board will be responsible for commissioning primary medical care for the unregistered patient population. I think that my noble friend Lady Tonge is confusing two issues.
Lord Warner
Can I just be absolutely clear that I have understood the noble Earl? Is he saying that a clinical commissioning group with a defined geographical area for which it is responsible also has a responsibility to find out about the needs of all those who are not registered with a GP, including homeless people, asylum seekers, rough sleepers and you name it? Is he saying that the group has a responsibility to find out how many of those people are in its area and that it must commission services for them?
Earl Howe
Let me be clear: each clinical commissioning group will have a specific geographic area and will have responsibilities linked to it. This addresses the question asked by the noble Lord, Lord Rea, as well. Unregistered patients of any shape or kind are one example. Clinical commissioning groups will be informed by the work done in the health and well-being boards, whose job it will be to define the health needs of an area and what they believe the priorities are for commissioning in that area, and to produce a joint health and well-being strategy that addresses those priorities. The interaction between the health and well-being board and the clinical commissioning group should ensure that the marginalised groups of people to whom the noble Lord refers will be catered for.
Earl Howe
My Lords, there are perhaps several issues bound up in my noble friend’s question. It is entirely possible that a CCG will cover two local authority areas. In that event, it will have a clear duty to work in partnership with both local authorities to improve health and well-being and to secure more integrated services. Do health and well-being boards need to translate their assessments for each clinical commissioning group area? The CCG will need to use the joint strategy of the health and well-being board to inform its commissioning plan according to the needs of its local population. It is in its interests to ensure that the information is translatable.
I would be happy to write to my noble friend because there is a clear narrative here, although I may not be expressing it entirely clearly. Obviously, there will be instances where boundaries do not coincide. As I have said, we are aiming for that not to happen but it will in some cases and it has to be dealt with in terms of the duties that we set out.
Lord Warner
I will not torture or tweak the Minister any further but I will ask him to make a sensible response on this issue after today’s Committee sitting. It would be extremely helpful if he could take two or three areas—perhaps an urban area and an urban/rural area—and show us where there is a health and well-being board and where there are pathfinder groups of CCGs, and how this would work in practice. I think that we would find this much easier to understand if there was a diagram.
Health and Social Care Bill
Lord Warner Excerpts(13 years ago)
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Lord Warner
“(c) the clinical integration of the delivery of health and social care”
Lord Warner
My Lords, as they say in commercial television, welcome back after the break. In moving Amendment 12, I shall speak also to Amendments 16, 17, 182, 183 and 184 tabled in my name and those of other noble Lords. I have also added my name to Amendment 18 to which my noble friend Lord Rooker will speak—I hope. The theme of these amendments is that of giving greater prominence in the Bill to the issue of service integration not just within NHS services, but across the health and social care boundary. At the same time, I will try to give some clearer meaning to this term by offering a definition in Amendment 184. This is a very complex issue and it has not been helped, if I may say so, in some of the public discourse by the way that the term “integration” has been used in a wide variety of ways by different people.
I shall start with some remarks about integration and its relationship to competition, which has been the subject of quite a lot of debate around this Bill and NHS reform. In recent months, the term “integration” has been bandied about as a kind of panacea for the NHS in the challenges it faces, but with little clarity about what it means. The Future Forum put the issue of integration on the map in its report. Some of this affection for integration has grown because it has been seen as a useful term by opponents of competition. They have tried to make the argument stand up that somehow if you have integration of services, you cannot support competition because the two are incompatible. I do not believe that to be true. It is perfectly possible to have the right kind of integration within a competitive market. Kaiser Permanente, among others, has shown this to be the case in the United States. Indeed, it was the very competitiveness of that market which caused Kaiser to offer patients more clinical integration in order to survive and flourish in the marketplace. That integration was done on the basis of reducing the use of in-patient hospital services. It is worth noting that there are NHS-Kaiser Permanente partnerships in six areas of the NHS which are adapting lessons from Kaiser’s experience in the US to apply in this country.
Having got that off my chest, I turn now to the issue of how integration and competition can coexist and how we need to be clear on what we are talking about when we use the term “integration”. There is, I suggest, good and less good integration. Much so-called organisational integration is effectively mergers of providers with little benefit to patients and often involving a reduction in choice. We see this in integration horizontally across organisations of the same kind and vertically between community and hospital services. The former is often done to save costs and reduce competition, while the latter is too often a way of securing patients for in-patient services and maintaining hospital income. Some will disagree with that, but it is certainly a perspective we should think about. Organisational integrations of this kind have sometimes fallen foul of the competition and collaboration panel. They are to be viewed with a sceptical eye, although I accept that integrated commissioning can be a major benefit for patients.
The integration, however, that is likely to benefit patients the most, and the cost structure of the NHS the greatest, is integration that brings together the assessment and delivery of health and social care services at the point of assessment and delivery to the individual person. This is the type of integration we have attempted to define in Amendment 184. At a time when such a large part of the NHS’s work involves patients with long-term conditions, who often require social care as well as healthcare, this is the type of integration that NHS and social care organisations and personnel should be focused on, particularly those commissioning services. These commissioners need to look for a new breed of service integrators who can take responsibility for integrating services for individuals across the health and social care boundary or divide, depending on your perspective. The Conservative’s community care reforms of 20 years ago produced care managers as integrators of social care in a mixed economy of providers. We now need to apply the same thinking to the whole spectrum of health and social care, especially for those with long-term conditions.
None of this will be easy, but if the NHS is to meet the financial and other challenges it faces and reduce its dependence on expensive, often unsustainable and often inappropriate, acute hospital services, it must begin the process of improving service integration at the level of the individual and not just the organisation. It is important that we use the Bill to set a new direction of travel on service integration for both the NHS and the social care worlds. The word “integration” needs to move from a term of rhetorical flourish to a reality that benefits people at the local level.
Of course, simply putting words in a Bill will not on its own change things; they will need to be backed up by changes in the professional culture, the use of IT and the financial reimbursement system. Later in the Bill I shall move amendments to help integration in the areas of tariffs and the use and extension of an electronic patient record. In the mean time, I want to establish a bridgehead in the Bill with this group of amendments that give more prominence to integration and try to define it. My co-signatories will expand on some of the arguments.
I should make it clear that I do not regard the wording of these amendments as the last word on the subject. I am sure they could be improved and they may have consequences for other parts of this leviathan of a Bill that we have failed to spot. I also recognise that the Labour Government had integrated care organisation pilots and that the Department of Health and the King’s Fund are working on the issue of integrated care following the Future Forum report. It is no purpose of these amendments to pre-empt or damage that work. I and my co-signatories are seeking to establish today whether the Minister is up for amending the Bill to give more prominence, more precision and greater reality to the term “integration” to shape the future commissioning and provision of services in ways that will benefit patients. We will be glad to sit down with him and his officials to improve the wording of the amendments and their placement in the Bill. I beg to move.
Lord Patel
I support the amendments to which my name is attached. This is an important issue. As the noble Lord, Lord Warner, mentioned, at some of the seminars we heard the word “integration” used in different forms with no clear definition of what it meant.
Future Forum, of course, put integrated care at the heart of NHS reform, but who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider? What can clinical commissioning groups do to stimulate providers to work together to meet the needs of the patient?
As the noble Lord, Lord Warner, mentioned, integrated care takes many different forms and may involve whole populations; care for particular groups or people with the same diseases; and co-ordination of care for individual service users and carers.
There is good evidence of the benefits of integrated care for whole populations and for older people. There is mixed evidence of its benefits for people with long-term conditions such as diabetes and for people with complex needs. I will return to that later. Of course, Kaiser Permanente is one of the good examples of managing integrated care for long-term conditions but there are not that many.
The commissioning groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. That includes advice on matters of contracting and procurement, outcomes and quality measures to include in contracts, and the tariffs and incentives to use. Work is also needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective care. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more co-ordinated, unplanned care when funding is tight. That will have to involve the providers.
Other factors that appear to support integrated care commissioning include robust performance management, sufficient time and resources from the provider side, and adequate investment in the main stages of the commissioning cycle, such as needs assessment, service design, contracting and tendering, and outcome-based evaluations. As management and resources shrink, there are obvious questions about whether clinical commissioners will have the necessary time and support to plan and contract for changed services in profound ways. To be more specific, there need to be resources at a national level to avoid commissioners at a local level reinventing the wheel many times over.
To turn briefly to long-term conditions, in the next decade the health and social care system will have to contend with an ageing population, increasing numbers of people with complex long-term conditions, budget constraints, increasingly sophisticated and expensive treatments, and rising expectations of what healthcare services should deliver. An integrated care approach to meeting these challenges—through better co-ordination of health and social care services, reducing the fragmentation or duplication of care—has the potential to improve support for the management of these complex needs.
Let me share a true story as an example of the issues here. Somebody approached me just before Second Reading of the health Bill. I mentioned this at one of the seminars and have since checked the authenticity, and visited the person in the hospital where care is currently provided. This person has insulin-dependent diabetes and was found to have an ulcer on the leg. He saw his GP who suggested that dressings would be required to try to heal the ulcer. During the process of that treatment, a specialist diabetic nurse who came in contact with the person suggested that they might be better getting advice from a specialist unit. While the GP suggested that the care provided was satisfactory, the person demanded to be referred to a hospital. By the time he got to the hospital, three of his toes were necrotic. They had to be removed last week. The patient needed an angiogram to decide whether the blood flow was satisfactory so as to put stents in so that he would not lose further parts of his limbs.
As we all know, it is crucial for diabetic patients to avoid certain complications. Good glycaemic control is required to manage that, so that their sight and renal functions do not deteriorate, their cardiovascular functions remain good and they also do not lose limbs because of necroticism. This shows the need for integrated care that requires the whole team to work together. For a start there need to be good records and IT that can transfer information between different carers, GPs, practice nurses, specialist nurses, and specialists in diabetes. There needs to be screening for eyes, kidneys, blood pressure, diet, cardiovascular disease and so on. Most importantly, there needs to be joint training for people who look after these patients, whether that is in the community or in specialist units.
If you are looking for good outcomes for patients, integrated care is what matters. It should be based on the journey of care—the patient pathway of care. That is what we need to establish. I hope, as the noble Lord, Lord Warner, said, that we can have further discussion to try to improve this Bill and see if we can deliver that.
Lord Warner
My Lords, this has been a good debate. The hour is late but I want to make a couple of points in response to the noble Earl. There is probably a fundamental difference between him and me and, I suspect, other Members on this side of the Committee about whether integration and access are just bits of process and whether we should focus entirely on outcomes. I say gently to the noble Earl that the public care about some of those processes. That is why we had targets for access; they care about access and integration. The outcomes framework will not adequately measure either of those areas, which are of public concern. Indeed, they are important contributors to good outcomes. Therefore, we probably have a philosophical difference of view over how we approach those issues.
I do not want to go over this ground tonight. However, we must look at the Bill to see whether it can give stronger signals to professionals and the culture in which they operate about the importance of integration, not just within healthcare but across the boundary between healthcare and social care. I hear what the noble Earl says but, looking at the Bill, I do not believe that the Bill goes far enough in changing that culture. I will certainly talk to some of these outside experts with a number of colleagues to see if we can come back with some amendments. I am happy to talk to the noble Earl about that with my colleagues before Report stage. I hope we can convince him that we can strengthen the Bill in this area. With that, I beg leave to withdraw the amendment.
NHS Commissioning Board Authority (Establishment and Constitution) Order 2011
Lord Warner Excerpts(13 years ago)
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Baroness Thornton
My Lords, in moving the Motion on the NHS Commissioning Board Authority (Establishment and Constitution) Order 2011, I will also speak to the NHS Commissioning Board Authority Regulations 2011.
These statutory instruments were laid before Parliament on 15 September, and the date when they expire is therefore 10 November. However, the NHS Commissioning Board Special Health Authority website says that it was,
“established on 31 October 2011”,
and plays,
“a key role in the Government’s vision to modernise the health service”.
Technically speaking, the NHS Commissioning Board has not jumped the gun by broadcasting its existence before the parliamentary process has been completed. However, given the whole way in which the change agenda for the NHS is progressing, there is an extent to which I feel our views may not count for very much at all, and may count for less as time goes on.
I would like the Minister to clarify whether there was a period of consultation before the order was laid, because I can find no evidence of it. I am aware that there was a statutory period of consultation with the staff unions during the summer under Section 28 of the National Health Service Act 2006. I am also aware that there was a consultation on the White Paper published last year. However, I am not aware that the decision to establish a shadow authority was taken or mentioned during that consultation.
The Explanatory Notes to the statutory instruments make play of the fact that the Future Forum said in its deliberations that the NHS Commissioning Board should be established as soon as possible. However, I do not regard the deliberations of the Future Forum as a substitute for a properly managed consultation involving all the bodies that have an interest in this matter. The Future Forum is a body with no official or statutory status or accountability to Parliament. Its members have not been appointed through the Nolan procedures and do not even need, for example, to register their interests. Praying them in aid of an order before Parliament is slightly odd.
The procedure for putting in motion important statutory instruments such as this should not be treated in a cavalier manner. Indeed, it is so important that there was an exchange of letters between the noble Lord, Lord Goodlad, the chair of the Merits of Statutory Instruments Committee, and the Leader of the House, the noble Lord, Lord Strathclyde, last summer when a matter of consultation was clarified. In answer to a question from the noble Lord, Lord Goodlad, about the consultation procedures, the Leader of the House said:
“The Government recognises the best practice established by the Code of Practice on Consultation and will continue to observe it wherever possible”.
I am concerned as to whether the code of practice was adhered to in this case, and if not, why not.
This order outlines how the proposed new commissioning architecture for the NHS might be delivered, so it is of huge importance. I would like some assurance from the Minister that, as we move forward with other orders pertaining to the Bill, proper consultations will take place.
Today, as the NHS Commissioning Board commences a period of shadow running before becoming fully operational, the emergent commissioning architecture has become far more complex. The paper developing the NHS Commissioning Board offers some insights as to what a very complex organisation is being developed. Between the NHS Commissioning Board at one end and the clinical commissioning groups at the other, the variety of commissioning support agencies is growing exponentially to include regional—I think I need to amend that to subnational—arms of the NHS Commissioning Board, PCT clusters, commissioning support units, clinical senates, special clinical networks, health and well-being boards and trustees of clinical commissioning groups. Public Health England, local health improvement boards, regulators such as Monitor and the Care Quality Commission, the National Institute for Health and Clinical Excellence, local GP councils, third sector suppliers, and individual practices that are enrolled as clinical commissioning group members can also be added to this list. Indeed, patients too are becoming commissioners, as they wield personal health budgets.
This is presumably the structure to be delivered by the shadow board. I do not object to being properly prepared for these huge changes—that is very wise. However, there are some very important questions to be considered about the statutory instruments before us today. Can the Minister confirm what the timetable is, subject to the passage of the Bill? My understanding is that October 2011 is the start date for the board in shadow form as a special health authority, although the word “shadow” appears nowhere that I could find on the website. Given that the board has already recruited its chair—a matter that I will return to in a moment—can the Minister tell the House how and when other board members will be recruited, and whether the Department of Health will be using the same company of head-hunters that recommended Professor Malcolm Grant? Can he confirm that another five board members will be appointed? I am asking because I am not clear from Regulation 6 of the NHS Commissioning Board Authority Regulations, on the suspension of non-officers, as to whether that includes the chairman. I can see that it deals with the situation of the suspension of the chairman, but I am unclear as to how the chairman might be suspended in the first place, and by whom.
If the shadow board is to run from October 2011 to October 2012, I gather that at that point it transmogrifies into an executive non-departmental public body responsible for planning for 2013-14. I ask the noble Earl: is that it then? Is that the status of the quango being created to run this part of the National Health Service? We know that strategic health authorities and PCTs will be disestablished in April 2013.
I have a series of questions arising from the timetable, and I am sure other noble Lords will have as well. I am going to limit myself to two main themes, accountability and cost, after which I will have a few questions about the appointment of Professor Malcolm Grant. What powers does the NHS Commissioning Board have at this point and what budget? How many people are employed by it at present, how many will be employed by it eventually and at what cost? We know that the board will be responsible for £100 billion of taxpayers’ money. When will they start disbursing that funding and what accountability measures will have been established before April 2013, or indeed before October next year? Am I right in thinking that from yesterday the board has been established as an independent statutory body with some accountability, such as the authorisation of clinical commissioning groups? If this is indeed the case, does the new board have control of the budgets that develop the clinical commissioning groups? How will it disperse that funding? Who will be responsible for the strategic health authorities and PCT boards and their continuing delivery of healthcare in their areas? Who will be responsible for the delivery of the Nicholson challenge while Sir David Nicholson is busy, presumably, with all of the above?
I turn now to the appointment of Professor Malcolm Grant, whom I know from my work with academic organisations in the past. I have the highest respect for his current position as the head of University College London, but I think he was put in an impossible position by the Department of Health. I have now read the transcript of his interview with the Health Select Committee, where he was approved only by the casting vote of the chairman. It seems clear to me that Professor Grant had been told that it was a rubber stamp exercise and that he did not expect to be cross-examined in the robust way in which the Health Select Committee proceeded to question him—a way that we all know and cherish, particularly when a Select Committee may suspect that it might be being taken for granted.
It is unfortunate that Professor Grant was unable to explain why or if he had a passion for the National Health Service. He said:
“I find it difficult to demonstrate because I am not a patient of the NHS”.
Will the Minister take this opportunity to clarify exactly what was meant by that remark? It has had negative media coverage because it has been interpreted as meaning that Professor Grant does not use the NHS at all. That is most unfortunate.
According to the record, Professor Grant instead pointed to his 37-year marriage to a central London practice GP as his experience of the NHS. I am married to a world expert on internet safety, but it has given me neither a passion for nor a particular knowledge of IT and the internet. Much as I support my husband in his work, I am not at all sure that it is good practice to use that in a job interview. However, it raises a separate question: did the department take legal advice about whether Professor Grant’s GP wife makes him a relevant person in terms of conflicts of interest? Given that GP primary care will be dealt with directly by the NHS Commissioning Board, which I understand is to have responsibility for GP contracts, will Professor Grant have to exclude himself from any discussions and decisions that might be to the advantage or disadvantage of GPs? What a curious state of affairs that would be. In fact, the whole episode is curiouser and curiouser.
I agreed with Professor Grant in his remarks to the Select Committee about the health Bill, which he thought was completely unintelligible. I suspect that the Minister may not. I look forward to the Minister’s remarks because I know that I will be wiser as a result. I beg to move.
Lord Warner
My Lords, I agree with everything my noble friend has said. In particular, I would like to know when the shadow becomes substance.
It is unfortunate that we are considering these statutory instruments before we have had a chance in Committee to discuss the clauses of the Bill relating to the NHS Commissioning Board. I shall try not to trespass on the ground that we will undoubtedly cover in the Bill, but there will inevitably be some overlap.
The board’s main role is to ensure a coherent and effective commissioning system as a proper counterbalance to the NHS’s historical dominance by provider interests. In considering these statutory instruments, it is important that we are clear that this is its main role. If it is to succeed in using commissioning to improve patient health outcomes, not only individually but across populations, it will be vital that the board is not sidetracked by being given other roles that Ministers cannot find other homes for. We will discuss these issues further, but can the Minister give some assurances today that we will not end up with a situation in which the board’s empire continues to grow and its membership may not be the most effective to deal with the range of circumstances and problems that it has to deal with? Can he give an idea of the scale of the board’s budget and staffing issues?
I always travel optimistically when I see a government department produce an impact statement and I always hope that there might be the odd number or two in it. However, in these statutory instruments, the numbers are conspicuous by their absence. I would therefore like to explore with the Minister what the scale of the board’s budget and staffing will be.
It is very difficult to judge whether the governance arrangements for the board in regulations such as these are satisfactory without knowing a lot more about the scale of the operations. Could the Minister give us more information about what he anticipates the budget of the board will be in its first year of operation? Again, we are less than certain precisely when that first year of operation will be, but for argument’s sake let us fix on either 2012-13 or 2013-14—I personally do not mind which. I would like to know what he thinks this body will be responsible for in cash terms and to have some idea of what he thinks its running costs will be. We will certainly be coming back to this issue as the Bill progresses in Committee, but it would be helpful to have some idea of the scale of this body’s operation before we can judge whether the provisions in the regulations on membership of the board and the way in which it is going to be run are adequate.
This request for numbers is not just a matter of idle curiosity on my part. It relates to the question of what is the most appropriate size for this board and its committee structure. From what we have learnt so far, the board seems likely to have responsibility for spending at least £80 billion a year. I have heard figures of up to 5,000 staff being bandied about as the possible number of people that the board will employ. With an annual expenditure of this size, my first question to the Minister is: is it right to be thinking about having a board with only five non-executive members? How does this compare with a FTSE 100 company with a similar turnover? With such a turnover each year, what is likely to be the scale and nature of the committee and sub-committee structure that the board requires? Is there a danger that, with only five non-executives, the board will end up with committees or sub-committees taking decisions on large sums of public money where board non-executives are in a significant minority in those decision-making committees? Certainly at first blush, the governance structure for the large sums of public money that this board will be disposing of looks potentially weak compared, for example, with a big local authority. Are the Government sticking with five non-executives or do they contemplate having a larger number of non-executives on this board?
Having made this comparison with local government, I will turn to the issue of the board and its committees meeting in public. As I understand the regulations, there is no requirement for the board or its committees to meet in public other than when the board presents its annual report. Given the sums of public money likely to be involved, this seems to me totally unsatisfactory. As someone who was a chief officer in a big local authority for six years, I thought it was good for my soul to have to argue my case in public. I think most members of elected local authorities accept that their way of having to account for large sums of public money is to talk about how it is going to be spent and to account for it in a public arena. I cannot see why this board should not be required, as a matter of course, to meet in public and conduct its discussions in a transparent way, except where perhaps personnel or commercial issues are involved. Can the Minister say why the regulations do not require this, when the Government themselves tend to make rather a song and dance about how they prefer there to be much more transparency in public bodies?
Finally, I turn to the issue of board competence and training. I was a little startled to learn of some of the answers provided to the Health Select Committee by the Government’s candidate to chair the board. Of course, there was a refreshing honesty, as my noble friend has said, about the way he described the Bill as “completely unintelligible”, and many Members of this House seem to agree with him, judging by the number of amendments that they have put down. However, more puzzling was his understanding of the board’s relationship with the Secretary of State under the terms of the mandate provisions in Clause 20 of the Bill. He seemed to believe that the Secretary of State would hand over the mandate for two or three years and then leave things to the board. Clause 20 makes it absolutely clear that the Secretary of State can issue a fresh mandate before the beginning of each financial year as well as modify it, particularly when there are exceptional circumstances. The Secretary of State also has extensive powers in Clause 17 to issue regulations that lay down standing rules on how the board conducts its affairs. Can the Minister tell us more about the arrangements for induction training of non-executives and their chair, so that there is no misunderstanding on the part of the non-executives about what the board can and cannot do?
I could go on because there were many other issues that were raised, but I will save those for Committee. In conclusion, I regard these regulations as looking somewhat feeble for a body operating on the scale that the Government seem to envisage and in such a complex environment. We will come back to some of these issues in Committee. In the mean time, I would welcome the Minister’s answers to my questions.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I welcome this, the second in a series of debates tabled by the noble Baroness, Lady Thornton, scrutinising various pieces of secondary legislation which together are intended to provide continuity and security to NHS staff, as well as maintaining the continuity and quality of NHS services, and delivering the £20 billion efficiency challenge.
This second debate provides an opportunity for me to set out the need for a proposed new preparatory body to ensure the most effective transition to a new system for commissioning NHS services. As noble Lords will know from our debates on the Health and Social Care Bill, a key part of the Government’s agenda is to turn the NHS into a more patient-centred organisation, with a clearer focus on improving patient outcomes, and designed around the needs of the local population.
The Government intend to create a more autonomous and accountable NHS, with greater clarity about the roles and responsibilities of different organisations for provision of commissioning. A stronger, more effective commissioning system is necessary to support the improvement in health outcomes that we all want to see. An autonomous but accountable NHS Commissioning Board is a key component in the realisation of this objective.
The NHS Commissioning Board will be rigorously held to account by Ministers and Parliament as a whole for delivering improved patient outcomes instead of top-down process targets. While it will be free from interference on a daily basis from Ministers, it will have clear duties set out in primary legislation, and will be held to account for objectives set by the Government through an annually refreshed mandate, giving it a clear long-term direction.
The board will allocate resources to clinical commissioning groups and support them to commission services on behalf of their populations, according to evidence-based quality standards. It will directly commission services in six areas: specialised services, primary care, specialised dental services, military health, prison health and some aspects of public health. It will develop a high-quality market for commissioning support, while minimising redundancy costs, living with reduced running costs and retaining the best of NHS talent. This means that the board will be at the centre of delivering improved, patient-centred services while cutting waste and bureaucracy.
It is essential that we get this right. With this in mind, the NHS Future Forum has recommended that,
“the NHS Commissioning Board should be established as soon as possible to ensure focused leadership for improving quality and safety as well as meeting the financial challenge during the transition”.
This shows that there is a recognised need to begin work now to ensure that the transition arrangements to the new system allow the NHS Commissioning Board to undertake its full responsibilities from the day it is established.
The NHS Commissioning Board Authority, as established in the statutory instruments that we are debating tonight—as well as the functions which were not laid before this House, but noble Lords may have seen earlier this week—is a preparatory vehicle, which will allow the organisation to recruit a leadership team; establish robust governance processes; develop an open and supportive ethos and culture; and begin to develop some of the key relationships with other organisations in the system. It will take on only limited functions, delegated by the Secretary of State for Health, with regard to the health system during the course of 2012.
The authority will ensure that the NHS Commissioning Board is able to function as intended as soon as it is established as an executive non-departmental public body, subject to the passage of the Bill. The authority will help the NHS to manage some of the challenges of the transition from the current system to the new one. Through establishing a body at arm’s length from the department, we can ensure robust accountability and governance arrangements.
There will be a letter from the Secretary of State setting a series of objectives that the special health authority will be expected to deliver. In addition, there will be a framework agreement defining the relationship between the Department of Health and the authority. This provides a level of transparency that would not have been present had this preparatory phase been handled wholly in-house. The authority will have an accounting officer who will be accountable to the department, and the Public Accounts Committee, giving Parliament and the Secretary of State for Health clear access to officers responsible for the major decision-making within the board.
Establishing an arm’s-length body also allows us to recruit a strong leadership team, who can provide strategic input and challenge. Wherever possible, we have drafted the establishment legislation for the special health authority to reflect the legislation that noble Lords have been scrutinising in this House. This has been done to build in continuity wherever possible, particularly around the balance of the board. Officials have sought and received the approval of the Appointments Commissioner to roll over the key non-executive director appointments to provide continuity of leadership as the body moves from being a preparatory one to an operational one, subject again to the passage of the Bill. The preparatory arrangements will ensure that the culture of national and local accountability is embedded in the board from an early stage, and does not see the centrally administered, top-down, performance-managed culture merely transferred into the board on the date of establishment, by transferring all staff and working practices on day one.
We have taken our administrative responsibilities extremely seriously during this process. We have been careful to balance appropriately the need for transparent and accountable preparatory arrangements, while ensuring that we still respect Parliament’s role in scrutinising the legislation for which these regulations prepare. Establishing a special health authority at this stage does not pre-empt the Bill’s progress through this House. It is intended as a short-term measure. The Secretary of State for Health can abolish the authority, subject to consultation with staff and parliamentary scrutiny. We are working to ensure that the costs of establishing the body are kept to a minimum, and the body will employ only staff whose roles are considered business-critical to its preparatory functions. The Government are committed to creating an NHS that is able to shape health services that are patient-centred and locally accountable. The NHS Commissioning Board Authority is a key step in this process.
I shall now address the specific questions raised by noble Lords in this debate. I was very grateful to my noble friend Lady Barker for reminding the House of the legislation passed under the previous Administration in relation to the establishment of the CQC. That is not an unreasonable comparator to the present situation. The orders before us do not pre-empt the outcome of the scrutiny of the Health and Social Care Bill. There are good reasons for establishing the authority now. They are, in sum, to ensure strong governance around the organisation’s preparations; to identify and induct a strong, independent board who could lead the NHS Commissioning Board, subject to the passage of the Bill; and to provide an important signal to the NHS about the future.
I say to my noble friend Lord Willis that this legislation is not subject to the successful passage of the Bill. It is a supporting measure, which could be reversed or amended as necessary, subject to consultations with affected staff. The functions of the authority, which are outlined in directions issued by the Government, could be updated as the Bill progresses.
The NHS Commissioning Board Authority was established as a special health authority yesterday. As I say, it will have a preparatory role and will be replaced by an executive non-departmental public body by October 2012, subject to the passage of the Bill. It is expected to be fully operational by 1 April 2013.
The noble Baroness, Lady Thornton, asked me about consultation on the setting up of the special health authority. Section 28 of the NHS Act 2006 is the basis for establishing special health authorities. The Act requires consultation with staff, which was carried out. It does not require consultation with others. As stated in the government response to the Future Forum report, the authority—the preparatory body, in other words—will continue operating until the provisions of the Bill relating to the establishment of the board are brought into force some time between July and October 2012. Only at this point will the full executive non-departmental public body be established with responsibility for establishing and authorising clinical commissioning groups. This would be followed in April 2013 by the executive non-departmental public body taking on its full suite of statutory responsibilities. The special health authority would therefore only have a preparatory role; it is currently envisaged that it will exist for a maximum of one year. The noble Baroness, Lady Thornton, asked a number of questions about the powers of the special health authority: how many would be employed; how many would be recruited and at what cost.
In order to prepare for the establishment of the board, we have established this authority with the purpose of developing the details around the processes and relationships required to carry out the board’s functions, developing the business model, and making such other practical arrangements that are necessary and appropriate for the effective running of the board on its establishment, including developing HR and governance models. I would simply say to the noble Baroness, Lady Finlay, and indeed my noble friend Lord Willis that that encapsulates the functions of the authority. The functions of the board are of course subject to the passage of the Bill and not dealt with in the orders that we are currently considering.
As regards staff, the publication of the NHS Commissioning Board People Transition Policy in July 2011 gave staff in relevant bodies, including PCTs, SHAs and arm’s-length bodies in the Department of Health, a description of how the NHS Commissioning Board would manage the transfer of functions and staff from other organisations. While further detailed work will need to be undertaken during the preparatory phase on the detail of transition, the People Transition Policy was able to set out how transfers will be managed and appointments will be made. The chair, as the noble Baroness mentioned, has been appointed—Professor Malcolm Grant. Other non-executive board members are recruited by the Appointments Commission; however, the department has used the intelligence gathered by the recruitment company to aid this process. The chair will lead the recruitment of other board members.
Recruitment to the NHS Commissioning Board is being managed in two phases. This phased appointment process will allow the senior leadership team to help take the NHS Commissioning Board forward, together with their support teams and some key transition and priority roles, while more of the work on the detailed structure is carried out. The immediate priorities for appointments as part of the first phase for recruitment are: first, the senior team and their support staff; secondly, the transition functions; thirdly, functions that have early deadlines; and, fourthly, transfers from organisations that may not be sustainable until October 2012.
The noble Lord, Lord Warner, asked about induction training of non-executives and the chair. An induction process has been developed for the chair by the authority transition team. It will also be adapted for the non-executive directors. The noble Lord also asked a series of questions about the budget of the board during its first year; what it will be responsible for in terms of that budget and about the number of non-executive directors.
The preparatory NHS Commissioning Board Authority has access to a transition budget of up to £6 million during the financial year 2011-12 to establish itself and to undertake consultation and analysis to design its future functions. This excludes staff costs and capital expenditure on estates and infrastructure—
Lord Warner
That was not the point of my question. It was what the board budget was going to be, so that we knew what this authority was preparing itself for. I am not frankly very fussed about the odd million or two going to this authority. I am more concerned about how it prepares itself for the transition to the board if it does not know what the expenditure and scale of the board’s operation is going to be.
Earl Howe
My Lords, I appreciate that and I was coming on to providing him with the answers to those questions. The impact assessment published alongside the Bill includes an analysis of the costs and benefits of establishing the NHS Commissioning Board. Preliminary estimates for the annual running costs of the board are in the region of £400 million. That budget will, of course, be partly dependent on the detail of secondary legislation that will be subject to parliamentary scrutiny.
The noble Lord expressed concern that we should not end up with a board that is too large and with the wrong membership for the remit placed upon it. We need here to distinguish between the role of the authority and that of the board. The authority has a clearly defined preparatory role. It is not responsible for commissioning in the NHS but rather for preparing for the establishment of the NHS Commissioning Board. The board will, when fully established, be responsible for the £80 billion commissioning budget.
As regards who will sit on the board when it is in its fully fledged form, the Health and Social Care Bill sets out details of the proposed membership of the board, including a chair and at least five non-executive directors, along with fewer executive directors than non-executive directors. The Secretary of State will appoint the chair and non-executive directors, and has identified Sir David Nicholson as the first chief executive designate. The board will appoint the executive members other than the first chief executive. As an autonomous body, the board will be free to appoint board members and, in turn, other staff below board level.
The noble Lord, Lord Warner, asked me to outline what the board will do with the money that it receives from the Government. The board will directly commission a wide range of services, including local primary care and the most specialised services in the country—meaning that the board will have direct responsibility for around £20 billion of commissioning spend. It will be accountable nationally: for the outcomes achieved by the NHS, which will be set out in the Government’s mandate to the NHS Commissioning Board; for contributing to improving broader public health outcomes; for how the NHS commissioning budget of around £80 billion is spent; and for maintaining financial control across the system.
As regards how the NHS Commissioning Board Authority will be held to account, the authority will operate in line with the establishment order, regulations and directions set by the Secretary of State. The Secretary of State will issue a letter as guidance under the directions setting out more specifically the priorities against which the special health authority board will be held to account. The Department of Health’s Permanent Secretary is its principal accounting officer. She will appoint the special health authority’s chief executive as its accounting officer. The principal accounting officer has responsibility to Parliament for overall expenditure in relation to the department and its arm’s-length bodies—thus making sure that an overall system of control is in place for ensuring proper stewardship of public funds and the issuing of grant in aid to the special health authority.
The noble Lord, Lord Warner, referred to the issue of the board meeting in public. The authority is not required to meet in public. The board is required to meet in public, subject to the passage of the Bill— I refer the noble Lord to paragraph 7 of Schedule 5. The authority is a preparatory body, and there is therefore a stronger case for the board rather than the authority to meet in public. The framework agreement between the department and the authority that we expect to be published in the coming weeks includes a commitment by the authority to carry out its activities transparently.
My noble friend Lord Willis asked whether the shadow authority will have a duty to commission research and whether it will take over the duties of the Chief Medical Officer. The authority, as I think I have made clear, will not commission research. The NHS research strategy policy will remain in the Department of Health until the board is established. The board, as my noble friend knows, will be under a duty to promote research.
The noble Lord, Lord Turnberg, asked further questions about the accountability of the board and the role of the Secretary of State, and whether there will be sub-committees. The executive officers of the authority and the board will account to their chair and the board. The Department of Health will hold the authority and the board to account. The Bill places the Secretary of State under a duty to keep the performance of the board under review—that is stated in Clause 49. The Secretary of State will set an annual mandate for the board, and the board is also accountable to Parliament in its annual report.
The noble Baroness, Lady Thornton, referred to the appointment of Professor Malcolm Grant as the chair of the authority. Professor Grant was selected as chair of the NHS Commissioning Board because he was the best candidate for the job. His experience as the head of an internationally respected organisation such as UCL means that he is highly qualified, and his appointment is backed by the Health Select Committee. I understand that when he remarked to the Health Select Committee that he was not an NHS patient, he was simply referring to the fact that he is not ill and is therefore not currently an NHS patient. I understand that he is registered with an NHS practice.
I think that I have covered all the questions that have been asked of me. I have certainly endeavoured to do so but if I have failed to answer any, I shall of course write to noble Lords.
Health and Social Care Bill
Lord Warner Excerpts(13 years ago)
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Lord Kakkar
My Lords, I strongly support the amendment in the names of the noble Lords, Lord Walton of Detchant and Lord Patel. I remind your Lordships of own interest as professor of surgery at University College, London. I point out that of all the Members of your Lordships' House who have a background in medicine, I completed my training most recently, some 12 years ago, and am acutely sensitive to the fact that training is vital if we are going to deliver high-quality care. I still remember vividly, and benefit from, the instruction that I was given in my training as a general surgeon.
The purpose of the Bill is to ensure that we provide the highest quality healthcare, achieving the very best outcomes and always putting the interests of the patients of our country at the centre of everything that we do. For this purpose, we need to achieve two fundamental objectives. We need high-quality education of undergraduates to prepare them properly for a life in any of the healthcare professions and to inspire them to be excellent doctors and other healthcare professionals. We must also ensure in postgraduate training that we train future doctors and other healthcare professionals to develop the skills that they require to deliver the best for our patients, and the judgment to apply their skills in an appropriate fashion.
Our system of training is so good and respected throughout the world because it is clinically based. Throughout, those who are fortunate enough to be taken on for training in positions in the National Health Service are exposed to, and have the great privilege to be involved in, the care of the patients of our country. However, the delivery of education and training is a hugely complex issue. Not only must we have the matter in the Bill; it must be dealt with in detail. Notwithstanding the fact that Her Majesty's Government propose to introduce a further Bill to deal with education and training in healthcare, which will be hugely welcome, in the intervening period we must recognise that the delivery of healthcare is integral to the delivery of education and training.
I give an example from training in surgery. Consultants who wish to take on training responsibility have to be trained to do so. They must make time available to have the training to become a trainer. They need to organise the delivery of their clinical practice in the care environment in which they work in a thoughtful fashion, to provide training opportunities for their trainees. Frequently that will mean that the utilisation of NHS resources is less efficient than if the facilities and sessions were delivered purely by a consultant. Training takes time; trainees work at a slower rate; they interrupt what they are doing to seek guidance; and they must be provided with the confidence to become good practitioners.
Beyond that, we need to release those working in our healthcare systems to support medical royal colleges and other professional bodies to set and then supervise the standards of training that must be applied across the National Health Service. That takes them away from clinical practice and again makes the utilisation of the resource potentially less efficient. For trainees, we have to provide an environment that supports training. This is complex, because it requires not only release from service commitments—again, this has an impact on resource utilisation in healthcare systems—but time within the delivery of clinical practice to learn to develop judgment in a fashion that is less efficient than it would be if the clinicians had been fully trained as medical or other healthcare practitioners.
For this reason, I strongly support the amendment that education and training must appear in the Bill as a commitment, an obligation on the Secretary of State for Health. We must also spend more time dealing with the issues that might present problems between the enactment of the Bill and the subsequent appearance of a future health Bill that deals specifically with education and training.
Lord Warner
My Lords, I support Amendments 2, 6 and 44 in particular in this group. However, I am sympathetic to and support the other amendments. The debate is going downhill. Following the eminent doctors, noble Lords will now get the perspective of a jobbing ex-Minister who was responsible for workforce matters in his time. What is particularly attractive about this set of amendments is not just that they put education and training of staff in the Bill, but that they bring a proper national perspective to this set of issues. I want to talk more about that national perspective because it is often lost sight of as people get very concerned about the responsibilities of employers at the local level. Of course, employers at the local level have a lot of responsibilities. They have the responsibility to ensure that the people they appoint to particular jobs have the skills, expertise and character, and can actually do those jobs. However, the sphere of operation of many of these local trusts, or even GP practices, is quite small geographically and they simply do not have the perspective to do the kind of planning that is required.
My noble friend Lord Davies said that planning is a dirty word. I am a child of the 1960s and was brought up to think that planning was rather a good idea, and I still think it is rather a good idea. Trying to work out what you want to do in the future seems quite a sensible way to run a National Health Service. We need to accept that there is a national role for the Secretary of State and the Department of Health in workforce planning and development. If you do not believe me, it would be worth going back to some of the Health Select Committee reports on this issue under the previous Government, which are very condemnatory of historical approaches by the Department of Health to doing good workforce planning across the NHS.
The issues that arise in this area for a Minister sitting in Richmond House are not ones that you can leave to employers at the local level to deal with. These issues are of long-standing provenance, such as the relationship between doctors from other parts of the world coming to work in the NHS, immigration law and the European working time directive, which has had a massive influence on the way doctors work. We cannot expect local employers to sort these issues out. We also have other big issues to consider; for example, revalidation of health professionals to ensure that they can and do keep up to date.
Another area where the previous Government have a lot to be proud of is the development of a range of sub-medical professionals who could take on jobs to relieve doctors to do more significant work. A good example of this was emergency care practitioners in the ambulance service, where totally new groups of people were brought in, who turned the ambulance service, if I may put it this way, from being just a taxi service to a hospital into a service that had people who could keep patients alive until they got to the hospital. We have a good tradition of developing those areas but in many cases, after a lot of good pilot schemes were introduced by particular local employers, the NHS was reluctant to go to scale. Nurse prescribing is a very good example where we trained lots of nurses but local employers did not always use them to do the job they had been employed for. You need some national perspective to tackle some of these areas.
I now want to say a few words about the much-maligned strategic health authorities. It has become fashionable to say that they were just bureaucratic empires that did not do anything terribly worthwhile. I am still proud that I set up 10 SHAs. They did a good job. The Government will find that they will need an intermediate tier between Richmond House and clinical commissioning groups and local trusts. No one has run the NHS since 1948 without an intermediate tier. The strategic health authorities were the hosts; they worked with the deans and helped to do some of the workforce planning and development in this area. They were the people you could rely on if you needed to ensure that there were enough training places at the local level for the next generation of doctors to secure their specialist training. If you do not have some capacity at that level, you will end up with the really rather difficult problem of how to find the training posts for the next generation of doctors to undertake their specialist training.
Lord Ribeiro
I should just like to acknowledge that the references that I made earlier were to wave 1. I fully recognise and appreciate the work done by the noble Lord, Lord Warner, in trying to get a training contract with the private sector. However, there was a determination on the part of the Government when ISTCs were first introduced to keep the NHS consultants and trainees out of those centres.
Lord Warner
I ought to make clear that I was not launching an attack on the noble Lord, Lord Ribeiro, with whom I had an excellent relationship as a Minister when he was president of the Royal College of Surgeons.
I finish by saying that although we are making progress on this Bill by having amendments of this kind early on, it is important to realise their limitations. A number of noble Lords, particularly my noble friend Lord Turnberg, have raised a whole raft of issues which still need to be grappled with. This may be the first of a number of debates we have on the issue of education and training as we try to strengthen the Bill in this area.
Baroness Emerton
My Lords, I rise as the one nurse here. The debate so far is music to my ears but it would be even more so to the professions. When the Bill was published there was great concern and great disappointment that we had to wait for education and training to come as a further step in the White Paper and after this Bill. They see, as I think every professional here sees, that education and training is a fundamental basis for ensuring the primacy of patients.
This Bill gives an opportunity to look at the future of health and social care and to bring in integration and holistic care, as was pointed out at Second Reading. To do that, we have to look at the education and training of all healthcare professionals, and the holistic approach from primary to secondary and tertiary, back to primary and community care, and to work alongside social care.
One of the things that we particularly need to address is the commissioning of the workforce in the future. The noble Lord, Lord Warner, has mentioned the strategic health authorities. I am sure that we all have comments against the strategic health authorities, but one of their functions was to engage in workforce planning. At the moment, it does not seem at all clear how the commissioning will be for the future workforce of healthcare professionals. This will be a great issue that needs to be addressed urgently because we all know that education and training is a three or four-year process—longer for doctors. It will need to be addressed immediately.
I want to support the amendment tabled by my noble friends Lord Walton and Lord Patel, proposing an overarching responsibility for the Secretary of State. I am sure that we will have certain other amendments, which have been already mentioned, and future debate. I would just say how urgent it is that we get something in the Bill to reassure the professions that education and training are essential for the primacy of patients.
Earl Howe
My Lords, I cannot speak for Amendment 44, which is not the government amendment; but I can speak for Amendment 43, which is. My advice is that the amendment delivers everything that my noble friend has just said. I have not given a critique of the amendment of the noble Lord, Lord Walton, but as I have been invited to do so, I will now offer one. It does not cover non-clinical staff or trainees; it covers the healthcare workforce. So, in actual fact, I think it is deficient; and I urge the Committee to accept the government amendment on that basis.
Lord Warner
I am sorry to interrupt the Minister’s flow, but he has been interrupted, so I thought I would ask my question now. The Minister has given us quite a lot of assurances about what the government amendment would cover, but I put to him a particular issue that came up—not that long ago, in 2006—when there was a major national row about the number of specialist training places. A large number of doctors and would-be doctors marched on London to complain about that system. It was absolutely clear that the only person who could deal with that issue in any satisfactory way, for both the professions and the public, was the Secretary of State. Is the Minister absolutely confident that the government amendment would enable the Secretary of State to act in such circumstances?
Earl Howe
The Secretary of State could act if Health Education England was failing in its functions. Our vision is that we will be giving functions to Health Education England to oversee a national system. If it does its job properly, then the situation the noble Lord describes would, one hopes, be handled in a satisfactory way. If it fails in its functions, then, yes, of course it would be the duty of the Secretary of State to step in and oversee the process.
Earl Howe
It might or it might not. All I can say is that the Department of Health will have designed and co-ordinated the new system and will develop the outcomes framework. Health Education England will be providing oversight and national leadership for education and training. The department and Health Education England, together, would no doubt have a role in sorting out the kind of situation that the noble Lord, Lord Warner, has adumbrated. However, it is a little difficult to discuss this in hypothetical terms. I have tried to set out, broadly, how the system should operate—
Earl Howe
It did happen, but it did not happen with the system that I have outlined in place. As I have just said, NHS Future Forum is talking to a great many people about where exactly responsibilities should sit for what, and how the system should work, which is why—I confess freely—I am in difficulties. While I would love to be able to answer detailed questions about the system, we have quite consciously deferred these matters to a second Bill.
Lord Williamson of Horton
I thought it would be nice to hear another voice, having been here since 3 pm or earlier. I should like to come back to these points and follow on directly from the intervention by the noble Baroness, Lady Jay. The word “provide” has not been used by the Secretary of State in the past; none the less it is there in the long history of this way of handling the operation of the National Health Service. We have continually heard here how in the past it has not been used, and I understand that. However, we are not legislating for the past here; we are legislating for the future. I feel that the retention of the word still has some value if we are looking ahead to the future. In this Bill we are not making special arrangements so that the Secretary of State can provide, but what will be the consequences of unexpected events which could hit us in the future when it might be sensible for the Secretary of State to provide? I do not think that that should be ruled out and, for that reason, I am attracted to the amendment of the noble Baroness, Lady Williams. It also has the advantage that in law it is highly intelligible to an ordinary person, which I always appreciate.
I now come to the amendment of the noble and learned Lord, Lord Mackay. I fully understand why he has put it forward and why he thinks that it is better to avoid putting something into the law which has not been operational, replacing it with something which is a more accurate description of what the future situation might be. However, I have one question, which I shall put to the Minister and indirectly to the noble and learned Lord, Lord Mackay.
In paragraph (b) in his amendment there is a cross-reference to Amendment 8, which lists the various intervention functions of the Secretary of State. Basically, all these interventions will be necessary because we will have been struck by some terrible problem—a failure by the Care Quality Commission or NICE. There are all sorts of terrible failures in which the Secretary of State has to intervene. However, I am still anxious about whether, under this formulation, the Secretary of State can intervene proactively—that is, without having to wait until disaster has struck in the various forms listed in Amendment 8. I make that point because I think it is of interest and importance to the people who have raised all the questions in relation to what we are now discussing and what was discussed at Second Reading and in relation to the previous amendment, which was not carried but was in fact discussed very widely in the press. Therefore, I am interested to know whether there is a possibility of proactive intervention by the Secretary of State.
Lord Warner
My Lords, I am a bit confused as to whether we are making speeches or asking questions of the noble and learned Lord, Lord Mackay, who seems to have volunteered to conduct seminars for us on many of these issues. In making some points I shall, in a way, be trying to be helpful to the noble and learned Lord. In a sense, the criticism he is receiving is unfair because his amendments bring the legislation up to date in terms of provision, which has been a fiction for many years. However, his proposal has to be read in conjunction with all the other provisions in the Bill, which continue to puzzle me. The Government have sworn that they want to be extremely hands-off, and they have their beautifully drafted Clause 4, which I think has incurred the wrath of the noble Baroness, Lady Williams, and others. Nevertheless, the Bill as a whole gives the Secretary of State quite a lot of powers to intervene, and I shall go through just a few of them.
Clause 12 confers a power to control services commissioned by the Commissioning Board or clinical commissioning groups; Clause 13, the ability to give direction on secure psychiatric services; Clause 14, the power to make arrangements for the supply of blood and human tissue; and Clause 16, regulations to require clinical commissioning groups to exercise EU health functions. Under Clause 17—even better—the Secretary of State can make regulations that impose standing rules on the Commissioning Board and clinical commissioning groups to arrange for specified treatments and a raft of other things. Clause 20 is the mandation clause, where the Secretary of State can mandate the board before the start of each financial year to specify objectives and the requirements for achieving those objections.
That set of measures looks very un-hands-offish to simple souls such as me. I think that we are getting ourselves into a bit of a state about this, because the Secretary of State seems to have very extensive powers. I admit that some of the public discourse may have been a bit confused by the explanation that the Government’s candidate for the chairmanship of the NHS Commissioning Board gave in his interview. He seemed to have a very hands-off picture of what the Secretary of State should do, and I suspect that he may not have read the Bill quite as carefully as your Lordships will have done. We have to look at the amendment of the noble and learned Lord, Lord Mackay, in the context of making the legislation honest but with the Secretary of State retaining huge powers in the Bill to intervene and direct operations.
Lord Newton of Braintree
My Lords, I am once again tempted, in this case by the noble Lord, Lord Warner, with whose views I almost entirely agree. Indeed, I find myself on an alarming number of occasions having quite a lot of fellow feeling with him. I will return to one or two of those points briefly. Being a singularly modest character, these debates are beginning to induce in me a feeling of considerable intellectual inadequacy—which I suspect is not the case with the noble Lord. I constantly feel that I am in the presence of angels dancing on the heads of pins. I hear the noble Baroness, Lady Jay—I hope she will not mind my saying this—saying, “We might as well retain this, because it has always been there”, even though we know it has never been the reality. At that point, we stop being angels dancing on the heads of pins, and we start dancing round a totem pole. On the whole, if we are going to dance round a totem pole, I would like a totem pole that reflects what we want to happen, not what was written into a Bill 60 years ago. The noble Baroness thinks I am being unfair.
Lord Owen
My Lords, this has been a fascinating debate and it has certainly taken the arguments further. I do not think that anybody expects that we will vote tonight, and I think that we will come back to this at Report.
There are merits in both of the cases put forward. In some respects—we can argue about the word “ultimate”—the idea of responsibility to Parliament has merit. It also tallies with the expression used by the noble Lord, Lord Newton. When people realise what the chairman of this largest quango thinks he will do, there will be uproar. Unfortunately, we have not yet been able to read those things—we know about them through reports, but we have not yet read them. It is very clear that the chairman-designate takes the view that he is given the money, he is given the mandate—a three-year mandate which is of course subject to change—and he then decides. It is pretty clear that some people think that that is a very good idea. I think that the noble Lord, Lord Warner, is pretty close to that position.
Lord Warner
I cannot resist responding to that. I do not accept that position. I was trying to say that what the putative chairman is saying seems to be in conflict with what is provided for in the legislation, which requires the Secretary of State to produce a mandate before the start of each financial year. That is a very clear marching orders provision in the hands of the Secretary of State.
NHS Future Forum
Lord Warner Excerpts(13 years, 2 months ago)
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Lord Warner
My Lords, I, too, welcome my noble friend’s ability to secure this debate today because it gives us a chance to limber up for the marathon that now approaches in a few weeks’ time. I also endorse her view and that expressed by my noble friend Lady Pitkeathley with their timely reminder that this is a health and social care Bill. I should declare my interest as a member of the Dilnot commission on the funding of social care. It is important that we do not shut the door on changes in social care in this Bill that would help the NHS to face some of its challenges for the future. I have in mind particularly some of the non-financial aspects raised in the Dilnot report, such as assessment and integrating better the assessment of people for adult social care and NHS continuing care. That is one of the great and difficult boundary issues in our modern world.
Let me be clear at the outset that I fully support the need for continuing reform of the NHS. I certainly do not view the proposed changes with the same level of horror as many of the Government’s critics do. As a former Minister responsible for NHS reform, I remain a strong supporter of more patient choice and competition among a greater diversity of providers of NHS services, with an economic regulator holding the ring. We need to finish the job of separating the commissioning function from service provision. We need to give clinicians a larger role in commissioning services and to accelerate the transfer of more care and treatment to community settings across the health and adult social care divide.
However, as I have set out in a book about my own experience of trying to reform the NHS, the forces of opposition to reforming this icon are formidable. I notice the noble Lord, Lord Fowler, in his place. He has, I suspect, had a very similar experience. The Government launched this blockbuster of legislative change on an unsuspecting NHS. If you do that, it is hardly surprising, if you have such a poor narrative of why this change was necessary, if you get a rather considerable adverse response. Rebellion from the usual suspects—many of whom were my old sparring partners—was totally predictable.
The NHS is a provider-dominated service with a huge element of public monopoly provision. That is the reality of today’s NHS. It is the reality of the NHS over a long period. If you attempt to change that, you must expect vociferous opposition. It should have come as no surprise that with such a poor narrative the Prime Minister felt the need to call time out and attempt to regroup. Today, we are having a peep at the regrouping, or at least at the bits we know about because the Future Forum is still at work. I hope that the Minister can lift the veil a bit more on this and explain to us what further homework the forum has been set and how long it has been allowed to complete it.
What are we to make of the changes that the forum has proposed so far? Do they improve the coherence of the reforms and the likelihood of their success? Do they improve the prospects of the NHS meeting the formidable financial, productivity and service reconfiguration challenges that it faces over the coming years? My good friend, Professor Paul Corrigan, has today produced a new pamphlet that identifies some of these problems, and I hope that all noble Lords will avail themselves of the chance to read it. Let me make it clear that I am not paid anything by Professor Corrigan for giving his work that small plug.
The proposed changes by the Future Forum seem to have pleased the leader of the Liberal Democrats, although, from my observations, many of his foot soldiers still seem to be pretty disgruntled. Although the coalition agreement advocated making Monitor an economic regulator, the reality seems to put the wind up a number of Liberal Democrats. I have not seen many NHS interest groups putting out a lot of celebratory flags as a result of the forum’s report. The disgruntlement of the BMA and other public sector unions seems little abated. Perhaps more significantly the NHS Confederation, for which I have very high regard, hardly seems to be bowled over.
If I was still a Minister, I would also be a bit more anxious about the continuing concerns of more objective and analytical observers such as the King’s Fund and the Nuffield Trust. They have drawn attention, rightly in my view, to the additional complexity and cumbersomeness that the forum’s proposals have introduced. The original enthusiasm for GPs running more of the commissioning show seems to be evaporating as the hospital specialists fight back to retrieve more ground through the modification of consortia membership and the rather ghost-like senates that will lurk there. We certainly seem to have a lot of fingers in the needs assessment and service commissioning pie—the National Commissioning Board, a rump of SHA and PCT clusters posing as outposts of the board, clinical commissioning groups and health and well-being boards.
The forum seems to have helped the Government further along a path of public confusion over who is really in charge of NHS commissioning and who is accountable when things go wrong. There is now plenty of scope for dodging accountability and laying off the blame for failure. This is particularly the case in the area of service reconfiguration which the NHS needs so badly. It is perhaps appropriate that we have just seen a Health Secretary finally take a decision on service changes in Chase Farm Hospital the best part of a decade after it should have been taken. Let me congratulate the Health Secretary on showing the courage to do this eventually.
In my view, the forum’s proposals make worse the already unsatisfactory accountability for service needs assessment and the commissioning of services, and will make the much needed reconfiguration of services even more difficult. We have to concentrate more hospital specialist services on fewer sites and provide much more care and treatment in the community on an ambulatory basis if the NHS is to live within its means. This requires us to reduce expensive, unsustainable, low-quality and unnecessary acute hospital services and to transfer service resources to new service configurations with different providers from the public and, yes, the private and, yes, the not-for-profit sectors. We have to face up to moving away from the outdated business model of the all-purpose district general hospital of the 1960s.
Modifying reform in ways that make these changes more difficult to achieve is bad news for those of us who believe in a tax-funded NHS that is free at the point of clinical need, especially given the £20 billion of efficiency improvements that the NHS has to make over the next four years. These are issues to which some of us will want to return in a lot more detail during the passage of the Bill. I very much commend the remarks of the noble Lord, Lord Ribeiro, about some of these issues.
I conclude by saying a few words about integration and competition, which seem to have produced rather more heat than light in the recent public discourse. We are all in favour of integration, but we need to understand what we are talking about. From my point of view, I think that patients benefit from integration if it is related to the delivery of services to individual patients, but they may not benefit from the horizontal integration of service providers if it simply produces mergers that create far more monopoly provision and little improvement for patients.
It is also nonsense to suggest, as some have done, that competition inevitably means the fragmentation of service delivery and is inimical to integrated delivery. It is perfectly possible to have competition for the provision of integrated services; it just depends on the commissioner’s service specification and the payment mechanisms. In the US, Kaiser Permanente and others have shown that the integration of patients’ service delivery can flourish in a competitive healthcare market. Again, these are issues that we will need to come back to in the Bill.
Let me end by wishing the Minister well as he faces the Herculean task of taking the Bill through the House, but I cannot guarantee that it will be a totally pain-free experience.