Health and Social Care Bill

Debate between Lord Warner and Lord Greaves

Monday 14th November 2011 Lords Chamber

[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.

Health and Social Care Bill

Debate between Lord Warner and Lord Greaves

Monday 14th November 2011 Lords Chamber

[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.

Health and Social Care Bill

Debate between Lord Warner and Lord Greaves

Wednesday 2nd November 2011 Lords Chamber

[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.