Health and Social Care Act

Debate between Lord Whitty and Earl Howe

Tuesday 5th March 2013 Lords Chamber

[Earl Howe]

My Lords, the department consulted on its proposals for these regulations between August and October last year on the basis of the commitments that had previously been given. All sectors had an opportunity to feed in their comments. Our proposals for the regulations did not give rise to any anxieties at that time.

[Lord Whitty]

My Lords, the Minister should have been made aware of the concern I expressed the other night in relation to the reference to Monitor in the Enterprise and Regulatory Reform Bill and to its supervision by the proposed Competition and Markets Authority which seems to some of us to introduce by the back door a situation where the CMA would override Monitor, making, in effect, competition trump integration and co-operation. Will he now advise the noble Viscount, Lord Younger, to delete the reference to Monitor in that Bill?

[Earl Howe]

My Lords, I took the opportunity to read the noble Lord’s comments a few days ago, and I am grateful to him for them. He will be receiving a communication in a few days’ time to clarify this issue. I thank him for raising it. The short answer to his question is that it is not our intention for competition to trump integration.

Care Quality Commission (Healthwatch England Committee) Regulations 2012

Debate between Lord Whitty and Earl Howe

Wednesday 21st November 2012 Lords Chamber

[Lord Whitty]

My Lords, I do not want to repeat the arguments that have been made. I was going to repeat the arguments that I made about the history of consumer representation in other sectors, but time is against us. The conclusion from that would be that independence and the perception of independence are vital for all the reasons that my colleagues have spelt out today. The Act is there, and the regulations will be there after tonight, but the Minister at least ought to be prepared to say that he will review the situation after, say, two years. If he were prepared to say that tonight, I would give Anna Bradley, who I have great respect for, and the other members the chance to prove that this situation works, but it might also show up some strains in it. If the Minister could say that, I would walk away tonight a happier man.

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

My Lords, the noble Lord, Lord Collins, has posed a number of questions about Healthwatch England and how it will work within the Care Quality Commission, and I welcome this debate. In view of the time constraint, I am not sure that I am going to be able to cover all the points, particularly those relating to local Healthwatch, but I will do my best.

First, I would like to take a step back to the White Paper Equity and Excellence: Liberating the NHS where our first plans for Healthwatch were set out. The Health and Social Care Act 2012 was passed by Parliament in March this year and enacted the proposals for Healthwatch to be the new consumer champion for people in health and social care. As a result, locally and nationally, Healthwatch will bring about better national leadership on public engagement and better communication for patients, service users, members of the public and communities to enable their concerns to be heard and acted on.

In the debate on the Bill in the Lords, the Government made it clear that Healthwatch England has an important role to play for patients and the public to present their views on health and social care at the national level to inform service improvements. Accordingly, the 2012 Act set up Healthwatch England to be the national body that would present the collective voice of the people who use health and social care services so as to influence national policy, advice and guidance. The Act sets up Healthwatch England to have relationships with other national bodies, such as the NHS Commissioning Board, Monitor and the Care Quality Commission itself, and with local authorities and the Secretary of State. Healthwatch England has the power to advise these bodies and the Secretary of State for Health, which could include making recommendations, and the recipients of such advice are under a statutory duty to respond. This is an important power for Healthwatch England to drive the consideration of issues, get a response and make the correspondence public, which I believe is a very tangible way of delivering openness and transparency in how these bodies respond to the issues that Healthwatch England raises. That could be a matter relating to the actions of the CQC itself.

I believe that these arrangements will engender trust. They will also embed the patient and public voice and the experiences of patients and the public at the heart of services. Healthwatch England is able to build other national relationships, such as with Public Health England. In addition, Healthwatch England will provide the leadership and support to a network of local healthwatch organisations which, in turn, will feed back the information from local people and communities to inform the national picture of what needs to be heard, and acted upon.

Since the Act was passed, the Healthwatch England committee was launched on 1 October at a stakeholder event hosted by the first chair of Healthwatch England, Anna Bradley. The chair has appointed to the committee 10 members so far who, collectively, bring the range of expertise and experience required for Healthwatch England to operate strategically at the national level. Those members were shortlisted and interviewed by a selection panel through an open and transparent process. Independent members of the panel included Joe Irvin, chief executive of the National Association for Voluntary and Community Action, and the criteria were drawn up in consultation with external stakeholders.

I shall name the 10 members for the benefit of noble Lords. They are: John Carvel, who was social affairs editor of the Guardian for nine years and a Guardian staff writer for nearly 40 years; Alun Davies, who has worked as a policy and planning manager in an adult social services department in a unitary council in the south-west and has been actively involved in disabled people’s politics; Michael Hughes, an independent policy and research adviser who was the director of studies for six years at the Audit Commission overseeing national reports on a range of topics including adult and children’s social care; Christine Lenehan, who is director of the Council for Disabled Children and has worked with disabled children and their families for over 30 years; Jane Mordue, who is deputy chair of Citizens Advice; Dave Shields, who was a health and well-being strategy manager for Southampton City Council, developing the city’s health and well-being partnership; Patrick Vernon, who was the chief executive of the Afiya Trust, one of the leading race equality health charities in the country and previously worked as regional director for MIND; Christine Vigars, who is chair of Kensington and Chelsea LINk and a trustee and former chair of Age UK Kensington and Chelsea—she has taught social work and worked in community care development in the voluntary sector; David Rogers OBE, who is a councillor for East Sussex County Council and chairs the Local Government Association’s community well-being board; and Dag Saunders, who is chair of Telford and Wrekin LINk and is one of two representatives for LINks on the Healthwatch programme board at the Department of Health. I hope the House will agree that this membership will give Healthwatch England not only strong and independent leadership but also the right skills and knowledge in relation to the commissioning and delivery of health and social care services, as well as on public engagement, consumer advocacy, equality and diversity, and specialisms such as children and young people.

The noble Lord, Lord Collins, has questioned the extent to which Healthwatch England will be able to act independently. I suggest to him that it will be able to do this in a very real sense. Healthwatch England will set its own strategic priorities, separate from the CQC; it will have its own operational and editorial voice, again separate from the CQC; and it will develop its own business plan and take responsibility for managing its own budget.

Under the leadership of its new chair, Healthwatch England has already made great progress in putting arrangements in place to ensure that it will function independently of the Care Quality Commission, while benefiting from its position as a statutory committee of the commission, without compromising good governance and lines of accountability. In fact, the benefit of this structure runs both ways. It will immensely strengthen the link between the views of patients and the public and regulation. The advice that Healthwatch England provides to the Care Quality Commission will enable the commission to address failings in the provision of health and social care services. It will also enable the commission to address any local risk management systems and, at the same time, Healthwatch England will have the commission’s offer of valuable expertise in data management, the gathering and use of intelligence, analysis, and an evidence base of information to pool and share knowledge. The CQC has publicly committed in its consultation document on its strategy for 2013-2016 to make the most of the opportunity Healthwatch offers and to support its development to make sure people’s views, experiences and concerns about their local health and social care services are heard. The CQC has made it clear that people’s views, experiences and concerns will more systematically inform its work.

Working as a committee within the Care Quality Commission makes Healthwatch England very well placed to connect people’s concerns about safety and quality with the work of the commission. This symbiotic and symbolic relationship is unique and will go a long way to embedding what I know noble Lords want to see, which are the voices of the patient and the public at the heart of care.

I was asked what will happen if Healthwatch England goes off the rails in some way or goes native. The Secretary of State has a duty to keep the performance of the health service functions under review. That requirement involves keeping the effectiveness of the national bodies under review; these bodies are listed in the Act. The list includes the Care Quality Commission, and Healthwatch England as its committee. That reassurance should go a long way to make sure that the functions that these bodies are meant to perform are ones on which they will be held to account.

Health and Social Care Bill

Debate between Lord Whitty and Earl Howe

Monday 14th November 2011 Lords Chamber

[Lord Whitty]

My Lords, I intervene briefly in this debate to ask the noble Earl whether, in his reply, he could perhaps cross-refer to a later section in the Bill, which deals with the role of one of the entities to which my noble friend Lady Wheeler has just referred, namely HealthWatch England. In any procedure for complaints, whether about treatment or the ultimate effects of commissioning on patients and the quality of service, an independent body that represents the views of the users of the health and social care system is required. There is a whole group of relevant amendments, but it is the last group printed on this list so we will probably not reach it much before Christmas. Nevertheless, within that group is a strong line that HealthWatch England should be an independent body, which means independent not only of the providers but of the regulators. In any proper complaints system—although I do not suggest that this is the only channel for complaints—you need an independent consumer view. This has stood the test of time in several other sectors. It would be a major role for HealthWatch England if it could be built into the kind of clear procedure to which the noble Baroness, Lady Jolly, referred.

[Earl Howe]

My Lords, this has been a valuable debate on what is an important topic by any standards. It is vital that patients feel able to raise complaints where services are not good enough. It is equally important that there are appropriate systems for ensuring that complaints and safety incidents are effectively monitored and addressed, and that wider lessons are learnt.

Amendment 57A would require the Secretary of State to create a new procedure, whereby complaints about both health and social care providers could be brought before the board. Amendment 143A would go further by giving the board a more specific role in collecting and analysing information relating to complaints about both the provision of health services and commissioning decisions by the board or clinical commissioning groups, and making this information available to the public. The current NHS and adult social care arrangements for handling individual complaints were developed to make the process of complaining quicker and simpler, and to put the focus on meeting the needs of the complainant. It is important that all NHS organisations view and manage complaints in a positive manner and use the information obtained to improve service delivery.

Under the current regulations, a complaint about poor service provision may be made either to the service provider or to the commissioner of that service. It is important that people have that choice. Someone may be deterred from making a complaint to the service provider if they consider that it may impact on their future healthcare provision. We consider it right for these general principles on complaints handling to be carried forward into the new system architecture. In future, we envisage that complaints about service provision would be made to the service provider, or to either the local clinical commissioning group or the NHS Commissioning Board, depending on which had commissioned that service. They would also deal with complaints about how they have performed their own functions.

Of course, where it proves not possible to resolve a complaint locally, the complainant has the right to refer the case to an independent arbiter. In the case of an NHS complaint, this referral is to the Health Service Ombudsman. The system of handling complaints will therefore continue to operate largely as it does now. The arrangements for monitoring complaints will also be similar. The NHS standard contract already requires all providers to report complaints information to commissioners. This information is collected by the NHS Information Centre and would be available to the NHS Commissioning Board. This is then discussed as part of the clinical review meetings between commissioners and providers, who are required by regulations to implement learning from complaints and other incidents. It will be vital that the NHS Commissioning Board is able to identify any emerging trends from this information.

In reply to the noble Lord, Lord Whitty, the board will be assisted by both the local healthwatch and HealthWatch England, which will act as a conduit for the views of service users about their experiences of complaints handling. It will also be able to make recommendations to providers and commissioners about how services and procedures could be improved. There will be a duty on NHS organisations to have regard to the recommendations of the local healthwatch, which will also put pressure on providers and commissioners to improve.

Finally regarding these amendments, the noble Baroness, Lady Wheeler, makes the valid point that it is important that information about complaints is made available to the public. Patient and service-user generated information, which includes complaints as well as information collected from patients and staff through surveys, real-time feedback, ratings of services and patient reported outcome measures, are all vital in helping patients to make informed choices about their care.

Separate arrangements currently apply in reporting patient safety incidents that have or could have resulted in harm to a patient. These are reported in anonymous form through the National Reporting and Learning Service, operated by the National Patient Safety Agency. Safety has to be the key priority of all those working in the health service. We cannot allow it to be an add-on or an afterthought. Patients rightly expect that any service provided with NHS funding will be safe.

For this reason, we want to put safety at the heart of the NHS by transferring these functions from the NPSA to the NHS Commissioning Board. Clause 275 therefore makes provision to abolish the NPSA as part of our plans to reduce the number of arm’s-length bodies. Instead, new Section 13Q, which Amendment 143B seeks to remove, gives the NHS Commissioning Board responsibility for those functions currently carried out by the National Patient Safety Agency. This is in relation to collecting information about patient safety incidents, analysis of that information and sharing the resulting learning within the NHS and more widely.

Safety is, of course, another of the core domains of quality. We believe that the NHS Commissioning Board, as the body that will be legally responsible for ensuring continuous quality improvement in the NHS, will be best placed to ensure that this learning is translated into improved practice. Its unique perspective will allow it to ensure that appropriate levers are used to drive safety improvement across the system. Bringing safety right into the core of commissioning activity in this way is the most powerful way of driving a safety agenda through the NHS.

--- Later in debate ---

[Earl Howe]

If the noble Lord will allow me, I will answer those questions in a moment. Amendment 101A would similarly duplicate existing provision by placing a duty on the NHS Commissioning Board to ensure that all CCG governing bodies meet the requirements for clinical and non-clinical representation. The board already has to do this; under proposed new Section 14C, the board can grant an application only if it is satisfied that the applicant CCG has made appropriate arrangements to ensure that the group will have a governing body which satisfies any requirements imposed by or under the Act. That would include regulations made under proposed new Section 14N providing for minimum levels of clinical and lay representation.

Amendments 170A, 175D, 175CA and 175CB seek to introduce alternative governance arrangements for CCGs. These amendments would remove the existing functions of the CCG governing body and, through the proposed new schedule, replace the governing body with both a board of directors and a board of governors. I was grateful to the noble Lord for explaining where this idea originated. However, the amendments do not propose functions for these boards to exercise. They concentrate almost solely on the form of CCG governance; they neglect the function. As to that form, there is much here which is already provided for in the Bill and in relation to a governing body. I should perhaps explain that our preferred approach is to set through regulations the key requirements in relation to the composition of the CCG governing body and the logistics of their qualification, appointment, tenure and so on. This will, most importantly, allow flexibility for the approach to evolve over time and in the light of experience.

Turning to Amendment 59A on the subject of the area covered by CCGs, in the light of our lengthy debate on this last week, a letter will shortly reach your Lordships to provide further information on the arrangements for geographic areas of CCGs. It includes some analysis of the key issues which I hope will be useful and reassuring. We accepted the Future Forum recommendation that the boundaries of CCGs should not normally cross those of local authorities. If a CCG wishes to be established on the basis of boundaries that will cross local authority boundaries, it will be expected to demonstrate to the NHS Commissioning Board a clear rationale in terms of benefits for patients; for example, to reflect local patient flows and to secure a better service for patients. The board will also be required to seek the views of emerging health and well-being boards. In addition, CCGs will have the flexibility to enter into lead or joint commissioning arrangements with other CCGs; for example, for commissioning of lower volume or more specialist services. I hope that this reassurance will satisfy the noble Lord’s concerns.

Finally, Amendment 92ZZA seeks to mandate the Secretary of State to make regulations imposing a ban on shareholders and employees of commissioning support organisations being given a seat on a CCG committee or governing body of a CCG—I assume that it is the governing body that the amendment refers to rather than the NHS Commissioning Board. We agree that there should be no conflicts of interest between a CCG and any commissioning support organisation that it uses. The support offered by such organisations should inform decisions made by CCGs, but we have always been clear that CCGs cannot delegate their duties or responsibilities. However, such an absolute ban would not take into account situations, for example, where a CCG may wish to invite individual employees from commissioning support organisations to provide expertise on a committee. The Bill already requires CCGs to have robust provision for managing conflicts of interest in how they discharge their functions.

It is clear from the debate that these amendments were proposed with the best of intentions, but I hope that noble Lords will feel that the points that I have made are sufficiently compelling to encourage them not to press the amendments.

I have a few questions that I would like to answer briefly. The noble Lord, Lord Hunt, suggested that the chair and deputy chairs of CCGs should be lay members. Each CCG must have at least two lay members. We are specifying that, and we have committed that one of the lay members of CCGs will be either the chair or the deputy chair of the governing body.

The noble Lord, Lord Rea, asked me how a CCG’s geographic area would be determined. The primary factor in establishing the CCG’s boundaries or geographic area would be the practices that made up the membership of the CCG. The NHS Commissioning Board must satisfy itself that the proposed area for a CCG is appropriate and that the CCG can commission effectively for that area. That is a very condensed explanation of what the Commissioning Board will be looking for.

The noble Lord, Lord Hunt, suggested that he could not understand how CCGs would be accountable. Accountability is a key area. There is no doubt about that and I share the noble Lord’s desire to get this right. We listened to the Future Forum when it said that there is a balance to be struck between the need for good governance and the need to avoid overprescription. Perhaps that is a generally accepted principle—I certainly agree with that. I think the amendment of the noble Lord, Lord Hunt, goes too far. However, we are absolutely clear that CCGs will be materially accountable in a number of ways. I could recite a number of ways that I have in front of me, but at this hour it might be appropriate for the noble Lord to receive that in writing from me. I would be happy to do that and to copy it round.

On the subject of conflicts of interest, we will be having a very full debate in the context of Clause 20 on conflicts of interest. I have a lot of material here, but essentially there are principally three safeguards in the Bill to prevent conflicts of interest: statutory requirements on clinical commissioning groups to have in place arrangements to manage those conflicts of interest—those have got to be set out in the group constitution; secondly, strengthened governance arrangements as regards the governing body, and I briefly outlined those; and specific provision for regulations to require that the board and the clinical commissioning groups adhere to good practice in relation to procurement and in commissioning healthcare services.

My noble friend Lady Jolly asked who will appoint members of the clinical commissioning group boards. We will work with patient and professional groups and with emerging clinical commissioning groups to determine the best arrangements for appointing members of governing bodies. As I have indicated, the Government will issue regulations in due course, setting out in more detail the requirements for appointing non-GP members to the governing body.

The noble Lord, Lord Hunt, asked whether non-executives would be in the majority on boards. I am not currently able to give that assurance. We are still working with a wide range of stakeholders on the regulations for governing bodies. We are well aware of concerns in this area. I will take the noble Lord’s points very firmly on board.

Very briefly in this group, I would also like to speak to government Amendments 172, 173 and 175, which are minor and technical in nature. Amendment 172 clarifies that the remuneration committee of the CCG governing body has the function of making recommendations to the governing body on its determination of allowances payable under a pension scheme established by the CCG for its employees under paragraph 10(4) of Schedule 1A. Government Amendment 172 allows regulations made under new Section 14L(6) to make provision requiring CCGs to publish prescribed information relating to determinations of the allowances payable under a pension scheme. Government Amendment 173 makes provision for the board to publish guidance for governing bodies on the exercise of this function. I trust the Committee will join me in supporting these minor and technical amendments.

[Lord Whitty]

My Lords, I thank the Minister for that detailed reply to what has been a fascinating debate. I fear, however, that he will have to return to a number of these issues.

The issues of accountability, governance, conflicts of interest and transparency are about confidence in the new system—not only confidence in this House but confidence in the population. The issue of coterminosity—which I thought was a word I had invented but I am glad that others took it up—is also vital to that because people understand the county boundary and where the services are and that there is a relationship between them. I am grateful for the Minister’s offer of a letter on the geographic boundaries but, before we complete the consideration of the Bill, we will have to be clear what the relationship between local authorities, providers of social services, those responsible for public and environmental health and the new CCGs is going to be. That also is an issue of confidence and understanding by the population and the people who use the health service.

Having said that at this hour of the night—I note the Chief Whip’s impatience—I beg leave to withdraw the amendment.