Health and Social Care Bill

Baroness Barker Excerpts

Monday 14th November 2011 Lords Chamber

I lived through the process of dealing with financial meltdown in the NHS in 2005-06. One of the main causes of that meltdown was that the NHS could explain to hardly anybody collectively the relationship between the level of activity and the cost of that activity. It had two streams of data—one about money and one about activity—and they were not related to each other. If we repeat that approach in clinical commissioning groups, we will end up in the same place as we ended up in 2005-06.

[Baroness Barker]

I shall speak to Amendment 92ZZA, which stands in my name and those of my noble friends. At this time of night, brevity is of the essence. This amendment addresses a crucial point.

The whole structure that the Bill sets up for the NHS depends on a number of things to work efficiently. It depends on the clarity of responsibilities and on different bodies having a clear understanding not only of their own role but of their role in relation to each other. One of the most important parts of the process underlying the structure is integrity. Although there has been much exaggeration about potential conflicts of interest in some of the things that I have seen, there is one—the one that I have highlighted in this amendment.

One commendable thing about this Bill is that in relation to acute care and hospitals we are stopping the process by which organisations—in this case acute trusts—are rewarded for the volume of the procedures they do rather than the quality of their outputs. It is important in commissioning that we stick to that same principle. There must be no possibility whatever that anybody who is involved in the commissioning of services stands to gain by the provision of those services, or their volume. That is why I have drafted this amendment. It may be imperfect in some way or another but its intention is to say that those commissioning decisions must be completely separate from the derivation of any benefit—or pecuniary benefit—as a result of that.

I have absolutely no problem whatever with people who either work for or are shareholders of commissioning support organisations advising CCGs on what to do. If they are, as we have been led to believe, experts in commissioning and clinical commissioning groups want to bring in their expert advice, that is absolutely fine. I do not have a problem with that at all, as it could be a much more efficient and effective way in which to do it. However, it would be unacceptable if those same people had any role whatever in the decision-making processes of the CCGs, either by being a member of a CCG board or by being a member of one of the CCG sub-committees. My amendment attempts to remove that potential conflict of interest. It is probably one that the Government had intended to remove, but they have not done so in the Bill as it stands, and so there is a loophole which needs to be closed in order that there is complete integrity about the process.

[Baroness Finlay of Llandaff]

My Lords, this group of amendments and this debate are incredibly important. The risk of conflict of interest relating to general practitioners is particularly high because they are independent contractors—they are not NHS employees and therefore are not answerable in the same structure as an NHS employee would be within an organisation. Independent contractor groups may be small or they may be as large as practices.

I have been a GP myself and have had to go through the business of partnership agreements. I know only too well from colleagues of mine how disastrous the break-ups in partnership agreements can be and the degree of animosity that can occur. When we talk about GPs being on commissioning groups, there is a real problem in terms of how much they are going to get paid for undertaking commissioning decisions. If they are commissioned from an organisation with which they have a link—because they are a GP with a special interest and they work in another organisation—what are they being paid for? The content of their general and medical services contract is not closely defined. If they have a special interest, which their practice then refers to one of the partners in the group who is providing a service as part of another provider group, there is a risk that people in that practice will be getting double-paid under the organisation of that arrangement.

To try to explore this, I telephoned Assura, a group which is providing dermatological services in an area. I tried to explore the situation with regard to their internal governance arrangements and commissioning arrangements if they have a GP working there and how those arrangements are monitored. I was reassured by what I was told by the person on the phone, who was most helpful. However, it did not take away my anxiety. This provider was being careful and making sure that clinical governance structures were in place, but I have not been able to understand where the controls are on a clinical commissioning group. Will they be only on people who are GP principals on it, or will they apply to all the doctors who are working in general practice? Where will the GPs sit if there are a small number of principals, a large number of salaried GPs in an area who are doing all the clinical work and who know what needs to be done, and a senior partner who is taking the profits out of the business which is the business of the general practice?

Where coterminosity links to this is that, if you have coterminosity between the commissioning group and other services—local authority services, education services and so on—you at least have another organisation, or two others, which will be seeing what is happening. If you take a complex family—perhaps a single parent with one child with developmental delays, another with complex conditions such as epilepsy, diabetes or whatever, and another child who might be being neglected—then, by having triangulation between local authority services, education services and those services being commissioned, the gaps in the commissioning process may emerge. However, if you do not have coterminosity, I can see each group saying, “It falls outside our area”, and the children or the patients will fall through the gaps. With regard to the commissioning group, poor decisions in commissioning or decisions which involve a conflict of interest may not be revealed for a very long time.

Therefore, I urge the Government to look closely at these amendments, particularly the one tabled by my noble friend Lord Kakkar on the Nolan principles, because, unless we tighten up on the processes that will monitor and provide governance over the way that members of the clinical commissioning group behave, we run a risk. I wish that I could share the optimism of the noble Baroness, Lady Barker, that the conflict of interest will lie only among those supporting commissioning decisions, but I do not.