Health and Social Care Bill

Baroness Jolly Excerpts

Monday 28th November 2011 Lords Chamber

Moved by

[Baroness Jolly]

135AA: Clause 20, page 19, line 16, leave out “encourage” and insert “mandate”

[Baroness Jolly]

I will be brief so perhaps we can make a little more progress this evening. These four amendments come as a group; originally they were in two groups of two, but actually they hang together as a suite. They are probing amendments, and I thank the Royal College of Paediatrics and Child Health for its help with them. These amendments are intended to arrange for the organisation of carer children and young people, particularly young people who are vulnerable, and are about guaranteeing their safety and well-being and safeguarding them. When I was rereading the amendments earlier and making my notes I realised that they are not in the context of children necessarily and thought that they might just as easily apply to vulnerable adults, but certainly the intention was around children.

Successive Governments have tried without an awful lot of visible success—or perhaps there have been successes, but with some high-level and visible failures—to integrate services for young people. From Victoria Climbié to Baby P, there are still issues around silos not talking to each other. We have not got integration absolutely right.

In many ways, the Bill does not help streamline services for young people: if you are under five and going to be looked after by health visitors it is the responsibility of the board; if you are over five, school nurses come under the auspices of the health and well-being boards; primary services, local services, mental health and acute services are all under clinical commissioning groups. Within the Bill there are several different organisations responsible for delivering services to young people.

I will very quickly go through the meaning of all the amendments. Amendment 135AA concerns the general duties of the board in promoting integration. The wording of the Bill encourages commissioning groups to enter into Section 75 arrangements with local authorities. The amendment suggests that we move to mandating—and it occurs to me that somebody really should produce for this House a sliding scale of verbs from “may” right up to “mandate” so that we can work out exactly where they all sit within the hierarchy. Certainly this is a probing amendment, however, so I am using the verb “to mandate”. We are talking about Section 75 arrangements involving pooled, shared budgets. Shared budgets will give you shared ownership and shared solutions to problems. With shared solutions one will get shared decision-making. For this vulnerable group, we need shared decision-making.

Amendment 197BA concerns the general duties of clinical commissioning groups. It covers the duty to obtain appropriate advice. The intention of the amendment is to add in experts in maltreatment. Nobody could gainsay that. Whether it needs to be in the Bill, I do not know. We would appreciate some indication from the Minister on this.

The third amendment in the group concerns the establishment of health and well-being boards. It would add to the board a representative who is a health professional, for safeguarding. The final amendment in the group, Amendment 331AB, concerns the function of health and well-being boards and the duty to encourage integrated working. Again, it uses the word “mandate”, which I appreciate is at the top of the scale. It mandates people who work in health and social care to work in an integrated manner.

I do not apologise for the verb, because the situation is very serious. Young people who need the most care run the risk of falling into holes where there is nothing joined up. We are saying that the Bill puts the patient first and we talk about integration running all the way through the Bill. Sadly, it does not look like this will happen in children's services. The amendments in the group try to make it happen. Perhaps the Minister will offer clarity on the level of detail—which clearly is not in the Bill—that will be in secondary legislation to help with this. Successive Governments have tried to get this right but it has not always worked on the ground. This is an opportunity to rectify that. I beg to move.

[Lord Beecham]

My Lords, I sympathise with the motives of the noble Baroness who tabled the amendments but I am not sure whether they are persuasive. Mandating is not necessarily the right approach. It is certainly not the correct approach for health and well-being boards, because they are not executive decision-making bodies. We hope that the boards will produce joint strategic needs assessments, to which the clinical commissioning groups will have to have regard. There will certainly be joint working there, but the boards will not be in a position to mandate anybody. Therefore, while the aspiration is noble—appropriately—the phraseology does not necessarily achieve what is intended.

I expect the Minister to say that he envisages that the precise object that the noble Baroness is pursuing will be taken into consideration and acted on by the relevant parties: in this case clinical commissioning groups in particular. Obviously these are probing amendments. They should not be reflected in a substantive amendment put to the vote—unless of course the noble Earl departs from his usual practice and accepts them.

--- Later in debate ---

Finally, the duty in new Section 14V to obtain appropriate advice is related to the definition of the comprehensive health service and is itself deliberately wide in scope. In response to Amendment 197BA, it could indeed include any health-related issues relating to maltreatment. There is no reason why CCGs would not seek professional advice in relation to maltreatment, but this is only one of many specialist areas. I hope that this reassures my noble friend and that she will feel able to withdraw her amendment.

[Baroness Jolly]

I thank the Minister very much for his reply. I am more than happy to withdraw my amendment.

Amendment 135AA withdrawn.

--- Later in debate ---

[Lord Warner]

My Lords, would the noble Baroness accept from me, as someone who was this great centraliser sitting in Richmond House, that we actually set up these capacity-building capabilities for social enterprise in the voluntary sector, in response to those sectors’ concerns about their inability to make headway locally and enter the market to provide services in those areas? That was not a centralising tendency on our part. It was actually a response to people saying to us that we needed more capacity-building capability at the centre because it was not being provided at the local level.

[Baroness Jolly]

My Lords, I can give an example of where it has been provided. Today I have been talking to the operations director of Peninsula Health Care. That was the provider arm for the Cornwall PCT which was providing community hospitals and community services, and which is now a community interest company as of 1 October 2011. It has already brought across all the arrangements that it has with its local authority; Section 75 and so on, shared budgets for equipment, and all sorts of innovative work alongside.

The whole thrust of the amendment of the noble Lord, Lord Rooker, was part of our manifesto, it was part of the coalition agreement, and I feel quite comfortable about supporting it.

[Lord Mawson]

My Lords, I am very sympathetic to the amendment of the noble Lord, Lord Rooker, for very practical reasons. I am building a street at the moment in Tower Hamlets, and part of that street is not only a new school but a new health centre, which has been under development for five years. The health centre proposals were begun in the previous Government’s time in office. It is true that the Bromley-by-Bow Centre, when competing for that practice, was not on a level playing field. It is very difficult to compete with a multinational company that could undercut the price per patient to £75 per head, when I, having run an integrated health centre for 20-odd years, knew that the real costs were probably around £119 per patient and that the £75 per patient was not sustainable. It was very interesting going through the whole of that process, of proper competition and then losing the competition, to three years later, when I was approached by that company which admitted that the business plan did not work and asked whether we could help rescue the situation, which we have now done, and the multinational business has now withdrawn. I know that there is a problem here that we need to get our heads round, and I know and believe that the Government are serious about wanting the social enterprise sector and the voluntary sector to play their full role. It is a practical problem that needs to be got hold of.

The other thing that I know from experience is that bureaucracies like to talk to bureaucracies. I know that large government departments often find it easier to talk to large businesses. Indeed, we have seen this happen over many years. I am in favour of the private sector. We work a lot with the private sector, and I do not think that it is a case of one of the other. However, I have noticed how easily civil servants translate across into large companies, with the bureaucracy carrying on under other names, and organisations that are leaner and more innovative sometimes find it very difficult to break in. Therefore, if the Government are really serious about allowing some of us who do this work but are smaller in scale to break into this market and grow in capacity, then something will need to happen here to help that.

I also know from experience that one way in which we have grown in capacity is by forming relationships with one or two businesses. They have got to know what we are about and we have got to know what they are about, and we have formed partnerships and grown opportunities together. As I mentioned earlier, a £35 million LIFT company has now built 10 health centres. When we formed that relationship, which is a bit like a marriage, we got to know about each other’s worlds. We are now in a social enterprise with that business carrying out landscape work on 26 school sites. Therefore, there are things that government can do.

In my experience, some businesses are becoming more intelligent about this, although some businesses are not. The Government should be using their muscle to encourage businesses to form these local partnerships. If they do not do that, the danger will be that the profits made in poorer communities will be sucked out of the area, rather than there being virtuous circles around the areas creating more jobs and opportunities in local contexts. Therefore, I am sympathetic to the amendment. I would encourage the Government to look again at some of the practical issues and how they work in practice on the ground.

Health: Flu Vaccine Research

Baroness Jolly Excerpts

Wednesday 23rd November 2011 Lords Chamber

[Earl Howe]

The noble Baroness is quite right. The Chief Medical Officer wrote to the NHS on 25 May, citing four studies that provide strong evidence of the benefit of influenza vaccination for front-line healthcare workers. These studies show clearly that healthcare workers can transmit influenza to patients, that vaccination of healthcare workers can prevent that transmission and that vaccination of healthcare workers can lead to better health outcomes in the vulnerable patients with whom they very often deal.

[Baroness Jolly]

My Lords, can my noble friend confirm that there is a problem with supplying the H1N1 vaccine? If that is the case, how is it proposed to target it more effectively and what steps will be taken to make sure that vulnerable people are targeted first?

[Earl Howe]

My Lords, there were supply problems last winter, but my advice is that there are none this winter. Indeed, the quantity of vaccine that has been ordered for this winter’s anticipated flu outbreak is considerably larger than was the case last year. The Government also have a reserve stock of vaccine to be deployed in the event of local shortages.

NHS: Waiting Times

Baroness Jolly Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Lord Naseby]

My Lords—

[Baroness Jolly]

My Lords—

[Lord Naseby]

My Lords, is it not strange that the figures show that certain hospitals consistently get nowhere near meeting the 18-week target? What action are the Government going to take to help those hospitals ensure that they perform like the average?

[Lord Warner]

My Lords—

[Baroness Jolly]

My Lords—

[Lord Clark of Windermere]

My Lords—

--- Later in debate ---

[Earl Howe]

My Lords, we believe that the safeguards are already in place, but the figure I cited in my original Answer is very similar to the figure we have seen over the past two and a half years. Little progress has been made over that time. We do not think that that is satisfactory, so we are broadening the operational standard to ensure that more patients are treated in a timely way. I am sure all noble Lords would wish to see that.

[Baroness Jolly]

My Lords, approaching 250,000 patients have been waiting for more than 18 weeks and I expect that they would like to know why, as would the House. Can the Minister give us any indication, apart from the five hospitals mentioned earlier, of whether there is a regional pattern to this—while we still have regions—or of whether it is the result of financial pressures, clinical management issues or maybe a combination of all three?

[Earl Howe]

It does seem to be a combination of all three, although it is clear that in certain areas there is a shortage of the necessary specialist consultants. Sir Bruce Keogh, the NHS medical director, is addressing this urgently with the British Orthopaedic Association in particular. That is expected to result in a solutions paper being put to the NHS Operations Executive in the new year.

Health and Social Care Bill

Baroness Jolly Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Lord Patel]

In response to the amount of funding, as I understand it—I am sure the noble Baroness, Lady Northover, will correct me if I am wrong—the Bill suggests that the funding for HealthWatch England will be a grant in aid provided by the department to the CQC.

[Baroness Jolly]

My Lords, they say that too many cooks spoil the broth, but I think this is an occasion where that probably has not happened. Many hands might make light work. I ask the Minister to take these amendments away because there is an awful lot of good to be found in each of them, but not in each together, as it were.

Amendment 318C, tabled by the noble Lord, Lord Whitty, inserts a new clause and subsection (2)(a) of the new clause is about complaints. It is a nice idea that complaints could be taken to HealthWatch England. Complaints are a big issue to which we will be returning on Amendment 108.

The noble Baroness, Lady Cumberlege, raised the relationship between local and national healthwatches. It is critical. We would support the election of local healthwatch representatives to the national body.

Finally, on independence and finance, I believe very strongly that it is very difficult to criticise and challenge an organisation if you sit within it. I understand the point about the benefits, but if you are local, and you sit within your local health authority or nationally you sit within the CQC, generally the feeling that you are monitoring the organisation that is your host is never a good place to start. Similarly, I, too, have had letters from people who were CHIPs and then LINks about budgets being not just cut a little bit but absolutely hacked away. I would be really uncomfortable if, for example, locally the healthwatch was going to be located within the principal local authority that held the budget. We have had it already today. Intentions will be good and then somebody will come along and say, “We really need a bit more just for this”. It will happen in a meeting where they are not present and, all of a sudden, there will be another slice taken. We have seen it before with lots of other things. You could look at it from a negative point of view and say these are like curate’s eggs and bad in parts or good in parts, but I think too many cooks will not spoil this broth. Many hands will make light work. I ask my noble friend to take this away and have a look at it.

[Baroness Northover]

My Lords, I sympathise with the noble Lord, Lord Patel. He is forgiven for being subject to the beatings of the noble Lord, Lord Harris. When I made my maiden speech, the noble Lord, Lord Harris, gave me a very interesting and less than usual tribute. Noble Lords will see that we have a slight history.

Health and Social Care Bill

Baroness Jolly Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Rea]

My Lords, I support all those noble Lords who have spoken so far and I agree with everything they have said; there is hardly anything for me to add. I just want to emphasise that a public health specialist will have had special experience and training in dealing with the massive amount of health data that comes into a health authority or, in this case, to the NHS Commissioning Board; it will be a huge amount. Public health specialists are trained in statistics and in epidemiology, and have other skills needed to handle this information and to help the board to make the correct decisions. I would like to emphasise the point made by my noble friend Lord Warner that very often this can be extremely helpful when certain services are deemed no longer appropriate. They may save a lot of money by giving backing to decommissioning and reconfiguring certain services, ensuring that populations are best served with the resources that are available.

[Baroness Jolly]

My Lords, it sounds as though there is a considerable level of agreement on this. I, too, believe that we should have a public health specialist sitting on the board. Members of the faculty have said that if there is not going to be such a specialist on the board by right, there should at least be one where the CMO is not a public health specialist. This Bill has put public health at its core and at every level.

I shall not say any more about the public health appointment but I will talk a little about the involvement of the patient. The patient is also meant to be fundamental to this Bill: “no decision about me without me.” Again, we have the patient involved through local government and the local commissioning groups but not necessarily on the board. I think that whoever is chair of HealthWatch England should have a seat on the board.

What would both of these positions bring to the board? They would bring a level of expertise that nobody else has. I understand the Government’s reluctance to be specific, and I know that lists are problematic. I also know that with these things there is a tendency to request that every man and his dog, or all and sundry, sit around the board table. However, it is a board table and not a representative council, so I would put those two people there for one distinct reason: they add a dimension that the board does not know it misses. Decisions made without them will be made in a vacuum and will be all the poorer for it. Somebody put it to me earlier today—your Lordships will have to excuse me for this—that the board knows what it knows, it knows what it does not know, and it does not know what it does not know.

[A noble Lord]

Was it Donald Rumsfeld?

[Baroness Jolly]

Apparently there was a Persian poet who got there even before him, but whether Donald Rumsfeld was a reader of Persian poetry, I know not. The point is that you do not know what you do not know. Both those voices would bring to the board serious added value.

I have another four or five amendments in this group which relate not to the composition of the board but to its work. Every year, the board is tasked with producing a three-year business plan on how it is going to discharge its functions. We have a Secretary of State who produces a mandate for the board. We are all in total agreement that the board has huge powers to shape the NHS. New Section 13S of the 1996 Act indicates that there should be an ability to revise the plan. It talks about a “revised plan” but says nothing about the process of revision. The Bill is silent also on the operational plans of the board. I am slightly curious as to which comes first—the mandate or the plan.

How might a conversation with patients and other stakeholders be managed to revise the draft plan? Clearly, we have to start with a draft and then it will be revised. To what extent does the Minister envisage the plan being amended? Might the details on board membership and business plan consultation be included in guidance to the board? One half of my amendments is about board composition; the others are about business planning. It will be interesting to hear the Minister’s response to the latter because it will give us some indication of the way that the board plans to work or it is planned that it should work.

[Lord Hunt of Kings Heath]

My Lords, I have a series of amendments in this group concerning membership of the national Commissioning Board and its cost. There is common consent that getting the board’s membership right is important.

My Amendment 52A would ensure that the chair could be appointed only with the consent of the Health Select Committee. I fully acknowledge that Professor Grant, the chair of the NCB, went before the Health Select Committee; I have already referred to the transcript. It is clear that the process ensured proper and effective scrutiny. However, I should just like to put the matter beyond doubt and make sure that the procedure will always be followed in future, and I hope that the Minister will agree to my amendment. I should say that I followed the legislation which established the Office for Budget Responsibility, so we have a precedent for ensuring that a Select Committee of the other place has an important role to play in such appointments in the future.

My Amendment 52B is simply a matter of good governance to ensure that a lay vice-chair is appointed, which I am sure I am right to assume is the Government’s intention.

On the composition of the board, my Amendments 54 and 56 are intended partly to probe and partly to make a point. It would be helpful if the Minister could give some indication of the likely make-up of the board, both executive and non-executive, and perhaps some details about how non-executives are to be appointed. My specific point is to encourage the Minister to ensure that, on the executive side, a medical director, a nursing director and a finance director are always appointed. To be frank, my main focus is in relation to a nursing director. I have no doubt that there will always be a finance director and a medical director; I want to ensure, and I want the Minister to give an absolute assurance, that there will always be a nursing director on the national Commissioning Board. I go back to 1991, when NHS trusts were first appointed. Some noble Lords here will recall that some rather foolish chairs of those trusts did not want to appoint a nurse to their board. They were forced to do so, I am glad to say, through the intervention of a Secretary of State at the time. I have no doubt that it is the intention of the Government to ensure that there is a director of nursing on the board, but I should like to make sure that it always happens.

I understand that getting a range of expertise on the non-executive side will always be difficult. As the noble Baroness, Lady Jolly, said, the risk is that Parliament will always seek to legislate for a list of backgrounds, which we know is not a practical way to ensure that a fairly small board is appointed. My amendments seek to ensure that there are at least some non-executives on the NCB who have some experience of the National Health Service. While the temptation will always be to appoint people from other sectors because of the experience that they can bring, there is something unique about the National Health Service. I think that non-executives find it helpful if, among their number, they have people who know the business and help them to challenge the executives. One of the risks of the fashion—my own Government were as guilty of it as any other—of thinking that what the health service most needs is outside business expertise is that, when it comes to issues of safety and quality, you do not have anyone on the non-executive side who can effectively challenge the executives. I urge the Government to ensure that there are non-executives on the board who have real experience of the National Health Service and how it works in order to enable a proper challenge to be put to the executive directors.

Amendments 52D and 54A are probing amendments, designed to tease out the place of public health on the national Commissioning Board. I support the comments already made by noble Lords. On my proposal that the Chief Medical Officer be a member of the board, the Minister may say that he thinks it more appropriate for the Government’s chief medical adviser to be seen purely as part of the department than to be on the national Commissioning Board. I sympathise with that point. I suspect that the answer to the question of the noble Baroness, Lady Jolly, in relation to HealthWatch is that there is always a problem if people are appointed because of their other positions. The problem is that they then have to take responsibility for the corporate decision-making of the NCB. I can therefore assure the Minister that my amendment to place the CMO on the NCB is probing, designed to enable us to hear how the public health function will be given sufficient prominence within the national Commissioning Board.

My Amendment 55 would remove the requirement for the appointment of the chief executive to be approved by the Secretary of State. I have no problem with paragraph 3(4) of Schedule 1, which provides for the first chief executive to be appointed by the Secretary of State. This is normal practice and is entirely sensible in view of the need to get the national Commissioning Board up and running. However, my question is why the Secretary of State needs those powers in relation to subsequent appointments. After all, the Minister has waxed lyrical about the need for there to be distance and for the Secretary of State no longer to intervene, so why on earth does he have to approve the appointment of a chief executive? Surely that is for the board to do. Surely it is for the Secretary of State to nominate the chairman of the board to go through the necessary parliamentary scrutiny. For the Secretary of State to actually have to approve the appointment of the chief executive is ambiguous. The department has not sorted out the real relationship between the Secretary of State and the national Commissioning Board. On the one hand, there is the desire to give the NCB as much freedom as possible; on the other hand, one knows that in these clauses there is a desire to control it. I should have thought that the fact that the Secretary of State has a veto over the chief executive appointment is an example of that. I hope that we can see that go between now and the conclusion of our proceedings on the Bill.

Health and Social Care Bill

Baroness Jolly Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I also have an amendment in this group. I say to the noble Lord, Lord Patel, that he anticipated the remarks of his noble friend Lord Walton remarkably well.

Having argued against bureaucracy in the previous group of amendments, I am now about to argue in favour of putting senates on a statutory basis. I shall explain why. First, this was a very good outcome of the listening exercise. I think that because I am concerned at the Government’s decision to abolish the strategic health authorities. It is what I call the Hagley Road issue. In 1948, the Birmingham Regional Hospital Board was established; its offices were in Hagley Road and throughout 60 years there has always been something there. It may have been a regional health authority, a regional hospital board, a strategic health authority—call it what you will—but there has always been a regional outpost of the department acting essentially as a leader, with a positive role in looking at the region as a whole, ensuring that its services were cohesive and had proper direction and that, by and large, it was self-sufficient. That is to be removed and we are going to get large SHA clusters which will cover a much larger part of the country. Although we do not know the size of the clinical commissioning groups, they will clearly cover much smaller population areas.

I believe that there is still a need for a mechanism whereby strategic leadership can be given over a region, and I see the clinical senates as being the best approach to that. Noble Lords have spent at least two days debating reconfiguration and are concerned that these difficult decisions often have intervention from the centre. Clinical commissioning groups will be too small to take on the kind of strategic leadership that is required. When you are trying to establish in a region where the super specialty and tertiary services should be and trying to come to a view about how many A&E and emergency departments you need, you require a body that can take a strategic overview. The clinical commissioning groups are too small to do that. They could, of course, possibly come together in a kind of federated meeting to try to resolve those kinds of issues, but that could prove to be very difficult. Therefore, the senates could have an important role in setting some of the parameters and giving strategic leadership to a region.

However, as the Government intend them at the moment, these will be informal groups of people who could easily be ignored by the clinical commissioning groups, by the health and well-being boards, by the deaneries and by all the organisations that have an influence on the way in which the health service is going. My amendment is designed to set out a more structured approach to ensure that clinical senates are created as bodies corporate, that they are properly accountable to the national Commissioning Board and that they have the ability to give strategic leadership and have some oversight of the work of clinical commissioning groups.

I suspect that my amendment will not find favour with the noble Earl but the point about the need for strategic leadership in a region is important. I fear that the super SHA clusters will be too large to do that and the clinical commissioning groups will be too small.

[Baroness Jolly]

My Lords, I would like to speak to Amendments 51 and 84, but before I do, I have an interest to declare. I am chair of the Specialised Healthcare Alliance, an organisation campaigning for those with rare and complex conditions. The move to commissioned services for this particular group of patients by the NHS board is really welcome. It is the first time that there will be a common standard across England under the auspices of the board. However, we are not totally clear about the composition of the senates or their roles. I am not sure that the amendment of the noble Lord, Lord Walton—who is not in his place at the moment—actually gets to the meat of this. There is concern that specialised services within senates might get lost. If a specialised senate with expertise and integration were set up, that might be useful to this group of patients, but more often than not networks are where the specialised services go to for the expertise. We welcome the commitment to ensure that networks stay as they are and possibly expand. Maybe a network could set up a task and finish group to look at the problems around specific conditions. I would be grateful if the Minister would make the role of the senates clear. Would they have a role in specialised commissioning? Similarly, I would be grateful if he would shed some light on the ways in which the board will commission specialised services in general.

--- Later in debate ---

Moved by

[Baroness Jolly]

57A: Schedule 1, page 277, line 37, at end insert—
“(1A) The Secretary of State must make provision for a procedure whereby complaints about health and social care providers in England can be brought before the Board.”

[Baroness Jolly]

My Lords, Amendment 57A is to do with reporting complaints to the NHS Commissioning Board. There are two distinct areas for complaints: complaints related to commissioning and those related to care or service delivery. In fact, they would filter through the board, clinical commissioning groups and local authorities. I include local authorities because, if we are talking about complaints about possible integrated services, we cannot decouple clinical commissioning groups from local authorities.

--- Later in debate ---

[Earl Howe]

Will my noble friend allow me to write to him on that point?

[Baroness Jolly]

I thank the noble Earl for his reply, the noble Baroness, Lady Wheeler, for her commitment to quality and the noble Lord, Lord Whitty, for the patient voice input. I beg leave to withdraw the amendment.

Amendment 57A withdrawn.

--- Later in debate ---

There seem to be a number of unanswered questions and this late in the day, in every sense, we cannot take them much further tonight. I hope, however, that the Minister can assure us that there will be an opportunity to have draft regulations and responses to all the issues that have been raised tonight in good time for the House, which has different concerns across the divide here, to consider them carefully, in order that we can take a clear view about how to close the gaps in the Bill on the basis of clear proposals expressed where necessary in the form of the draft regulations which will apparently be heading our way at some indefinite point in the future.

[Baroness Jolly]

My Lords, I think I am the last Member of the Committee to speak on the amendments in this group and I promise I will be brief.

I have two amendments in this group. One concerns a public health specialist on the clinical commissioning groups. We have been around the houses with this and my noble friend Lady Williams has spoken most eloquently on this matter so I will not emphasise the points again. My second amendment is to do with the recruitment and remuneration of lay members of clinical commissioning groups. The Committee has rehearsed the arguments that there is a lot of silence around clinical commissioning groups and their governance. This just underpins that. There is a bit of a Catch-22 with this situation because the Bill makes provision for an audit committee and a remuneration committee and also for a lay member to chair each of the two groups. Therefore, you could argue that a remuneration committee might play a part in deciding how much a lay person would be remunerated for sitting on the group. However, we do not yet have the lay person to chair the group and take the decision, so who will take the first decision about the appointment of these two lay members? They will also need remuneration; who will take that decision?

The other big issue that has been discussed by the Committee this evening is that of transparency within the governance of clinical commissioning groups. I expect the noble Earl hopes to wind up soon. When he does, I hope he will be able to give us a steer on the Government’s thinking on this.

[Baroness Armstrong of Hill Top]

Briefly, this is a very important set of amendments, which we do not have time to deal with effectively in the next 10 minutes. I understand that the Government do not want to spend more money. Indeed, the Minister said earlier that the whole idea was to cut down the amount of money spent on CCGs, relative to what was previously spent on PCTs. The problem is that there will be more CCGs than there are PCTs and there is deep anxiety over the lack of clear governance. The Government have a problem here. So far we have had clues that there is to be accountability upwards. These amendments make it clear that there must be accountability downwards, too.

As the noble Baroness, Lady Finlay, said, GP groups are different from other groups in the National Health Service. They are not used to this level of accountability or this level of governance—even at the level that the Government have already put into the Bill. Nobody outside, particularly in other aspects of the NHS, thinks that the governance in the Bill is adequate. I share the concerns that other people have expressed tonight; I share the concerns about coterminosity.

I have mentioned previously to the Minister that Durham is now a unitary county. We used to have seven PCTs in Durham and Darlington; we now have one. We will have three CCGs. I do not believe that that will be cheaper and I am not yet convinced that it will be more effective for commissioning. The Government have a lot to do to reassure people that this will be more effective and that it will be accountable. There are many GPs who are now anxious the other way around. They are anxious that if they go into CCGs, the level of accountability, governance and bureaucracy will be so great that they are saying, “We’re not sure we want to have anything to do with it”.

This is an area where I suspect the Government will say that, in all truth, this is not where they want to be. However, this is where we are and the responses that we have heard so far simply do not meet the level of anxiety and the need for accountability that everyone thinks is there.

NHS: Hinchingbrooke Hospital

Baroness Jolly Excerpts

Thursday 10th November 2011 Lords Chamber

[Earl Howe]

I will, of course, write to the noble Baroness with detailed answers to the first part of her question, which would take too long for me to answer now. I can say that this is a transfer of risk to the private sector. That is why it is a good deal. It is also a good deal in another sense, because patients will still have a hospital in Hinchingbrooke. This is a hospital that in common parlance could be described as a financial and clinical basket case. No NHS bidders were willing to take it on. When the previous Administration left office, only independent sector operators were in the frame to do so. We therefore knew at the last election that there would be an independent sector solution. I think that it is a win-win situation all round. It is good news for Hinchingbrooke patients, and I understand that under normal Freedom of Information Act rules the contract involved will be made available, subject to commercially confidential details being redacted.

[Baroness Jolly]

My Lords, will the Minister please tell the House who was consulted in making this decision and what sort of support was found among the local community and hospital staff?

[Earl Howe]

My Lords, there was extensive consultation, but the important point for my noble friend to understand is that this was a locally led process. Ministers—and, for that matter, civil servants in the department—were not involved in the decision process. The decision was made by the strategic health authority board and the recommendation then came to Ministers. However, I can tell my noble friend that support for this decision has been very widespread, not least among the medical community in the area.

Health and Social Care Bill

Baroness Jolly Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Jolly]

My Lords, given the hour, I shall be brief. I understand exactly why the noble Baroness, Lady Gibson, has tabled the amendment. I come from the south-west and my GP practice is 25 miles from where I live. The hospitals are 25 or 50 miles away. The noble Baroness and I share that sort of background. The amendment would work in the south-west, the north-west, the north-east, or even north-east Lincolnshire. We have factors of distance, sparsity and rural poverty which are often hidden in poorly measurable clusters.

Before I came here I had a view about policy and legislation being made in a bubble in the south-east and being very metropolitan-based. I had hoped that when I arrived here I would find to the contrary, but I confess that I have not. For a while I was linked with a Defra team and corresponded with a Defra Minister about rural-proofing legislation. It is fair to say that he was not hugely optimistic, but someone really needs to say, “Would it work in a rural area?”. My noble friend Lord Greaves has already started this job on the Bill and has tabled an amendment—and I fear there may be more—about district councils. They play a hugely vital part in areas of rural England that have not become unitary authorities. In one or two areas of the Bill—perhaps in a few more—there are instances where district councils need to be factored in.

Perhaps the Government should have some sort of rural policy champion—I hesitate to use the word tsar. I should be grateful if the noble Earl would give us his assurance that that will happen for this Bill.

[Baroness Thornton]

My Lords, my noble friend Lady Gibson is to be congratulated. I particularly indentify with her remarks about dispensing chemists. As she knows, I supported her on this when I was on the other side of the House, and the issue is close to my heart. She and the noble Baroness, Lady Jolly, have raised a very valid issue and I look forward to hearing the Minister’s remarks.

EU: Economy

Baroness Jolly Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Earl Howe]

My Lords, except in limited circumstances, which must be set out in their contract, primary medical service contractors—GPs, in other words—cannot directly or indirectly seek or accept from any of their patients a payment or other remuneration for any treatment. The prohibition not only relates to treatment provided under the primary medical services contract but extends to any treatment that may be provided to the patient.

[Baroness Jolly]

My Lords, we all agree that the NHS logo must be one of the most trusted brands in the UK. It is currently outside diagnostic and treatment centres which are privately run, so can the noble Earl tell the House whether the Government will issue guidance to any qualified private providers about the use of the logo?

Health and Social Care Bill

Baroness Jolly Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Jolly]

My Lords, I am hugely grateful for the position where we now find ourselves. I am in total agreement with the previous speakers that we need to move this issue on, take back Clauses 1 and 4, use the same sort of language, and bring the matter back on Report. I should like to put on record how I am totally in awe of the work of my noble friend Lady Williams in this regard. We have also been hugely helped by the clear thinking of the noble Lord, Lord Marks of Henley-on-Thames.

While I am thanking people, I should also like to say how much I welcomed the approach of the noble and learned Lord, Lord Mackay of Clashfern. We should recognise the amount of work he put into his amendment. It was useful to take a fresh approach to what was becoming a thorny problem and bring to the House new language to look at, because, for reasons that we have already rehearsed, we were not too happy with the proposals. One of the matters that I should like the Minister to take back with him—here I borrow some language from the noble Lord, Lord Hennessy, which I think he used at Second Reading—is consideration of whether we can maintain the DNA of the Bill when producing the new work that will come before us on Report.

From these Benches, I repeat that we need a reworked clause with completely unambiguous language that will reflect the duties of the Secretary of State for the 21st century and the new NHS that we are trying to forge.

[Baroness Andrews]

My Lords, I think I can add the support of these Benches to the extraordinary way in which this matter has been resolved. It is a great tribute to my noble friend Lady Thornton, who has led so many of the debates across this House, during which many aspirations have been drawn out, problems identified and voices collected. The Minister responded clearly to what the noble Baroness, Lady Williams, expressed so well: the peculiar trust and confidence that is held in the National Health Service in this country and how careful we must be in our processes to honour that expectation and trust, so that clarity on the legal responsibilities and the future of the NHS is absolutely secure.