Health and Care Bill

Baroness Penn Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, the noble Lord, Lord Lansley, has once again put his finger on an issue that the Government need to take seriously and which, as the noble Lord, Lord Scriven, said, has run through our debates at Second Reading and in Committee. What is the role of the ICPs’ joint working and what should a place board be doing? As I said during the previous day’s debate on Report, we need also to treat place boards—or any commissioning body—in the same way as we do the ICBs.

The noble Lord, Lord Lansley, is right. If the Government do not address this issue in the next few weeks by putting something in the Bill, we may well find ourselves back here in two or three years’ time, doing exactly what we are doing now.

[Baroness Penn (Con)]

My Lords, this has been an important discussion about place and joint working, and although the Government are unable to accept my noble friend’s amendments, for reasons I shall touch on, I hope I can reassure him that the questions which he and other noble Lords have raised have been considered in the Bill.

England is so large and diverse that a one-size-fits-all approach will not be right for everyone, and that is why we have been flexible about the requirements for integrated care partnerships and joint working arrangements. We fundamentally believe that, if integration is to work, we must allow local areas to find the right approach for them.

As my noble friend will appreciate, our provisions on integrated care partnerships build upon existing legislation, particularly in the case of health and well-being boards. We know that health and well-being boards have played an incredibly important role in the last decade, and this legislation intends to build on their success. We will be refreshing the guidance for health and well-being boards in the light of the changes that this Bill proposes, in order to help them understand the possibilities of these arrangements and their relationships with ICBs and ICPs, so that they can find the most appropriate model for their area.

Fortunately, this Bill and existing legislation already provide the framework to do what these amendments intend to achieve. Two or more health and well-being boards can already jointly exercise their functions, and where the local authority area and ICB area are the same, there is no reason why the health and well-being board and the ICP cannot have the same membership. The ICP is intended as an equal partnership between the local authorities and the ICB. By restricting the right of the local authority to nominate a member who they see fit and requiring them to do so through a committee with a potentially wide membership, including the ICB, risks undermining that equality. Local authorities may ask their health and well-being board to nominate those members. However, we do not wish to restrict their options and unintentionally prevent better collaboration and integration by adding further requirements to the Bill.

I turn to the joint working arrangements. The Bill also provides for the ability to establish place-based committees of ICBs and to set them out clearly in their constitutions. I assure my noble friend on this point that the legislation allows the flexibility to establish these committees, so we should not find ourselves in the situation that he talks about. ICBs will be able to enter arrangements under new Section 65Z5, which allows an ICB to delegate or exercise its functions jointly with other ICBs, NHS England, NHS trusts, foundation trusts and local authorities, or any other body prescribed by regulations. Under these powers, a committee of an ICB could be created to look at population health improvement at place level and could consider entering an arrangement under Section 65Z5 to work jointly where appropriate.

The membership of that committee can be decided locally by the ICB, and it is entirely open to the ICB to seek views from other organisations as to who best to appoint. I hope that reassures my noble friend that there is already the legal framework for ICBs to look at population health improvement at a place level. We are trying to protect the ability of ICBs to determine the structures that work best for them. To help them to do that, NHS England has the power to issue guidance to ICBs on the discharge of their functions. The flexibility that we have set out in the Bill makes my noble friend’s intentions possible. However, our provisions also give a degree of flexibility, so that areas can take control, innovate, and adopt what works best for them, rather having to meet prescriptive top-down requirements.

It is for these reasons that I hope that my noble friend feels able to withdraw his Amendment 61 and not move his Amendments 95 and 96 when they are reached.

[Lord Lansley (Con)]

My Lords, I am most grateful to noble Lords for their support, and to my noble friend for responding. I have a couple of important things to say.

First, I was not suggesting these things. I was suggesting that the legislation should reflect what the Government’s intentions are, because the integration White Paper set them out. Secondly, my noble friend said very carefully that the health and well-being boards and integrated care partnerships can have the same membership, but that is not the same as them being the same organisation. I am looking for my noble friend to say, without fear of contradiction, that where they choose locally to do so—and I am perfectly happy for there to be flexibility—local authorities and the ICBs can create an integrated care partnership which serves the functions of the health and well-being boards and the integrated care partnership in one organisation. That is the question.

On Amendments 95 and 96, I take the Minister’s point. I looked at it and thought, yes, there’s no difficulty about the place boards being a committee of the integrated care boards, but the Government in their White Paper said that there should be a single person accountable for shared outcomes in each place. That place board would have functions delegated to it from the integrated care board and local authorities. For that to happen, I cannot understand why it is not necessary for that to be reflected in Clause 62, since the existing legislation makes no reference to place boards. Also, if the person who is accountable is the chief executive of the place board, we must assume that that will not necessarily be the chief executive of the integrated care board, yet as things stand in the legislation, the chief executive of the integrated care board will be the single accountable officer. How is the accountable officer to be the chief executive of the place board?

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[Lord Farmer (Con)]

But I did not withdraw it. I was waiting for the response; nor did I have a chance to say whether or not I would divide the House.

[Baroness Penn (Con)]

The noble Lord is correct that he can speak to Amendment 64 and, in doing so, move it, but he should then choose to withdraw it or test the opinion of the House.

[Lord Farmer (Con)]

I thank the noble Baroness, Lady Tyler, and other noble Lords, for their support, and I thank the Ministers for helping on the direction of travel for family hubs, and for family hubs being included in statutory guidance for integrated care services and bespoke guidance specifically covering family help. However, we are talking about the bronze medal position. Gold medal is primary legislation, silver is secondary, and statutory guidance is bronze, although at least we are on the podium. As the Minister said, this is ongoing. They are awaiting the review of children’s local care evaluations from 75 local authorities. I will be with them on the journey. That is all that I can say, as it is ongoing.

Amendment 75 still presents a possible risk of imposing an additional burden on local authorities in their delivery of local services. Given that I have mirrored what the Children Act 1989 says regarding now defunct family centres, the Government should really consider amending this themselves if it inappropriately burdens local authorities. In any event, I welcome the Government’s movement. I beg to withdraw my amendment.

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[Baroness Penn (Con)]

My Lords, I thank my noble friend for raising this issue. I hope in the spirit of collaboration and compromise I am able to provide him with some further clarity and reassurance, even if I am not able to support his amendments.

Flourishing systems are critical to the success of integration and many of the proposals in the Bill. In that context it is right that the Secretary of State, who is accountable to Parliament, can set the overall strategic direction of reviews of integrated care systems through setting objectives and priorities for the CQC in relation to those assessments. However, it will be the CQC as the independent regulator and expert which will develop and carry out those reviews.

In Committee, noble Lords across this House raised several matters that these reviews should or could look at—from children to rare conditions—and it is right that the Secretary of State should be able to set objectives to explain the intent that lies behind high-level priorities such as leadership, integration quality and safety. These objectives will aid the CQC in its development of the review methodology and quality indicators and lay out where specific focuses should be given. The current clause allows the Secretary of State to make these distinctions and be more nuanced, just as is permitted for CQC reviews of local authority functions relating to adult social care set out in Clause 152. To remove the Secretary of State’s ability to set objectives is to remove nuance, which in turn could dilute the focus of these reviews on particular patient pathways or integration arrangements.

Furthermore, the Secretary of State must be able to ensure that the CQC’s role is complementary to other assessments, such as NHS England’s oversight of ICBs. This is achieved in part through the Secretary of State’s role in approving and directing to revise the indicators of quality, methods and approach. Removing the Secretary of State’s ability to direct the CQC to revise indicators risks the Secretary of State being locked in after approving the methodology. This could prevent the Government being able to respond to shifting developments in health and care, thus undermining the review’s relevance as time progresses.

I further reassure my noble friend and other noble Lords that we expect the power to direct to revise to be used infrequently, so as not to disrupt CQC reviews. The Government fully respect the independence of the CQC, and these powers are designed to ensure that its reviews of the integrated care systems are effective without undermining that independence.

It is for these reasons that I hope my noble friend feels able to withdraw his amendment and not move his further amendments when they are reached.

[Lord Lansley (Con)]

I am most grateful to my noble friend and for the support of noble Lords for the concept. I hope the CQC will find that this assists it in ensuring that it remains independent in how it goes about its job, and, indeed, how it derives indicators of quality and fitness for purpose. I take my noble friend’s point about what objectives might be. They might be, for example, objectives of the nature of the service that the review should cover so the Government might have some national priorities. I think the word “priorities” would have been sufficient.

I confess to my noble friend that I did not understand why the Secretary of State might come in and direct the CQC to change its indicators. It would have been perfectly reasonable for the Secretary of State to have waited and seen what the CQC said. The CQC will clearly change its indicators from time to time as technologies and services adapt, and it could have been trusted to do it. I will not press the point and I beg leave to withdraw Amendment 69.

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Moved by

[Baroness Penn]

76: Schedule 4, page 173, line 29, at end insert—
“Armed Forces Act 2006
82A_(1) Section 343AA of the Armed Forces Act 2006 (due regard to principles: England)(as inserted by section 8(3) of the Armed Forces Act 2021) is amended as follows.(2) In subsection (3), for paragraph (h) substitute—“(h) an integrated care board;”.(3) In subsection (8)—(a) omit the definition of “clinical commissioning group”;(b) at the appropriate place insert—““integrated care board” means a body established under section 14Z25 of the National Health Service Act 2006;”.”Member’s explanatory statement
This amendment is consequential on Clause 14 of the Bill, which establishes integrated care boards.

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Moved by

[Baroness Penn]

78: Clause 29, page 39, line 34, leave out “also”
Member’s explanatory statement
This amendment is consequential on the insertion into section 13U of the NHS Act 2006, by another amendment, of a duty for NHS England to include additional matters in its annual report.