Health and Care Bill

Baroness Thornton Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I support my noble friend’s proposal for this simple reason: it would enable focus on the very particular needs of women’s reproductive health. As we heard earlier in our debate, children have specific needs. Well, so do women, particularly with reference to their reproductive cycle.

I am particularly keen on the element of prevention of ill health. Many services for women focus on it. Obviously, we all have cause to be grateful for the breast and cervical screening services that are available; I was professionally involved with them many years ago. It is also, however, cause for concern that the number of women taking advantage of those important preventive services has been falling. A national lead would have the expertise, responsibility and ability to focus on areas where women need to be encouraged to take advantage of the services that are available to them.

There must be concern about the quality of maternity and perinatal services, given some of the dreadful cases that we have heard about and the poor quality that has been rife in a few centres in the country in the past. I hope that things are being put in place to improve that, but there is an element of prevention here too. Good-quality maternity services prevent women and their babies having a bad experience at the beginning of their life together. It is so important for the ongoing mental and physical health of the child that women can bond with their children and babies can bond with their mothers. That bonding starts at the very beginning, but it is less likely to happen with poor-quality maternity services, which of course cost the health services and the country later on.

These services are vital for preventing further problems not just for the mother but for the children. It is the sort of thing that a highly qualified and knowledgeable national lead can focus and advise on in trying to ensure that access to good-quality services is available to all communities in the country. My noble friend Lady Barker highlighted the difficulties that some communities face in getting those good services. I hope that the Minister will consider this amendment in a positive light.

[Baroness Thornton (Lab)]

My Lords, first, I thank the noble Baroness, Lady Barker, for introducing this amendment. Yet again, it is an indication that if this Bill actually presents the opportunities that the Government tell us it does, they need to accept something that recognises the opportunities that are being suggested to them across a whole range of issues, including children, about whom we have just had a very good debate.

The amendment would require NHS England to appoint a national clinical director for women’s reproductive health to provide the kind of clinical leadership that the noble Baroness, Lady Walmsley, talked about and to support this important area of women’s reproductive healthcare. In recent years, the Government have issued policy papers about women and health, so I would have thought that this particular proposal would chime with that.

We know that almost half of British women will experience poor sexual and reproductive care. It is clear that we can take the opportunity to improve this situation, particularly on the postcode lottery that some women face. I can certainly see, as the two noble Baronesses have said, that a single clinical director for the whole of the UK would give the area energy and focus, particularly for the 50% of women who have not had a good experience. We agree with the Faculty of Sexual and Reproductive Healthcare, which supports this amendment. I am glad of the opportunity to speak on this important issue, and I hope that the Minister may have some good news for us.

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[Baroness Bennett of Manor Castle (GP)]

My Lords, I declare my position as a vice-president of the LGA and the NALC. I will speak particularly to Amendment 23 in the name of the noble Baroness, Lady Thornton, to which I have attached my name; it is unfortunate that we have not heard from her yet. It is about consultation with local authorities, which is what so much of our debate on this group thus far has already addressed. I particularly associate myself with the comments of the noble Lords, Lord Hunt and Lord Davies. A great rearrangement of the NHS has happened entirely under the radar, and it is deeply disturbing to those of us concerned about the risk of the Americanisation of our NHS and its takeover by private US healthcare for-profit companies.

I am slightly surprised that no one has yet mentioned the report in the Times this morning about the Health Secretary seeking to model NHS hospitals on academy schools, which has been seen as a large privatisation of our education system. Also, we found out only recently and entirely by accident that the Chancellor was giving days of his time to visit US healthcare companies in California. When you look at those facts, the runes seem very disturbing. To defend against the incidents that the noble Lord, Lord Davies, referred to, and the restructuring by stealth, we need local authority involvement. That is what Amendment 23 seeks to ensure, at least in part.

I also want to comment briefly on another amendment in the name of the noble Baroness, Lady Thornton, Amendment 44, which is about protecting the collective arrangements for pay and conditions for staff. We have to look at it in the context of the survey this week that showed one in four doctors saying that they were exhausted to the point of being impaired in their work. We have an exhausted, utterly worn-down workforce, and we have nurses who are not paid enough and end up going into food banks to feed their families.

It is obviously a matter of justice that we at least protect, and in fact improve, the pay and conditions of healthcare workers. But more than that, it is very much an issue of health as well, because workers who are overworked and underpaid are simply unable to deliver the quality of care that we would hope to provide.

I very much hope that this group of amendments will get some attention, because this has all happened under the radar. There has been no public discussion of this and that desperately needs to happen, so once again it seems to fall to your Lordships’ House to try to get this on the agenda.

[Baroness Thornton (Lab)]

My Lords, I will speak to the amendments to Clause 14, which is a very important clause. There is absolutely no doubt about that, and the Minister can be in no doubt that that is exactly how we see it. It was touch and go whether we would have a clause stand part debate on this, and I am not sure that we were right not to do so, because this debate, particularly my noble friend Lord Hunt’s comments, has highlighted some serious problems.

My noble friend Lady Pitkeathley is quite right that the arrangements that we are seeking to put into statute, which have grown up over the last few years to allow areas to collaborate, were the right thing to do. In my area of the world, I have no doubt that it was important that the boroughs collaborated together, particularly in their relationship with and commissioning of services from the very big providers.

The question in Clause 14 is: what is going on with the arrangements that the Government are putting into statute? I am very pleased to follow the noble Baroness, Lady Walmsley, and to speak to Amendments 23 and 44 in my name. Amendment 23 addresses the vexed issue of boundaries for an ICB. In this Bill we are dealing with geography, whereas the 2012 Act dealt with GP lists. The area of an ICB is defined in terms of tier 1 local authorities.

Concerns have been expressed, because the NHS is often a bit clueless and sometimes very defensive about local government, its boundaries and its powers. Maybe the Minister will tell me I am wrong, but I suspect that one of the reasons why elected members have been precluded from the boards is that the NHS does not feel comfortable with the direct democratic accountability at that level. That is a great shame. I think it is wrong; accountability is extremely important.

How can we have an integrated service when social care is provided by local government, which is democratically accountable, and we want to integrate that with the NHS at a local level in an area to provide the best service that we can for that population and those patients? The almost offensive way of constructing a board that does not allow elected representatives is not acceptable.

My quite modest amendment seeks to change that situation for the future. There were exchanges in the Commons about this, and there have been meetings with disgruntled authorities that seem to have ended without agreement. We may need to take a step back and learn some of the lessons, perhaps from Scotland and Wales where more logical boundaries have been applied for their health boards.

We may learn a bit more about plans for integrated commissioning at this level when we get the promised but overdue White Paper on integration. It is possible that it will set up a third set of geographies, and who knows how that will line up? This seems to be the wrong way around. Our amendments at least elevate the need to consult with local authorities over boundaries to start off with. That is perhaps a pious hope, but we can agree that any future changes can be made only if the local authorities agree.

Amendment 159 arises out of lengthy discussions elsewhere. In the twin-striker model for ICS, we have the ICBs and the ICPs. We know almost nothing about ICPs; all that is said is that it is part of the “flexibility” and so should be valued. Referring back to my previous remarks, I just hope that local authorities will be genuinely involved in the ongoing discussions about ICPs, how they are set up and their governance. What we do know is that the ICPs will own the analysis of needs and the strategy that follows from that. What, therefore, is the role of local health and well-being boards?

There are echoes of 2012 here, as, during the consideration of the 2012 Bill, amendments were advanced on the same issue. In the 2012 version, it was the health and well-being boards that did the strategy and the CCGs that did the commissioning, at least of health. Nobody ever properly addressed how social care would be commissioned in any integrated way in a wider strategy. It was proposed in 2012 that the health and well-being boards had to approve the plans of the CCGs, and that was the glue that would hold the whole thing together. We know that that has not worked. It has sometimes worked on paper, but it is not the thing that has driven the work of the CCGs.

The answer so far for 2022 is that everyone will play nicely and it will all be resolved. I do not think that can possibly be the case when there is such a serious imbalance. Our Amendment 159 acknowledges that there just might be a dispute over whether some decision or plan of an ICB was genuinely aligned to the strategy that it was supposed to be following, so a process for resolution is needed.

I am not sure whether Amendment 44 sits easily in this group, but it is a matter on which assurance is needed. When foundation trusts came into being, they were rather bravely given the power to set their own terms and conditions for staff. One of them might have tried it, and it was not a great success. In general, despite whatever powers exist, almost every part of the NHS follows the Agenda for Change, the collective agreement that took 10 years to agree but which has stood the tests of time.

Now, as with CCGs, we have the power of ICBs to set their own terms and conditions. They are probably unlikely to do so, as it takes an enormous amount of work and the risks that it brings are probably not worth the effort. Without doubt, some staff are worried that they just might be the ones picked on for special treatment. The Minister will no doubt say that the ICBs need the flexibility, but surely, given the pandemic and everything else that faces the NHS, it would be much better to give staff certainty and confidence they will be treated properly.

We agree with the sentiments of Amendments 22 and 24, which try to ensure that agreement on ICB constitutions will be done promptly. We agree with the sentiments of Amendment 53, which echoes a previous amendment about the need to drive improvement. In my noble friend’s Amendment 45, he asks a legitimate question, which I think the Minister will need to answer.

[Lord Kamall (Con)]

Once again, I thank all noble Lords for bringing this debate before the Committee today. There have been a wide range of views on the establishment of the ICSs and on what is currently going on in the NHS.

I will start with Amendments 22 and 24 from the noble Baroness, Lady Walmsley, which were supported very strongly by the noble Lord, Lord Hunt of King’s Heath, and on the ICBs’ establishment. I am grateful to the noble Baroness, Lady Walmsley, for bringing the amendments, and I understand her concerns about ensuring that ICBs are established in a timely way. We agree. We have had an interesting debate here. A number of people have said that it is really important, given that ICSs have already been established, that you put it on a statutory footing, but we are also being asked how they dare to go ahead and do this, because the legislation is not there yet.

In recognition of the fact that ICSs have been set up in some areas and are being established, we are trying to get the right balance. That is why work is under way to prepare existing organisations, including CCGs, for the transition once the Bill comes into force.

The noble Lord, Lord Hunt of Kings Heath, rightly asked whether NHS England is pre-empting Parliament. He raises an important point but I assure him that the powers necessary for establishing each ICB and publishing any statutory guidance cannot be made until the Bill has been enacted and the relevant provisions commenced. However, to ensure that ICBs are ready to begin work, NHS England is producing a range of draft guidance, including a model constitution, so that system partners can start work on preparations—but this does not have the power of statutory guidance. The guidance and the model constitution are based on the proposed requirements—

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I hope that we can have further conversations. I will go back to my right honourable friend the Secretary of State for Health to raise the issue about NHS England effectively saying that local councils should not be on these bodies, as well as the other concerns raised about the health and well-being board. With that in mind and further conversations, I hope that noble Lords will feel able not to press their amendments.

[Baroness Thornton (Lab)]

Before the noble Baroness, Lady Walmsley, decides what she wishes to do with this amendment, I say to the Minister that this is very important; I cannot stress this enough. The noble Lord, Lord Lansley, and I are in agreement again about this. At the next stage of the Bill, the Government could find themselves in very serious trouble indeed if we do not resolve it between now and then.

[Baroness Walmsley (LD)]

My Lords, I appear to have opened a can of worms. I very much welcome the Minister’s commitment to go back to his boss and talk about some of the serious issues raised by noble Lords.

My purpose in introducing Amendments 22 and 24 was simply to ensure that once the Bill has passed through all its stages in Parliament and an implementation date has been reasonably proposed, from that point onwards there is reasonable coherence across the country so that there are no gaps in the proper commissioning of services and everybody gets on with it in a reasonably timely way.

However, noble Lords will remember that both at Second Reading and when I introduced this group of amendments I expressed my view that it is too soon, for a number of reasons—first of all, the state of the NHS. Also, as has been pointed out by me and other noble Lords, the Bill has not gone through Parliament yet. Last week noble Lords proposed a number of amendments about who should be on the ICB and what skill sets, knowledge and experience should be represented on it. It has become quite clear that, should this House decide to press those amendments, the shadow boards may have to look again at who they have appointed, because Parliament will have said that perhaps they need to appoint some more appropriate people to carry out the objectives that the Government have rightly laid down for them. It became clear to me that the three months I had suggested might not be quite enough, because of the consultation. It would not be the first time that noble Lords had laid amendments that were to some extent faulty but had stimulated an important discussion among other noble Lords.

I very much appreciate the Minister’s commitment to going back. I hope that, when he has those conversations, he remembers that noble Lords in this House are very supportive of the objectives of allowing local authorities to play their appropriate part in the establishment and running of these new boards, and allowing health and care people to work collaboratively in the interests of patients.

I want to say a brief word about Amendment 53. The Minister gave me several reassurances about where, in other parts of the Bill, there really is a duty to improve. I am afraid that he succeeded only in convincing me that changing “may” to “must” in the place I suggested in the Bill is totally consistent with what he says exists in other places, so I may come back to that at later stages.

Noble Lords will have their say about who should be on these ICBs. Things may have to change and appropriate time may need to be allowed for the now-appointed chairs of all the ICBs to make some corrective measures regarding who they have on their boards. I will leave all those thoughts with the Minister. For the moment, I would like to withdraw my amendment.

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I urge the Government to think again about this. They may want to push on and have it accepted with a fait accompli but, in the end, it is their decision in Parliament as to how these bodies operate. Unless we do this, it is pretty clear that we will be coming back within the next year or two with another NHS restructuring Bill. We have already heard about the ludicrous decision to keep health and well-being boards at the same time as having ICBs. We all know that, looking at it, this structure will not keep. It would be better if the Government started to sort it out now. I beg to move.

[Baroness Thornton (Lab)]

My Lords, I rise only to say that I agree with my noble friend Lord Hunt. I will speak very briefly to Amendment 24 in the name of my noble friend Lady Merron, which would ensure the involvement of the integrated care board and the integrated care partnership in the appointment of the ICB chief executive. That seems to me to be sensible.

[Baroness Walmsley (LD)]

My Lords, I support that. I am glad that the noble Baroness, Lady Thornton, introduced Amendment 34. According to the Bill as it stands, the chief executive of the ICB could be appointed only by the chair—of course with the approval of NHS England. Like many of your Lordships, I have been on a board, including being the chair of a board, and as such, I always thought it good practice to appoint my chief executive with the help and approval of my board members. As an ordinary member of a board, I cannot imagine how I would have managed the relationship with a chief executive officer who had been appointed over my head only by the chair without any consultation with me or other members. If we want to encourage collaboration, that is not the way to do it at board level.

It is inconceivable that the mechanism would work in practice in such a situation. Indeed, it is vital that all the senior people who steer the ICS, the members of the ICB, and indeed the chair and members of the ICP, must have confidence in the chief executive; the word “confidence” was so appropriately used by the noble Lord, Lord Hunt of Kings Heath. How could that be if they had no involvement whatever in the appointment? It is a simple matter of good practice and I shall be very interested to hear what the Minister can possibly find to say against it.