Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
“(c) is to continue as regulator of NHS Foundation Trusts as set out in Chapter 5 of Part 2 of the National Health Service Act 2006”
Baroness Thornton
My Lords, at last we move to Part 3. I hope the House will tolerate a longer speech from me than I normally make. I have made just a series of very short speeches so far on the Bill. There are many amendments in this part in my name and that of my noble friend Lord Beecham. I would like to take this opportunity to explain the rationale behind the suite of amendments that we have put before the Committee today. I thought the Committee might prefer one longish speech rather than 10 short ones, which will almost certainly save time.
Our amendments are largely in this group, which addresses the role and powers of Monitor, and the next two groups, which address Monitor as a licensing body and its accountability. Later today, in groups eight and nine, there are the issues of pricing and the failure regime.
On these Benches, we decided some time ago that this was the heart of the Bill. Over all the debates we have had in the last 11 days, it has become abundantly clear that the reason we have this mammoth Bill, bringing about the expensive and risky reorganisation of our NHS, is to create a regulated market in the NHS. On these Benches, we have always believed that fundamentally, this Bill was conceived and constructed, around Part 3. Even after the pause for reflection and the report from the Future Forum, that remains the case.
Version 1 of the Bill was at least honest in being the embodiment of what Andrew Lansley had promised to do to our NHS back in 2005. He is at one with his colleagues Oliver Letwin and George Osborne. Mr Lansley wants markets and is against a communally owned and publicly run public sector. Like his Conservative colleagues, he believes that competition solves every problem and is a cure-all. Indeed, Mr Lansley’s background in establishing regulated utilities in his five-year preparation as the shadow Health Secretary makes it clear that he wants to treat our healthcare just the same as gas, water and electricity. That was version 1.
That finally collapsed when people including the Liberal Democrats actually read and understood the White Paper and the Bill. I will not trouble your Lordships’ House by picking over the corpses of versions 2 and 3 of the Bill, but we now have version 4, and I suspect that we are still far from finished. This Bill is a mess. It is now a catalogue of compromises, except, it has to be said, the framework that we have on offer in Part 3, which would, over time, allow Mr Lansley’s vision to be fulfilled. He must be hanging on to that for dear life.
We believe that Monitor is being asked to fulfil too many functions and set too many priorities, and that some of these are potentially, if not actually, in conflict with each other. We hope the House will appreciate that, on these Benches, we have done the House a big favour. We have rewritten Part 3 to make it simpler and more coherent. We have taken out the nonsense parts, such as the voting system in Clauses 116 to 121, which as it were bring the X Factor system into the NHS. Why not have phone-in votes for CCG chairs, for example?
We have taken out the convoluted and bureaucratic ideas around levies and risk pooling. After all, that is part of what the NHS is for—to pool the risks. Our advice is to keep it simple. We believe that the attempt to define the rules-based system for the NHS was always doomed. The idea that, like a true regulated market, we can set out the rules in primary legislation and contracts and then let the courts decide everything is just plain daft—unless you are a lawyer, of course. They must be salivating at the business coming their way if this Bill becomes an Act in its current form. Does the presence of excessive legality and constant contracting sound familiar? It should, because essentially that is what happens in the United States healthcare system.
We have, like Monitor, suggested that instead, the principles and rules for co-operation and competition—PRCC—that we put in place when we were in government should be left as the basis for the system. We also suggest that the Co-operation and Competition Panel should retain its role of advising on complaints about any breaches of the rules, which was at one time the Government’s position, and it may still be. For us, a defining characteristic is that the pinnacle of such a system is that there is a Secretary of State who sets the framework through the PRCC.
I would like to dispel the myth that Labour is against reform. In 1997, we came in to rescue the NHS after many years of neglect. On everything worth measuring, the NHS of 2010 was far, far better than in 1997. It is only in 2011 that we have seen it start to go backwards again, as waiting times get longer and access is restricted. Our track record on reform is there. Clearly, we did not get everything right, but we learnt. The current Administration have launched the biggest reorganisation of the NHS in its history, despite the promises that they would not and despite all the evidence that reorganisations set the NHS back two to three years, and despite the costs and risks involved—except, of course, that we are not allowed to know exactly what those risks are.
Labour introduced independent regulation of quality to the NHS. We support the continued role for Monitor with regard to foundation trusts, which we put in place. We accept the idea of extending tough financial regulation over all providers in the NHS through the use of a licensing scheme. But we do not accept the handing over of economic regulation of the NHS to a quango. We wish Monitor to retain its powers to oversee foundation trusts, and, like Sir David Nicholson, we see the value in retaining the possibility of de-authorisation of a foundation trust into a safe haven to permit restructuring and reconfiguration. But more on FTs later.
We have never been against the idea of competition. Indeed, we set out the principles and rules basis on which it could operate. We have never been against using the private sector where this adds necessary capacity or provides expertise not available within the NHS. Our experience, good as well as bad, informs our response to the Bill.
There is a place for competition. It is not, and never should be, the main driving force for reform of the NHS. We are against the promotion of competition for its own sake, as this Bill originally intended. We believe the balance between co-operation and competition is a matter for the Secretary of State to determine, in the best interests of patients, not for a quango to determine in the interests of some ideological bias.
Further along in the consideration of our amendments, we set out the process by which major reconfigurations could be proposed, consulted on and determined. We set out for the first time the idea of a rules-based failure regime. We do not see failure as a desirable feature of a market system; we see it as a failure of planning and commissioning and as something to avoid, not welcome. But if all early intervention efforts are insufficient, then an orderly rules-based administration process is necessary, so we set one out.
In all these areas, we do not oppose development of the NHS or reform. We simply fundamentally disagree with the approach being used by this Administration, which is highly disruptive and expensive and takes focus away from the Nicholson challenge. Along with the Liberal Democrats of old, we oppose the change to a regulated market at the expense of democratic control. These are the wrong reforms at the wrong time and, we add, for the wrong reason. Healthcare is not another utility to be regulated and privatised. Our NHS has as its foundation the twin principles of universality and social solidarity. It is not a candidate for conversion into a fully fledged market. We introduced regulation to give the public some independent reassurance. We introduced external assessments of quality in the NHS. The role of the quality regulator, the CQC, is unchanged by the Bill. We support the CQC, but only if it is properly resourced. We set up NICE, which is acknowledged as a world leader in its field. We set up Monitor and we think it is too early to evaluate its success, as the move to an all-FT system has taken far longer than envisaged and proved more complicated than was assumed—a lesson not yet learnt by this Government.
The job is really only half done. What we do know is that there is no miracle transformation tool. The evidence is that foundation trusts do not progress any faster than non-foundation trusts. There is little, if any, evidence that foundation trusts are more innovative, more risk-taking or more competitive than their non-FT colleagues. It is a mix.
Earl Howe
My Lords, I thank all noble Lords who have contributed to what has been a first-class debate. While I will not repeat what I said earlier, the value of this summing up will be in me responding to some of the specific questions and points that have been raised by noble Lords.
The debate has demonstrated broad agreement, if I am not putting words into noble Lords’ mouths—no doubt they will tell me if I am—that competition, when used appropriately, has an important role to play in realising what we all want to see in the NHS. It should be a means of improving the quality of care and productivity in the health service, and of improving patient choice, including choice of treatment. I would like to believe, from what noble Lords have said, that there is no disagreement about that as a general principle. It is consistent with the policies of the previous Government, reflected in published statements on behalf of all the main political parties over the years.
A further area of potential consensus appears to be on the merits of sector-specific regulation that is applicable to both commissioners and providers, with the starting point being the existing principles and rules for co-operation and competition in the NHS, as the noble Baroness, Lady Thornton, made clear.
Speeches from several noble Lords demonstrated the concern that competition law should never be applied to the NHS. The noble Lord, Lord Owen, in particular, expressed that view very forcibly. However, that is not in the gift of the Bill. The Bill provides for Monitor to consider cases of potential breaches of the Competition Act 1998, to undertake market studies and to determine where and when matters should be referred to the Competition Commission for investigation under the Enterprise Act 2002. Establishing concurrent powers for Monitor would not extend the scope of competition law or its applicability to the NHS.
Baroness Thornton
If that is the case, why do 20 clauses in this part of the Bill refer explicitly to the Competition Commission and the panoply of competition law? Should they not be there?
Earl Howe
They are there because this is the first time that any Government have attempted to bring together under one umbrella the disparate parts of our existing system for regulating and controlling competition. As I said earlier, we have that system in skeletal form, but there are lots of gaps and inconsistencies. By bringing them under one umbrella, as this Bill does—I am afraid that it inevitably occupies a goodly number of clauses—we will have a coherent system of regulation for the future.
Establishing concurrent powers for Monitor would not extend the scope of competition law or its applicability to the NHS; that is an important point for noble Lords to appreciate. Why have a sector-specific regulator? For me, the reason is that, instead of such matters being reserved for the Office of Fair Trading, Monitor will be able to lead on these issues in its capacity as a regulator with statutory duties to protect and promote patients’ interests and to enable integration, and as a body with much greater knowledge and expertise of healthcare compared with the Office of Fair Trading. That would include, for example, where arrangements such as clinical networks, which may restrict competition, deliver overriding benefits to patients. Just because there is no competition, that does not mean that the behaviour in question is anti-competitive.
That view was forcibly brought out by the NHS Future Forum. As I have said, competition is just one of the tools available to the commissioner in securing access and improving services, and it will be the commissioner, not Monitor, who will decide where and how to use it. That is not new. The use of competition—for example, through competitive tendering—is already well established in the NHS. A range of providers—NHS, voluntary, and independent—are contributing to improving services for patients.
Of course I understand the passion with which the noble Lord, Lord Owen, spoke; my concern is that his amendments would remove from the Bill a protection for patients in relation to the actions of commissioners. That is very important; if the noble Lord’s amendments were accepted we would have commissioners taking decisions that were not overseen or checked in any way, which would be very dangerous. It would also be a backwards step from the existing principles and rules that apply to primary care trusts and that were introduced by the previous Government. The noble Lord, Lord Owen, said very interestingly that according to his research the French railway system is not subject to EU competition law. I defer to his knowledge of French railway legislation but, as is made clear in the OFT’s recent guidance, the issue of whether competition law applies requires an analysis of the activity in question. To insert a clause into the Bill just to say that EU competition law shall not apply to the NHS would not achieve that aim. EU competition law is a fact, so we have to ensure that the system that we put in place protects patients against breaches of the law and that when breaches do occur they are remedied effectively.
Earl Howe
My Lords, the noble Lord, not for the first time, is ahead of me. It is no accident that we have a group of amendments that deals with potential conflicts and how these are to be resolved. It might be better, if the noble Lord agrees, to wait an hour or two until we reach those amendments.
My noble friend Lord Newton indicated from his own personal experience that mergers, when they occur, are far too bureaucratic. I fully agree with him. The Department of Health, the Co-operation Competition Panel and, if it involves a foundation trust, Monitor, all currently play a role and may have conflicting views which lead to uncertainty and delay. Our proposals would create a simpler and much more streamlined process for the NHS.
My noble friend indicated his strong view that safety and quality—not competition—should be paramount. I am sure it will not have escaped his notice that improving quality is what these reforms are meant to be about. We have been clear that patients’ interests, especially their safety and the quality of the services they receive, have to be paramount. That is why Monitor’s overriding purpose is to protect and promote patients’ interests. It is why the board will have a duty to improve quality, why the CQC will underpin quality; and why competition will be used only as a means to improve quality. Where there are better ways to improve quality—and there may be—they will be used instead.
My noble friend Lord Clement-Jones, in his extremely interesting and—I do not mean to sound patronising—well-informed speech, took us through some of the intricacies of competition law. Although he did not say this, there has been a suggestion from a number of quarters that we are in a knowledge-free zone when we look at competition laws applied to the NHS. In one sense that is true because there is no case law that can guide us, but in another sense it is not true.
We can say many things with confidence. The point of competition law is to protect people from self-serving abuses like collusion or abuse of market power by restricting access to services. These self-serving abuses that harm patients are already prohibited in the NHS by the principles and rules for co-operation and competition, as introduced by the previous Government. This is not something new introduced by the Bill. Competition law applies to foundation trusts only in so far as they are acting as an undertaking, as my noble friend indicated—in other words, only where they are providing goods and services within a competitive market. Given the lack of directly applicable case law to NHS providers, there is some uncertainty about where that line is drawn.
A body can be an undertaking for some activities and not others. That is very clearly laid out in the OFT’s recent guidance, Public Bodies and Competition Law. For example, the foundation trust might be an undertaking for elective surgery, if it were provided in a competitive market, but it would be very unlikely to be an undertaking when providing NHS services in the absence of competition and while under a licensed obligation to maintain service continuity, which it could well be if Monitor chose to build that into its licence. In so far as foundation trusts may in the future be found to have abused their market power, what would then follow? It is important to understand what the consequences would be. In that situation, Monitor—
Baroness Thornton
Before the noble Earl moves on, I would like to be completely clear. Is the Minister saying that Monitor will decide which parts of the NHS are subject to competition law—and not the Secretary of State?
Earl Howe
My Lords, competition law potentially applies to the provision of services throughout the NHS. Monitor is there to protect patients from breaches of competition law, as it perceives them to be. The noble Baroness is right that it will not be the Secretary of State who makes those judgments. We are charging Monitor with that duty as a sector-specific regulator. I hope I have answered the noble Baroness’s question; if I have not, I am very happy to write to her on that.
In a situation where a foundation trust was found to have abused its market power, Monitor or the OFT would have the power to remedy the breach and impose proportionate sanctions, which might be a fine, or it might be to set aside a collusive agreement or to apply to the courts for a director disqualification. The effect would be to ensure that the anti-competitive conduct and the associated harm were addressed. That can be only a good thing. It is in the interests of patients, and it prevents the whole thing escalating further. The noble Lord, Lord Rea, indicated his doubts that there was any evidence that competition really did drive up quality. If he will allow me, rather than taking up time now, I will write to him, because there is quite a deal of evidence to indicate that it does drive up quality.
On reflecting upon the question that the noble Baroness, Lady Thornton, asked a moment ago, Monitor will not decide whether competition law applies; Monitor will apply the law as it exists. In the end, only the courts will decide the question that she put—certainly not the Secretary of State.
Baroness Thornton
In a way, that goes back to my original question: will the Secretary of State no longer decide, for example, that accident and emergency will be exempt from competition law? Will Monitor decide? Could the noble Earl please be patient with me and give me an example of what will be exempt and what will not be exempt, and who takes that decision? Is he saying that Monitor takes that decision and that if Monitor gets it wrong, the matter goes to the courts?
Earl Howe
Monitor would ask itself: is the arrangement we are looking at for, let us say, an A&E department that had no competition for miles around, anti-competitive? The answer might well be no, it is not. As I said earlier, the very fact that there is no competition to a service does not mean that it is anti-competitive. Monitor will make a judgment on whether the service is operating in the interests of patients. However, I think that we are getting into an area where it would be beneficial to have a letter from me setting out exactly how the law is applied and by whom.
Baroness Thornton
My Lords, this has been an absolutely brilliant debate and very helpful to everybody in the Committee; I hope that that includes the Government. I start where the Minister left off about intentions—it is not the Government’s intention to introduce competition red in tooth and claw. However, the Minister must by now have realised that that is not what people understand by what is actually in the Bill and how it might be applied. That is the dilemma that faces the Committee and the Government. We on these Benches will certainly take up the offer that the noble Earl made in his opening statement, which was extremely useful, of discussing how to improve and change this part of the Bill. We would like to be part of that process. There is definitely work to be done on that.
I will briefly sum up our position on this debate. I have a series of questions for the Minister and I am very happy for him to write to me about them. We are not convinced as yet by the idea that having a quango as an economic regulator is the only way to bring a clear and comprehensive legal framework into the Bill. The purpose of Monitor in the Bill is to develop competition, which is why we have the Bill. We believe, and this debate shows us, that the contents of this part of the Bill in fact open the door and invite in the issues that were raised, for instance, by the noble Lord, Lord Clement-Jones. If competition is not at the heart of the Bill, why do we need all that detail? The noble Lord, Lord Clement-Jones, made a very helpful intervention and a useful analysis. I, for one, will be rereading his speech about EU competition law.
I ask that the noble Lord, Lord Clement-Jones, and his colleagues look at our Amendment 262A, which would add a third subsection to Clause 59(1). The proposed paragraph (c) says the provision of health services should be,
“based on the principles of universality and social solidarity”.
We were not making a particularly left-wing statement with that. We were actually lifting it out of European law, which our advice tells us is one of the ways in which you keep at bay the procurement processes of European law. I strongly ask the noble Lord, Lord Clement-Jones, to look at that; I would be interested to hear his comments.
One part of the debate that I have been disturbed about was that raised by the noble Lord, Lord Owen. He also has a freedom of information request in for information that would help to inform the discussions of this House. We know that we have had our debates about the lack of access to the risk register to help us in our deliberations. Indeed, my honourable friends in another place asked if they could also have access to the legal opinions that the department had got on this part of the Bill, and were refused access to that, too. We have all had to find our lawyers to advise us about competition law. We are now all a lot better informed than we were several months ago. The noble Lord, Lord Owen, was right when he said there is no consensus about this; indeed he was right when he said that parts of this Bill are feared and hated. The Minister needs to understand that there is a lot of fear out there, about this part of the Bill in particular. The noble Lord was expressing very grave concerns.
The noble Lord, Lord Newton, made a threat to the Government about patient safety and quality being the order of the day and said that he will be returning to this on Report. He will probably have more effect than the rest of us put together in his interjection on this matter. We will be behind him if he does so, which may not do his reputation any good at all.
The noble Baroness, Lady Meacher, made a very thoughtful speech, her most important point being that we already have the tools to make the system work. There is no need to put in an economic regulator and the competition regime that this Bill suggests, because the tools are already there. That is very important.
I say to my noble friend Lord Whitty that there is absolutely nothing wrong with a bit of slash and burn to make the point about this part of the Bill. In effect my noble friend was at one with the noble Lord, Lord Clement-Jones.
The message from the noble Baroness, Lady Cumberlege, is that the NHS needs to improve. Yes, we would all agree with that and every health system in the world needs to change and improve. I would, however, refer the noble Baroness to my speech, which embraced change, embraced development and even embraced the use of managed competition. Where we part company is that the way to improve the NHS is not to treat it as a utility or a supermarket; we do not think the evidence is there to prove that. In fact, there is a lot of evidence to suggest that we should be very wary of the introduction of market forces as a way to improve our health service.
My noble friend Lady Armstrong made the important point that we agree with the Minister that there is a case for the use of competition in its place. The challenge before us is how we ensure that this Bill delivers that without threatening the whole fabric of our health service.
Baroness Cumberlege
Is the noble Baroness aware of Gaynor et al and the work they have done? I quote again from Protecting and Promoting Patients’ Interests: the Role of Sector Regulation, a research study in 2010:
“We find that the effect of competition is to save lives without raising costs. Patients discharged from hospitals located in markets where competition was more feasible were less likely to die, had shorter length of stay and were treated at the same cost”.
Baroness Thornton
All I would say in answer to the noble Baroness is that there is no known health service in the world that shows competition improves health outcomes. I challenge the noble Baroness to send me the information that shows that is the case.
Baroness Cumberlege
The noble Baroness should look at this document and at the research which is stated in it.
Baroness Thornton
We are talking about the whole system, not a small part of it. We can share our intelligence outside the Chamber; the noble Baroness makes a good point but there is no evidence that says this is the way to improve our national health system.
Lord Reid of Cardowan
Perhaps I can be helpful. The noble Baroness referred to a study of the competition element, which was introduced into the British health system by the previous Government, as far as I am aware. That was carefully circumscribed competition. It did not amount to more than 10 per cent. It was based on the insistence that competition be fair in terms of quality, standards and price; it excluded emergency; and it applied only to elective operations. The difference here is not whether competition is beneficial where appropriate. The real question is: where is it appropriate? That is the distinction between the two comments.
Baroness Thornton
My noble friend comes to my assistance in a very appropriate fashion and puts it much better than I did.
Finally, the question that we need to answer is: does the Bill increase the likely interference of competition law in the National Health Service? Does the Bill transfer power from the Secretary of State to Monitor, and is that a good thing? That is why I was pressing the Minister about who takes the decision about where competition law applies.
The Minister said at the outset that Part 3 is misunderstood. He is absolutely right. If the Government really want to put beyond doubt the issue of competition law and its place in the delivery of our National Health Service, we have to simplify, clarify and delete parts of Part 3 of the Bill. We have to take the NHS out of the danger zone of EU procurement law and competition law. That is the challenge that lies before the House when we return to consider this at a later stage in the Bill.
Earl Howe
My Lords, before the noble Baroness sits down, does she accept that European procurement law already applies? I do not think there is any dispute about that. I hope she will welcome my offer to write to cover issues relating to competition law, including giving my view on my noble friend’s suggestion of having an independent legal view. I have not taken a view about that at the moment, but I will gladly consider it.
Baroness Thornton
I accept both the invitation and comments that the Minister has made about procurement law. I refer him back to my comment about opening the door wide and inviting in the lawyers. I beg leave to withdraw the amendment.
Baroness Thornton
“(d) is to take on the further duties as set out in this Act in relation to authorising through licensing any person who provides health care services for the purposes of the NHS as set out in Chapter 3 of this Act.”
Baroness Thornton
My Lords, I promise that this will be a very much shorter speech. We now turn to the second group, which concerns Monitor’s function as a licensing provider—a part of the suite of amendments that we have put down about reconfiguring Monitor.
The Bill extends the concept of financial regulation to non-financial trusts, and we can see the logic in this. For consistency, however, we argue that all providers of services to the NHS—not just foundation trusts—should have to meet requirements around their financial position and have this subject to oversight, as well as the obvious fit and proper test that they would have to go through.
We can see the argument for a robust evaluation, for example, of capital structures, which certainly would have been helpful in the case of Southern Cross. The regulator should be allowed to make authorisation subject to this kind of probity test—something like a fit and proper persons test. For us, the key aspects of the licensing regime should be determined by the Secretary of State, not by the regulator. The job of the regulator in our view is to operate the system, not to define it. I would invite the Minister to say whether he agrees with that analysis.
With foundation trusts we set out that Monitor shall use the licence to ensure that information flows to the regulator to enable it to have effective oversight and to intervene if necessary. The licence has to extend this to other sorts of providers which may be reluctant to supply information or submit to the idea of intervention. They may claim commercial confidentiality. The Bill resolves this problem, as far as we can see, by simply having no oversight—in other words, the “nothing to do with us, guv” approach to regulation. We believe that the public would not accept this. The Mid Staffs example, where Monitor came into much criticism, or the Southern Cross example might be instructive here.
Baroness Murphy
I am sorry to interrupt. The situation at Mid Staffs arose following the approval of the Department of Health and the Healthcare Commission. It was passed to Monitor as a fit and proper hospital. The scandal emerged only three weeks after it was approved by Monitor.
Baroness Thornton
The point I am making concerns what we need to do for the future. What happened in Mid Staffs has some bearing on that and I said “instructive”.
The tests that we are suggesting should be applied to any organisation wishing to supply clinical services to the NHS around probity and can be enforced through contracts and licensing. Meeting the conditions without trying to argue commercial confidentiality is now the price of doing business with the NHS, in our view.
Finally we have reservations about the interaction between the licensing regime and the use of standard contracts. Why have both as enforcements? What would be appropriate for each? What is the role of Monitor as regards the contracts? What happens to disputes between providers and commissioners? Do they all go to court? What is the role for Monitor in the resolution of disputes? We have accepted that if you have a licensing system then you have to build a bureaucracy to support it, moving from a top-down management bureaucracy to a regulatory bureaucracy. To keep this to a minimum while remaining effective is not simple, as the CQC is finding. But the system set up in the Bill is very complicated and our amendments seek to simplify it. The nature of the operation as to whether it should be a light-touch risk-based approach or continuous direct inspection is another issue which has plagued the CQC and will have to be resolved by the new Monitor. That is a question we need to put on the table.
I now turn to our amendments. In Amendment 260EB Monitor is to take on duties in relation to authorising through licensing any person who provides healthcare services for the purposes of the NHS. Amendment 279A is to remove any potential ambiguity and stress that providers of primary medical services for the purposes of the NHS must hold a licence. Clause 82 stand part is to facilitate a discussion about who can be exempt from the requirement for health service providers to be licensed and who makes those decisions. In Amendment 282A, since this a strong power granted to Monitor to revoke a licence, we add qualifications that in the case of a foundation trust Monitor must consult the Secretary of State, and the Secretary of State may veto any revocation if it is deemed not to be in patients’ or taxpayers’ interests. In Amendment 282B the Secretary of State, not Monitor, should determine the principles or framework behind the licensing conditions and Monitor must then have regard to these. Amendment 283 specifies that the standard conditions included in each licence must set out various minimum standards such as for governance arrangements, meeting in public, employment conditions, co-operation with local-authority overview and scrutiny functions. Amendment 283A contains the issue of there being no need to have different standard conditions for different descriptions of licences.
Amendments 286ZA, 287ZA and 287ZB set limits on Monitor’s functions to set and modify the licence conditions, simplifying its role. Amendment 287BA leaves out the roles of Monitor relating to licence conditions, price and charging. Amendment 287F requires licence holders to be fully subject to the overview and scrutiny functions of local authorities. In Amendment 288ZB Monitor has the power to modify the standard conditions applicable to all licences, and in doing so there should be no need for a vote among providers but consultation and consent from the Secretary of State is required. In Clauses 99 and 100 stand part we raise the issue of minimising the bureaucracy surrounding licensing. In Clause 101 stand part we argue that the requirements for fair eligibility and transparency in selection should be covered under the PRCC. This is a probing amendment designed to strengthen the clause instead of deleting it on Report. We think that that should be a matter for discussion. Amendment 288DZA regards Monitor’s power to impose discretionary requirements, including fines, on providers and licence holders if they fail to provide required documents or information, which can only occur with the consent of the Secretary of State. Any fine must be held by the local CCG for reinvestment in services in that area. Amendment 288DA states that if any provider is in breach of a licence Monitor may take action against them, including the imposition of fines, but only with the consent of the Secretary of State. I beg to move.
Baroness Williams of Crosby
I would like to address just one of the amendments in this group, which is in my name and that of my noble friend Lord Marks of Henley-on-Thames. Unfortunately my noble friend has been taken ill and is unable to be here. He extends his profound apologies to the Committee.
This amendment is significant in strengthening the general approach towards competition under Section 3 of the Bill, by making it quite plain that the requirements that have to be met, which we will come to in Part 4, must also apply to licence holders. I am in a slight difficulty, as my noble friend Lord Howe will appreciate, as the Government have tabled amendments on aspects of foundations trusts which will arise at a later stage in the Bill, particularly under Clause 161, which are related to the amendment to which I am now speaking. I will therefore do my best to navigate around Clause 161 in so far as I can. However, I may have to make limited reference to it in order to make clear what my own amendment is about. My own amendment is essentially one that would support, and indeed further improve, the proposals put forward in this particular amendment. They should therefore be read together with Clause 161 and Amendments 299ZA and 299AZA in the name of the Government.
We want to make two requirements as a fundamental part of the requirements that licence holders have to meet. We appreciate that, in many ways, the licence-holding requirements are fundamental to the way in which the Bill operates, because it must be the case that providers are brought within the general structure of the Bill itself. Our amendment makes two particular points about that. The first is that the revenue from private patients, as a percentage of the licence holder’s total revenue, must be kept below 50 per cent. Secondly, and at least as importantly, the number of private patients in a foundation trust hospital must also be kept below that proportion.
The main point of this amendment—I think that it is an important one—is again to establish that we are looking at foundation trusts that are part of the provision under the NHS and that a minority of both income and patient numbers would be required for any provision made. We hope, as I think the noble Baroness said, that this set of requirements continues well beyond 2016 as part of the structure of the relationship of foundations trusts to the health services, and that this is therefore not standing alone but a crucial part of the whole strategy.
If the noble Lord, Lord Owen, were in his place, I would say that if this is not the rail track of the French railways, it is at least the rolling stock, and we need both to have an effective railway service. However, I wanted to say one other thing. The first part of the amendment tabled this morning by the noble Earl, Lord Howe, goes a very long way. We will talk about this in more detail later so I shall only sketch it out now, given the time. I think that the first part of the amendment, with regard to income—and indeed the requirement that income must exceed the costs of providing that income, and that it must be used for the purposes of patients within the health services—is a very full and useful advance. It is very close to the phrasing of the 2006 Act, which is a point that I am sure will come across to the noble Baroness, Lady Thornton, and her colleagues, but with the additional wording that makes it, if anything, even stronger.
The noble Earl, Lord Howe, will know from discussions which I and my colleagues have had with him that we would want to see this supplemented, if possible, by a reference to the proportion of patients in foundation trust hospitals. Quite broadly, that is something the public can understand, whereas references to quite complicated percentages of income, although equally important—if not more so—are perhaps less transparent and less apparent.
I will not pursue further the new amendments beyond welcoming them, but I want to advance this particular, although limited, amendment as thoroughly as I can, as I think it would ensure that licence holders were held to the same kind of requirements that we are imposing upon Monitor, the national Commissioning Board and the CCGs. It must be the case that this should be a common approach across the front.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
I am glad that the noble Lord, Lord Clement-Jones, asked that, because I was waiting to hear what the answer would be. I look forward to the noble Earl’s response. I fear that the noble Earl will be spending the whole of the weekend writing letters to all of us about these matters.
I am not going to say very much about this. This has been a divided debate, but many of the questions asked have been similar. The noble Baroness, Lady Williams, was quite right to raise the issue of requirements. She and her noble friend Lord Clement-Jones were right to raise the issue of transparency, which is very important here.
I am not sure that we on these Benches would agree that the checks and balances are the right ones. At this stage, we will wait for the letters from the noble Earl. I will also read his remarks again in Hansard. We may return to discuss this matter again. I beg leave to withdraw the amendment.
Baroness Thornton
“( ) The chair and the chief executive must be separate roles, and cannot be held by the same person.”
Baroness Thornton
We turn now to the very important matter of Monitor and accountability. I see that many noble Lords have amendments in this group, many of them echoing each other. The reason for that is that, given the powerful role that Monitor is to have—whether it will have this role under the regime proposed by the Minister or the alternative architecture proposed by myself earlier today—we think that accountability is very important indeed.
We propose two improvements to Monitor’s governance. We believe that its functions should be exercised in the public interest and therefore that it should meet in public, as the NHS Commissioning Board will. We should also no longer have a combined chair and chief executive post. I hardly need say to the House that this arrangement is totally against established good practice in the public or private sector. I rest that issue there and look forward to the noble Earl’s response.
When foundation trusts were set up, the idea was that they could earn freedoms from traditional NHS management and also bring an element of democratic accountability and community ownership. It must be said that much of this has not materialised. Some foundation trusts up north have made an effort to engage locally with the people they serve. Some have adopted a business model rather than a community ownership model. I am sure that all noble Lords are members of their foundation trusts—I hope that they are and that they take part when asked to do so. The target to push up membership numbers in the trusts seems to have been forgotten.
Being successful in becoming a foundation trust shows that a fairly high barrier was overcome but that represents only the position at one point in time. As with the share market, things can go up or down. Some big-name foundation trusts have had their bad patches. A few, surprising names have been at the edge of intervention. If you compare the list of foundation trusts flagged as being in difficulty by Monitor with the list of ratings from Dr Foster or, in its time, the ratings from the Healthcare Commission, there seems to be no pattern at all. Indeed, a double-excellent foundation trust came close to de-authorisation.
Every large, complex organisation can get into trouble. Past success is no guarantee of future performance nor is it necessarily even a good predictor. That is why we argue that the oversight of foundation trusts by Monitor should continue and its intervention powers should remain. We have long argued for shifting the balance of power and we fully support the idea of earned autonomy with the regulator as an independent judge. But if it is earned it can also be taken back. We shall see what transpires when one foundation trust is obviously unable to present a viable business plan. What will happen to its future?
Monitor has to continue in the role we gave it as the authoriser of foundation trusts as they earn their limited independence. In recent times, it toned down the role it took as the promoter of foundation trusts and as a trade body as a step too far. We argue that Monitor as a regulator should be neutral not a cheerleader. We can accept the principle that it is wrong to favour any type of organisation for arbitrary or political reasons, as is set out in the operating framework. We do not accept the convoluted and ultimately meaningless formulation contained in the Bill. Monitor should retain its intervention powers. We accept the case for autonomy and community ownership but in the final analysis we see foundation trusts as still part of the NHS and so, in the end, subject to the powers of the Secretary of State.
We accept that the governors should be a strong element in foundation trust governance but, as the Bill accepts, they need support and development in that role. Most foundation trusts will say that governor effectiveness takes at least five years but governors, no matter how effective under normal circumstances, may be completely ineffective in times of overwhelming crisis. It is then that the Secretary of State must have the power to intervene to ensure the overall functioning of the NHS and to protect the interests of patients and their communities. A major change here is that the Bill extends the concept of financial regulation to non-foundation trust providers—that is, the private sector. As I have said before, we can see the logic in that.
I am going to skip ahead and do what I said earlier in the Bill: you do every other page of your brief and see whether anybody notices. We have already had a lot of debates about these issues.
Finally, we come to reservations about the interaction between the licensing regime and the use of standard contracts. Actually, we have also discussed that so I will not ask those questions again. We have recently seen missives from the Department of Health and from Monitor exploring the ideas around regulation. It is slightly amazing that these are all coming out now, as helpful as they may be. The general idea, as we have said before about the Bill, is that you should consult on the legislation, allow Parliament its scrutiny role and then implement it. However, as we know, the Bill exhibits the principle of reverse engineering. When its progress was paused to allow consultation, the Government continued to roll out the implementation and the Bill is catching up with that now. We scrutinise the Bill alongside its implementation and the secondary legislation is written up in the form of documents coming out of the Department of Health.
I turn to our amendments in this group. Amendment 260EC provides that the chair and chief executive of Monitor cannot be the same person, Amendment 260GA provides that Monitor must meet in public and Amendment 267D would apply the mandate to Monitor. We think that Amendment 267D might be improved on and might even be better located in Clause 20 on the mandate itself, but the point of it is to raise the idea that the Secretary of State may be given a greater power of direction of Monitor and ultimately boost its accountability. I beg to move.
Lord Clement-Jones
My Lords, I would like to continue the train of thought started by the noble Baroness, Lady Thornton, about the specifics relating to Monitor. I shall speak to Amendments 260F, 260G, 260H, 269A, 294BA, 294BB and 294BC.
First, I may not have got Amendments 260F and 260G, relating to the first chief executive of Monitor, completely right, because Monitor is already in existence, but in principle the chief executive of Monitor should surely be appointed by the Secretary of State in the same way in which the chairman and chief executive of the national Commissioning Board are. As we go through this debate, it will become increasingly obvious that Monitor’s role is as important as that of the NHS Commissioning Board, so I would have thought that having an appointments system on all fours with the board would be imperative. Then again, we come to the question of the provision of information to the Secretary of State. Amendment 260H mirrors the powers possessed by the Secretary of State in relation to the NHS Commissioning Board. It seems sensible that that should be in place as well.
Harking back to our debate on competition and the application of EU competition law, we come on to a rather different issue. This is an interesting place for these amendments to be put. In Clause 118 it is the Competition Commission that deals with the determination of methods of setting prices under the national tariff if there is a disagreement—the Competition Commission has that referred to it by Monitor. For all the reasons that we explored in the debate on the first set of amendments today, it is inappropriate, in my view and in the view of many others, for the Competition Commission to be so heavily involved in matters relating to the NHS. Substituting the Secretary of State for the commission seems to be sensible.
The objection is sometimes raised that we need an independent body in order to set the method. That is a fair point but it is an objection to the Secretary of State doing this entirely on his own, whereas an independent panel appointed by the Secretary of State could do the job equally well. That would ensure that there was some arm’s-length relationship with the Secretary of State in these circumstances. It is quite unnecessary for the Competition Commission to do what is going to be an extremely unfamiliar job for it in assessing the methodology of setting the national tariff—far better that others who will become familiar with it should undertake that task as advisers, consultants or whatever to the Secretary of State. All these amendments make good sense.
Earl Howe
My Lords, I think that this has been a very useful debate. The Bill provides a more autonomous NHS, and it does so in order to deliver high-quality services and value for money. Monitor, as sector regulator, would establish clear standards and rules to protect patients’ interests in the provision of NHS services. Monitor would be required to lay its annual report and accounts before Parliament and have the accounts audited by the Comptroller and Auditor-General. It would also need to comply with other rules and guidance that cover central government public bodies, including the seven general principles of public life, the Treasury’s guidance document, Managing Public Money, and rules on corporate governance. Monitor would also have to respond in writing to parliamentary committees and any advice from HealthWatch England. The Secretary of State would oversee Monitor’s performance of its functions to ensure that those functions were performed well. The Secretary of State would not have control over Monitor’s day-to-day decisions, but would hold Monitor to account for discharging its duties. That point is extremely relevant in the context of a number of amendments in this group. The Secretary of State would appoint the chair of Monitor and other non-executive directors and would have to give consent to the appointment of the chief executive. I hope that point answers Amendments 260F and 260G.
Earl Howe
My Lords, I will come on to that in a moment. The Secretary of State would also have specific powers of veto; for example, over the first set of licence conditions and, in individual cases, of provider unsustainability, where he considered that Monitor was failing in its functions to support commissioners in securing continuity of services. In addition, he would be able to request information from Monitor regarding the exercise of its functions as and when he considered it necessary. I hope that this therefore allays the concerns of noble Lords who put their names to Amendment 260H.
However, Monitor needs to be free from day-to-day political and other inappropriate interference in order for it to be able to act in the best interests of patients. In order to maintain the integrity of its relationship with the Secretary of State, Monitor must be able to take independent decisions on the exercise of its functions, such as calculating prices, setting and enforcing licence conditions and resolving conflicts of interests. Making such decisions subject to approval would be inconsistent with this approach, and would conflate responsibilities. In particular, it would undermine the Secretary of State’s ability to hold Monitor to account. There would also be significant risk of decisions being politicised inappropriately. By contrast, independence in such decisions would increase transparency and help ensure that providers were treated fairly.
I understand the motives of noble Lords who added their names to Amendments 274AA, 274C, 274D and 247E, relating to the Secretary of State’s involvement in resolving conflicts of interest. The Government agree that where they occur, conflicts must be resolved, but giving the Secretary of State a role in decision-making would undermine his ability to hold Monitor to account. The Secretary of State would be obliged to keep under review Monitor’s performance in discharging its duties. He would be able to direct Monitor, where it had failed or was at risk of failing significantly, to carry out its functions. In extremis, he could arrange for a third party to perform those functions or perform functions himself. I hope that those points answer the question of the noble Baroness, Lady Thornton.
The Bill also ensures transparency and fairness, through requirements on Monitor to consult widely when discharging functions and appeal mechanisms for the major decisions it makes. Here, I am addressing Amendments 294BA, 294BB, 294BC. In this way, our proposals strike a balance between maintaining sufficient independence and ensuring that the Secretary of State has sufficient ability to hold Monitor to account for the performance of its functions. I believe there is consensus that we need to ensure that this balance is correct.
My noble friend Lord Clement-Jones asked why it should be the Competition Commission that decides on challenges to Monitor’s proposals on licence modifications, pricing methodologies or whatever. I am grateful to him for that question. It is fundamental to our proposals that Monitor would be an independent regulator and that the appropriate role for the Secretary of State is to oversee Monitor’s performance against its duties, and to intervene where he considered that Monitor was significantly failing in any of its functions. However, it is vital that the legislation provides appropriate checks and balances on Monitor without undermining its day-to-day independence from political control. That is why we proposed that Monitor must consult on the licence conditions that it proposes to impose on providers and on its draft methodology for pricing. Providers and, in the case of pricing, providers and commissioners should be able to object to Monitor’s proposals, and where a sufficient percentage objected, there should be a mechanism for independent and impartial adjudication. That is the role we propose for the Competition Commission. It would act as adjudicator on disputed licence modifications and on disputes over the pricing methodology. The basis for this adjudication would be Monitor’s overarching duty to protect and promote patients’ interests.
Baroness Thornton
Did the Government consider any bodies other than the Competition Commission as being appropriate to fulfil this role? If so, which were they and why were they not thought to be appropriate? This is a rather heavy-duty form of monitoring Monitor.
Baroness Williams of Crosby
I am puzzled by why the Government do not see the Competition Commission’s overseeing of this area of Monitor’s responsibilities as not being neutral. Would not a body such as the Office of Fair Trading be more appropriate? It has a reputation not only of being more neutral but of having shown in the past particular sensitivity and understanding of health as a service provided to the people of England.
Earl Howe
I think it is a question of specialist expertise. I do not regard it as heavy-handed to have the Competition Commission acting in this role—which, we hope, would not be a role that it would need to perform with any regularity. It is an established body. It would apply a public interest test rather than a competition test, which is important. One has to question whether the Office of Fair Trading is the right body. I will of course reflect on my noble friend's suggestion, but we believe that the Competition Commission is a good fit in this sense. If the Secretary of State were to play the role of adjudicator, that would be very detrimental. The result would effectively be the politicisation of Monitor's decisions. As I said earlier, that in itself would undermine the Secretary of State's role in holding Monitor to account for the outcomes that it achieves.
The noble Lord, Lord Warner, referred to conflicts in the role of Monitor in overseeing foundation trusts. We are quite open about the fact that there is a risk of conflict of interest here. That is why it is essential that the Bill sets out a robust way for conflicts to be resolved. In a later debate, we can discuss that at greater length. I listened with interest to the speech of my noble friend Lady Williams, and I will of course reflect further on everything she said, as I always do. I think I have covered the main issues raised by the amendments in this group.
Baroness Thornton
I think that almost the first sentence I uttered in this debate was: will Monitor meet in public; and what do the Government intend to do about joint chairmanship and chief executiveship? If the Minister answered those questions, I did not hear him and I apologise.
Baroness Thornton
My Lords, I think this has been an extremely useful debate. I can see why this Government may not trust their Secretary of State to hold Monitor to account. However, I am concerned about the idea that because we—and I do not just mean Members on this side of the House—are anxious that accountability rests in the right place in the Bill, that must therefore translate into political influence or micromanaging. I do not think that is at all the case here. Therefore, we do have an issue still to explore regarding the accountability of Monitor.
I also think we need to explore whether the Competition Commission is the right place for a public interest test to rest. The noble Baroness, Lady Williams, may have made a useful suggestion about which other bodies could possibly undertake that function. Again, we find that this quango is determining its own rules and then implementing them. That is not a satisfactory situation. However, I did take hope from the fact the Minister said yes to the question of whether the chair and chief executive of Monitor would not continue to be the same person, and that Monitor should meet in public. Is the Minister accepting Amendments 260EC and 260GA, or is that the statement of principle with a government amendment coming forward at a later stage or, indeed, a letter from the Minister, clarifying the issue? Otherwise, I beg leave to withdraw the amendment.
Lord Clement-Jones
My Lords, I think that that is inadvertent. We seem to have missed a whole group of amendments.
Baroness Thornton
Perhaps I may help. I think that the thing to do is to deal with this group of amendments and the noble Lord can then move his amendment. We will then take the group of amendments that we should have been taking out of turn. Am I right in that? I think that that is the best thing to do.
Baroness Thornton
“Duty as to continuous improvement
(1) Regulations must provide that commissioners have a duty to make arrangements to secure continuous improvement in the way in which their functions are exercised, having regard to a combination of economy, efficiency and effectiveness.
(2) Such continuous improvement is to involve—
(a) consideration of costs,(b) making the most of money spent, and(c) making sure that services meet the needs of patients, communities and the priorities agreed in any Health and Wellbeing Strategy.(3) For the purpose of deciding how to fulfill the duty, commissioners must consult the relevant Health and Wellbeing Boards, patients and public, as provided in the regulations.
(4) Commissioners must conduct reviews of the services commissioned in accordance with the regulations, and publish the results.
(5) In conducting a review a commissioner—
(a) shall aim to improve the way in which its commissioning of services is exercised, having regard to a combination of economy, efficiency and effectiveness, and(b) shall have regard to any guidance issued by the Secretary of State under this section. (6) Regulations may specify matters which commissioners must include in a review of a service under this section, and in particular may require a commissioner—
(a) to consider whether the current providers of the service were meeting all reasonable requirements;(b) to consider the extent to which competition for the provision of the service may or may not be appropriate;(c) to consider its objectives in relation to commissioning the service;(d) to assess its performance as regards the commissioning of the current provider;(e) to consider the outcome of consultation with relevant persons and bodies as specified in the regulations.(7) Regulations may specify the circumstances for use of tenders as a result of a service review in order to sustain continuous improvement.
(8) These regulations may include—
(a) single tender actions,(b) restricted tenders,(c) open market tenders.”
Baroness Thornton
My Lords, we have yet again leapt to a larger group, and I know that the noble Lord, Lord Clement-Jones, will get his turn, although possibly not until after dinner. We have moved on to a large group of amendments that concern pricing and the setting of tariffs. Many other noble Lords have tabled amendments in this group, as indeed has the Minister. I do not intend to make a long speech, but I will address the issue of pricing.
On reading the Bill you would think that having a tariff in the sense of a complete list of NHS services with all the prices and currencies set out was just around the corner, but I suggest that that is a bit of a myth. Even well developed healthcare systems that are much more market-orientated than our NHS are still a long way from such a state; we are years or perhaps decades away from that condition. For a start, for many services there are no data—not just bad or incomplete data, but none. Getting the datasets defined, collecting the data, then making the analysis, road-testing and rollout will take time. The Minister might like to tell us just how large the team in the Department of Health working on this task is, because I have to say that I heard that it is small and getting smaller as the cuts bite. But, of course, there is always KPMG or McKinsey to step in. Apart from anything else, it seems that this Bill is intent on creating a lot of jobs for lawyers and now, we see, for accountants too.
We are in the midst of a major argument about how relevant different types of currency and tariff might be, with some suggesting that returning to block payments might be better, in the interest of integration, stability and cohesion. This has been stamped on by the operating framework but that does not mean that it will not happen. Using choice and the right financial incentives to drive change in the system is the new orthodoxy. Some are trying to find out how different currencies, uses of penalties and fines and even bonus payments can reward good outcomes and deter bad. This has now extended to how to incentivise integration. These are all problems for which we would like to have answers. We are years away from a system where all these levers are available in the way that the Bill likes to suggest that they are.
In mentioning the framework, we should point out that the re-emergence of price competition shows the need for some communication between the chief executive and the Secretary of State.
Who, then, sets the prices? The arguments are well balanced. My noble friend Lord Warner argues in his book that it should be the national Commissioning Board. He is not in his place at the moment, but I have read his book. However, the national Commissioning Board is in the ludicrous position of also being the commissioner of local services. Monitor may also be compromised, as it is aligned to providers. So we return to the role of the Secretary of State. In any event it must surely be for the Secretary of State to determine the strategic approach, namely the global uplift or reduction. Our priorities for a system as determined by the Secretary of State also need translating so that the incentives are aligned to the desired outcomes, something the NHS has not always been good at. If the Secretary of State determines the approach within the strategy, then we may need genuine independent input into the detailed work of pricing and tariff. At the very least, a full list of the proposed tariffs should be published along with all the data and the analysis, so that the big brains of people at organisations like the King’s Fund and the Nuffield Foundation can tell everyone what is wrong.
Widespread consultation before any major change is a good idea, as is road testing changes before inflicting them and all the suffering of the unintended consequences that may arise. In the end, we think that the Secretary of State must make the strategic decisions in this crucial part of the economic architecture. It cannot be handed over to a quango.
The details of the amendments in my name and the name of my noble friend are as follows. Amendment 277B would insert a new clause which would place a duty on commissioners as to the continuous improvement in terms of cost, value for money and the needs of patients. It would also encourage co-operation with health and well-being boards, patients and the public. It would allow the Secretary of State to issue guidance, via regulations, including in relation to whether,
“competition for the provision of a service may or may not be appropriate”,
and in relation to,
“the circumstances for use of tenders as a result of a service review”.
Noble Lords who were here this morning—which now seems like a long time ago—may remember that, when I explained the overall purpose of our amendments to reconfigure Part 3 of the Bill, the setting of prices was part of that.
Amendments 288J and 289 are about setting a national tariff: they would make it a matter of policy for the Secretary of State, and not a matter for Monitor. Amendment 291B would ensure that regulations relating to the national tariff must state how the prices and methods were determined and how any proposed changes to the national tariff,
“will be subject to proper evaluation and testing” ,
as well as dealing with evidence of consultation between the Secretary of State and Monitor. As the national tariff should not vary in relation to different descriptions of provider, Amendment 292ZC would deal with that issue and the issue of a preferred provider. Monitor should also have no powers over commissioners—in this instance, in relation to the tariff—as commissioners are regulated by the board. We oppose the question that Clauses 116 to 121 stand part of the Bill, because we believe that the Secretary of State should set the national tariff: if the Secretary of State were to set the national tariff, then those clauses would be unnecessary. Once more, as you can see, we are reducing the size of this part through our amendments.
Amendment 294LA would insert a provision that regulations must be laid to issue “guidance on the circumstances” in which there can be local modification of prices. That decision should not be for commissioners and the providers of healthcare services alone. Amendment 294LB would provide that any local modifications of prices would occur with the approval of both Monitor and the board. Amendment 294LC also concerns local modifications of prices: it would ensure that if they were approved, Monitor would have to notify the relevant health and well-being boards. Amendment 294MA deals with situations in which a provider fails to reach an agreement with a commissioner about local variation of prices: in such circumstances it would allow Monitor to authorise such changes only,
“with the consent of the Board”.
Amendment 294MB would ensure that no modification of prices could happen,
“without the consent of the Secretary of State”.
In the area of the setting of prices we are perfectly happy to acknowledge that this may not be a perfect set of amendments. But we think that the very important matter of who sets the prices, and where the accountabilities lie, needs to be discussed. I beg to move.
Lord Butler of Brockwell
My Lords, I shall speak to Amendments 288H and 291A, in my name and the names of the noble Lords, Lord Newton of Braintree and Lord Turnberg. The amendments are related. Like other amendments in this group, they relate to the tariff—that is, the remuneration which a healthcare provider receives for a healthcare service. The amendments to which I am speaking are designed to facilitate the introduction of new treatments made possible by the development of new technology. When an innovative treatment requires a new procedure code or an updated healthcare resource group classification, a new code can take up to three years to be implemented and a new healthcare research group can take up to six years to develop. Meanwhile, NHS trusts cannot be remunerated for potentially useful and cost-effective improvements made possible by new technology.
In Germany, an intermediate step has been developed, under which providers can apply for an on-top payment while a new code is being developed. This is known in Germany as the NUB system, although I hope that noble Lords will not ask me to say what NUB stands for. These amendments provide for a similar “innovation tariff” to be provided in the United Kingdom, to allow for providers to be remunerated for an innovative procedure on a temporary basis while a new procedure code or healthcare research group is being developed.
These amendments are in line with the Government’s Strategy for UK Life Sciences, which was published last week, but are not already covered by it. I hope therefore that the Minister will give sympathetic consideration to the introduction of arrangements of this sort to facilitate the introduction of health improvements made possible by new technology.
Baroness Thornton
My Lords, I do not want to stand between noble Lords and their dinner—and indeed, on this side of the House, yet more defrosting. I would like to be able to say that the Minister had given us some comfort in this debate, as he has in one or two of the others, but I am not sure that that is the case.
I did not moan about a quango. I have mentioned only two quangos today, but they are rather large and important ones. One of them will have a budget of £20 billion, and the whole House has agreed that it is concerned that accountability to the Secretary of State for those quangos is right. We have not quite settled that and have returned to that issue consistently, almost every day throughout discussion on the Bill, but that probably now needs to be left until the new year.
I support my noble friend Lady Gould and the noble Baroness, Lady Tonge. The funding of sexual health services is one of those cases which will have potentially disastrous unintended consequences—in more ways than one, if one may put it that way. My noble friend is right to raise that, and we will support her fully if she decides that she wants to take it to the next stage of the Bill.
As ever, my noble friend Lord Davies gave an original flavour to the debate and raised some important and pertinent questions. I will read more carefully the Minister's answers. Ditto to my noble friend Lord Warner, whose amendments are very important. What underlaid what my noble friend Lord Warner and the noble Lord, Lord Clement-James, said, was that this is not a quick job. This will take a long time and it is important that we get it right. We are not convinced that the national Commissioning Board and Monitor together will not create a very bureaucratic, slow way to set the tariff. We are not convinced that that is the way forward. We need to consider an independent voice and some other way to do that. We will probably continue that discussion at another time, and I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
“( ) Such criteria must include the requirement, at regular intervals, for all licensees to supply Monitor with financial information, in the interests of meeting standards of financial stability and probity.”
Baroness Thornton
My Lords, I start by congratulating noble Lords on making it through this day of debate. We are ending the day with this large group on failure, and the smaller group on pre-failure, tabled by my noble friend, in a moment or so.
In the NHS of 20 years ago, the trusts that got into problems were helped, although the help may have been brutal, with chief executives removed or moved on and nasty phone calls to trust chairs. The system gave powers of intervention from the Secretary of State through local strategic bodies, as they became. Financial help was grudgingly provided, usually for a recovery plan, sometimes delivered and sometimes not. The relationships were not defined by legal contract, and NHS contracts could not be enforced in the courts, so there was a system of arbitration within the NHS.
Those days have gone, and we now have an NHS as a network of many sub-organisations, some with linkages through real contracts. With FTs came the idea of a real contract, although in reality, of course, disputes are still sorted out long before reaching a court. We know that services, and even whole organisations, can fail as the impact of demographic, technological and behavioural changes shape our NHS. In reality, we have to deal with trusts that get into severe difficulties and may be technically insolvent, at which point a real organisation may not be allowed to trade. Then we have to accept that a whole trust might need to be shut down. Indeed, how should that be done? How should the continuity of services be maintained, how should the staff be dealt with, and how should the assets, most of which are owned by the state, be dealt with?
We know that this is the tail end of a bigger and important issue of reconfiguration. So how do we ensure that we can adapt services that show poor quality or that need to be delivered in different ways in different settings? Maybe, as with an increasing array of subspecialities, we have to accept regionalisation. Maybe we need network solutions. Is the market the way to do this? In other markets, innovations lead to changes in demand, and the organisations that cannot adapt close down. Is that what we want for our NHS?
Those who might be so inclined might like to wander through the delicate prose of Simon Burns MP in Committee in the Commons. He loves failure. The idea that you have competition is inextricably linked to having failure. It facilitates the market, brings in the innovators and drives out the inefficient. He believes that failure is a measure of market success, not failure.
It is true that in government we introduced a failure regime as we came to realise that, even after all the support and changes of management team, there may be organisations that are simply not viable. However, it is not so much that they were not viable; it is what that means, that continuing to support them is not giving value for the NHS, however much we adjust that value to include non-financial aspects. Indeed, we also wanted to bring out into the light the murky transactions used within the NHS to support organisations, through means such as brokerage loans. The tendency was for bad performers to be bailed out by the good—the opposite of a reforming system. The way NHS accounts were done also had to be changed to make this kind of smoke-and-mirrors accounting more open.
Issues around failure are more likely to operate at service level than at a whole-organisation level. To take a recent example, a well known and respected financial trust is having issues around its 18-week performance. Its general quality is good but it has signalled that it needs help, and it is indeed getting it from a Department of Health team. The question that we need to ask is: would this kind of support be available in the new world? Presumably, it would not; and even if it were, might that help be deemed anticompetitive? Would that good trust be allowed to fail? The link here to reconfiguration is inescapable.
We know and even admit in our rational moments that reconfiguration on a grand scale is what the Nicholson challenge is really about. The need to move services into community settings and to reduce dependency on the district general hospital model is widely recognised. However, we also know that reconfiguration is beset with political problems. In the run-up to the election, about one-third of constituencies had some kind of campaign to keep open a hospital, a surgery or whatever. One felt sometimes that even if there was no threat, one was invented. We had Andrew Lansley and David Cameron claiming that they would prevent any closures. I think that the Government are learning the hard way that promises made in opposition, especially during election campaigns, may turn out to be millstones when the real burden of decision-making passes to them. The examples of broken promises will continue as reconfigurations gather apace.
This is the issue to which our suspicions should be addressed. Is it part of the rationale to put the blame for nasty politically damaging decisions on others? This abdication of responsibility is characterised by the way that Ministers are trying to give away the key roles of the Secretary of State. This is in part a failure of process but is also a failure of leadership. The leadership should be accountable for delivering answers and necessary changes within a reasonable timescale. If we get reconfiguration right, the failure regime would look less necessary. This is far better for patients than the trauma of seeing their local facilities under constant threat or even being closed down. There are examples of where this has been done, and done well—and we need more of them.
In Committee in the Commons, the Conservatives in particular appeared to believe that these unpopular local changes would be less likely under the Bill—if changes in organisations are branded as failures, then those MPs would be well clear of any responsibility. In fact, we have years of evidence because every reconfiguration has to go through a clinical and management review at an early stage—so we know what works and what does not. We could use that evidence, rely on a robust process and stop opportunist politics. However, we know that the market will not bring about these changes any time soon.
In our NHS, the best interests of patients are served by good information that allows early intervention to improve failing services. CQC inspections are also of value in raising the prospect that poor services will be detected early. If you rely on competition, how long does it take for the public to react to the information that a service is bad and for them to choose to go elsewhere, or for that to impact on the finances to the extent that the service is closed down? In our view, using choice and competition to detect and close poor services takes too long and the cost for patients is indeed too high. That is what this suite of amendments aims to tackle.
The amendment sets licensing criteria to ensure that private providers meet standards around financial stability and probity. We need to supply regular financial information for the good providers. This is, in other words, a sort of Southern Cross test. Amendment 249MBA brings into effect the remaining inactivated arrangements for trust special administration from the 2009 Act, as amendments to the 2006 Act. I remember those well. Amendment 353ZZA is a commencement provision for that. Amendment 295 states that health special administrators must exercise their functions to “protect the interests of patients”. As to the Questions that Clauses 125 to 130 stand part of the Bill, this would create a regime for private companies that provide services to the NHS to have special procedures that augment the normal company provisions under the Insolvency Act. It arguably implies that we need stronger protection from the risk of private provider failure. It should be for the commissioners to factor in the risk of using private providers and contract to ensure that arrangements are in place for contingencies. The licensing regime needs to be tough enough to prevent Southern Cross-type failure through active monitoring.
Risk pooling is what the NHS does. We do not need new risk pools, with the costs that they involve. That is why we think that the clauses should be deleted. Clauses 131 to 143 inclusive allow Monitor to set up the regime to provide special administration for both private and public providers to levy charges on providers and commissioners and to manage the finances of a risk pool.
We argue that none of that is required; it just adds extra complexity and cost. Clause 170 is about FTs and failure. The clause removes the ability to deauthorise a foundation trust. We argue that that power should be retained, along with the recognition that some NHS provider trusts may need to be directly managed under the powers of the Secretary of State.
The new clause in Amendment 303ZA makes clear that the initial effort, in the context of failure, should be remedial action rather than going straight for a failure regime. My noble friend has a similar idea behind his amendment. On Amendment 303ZB, the new clause is intended to reinforce and strengthen how reconfiguration is carried out. Under Amendment 303A to Section 65A of the 2006 Act, bodies to which trusts’ special administration regimes apply should remain, so that the special administration regime applies to FTs and NHS trusts.
Again, we are shortening the Bill and making it simpler and probably taking out quite a lot of cost. I beg to move.
Baroness Finlay of Llandaff
My Lords, I have several amendments in this group. I shall start with Amendment 294N, which is a probing amendment. As far as I have understood it, social enterprise bodies which are NHS bodies in all but name are coming into existence. They have evolved from PCTs under the transforming community services programme. They will be subject to special health administration arrangements. I ask the Government to confirm whether the social enterprises that come under the health special administration arrangements are coming under arrangements based on insolvency law and that, as such, that allows assets to be transferred outside the NHS and the redundancy payments are not guaranteed.
Amendment 295CA is intended to ensure that clinical commissioning groups are consulted before the Secretary of State makes regulations that allow Monitor to impose charges on commissioners. The charge imposed can include a levy to fund Monitor’s functions that have to be invoked in the event of failures. Amendment 295CB is intended to ensure that when setting such a levy, Monitor takes into account the impact of the levy on the financial stability of the organisation, especially a financial trust that is already in distress or failing. Amendment 304A requires that the commissioners are considered when the services of a failed financial trust are considered by Monitor and should be involved in the decision as to which should be continued, and that such services must include some continuation of education and training, because in planning for the future workforce, if a whole lot of posts were suddenly lost, it would destabilise the workforce planning. That is in addition to considerations such as the service provision and issues of equity and access. That becomes particularly important because if you do not have the staff with the appropriate training, you cannot, in the long term, provide the service anyway.
Amendment 304B is intended to ensure that commissioners are involved in the board's role in agreeing arrangements to secure continued access to NHS services will be achieved. Will that include the board’s selecting which commissioner would become lead commissioner for the process during a failure?
Baroness Thornton
Perhaps I may ask for clarification. The noble Earl refers to providers all the way through. Can we be completely clear that this means all providers —that is, private sector providers, NHS providers, social enterprises and charity providers of health services? Do all these levies and fines apply to them?
Earl Howe
My Lords, when I refer to providers of NHS services, I am referring to NHS providers and non-NHS providers. It is to be determined who will contribute to the levy. That is being worked through and I am sure that the noble Baroness will have noticed from the document that we published the other day that this work is ongoing. We will make further announcements about that in due course.
On Amendment 304B, I say that the board should consult the relevant commissioners but it must make the decision itself, which is what the Bill provides for. The noble Baroness, Lady Finlay, asked whether social enterprises will be within the scope of the health special administration regime. Social enterprises are companies so they will be within the scope of health special administration. It is right that they are not treated as NHS bodies as when assets are transferred from PCTs robust rules apply, as I have set out in detail in previous debates. She asked whether the NHS Commissioning Board would nominate a lead commissioner if a provider becomes unsustainable. The answer is yes.
I hope that noble Lords will find that series of explanations helpful and I ask the noble Baroness, Lady Thornton, to withdraw the amendment.
Baroness Thornton
I thank noble Lords. I will take only a moment, but we will need to return to this. First, this was not looked at properly in the Commons and I can see that that is the case. Secondly, I recall that the chief executive David Nicholson disagrees. He said that he advocates de-authorisation. I believe that the pooling and the levy are bureaucratic and expensive and that the noble Earl does not understand that reconfigurations will not be led locally. I do not think that the Bill adequately approaches how we will manage reconfigurations. To be kind one has to say that the work is ongoing; I am not quite saying that the department and the Bill team are making this up as they go along, but it is definitely an area to which we will need to return on Report. I beg leave to withdraw the amendment.
Baroness Thornton
I have a very small piece of advice to give the Minister. I always think that it is best to give in and agree with my noble friend Lord Warner. I have almost always found that this is the best course of action. The noble Earl might recall that, when I was a Minister, on one of the occasions where I did not give in I certainly came a cropper. I urge the Minister to think very carefully and seriously about what my noble friend has had to say. It merits great attention and it merits being in the Bill.
Earl Howe
My Lords, before that intervention I was about to say that I was very pleased that the noble Lord, Lord Warner, had returned us to this issue, which I, like he, regard as extremely important. It is a thoughtful amendment and will certainly prompt further thought on my part after this debate.
I do not think that there is any difference between the noble Lord and myself in this respect. I am certainly all in favour of ensuring that wherever possible there is early intervention and proactive monitoring of organisations well in advance of failure so that failure can be averted. The main difference between us, if there is one, is that we believe that this process should be locally led and not led from the centre, which is how I read his amendment. I probably read it wrongly. When the noble Lord spoke to it, he indicated that nothing in it was intended to run counter to that locally led process. I take that on board.
Why are we so keen on a locally led process? The overall aims that we set out are to put patients, carers and local communities at the heart of the NHS, shifting decision-making as close as possible to individual patients and devolving power to professionals and providers, liberating them from top-down control. This amendment would appear to do the opposite and could lead to an increasing level of decisions being centralised and moved away from local communities and their democratic representatives. The more that one does that, the less likely one is to get local buy-in. In a patient-led NHS, if it is to be worthy of the name, any changes to services have to begin and end with what patients and local communities need.
Baroness Thornton
Does not the experience of the last few years—we can name the hospitals concerned—show exactly the opposite of what the noble Earl is now saying to us, that this has to be locally led? We have to find some mechanism which allows decisions to be taken that does not dismiss or ignore local feelings. Of course people have to be involved in those decisions but, at the end of the day, we know about Chase Farm and several hospitals I could name. In north London, we know that we have too many hospitals. They have not been closed down because it is politically too difficult to do so. If the decision remains at local level, in north London we will still have too many hospitals. I have lots of MP friends who have campaigned to keep those hospitals in place, particularly before the last general election. It seems that what the noble Earl is outlining now will not work.
Earl Howe
Contrary to popular opinion, there have been cases of very successful and rapid reconfigurations of services. Of course, the ones that come to our attention are those that have taken a long time, such as Chase Farm. There is no better or worse example than that.
In reading this amendment, we should be cautious about any process that would significantly weaken both local commissioner autonomy and public engagement. We do not want to conflict with the statutory requirement for NHS bodies to ensure appropriate and proportionate involvement of patients and the public in service changes or reduce the ability for local authority scrutiny to bring effective democratic challenge to reconfiguration plans. I certainly do not think there is a case to reduce democratic accountability in this way.
I agree with the noble Lord that, where it is not possible to reach local agreement on a service change proposal, there should be mechanisms for independent review. We are retaining powers in the Bill for local authority scrutiny functions to be able to refer reconfiguration schemes. As part of the transition, we are also exploring how the NHS Commissioning Board and Monitor can work together to support commissioners and providers. As I have said, the key to successful service change is ensuring engagement with the local community and stakeholders so as to secure as broad support as possible in what can be very difficult decisions.
Health: Neurological Conditions
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
My Lords, it is an honour to be replying from our Front Bench to the debate initiated by my noble and long-standing friend Lord Dubs. As ever, it has been an excellent debate, revealing the depth of knowledge residing in your Lordships’ House.
Neurological disorders are very common. They account for 10 per cent of all GP consultations and around 10 per cent of acute admissions to hospital, excluding stroke, and amount to a disability for about one in 50 people. They range from migraine to motor neurone disease. I was very struck by a fact in the extremely helpful June 2011 report about neurological disorders, compiled and written by the Royal College of Physicians. It said that, unlike stroke, acute neurology services are rarely provided by neurologists in hospitals when people are admitted with acute conditions, which the Royal College of Physicians believes has adverse outcomes for patients. How many neurological consultants are there and how many do the Government estimate are needed? If the noble Earl agrees that there is a gap between those two numbers, what do the Government intend to do about it?
The report makes three proposals, which are worth quoting here. First, it says that local services should be expanded and improved, with a shift in emphasis from scheduled to emergency care. Secondly, it says that there should be better organised care for patients with long-term neurological conditions, managed in part through an enhanced role for specialist nurses and general practitioners with specialist knowledge in neurology. Thirdly, it says that there should be better local planning of services with increased clinical involvement within a commissioner-provider forum, creating a neurological network to improve clinical and financial outcomes. How will those proposals be delivered under the new architecture proposed for the National Health Service in the Health and Social Care Bill, and how will specialist nurses be trained, retained and encouraged under this new architecture? Will it be done through CCGs, the National Health Service Commissioning Board, or where?
I turn to some specific conditions. I am very grateful for the briefings that we have received from a range of organisations, which shows the strength of the Neurological Alliance. I commend it for the work that it has done. On epilepsy, the provision of services is actually rather poor, and I think that other speakers may have suggested that that is the case with other conditions. People seem to agree that provision is rather poor, and yet it seems that action is slow in coming. My noble friend Lord Dubs put his finger on this—it is a bit of a Cinderella area in the National Health Service. There are several things that the Government could do. The priority of the new national framework for the NHS to tackle avoidable mortality is to be welcomed, but how will the Government commit to explicit inclusion of epilepsy mortality in the outcomes framework? I will refer to epilepsy mortality again in a moment. Will the Minister consider providing a specified neurology lead in each commissioning group? Without that, the Epilepsy Society believes that it will remain a Cinderella service.
On avoidable mortality in epilepsy, the figures bear some exposure. In England and Wales about 22,807 years of life are lost each year through epilepsy. That number of years lost is larger than the years lost by people with asthma. The average number of years of life lost per person is over 30 years. In England and Wales, 11 per cent of all epilepsy-related deaths are in children and young people under the age of 25. The Epilepsy Society believes that these deaths are avoidable.
I happen to know that the Minister shares many of the concerns in this area, because immediately before he was elevated to his present position he was the chair of the All-Party Parliamentary Group on Epilepsy. He addressed a conference in January last year before the general election, which was jointly organised by the Department of Health and the Joint Epilepsy Council. My honourable friend Ann Keen, who was then the Minister, was won over by the case made by these charities. The conference was specifically aimed at NHS commissioners of epilepsy services, and at the end it is reported that the noble Earl who is now the Minister told the commissioners to go away and make a difference. I hope the noble Earl will forgive me if I use his words to urge him to do the same.
I turn to muscular dystrophy, and related neuromuscular conditions, which comprises a group of about 60 different conditions affecting children and adults and can be genetic or acquired. The House has discussed those conditions before, partly as a result of the work of the noble Baroness, Lady Thomas. Recent data suggest that many patients with neuromuscular conditions are being admitted to hospital for emergency treatment but that 37 per cent to 42 per cent of these admissions could have been prevented if the patients had access to the right specialist support. I also received briefing by Professor Mike Hanna. I do not intend to report the case histories that the noble Baroness recounted to the House, but I think that they raise some very important issues, as they illustrate the importance, particularly going back to the Royal College of Physicians’ report, of neurological expertise being available in district general hospitals. That has to be a priority.
Turning to multiple sclerosis, which has also featured in this debate, the Multiple Sclerosis Society has produced an excellent brief about neurological conditions in general and, indeed, about people with MS. As the noble Baroness, Lady Gardner, mentioned, those people with MS rely on a multidisciplinary team of MS nurses, physiotherapists, occupational therapists, psychologists and others to maximise their independence and quality of life. The MS Society legitimately raises some very serious questions about what is proposed in the Health and Social Care Bill. What will happen to commissioning at local level by clinical commissioning groups? It is concerned that many of these groups will cover a relatively small population area, which means that it will not be cost effective to commission services for less common conditions such as MS. The society submitted a response to the Future Forum. The Future Forum itself said that the Bill did not satisfactorily address the concerns that are raised by what is called low-volume commissioning.
Motor neurone disease absolutely amplifies the problems that occur with low-volume commissioning. My understanding is that to commission effectively for a condition such as motor neurone disease, you need a population group of between 2 million and 4 million because it is such a rare disease. This is a point that I have put to the Minister before, but I really fail to see how the architecture being proposed in the Health and Social Care Bill and the way that things are being structured will be able to deliver that effectively. Like the noble Baroness, Lady Hollins, and my noble friend Lord MacKenzie, I fear for the transition as much as I am concerned about the outcomes. It is also unclear as yet what impact the National Health Service reforms will have on MS post nurses. One of the themes that the noble Earl needs to address, which has run throughout this debate, is the importance of specialist nurses for those with neurological conditions.
My noble friend Lady Gale is a great champion for Parkinson's disease. As part of the NHS workforce projects briefing that we received from the Library, page 13 was very interesting. That page shows the complex web of care that is necessary for somebody with Parkinson’s disease, or indeed any of the neurological conditions. The diagram shows that there are at least 20 different people with specialities who are involved in the care of somebody with a neurological condition. Those 20 go from ward hospital staff through voluntary groups to respite care staff, dietician, health visitor, school nurse, if the person is young, and physiotherapist. The person who can co-ordinate those 20 people is of course the specialist nurse who can work with that sufferer and their family.
I should like to return to a theme which I picked up particularly from the comments made by the noble Baroness, Lady Gardner, about integration. My noble friend Lord Dubs and other noble Lords also addressed this issue. Regarding integration and support for people with neurological conditions, we will be debating the Welfare Reform Bill next week in this Chamber but it is difficult to escape from the fact that current government proposals will have a serious impact on people suffering from conditions as complex and fluctuating as motor neurone disease or MS. For example, people receiving contributory employment and support allowance in the work-related activity group will have the payment of their benefit limited to 12 months. We know that many of the 40 per cent of people with MS in this category already face significant barriers to work and a large proportion will not qualify for income-related ESA, leaving them with no financial support. Will the new PIP, referred to by the noble Baroness, Lady Gardner, take proper account of fluctuating conditions? The current proposal not to carry over automatic entitlement to PIP will lead to costly and unnecessary reassessments for those with long-term degenerative conditions, and how much worse will that be in a case like that mentioned by my noble friend Lord MacKenzie—motor neurone disease, which can progress very rapidly?
The range and quality of the briefing that we have all received is testament to the seriousness of the challenges facing those with the many different kinds of neurological disorders mentioned today. I am afraid that the progress made, such as it is, may even now be faltering, stalled or in jeopardy, due to a combination of the reorganisation of the NHS; the loss of posts—for example, specialist nurses; the lack of clarity about who will be responsible for what, particularly during the transition; the cuts to local authority funding; the loss of strategic health authorities to commission the training of those specialising in these conditions; and, indeed, the funding problems of the voluntary organisations that provide support for those with neurological conditions.
I am not surprised that my noble friend Lord Dubs wanted to have this debate. It has been illuminating and important and has outlined a huge challenge for the Minister when he responds.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
At end to insert “but that this House regrets the Government’s appeal against the Information Commissioner’s ruling that the Government should release the Transition Risk Register; notes that the Information Commissioner says that disclosure would aid public understanding and debate on crucial aspects of the Bill; and requests that the Secretary of State reconsider his decision to withhold the information in order that this House can have the information in time to be considered during the passage of the Bill.”
Baroness Thornton
My Lords, I move the amendment, which is for a Motion of Regret, in my name on the Order Paper. This is the third time that I have asked for the indulgence of the House to bring this important matter before it and I hope that this will be the last. My amendment is not a fatal Motion. It does not intend to stop the progress of the consideration of the Bill, much as the doctors, the BMA and others might desire it. The battles to change the Bill are for later today and in the new year. This is a broader issue.
This amendment will allow the House to express its dismay, should it so wish, that the Government are denying the Committee currently considering the Bill information that may be pertinent to its deliberations. Noble Lords may recall that my right honourable friend John Healey MP and the Evening Standard both submitted freedom of information requests in November 2010 to have the register of risks relevant to the Bill released. They went through the procedures of review and appeal with the Department of Health.
On Friday 2 November, the Information Commissioner ruled that, given the particular circumstances—that is, the passage of primary legislation through Parliament—the register of risks should be released. I raised the matter in the House on 14 and 16 November, asking for the information to be made available. On 28 November, the Minister informed the House that the Department of Health was appealing the decision of the Information Commissioner. He was unable to inform the House of how long the appeal process might take and whether the risk register might ever or eventually be made available to the House in time to be considered during proceedings on the Bill.
The Minister also said that some information might be made available. However, he said:
“I cannot share the detailed breakdown of the information recorded in the risk register, or the wording”.—[Official Report, 28/11/11; col. 16.]
The noble Baroness, Lady Williams, supported the need to make this information available to the House, for which I for one am very grateful. It underlines the fact that this is not a party-political issue and is not for point-scoring. It is about the proper functioning of this Chamber doing the best job it can with all the information available to enable us to do so. The pros and cons of releasing the information have been thoroughly explored by the Information Commissioner in his ruling, including addressing the concern about precedent-setting expressed by the noble Lord, Lord Butler, on 28 November. The Information Commissioner argues with great clarity in his ruling that the particular circumstances of the Bill mean that the information is directly relevant and should be released. He said in his ruling of 2 November that:
“The Commissioner finds that there is a very strong public interest in disclosure of the information, given the significant change to the structure of the health service the government’s policies on the modernisation will bring”.
In this ruling the commissioner goes on to say that he,
“considers that disclosure would go somewhat further in helping the public to better understand the risks associated with the modernisation of the NHS than any information that has previously been published”.
This is the information that we have been refused. Today we start day 11 in the Committee on this huge and complex Bill, with its implications for our NHS. We have been considering this Bill for over 60 hours, and by my reckoning we have about another 25 or so to go before we embark on the next stage in the new year. We do so ignorant of this information.
As well as regretting the decision taken by the Government, the amendment asks the Minister to reconsider the decision to appeal the Information Commissioner’s ruling. I appreciate that the decision about this matter may be above the Minister’s pay grade, and I sympathise with his position. It seems to me that a clear expression of the House’s dismay and regret may strengthen the Minister’s hand when he discusses this further in the department.
There are two final matters which I ask the House to consider. The first is that the last Government, under similar circumstances, and indeed after a year of resisting, released the third Heathrow runway risk register to Justine Greening MP. It did not create a rush to request risk registers. Secondly, it has also emerged, as was published in the Evening Standard, that NHS London publishes quarterly on its website a risk register for health services in the capital, including how they could be affected by the Government’s reforms. NHS London’s frankness can only add to the case for publication. I understand that one other NHS region is also considering this course of action. I ask the Minister if he is aware of this, and does it not rather undermine the argument the Government are using to appeal this decision? Indeed, does his department intend to stop NHS London?
I hope the House will regard this as a very serious matter. I hope that noble Lords will consider supporting this Motion of Regret if there is no change in the Government’s position. Like all noble Lords here, I hold the noble Earl, Lord Howe, in great respect and esteem, and I have come to the decision to proceed only after much reflection. It is because this House is a body of revision and scrutiny. It has without doubt a worldwide and distinguished record of scrutiny, which includes, after consideration of evidence and facts, telling Governments that they need to change legislation. This House has a reputation for standing up to Governments when it believes that rights and liberties are in jeopardy, and having access to the information allows us to reach considered decisions. I suggest that we are being denied the ability to do our job. A GP sent me a message this morning:
“Glenys Thornton, how can you debate a Bill without knowing the risks?”.
He is right.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, as the House will recall, I have made clear on earlier occasions why the Government do not believe that it is appropriate to reveal the details of my department’s risk registers. This decision was made not solely in consideration of the current Bill but in the wider context of government. It is important for me to emphasise that.
However, in addressing the noble Baroness’s Motion, it may be helpful to put the issues that she has raised into the broader context of the Freedom of Information Act. The overriding aim of the Act is to maintain a balance between openness and confidentiality in the interests of good government. Openness is an intrinsic part of good government and is a principle that I and my fellow Ministers firmly believe is important. At the same time, it is equally important to acknowledge the need for a safe space when formulating policy and the associated risks. Those noble Lords who took part in the debates on the FOI Bill will recall the clear position taken by Ministers of the day about where that balance should be struck in relation to the workings of government. It was made clear that the Act was not intended to change the way that the Government conduct their business by requiring all their deliberations to be made in public. Some element of confidentiality must remain for the proper and effective conduct of that business.
Ministers and civil servants need the space to be able to consider the worst risks—even to broach quite unlikely risks—and to do so openly and frankly, without the threat of disclosure. Without this safe space for open and frank risk assessment, the registers would be in serious danger of becoming anodyne documents and their purpose would thereby be significantly diluted. That is why information relating to the formulation or development of government policy is explicitly exempt from disclosure under the Act. There is also an explicit exemption for information that would inhibit, or be likely to inhibit, the free and frank exchange of views for the purposes of deliberation.
It is my department’s very clear view, and the view of other government departments, that departmental risk registers of this type and nature should be treated as being exempt from disclosure. That was also the view taken on several occasions by health Ministers in the previous Government. I say to the noble Lords, Lord Pannick and Lord Martin—I was grateful to the noble Lord, Lord Martin, for his remarks—that the Government have no wish to be discourteous or obstructive to this House. Quite the opposite.
We are absolutely not using the right of appeal as a delaying mechanism. The department has published and discussed its proposals for reform at every stage of the process; we have debated them at length in both Houses; it has released some detail about the associated risks and what it is doing to address them in its impact assessments. In response to the noble Baroness, I myself have provided the broad issues covered by the risk register in my Statement of 28 November. Incidentally, that Statement was meant to be complete. I assure the House that in taking forward the Bill, no further risks are identified on the register that would fall outside the list of broad issues that I provided. I am therefore satisfied that I have not misled the House as a result of the Government's decision to appeal.
I am very grateful to my noble friend Lady Williams for her suggestion that the case should be expedited. I am as keen as anyone to see the matter speedily resolved. As my noble friend knows, she and I discussed this yesterday privately and I have since pursued the matter actively with my officials. I should say, however, to place my noble friend's suggestion in context, that since we met, the solicitor acting for the Information Commissioner has requested an extension of time to file the commissioner’s response to our appeal notice and has indicated that the appeal raises issues of considerable importance that will require the tribunal's normal target time for listing an appeal hearing in order for the case to be properly prepared.
I should also make clear a further point. For our part, as the House knows, we take the view that this case raises an important matter of principle for the Government as a whole. We took the decision that we have taken after very careful thought and discussion. Now, the burden is on us as appellants to provide accurate and pertinent evidence to the court to support our case. In preparing that case, we need to consider and consult across various parts of government, as indeed we consulted about our decision to appeal. It is obviously important that we have the necessary time to prepare and carry out those consultations. We have not asked for more time, but I suggest that we need enough time.
I completely understand and sympathise with the desire of my noble friends to see the matter resolved, and I undertake to use my best endeavours to pursue the suggestion so helpfully made by my noble friends Lady Williams and Lord Clement-Jones. The decision to appeal the Information Commissioner's ruling has not been taken lightly, but we have taken it because we believe that the commissioner has not given sufficient weight—
Baroness Thornton
Can the Minister give us some times here? How long is it going to take? When does he expect to have the tribunal sit? He keeps saying that it will take time to prepare and to do this, but I think that we need to know how long that will be.
Earl Howe
Having anticipated that question before this debate, I made a point of asking but I am afraid that I do not have a definite answer to give the noble Baroness at this stage. As soon as I am able, I would be delighted to do so.
Our appeal is based on the belief that the commissioner has not given sufficient weight in his judgment to the considerations embodied in the relevant provisions of the relevant FOI Act. As the noble Lord, Lord Butler, made clear on 28 November, the ruling has serious implications across government in the precedent it sets for all risk registers.
Earl Howe
The noble Lord knows that that is a matter for the House and the usual channels and not for me. However, I have no doubt that his suggestion will be registered in the appropriate places and will be considered. He must understand that it is not solely in my gift to order the business of this House.
I am of course acutely aware of the concerns of noble Lords on this issue. However, I would just ask those noble Lords who may at first blush be inclined to side with the noble Baroness in her amendment to recognise that there is room for an honestly held difference of view on this matter, that the principle involved is very important for the workings of government and that the Government have acted both properly and reasonably in asking the Information Tribunal to reconsider the merits of the case.
Baroness Thornton
My Lords, I thank noble Lords for this very illuminating and important debate, and I feel the weight of that importance. I think that the Minister would admit that over the past four weeks we have been very measured in our approach to this issue. We have not rushed at it; we have not sought to delay the Bill; and we have been very measured and patient in trying to work out the best way forward.
I thank the noble Lord, Lord Pannick, my noble and learned friend Lady Scotland and my noble friend Lord Richard and others for their support on this. I also thank my noble friend Lord Richard for crystallising the point that we should not proceed to the next stage of the Bill until we have the results of the appeal, and perhaps that would concentrate minds. In that context, I think that my amendment, which is a regret Motion, will help.
The noble Lord, Lord Clement-Jones, spoke about a chilling effect. I found the remarks of the representative of our former Permanent Secretaries in the House, the noble Lord, Lord Turnbull, interesting but possibly not to the point. The Freedom of Information Act may need reforming but that is not the point of my regret Motion. Particularly in response to the noble Lords, Lord Clement-Jones and Lord Turnbull, I should like to quote to the Committee from “Yes Minister”. This is from episode one of the first series and is about open government. Bernard, who noble Lords will all remember is the Private Secretary, says:
“But surely the citizens of a democracy have a right to know”.
Sir Humphrey—or maybe we should call him “Sir Andrew”—says:
“No. They have a right to be ignorant. Knowledge only means complicity in guilt; ignorance has a certain dignity”,
although it is not dignity that I would particularly welcome.
I confess that I am disappointed by my colleagues on the Liberal Democrat Benches. I was here with them in the Chamber fighting for the Freedom of Information Act all those years ago, and I know that they would have liked my Government to have gone even further than we did. Therefore, it is a matter of regret and disappointment that they are not joining with us in saying that the commissioner’s ruling is a good and measured ruling, that it takes account of all those issues and that this information should be made available to the public and, indeed, to the House.
Finally, the question is very simple. It is not about the appeals tribunal, and the noble Lord, Lord Pannick, was right. It is about how this House amends legislation to make it good legislation, and it is an amendment to regret the fact that we are not being given the information that we need to help us in that job. It is a very mild rebuke—it is an amendment expressing regret. It is a regret that we cannot do that job because we need this information. My view on that has not changed as a result of this debate. I feel enlightened by this debate to a certain extent and think that we may see a way forward. However, we need to regret the fact that we do not have this risk register, and I wish to test the opinion of the Committee.
Lord Warner
I was not doubting the enthusiasm on the Liberal Democrat Benches regarding this area. I just wanted to provoke the noble Baroness into giving the kind of excellent speech that she has given. I was hoping that we would hear from her. I also join her in paying tribute to Paul Burstow, and indeed Norman Lamb, for the very supportive way in which they have approached this issue.
Baroness Thornton
My Lords, we have had a very interesting debate on this imaginative amendment from my noble friend Lord Warner. Today’s debate might well be the only debate on social care in the whole life of this Bill, including in the Commons. I would like to talk about some real people, with real conditions and real problems, because it is only by testing this Bill against those that we will know whether it is going to work, and whether the issues that are being raised by noble Lords across the House are going to be taken into account.
I would like to pick up where the noble Baroness, Lady Greengross, left off, and talk a bit about dementia, partly because I have a very close friend whose wife has dementia and I have been following the path of this for the last seven or eight years, but also because this is an issue that affects hundreds of thousands of people. The Alzheimer’s Society reckons that: there will be 1 million people with dementia by 2025; dementia costs the country £20 billion now; one in three people over 65 will die with dementia; only 40 per cent of those have a formal diagnosis—that figure varies enormously across the UK; and, of course, which is the reason why they are important to this debate, people with dementia are very significant users of health and social care services. We know that people over 65 with dementia are currently using up one-quarter of hospital beds at any one time. The current system of charging for care, such as help with eating, hits people with dementia hardest, as the noble Baroness, Lady Greengross, has said, and amounts to what the Alzheimer’s Society calls a “dementia tax”.
We know all of this. The All-Party Parliamentary Group on Dementia, the National Audit Office and the Alzheimer’s Society have identified that significant resources are wasted on poor-quality care—for example, through crisis admissions into hospital or long-term care. There are opportunities to save money in dementia care across a wide range of settings; for example, by investing in early intervention and prevention services. In a way, those matters are the test of this Bill. Can we save the money and deal with the people who have got dementia? How can we promote a shift of NHS resources away from acute hospitals into community-based services, as recommended by the NHS Future Forum and the recent inquiry by the All-Party Parliamentary Group on Dementia?
I know that the Government recognise that a sustainable NHS in the future requires a new long-term settlement on social care to ensure quality for people facing disability and long-term illness. We think that this amendment will help with that. When I was looking at this amendment, I remembered that I myself was given a speaking note that said, “Of course, health covers social care, too”. That is not good enough any more; it is not good enough to say that by writing health into the Bill and giving the Secretary of State responsibility for it, we are somehow covering social care. Apart from anything else, it has not worked. We know it has not, and we are where we are. There are some very serious issues.
Earl Howe
My Lords, this set of amendments is predominantly made up of a series of minor government amendments to Schedules 4 and 5. Many of them make minor or technical changes to these schedules to correct errors, ensure the Bill’s provisions work as they are intended to do and make minor consequential amendments to the NHS Act 2006. They correct a couple of errors in cross-references and the placement of consequential repeal; add references to the Bill’s provisions on transfer schemes to Sections 216 and 220 of the NHS Act, which relate to the transfer of property held on trust by the NHS, such as charitable property; and remove a reference to Section 2 of the Local Democracy, Economic Development and Construction Act 2009, which is being repealed by the Localism Bill.
The amendments also amend the definition of “qualifying company” in Clause 294, so that under the Bill we will be able to transfer property to a subsidiary of a company wholly owned by the Secretary of State, not just to companies owned directly by the Secretary of State. They also amend Schedule 4 to allow such subsidiary companies to be members of the statutory risk-pooling schemes for meeting liabilities of NHS bodies.
This group also includes one other amendment on Schedule 5, tabled by my noble friend Lord Lucas. Amendment 254 amends the Freedom of Information Act 2007 so that the criminal offence of taking certain actions to prevent disclosure of information held by a public authority is expanded to include information held by service providers. I can reassure my noble friend that the Government are committed to extending the scope of the Freedom of Information Act to increase transparency. To do this effectively, we need to spend time properly considering the issues raised. It would not be appropriate to rush through changes that have not received proper scrutiny.
As part of this work, the Freedom of Information Act will be subject to post-legislative scrutiny and the Cabinet Office has recently concluded a public consultation on an open data strategy, which is aimed at establishing how we ensure a greater culture of openness and transparency in the delivery of public services. I understand that my noble friend has already met with officials to discuss his concerns around freedom of information and this Bill, which I hope reassured him. If he has additional concerns following this debate, I would be more than happy to write or to meet him to discuss this further. I hope that that will enable him not to press his amendment when we reach it.
I also hope that I have satisfied noble Lords that this set of government amendments should be made and that my noble friend will feel equally content.
Baroness Thornton
My Lords, I should like to ask one question and to make one remark. Even the Minister smiled when he used the words “openness” and “scrutiny”. Given our previous conversations about the information that the House has not received, I do not intend to rehearse that again but I would look at colleagues in the Liberal Democrat Party and say just how shocked and amazed I am by their lack of willingness to want proper openness and scrutiny on this Bill.
My question concerns the strategy risk-pooling schemes. I understand what those are, but I would like to know who the pooling would be shared with.
Life Sciences
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Baroness Thornton
My Lords, I thank the Minister for repeating the Statement. I, for one, certainly believed it was important that we took this Statement in the House, even if it is a day later than we might normally have done, because our great panoply of scientists, doctors and experts should have an opportunity to respond to it. It is likely that we can see the Minister’s hand in this initiative as research is one of his responsibilities and, indeed, one of his passions.
I share the Minister’s pride in Britain’s strength in life sciences. We all agree in the House that the industry needs government support and focus if its potential to contribute to the country’s industrial future and to its people is to be maximised. I also think the whole House will agree that there are huge potential benefits to British patients from closer collaboration between the NHS and the industry. We all want patients to have the quickest possible access to the latest life-saving and life-enhancing treatments. Indeed, it was for those two principal reasons that when we were in government we prioritised the life sciences sector and established the Office for Life Sciences to support an industry that employs more than 100,000 people. Indeed, we created a Life Sciences Minister—a contact point for the industry and someone of huge experience and real personal commitment to it. It has to be said that one of our criticisms of this Government is we believe that they have allowed the momentum that we established behind promoting this industry to fall away. Indeed, the unexpected closure of Pfizer earlier this year exposed the Government asleep at the wheel and was a wake-up call. Therefore, to some extent we see this as the Government playing catch-up but it is nevertheless an extremely welcome development and we wish it well.
Although the Minister is concerned about the need to lift a regulatory burden from industry, I think we all agree that proper regulation on the use of patient data is most certainly not a burden that we want to lift. We want that properly addressed. My questions are around those issues. Some patient groups have already expressed concern about the media-briefed statement from the Government and the lack of accompanying detail, so I hope that the Government will be able to give some reassurance here. Will all patients have the ability to opt out of sharing their data, even in anonymised form? Will the fundamental principle of consent form the bedrock of any new system as control of data should be possible in today’s information age? I understand that the patients’ representatives walked away from the Department of Health working group on these important matters. If that is the case, why did they do so? Does the Minister accept that he needs to work harder to uphold public confidence in this process or risk undermining trust in the whole principle? Therefore, the safeguards are very important. What safeguards will there be to ensure that patient data are stored securely? What precisely are the changes that the RHG plans to make to the NHS constitution?
Is it the case that the anonymity of data cannot always be guaranteed? If that is the case, what are these circumstances, and why not? The Minister is very familiar with this issue, as, indeed, is his noble friend Lady Northover, because in May 2002 both of them were involved in a debate on precisely this issue. It was a debate on the safeguarding of patient data. It was said in the debate:
“For example, the Gulf War-related research and the research relating to leukaemia in the area of Sellafield could not have been carried out with purely anonymised data. There has also been recognition of new variant CJD and its relation to the BSE epidemic”.
It is not appropriate to use anonymised data in that context either. It was also stated, in my view very wisely:
“Apart from the medical profession, who else will be subject to the contractual duty of confidentiality? What type of contract does the Minister envisage will be entered into by, for example, civil servants and those who act with the various agencies which may process that information? What review process for the regulations will be followed by the Secretary of State in 12 months' time? Will it be an open and transparent process? Will there be an opportunity for debate? There is also the very important issue of informing patients that their information has been processed. I believe that the Minister should spend some moments explaining how patients—or, at least, doctors—will be able to tag their medical notes in some shape or form so that it is clear that their information has been processed by researchers”.—[Official Report, 21/5/02; col. 750.]
I could not have put those questions better myself, and they are the ones that the Minister needs to address in this case.
Who will judge which companies will receive this information when they are in competition with each other? The Statement assumes a very prettily organised and co-operative world but that is not the world out there in the pharmaceutical industry. Companies are competing with each other for the research they do, its outcomes, availability and how you make it available. How will the Government judge which companies they make this information available to and what criteria will they use under those circumstances?
I wish to ask the Minister a specific question about one of our great institutions which is involved in this research—Cambridge University. It seems to me that the Government need to manage these sorts of challenges, and this is a very serious one. I have given the Minister notice that I was going to raise this question. In October 2011, the European Court of Justice, responding to a reference from a German court about the interpretation of the European directive on the legal protection of biotechnological inventions, made a judgment which will have the effect of banning the issuing of patents for embryonic stem cell research. The ruling means that existing patents involving the use of embryonic stem cells are no longer valid and that future patent applications will not be considered. Many researchers at Cambridge are concerned that the ruling could damage the entire field of research and drive much of it abroad. The ruling could act as a huge disincentive for investment as patents are important if pharmaceutical companies are to recoup their investment in clinical trials and turn a profit. It could therefore set back possible new treatments for a range of disorders from heart disease and diabetes to blindness and Parkinson’s. The ruling also leaves scientists in the contradictory position where they are funded to do research for the public good yet prevented from taking discoveries to the marketplace where they could be developed into new medicines. It would be a tragedy if our great institution of Cambridge University had to take this research abroad because of a ruling of the European Court of Justice. I would like to know what the Government intend to do about that.
I am afraid that I cannot resist making this final point. It is a great irony that while Ministers are happy to offer up other people’s data, they continue to withhold the risk register on their own reforms despite a clear ruling from the Information Commissioner to publish.
Health: Oral Cancer Detection
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Earl Howe
My Lords, I agree with my noble friend that it is not satisfactory. However, the position with research funding from government sources is that proposals are evaluated on the basis of merit; there is no predisposition to any particular kind of research as long as it is high quality. Both the MRC and my department, with the National Institute for Health Research, are open to proposals of high quality to address unmet areas of research.
Baroness Thornton
My Lords, I congratulate the noble Baroness, Lady Gardner of Parkes, because I answered Questions that she asked on this issue in my time. She has shown great persistence and no small amount of success in pushing this issue along. I would like to ask the Minister a question about smoking, because, as he rightly says, smoking is a factor in the incidence of mouth cancer. In the public awareness campaign about tobacco and tobacco regulations, are the Government including the implications of mouth cancer?
Earl Howe
Yes, we are continuing to invest in tobacco control activities. The noble Baroness will know that in March, we published our tobacco control plan for England, which sets out a range of action points. We are running marketing communications campaigns, with a campaign currently on television. In the new year, we will be making Quit Kits available through pharmacies across England; in the spring, we will run a campaign to highlight the risks of exposure to second-hand smoke and to encourage smokers to make their homes and family cars smoke-free.
Health and Social Care Bill
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Baroness Howe of Idlicote
My Lords, I have listened to what has been said by all these expert professionals and I am very much persuaded in favour of something along the lines of this amendment. I think that one of the most worrying things from the public viewpoint has been the sheer number of concerns about nursing that we have had in the press—not least, I may say, about the mortality rates et cetera going up during weekend staffing. Quite clearly there is a need for better reorganisation.
I go back quite a long way, to the time when I sat on the Briggs committee on the future of the nursing profession, and will never forget one of the nurses saying to me at the time: “I’ve been nursing for”—however long it was; she had just got her qualification—“and now I’m going to have a rest”, which was roughly what she was up to. I had a great deal of sympathy with her from that viewpoint.
I hope the Minister will bear in mind—I am sure that he must be more than aware of it—that the number of cuts in nursing staff are considerable in the present plan. Something like 8.3 per cent of qualified nursing jobs are to be lost. As the Royal College of Nursing pointed out in its briefing, that is on top of something that was done no less than about 18 months ago and is more than 10 times the original figure. Axing up to a quarter or a third of nursing posts will undoubtedly have a deep and potentially dangerous impact on patient care. Of course the training of the nurses—the experts in the really expert places—is essential. The training and up-skilling of those nurses on the real needs of patients is vitally important, but so are the numbers.
Baroness Thornton
My Lords, I thank the noble Baroness, Lady Emerton, the noble Lord, Lord Patel, and my noble friend Lord MacKenzie and other noble Lords for bringing these important amendments into Committee. Amendments 138 and 139 make provision for the NHS Commissioning Board to mandate safe nursing staffing levels and the number of patients a registered nurse is designated to care for. At the risk of stating the absolutely obvious about safe and effective staffing levels and patient ratios, where there are insufficient nurses and too many patients allocated to care for, then the level of care that can be administered will be affected. These amendments are about patient safety and well-being and the noble Baroness, Lady Murphy, hit the nail on the head. In response to her remark about speeches and the length of speeches, my observation, which is shared on these Benches, is that the Cross-Benchers are not the problem. They have been making admirably short and speedy comments. I hope that mine will be also. Other noble Lords might think about that.
This is a current problem as well as a long-term problem. As my noble friend Lord MacKenzie said, it has been with us for a long time, but it is current at the moment. The Royal College of Nursing tells us that some NHS trusts are diluting the skill mix on wards and in other care environments. This dilution is when non-registered healthcare support workers are employed in the place of a registered nurse. Healthcare support workers are paid—as one might guess—significantly less than registered nurses due to their comparative lack of vocational qualifications, so are seen by employers as a cheaper option. We think that that potentially puts patient safety at risk. Recent research by the Nursing Times has highlighted a significant variation in skill mixes between different hospitals in different regions. It seems to us that when cost becomes the overriding factor at the expense of the quality of service, patient outcomes and even patient safety become endangered. The most high-profile recent example of this was the care failings of the Mid-Staffordshire NHS Trust. Sadly, due to a range of factors—including financial pressures—costs were cut, nursing staffing levels were reduced and patient safety declined. It is vital, therefore, that stakeholders, including the RCN, work together with the national Commissioning Board to set the appropriate staffing levels and standards. There is some evidence from the NHS Information Centre that there is an accumulating problem here. Between January and August, the decline in terms of full-time equivalents in nursing, midwifery and health visiting staff in England fell by 1.6 per cent, from 310,989 to 306,028. There is evidence of a growing problem.
I would like to ask the Minister about an exchange in October when the Secretary of State gave evidence to a Select Committee. He stated that he was not aware of the down-banding, which is the issue at stake here, relating to the ratio. He was not aware that this was a problem or that the Royal College of Nursing had raised it with him. The Director of Nursing at the Royal College of Nursing then gave evidence to the same Select Committee the following day. She claimed that the Secretary of State was aware of down-banding practices; that the Royal College of Nursing, among others, had drawn it to his attention; and that it was a matter of some concern. I ask the Minister whether the department is aware that this is a problem and what it is intending to do about it.
These Benches support the amendments, and we are keen that this issue should be addressed robustly.
Health and Social Care Bill
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Baroness Thornton
“( ) Subsection (1) shall not apply to any providers who have any financial interest, directly or indirectly, in the provision of any service that the clinical commissioning group may be required to commission.”
Baroness Thornton
My Lords, I also speak to my other amendments in this group. Over supper my noble friend reminded me that the late lamented Lord Carter, a previous Government Chief Whip, used to say to Ministers and others that if we needed to save time, the thing to do was to speak only from every other page and see if anybody noticed. What I intend to do is to try and speak from every other paragraph.
These issues deal with the serious potential conflicts of interest that GPs will face in their new role as commissioners of health services. When this group of amendments first started out it contained only two amendments but it has now, quite rightly, grown substantially to address the major concerns of transparency, integrity and patient confidence and the issue of trust that must be addressed in their new role. In passing, I would say that the publication of the Government’s recent draft guidance on commissioning, Developing Commissioning Support: Towards Service Excellence, in effect decrees that by 2016 the real work of CCGs will be outsourced, presumably to large private providers, which makes me start to question what is left for CCGs to worry about. However, the issue that these amendments deal with is a fundamental issue of the Bill.
We all have high regard for our GPs and we trust them as experts and advisors. We know from the evidence that they do a cost-effective and good job. Our national system of GPs may be quirky, half in and half out of the NHS, but it works. At its best, it is the very best system in the world.
We are concerned that the Bill endangers the trust that patients have for their GPs and, essentially, these amendments seek to explore and to test that. GPs are going to be decision-makers across the whole breadth of commissioning, making decisions about priorities and standards, things that may often be unpopular, and reconfigurations of service. They will handle huge amounts of money, own budgets and get bonuses for good financial performance. So patients need to be assured that they can continue to trust their GP and that their GP will always act in the patient’s best interest. This concern has been flagged up by the BMA and the Royal College of General Practitioners, so I hope that the Minister can tell the House how we will be able to protect the image and reputation of our GPs after the first CCG goes wrong. Amendment 156 starts with the obvious necessary safeguard that providers of primary medical services who have a direct or indirect financial interest in the provision of services that a CCG is required to provide must not be members of the CCG. Amendment 161 is also key in requiring the Secretary of State to issue guidance which must be incorporated into CCG constitutions on how conflicts of interest must be dealt with by consortia as part of their decision-making. Transparency and clarity about how potential conflicts of interest would be managed is essential if the confidence of the public is to be maintained.
Openness and transparency are supported by Amendment 176A, requiring CCGs to maintain a publicly accessible register of all potential conflicts of interest of individuals involved in any part of their commissioning process. Taken together, Amendments 176A and 224 reinforce this, and call for regulations to stipulate that no provider should be a member of a CCG if they have any financial interest in the provision of any service the CCG is required to commission; in other words, open book accounting.
We do not think it is enough, as Amendment 228 proposes, for a CCG member merely to declare their financial interest in a commissioning decision being taken by their CCG, or absent themselves from decision making on that provider. We expect our councillors to operate under this regime. We should expect other people responsible for public money to do the same. Indeed, this transparency and openness, and the declaration of interests, should be extended to their families, in the same way that it is for other public servants.
Finally, I want to underline that we recognise that extending GP commissioning and setting up CCGs has the potential to give GPs freedom to innovate, improve services and use commissioning to develop new models of care in the interests of the communities they serve. The safeguards against conflicts of interest proposed in these amendments are not designed to shackle CCGs. As I have said, the Department of Health commissioning guidance already does that. The safeguards will ensure that they abide by the reasonable rules, regulations and codes of practice that we would expect of any statutory body responsible for taxpayers’ money worth millions of pounds.
The public needs to be assured that robust governance arrangements are in place for commissioning consortia, and that conflicts of interest will be managed effectively. I beg to move.
Baroness Williams of Crosby
My Lords, I have a great deal of sympathy with the intention behind this amendment. Noble Lords will remember that from the very beginning of the discussion about this Bill, there has been a great deal of concern about the conflict of interest that could so easily arise. Many of us recognise that the relationship between patients and general practitioners crucially depends upon that relationship being one of trust. The same will apply, if the commissioning groups work well, to the relationship between them and the patients who are within the practices of which they are part. So I sympathise very much with what the noble Baroness, Lady Thornton, has proposed, and also with what the noble Baroness, Lady Finlay, has proposed in Amendment 161.
Our concerns on this side of the House are not with the whole motivation behind this. We believe that that is extremely important and we completely share it. It is our feeling, rather, that the remedies are not adequate to the scale. We feel, for example, that one of the weaknesses of both amendments is the lack of any effective sanctions against those who breach what would be a relationship of trust. At the moment there is not provision within the Bill for effective sanctions, which can be used to ensure that these high-minded and perfectly proper principles are lived by.
The Nolan principles have been very effective in local government—as we all know—and increasingly effective in national Government. There are references to those in the course of the Bill, but there is no specific determination that members of the partnership groups or the CCGs would be dealt with, if they were in breach of the requirement that they should not ever put their own interests ahead of those of their patients.
I suggest to the noble Baronesses, Lady Thornton and Lady Finlay, and her associates in moving these various amendments, that they would look at the amendment we have put down—and I suggest this with due humility—which effectively brings into practice powerful sanctions. We believe these will be effective in ensuring that this relationship of trust is upheld, and also that powerful requirements lie on every CCG, as well as on the board itself, that it would be absolutely clear that all interests must be declared publicly.
These will ensure that once people’s names are on the register, and they have made a declaration of the appropriate kind about their own interest never being put forward as the reason for a decision, there are then effective measures that will enable the whole issue to be dealt with in detail, with appropriate requirements of sanctions and of effective punishment for those who breach them. We believe this to be absolutely central to the working of the clinical commissioning groups and to the whole relationship of doctors to their patients.
So, with those few words, I hope I can persuade the noble Baronesses, Lady Thornton and Lady Finlay, to have a look at the proposals that we have put forward, which, I am pleased to say, have at least to some extent the support of the noble Baroness, Lady Finlay.
Earl Howe
My Lords, I know full well that noble Lords have some concerns about the potential for conflict of interest in a system of clinical commissioning groups. Those are natural concerns, but I hope to show that the approach that we are advocating has some very specific and robust safeguards within it, which meet the intentions of the amendments in this group.
The CCG constitution provides for dealing with conflicts of interest and specifies arrangements for securing transparency about the decisions of the CCG and its governing body. The governing body must in turn ensure that the group has arrangements in place to ensure adherence to relevant principles of good governance. The CCG’s governing body will have responsibility for ensuring that the CCG adheres to relevant principles of good governance. The Secretary of State can also make regulations for CCGs under Clause 71 of the Bill, which are designed to ensure that in commissioning, CCGs adhere to good procurement practice. These regulations may impose requirements relating to,
“the management of conflicts between the interests involved in commissioning services and the interests involved in providing them”.
These regulations can also confer on Monitor powers to investigate suspected non-compliance. These are the safeguards that the Bill puts in place. My view is that it is unnecessary and indeed undesirable to go further.
Requiring CCGs to adhere to examples of good practice in managing conflicts of interest, such as declarations of interest; or maintaining a register of interests; or the monitoring or registration of hospitality received by members is a temptation, but one that should be resisted. We have got to be very careful about encumbering the Bill and CCGs with inflexible prescriptions as to how CCGs should operate within the statutory framework, or procedure about how they specifically manage potential conflicts of interest. This does not mean that these are not reasonable safeguards. Requiring the governing body to discuss in public choices between potential providers, or publish any decisions made in camera, for example, would remove a necessary discretion around ensuring that sensitive issues, either relating to contract values or performance, or staff matters, were given the appropriate level of confidentiality. I would urge in particular that we do not—as proposed in Amendment 175CC—put restrictions on those from whom a CCG can commission services. Given the importance we attach to ensuring that services are delivered in an integrated way, we cannot afford to cut CCGs off from being able to commission services from local GPs with a special interest, for example, who could deliver secondary care services in a community-based setting.
Baroness Thornton
Will the noble Earl acknowledge that there is a conflict of interest there? There must be a potential conflict of interest there. How does the Bill mitigate that? How does the Bill deal with that? I cannot see from what the noble Earl has said so far that that is going to happen.
Earl Howe
I do not disagree with any of these principles, but I am not sure whether the noble Baroness understood what I said earlier: there have to be arrangements for securing transparency about the decisions of CCGs, and governing bodies have to ensure that CCGs adhere to relevant principles of good governance—think of the Nolan principles, for example, and many other ways in which good governance can take place—but there is no need to specify all this in the way these amendments suggest because the arrangements provided for in the Bill will cover these things. As the noble Lord, Lord Warner, said we are not in new territory here. There are very well established procedures for tackling conflicts of interest when they arise. There might very well be a conflict of interest in the kind of situation to which the noble Baroness, Lady Thornton, has alluded, but there are ways of addressing and coping with that.
The key to this is to have in place a rigorous framework of requirements, approved by the board as part of the CCG establishment process, to ensure absolute transparency and to manage conflicts of interest, subject to oversight—the oversight must be proportionate, but it has to be there. We can put on the face of the Bill, as Amendment 176AD would have us do, a detailed list of behaviours that we would expect members of CCGs to observe. Obviously I cannot disagree, as I say, with the stipulations on this list, but they are already provided for in the Nolan principles and indeed the GMC code Good Medical Practice, to which the noble Baroness, Lady Finlay, referred—and adherence to that is a condition of registration for medical professionals. The noble Lord, Lord Warner, was absolutely right: this code is what GPs and doctors in general fear to transgress. Of course, if one looks at that set of behavioural requirements, they are actually only an ideal and they have no specific system in place to ensure that they are met. The sanction on doctors is the threat that they will be referred to their regulator.
The NHS Confederation was very clear about this, and I have to say I agree with it. The Bill has to allow flexibility for the way that conflicts of interest are handled and developed over time, rather than being rigidly set in law. What the NHS Confederation told us was that conflicts of interest need to be managed effectively otherwise,
“confidence in the probity of commissioning decisions and the integrity of the clinicians involved could be seriously undermined. However, with good planning and governance, CCGs should be able to avoid these risks”.
I agree with that. There is a balance to be reached, and we believe the system that the Bill would introduce for managing conflicts of interest—the key points of which I hope I have described—provides that.
Baroness Thornton
My Lords, I thank the Minister. He will know, as will all those who have been Ministers, that when we are first appointed, we are told—the noble Baroness, Lady Williams, will remember this—that not only must we declare all our interests and have probity about the way we conduct ourselves, but we have to be seen to be doing it. A lot of these amendments are about being seen to do the right thing, and in terms of the relationship between GPs and their patients that becomes even more important. I agree with the noble Baroness, Lady Williams, and the noble Lord, Lord Marks, about their amendments and the need to have proper safeguards and remedies on this.
I think that if we co-operate, the noble Baroness, Lady Finlay, and I can probably crystallise these into something on the face of the Bill. I was disappointed that the noble Earl feels that this is satisfactory in the Bill at the moment, because I think the noise outside this Chamber and the comments from GPs tell us that people are very concerned about it. We need to address that in the Bill. I am happy to withdraw this amendment, but we may need to return to this at a later stage.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 12 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, before the House goes into Committee on the Health and Social Care Bill, I should like to take the opportunity to update noble Lords on the latest position with regard to the Department of Health risk registers. The House will recall that my department received a specific request under the Freedom of Information Act to release the transition risk register, which covers risks relating to the development and implementation of our health reforms. There was also a separate request to release the strategic risk register, which covers the most important risks the department faces.
We have taken the view that the information in both registers should be treated as exempt from disclosure under Section 35 of the Act on the grounds that the information contained in the risk registers is integral to government policy-making. Risk registers of this sort are a tool by which information about potential risks—both actual and theoretical—can be recorded in worst-case terms to enable them to be mitigated and managed. The Information Commissioner accepts that the information falls within this category of exemption. Following our decision not to release the registers, the two individuals who made the FOI requests lodged appeals with the Information Commissioner.
In early November, the Information Commissioner published his decision notices in both cases, deciding that the public interest lay, on balance, in full disclosure of both registers. Since then, as is allowed for under the rules, we have been considering whether we should appeal the Information Commissioner’s decisions. As I explained to the House previously, this was not a decision that the Department of Health could make on its own, as the issues which bear upon the decision have significant implications for every government department.
While the principle of openness is one to which we have adhered to the maximum extent through evidence given to the Health Select Committee in another place and the publication of impact assessments, it has been our firm view, and that of other departments, that for risk registers of this type to fulfil their function, civil servants must be free to think the unthinkable and record potential risks and mitigations fully, frankly and with absolute candour, confident in the knowledge that this information will not be publicly disclosed.
The logic of the Information Commissioner’s decision to order the release of information of this nature would entirely undermine the concept of safe space for these sorts of circumstances. The matter has accordingly been the subject of much careful consultation across Government, and a very clear and firm view has emerged that the publication of information in risk registers of this type would be likely, in the future, to undermine the very purpose for which a risk register of this sort is produced, and thus directly threaten the successful implementation of government policy. I can, therefore, tell the House that my department has decided to appeal both decisions by the Information Commissioner.
I would, however, like to respond to the request made on 16 November by the noble Baroness, Lady Thornton, by sharing with the House as much further information as I can about what my department’s transition risk register contains. On that occasion I undertook to examine whether there were any risks covered in the Department of Health transition risk register that are not already in the public domain and on which information could be provided without further ado.
While I cannot share the detailed breakdown of the information recorded in the risk register, or the wording, I am happy to set out for the record the broad issues covered by the transition risk register. They are as follows: how best to manage the parliamentary passage of the Bill and the potential impact of Royal Assent being delayed on the transition in the NHS; how to co-ordinate planning so that changes happen in a co-ordinated fashion while maintaining financial control; how to ensure that the NHS takes appropriate steps during organisational change to maintain and improve quality; how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively, including the risk of replicating what we already have; how to minimise disruption for staff and maintain morale during transition; how best to ensure financial control during transition, to minimise the costs of moving to a new system, and to ensure that the new system delivers future efficiencies; how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board; how stakeholders should be engaged in developing and implementing the reforms; and finally, how to properly resource the teams responsible for implementing the changes. I hope that this information will prove useful to noble Lords as the Bill continues its passage in Committee.
Baroness Thornton
I thank the Minister for that statement, of which I did not have more than two minutes’ notice. It is very disappointing indeed. Basically, the noble Earl is saying that the Government are choosing what they do and do not disclose to the Committee on this matter. It is an issue of trust—whether or not we can trust that we will know what we need to know to make judgments about whether this Bill will work.
I thank the noble Earl for the issues that he has decided that the Government can let us know about, but of course I am therefore concerned about what the issues are that the Government have decided that we should not know about. What are the risks that we cannot know about? That is a matter of grave concern to the Committee.
I shall be looking in detail at the Minister’s statement to the House and I reserve the right to return to this matter if I feel that we need to. For example, during the last two days in Committee I put two direct questions to the Minister about whether certain matters—one concerning children—were on the risk register and what the register said about them. I have not received answers to either of those questions. I shall continue to put my questions in that context and I suggest that other noble Lords do the same.
I am very grateful for the Statement as far as it goes but I do not think that this is an end to the matter. I can see why the Government might think that there is a cross-government issue here. However, no other department is in the position in which we find ourselves here—that of discussing a Bill that is going through the House right now. We need full information on this matter in order to be able to make proper decisions but I believe that we still do not have that. Therefore, I thank the noble Earl so far as this goes but I reserve the right to return to the issue in due course.
Lord Campbell-Savours
Perhaps I may ask the Minister a question. He gave us a list of all the areas which he thought it was not possible for Parliament to scrutinise in some detail. Did the Information Commissioner have access to all the document headings to which the Minister has referred, and did he have the opportunity to read all the documentation under those headings? If the Information Commissioner did have access to information on, for example, the handling of the legislation as it goes through Parliament, why did he, throughout the whole report, repeatedly say that these matters should be placed in the public domain? Again, is it not clear that the Government are trying to hide something from Parliament? The Minister’s first reference was to the handling of the legislation by Parliament. Why should not Parliament see what considerations took place within the department concerning how legislation should be handled as it goes through this House?
Baroness Thornton
My Lords, perhaps I may speak to the amendments in this group which are in my name. First, Amendment 110A concerns NICE guidelines and is very much like that tabled by the noble Lords, Lord Newton and Lord Butler. In fact, theirs may be even better than mine so I intend to say no more than that we are interested in the Minister exploring this issue, because those noble Lords both more than adequately covered the points that need to be made in that regard. I am also very pleased to support the amendments in the name of my noble friend Lady Royall and to put my name to those, because the role of specialist nurses is extremely important.
Amendments 118, 119 and 120 concern the duty of the board to reduce inequalities. Proposed new Section 13G of the 2006 Act states that the board must,
“have regard to the need to—
(a) reduce inequalities between patients with respect to their ability to access health services;
(b) reduce inequalities between patients with respect to the outcomes achieved for them by the
provision of health services”.
This seems a rather narrow definition concerned solely with health services, which I assume flows from the continual and overriding responsibility of the Secretary of State for tackling health inequalities. I would be grateful if the noble Earl could confirm to the Committee how the Secretary of State intends to tackle health inequalities—what information he will need, where he will get it from and how those decisions will then be moved through the proposed structures of the National Health Service Commissioning Board, the CCGs and so on.
Surely, the health and well-being boards would want to have some involvement from the NHS on health inequalities, so Amendment 118 seeks to ensure that the board has health inequalities in its remit. I particularly refer the Minister to the letter from the NHS Future Forum to the Secretary of State on 17 November where it devoted much attention to the NHS role in improving public health and made its claim that the NHS must design its services in a way that both promotes good health and prevents poor outcomes. It is thus important that the legislation provides sufficient leeway to allow the NHS Commissioning Board to do this and that legislation relating to health inequalities is not confined solely to the provision and commissioning of services.
What is also important, in coming to my Amendment 119, is that funding to the clinical commissioning group reflects the deprivation levels within its area. Can the Minister tell the Committee whether there has been a risk assessment on the issues of funding? What risks has the department found that go with the levels of funding that might be made available on the basis of deprivation levels within areas?
Of course, the decision of the Secretary of State not to make clinical commissioning groups area-based is a serious problem in ensuring a population base for commissioning, but it will be doubly important to ensure that clinical commissioning groups with large numbers of deprived patients receive financial support. I would be grateful if the Minister could spell out the intended principles behind the funding associated with clinical commissioning groups.
On Amendments 110B, 127ZA and 190AA, which concern maternity services, the noble Baroness, Lady Cumberlege, has adequately covered the major concerns about those services and we would be keen to support her amendments. I am grateful to the Royal College of Midwives for its briefing on these amendments. My only questions are about maternity networks and the recognition of their potential contribution to the type of maternity care and providing clinical commissioners with expert guidance and advice on driving up standards.
The Committee will be very pleased to hear that I do not intend to share any birthing stories. On the other hand, I am concerned. Without a national standard for maternity services, how will the new commissioning arrangements avoid significant variations? We know, for example, that there is a significant variation between trusts in the number of home births that take place. We can explore the reasons for that, but I would like to know how the new structures would deal with such variations and how that would be reflected in the work of the National Health Service Commissioning Board.
Baroness Williams of Crosby
My Lords, I have Amendment 112 and 113 in this group. I have a comment regarding the excellent speech of the noble Baroness, Lady Cumberlege, and would like the Minister to reply to it. NICE has suggested that all women expecting babies could have the right to consider the possibility of a caesarean birth. Before the choice is finally made, will that be associated with advice from doctors indicating that caesarean births are certainly not as straightforward as some people believe them to be, and for cosmetic reasons may be deeply regretted afterwards? I was a little worried that NICE had given this green light, as it were, to caesarean births without associating it with any form of counselling to the mothers concerned, not least because, as many people in this House will know, the outcomes in terms of morbidity and infant mortality are not as good as people imagine them to be in comparison with a normal birth. Perhaps the Minister could say something about that. Perhaps the noble Baroness, Lady Cumberlege, could also say something about it when she responds on her useful and important amendments, to which I hope the House will give an extremely warm welcome.
Amendments 112 and 113 are about strengthening the language about health inequalities. On that issue, we have had a helpful letter from the noble Earl, Lord Howe, dated 24 November, in which he sets out in detail some of the steps that will be taken, not least the creation of the Institute of Health Equity, to deal with health inequalities. My question is rather a big one but it boils down to the old problem of how one ensures that these worthy and excellent intentions are actually carried out.
The House will remember that new Section 13F of the 2006 Act proposed in Clause 20, which deals with the autonomy of clinical commissioning groups from the Commissioning Board and restricts the board’s actions in terms of having to bear that autonomy in mind, was put into a different set of considerations—the consideration of the whole of the responsibility of the Secretary of State and the responsibilities of the boards—under the headings of Clauses 4 and 10.
All of this means that we are still debating these issues without being clear about where responsibility for them ultimately lies. I do not propose to go over that ground again, but it is appropriate for this debate to notice that the whole set of duties that are laid out in detail—and to which this debate will undoubtedly add as it lays down further duties for clinical commissioning groups and the board as a whole—in a sense therefore depends upon the outcome of those discussions about the constitutional structure. That matters because we need to bear it in mind all the way through our consideration of the duties that are laid upon clinical commissioning groups.
What makes me, to be honest, even more concerned is that I recently read the discussion paper The NHS: Developing Commissioning Support, which was quite improperly, no doubt, leaked on the internet. My attention was drawn to it by a couple of doctors who had access to the internet. The paper sets out in detail the ultimate objective of moving towards a commercial market in the health service and sets it out under a considerable number of different headings. For example, there is a specific mention in this report that,
“Clinical commissioning groups will have a statutory freedom to secure the commissioning support from wherever they want”.
It goes on to say that the commissioning support should be given in a vibrant, commercial market. What worries me about all this is that I am not at all clear—and never have been in our long debate on health—about what the ultimate goal is. I suspect that we are discussing two things at the same time. One is the attempt to keep improving the existing NHS, sometimes by an extraordinary degree of micromanagement—from this House, I have to say. The other is the determination of many people in this House to ensure the safety and continuation of the NHS which is free at the point of need and which is available to people regardless of their ability to pay. Somewhere along the line and at some point, we really have to be clear what we are talking about. I do not know whether others taking part in this debate share my sense that we are walking in without knowing the constitutional responsibilities and quite where we are going.
I commend my two amendments. They both strengthen the words on equality of health outcomes. I congratulate the Government very much on establishing the Institute of Health Equity and carrying forward the detailed research we are now doing on lifestyles and many other things, which are important and which I am sure the whole House will applaud. However, I have to raise the big question about destinations. I hope that at some point before we abandon the Committee stage, we will have a clearer view about the Government’s ultimate destination: whether it is to retain an NHS; whether it is to make it more open to innovation and other contributions from the private sector, with which many of us would certainly not disagree; or whether the ultimate outcome is to move towards a commercial market system, this being essentially a transitional stage.
Lord Warner
My Lords, I do not intend to follow that in a similar style. I support Amendment 144 in the name of the noble Lord, Lord Patel, to which I have added my name. I do not want to go over the ground covered by the noble Lord, Lord Patel, but I just wish to share with the Minister in particular and the House in general my own experience from introducing near-miss reporting in the NHS when the National Patient Safety Agency was established. In those good old days the figure was around 800,000 a year. The current figure, as my noble friend Lord Patel said, is of the order of 3,000 a day; it is on an upward incline.
The issue at stake in those days was not the principle of trying in effect to copy the airline industry and improve safety by having people come clean about near misses—some very serious, some less serious. No one disputed the merits of trying to learn from those experiences. Where everybody got a little concerned was around the making public of the information. I will not delight the House with some of the discussions that took place in Richmond House about whether the first lot of information should be made available, because who knew what the Daily Mail would do with it? Noble Lords will be pleased to know that the Daily Mail behaved in a predictable manner and ran screaming banner headlines about how near to death 800,000 people came each year.
The important point was that one was beginning to change the culture of the NHS, which knew that the information was being put in the public arena. The problem with the Bill is that it leaves to the board the decision about how to disseminate information. We as citizens would be better off putting in the Bill the specific organisations to which the information should be disseminated—which is what the amendment of the noble Lord, Lord Patel, does. I strongly support it and hope that the Minister will give it very careful consideration, and will carry on the publication and dissemination of the information on an agreed basis.
I will make a couple of remarks in response to the concerns expressed by the noble Baroness, Lady Williams, about a market in commissioning skills. I have no particular wish to promote a market in commissioning skills. However, as a former Minister responsible for the performance of primary care trusts, I say that many trusts seriously lacked commissioning skills. These were lacking particularly in areas such as collecting information, analysing it and using it to establish need and to procure services to meet those needs. We should not in the Bill do anything to limit the ability of the new clinical commissioning groups to receive and acquire the skills to enable them to do their job effectively, wherever the skills may be located. That is a very important part of introducing successful new arrangements for clinical commissioning.
I pray in aid of that approach the history of Dr Foster. The dear old NHS had been collecting data for decades but was unable to use them effectively to improve performance. It took an outsider coming in—Dr Foster—to use the information and turn it into something that was useful to the NHS in terms of improving its performance. We should not be too hung up on precisely where clinical commissioning groups get their skills from to do their job.
Baroness Thornton
My Lords, I forgot to speak to my Amendment 137A. I will make three points. The first is not about my amendment. I say how much I agree with the noble Baroness, Lady Williams, on the issues that are the subject of all the amendments to Clause 20, and of the debate and discussions that we are having in the Chamber and outside it about the mandate. I also say to the noble Lord, Lord Marks, and my noble friend Lord Harris that there is clearly an issue about information and confidentiality that must be addressed before the Bill leaves the House.
I will also say how much I agreed with the orphan amendment of the noble Baroness, Lady Finlay. Mine, too, is something of an orphan amendment but is rather important. Amendment 137A states:
“The Board must ensure that in relation to its duties under sections 13C to 13N, those persons in the private sector contracted to provide health services must contribute in the same way as public providers towards the achievements of those duties”.
Those duties are to do with the NHS constitution, effectiveness, quality, reducing inequalities, patient involvement, patient choice, innovation, research, integration, and the impact of those services. It is very important that we have clarification that all providers have a duty to promote those.
Baroness Thornton
Baroness Thornton
My Lords, we move on now to discuss innovation and research. The amendments in this group are very important and were prefigured to an extent by the discussion we have just had. The amendment tabled by the noble Lord, Lord Hunt, and me, is modest in some ways. However, it strengthens the promotion of innovation in the provision and commissioning of health services. Taken together with the amendments tabled by my noble friend Lord Warner and the noble Lord, Lord Patel, it strengthens the Bill significantly and in a very important way.
We have come to what seems an intractable problem: how to encourage innovation in the NHS. This is part of the Minister's area of responsibility and was also part of the area of responsibility of my noble friend Lord Warner when he was a Minister. I look forward to both of their contributions on this matter.
We know that often, the taking up of great innovation is a painfully slow, complex and bureaucratic process. Our amendment strengthens the promotion of innovation through commissioning as well as through the provision of health services. I would like the Minister to explain why that should not be possible—because it would strengthen and help innovation—and also how it could be done, because we are looking for incentives to promote and spread innovation throughout the NHS.
Last week, the noble Lords, Lord Willis and Lord Ribeiro, and I, with others, enjoyed a dinner and an evening with organisations and businesses to discuss how to ensure that innovation is disseminated, promoted, supported and invested in throughout the NHS so that both the NHS and UK plc benefit. The point was made during the evening that often we do not talk about sophisticated issues but about simple changes to nursing practice, such as the way dressings are done, or to information management, that nevertheless can have an important impact on patient care and progress.
I will not speak further on the amendments because I will be very interested to hear what other noble Lords speaking to their amendments in the group will say. I hope that the Minister, with his passion in this area, will give us some comfort on the matter. I beg to move.
Lord Warner
My Lords, I will speak in support of Amendments 129 and 129A in the group. First, I will take up the point made by my noble friend Lady Thornton about the long-standing problem of the slowness of the NHS to take up innovative ideas, and the frustration often felt by people in this country who have invented new approaches and created new innovations, only to find that they have had to go abroad to get them projected, promoted and sold, with the NHS being one of the last to take up the innovation, which was often funded in one form or another with public money by the British taxpayer. It is a long-standing problem and not a party-political issue; it has been a challenge for successive Governments. One of the most embarrassing moments one has as a Minister is when one meets foreign delegations or travels abroad to back Britain and is asked, “Has this innovation been taken up in the NHS?”, whereupon one has to shuffle one’s feet and think of a suitably weaselly form of words to avoid answering the question directly. It is a very long-standing and difficult issue.
Amendment 129 draws attention to the importance of the procurement of goods and services in the promotion of innovation, and to the duty that that places on the national Commissioning Board. There are many reports about the importance of public procurement in advancing innovation and in ensuring the take-up of UK inventions and innovative practices. The latest one was by the Science and Technology Committee of your Lordships' House, of which I was a member. The report brought out some of the dilemmas around using procurement to take forward innovation. Yet again it cast doubt on central government's use of their purchasing power and muscle to drive the take-up of UK innovations in public services.
The NHS is not alone in having this problem, but it is part of the problem and it is a big part of the public sector. A major and long-standing problem is that too many purchasing decisions are taken too far down the organisational food chain, with too little intervention at senior level and too little willingness to use large-scale purchasing to spread the use of innovative approaches. Whatever else the national Commissioning Board has, it has a lot of financial muscle. It must use that, through the NHS’s purchasing capacity, to drive innovation, which often comes from publicly funded research. I hope that the Minister, who is well aware of the issue, will see the sense in putting something like Amendment 129 in the Bill. We cannot say too often that public procurement is a way of helping to establish and drive innovation in the NHS.
Amendment 129A seeks to add the idea of an innovation fund to the board's armoury on innovation in new Section 13K. There is nothing novel in this. The amendment continues and builds on the proposals of my noble friend Lord Darzi, which led to regional innovation funds that strategic health authorities currently manage. Again, we need to strengthen the mechanisms in the Bill for driving innovation in an NHS that historically has been slow to take up innovations and apply them to scale for the benefit of patients. We are not talking about huge sums of money in the innovation fund, but relatively modest amounts in relation to the scale of NHS expenditure. However, an amendment of this kind would ensure the continuance of the useful work that has been started by the strategic health authorities following the promptings of my noble friend Lord Darzi.
It is typical of what we sometimes do in this country. We start an initiative with a fund at strategic health authority level and then shuffle the cards so that somehow, along the way, some of the initiatives and their benefits get lost. I hope that we can get some reassurance from the Minister that some kind of innovation fund will be available so that we can continue the work that my noble friend Lord Darzi so ably started to ensure that patients can secure the benefits of UK innovations.
Earl Howe
My Lords, the NHS has a long and proud track record of innovating and delivering better care for patients. That must continue—we all agree about that. That is why new Section 13K of the 2006 Act places a duty on the board to promote innovation when exercising its functions, including innovation in the provision of services and the,
“arrangements made for their provision”.
That last phrase means the commissioning of services. As a result, although we completely sympathise with the principle behind Amendment 128A, it is not necessary. The duty is intended to support the delivery of quality and productivity improvements across the NHS to help transform healthcare for patients and the public. In response to the noble Lord, Lord Warner, I say that I expect that innovation in procurement of goods and services will be an essential part of this. The duty certainly allows for it as it stands. It is an important part of the QIPP programme at the moment, and I am sure that it will continue to be. If we were to specify one area of activity in which the duty should be exercised, as Amendment 129 suggests, we would face the perennial problem of listing those areas where the duty should be exercised to the detriment—
Baroness Thornton
I am sorry to interrupt, but it strikes me that if none of us understood that that was what those words meant—that was what led us to table the first two amendments in this group—maybe the Minister should look at those amendments, because they offer more clarity.
Earl Howe
I am always keen to accept the wise suggestions of the noble Baroness, and I will of course go away and consider the words that she has proposed.
I was just referring to the amendment proposed by the noble Lord, Lord Warner, on procurement, and saying that we would face the perennial problem of listing those areas where the duty should be exercised to the detriment of those not listed.
Earl Howe
I recognise that and, after what I said a moment ago, we know that procurement can be an important lever in the innovation agenda. Indeed, that will be recognised in the innovation review, which is due to be published next month. Furthermore, we are planning to launch a procurement strategy by April 2012. I will not go into huge detail about it, although I have it here, but it will consist of three elements—system levers, standards for procurement and system level support. We can look to take forward some of the ideas that the noble Lord, Lord Warner, put forward in his speech.
All this goes to show that there is a substantial amount of work already under way to create the right conditions for innovation to flourish. These include dedicated regional innovation funds to support front-line innovation and innovation challenge prizes to recognise and reward ideas that tackle some of the biggest health and social care challenges facing the NHS and in future. I have named only two from a long list of current initiatives.
I will just say to the noble Baroness, Lady Finlay, that the Secretary of State already has a power to awards prizes. New Section 13K of the 2006 Act, inserted by Clause 20, simply gives the board the same power. Should it choose to use the power to make payments as prizes—and it is a power rather than a duty—this is one way in which it might decide to promote innovation in the provision of health services. Recently I presented the very first group of innovation challenge prizes, and it was a very heart-warming and exciting occasion.
The noble Lord, Lord Warner, rightly made the point that the NHS was slow to take up innovation and that people were forced to go elsewhere to take their new ideas forward. Again, this is an issue that we are tackling with considerable energy in the NHS chief executive’s review of adoption and diffusion of innovation, which will be published next month. I look forward to talking more to the noble Lord about what is in that review in due course.
I say to the noble Baroness, Lady Morgan, in particular that the main way in which the board will collaborate with research funding bodies is to fund the treatment costs of patients who are taking part in research funded by government and research charity partner organisations.
The existing innovation funds were not put in primary legislation; there is no need to put a specific power in the Bill, as Amendment 129A seeks to do, to enable the board to establish an innovation fund. As with prizes, establishing innovation funds is only one way in which the board might seek to exercise its duty to promote innovation; innovation funding is being considered as part of the chief executive’s innovation review.
Amendments 130 and 131 reflect the similar and previously debated Amendments 39 and 41 on the equivalent duty on the Secretary of State in Clause 5. I agreed to undertake a closer consideration of that duty and I shall do that. I reassure noble Lords that our discussions will include the board’s duty. Work is under way to look at these duties ahead of future stages of the Bill. Indeed, I undertake to reflect carefully on the points raised by the noble Baroness, Lady Morgan of Drefelin, and to write to her with answers to her questions. I have also written to all noble Lords who spoke in that earlier debate, picking up points that I was not able to cover at the time. I explain in that letter how public health falls within the definition of the health service, which was one of the points touched on by the noble Baroness. It will therefore be covered by the existing duty on the board to promote research in proposed new Section 13L of the 2006 Act.
The noble Lord, Lord Patel, spoke about the role of the tariff in promoting innovation. He is absolutely right to do so; the new tariff could indeed play a key role in encouraging innovation. The Bill introduces a new, independent, transparent and fair pricing system where the board and Monitor would collaborate to set prices for NHS services. That would create a more stable and predictable environment, allowing providers and commissioners to invest in technology and innovative service models to improve patient care. We are actively looking at the way in which the tariff could drive that.
My noble friend Lord Willis and, indeed, the noble Baroness, Lady Morgan, asked how exactly the board will go about promoting research. As previously set out, we will make sure that the systems and processes for commissioning used by the board and clinical commissioning groups ensure that research is promoted, supported and funded by the NHS. That will include the tariff, the commissioning guidance and the processes for authorising and supporting development of clinical commissioning groups. However, noble Lords will be aware that a great deal of the practical detail of the board's role is still under development. Further detail will be published in due course and we must respect the autonomy of the board in devising for itself how exactly it will undertake this function.
I turn to Amendments 147, 149A, 150, 215 and 218. Given the wide range of statutory duties placed on the board and CCGs, the approach we have taken in the Bill is to emphasise a few key duties that the board must look at—in particular, in its business plan, annual report and its performance assessments—and that CCGs must, in particular, look at in their commissioning plan and annual report. We feel we have chosen the right duties to emphasise, not because they are the most important but because they are duties about which any annual report, business plan, commissioning plan or assessment should provide explicit evidence, specifically linked to the exercise of the board’s or CCGs’ functions.
That said, with respect to clinical commissioning groups I say to my noble friend Lord Willis that the department has published Developing Clinical Commissioning Groups: Towards Authorisation and that, to be authorised, a CCG will need to demonstrate that it has in place the systems and processes both to promote patients’ recruitment to and participation in research, and for funding the treatment costs of patients taking part in research, so this will not be overlooked. However, we are clear that an annual report, business plan, commissioning plan or annual assessment should provide an assessment of all the body's functions, including the exercise of its innovation and research duties. There is also nothing to prevent the documents going into significant detail about the exercise of a specific duty. I add that the board has the power to issue guidance to CCGs on the contents of commissioning plans and directions as to the form and content of the annual report. I hope that those remarks are helpful in answer to the questions and points from noble Lords, and that they will be sufficiently reassured by what I have said not to press their amendments.
Baroness Thornton
I thank the Minister for those remarks and all other noble Lords for theirs. This has been a very high-quality, expert debate. I do not want to delay noble Lords from their supper and, indeed, on this side, from an opportunity to defrost—we have hypothermia on this side. The Committee has again shown its great expertise, commitment and enthusiasm to innovation and research and there is great consensus across the Committee about this. This suite of amendments would have given practical action and voice, and would have strengthened this part of the Bill on innovation and research. We need to look at what the Minister has said. I am grateful for those areas where he said that he would reflect upon these issues and let us know. However, it is safe to say that because of the consensus in the Committee on these issues, we would all be keen to make sure that the issues of innovation and research are, indeed, put beyond doubt in this Bill. I beg leave to withdraw the amendment.