Health and Social Care Bill

Earl Howe Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Mackay of Clashfern]

My Lords, in response to the obvious concern over the Secretary of State’s responsibilities, as narrated in the Bill, I attempted to find, from a completely impartial point of view, a solution that would commend itself to everyone. In due course, I came up with an amendment, which your Lordships have seen. My first action was to send a copy of it to the noble Lord, Lord Owen, and others, including the noble Baroness, Lady Thornton. I hope that demonstrated that there was nothing partisan or anything of that sort about it. In trying to put the amendment together, I looked very closely at what the Constitution Committee had said. I think the noble Baroness, Lady Jay, and I demonstrated last time that we had considered these matters in some detail.

I also considered all that had been said about concerns on this matter in the Second Reading speeches, of which there were quite a few. I have endeavoured to meet these concerns in the amendment. As I say, I hoped that the House would find it acceptable but a number of questions have been raised and, as the noble Baroness said, lawyers are apt to disagree on these matters. On the other hand, lawyers are usually reasonably able to reach agreement when they set their minds to it. Therefore, I have no intention of moving my amendment today so there can be no question of its acceptance or otherwise today. An amendment to it has been proposed by my noble friend Lord Greaves. He told me that his idea was to find out what the meaning of “ultimate” was. Maybe I should briefly deal with that now. “Ultimare” is the Latin verb from which it comes, which means to come to the end—not always a comfortable position. The definition in the Oxford English Dictionary is:

“Lying beyond all others; forming the final aim or object”.

That is the sort of idea that I had—that it is the final responsibility of the Secretary of State; in other words, in ordinary language, “The buck stops here”. That was my object in using that phraseology.

During my researches in the Oxford English Dictionary I noticed that Dr Johnson said in 1758 that to be idle is the ultimate purpose of the busy. As I say, I have no intention of moving my amendment today. I hope that we can reach agreement on this matter in informal discussions outside the Chamber. A large number of important practical issues remain to be considered in subsequent Committee days. This sort of question, which is primarily rather theoretical but very important from the point of view of people’s attitude to the National Health Service, should be determined. However, it would be more conveniently determined in discussions between ourselves outside the Chamber. Certainly, I would be willing to participate in those discussions if the amendments before us today are not proceeded with.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, before we move further forward with our debate, I hope that noble Lords will find it helpful if I make a very brief intervention. I am aware that a number of noble Lords wish to speak and I have no wish to prevent that. The Committee must, of course, proceed as it sees fit. However, I felt it might be useful to those intending to speak if I indicated now rather than later what the Government’s preferred course is in relation to this group of amendments. Some noble Lords will be aware that the Government regard the amendment tabled in the name of my noble and learned friend Lord Mackay and the noble Lord, Lord Kakkar, as having particular merit in the context of this debate. Notwithstanding that, and having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report to reflect further on these matters in a spirit of co-operation. I shall, of course, say more when I wind up the debate but it may assist the Committee to know that that is the position that I shall be taking.

[Baroness Thornton]

In the spirit of co-operation across the House it might be useful if I outline the position of these Benches, too. During the past few days I have said to anybody who would listen to me that this is the position in which I thought we probably ought to end up. Those who have been sitting with me on the Long Table can bear testament to that. The reason I added my name to the amendment of the noble Baroness, Lady Williams, is because I feel strongly that that is the right way forward. I am very pleased to hear that the noble Baroness has not resiled from her position on that. I have talked to several lawyers and consider that the amendment in the name of the noble and learned Lord, Lord Mackay, may address political issues but does not fully address the legal issues concerning the responsibility of the Secretary of State.

I have what I can assure noble Lords is a sparkling 10-minute speech, but I do not intend to make it now. However, I may save it for a later occasion. I think this is a good solution if other noble Lords agree with it. I look for an assurance from the Minister about how the discussions on this matter should proceed. We have a record on this Bill of cross-House discussions involving all the people with an interest and expertise in matters relating to it. In that spirit, I wish these amendments to be withdrawn so that not only our lawyers but our medical experts, and, indeed, the Constitution Committee, can be persuaded to have another go at this issue. Towards Christmas we may find a solution that suits us all. If not, I may instead have to make my 12-minute sparkling speech on Report. I hope that the House will feel that this is a good way forward.

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[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, this has been an excellent debate. It has proved one thing in my mind: an issue of this importance for the Bill—the overarching duty of the Secretary of State for the NHS—has benefited enormously from having a Committee of the Whole House to consider it. Without unnecessarily detaining the Committee, I hope it will be helpful if I say something on the record about each amendment.

I begin with Amendment 3, tabled by my noble friend Lady Williams, the noble Lord, Lord Patel, and the noble Baroness, Lady Thornton, and Amendment 5, tabled by the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt. Both amendments would have the effect of restoring the Secretary of State's current duty to provide services in Section 1 of the National Health Service Act. There has been extensive discussion of this both today and at Second Reading, so I shall not recap all the arguments. The core argument is that the duty to provide no longer reflects the practical reality of how NHS services are delivered or our proposals for the Secretary of State's functions in the new system.

Before I explain further, I should make clear that we are now discussing the Secretary of State's relationship with NHS services rather than his duties in relation to public health, where his direct responsibilities for provision remain firmly in place. In that context, I refer noble Lords to Clause 8 of the Bill. While I understand that many people are attached to wording that dates back to the founding Act of 1946, it is now more than 20 years since the Secretary of State had any direct responsibility for the provision of services. Only a tiny minority of NHS services—those still provided by PCTs —are carried out under the Secretary of State's delegated function of providing services. In future, all NHS services will be provided by NHS trusts or foundation trusts, both of which have their own self-standing powers to provide services and do not rely on the Secretary of State's duty to provide under Section 1(2), or by independent providers. The Secretary of State will have no powers to provide NHS services. That is the reality.

I am grateful to the noble Lord, Lord Warner, and to my noble friends Lord Newton and Lady Cumberlege for their persuasive arguments articulating the need to reflect this reality in legislation. As my noble and learned friend Lord Mackay helpfully explained, the Secretary of State has never had an unqualified duty to provide services; he has had a duty to provide or secure the provision of services. In recent years he has relied on the latter part of that duty to fulfil his functions, while the former part has ceased to have any practical relevance. I hope that that answers the question posed by the noble Baroness, Lady Jay.

There is another reason why it would be wrong to reinstate the duty on the Secretary of State to provide. Under the legal framework of the Bill, the Secretary of State no longer possesses powers to direct others to provide services. Therefore, unless we were to re-impose a system of regulations or directions by which the Secretary of State could delegate his duty to provide and control its exercise, which would risk replicating the micromanagement of the status quo, it is hard to see how this legal obligation to provide services could be fulfilled. For obvious reasons, it would be undesirable to create a situation in which the Secretary of State provided services himself. Also, in practice he would lack the capacity to do so, for example in terms of staff and facilities.

Instead, the duty we propose in the Bill is a more accurate reflection of what Ministers do. In line with policy that has evolved over two decades, the Secretary of State will not provide services or directly manage providers; nor will he have the powers to do these things. Instead, providers will be regulated independently. Rather than intervening in day-to-day decisions by local providers, the Secretary of State will have powers to hold to account the regulators, Monitor and CQC, for the way that they are performing their functions, and powers to hold the NHS Commissioning Board to account for the way that services are commissioned. In other words, the Secretary of State—

[Baroness Scotland of Asthal]

My Lords, I hesitate to intervene on the noble Earl, who knows I hold him in the highest possible esteem, but I think he is now treading on some contentious legal issues. Bearing in mind the wonderful consensus that we have now reached, I would just ask him to consider whether, at this stage, some of those issues are really helpful because the noble Earl will know that the Secretary of State does, by his servants, agents or otherwise, provide services and, indeed, there have been times when there has been a pandemic when the Secretary of State has had to make such provision. These are contentious issues which I am sure could intrigue us for many hours, but since we have happily come to the conclusion that we have had a surfeit of such happiness and wish to go forward, I gently say to the noble Earl that this might be a moment when we could swiftly do that.

[Lord Lester of Herne Hill]

My Lords, I would not have intervened otherwise, but I respectfully disagree with what the noble and learned Baroness, Lady Scotland, has just said. I am finding it very helpful to listen carefully for this reason: it seems to me that the Secretary of State must have a duty to secure the provision, as has been said by the Minister, for the purposes of giving effect to our international treaties, including those on human rights. Therefore, what he is saying at the moment is very important to me in trying to see how one can get wording that will include that as well.

[Earl Howe]

I am grateful to my noble friend. I apologise to the Committee. I had thought that it would be helpful if I commented on each amendment for the sake of the record so that, going forward, the Government’s view of each amendment would be clear.

[Baroness Thornton]

The reason I did not make my 12-minute speech was that we are now going to go into a period of consideration. I respectfully say to the Minister that we could start the whole debate all over again if he continues telling us what the Government do or do not believe on this because that is presupposing, and possibly pre-empting, the discussions that we are about to have. The noble Lord may find it useful, but we have had a lot of this discussion. We have now, I thought, agreed to move into discussions outside the Chamber.

[Earl Howe]

I shall, of course, be guided by the Committee. If it is the wish of the Committee that I do not explain the Government’s view, then I will not do so. With apologies to those noble Lords whose questions I am not going to answer now—

[Lord Harris of Haringey]

I appreciate that the noble Earl is moving to a position of not addressing those questions, but it is important that he tells the Committee whether the Government have a fixed mind on these matters or whether they are going to approach with an open mind the discussions that we, in an outbreak of consensus, have agreed should happen and try to build on that consensus. If the views are closed, it raises some very difficult issues for the Committee.

[Earl Howe]

No, my Lords, there are no closed views. That is the reason why I suggested earlier that it was time to reflect and engage in discussions in the spirit of co-operation. I would not have said that if I had had a closed mind to them. There would not have been any point in the discussions. I simply wished to do noble Lords the courtesy of answering their questions and addressing the points that they had made. If noble Lords would rather that I did not do that, then we can make life easier for ourselves. I will certainly write to noble Lords if they would like to inform me afterwards that they wish to receive a letter. If they do not, I will not write. It is entirely up to them. I do not wish to make work for myself unnecessarily.

I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters. I would just say to my noble friend Lord Marks that that includes the issues that he has helpfully raised this afternoon. I believe that he is right to associate Clause 4 in particular with the matters that we have been considering. Those discussions can be carried out in an informal way with interested Peers or in individual meetings in the House or my department. There is a place for either type of discussion. My concern is only that it is an inclusive process involving Peers from all sides of the House, and that will include listening to the views of the Constitution Committee should it choose to continue its valuable role.

With that, I hope that no noble Lord will feel cheated by the brevity of my contribution and I shall sit down.

[Baroness Williams of Crosby]

I am happy to withdraw my amendment given the statement made by the Minister. I also join the many people in this House who have said how much we appreciate his almost unending patience with us and his willingness to listen and engage in extremely informed and very intelligent debate. It gives me pleasure on this occasion to withdraw the amendment.

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[The Earl of Listowel]

I thank the noble Lord, Lord Beecham, for moving this amendment and for giving us an opportunity to discuss a definition of the services of the National Health Service. Perhaps the Committee will forgive me if I make now the arguments that I had hoped to make in the later debate on mental and physical health in the health service, for which I am unable to be present. Those arguments are also pertinent to this amendment.

I seek reassurance from the Minister that the new arrangements for the health service will have a specific duty to focus on support of the relationship between the parent and the child, or whoever is acting in loco parentis for that parent, particularly during the early years and in adolescence. Professionals say that adult mental health hinges on the relationships between the primary carers and the child in early life and in adolescence.

The Government’s White Paper highlighted that mental health is important to public health. It follows that in the future we have to be even more careful to ensure, without being overly intrusive, that the relationships between parents and children in the earliest years and in adolescence are as supportive as possible. The health service should have an important role in that. For instance, there is tremendous pressure to generate more early years nursery places. In a recession, we want parents to work and to help build capacity. Nurseries need to be cheap, yet we know that high-quality early years intervention is crucial to better outcomes for children. We also know that the people who work in those settings are often underpaid and not properly supported, and that there can be a high turnover of staff. In driving people, for understandable reasons, to use nursery provision more, there is a danger that the relationship between the parent and the child could be undermined.

The evidence indicates that high-quality early years education produces better outcomes in school for children. Professor Jay Belsky at the University of London investigated this issue. Exposure to poor-quality early years education and nursery care over a number of years can have serious, although small, deleterious effects. But if a lot of children go through these experiences, the overall impact can be significant. It is very hard to measure—this is probably why it does not get prioritised enough—what difference it makes if there is not sufficient support for relationships between parents and children in the earliest years and in adolescence. It is easy to measure cognitive performance in schools, whereas the relationship between parent and child in the earliest years and adolescence is hard to measure. However, qualitatively I am very clear, after consulting with colleagues in the mental health profession, that it is hugely important to get that support right.

I know that the Department of Health works closely with early years services to try to offer such support, but there are still shortcomings. For instance, there is not sufficient support in adult mental health services for adults as parents in children’s centres, and more work could be done. An old chestnut is that, if a parent is presenting with mental health issues, thought is not always given to the fact that the parent has children who will have needs. If a parent is mentally ill, what are the mental health needs of the children? Again, if a child presents with mental health problems, a proper assessment needs to be made to look at whether perhaps the best input is to support the parents. That may help the child to get better.

Noble Lords will be pleased to know that I will not say much more. A few years ago I remember working with a young man who was just coming out of adolescence. His father was an alcoholic and he had experienced domestic violence in his home. I was seeing him and working with him once a week for six months. The issues he had were that he was experiencing growing paranoia, he was fearful and distrustful of the staff, he was mercurial and unpredictable in his behaviours and he had a difficult relationship with women. If there had been better support for that family, perhaps the nascent problems we saw at the time could have been nipped in the bud and he would not have had those difficulties.

I am sorry if I am not explaining myself sufficiently clearly, but I would be grateful if the Minister could reassure the Committee that in any of the new arrangements there will be a particular focus on getting in early to support families, both parents and those acting in the role of parents, in their relationships with their children to make sure that those relationships are strong. Children will then have a good basis from which to grow and enter adulthood. I hope that that will be a priority in the new arrangements.

[Earl Howe]

My Lords, Amendment 7, tabled by the noble Lords, Lord Beecham and Lord Hunt, and the noble Baroness, Lady Thornton, seeks to set out a new definition of the health service in England as,

“those services provided under section 3”,

of the 2006 Act. While I know that the noble Lord has the best interests of the NHS at heart, I fear that this amendment might achieve the opposite of what he intends because its effect would be to narrow the definition of the health service.

Section 3 of the NHS Act 2006, as amended, will set out the services that clinical commissioning groups will be required to commission, including, for example, maternity services, hospital accommodation and, in answer to the noble Earl, Lord Listowel,

“such other services or facilities for the care of pregnant women, women who are breastfeeding and young children as he considers are appropriate as part of the health service”.

Defining the health service as meaning only those services set out in this section would limit the application of the provisions of the Act, excluding other vital parts of the health service that are not defined in Section 3. For example, that definition would exclude primary care and specialised services, which would be commissioned by the NHS Commissioning Board, and public health services, which would be provided or commissioned by the Secretary of State or local authorities. Clause 1(1) of the current Bill retains the Secretary of State’s duty to promote a,

“comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and … in the prevention, diagnosis and treatment of illness”.

This clearly sets out what the health service must do. Any attempt to define it more precisely might have the perverse effect of leading to an NHS which delivered fewer services.

I can assure the noble Lord that services commissioned by clinical commissioning groups will be covered by the wording of the unamended clause, and thus these services will be covered by the Secretary of State’s duty to promote the comprehensive health service. As part of the health service, those services must remain free of charge. Clinical commissioning groups will be responsible for commissioning the services listed in Section 3 of the 2006 Act such as hospital services and maternity services. They must arrange those services, although as with primary care trusts at present, Section 3 will permit them discretion to determine precisely what services are necessary to meet the reasonable requirements of their local population. The Commissioning Board will issue commissioning guidelines and monitor the commissioning activity of CCGs with a view to ensuring that no essential services go uncommissioned in any given locality.

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[Earl Howe]

Yes, my Lords. I hope that I can reassure noble Lords on their very valid concerns on this topic. Perhaps I can say a few general words first of all about quality. The Government’s ambition in modernising the NHS is to create a health service that delivers outcomes as good as any in the world. We all know that at its best the NHS is world-class, but we also know that there are important areas where the quality and outcomes of care could and should be improved. If we are to safeguard the quality of services and drive improvement, we must take positive action. We are addressing the structural weaknesses in the system and seeking to embed the principle of quality throughout. This is why the Bill creates a legal duty for the Secretary of State and for the NHS Commissioning Board and clinical commissioning groups to be guided by the need to improve quality in all that they do.

In doing this we are building on the work of the previous Government under the noble Lord, Lord Darzi, and in particular we are using the definition of quality that he introduced—care that is effective, safe and delivers a good experience for patients. By positioning the quality duty in the context of a duty in Clause 3—to bear in mind the need to reduce inequalities within the population in designing services, particularly the most vulnerable members of society—we intend that these reforms will deliver the vision of high-quality care for all, as he so ably articulated.

Amendments 9, 10 and 14 place a duty on the Secretary of State to provide or secure the provision of services that in their turn should secure continuous quality improvement. We have already debated at great length Clause 1 and the duty to provide, and I shall not rehearse that discussion again, but I should like to be clear that it is the role of commissioners to drive quality improvements and the role of the Secretary of State to seek to improve quality by exercising his functions. He will do this, for example, through the mandate that he sets for the board, or the outcomes framework which he will issue and to which the board must have regard when it exercises its duty in relation to quality.

The amendments also place a duty on the Secretary of State to secure continuous improvement in the quality of services. Similar amendments were debated at some length in another place. It was clear throughout those debates that there is extensive and wide-ranging support for the principle that the health service should strive to provide the best possible service to patients. I thank the noble Baroness, Lady Thornton, for indicating her support for that principle. I am sure that we share it. As drafted, the Secretary of State, and in practice the Department of Health, is required to seek to achieve continuous improvement even if external factors mean that in particular cases such improvement may not be delivered. In our view, the clause as drafted should do what is necessary to deliver improvement in the quality of services while not imposing unreasonable or unrealistic burdens on the Secretary of State and the NHS. We believe that this duty, taken alongside those placing the same duty on the board and clinical commissioning groups, and the expectations that the Secretary of State will set through the outcomes framework, already ensures that the principle of securing continuous improvement in service quality is embedded throughout the health service and the wider care system. I hope that I have reassured the noble Baroness, Lady Thornton, of the Government's commitment to the continuous improvement of quality within the health service, and that she will not press her amendments.

I turn to Amendments 10A, 10B and 11A, tabled by the noble Baroness, Lady Finlay. They seek to strengthen the duty by inserting “and” in place of “or” where the clause lists the areas that the duty to secure quality improvement applies to. The noble Baroness expressed concern previously about the wording. I assure her that “or” is the appropriate word and that we are not allowing the Secretary of State to neglect certain aspects of healthcare when exercising their duty. There is no risk that the courts could misinterpret the unamended clause as meaning that the Secretary of State has to exercise his functions with a view to securing continuous improvement in the quality of services in only some rather than all areas that the Bill specifies.

The duty refers to quality in respect of services provided to individuals. In many cases, particular services provided to an individual will relate to one or more of the matters referred to in new subsection (1)(a) and (b), but not to all of them. For example, the service may be to prevent or diagnose illness but not to treat. Another service might be to treat but not to diagnose. The use of “or” makes it clear that the duty applies to the quality of all services, whatever the purpose for which they are provided. Although I am certain that it is not the noble Baroness's intention, the use of “and” would inaccurately suggest that the duty could apply only to the provision of services that prevent or treat illness.

Amendment 10A seeks to extend the duty to improve the quality of services from those provided to individuals to those provided at a population level. Of course it is just as important for public health services to improve as it is for any other sort of health service, but new Section 1A already recognises that with its explicit reference to public health services in subsection (1)(b), which refers to the,

“protection or improvement of public health”.

The wording is echoed in Clauses 8 and 9, which set out the new public health duties of the Secretary of State and of local authorities.

Clauses 8 and 9 provide examples of steps that may be taken under those duties and that might therefore be subject to the duty of quality in new Section 1A. They include providing information and advice, for example, as well as preventing or treating illness. This means that new Section 1A already applies to a wide range of public health services. Any public health activity that involves the provision of a service to individuals—albeit that the general purpose is to improve or protect health at a population level—such as vaccination or smoking cessation, would be covered by the duty in the clause as drafted. Of course, improving the health of populations cannot be achieved without improving the health of individuals. I make it clear that some steps may be taken to improve or protect public health under Clauses 8 and 9. These extend beyond services provided to individuals.

I turn to questions that were raised. The noble Baronesses, Lady Thornton and Lady Finlay, spoke about the importance of commissioning for an area-based population. We completely agree with the general sentiment. That is why CCGs, contrary to the perception of some noble Lords, will commission for all unregistered patients within their geographic area, as well as for those on their registered lists and others to be defined in regulations. I refer noble Lords to Clause 10(3), which is on page 6. It is also why we are establishing health and well-being boards to agree a holistic strategy for their area. That is Clause 190.

We amended the Bill in another place to clarify that clinical commissioning groups have responsibility not only for patients registered with the GP practices that comprise their membership, but for those usually resident in the clinical commissioning group’s area who are not registered with any GP practice. We must also ensure, when we exercise the power to set out other persons for whom a CCG has responsibility, to provide through regulations that a CCG has responsibility for ensuring that everyone in its area can access urgent and emergency care. I turn to my noble friend Lady Tonge, who asked me about that issue.

[Baroness Tonge]

Will the Minister clarify the phrase “clinical commissioning group area”? I thought that it was not going to be defined. I obviously got the wrong end of the stick. GPs are free to have patients on their lists from wherever; therefore, what does he mean by their “area”?

[Earl Howe]

My Lords, I will address that question in a moment, if I may. The noble Lord, Lord Warner, asked how clinical commissioning groups will deal with the non-registered population in practice. Individual clinical commissioning groups will have responsibility for ensuring that patients resident in their area who are not registered with a GP have the same access to the care for which the clinical commissioning group has commissioning responsibility as a patient registered with a GP. Individual clinical commissioning groups will need to ensure that they have sufficient geographical focus to be able to commission emergency care services for anyone who needs them when in their area. The National Health Service Commissioning Board will be responsible for establishing a comprehensive system of clinical commissioning groups covering the whole of England, and the board will be responsible for commissioning primary medical care for the unregistered patient population. I think that my noble friend Lady Tonge is confusing two issues.

[Lord Warner]

Can I just be absolutely clear that I have understood the noble Earl? Is he saying that a clinical commissioning group with a defined geographical area for which it is responsible also has a responsibility to find out about the needs of all those who are not registered with a GP, including homeless people, asylum seekers, rough sleepers and you name it? Is he saying that the group has a responsibility to find out how many of those people are in its area and that it must commission services for them?

[Earl Howe]

Let me be clear: each clinical commissioning group will have a specific geographic area and will have responsibilities linked to it. This addresses the question asked by the noble Lord, Lord Rea, as well. Unregistered patients of any shape or kind are one example. Clinical commissioning groups will be informed by the work done in the health and well-being boards, whose job it will be to define the health needs of an area and what they believe the priorities are for commissioning in that area, and to produce a joint health and well-being strategy that addresses those priorities. The interaction between the health and well-being board and the clinical commissioning group should ensure that the marginalised groups of people to whom the noble Lord refers will be catered for.

[Lord Walton of Detchant]

The noble Earl has been extraordinarily helpful in his comments. However, in new Section 1A, entitled Duty as to improvement in quality of services, subsection (1) states:

“securing continuous improvement in the quality of services provided to individuals for or in connection with … the prevention, diagnosis or treatment of illness, or … the protection or improvement of public health”.

However, it reads as if (a) and (b) were qualifying clauses, qualifying the services provided to individuals. As I read it, it does not make it clear that the quality of services provided to communities would be embraced by this even though it refers to public health. That is my concern, and I would be grateful if the noble Earl could in due course consult as to whether I am totally mistaken in that view.

[Earl Howe]

I will cover that point in a second. I should perhaps clarify that the area covered by an individual clinical commissioning group will be agreed with the NHS Commissioning Board and, as I will explain in a minute, that area should not without good reason cross local authority boundaries. That is a different issue from the issue raised by the noble Lord, Lord Rea, of GP practice boundaries, and we need to distinguish the two in our minds.

The right reverend Prelate asked why we could not remove the words “provided to individuals”. The duty on the Secretary of State to act,

“with a view to securing continuous improvement in the quality of services”

is worded to refer to the “services provided to individuals”. This is because the NHS treats patients on an individual basis. Overall improvement in the quality of the treatment service will improve the health of the population as a whole, but we must not forget that there is a separate, complementary duty to improve the health of the population as a whole using public health mechanisms. Improvement is necessary in both prevention and treatment, and the Bill sets out separate duties in relation to other population-based activity; for example, population-based public health research.

In answer to the noble Baroness, Lady Finlay, the Government accepted the NHS Future Forum’s recommendation that the boundaries of local clinical commissioning groups should not normally cross those of local authorities, and this is now reflected in the proposed authorisation framework for CCGs, subject to the agreement of the process with the NHS Commissioning Board. However, we do not believe it would be in patients’ interests to make this an absolute rule. One of the key roles for clinical commissioning groups will be to manage relationships with local hospital providers and in some areas patient flows into acute hospitals do not match local authority boundaries. The proposed authorisation framework makes clear that CCG areas may cross local authority boundaries only where, for reasons like these, it is demonstrably in the interests of patients.

In answer to my noble friend Lady Cumberlege, whose comments I very much welcomed, all relevant clinical commissioning groups will be required to appoint a representative to the health and well-being board if part or all of their area falls within or coincides with the local authority area. That will provide a vehicle for NHS and local authority commissioners to work together on the health and well-being of the population. There is nothing to prevent health and well-being boards from inviting other clinical commissioning groups that have large numbers of registered patients within the local authority area to attend and be represented. I hope that goes some way towards addressing the concerns that the noble Baroness raised. She expressed a general fear about lack of coterminosity between local authorities and CCGs, leading to fragmentation. As I have said, there is going to be a presumption against CCGs crossing local authority boundaries, but there is an important point in this connection in Clause 20, which will impose a duty on the board in new Section 13M in relation to promoting integration; in particular, new Section 13M(3) will impose a duty on the board to,

“encourage clinical commissioning groups to enter into arrangements with local authorities”

where this would assist with integration of health and social care.

The noble Baroness also referred to GP practice boundaries. She will know that the previous Government, as well as the present Government, were keen to ask patients about the choice of GP practice. It is our aim, which we expressed in the White Paper, to give every patient a clear right to register with any GP practice they want from an open list without being restricted by where they live. Many, if not most, patients are quite content with their local GP practice, but a significant minority have problems registering with a GP practice of their choice or with securing access to the high quality and range of care services that they deserve.

I can inform the Committee that agreement was reached with the BMA today. NHS employers have been discussing our proposals with the General Practitioners Committee of the BMA as part of the annual GP contract negotiations, and the agreement that we have reached with that committee is that from April 2012 GP practices will agree with their primary care trust an outer practice boundary whereby they will retain, where clinically appropriate, existing patients who have moved house in the outer boundary area.

There will also be a choice pilot in two or three cities, or possibly parts of cities, whereby patients will be able to visit a practice either as a non-registered out of area patient, for which the practice will receive a fee, or as a registered out of area patient. Practices will join the pilot on a voluntary basis. I think that that represents a very satisfactory way forward. We can look at which model works, if either of them does, and see what the problems are with each.

The noble Baroness asked about the risk of cherry picking patients. We do not see that as a danger. Under their contracts, GPs have a measure of discretion in accepting applications to join their patient lists. However, they can refuse to register a patient only on reasonable and non-discriminatory grounds. They cannot turn patients away simply on the grounds of their medical condition, or for that matter on the grounds of their race, gender, social class, age, religion, sexual orientation, appearance or disability. In future, we want to make it easier for people to choose the best GP practice for themselves and their families. The pilot arrangements that we have agreed will be invaluable to understanding more fully the issues of GP choice.

I hope I have covered most of the points that have been raised. I hope that my answer to the question posed by the noble Lord, Lord Warner, satisfied him, but I just reiterate that CCGs’ responsibility for planning for homeless people and all the groups that he mentioned is a core part of the CCGs’ functions.

[Lord Newton of Braintree]

My Lords, I take it that the answer to my question is that CCGs do have a duty to plan for everyone in their area. However, along the way, the Minister indicated that some of the information that will enable them to do this will come from health and well-being boards and their assessment of the needs of the population. The fact is that the health and well-being boards do not cover the same areas. They might cover the area of a number of CCGs, but they do not relate to the specific area of any specific CCG. The question is therefore: do the health and well-being boards have a duty to translate their information into the areas covered by CCGs?

[Earl Howe]

I am grateful to my noble friend. The point I was seeking to make was that health and well-being boards will be in a very good position to assess and have a sense of the unregistered and, if I can express it this way, the more dispossessed elements of society. I think CCGs will find that an invaluable source of information in planning the commissioning of services.

My noble friend asked me a yes or no question: are CCGs just like PCTs? In terms of population responsibility, the responsibilities are very similar. CCGs are responsible for patients on the registered lists of their constituent practices as well as having specific area-based responsibilities, as I pointed out, linked to their unique geographic coverage. It is possible for individuals within that area to be registered with a GP practice which is a member of a different CCG. They would therefore be the responsibility of that other CCG. So that is a slight complication. However, it is important to remember the critical role of health and well-being boards in planning in a holistic way across an area covering not just the NHS but public health, social care and other services.

[Lord Newton of Braintree]

I am sorry to press the Minister further. I want to ask one further question and then I will shut up—I promise. Health and well-being boards, and possibly CCGs, will cover widely differing kinds of area: urban populations where there may be many more homes and people, asylum seekers and the like; conurbations of one kind or another; and a rural periphery. Let us make this oversimple. Do the CCGs in the conurbations know what their situation is in respect of homelessness, asylum seekers and all the other things that the noble Lord, Lord Warner, talked about?

[Earl Howe]

My Lords, there are perhaps several issues bound up in my noble friend’s question. It is entirely possible that a CCG will cover two local authority areas. In that event, it will have a clear duty to work in partnership with both local authorities to improve health and well-being and to secure more integrated services. Do health and well-being boards need to translate their assessments for each clinical commissioning group area? The CCG will need to use the joint strategy of the health and well-being board to inform its commissioning plan according to the needs of its local population. It is in its interests to ensure that the information is translatable.

I would be happy to write to my noble friend because there is a clear narrative here, although I may not be expressing it entirely clearly. Obviously, there will be instances where boundaries do not coincide. As I have said, we are aiming for that not to happen but it will in some cases and it has to be dealt with in terms of the duties that we set out.

[Lord Warner]

I will not torture or tweak the Minister any further but I will ask him to make a sensible response on this issue after today’s Committee sitting. It would be extremely helpful if he could take two or three areas—perhaps an urban area and an urban/rural area—and show us where there is a health and well-being board and where there are pathfinder groups of CCGs, and how this would work in practice. I think that we would find this much easier to understand if there was a diagram.

[Earl Howe]

I absolutely agree with the noble Lord. It is all very well me trying to describe in words what the duties will lead to but a graphic depiction of how this might work is a very good idea, which I would be happy to follow through.

[Baroness Tonge]

I am sorry to torture the Minister further. He seems to be saying that clinical commissioning groups are PCTs by another name, with the exception of public health services and community services. That is the impression I get. Can he tell us how much it will cost to transfer the bureaucracy of the PCTs to the bureaucracy of the clinical commissioning groups?

--- Later in debate ---

[Earl Howe]

There is a hypothesis in my noble friend’s question that I do not necessarily accept but I would be happy to write to her with the figures.

[Baroness Hussein-Ece]

I am sorry to press the Minister on the point I made about homeless families who are placed in different boroughs or areas by their local authority. Under the present system, the GP practice where the family was originally based would wash its hands of that family and say, “You are no longer in my area”. Is the Minister saying that wherever a family has been placed, they would still be able to retain the services of the GP where it originated from or would they have to register with a practice close to the temporary accommodation in which they may have been placed. Such placements can last for many years. Will the family have to seek a GP close to where they have been placed or could they still use the GP services from whence they came?

[Earl Howe]

It would depend how far the family had moved away from the GP practice. What I was trying to say was that the agreement we have reached with the BMA comprises two elements. One is that the outer boundary of a GP practice is going to be flexed in a sensible and pragmatic way so that if you move a few streets away from where you were previously living, you can still be treated in the same GP practice. The other element of the agreement is the pilots that we are looking at. They are only pilots and we will set them up in order to experiment and learn lessons from how they work. It is impossible for me to give my noble friend a generalised statement at the moment because it will depend on the circumstances. At present, the rules will remain roughly as they are other than the flexed boundary rule that I have mentioned.

--- Later in debate ---

[Baroness Thornton]

My Lords, I congratulate the noble Baroness, Lady Hollins, on bringing forward the amendments and all those who have spoken in what I think has been an extremely useful debate. All those months ago, we had all-Peers meetings about this and many other issues. I am sure that the quality and comprehensive nature of the amendments owes something not only to talent and expertise but also to the fact that the experts in the House have been working with many organisations over a long period. I congratulate everyone on the quality of the debate and the amendments.

The amendments approach the Bill holistically—I do not really like that word. They concern the Secretary of State's responsibilities, the duties of the Commissioning Board and the duties of the clinical commissioning group—the triggers, the levers that may make this a reality. Because of that, I am very attracted to them. It is also important that they express the expectation of parity of esteem between mental and physical health services. As has been said, my Government and this Government have certainly made progress on this issue. I look forward to hearing the Minister’s comments, and I hope that he will find some way to recognise the support for the amendments across the House.

[Earl Howe]

My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a debate of very high quality, covering a topic of huge importance. All the amendments deal with the same matter. Each seeks to amend the duty of quality to include an explicit reference to the prevention, diagnosis or treatment of physical and mental illness. Amendment 11 does so for the Secretary of State; Amendment 105 applies to the NHS Commissioning Board; and Amendment 180 applies to clinical commissioning groups.

I completely share the noble Baroness’s concern that we should never forget mental health in the drive for improving quality—quite the contrary. The noble Lord, Lord Patel of Bradford, and many others, mentioned parity of esteem between mental and physical health and the need to end the dualism in thinking that has in the past hindered an holistic approach to care. Noble Lords have expressed the concern that the Bill is wrongly silent in not referring explicitly to mental illness. I hope that I can successfully plead not guilty to that charge. First, I reassure all noble Lords on the central point of drafting, which is that all references to illness already include both mental and physical illness. The term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. As a result, references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words. The definition is already there. Therefore, the signal mentioned by the noble Lord, Lord Rooker, is already there.

The new duties placed on the Secretary of State for Health, the NHS Commissioning Board and clinical commissioning groups continuously to improve quality as defined by the noble Lord, Lord Darzi, already apply to the provision of both physical and mental health services. That is not to say—and I would not seek to suggest—that such services need no improvement. The noble Lord, Lord Patel, was quite right to draw attention to variations in mental healthcare around the country, despite the significant additional resources that have been directed to mental health services in recent years.

I fully agree that the National Health Service must look holistically at both the physical and mental needs of the patients whom it is there to serve. That is why the NHS outcomes framework, which we published last year, seeks to drive better health outcomes for those with mental illness. That is where the difference will lie in future. For example, Domain 1 of that framework, which focuses on preventing people from dying prematurely, includes a specific indicator on premature mortality in people with serious mental illness. Domain 2 of the framework focuses on enhancing the quality of life for people with long-term conditions, regardless of whether these are physical or mental health-related. However, to guard against the risk that there might be an overriding focus on physical health, there is also a specific indicator looking at the employment of people with mental illness. Clinical experts, including the Royal College of Psychiatrists, agree that this is an important outcome for people with mental illness and one that the NHS can make a significant contribution to improving. Finally, Domain 4 of the framework focuses on:

“Ensuring that people have a positive experience of care”,

including a specific indicator to capture the experience of healthcare for people with mental illness.