Health and Social Care Bill

Lord Beecham Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Warner]

My Lords, I want to say a few words about children in this group of amendments. I know and agree with the arguments put forward by the noble Baroness, Lady Cumberlege. We do not want this to become a huge talking shop. I sympathise with and support that idea, but I think that children are different in kind, in part for the reasons given by the noble Baroness, Lady Benjamin. If we are serious about investing in the future, we need to pick up some of the issues around children much earlier. Diabetes and obesity are big issues facing our society. Many of our services are not very good at picking up the needs of children and responding to them in a comprehensive manner. There are lots of organisations that speak on behalf of them, just as there are lots of organisations that speak up for other interest groups, but I would say that the investment issue on children is much more significant than the investment issue on 80 to 85 year- olds, or even 70 year-olds. That is not to say that those people do not need a good or compassionate set of services responding to their needs, but if we as a society neglect the voice and needs of children, we are just bringing a lot of problems upon ourselves as a society—more so than if we have less good care at much older age groups.

From my time as a Minister, I thought that the voice of the child in the NHS was really quite muted. The working across boundaries in the needs of children is often far less good than it should be. We need to put in the Bill a stronger requirement to listen to the voice of children and to have their representatives fully focused in the health and well-being boards. They are different in kind and their voice has not been heard enough. Too often, public services operate through parents rather than going straight to the child. That is particularly an issue with young carers and with adolescents. We need a bit of a wake-up call on the needs of children in our NHS and social services and across the spectrum of their needs. I hope that the Minister will look carefully at this issue in the particular circumstances of children.

[Lord Beecham]

My Lords, these few clauses relating to health and well-being boards are perhaps less politically exciting than many of those that we have spent days debating—days that are rapidly drawing to a close—but they are potentially highly significant and their importance will be realised over time. The purpose of these boards is to facilitate integration between local government and the National Health Service in the planning and provision of all services relevant to the health and well-being of the present and the future population. They should take a strategic view of a range of services—health in its conventional sense; public health, which is now effectively to be restored to local government; social care; children’s services; housing; environmental services; leisure; and the criminal justice system, all of which have been mentioned by various of your Lordships this morning.

In addition to that fundamental strategic role, these clauses provide for greater democratic accountability at local level and the engagement of the community and the voluntary sector. As we have heard, they also ought to provide for the engagement of staff with a range of professional skills to be brought to bear on the issues that communities face.

I listened with some care and, frankly, growing concern to the observations of the noble Baroness, Lady Cumberlege. If I may say so, she got it wrong about the purpose of the health and well-being boards. They are not operational boards. They are to produce a health and well-being strategy. They operate at that level. They will not be directly involved with implementing that strategy. They will not be responsible for the range of services which will be required both to work together and to work efficiently to impact on the health and well-being of an area.

The noble Baroness also perhaps misunderstands how influential bodies like local government can be. When I had responsibility in the area of social care in Newcastle, many years ago, I was able, with a committee of 15, to drive through a significant programme of change in our authority. We created one of the first welfare rights services, we trebled meals on wheels, we doubled the home help service and we made vast changes in the way that we provided for children’s services and adult services alike. It is perfectly possible to do that with a reasonably sized committee, provided that there are people on it with the kind of vision which is necessary, and people in the employ of whatever authority is providing those services who, equally, have drive, sensitivity and vision.

In looking at the role of the health and well-being boards, then, we have to have regard to that area of responsibility. Of course they will be working to an agenda which will actually be set rather separately, in a sense, because it is the local authority and the clinical commissioning groups which will be responsible for the preparation of the joint strategic needs assessment. That is the basis upon which matters will have to be carried forward.

I am afraid that the noble Baroness, Lady Jolly, joins the noble Baroness, Lady Cumberlege, in possibly having slightly misunderstood the nature of one of the problems that she touched upon. She is absolutely right that housing has to be an integral part of the programme to deal with health, both for communities and individuals, but her amendment is the wrong way around. It is not that the health and well-being board has to take into account the views of the planning authority. It is the other way around—the planning authorities and housing authorities should be drawing up their plans on the basis of the strategic needs assessment and the health and well-being strategy that follows it. We are not at odds about that, really; it is perhaps simply the wording of the amendment. I will have to make a confession about the wording of my amendments later, so I might also plead guilty to the charge that I have levied at noble Baronesses opposite.

Before coming on to the amendments as such, there are two or three questions upon which I would like to hear the Minister’s views. The first is in relation to the relationship between the national Commissioning Board, and its local outposts in particular, and the health and well-being boards. The Bill refers to the position of the national Commissioning Board, but I am interested to learn how he sees the role of the local outposts—I think that is the phrase—which will be established, because part of the agenda which will remain with the national Commissioning Board will impinge pretty directly upon the local strategy and will have very significant and very specific local implications.

Going beyond that, perhaps the Minister would comment upon whether the Government intend to replicate at national level the kind of joint working across departments that they are, perfectly properly, looking to create at local level. Will we see some ministerial committee or some forum for relevant government departments? I go beyond even those that have so far been mentioned. I am thinking in particular of the Department for Work and Pensions and the impact of the Welfare Reform Bill, as well as its general responsibility for benefits; and, bearing in mind the observations of many noble Lords about having regard for the needs of children and young people, but also adults and people with learning disabilities and so on, the Department for Business, Innovation and Skills clearly has a role. It would be interesting to learn whether the Government’s thinking has taken them beyond the local level to looking at how these matters might be addressed nationally.

In addition to that, there is the question of community budgeting, as the phrase now is: whether it is envisaged that it has a role in this context and whether some of the pilots being considered nationally could address those issues.

I will now speak to the amendments in my name and those of my colleagues, Amendments 330ZB, 330ZAB, 331A, 331AAA, 335A, 336A and 336AA. Amendment 330ZB requires the publication of an integrated commissioning plan to which all partners must have regard. That might go somewhat beyond the terms of the Bill as it stands at present, but it seems essential that there should be an integrated commissioning plan across the piece. We are, after all, talking about very considerable sums of public money being spent. Since most of the health budget as such is being devolved to clinical commissioning groups, we are talking about £80 billion nationally. That would be translated into smaller but nevertheless significant sums of money locally, to which would be added the local authority’s own contributions in any given area across its own responsibilities. For a large authority, we are probably talking of a budget of close to £1 billion —possibly more—which will be encompassed within, though not directly administered by, the health and well-being board.

Amendment 335A calls on the health and well-being board to have the responsibility of signing off the clinical commissioning group’s commissioning plan. This is to ensure consistency and a degree of accountability for the work undertaken by the clinical commissioning groups. That is backed up by another amendment which gives the health and well-being board the right to request information as to the progress in implementing the strategy, so that, in addition to the scrutiny committee of the local authority—it in any event has a wide range of possibilities to scrutinise what is happening—the board itself, having set the strategy, is able to see how it is being implemented.

We now come to the question of membership. This is certainly a somewhat difficult issue. There are a whole range of amendments, most of which I would agree with, setting out the wide range of organisations which should be included in membership of the board. They include representatives of education providers; pharmacies; the probation and police services, mentioned by the noble Lord, Lord Ramsbotham; allied health professionals, about whom the noble Baroness, Lady Finlay, spoke; and people from the field of alcohol and drug abuse and the field of safeguarding. It is a significant number.

The Bill at present constitutes the health and well-being board as a committee of the local authority, yet somewhat paradoxically, as the noble Baroness, Lady Jolly, pointed out, only requires a single member of a local authority to be appointed to a board. Admittedly, this is as a minimum, but it could hardly be less. Interestingly, my own authority in Newcastle recently agreed a shadow board, in my absence, which is 25 strong. That strikes me as slightly on the high side, but it includes two representatives from each of the two clinical commissioning groups in the city, from the three trusts that serve the city and from a range of other organisations —many of which reflect the bodies to which noble Lords have referred this morning in debate or in amendments—as well as just three councillors.

--- Later in debate ---

[Lord Mawhinney]

I am most grateful to the noble Lord. I think he knows that I listen carefully to him when he is on his feet. The essence of a democracy is that people are elected to represent their community. I can see an argument for having some professionally trained people adding their expertise, because it might be a stretch to expect locally elected people to command the technicalities of a professional view, but given that commitment of democracy, why does the noble Lord think it necessary to have so many other people representing—in the best possible spirit, I hasten to add—specialist vocations or vested interests?

[Lord Beecham]

In the first place, I am grateful to the noble Lord, Lord Mawhinney, for recognising when I am on my feet, given that there is not much of me to be seen. In relation to his question, I am not suggesting that they should be voting members. That is the point. There is a difference. The voting members—I do not mean executive members—should be confined to elected councillors and those representing the other partners, the clinical commissioning groups and the trusts. It is a partnership arrangement. You have this sort of arrangement in care trusts and the like. It is an acceptable one, but at the very least there should be equality of arms between the elected members and those from other organisations.

[Baroness Murphy]

Can we be quite clear that the noble Lord, Lord Beecham, is asking for a health and well-being joint board on which the director of social services and the director of public health—two crucial people contributing to the board—have no vote?

--- Later in debate ---

[Lord Beecham]

That is exactly right. They do not have a vote in the council, which determines a budget of several hundred million pounds and deals with huge issues of social care and public health. They are paid officers. That is a distinct, separate role. On this, the noble Lord, Lord Mawhinney, and I are entirely at one.

There are ways in which the current positions can be improved. I hope that the Minister may be able to give an indication today that there is some scope for change. However, there may be issues that we need to address on Report if what is basically a good plan cannot be further improved today.

[Baroness Cumberlege]

I do not really accept the noble Lord’s criticism of my thinking. Of course I understand that these health and well-being boards are essentially planning boards. I will read very carefully what he has said in Hansard, but I am sure he accepts that you cannot do the planning if you are totally ignorant of the implementation of what you are planning. Clearly, finance and other things come into this. The health and well-being boards that I have spoken to say that what is really important to the success of the board is the equality of members on it. If he is saying that only local government councillors have a vote, I think that people who also hold budgets—the clinical commissioning group people and the health people—would be very upset if decisions were made involving their finances without them having an opportunity to put their case in a vote, if it comes to that. Again, the boards that I have been speaking to and working with have said that they would always try very hard to avoid a vote.

When I came into the health service from local government, I found the whole culture very different. I enjoyed working as an equal partner with those who were advising me, such as the district or county medical officer and others. We really should leave this to the health and well-being boards to decide how they want to run their business. Why do we always think we know best? Every health and well-being board will be totally different, representing different areas of the country and all sorts of different interests. For once, let us have a light touch and trust the people who are going to be doing this business.

[Lord Beecham]

I think we need to set out a minimum requirement. That is all I am seeking to do. I am not seeking to circumscribe.

[Baroness Cumberlege]

It is in the Bill.

[Lord Beecham]

The minimum requirement in the Bill is the wrong requirement. That is the point for some of us, at any rate.

[A noble Lord]

Rubbish.

[Lord Beecham]

Rubbish is the responsibility of district councils, as the noble Baroness, Lady Jolly, would point out—at least its collection is.

We clearly do not agree about this. The Bill does not go sufficiently far to underpin democratic accountability. It goes too far to entrench professional and bureaucratic interests, whose voice should certainly be heard but who should not be able to vote on these decisions, just as they are not in central or local government.

[Earl Howe]

My Lords, this group of amendments has prompted a very worthwhile debate. They all relate to health and well-being boards, and in particular their statutory minimum membership, their responsibility for preparing joint strategic needs assessments and joint health and well-being strategies, as well as their role in promoting integration. On the first of these issues, concern has been expressed about the membership of health and well-being boards. I am sympathetic to the very important points that several noble Lords have raised. We are all keen to ensure that health and well-being boards access the best expertise and professional advice on the myriad complex challenges facing the health and well-being of their local populations. However, taken together these amendments would significantly increase the minimum membership of each health and well-being board, making the requirements substantially more prescriptive. We want to preserve local discretion and flexibility in these arrangements and the ability of boards to shape wider membership in a way that reflects local priorities. These amendments would severely limit that flexibility and discretion. Their other big downside is that they could lead to larger and somewhat unwieldy boards, making meaningful dialogue and decision-making more difficult. My noble friend Lady Cumberlege was absolutely right to sound the note of warning that she did.

In general, we want to avoid being too prescriptive. The Bill sets out a minimum membership for health and well-being boards, but members can be added by either the local authority or the health and well-being board. I would say to the noble Lord, Lord Beecham, in particular that following the Future Forum report, we made a commitment that it will be for local authorities to determine the precise number of elected representatives on their board. We fully recognise that health and well-being boards will want to draw from a range of expertise beyond the statutory membership, such as clinicians, allied health professionals, police, probation service and voluntary sector groups. However, in deciding who to invite, they will need to consider local needs and priorities and the delicate balance between having the right people and having too many to make it an effective board.

The noble Baroness, Lady Finlay, was quite right to emphasise that the right people needed to be there. It is perhaps worth highlighting in that context that we have retained the power for the Secretary of State to issue guidance on the preparation of joint strategic needs assessments, and there will be power to issue guidance on the preparation of joint health and well-being strategies, particularly when it comes to defining what best practice looks like.

The noble Lord, Lord Beecham, asked how the NHS Commissioning Board would fit in with health and well-being boards. The NHS Commissioning Board will be required to send a representative when asked by the health and well-being board and where the discussions touch on the proposed exercise of local commissioning functions of the commissioning board, for example when discussing primary care commissioning. It will also be required to send a representative to participate in the health and well-being board’s preparation of the JSNA and a health and well-being strategy. With the agreement of the health and well-being board, the Commissioning Board may appoint someone to represent it who is not its member or employee, such as a clinical commissioning group representative.

[Lord Beecham]

Does that mean that it will be the local outpost, if that is the correct phrase, of the national Commissioning Board that will have that relationship, or will this in effect be directed from London?

[Earl Howe]

It will almost certainly be the local outpost that will have direct responsibility for those matters.

A number of amendments would introduce specific requirements in relation to the JSNA, but before I move on to that I have been informed of something that I think I probably implied, if not stated. It would be up to the board to decide who would be most appropriate to attend at a particular health and well-being board meeting.

I agree that the JSNA must be a full analysis that covers the current and future health and social care needs of the local population. It will be a framework to examine inequalities and the factors that impact on health and well-being. This could include aspects such as deprivation. Its scope will naturally include health and social care needs that are related to a wide range of areas, such as alcohol harm, disability or older people.