Health and Social Care Bill

Lord Bishop of Bristol Excerpts

Tuesday 11th October 2011 Lords Chamber

[The Lord Bishop of Bristol]

My Lords, what is clear from the vast volume of correspondence that has arrived in my office in recent weeks is that there is something deep in the psyche of our nation which is extremely anxious about the reforms to the NHS being proposed by the Government in this Bill. Some of that concern is based on a misunderstanding of what is being proposed, but much of it is, in my view, substantive criticism and, significantly, often being voiced by organisations that represent thousands of healthcare professionals. The Government have argued with force that reform is necessary given that the projected costs of the health service going forward are not sustainable. In varying degrees, this observation carries some support. Their stated aim to improve the quality of care is to be welcomed.

The Government made a number of welcome changes to the Bill following the first report of the NHS Future Forum in June 2011. Those changes went some way to addressing concerns, particularly with regard to the composition and remit of commissioning groups, and to the expansion of competition within the NHS. Some outstanding issues, however, still remain to be resolved.

First, despite the reassurances given by the Minister, I wish to make a foundational point which I hope the noble Earl will take into account in his further deliberations on this matter. The Health and Social Care Bill as is runs the risk, I believe, of breaking the obligation of the Government to take responsibility for healthcare in the nation. This is not merely a matter to be judged on the grounds of efficiency or effectiveness, although both are important and, of course, as yet there is no evidence that the proposed changes set out in the Bill will promote either. Rather, the Government’s responsibility for the welfare of the people, including healthcare, is part of the fundamental legitimisation of the state, and a main reason why individuals should subordinate themselves, within limits, to the state. Is it too much to say that a state which withdraws from the responsibility to deliver the welfare of the people loses its legitimate claim on the lives of its citizens? There can be no more fundamental aspect of welfare than healthcare. For this reason, as well as for reasons of practical accountability, it is absolutely essential that the Secretary of State for Health retains final executive authority for the delivery of healthcare and does not relinquish ultimate responsibility either to Monitor or to the NHS Commissioning Board.

Moving on to the NHS Constitution, the Bill now places an onus on both the NHS Commissioning Board and the clinical commissioning groups, formerly the GP consortia,

“to take active steps to promote the Constitution”.

The NHS Constitution contains seven key principles which include providing a “comprehensive service to all”, and providing services that,

“reflect the needs and preferences of patients, their families and their carers”.

This new role of promoting the NHS Constitution through commissioning strategies and decisions is to be welcomed. It means that the commissioning of services cannot be based solely on a traditional medical model of care. The whole needs of patients and others must be met through the provision of comprehensive services. This includes, among other things, meeting their spiritual needs. For many people, spiritual needs may be met only through the provision of religious care. Chaplains are uniquely trained and qualified to provide both religious and spiritual care and, as such, it ought to be explicitly understood that both commissioners and providers should take into account the need for spiritual care where appropriate.

Similar consideration ought also to be given to ensuring that the range of services provided by allied health professionals are maintained and protected, and that the viability of small specialist departments is not compromised through financially driven reorganisation. In a proposed environment of competition, there is a real risk that providers may compromise the quality of their services in order to obtain a contract. It is essential that the requirements of the NHS Constitution are rigorously adhered to by both commissioners and providers in order to minimise this risk.

Concern with regard to providers cutting corners in order to obtain contracts extends also to the nursing profession. Both the Queen’s Nursing Institute and the Royal College of Nursing have noted the real risk of underskilled staff being used by providers in the community and in care homes, partly to enable their bids to be competitive. Commissioning bodies, in order to provide adequate services, need to understand the breadth and quality of nursing care required to meet patient and carer needs.

I have an anxiety about the complexity of the NHS structures that will be created by the Bill. Part of the rationale for reconfiguring the NHS was to simplify its structures and management. At present, the Bill envisages a health service that has a much more complex structure and a greater array of interlocking organisations than before. In addition to the Secretary of State, whose function is to become one of oversight rather than of direct involvement, the new look NHS will encompass the NHS Commissioning Board, clinical commissioning groups, health and well-being boards, Monitor, the Care Quality Commission, the National Institute for Health and Care Excellence, HealthWatch England, Public Health England, clinical networks and clinical senates. In addition, local authorities will have direct input into both public health and the proposed health and well-being boards.

The main problem with the proposed structure is that it may render it difficult to determine precisely where, in practice, decision-making powers lie. The proposed remits of these organisations not only interlock, but frequently overlap. There is a twin danger of the NHS Commissioning Board retaining too much control so that the clinical commissioning groups and health and well-being boards are stripped of any real decision-making powers, or conversely of the checks and balances within the system becoming so cumbersome that decision-making becomes frustratingly difficult to achieve. For example, local authorities and health and well-being boards will, on occasion, be at variance with clinical commissioning groups. The proposed mechanisms for resolving such disputes are complex and may result in the NHS Commissioning Board being drawn into a level of micromanagement that it never envisaged. There is a real danger that the complexity of the proposed structures could lead to a paralysis in decision-making that would be reflected in compromised patient and client safety and care.

I want to make a further point about clinical commissioning groups. The change from GP consortia to clinical commissioning groups reflects the need for the involvement of other health professionals as well as patients and clients in the commissioning of services. The proposed establishment of governing bodies within each clinical commissioning group is to be welcomed both for governance and transparency reasons. So, too, is the requirement that these governing bodies must include two lay members, at least one registered nurse and one secondary care specialist. The failure, however, to prescribe in detail the wider professional membership or the ratio of GPs to other professionals is an error. While there ought to be flexibility to co-opt members according to the requirements of local need, it is important that all clinical commissioning groups have the same core membership. There is a huge difference in having a place at the table by right and being invited to sit there by a pre-existing statutory group. Professionals such as pharmacists, allied health professionals, chaplains and psychologists provide valuable and essential insight into the health needs of populations. This ought to be reflected in the core membership of clinical commissioning groups.

There is much more I could say, but I will adhere to the time limit by concluding that I believe, along with many noble Lords, that some reform of the NHS is necessary to enable it to face the challenges of the future. Aspects of this Bill are to be welcomed, such as the desire to bring greater transparency and patient choice into healthcare, and the desire to involve health professionals more fully in commissioning services. None the less, there are still major problems with the Bill, including those outlined above, that require to be addressed before it can be supported.