Health and Social Care Bill

Lord Davies of Stamford Excerpts

Monday 14th November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

Briefly, this is a very important set of amendments, which we do not have time to deal with effectively in the next 10 minutes. I understand that the Government do not want to spend more money. Indeed, the Minister said earlier that the whole idea was to cut down the amount of money spent on CCGs, relative to what was previously spent on PCTs. The problem is that there will be more CCGs than there are PCTs and there is deep anxiety over the lack of clear governance. The Government have a problem here. So far we have had clues that there is to be accountability upwards. These amendments make it clear that there must be accountability downwards, too.

As the noble Baroness, Lady Finlay, said, GP groups are different from other groups in the National Health Service. They are not used to this level of accountability or this level of governance—even at the level that the Government have already put into the Bill. Nobody outside, particularly in other aspects of the NHS, thinks that the governance in the Bill is adequate. I share the concerns that other people have expressed tonight; I share the concerns about coterminosity.

I have mentioned previously to the Minister that Durham is now a unitary county. We used to have seven PCTs in Durham and Darlington; we now have one. We will have three CCGs. I do not believe that that will be cheaper and I am not yet convinced that it will be more effective for commissioning. The Government have a lot to do to reassure people that this will be more effective and that it will be accountable. There are many GPs who are now anxious the other way around. They are anxious that if they go into CCGs, the level of accountability, governance and bureaucracy will be so great that they are saying, “We’re not sure we want to have anything to do with it”.

This is an area where I suspect the Government will say that, in all truth, this is not where they want to be. However, this is where we are and the responses that we have heard so far simply do not meet the level of anxiety and the need for accountability that everyone thinks is there.

[Lord Davies of Stamford]

My Lords, what I want to say might have been a little long as an intervention in the Minister’s speech but it will be very short as a speech. I simply want to ask the noble Earl, when he replies to this debate, to address in a considered way how the Government intend to deal with an enormously significant and worrying conflict of professional interest that could arise in this context. Anyone who is a member of a clinical commissioning group, whether he or she is a GP or not, must presumably be committed and signed up to the priorities, policies and plans of that clinical commissioning group. However, where that individual is also a GP who has his or her own patients, some of those patients may have conditions that do not get a very high priority in those plans and policies. Surely there is an immediate conflict of interest. In the present circumstances, the GP can say to his or her patient: “I am doing my best to battle with the PCT to get the treatment that I really think you need”. However, in the situation that arises as a result of the structure in this Bill, that GP would be on both sides of the table. He would be arguing with himself and making representations to himself. Surely the noble Earl would agree that it is a thoroughly unsatisfactory situation. Can he assure the Committee that it will not arise and, if it does, that the Government have a clear set of rules or procedures for dealing with it?

[Earl Howe]

My Lords, we have had another well informed and stimulating debate. I will start by going back to the beginning. On paper, clinical commissioning groups can seem like a dry concept, but I would encourage your Lordships to look beyond the words and duties on the page and consider what CCGs will be able to achieve in practice. GPs and other front-line professionals already make the clinical decisions that determine how most NHS resources are used. Putting them in charge of shaping services will enable NHS funding to be spent effectively to provide high-quality care.

I have seen at first hand the work of primary care clinicians—GPs, nurses, allied health professionals and others—in leading the commissioning of services. I have been struck on numerous occasions by their dynamism, innovation and their absolute dedication to ensuring that their patients receive high quality care. It is in that context that we should consider our debates on this topic, including this one, which have focused primarily on ensuring that CCGs have effective governance arrangements, but have also touched upon CCG boundaries.

I do not agree with the noble Baroness, Lady Armstrong, that the arrangements are weak. We have already responded to the Future Forum’s recommendation to strengthen the Government’s arrangements for CCGs and made it a requirement for every CCG to have a governing body. We recognise that good governance will be critical to the design and operation of CCGs, in order that they act transparently, manage conflicts of interest and have the proper checks and balances in place to provide assurance that decisions are taken in ways that protect patients' best interests, promote continual improvements in quality and provide assurance that public money is well spent.

That is why I believe that the Bill already achieves the intent of Amendment 60, which would place the Secretary of State under a duty to publish a code of conduct for CCGs, incorporating the Nolan principles on public life. I am fully in support of CCGs adhering to the principles established by the Committee on Standards in Public Life. However, new Section 14L already states that the main function of a governing body of a CCG includes ensuring that the group complies—and these were the words quoted by the noble Lord, Lord Warner—

“with such generally accepted principles of good governance as are relevant to it”.

The Nolan principles, or any successor principles which the Committee on Standards in Public Life or another body was to issue, would be foremost among these. However, the provision in the Bill will also encompass any other relevant, generally accepted principles of good governance issued by appropriate bodies, such as the Institute of Good Governance, and therefore has the potential to be of wider effect. That is why I feel that Amendment 171 is also unnecessary, as it appreciably narrows the field of vision of the governing body.

In addition, the Bill already sets out other provisions which relate to a CCG’s conduct. For example, with respect to the constitution of a CCG, the constitution must include arrangements for ensuring absolute transparency. It must specify the arrangements for discharging the CCG’s functions, its decision-making process, how it will secure transparency about the decisions of the group, and how it will deal with conflicts of interest of members and employees of the CCG or members of the governing body.