Health and Care Bill

Lord Lansley Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

Moved by

[Lord Lansley]

61: Clause 21, page 29, line 14, leave out from “committee” to the end of line 20 and insert “(an “integrated care partnership”) for the board’s area.
(2) The integrated care partnership may be designated as the Health and Wellbeing Board where the area of the integrated care board and the responsible local authority are coterminous.(2A) If more than one Health and Wellbeing Board relates to the area of the integrated care board, the integrated care partnership may be designated as the Health and Wellbeing Boards of each responsible local authority acting in combination.(2B) The integrated care partnership must consist of—(a) one or more members appointed by the Health and Wellbeing Board or Boards,(b) members appointed by the integrated care board (equivalent in number to the number appointed by the Health and Wellbeing Board or Boards), and(c) such further members as are appointed by the integrated care partnership.”

[Lord Lansley (Con)]

My Lords, Amendments 61, 95 and 96, which are all in my name, are to two separate issues. Amendment 61 relates to an issue we debated a number of times in Committee, when, if I may presume, there was a degree of support among noble Lords for the proposition that integrated care partnerships, in so far as they have to produce a strategy for a needs assessment for their area, have a very complementary—indeed, one might say overlapping—responsibility with health and well-being boards established in local authorities.

I will not go into the detail of how this works, and nor do I rest on the construction of Amendment 61. I freely acknowledge that this is a tricky thing to do. There will be circumstances where one ICS, one ICB or one ICP covers a lot of local authorities and others where it covers only one or two. In the latter case, it is pretty straightforward to integrate health and well-being boards and integrated care partnerships. In other cases, the membership and construction may be more complicated.

--- Later in debate ---

[Baroness Penn (Con)]

My Lords, this has been an important discussion about place and joint working, and although the Government are unable to accept my noble friend’s amendments, for reasons I shall touch on, I hope I can reassure him that the questions which he and other noble Lords have raised have been considered in the Bill.

England is so large and diverse that a one-size-fits-all approach will not be right for everyone, and that is why we have been flexible about the requirements for integrated care partnerships and joint working arrangements. We fundamentally believe that, if integration is to work, we must allow local areas to find the right approach for them.

As my noble friend will appreciate, our provisions on integrated care partnerships build upon existing legislation, particularly in the case of health and well-being boards. We know that health and well-being boards have played an incredibly important role in the last decade, and this legislation intends to build on their success. We will be refreshing the guidance for health and well-being boards in the light of the changes that this Bill proposes, in order to help them understand the possibilities of these arrangements and their relationships with ICBs and ICPs, so that they can find the most appropriate model for their area.

Fortunately, this Bill and existing legislation already provide the framework to do what these amendments intend to achieve. Two or more health and well-being boards can already jointly exercise their functions, and where the local authority area and ICB area are the same, there is no reason why the health and well-being board and the ICP cannot have the same membership. The ICP is intended as an equal partnership between the local authorities and the ICB. By restricting the right of the local authority to nominate a member who they see fit and requiring them to do so through a committee with a potentially wide membership, including the ICB, risks undermining that equality. Local authorities may ask their health and well-being board to nominate those members. However, we do not wish to restrict their options and unintentionally prevent better collaboration and integration by adding further requirements to the Bill.

I turn to the joint working arrangements. The Bill also provides for the ability to establish place-based committees of ICBs and to set them out clearly in their constitutions. I assure my noble friend on this point that the legislation allows the flexibility to establish these committees, so we should not find ourselves in the situation that he talks about. ICBs will be able to enter arrangements under new Section 65Z5, which allows an ICB to delegate or exercise its functions jointly with other ICBs, NHS England, NHS trusts, foundation trusts and local authorities, or any other body prescribed by regulations. Under these powers, a committee of an ICB could be created to look at population health improvement at place level and could consider entering an arrangement under Section 65Z5 to work jointly where appropriate.

The membership of that committee can be decided locally by the ICB, and it is entirely open to the ICB to seek views from other organisations as to who best to appoint. I hope that reassures my noble friend that there is already the legal framework for ICBs to look at population health improvement at a place level. We are trying to protect the ability of ICBs to determine the structures that work best for them. To help them to do that, NHS England has the power to issue guidance to ICBs on the discharge of their functions. The flexibility that we have set out in the Bill makes my noble friend’s intentions possible. However, our provisions also give a degree of flexibility, so that areas can take control, innovate, and adopt what works best for them, rather having to meet prescriptive top-down requirements.

It is for these reasons that I hope that my noble friend feels able to withdraw his Amendment 61 and not move his Amendments 95 and 96 when they are reached.

[Lord Lansley (Con)]

My Lords, I am most grateful to noble Lords for their support, and to my noble friend for responding. I have a couple of important things to say.

First, I was not suggesting these things. I was suggesting that the legislation should reflect what the Government’s intentions are, because the integration White Paper set them out. Secondly, my noble friend said very carefully that the health and well-being boards and integrated care partnerships can have the same membership, but that is not the same as them being the same organisation. I am looking for my noble friend to say, without fear of contradiction, that where they choose locally to do so—and I am perfectly happy for there to be flexibility—local authorities and the ICBs can create an integrated care partnership which serves the functions of the health and well-being boards and the integrated care partnership in one organisation. That is the question.

On Amendments 95 and 96, I take the Minister’s point. I looked at it and thought, yes, there’s no difficulty about the place boards being a committee of the integrated care boards, but the Government in their White Paper said that there should be a single person accountable for shared outcomes in each place. That place board would have functions delegated to it from the integrated care board and local authorities. For that to happen, I cannot understand why it is not necessary for that to be reflected in Clause 62, since the existing legislation makes no reference to place boards. Also, if the person who is accountable is the chief executive of the place board, we must assume that that will not necessarily be the chief executive of the integrated care board, yet as things stand in the legislation, the chief executive of the integrated care board will be the single accountable officer. How is the accountable officer to be the chief executive of the place board?

--- Later in debate ---

Moved by

[Lord Lansley]

69: Clause 26, page 37, line 24, leave out “objectives and”

[Lord Lansley (Con)]

My Lords, this group of amendments in my name relates to Clause 26. Noble Lords will recall that we had a rather helpful debate about this in Committee. The point is that the Care Quality Commission is an independent organisation. We want to respect that and see that carried through into its new responsibility of reviewing and inspecting the integrated care systems.

The Bill asks for “objectives and priorities” to be set by the Secretary of State. In another place, Members of the Commons inserted the idea that these priorities must include—as seen in proposed new Section 46B(3)—

“leadership, the integration of services and the quality and safety of service”.

That is fine; if they want that, let us leave it in, but I have no idea what “objectives” are in this context. Although I do not want to go down the path of semantics, for the Secretary of State to say what his or her priorities are is entirely reasonable and should be reflected in the indicators used by the CQC, but I am not sure that I know what “objectives” are in this context. Either my noble friend will explain to me what the objectives are, in which case the question of why they are not clarified further in the Bill arises, or let us leave them out—which is what most of these amendments do.

Regarding two of these amendments, it seems particularly undesirable for the Secretary of State—as in proposed new Section 46B(5) and (10)—to

“direct the Commission to revise the indicators”.

The indicators that the Care Quality Commission devises require the approval of the Secretary of State, so I am not sure why we should so trammel the independence of the CQC by enabling the Secretary of State to “direct” it to revise its indicators as opposed to denying approval, so I would rather that were not there.

Our noble friends on the Front Bench have been very accommodating; a spirit of compromise and understanding seems to have imbued the Front Bench splendidly so far. If the Minister is not minded to accept my amendments, I hope that she can at least give me some reassurance about the manner in which the Secretary of State’s powers are to be used or—in my view, this would be better—not used or extremely rarely used. I beg to move Amendment 69.

[Baroness Walmsley (LD)]

My Lords, the CQC is a competent and independent organisation. Long may that continue, and any attempt to trammel it is unwelcome. We have here a 265-page Bill. If the CQC cannot get from the Bill the intentions of the Government and carry them out carefully in doing its job inspecting and reporting on how the integrated care systems are working, I do not think it needs any further direction from the Secretary of State.

--- Later in debate ---

[Baroness Penn (Con)]

My Lords, I thank my noble friend for raising this issue. I hope in the spirit of collaboration and compromise I am able to provide him with some further clarity and reassurance, even if I am not able to support his amendments.

Flourishing systems are critical to the success of integration and many of the proposals in the Bill. In that context it is right that the Secretary of State, who is accountable to Parliament, can set the overall strategic direction of reviews of integrated care systems through setting objectives and priorities for the CQC in relation to those assessments. However, it will be the CQC as the independent regulator and expert which will develop and carry out those reviews.

In Committee, noble Lords across this House raised several matters that these reviews should or could look at—from children to rare conditions—and it is right that the Secretary of State should be able to set objectives to explain the intent that lies behind high-level priorities such as leadership, integration quality and safety. These objectives will aid the CQC in its development of the review methodology and quality indicators and lay out where specific focuses should be given. The current clause allows the Secretary of State to make these distinctions and be more nuanced, just as is permitted for CQC reviews of local authority functions relating to adult social care set out in Clause 152. To remove the Secretary of State’s ability to set objectives is to remove nuance, which in turn could dilute the focus of these reviews on particular patient pathways or integration arrangements.

Furthermore, the Secretary of State must be able to ensure that the CQC’s role is complementary to other assessments, such as NHS England’s oversight of ICBs. This is achieved in part through the Secretary of State’s role in approving and directing to revise the indicators of quality, methods and approach. Removing the Secretary of State’s ability to direct the CQC to revise indicators risks the Secretary of State being locked in after approving the methodology. This could prevent the Government being able to respond to shifting developments in health and care, thus undermining the review’s relevance as time progresses.

I further reassure my noble friend and other noble Lords that we expect the power to direct to revise to be used infrequently, so as not to disrupt CQC reviews. The Government fully respect the independence of the CQC, and these powers are designed to ensure that its reviews of the integrated care systems are effective without undermining that independence.

It is for these reasons that I hope my noble friend feels able to withdraw his amendment and not move his further amendments when they are reached.

[Lord Lansley (Con)]

I am most grateful to my noble friend and for the support of noble Lords for the concept. I hope the CQC will find that this assists it in ensuring that it remains independent in how it goes about its job, and, indeed, how it derives indicators of quality and fitness for purpose. I take my noble friend’s point about what objectives might be. They might be, for example, objectives of the nature of the service that the review should cover so the Government might have some national priorities. I think the word “priorities” would have been sufficient.

I confess to my noble friend that I did not understand why the Secretary of State might come in and direct the CQC to change its indicators. It would have been perfectly reasonable for the Secretary of State to have waited and seen what the CQC said. The CQC will clearly change its indicators from time to time as technologies and services adapt, and it could have been trusted to do it. I will not press the point and I beg leave to withdraw Amendment 69.

Amendment 69 withdrawn.

--- Later in debate ---

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise briefly to support this group of amendments and to declare my interest as a fellow of the Royal College of Nursing. It is absolutely clear to me that, without the right staff in the right place, you cannot give the right care. This is the situation we are in at the moment, and we must get it right for the future. We are on an improvement trajectory, and there is an increase in the number of nurses employed in the NHS. However, this is not universal across all areas of the NHS, particularly in learning disability and mental health.

If we could get the Government to support Amendment 80, we could resolve the issue through guidance. On Amendment 81, I also speak for my noble friend Lord Patel, who unfortunately cannot be here today and who believes that an elegant solution as described by my noble friend Baroness Finlay, in terms of guidance subsuming Amendment 82 in particular, would enable directors of nursing, medicine and care to be responsible for ensuring that they have a safe staffing structure in the areas for which they commission care. That would be reported up every two years through the Secretary of State, rather than every five years, as indicated in Amendment 82. This would be a much more suitable solution.

[Lord Lansley (Con)]

My Lords, I will intervene. I was not intending to speak but I was prompted by a recollection arising from the reference to anaesthetists by the noble Baroness, Lady Finlay. I recall that the Centre for Workforce Intelligence produced in February 2015 a report on the future supply and demand of anaesthetists and the intensive care medicine workforce. I have just checked the report, and it projects for 2033 that the number of full-time equivalent staff required will be 11,800, and supply will be 8,000. Therefore, in February 2015, we knew of this set of projections produced by the CWI. It said, among other things, that there should be

“a further review in the next two to three years.”

However, the CWI was abolished in 2016 and its functions were restored, I think, to the Department of Health.

The noble Lord, Lord Stevens, did not refer to this directly, but we must bear in mind the general presumption that there has never been workforce planning, although in certain respects, there has. The report on anaesthetists is only one of a whole string of reports—I could list them, but I do not need to—produced by the Centre for Workforce Intelligence before it was abolished. Their main purpose was to say to Health Education England, “This is the level of education and training commissioning you should be undertaking in the years ahead”. As the noble Lord said in Committee, it did produce a set of proposals; it is just that they were not acted upon.

I just say this: legislation may be the right way to proceed now, but let us not lose sight of what is actually required, which is for Health Education England not to have its budget cut, as happened in 2016, but to have its budget increased and for that budget to be turned into an education and training commissioning programme that delivers the numbers of trained professionals in this country that we project we will need. It is no good saying, “Oh, we’ve never had planning; we passed a piece of legislation.” I am sorry, it could be a case of legislate and forget unless the money is provided and the commissioning happens. There have been organisations whose job it was to do it—Health Education England, the Centre for Workforce Intelligence—but they were not supported, and in one case, abolished.

[Lord Warner (CB)]

My Lords, I support Amendment 111 in the name of the noble Lord, Lord Hunt, to which I have added my name, and Amendment 80 in the name of the noble Baroness, Lady Cumberlege. On Amendment 111, I want to emphasise two points. First, GPs are and have always been the gatekeepers to the NHS. Without GPs, there is less primary care and less access to the NHS. Over 90% of patients access the NHS through their GPs and primary care. If you are unlucky enough to live in an area with a serious shortage of GPs, your access to NHS services is highly likely to be diminished and your health put at greater risk.

My second point is that it follows that a shortage of GPs is also likely to contribute to health inequalities, a topic much discussed during the passage of the Bill. In addition, this is likely to mean that you live in a place which the Government say they want to level up. So, if the Minister accepts the amendment of the noble Lord, Lord Hunt, he will be helping to deliver two government objectives: reducing health inequalities and levelling up. What’s not to like? Who knows—he might even get a promotion out of it.

I turn briefly to Amendment 80, which I support and will vote for if the noble Baroness pushes it to a vote. I want, however, to emphasise two points that follow on a great deal from what the noble Lord, Lord Lansley, said. For too long the NHS has relied on buttressing its inadequate system for training home-grown staff by recruiting from abroad. Brexit and tighter immigration policies have significantly reduced this supply line. It will take long-term planning and consistency of purpose over many years to rectify the health and care workforce supply problems.

My second and last related point on workforce is that the track record of the Department of Health on long-term planning is appalling. It is not just me saying that; it was made absolutely clear in the report by this House’s Select Committee on the Long-term Sustainability of the NHS and Adult Social Care, so ably chaired by the noble Lord, Lord Patel, who unfortunately, as we all know, is laid low by Covid. Those who support Amendment 80 should hear the arguments in the debate on Amendment 112, which would support its implementation. The noble and learned Lord, Lord Mackay, thought that something more elaborate than Amendment 80 was required. That may be the case, particularly for social care, but Amendments 80 and 112 complement each other. They are not rivals or alternatives; they put in place a structure thoroughly independent of government and which requires the Government then to pay attention to what has been independently provided.