Lord Warner
Main Page: Lord Warner (Crossbench - Life peer)Cities and Local Government Devolution Bill [HL]
Lord Warner Excerpts
Lord Warner (Lab)
My Lords, I support my noble friend’s amendments, which provide us for the first time with an opportunity to discuss the relationship between the Bill and existing NHS legislation. I have degrouped my own amendment on NHS responsibilities for later discussion, because I wish first to hear the Minister’s response to this group of amendments. However, I promise the Minister that I will be returning to this matter on Monday.
I decided on this approach when I heard the Minister’s reply on Monday to my question about where the Health Secretary fitted in to the accountable Ministers in relation to the Bill, given the decision in February to delegate £6 billion a year of the NHS budget to the Greater Manchester Combined Authority. Her response was that Greater Manchester had agreed a memorandum of understanding with NHS England. That is true, and it may well be a good and sensible thing to do. However, it does not tell us very much about where this leaves the Health Secretary and his many duties and powers under the monster Health and Social Care Act—all 457 pages of it.
The Bill certainly does not make clear what happens when other areas come forward with their own proposals for delegating chunks of the NHS functions and budgets to combined authorities. I have read the current memorandum of understanding, which relates largely to 2015-16 as a build-up year for what will come later. The memorandum leaves a large number of loose ends relating to later years and the relationship of the combined authority with the Health Secretary under existing NHS legislation.
Having said all this, I make it clear that I am a strong supporter of the Bill and its approach to devolution. I very much share the views of the noble Lord, Lord Heseltine, about it. Unlike many of my colleagues on these Benches, I do not particularly oppose the idea of elected mayors; as a lifelong Londoner, I have experienced the benefits of a mayoralty. This year I also co-authored a policy paper for the think tank Reform entitled Letting Go, which discusses how English devolution could help solve the NHS care and cash crisis. Here I should declare my interests as a member of the advisory council of Reform and an adviser on health and care to the law firm Capsticks.
In the conclusion of our policy paper, my co-author and I went on to say about Greater Manchester:
“For the first time, a large city region has offered a model of healthcare in the UK that focuses on preserving and improving the health of all citizens rather than merely treating them when they are sick. It could provide a step change in health outcomes, particularly for the worst off. If successful in fixing the care model, this innovative approach could help make the NHS more financially sustainable, by controlling the numbers needing expensive acute care”.
This is a very big prize, but why are the Government so shy about putting some of this stuff in the Bill? Those are outcomes that we would all desire. We want them all for most parts of the country from our NHS, so why can we not be upfront and clear in the Bill about where the health and social care stuff—particularly the NHS functions and budgets—sits in relation to this Bill and combined authorities and sort out more precisely than at the moment the relationship between a combined authority and the Health Secretary, not just NHS England?
The key issue is how the Bill interrelates with the Health and Social Care Act 2012. If we want successfully to devolve NHS responsibilities in the way envisaged for Greater Manchester, as I hope we do, does not Parliament have to insert some provisions in this Bill which explain the relationship between those functions and the role of the combined authority and the Health Secretary and his duties and powers in the 2012 Act? This House spent months on that Bill and had to have a pause because there was so much difficulty and controversy over that legislation.
Only three years ago, Parliament and the previous Government set the future path for the NHS in a monster of an Act. Now we seem to be going into dark corners, shuffling away, trying to undermine that Act by slipping some functions through something called a memorandum of understanding to a combined authority without being clear where that leaves the Health Secretary and his duties.
I am not normally particularly sympathetic to the Health Secretary or to the problems of the 2012 Act, which was not one of Parliament’s finest hours, but the facts of life are that that is the legislation which governs the way the NHS is run in England now and for the foreseeable future, so trying to slide a set of changes through with combined authorities without being clear in the Bill what is going to happen in relation to the Secretary of State’s powers is a surefire recipe for confusion in the minds of the public, of the NHS and its staff and of the combined authorities.
My key questions to the Minister are: first, what collective discussions have taken place in government on the interrelationship of this Bill to the Health and Social Care Act 2012 when NHS responsibilities, funding and assets are to be devolved to combined authorities? Secondly, will the Minister tell the Committee whether the terms of the agreement with Greater Manchester will be further amended following the passage of this Bill before the Greater Manchester changes go live in 2016-17? Thirdly, what legal advice have the Government had on whether actions could be taken by authorities or the public under the terms of the 2012 Act to overrule the terms of a memorandum of understanding with a combined authority? Fourthly, is the process used with Greater Manchester going to be the way that subsequent transfers of NHS responsibilities to combined authorities will be handled after the passage of the Bill? We need answers to questions of that kind to be certain what is going to happen when the Bill goes on the statute book with relation to any transfer of NHS responsibilities.
In conclusion, I am a supporter of this Bill and of using it to devolve more responsibility from the NHS to local and regional levels, linked to other devolution to combined authorities. I do not want the Government’s proposals in the Bill to fail because insufficient thought has been given to the issues I have raised. We saw what happened with Andrew Lansley’s rushed and ill-thought-through NHS legislation, when its implications were not seriously addressed before Parliament passed it. I remind the Minister that the Prime Minister had to impose a pause on the consideration of that legislation because so much of it was ill considered and undeliverable.
I would very much like to work with the Government on the Bill and try to get it right; this is not a partisan matter. I hope that the Minister will clarify, either today or later in a meeting, how we can progress this issue. In the mean time, I can promise a debate next Monday on a revised version of Amendment 44D that seeks to define how NHS responsibilities can be devolved to combined authorities in a way consistent with the 2012 Act. I hope that the Government will accept in principle that something in this area has to be put in the Bill.
Baroness Williams of Trafford
Yes, my Lords, I am. They would be done by order, and any orders will be scrutinised through the affirmative process in both Houses of Parliament.
As to reporting on how a deal is proceeding, as I said in one of our debates earlier this week, a process for evaluating the progress on each deal will be discussed and agreed with each area as part of the deal. For example, the Greater Manchester deal has an extensive programme of evaluation, with evaluations being public documents available to all Members of the House, as well as to all with an interest in the area and the progress it is making. But again, I do not believe it is appropriate in our enabling Bill to make a requirement about the reporting or evaluation of some particular aspect of a deal, indeed an aspect that may not be in all the deals that are agreed.
I turn to specific questions that noble Lords have asked. The noble Lord, Lord Bradley, asked whether I would support the view that joint board membership should include representatives of the police, et cetera. In any one place, this will be a matter for the area concerned. In Greater Manchester, for example, it is for those concerned to agree who should be on the joint boards, which will reflect the responsibilities that the combined authority has. He asked the very simple question of whether the Secretary of State for Health will be ultimately responsible to the public for the delivery of health and social care. The answer is yes. He also asked about the Manchester MOU. Greater Manchester and all the health bodies concerned, including national bodies such as NHS England, as well as the Greater Manchester clinical commissioning groups, continue to work on the full details of the arrangements that they have agreed.
Lord Warner
I am sorry to interrupt the Minister’s flow, but I am becoming extremely confused. Twice in her response the Minister has said that all decisions about Greater Manchester will be taken “with” Greater Manchester—in other words, not “by” Greater Manchester. In this last set of responses to my noble friend, she makes it clear that the Secretary of State is responsible for decisions about health in Greater Manchester. What I am struggling with is this: what is the purpose of devolving some of these health responsibilities to the Greater Manchester Combined Authority if the Secretary of State reserves a right to overrule or vet those decisions? I thought that when the Chancellor announced the Greater Manchester project with a great song and dance, a very strong emphasis was given to the ability of local people to take the decisions that affect their area.
Let me give the Minister one example to chew on. Greater Manchester is proposing to remove a significant number of beds from acute hospitals to put more money into preventive medicine and community- based services. The Minister will know that closing hospital acute beds is a very contentious issue up and down the country. Who will take that decision? Is not Greater Manchester at risk of saying, “Our population’s health would be improved by removing some of those acute beds and spending some of that money on preventive public health and community-based services”? Can the Secretary of State then simply overrule it, using his powers in the 2012 Act? That is a very practical, real example of where we could have conflict. I would like to know where the Government stand on that issue.
Baroness Williams of Trafford
My Lords, Greater Manchester would work with clinical commissioning groups, et cetera, but would not itself deliver NHS services.
Lord Warner
That was not my question. Perhaps I could explain to the Minister what it is. The clinical commissioning groups in Manchester could all agree that they should take a large number of beds out of acute hospitals in Manchester—not anywhere else—because it was in the best interests of and would achieve better health outcomes for that population. Could they—all the interested parties, clinical commissioning groups and even NHS England, with the combined authority—agree that that is sensible to do? Could we then have a situation in which the Secretary of State, under pressure from some bits of the local community or from the acute hospital, declined to approve that well thought-out plan by the combined authority with the clinical commissioning groups? It is a straightforward question. Is the answer yes or no to whether the Health Secretary can overrule them?
Baroness Williams of Trafford
My Lords, perhaps I may clarify what exactly is being devolved. Greater Manchester will have the powers necessary to participate in a collaborative partnership which will develop health strategies for the place and commission health services. It would be a partnership arrangement. If within that partnership the Secretary of State thought that all of them collectively were making the wrong decision, I am sure that he would have something to say about it.
Lord Warner
So the result is the Secretary of State reserving unto himself all the authority to overrule a locally reached decision. We can talk about partnership till the cows come home, but is not the reality—and this is a critical issue—that the Secretary of State, as one of the partners but the partner with the power under the 2012 Act, can simply overrule them because he thinks that is the right thing to do?
Baroness Williams of Trafford
My Lords, I was not saying that the Secretary of State would overrule them for overruling’s sake, but if it was fundamentally a wrong decision, I am sure that he would have the power to intervene. I think that that is what the case would be. Does the noble Lord want to respond?
Lord Warner
I will read Hansard and come back on Monday, because this issue seems to me an Exocet under some of the principles in the Bill.
Lord Woolmer of Leeds
My Lords, surely devolution means giving power to the local level; it does not mean doing that—as long as the Government at the centre agree. Surely devolved authorities must in principle have the right to take local decisions, otherwise it is not devolution.
Lord Warner
May I suggest to the Minister that we return to this on Monday afternoon because I do not think she will satisfy us this evening?
Baroness Williams of Trafford
I know that we will return to it, and I look forward to that.
The noble Lord, Lord Warner, asked what legal advice had been received about the relationship between the MOU and the 2012 Act. NHS England and Greater Manchester have developed the MOU, and any draft order that the Government bring before the House to implement any arrangements agreed will of course be compliant with the relevant primary legislation. The noble Lord also asked about further change to the terms of agreement with Greater Manchester. We can envisage that, with the agreement of all concerned, devolution in Greater Manchester will develop.
The noble Lord, Lord Beecham, asked what the statutory roles of health scrutiny committees are in the context of devolution. Health and well-being boards will continue to exercise their statutory functions.