16:51 - The House divided: - Ayes: 276 / Noes: 152 - Question accordingly agreed to.
The Minister of State, Department of Health (Norman Lamb)
I beg to move,
That the draft Legislative Reform (Clinical Commissioning Groups) order 2014, which was laid before this House on 13 March 2014, in the last Session of Parliament, be approved.
The draft legislative reform order seeks to amend the National Health Service Act 2006 in two ways. First, it will allow clinical commissioning groups to form a joint committee when exercising their commissioning functions jointly. The 2006 Act already allows two or more CCGs to exercise their commissioning functions jointly, but makes no provision for them to do so via a joint committee. Secondly, it will allow CCGs to exercise their commissioning functions jointly with NHS England and to form a joint committee when doing so. The Act already allows NHS England and CCGs jointly to exercise an NHS England function and to do so by way of a joint committee, but it makes no provision for them jointly to exercise a CCG function.
This draft order has already been scrutinised by the Regulatory Reform Committee, and I was pleased with its recommendation that it be approved under the affirmative resolution procedure.
I should say from the outset that the proposed arrangements are voluntary. One party cannot impose the arrangements on another. This allows CCGs to retain their autonomy and to continue to make decisions that are in the best interests of their local populations. They can decide whether to enter a joint committee arrangement with other CCGs. At the moment, the lack of provision for CCGs to form joint committees is placing a burden on CCGs and preventing them from working in the most effective and efficient way. Without the power to form joint committees, CCGs have had to find other means of reaching joint decisions that are binding. That means that they often end up seeking legal advice to ensure that they are on a firm footing, and that adds to cost and complexity without a proper process in place.
As an interim measure, therefore, some CCGs are forming committees in common whereby a number of CCGs may each appoint a representative to such a committee. Those representatives then meet, and any decisions reached are taken back to their respective CCGs for ratification. This leads to additional costs in terms of people’s time in sitting on multiple committees, administrative resources, and extra financial cost. Clearly, such arrangements are burdensome, particularly when compared with the simplicity of a joint committee. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which all participating PCTs were bound by the decisions reached, subject to the terms of reference of that committee.
Graham Stringer (Blackley and Broughton) (Lab)
The Minister’s advice that all the members of a committee acting in common have to report back is at odds with the letter from the Department of Health to a committee dated 8 April 2014, where part of its case is that decisions have to be taken unanimously. That is quite different from having to report back, and it undermines his case about the administrative burden.
Norman Lamb
Currently, because there is no provision for a joint committee, the participating CCGs have to enter into some sort of arrangement that allows them, under their constitutional arrangements, to approve whatever plan of action is discussed and agreed at the committee in common. There could be a process for each CCG to delegate responsibility to the person attending the committee in common to take the decision at the committee on a unanimous basis, as the hon. Gentleman suggests. Alternatively, there could be an arrangement whereby they have to go back to their own CCG and then have a further committee meeting to endorse the proposal that has been discussed at the committee in common. However it is done, it adds complexity and additional cost to the process. It does not stop anything happening; it just makes it more complicated than it has to be.
As I said, such arrangements can be burdensome. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which participating PCTs were bound by the decisions reached. We therefore want to allow CCGs—I stress that we are allowing them, not imposing anything on them, and it is entirely up to them to decide whether they want to participate—a route through which they can take decisions in a properly constituted forum when they are collaborating with other CCGs.
Similarly, the lack of any power for CCGs to exercise their functions jointly with NHS England is causing inflexibility. NHS England and CCGs may wish to act jointly to commission better out-of-hospital services, for example. Making sure that services are integrated around the needs of the patient is the best way of ensuring that care is provided in a safe and compassionate way that most benefits the person involved.
Sometimes there are issues that straddle the commissioning responsibilities of NHS England—the specialised end of the commissioning spectrum—and the responsibilities of the local CCG, and it seems to me that it is worth trying to secure joint working on both sides of that divide in the most effective way possible. The amendment would allow CCGs and NHS England, as co-commissioners, to develop and agree strategic plans and delivery processes that take into account the effects of services across the whole pathway—from specialist to local commissioning—supporting design and continuity of services across primary, secondary and community care.
For example, CCGs and NHS England may wish to review service delivery across specialised services commissioned by NHS England and any impact a redesign may have on non-specialised acute services commissioned by CCGs, in order for services to be designed and delivered to achieve the best possible outcome for the population served. The inability of NHS England and CCGs to jointly exercise a CCG function, and to form a joint committee when doing so, makes it more difficult to make timely decisions, which can delay the ability to improve patient safety. The proposed amendments will encourage the formation of new commissioning partnerships, allowing the most effective approach to be used.
When CCGs agree to form a joint committee, they will have the freedom to agree terms of reference, including voting arrangements. They could, therefore, agree between them to allow decisions to be reached by a majority. Equally, however, if a CCG wants to be absolutely sure that there would be no adverse effect on the area it serves, it could, as part of the agreement to enter the joint committee, require unanimity before anything is approved. This will not dilute the emphasis on local decision making.
It is important that patients, members of the public and other stakeholders are able to see how joint committees operate and, in particular, how decisions are made. CCGs must specify in their constitutions the arrangements made for the discharge of their functions and for ensuring that there is transparency about the group’s decisions and the manner in which they are made. That applies whether CCGs are discharging their functions individually or as part of a joint committee with other CCGs.
CCGs already have a duty to involve patients and the public in plans and decisions about commissioning arrangements. This involvement can be by way of consultation, by the provision of information or in other ways. We would still expect CCGs to make suitable arrangements to make sure that that duty is complied with when exercising their functions in a joint committee. In other words, the duty is exactly the same: arrangements for public involvement apply equally to decisions made by CCGs in a joint committee as they do to those made by CCGs individually. There is no reason why decisions taken in joint committees should be any less transparent than any decisions taken individually. The creation of joint committees would enable CCGs to take binding decisions without the need for separate ratification of complicated delegation structures.
CCGs are still accountable as individual organisations—they do not lose that by entering a joint committee. Joint arrangements mean that each CCG is still liable for the exercise of its commissioning functions, even where they are being exercised jointly with another CCG or with NHS England. To be clear: joint working does not abrogate a CCG of their responsibilities as a statutory, independent and accountable organisation. The proposed arrangements will not lead to reconfiguration by the back door; they will not affect the existing processes, the tests that any significant service redesign needs to follow or the role of the overview and scrutiny committee locally.
The proposed amendments build on existing powers by giving CCGs greater flexibility and control in the way they work. They return, in a sense, to the arrangements that were in place with primary care trusts. The changes will support more effective and efficient joint working and allow discussions about service redesign to take place across the local health economy. As CCGs become more established organisations, they need to have more flexibility to work together and with NHS England. In any commissioning structure, there will always be some decisions that need to be taken locally and some that span a wider population.
Liz Kendall
No. I will make some progress. The hon. Gentleman may want to listen to what the Secretary of State for Health admitted in a letter to the chair of Healthwatch England on 11 August:
“The Health and Social Care Act, when it established CCGs, did not make provision for CCGs to form joint committees and other CCGs. PCTs previously had this provision in legislation and many formed joint committees to progress partnership work.
Health organisations, including CCGs, have expressed concerns about CCGs’ inability to form joint committees that are able to make binding decisions. This inability has brought many practical challenges in working together on issues that cut across boundaries, such as continuing healthcare, patient specific funding requests and service change”
across the country. I do not know whether the Minister wants to explain why the Health and Social Care Act removed that provision, as the Health Secretary admitted in the letter to Healthwatch England. Does he want to stand up? If not, I will make some progress.
The Minister was fortunate not to be on the Committee that looked at the Health and Social Care Bill twice, so he will not know that Opposition Members repeatedly warned during its passage that CCGs would often be too small to secure effective changes to services across wider areas. We have consistently made it clear that the only way we can get the big changes we need to be able to improve care for patients, including by specialising some services in regional centres and shifting others out of hospitals into the community and towards prevention, is by working in partnership across larger areas.
In principle, we support the need for collaboration and for CCGs to come together both with one another and with NHS England, particularly in wanting to commission good services across primary, secondary, community and specialist care. However, serious concerns have been raised about the draft order by local healthwatch organisations, Healthwatch England and some of the organisations that responded to the consultation, and my hon. Friends may want to raise real concerns. I will go through the concerns in some detail.
The Minister has talked about the fact that CCGs will remain autonomous, but many of them are concerned that that is not written into the draft order. Many CCGs feel that they are coming under increasing pressure from NHS England and some of its local offices. They are concerned that the draft order might take away their autonomy, forcing them into committees and decisions that they do not think are in the best interests of local people.
Liz Kendall
If the Minister will give me two seconds, before I allow him to intervene I want to read out what NHS Clinical Commissioners—the independent collective voice of CCGs—said in its response to the consultation. It said that it
“would not want the Legislative Reform Order to become a ‘back door mechanism’ for reconfigurations.”
It asked for
“some assurance the change will continue to respect the decisions of CCGs as statutory bodies”,
and it insisted that
“CCGs must not be pushed into shared arrangements with NHS England if it is not in the interests or needs of their population”.
I have heard the Minister’s words about that, but the draft order has not been changed. Perhaps he would like to say more about it.
Norman Lamb
It is worth putting it on the record again that this does nothing to change the legal duties of a CCG and nothing to put any pressure on a CCG to enter any arrangement, either with other CCGs or with NHS England. If a CCG feels under pressure, it has every right to resist it, if it feels that to do so is in its interests or those of its local community. This is entirely voluntary. With regard to the legal duties, nothing changes.
Liz Kendall
If one of the 22 CCGs in the east midlands, part of which I represent, decided that it did not want to come together to commission one body to perform NHS continuing health care, for example, because it did not like it, could it say no?
Norman Lamb
Absolutely. There is nothing in the proposed amendment that could force any CCG to do anything. I suspect that in such circumstances common sense might prevail, as everyone recognises that on something such as NHS continuing health care, collaboration makes a lot of sense, as the shadow Minister indicated, but there is nothing to force anyone to do that.
Liz Kendall
Will the Minister also clarify that if NHS England wanted to form a joint committee with CCGs in the area, it could not force them into it?
Norman Lamb
This is a good exchange of views. Again, I can confirm that this is about a voluntary arrangement between a CCG or CCGs and NHS England. There is no compulsion at all.
Liz Kendall
I am very grateful to the Minister, who has perhaps been much clearer on that point than the Minister in the other place was.
The Minister has been clear that CCGs will not be forced into joint committees, but the second concern relates to majority voting in the committees. He will know that the Regulatory Reform Committee’s report cites a couple of CCGs that have been concerned that
“Joint committees would be able to take majority decisions on behalf of their constituent CCGs and NHS England, and so individual CCGs might find themselves accountable for implementing policies that their members did not consider to be in the best interests of the local population.”
To put it bluntly, if one or two CCGs on the committee disagree, they can be outvoted. Is that the case, and would it be possible for NHS England to have the casting vote on a committee?
Norman Lamb
It is helpful to respond straight away on these specific points. Again, I stress, as I think I made clear at the beginning, that it is up to the participating CCGs to determine what voting arrangements should be in place. If they felt that unanimity was required in order to protect the interests of the community they serve, they could make that a condition of entering the joint committee. It is entirely up to the participating CCGs to agree the rules.
Liz Kendall
I am grateful to the Minister for that helpful clarification.
The third concern has been raised by the Association of Directors of Adult Social Services and by the Local Government Association. They are concerned that any joint arrangements between CCGs, or between CCGs and NHS England, must be fully aligned with the geographical boundaries and strategies of local health and wellbeing boards. That is not only because we have to get health and social care working together, with council care services and the NHS, but because of accountability issues. Perhaps the Minister will say something about that later.
The last two concerns about the draft order are, for me, the greatest. The fourth is about how the joint committees will be held to account for the decisions they take and how patients, the public, local healthwatch, health and wellbeing boards and Members of this House can know what decisions are taken and hold the joint committees to account, because I understand that they will not be required to meet in public. I raise that concern because it has been raised in two letters from the chair of Healthwatch England to the Secretary of State. In her first letter on 16 July, she wrote:
“I am concerned about the impact this reform could have on the statutory role of local Healthwatch, the integrity of local accountability mechanisms, and meaningful public involvement in decisions about service redesign.”
She goes on:
“Whilst I recognise the important role CCG collaborations can play in the effective commissioning of health and social care and the transformation of traditional service models, I am sure you will agree that it is vital they are accompanied by strong accountability and engagement mechanisms. This is of particular importance given the scale of decisions being made by joint committees, and our anticipation that many more of these joint arrangements will be put in place. Without these safeguards in place, the public are far less likely to understand, or be accepting of, the changes that happen in their community.”
She recommends that the draft order be strengthened, and makes four proposals:
“Ensure CCGs acting in collaborative arrangements have in place adequate mechanisms meaningfully to engage the…community.”
She suggests a
“mandatory non-voting constitutional seat on Committees…for local Healthwatch”
and a
“duty on all lead or co-ordinating commissioners to have due regard to existing local agreed priorities…(including Joint Strategic Needs Assessments and Health and Wellbeing Plans).”
Finally, there should be
“a duty on all lead or co-ordinating commissioners to act within existing local accountability mechanisms”
including local health and wellbeing boards.
When the Secretary of State replied to Anna Bradley, he said he felt that mechanisms for public accountability were in place and that there would be no proposed strengthening of the order. In her reply to him on 20 August, Anna Bradley stated:
“I do not yet share your confidence that the new joint committee arrangements will address our concerns about transparency and accountability.”
The Government said throughout the Health and Social Care Act 2012 and all their reforms that there should be “No decision about me without me”, but the patient and public voice, local and national Healthwatch, has said it does not believe that that strong patient and public voice will be effective under the proposed order. The Minister needs to respond to that.
Finally—this is a particular concern of mine—one decision that joint committees can take concerns individual patient-specific funding requests for things such as NHS continuing health care. Any hon. Member whose constituent has applied for that kind of funding, or funding for a number of different areas, knows that it can be difficult to get to the bottom of those decisions. I had a particular problem with Greater East Midlands commissioning support unit, which manages continuing health care for the 22 CCGs in the east midlands. I have barely been able to get any information out of it about the bad decisions it has taken, and that is a real worry because I am concerned that the joint committees will repeat that. How will we know how those decisions are taken or hold them to account?
Norman Lamb
Perhaps the hon. Lady will give me details of that concern in her local area. It is important that we hold the different parts of the system to account, and she should be able to establish the position. I am happy to pursue that matter for her if she would like.
Liz Kendall
I am grateful to the Minister. I will forward him my concerns, just as I have done to my local CCGs and the chief executive of NHS England.
To conclude, Healthwatch raised these concerns in relation to a particular issue in Greater Manchester and the Healthier Together project, where 12 CCGS have grouped together to reconfigure services. The local healthwatch is concerned that under the draft order some of the problems it has seen with Healthier Together could be replicated. For example, I understand that governance meetings for Healthier Together started to take place in public only in March 2014. That was after major decisions—such as the model for service reconfiguration—were discussed in a closed session of that committee. The local healthwatch remains concerned about the lack of clarity on planned public involvement in Healthier Together in future, and, like the local healthwatch, Healthwatch England is concerned that the joint committees will not be accountable to patients and the public.
Hon. Members across the House will say that previous primary care trusts were sometimes not open and accountable, and I may have shared some of those concerns. This is a chance to put things right, but I am concerned that the draft order is not strong enough and I know other hon. Members will also raise that point.
Richard Fuller
I am not an expert, but in that particular instance I do not think I would fear the joint committee making a different recommendation from the current committee in common, although it has yet to come back with its report. The point is that the hon. Gentleman and others have aired important questions for the Minister to answer. He has answered some of them, and that has been the purpose of the debate today.
Underpinning all this is the fact—whose importance I hope the Minister will emphasise in his response—that people want important health decisions to be taken locally. They can be persuaded of, and they can understand, the issue of common advance, but they want to know that a decision is being taken locally. I think that the Minister dealt with this in his response to the shadow Minister, but I would be grateful if he answered these points quite specifically. First, am I right in thinking that he said that decisions on the part of commissioning groups to go into joint committees were voluntary, rather than compulsory, and that it would therefore remain possible for them to continue to set up committees in common if they so wished? My second question—
Richard Fuller
I am happy to give way to the Minister iteratively, or he can wait until I have given him the full menu. Which would he prefer?
Norman Lamb
The answer to that question is yes, absolutely; I repeat that this is a voluntary act by any CCG. To address one of the concerns raised by the shadow Minister, let me say that there may well be circumstances in which CCGs want the rules of the game established at the start of the joint committee saying that there will be circumstances in which they can withdraw from that committee. So there are no circumstances in which any CCG needs to feel that it will be oppressed in any way by its neighbouring CCGs, NHS England or anyone else.
Richard Fuller
I am grateful for that clarification. My second question is on the issue of voting on the joint committees. To be effective, is it a requirement that joint committees should be based on unanimous voting only and that all CCGs would have to agree, or will joint committees be substantially based on majority voting? Is it open to CCGs to create joint committees with majority or unanimity voting depending on how they wish to set those up?
Madam Deputy Speaker (Dame Dawn Primarolo)
Order. May I say to the Minister that I know he is trying to be helpful, but he will soon be seeking to answer this debate? We have only one more speaker to go, so to help the flow of the debate perhaps Members could finish their speeches and then he can respond.
Norman Lamb
I am grateful to all Members for their contributions to this debate. Regarding the shadow Minister’s contribution, I am pleased to hear that she is supportive, at least in principle, of this capacity to facilitate greater collaboration at a local level. As my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) said, it is rather ironic that this is all about a reformed health system that has much better clinical and democratic legitimacy than the one we inherited from the Opposition. I notice that no one is out there waving banners demanding the return of the primary care trust. Ultimately, that body had no accountability to the local community—[Interruption.] No, it had no accountability. Its accountability was entirely upwards to the strategic health authority and to the national level.
Liz Kendall
That is completely over the top. Sometimes I have had great trouble getting any answers out of my CCG. Sometimes they have been good and sometimes they have been bad. I have also had great trouble getting anything out of the commissioning support unit. The Minister should not paint some super rosy picture of fantastic accountability and patient involvement, as there are still some real issues.
Norman Lamb
I fully understand that we should always be arguing the case for greater openness and for greater legitimacy and accountability. All I am saying is that the system that we inherited had no local legitimacy at all, and that this is a significant improvement.
The shadow Minister talked about alignment with health and wellbeing boards. I think that that will almost always be the case. In my county of Norfolk, there are several CCGs, but all are operating within a health and wellbeing area and a local health economy. There may be circumstances in which more than one health and wellbeing board area is being considered, and I think that that is the case within the Manchester area and the discussions that are going on there. But in most circumstances, the sort of collaboration that we are talking about will be consistent with the health and wellbeing board area.
The shadow Minister also asked how CCGs will be held to account for joint decisions. When they act in joint committee, they will be subject to the same duties as when they act on their own and the accountability they face will be exactly the same. It is very important to reiterate that point.
The hon. Lady also raised concerns about the issues that Healthwatch England has raised, and I stress that the Department, NHS England and Healthwatch England are working together to ensure that CCGs have the materials and resources they need to support their effective and accountable collaboration and that local healthwatch organisations and others are supported to hold the system effectively to account. Everything on our side is about facilitating accountability at a local level, not undermining it.
My hon. Friend the Member for Stafford (Jeremy Lefroy) raised concerns about the issues in his area. I think that it is fair to say that they are not directly related to the proposals under the order, in that his concerns are about issues under the current arrangements rather than any potential impact of the proposed change. I want to reassure him that nothing in the order in any way undermines effective accountability for changes. I think it would be dangerous for me to go down the route of responding to the points he raises about his local circumstances, and I suspect that you, Mr Deputy Speaker, would rule me out of order if I tried to do so.
Jeremy Lefroy
The point I wish to make is that in our case the group of CCGs that is seeking to put out to tender the commissioning of end-of-life and cancer services appears to be abrogating its responsibilities for commissioning. These are clinical commissioning groups, yet they seek to put out to tender the commissioning of vital services for our constituents for 10 years. One might be concerned that the groupings would seek to do more like that.
Norman Lamb
My hon. Friend expresses a concern about what is happening at present and he is absolutely right as a local Member to challenge, question and hold to account the clinical commissioning groups in his area, but I do not think that there is anything in the order that changes the arrangements about which he is concerned. Indeed, I think that streamlining the system so that there is more effective accountability and less opaque decision making is better for local people.
Concerns were raised that joint committees might not meet in public. Joint working does not need to mean that it will take place behind closed doors and exactly the same responsibilities will apply to CCGs when they work jointly as when they work on their own or through committees in common. Indeed, I understand that committees in common have already on occasion met in public and I would always encourage accountable organisations to operate in public wherever possible. That is the approach that I seek to advocate.
In response to concerns raised by my hon. Friend the Member for Stafford, let me make the point that the requirements for service change that apply to a CCG regarding any major proposal for change will still apply, including that for appropriate consultation. Joint committees might want to consult jointly to co-ordinate their communications to patients and the public where appropriate, but the duty remains on the clinical commissioning group and it must demonstrate that it is meeting it.
The hon. Member for Blackley and Broughton (Graham Stringer) again raised concerns about the process going on in Manchester and he and I debated the matter in the debate to which he referred. I stress that his concerns are about actions taken under the existing regime, with a committee in common, rather than under the proposals in the order.
The hon. Gentleman expressed worry about the appropriateness of the order under the Legislative and Regulatory Reform Act 2006, but both the Regulatory Reform Committee and the Delegated Powers and Regulatory Reform Committee judged that a satisfactory case had been made for the LRO and that the order met the tests under the 2006 Act, so his concerns are misplaced. Although he has legitimate and genuine concerns about the process in Manchester and whether it is right for local people, I suggest to him that accountability will be encouraged and improved if the new system is less opaque and more clearly set out in legislation than the existing one. All the things about which he worries are happening under the existing arrangements.
It is up to CCGs to set out terms of reference for any joint committee arrangement, such as the scope for decision taking, and arrangements for membership or voting. They may also determine situations in which a CCG would wish to withdraw from a joint committee arrangement. The hon. Gentleman was worried that one CCG might feel oppressed or bullied by others, but it could set the terms of reference so that it could withdraw in defined circumstances, so his concern is misplaced.
My right hon. Friend the Member for South Cambridgeshire spoke about important improvements in democratic accountability and clinical leadership in commissioning, and the benefits that that secures. He asked about collaboration on commissioning not only between CCGs, or between CCGs and NHS England, but, critically, with local authorities and public health bodies. Such collaboration is facilitated, and he and I share the view that we should try to promote a more permissive NHS health and care system within which local arrangements may be put in place to ensure that the resources available throughout the health and care system are used as efficiently as possible. We should encourage such joint commissioning, rather than putting blocks in its way.
My hon. Friend the Member for Bedford (Richard Fuller) rightly talked about the tension that exists between local decision making and clinical best practice. This approach is all about managing that tension, rather than trying to pretend that it does not exist. He made the vital point, with which I agree, that people want health decisions to be taken locally, and we should try to facilitate open discussion and debate about the difficult choices that we sometimes have to make, rather than taking power away from people, which just undermines confidence in the system.
My hon. Friend asked about unanimity, so I repeat that if a CCG wants to enter into a joint committee arrangement, and protect its position on behalf of its local community, it can insist that unanimity is the basis on which decisions are taken. That is entirely a matter for the participating CCGs.
My hon. Friend asked about the cost and burden of the existing arrangements. We all understand the possibility of legal challenge, and there can be complex arrangements that involve organisations going through hoops to ensure that they meet their legal duties, perhaps by going back to their CCGs so that a decision taken in a committee in common may be endorsed. The more complicated those arrangements, however, the greater the risk of legal challenge, and therefore the cost, so simplifying in law the basis by which CCGs and NHS England can come together to make joint decisions, should they want to, improves accountability, makes the system less opaque and reduces the risk of unnecessary costs. I totally agree with my hon. Friend that this is not about the burden of localism. Localism is a burden worth carrying; it is not to be avoided. The burden is bureaucratic complexity and the involvement of lawyers—I speak as an ex-lawyer. The more we can keep lawyers out of it, the better, and I am sure many hon. Members would agree.
My hon. Friend made the point that not all consequences may be known at the outset and that things may change, but CCGs can set the terms of reference to provide for that if they choose to. The measure is absolutely permissive; it does not impose anything on anyone.
My right hon. Friend—sorry, my hon. Friend the Member for Totnes (Dr Wollaston). I thought something might have happened as a result of her election to the Chair of the Select Committee, but it will happen in time, I am sure. I am delighted that she supports the measure. She made the perfectly legitimate point that we ought to be encouraging and facilitating working across boundaries, both of CCGs and of the different organisations involved in health and care, to get the best possible use of the resource available for any local area.
Finally, I repeat that we take on board the concerns of Healthwatch England. We intend to work with that body to ensure maximum accountability for the decisions taken as part of these joint committees.
Question put.