Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 4 months ago)
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Baroness Greengross
My Lords, my Amendment 332A follows well from the previous two speakers. It would ensure that integrated working in health and social care delivery—particularly the latter, which we know from many noble Lords who have spoken, including the noble Lord, Lord Warner, is often very much the junior partner in these discussions—is given an explicit place on the face of the Bill, rather than simply being relegated to regulations and guidelines. In his report on Fairer Care Funding, Andrew Dilnot commented that when someone has a care or support need, they do not really know which part of the range of state funding is going to provide the services that they need. This particularly applies to people with multiple needs and co-morbidities, which is often the majority. We know that there are many different services delivered at national and local level—for example, the NHS, the adult social care system, social security benefits, public health services and housing services. They can all be critical in meeting people’s needs. The problem is that all these elements overlap and interact, sometimes positively but sometimes rather negatively. Dilnot noted forcefully that when services that are shaped around people work well together, outcomes are better; when they do not, people experience very disjointed services and their experiences are poor.
We need a care system that is more consistent, with less variability, and one in which people feel that services are working for them, not against them. In this context, I welcome the Department of Health’s commitment to breaking down the barriers between health and social care to improve the outcomes and experience of users. Having a National Health Service that is free at the point of need, but a shared-responsibility system of social care, means that difficult decisions will continue to be made if this carries on. For example, in response to the Nicholson challenge, how will clinical commissioning groups ensure that the focus stays on the patient and on integration of services and not on contracting and other arrangements? Do we know what type of support managers need to make integrated services a reality? How can staff be encouraged to work collaboratively? Through this process, how can the correct values and ethos concerning the dignity and respect of patients, which we all believe in, be developed and maintained within and across organisations? There are many examples of where the consequences of having different care streams can seem extremely unfair to people. But when streams have been integrated or a more co-ordinated approach is taken, there is evidence of improved outcomes, high-quality services and better value for money, as well as the fostering of innovation. In my view, the powers proposed in Clause 192 for the health and well-being boards to support integrated working should be extended to encourage explicit joint commissioning.
In support for innovation in Part 5, greater regard should be given to the role that service and technology solutions, for example, can have in breaking down traditional boundaries and in encouraging better integration of health and social care services. All generations, including older people, are having their lives transformed by the dramatic changes that we daily witness in communications technology, yet in the UK the adoption of telehealth into health and social care, particularly in prevention and intervention, has sometimes been much slower than in many countries in the industrialised world. In other parts of the world, we have clear evidence of the key role that these systems play in the prevention of ill health, in self-management, in the provision of improved outcomes and in dependence for service users and efficiency savings for the taxpayer. As part of the overall redesign of care, this represents a vital element in the shift towards more preventive care, reducing the imbalance between hospital and primary care spend and making better use of scarce clinical resources. Better integration should facilitate such innovations and would go a long way to making health and social care more self-directed and giving a boost to the personalisation agenda. Integration deserves to be more than a footnote in this Bill. It could be the cornerstone of better quality, value for money and patient-centred care.
Baroness Jolly
I have put my name to Amendments 328B and 330ZAA. I send the apologies of the noble Baroness, Lady Tyler, who is not well. She had hoped to be able to speak to these instead of me. First, I should like to make a few general points about health and well-being boards. It should go without saying that the Liberal Democrats really welcome local democracy in health and the far greater involvement of local authorities than is the case at the moment, as well as the use of scrutiny committees. We are somewhat saddened that in the legislation there is only one elected decision-maker on a health and well-being board. I understand the Government’s unwillingness to prescribe, but they have not quite got the balance right. There may be as many elected councillors as other voting stakeholders, with maybe a casting vote given to the chair. That feels much more like localism in action than what we currently have.
Linked with that is the role of district councils, which is not mentioned terribly clearly. Here I have another apology, because I know that the noble Lord, Lord Greaves, had hoped to speak on this point. What we are losing in his eloquence we are probably making up for in brevity, but I still feel as strongly as I am sure he will. I can almost feel him behind me now, as I speak, but he is not well and is not able to be with us.
Where are district councils in this framework? I know that a lot of local authorities have now become unitary, but there are really key parts of England where strong county councils are well underpinned by district councils. They need to be there, because they provide planning, housing, leisure and environmental health—all these things that have to be well woven into the fabric of this Bill and the delivery of services. They are also part of the solution for the big public health issues. Three examples come to mind without even having to think very hard. Wearing their leisure hat, obesity is a very big issue. Some people prescribe exercise for obesity. On housing, in my neck of the woods, with the warm, wet westerlies, housing gets damp very easily. That brings with it chronic heart and lung problems, particularly if you cannot afford to heat. District councils also play a key role in housing on mental health issues. They are often providers for county councils and PCTs and I know that they would hope for a similar relationship with clinical commissioning groups, when things become established. They should be at the table of the health and well-being boards. I appreciate that you cannot have every district council having one representative. In Kent, where there are 16, or in Devon, where there are eight, you cannot bring those in, but there needs to be some arrangement for working together to ensure that district councils should be there.
Baroness Pitkeathley
My Lords, I, too, support this amendment. I remind the Committee of my role as chair of the Council for Healthcare Regulatory Excellence, which has an oversight role with the General Pharmaceutical Council. We believe that single dispensing errors should be treated in a proportionate way that still prosecutes those who have been negligent or have committed a deliberate act but does not penalise pharmacists who want to declare a dispensing error in the interests of patient safety—and I very much agree with the noble Baroness, Lady Finlay, that this is about patient safety.
In the interests of patient safety and public protection, we of course expect the regulator to be able to co-operate with other agencies if it is aware of a pattern of repeated single-dispensing errors that might reflect wilful and deliberate acts with the intention of harming patients. In those circumstances, there would of course still be recourse to criminal prosecution. With these exceptions, I very much support this amendment.
Baroness Jolly
My Lords, I, too, support this amendment. I have some personal experience that I can bring to bear, and it was not until I was reading through the amendments a week or so in advance that I put these things together. Some years ago my mother became really ill with a very strange set of symptoms and no one could work out what the problem was. Eventually her GP came round. Like many people of that age, she takes several drugs. He sat down on her bed, took out her box of drugs from her bedside table drawer and went through them. There was one drug that she should not have been taking at all. It was completely wrong and should have been taken sparingly, not three times a day. My mother lives in a small town and the GP knows the pharmacist well, so he high-tailed down to him straightaway to find out what exactly the issue was. In this case, the dispensing pharmacist was unaware that there was a mistake.
It was really quite interesting to see how it had all happened. The medicines were all stored on a shelf in alphabetical order by drug name, not brand name. The drug in question was adjacent to my mother’s normal drug, and both were generics produced by the same pharmaceutical company. The narrow little rectangular boxes looked the same, so the pharmacist had picked the wrong one off the shelf, popped it into the bag with the rest and it had gone home. My mother, whose sight is not what it was, had taken them all out of their boxes and popped them all into her pill box. The deal was done, it was really very easy, and the whole thing was completely indistinguishable.
Fortunately my mother recovered once it was sorted out. It was a regular, well-known, high-street pharmacy, and it was absolutely excellent. It wrote a letter immediately saying that it was going to instigate a clinical governance review. It then wrote again to tell us exactly what it had done, including changing its methods of storage and ensuring that someone double-checked all drugs before they were bagged-up. This had been a mistake, but there is absolutely no doubt that it was completely negligent, and also avoidable. However, it was not criminal. There was no malicious intent. It could have been terrible, but mercifully it was not. The employer spoke to the pharmacist who admitted exactly what she had done once they had worked it all out. The pharmacy took proportionate discipline, and that is what we as a family wanted. We wanted something to happen, for it be arranged that the mistake could not happen to anyone again and for anything that happened to be professional and proportionate. That is what happened. As a result, I totally support the amendment that my noble friend has tabled with the support of the Royal Pharmaceutical Society.
Baroness Masham of Ilton
My Lords, I shall add a few words because a pharmacist contacted me. Pharmacists are being encouraged to take on more and more, and the drugs are extremely difficult. Some drugs are the same but have different names. It is extremely difficult for patients too, and as they often go to pharmacies for advice it is really very important there this is openness and honesty when a mistake is made. However, I would not like this amendment to open a door for more mistakes to be made.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 4 months ago)
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Baroness Jolly
I rise to speak to Amendment 311ZA, in the name of my noble friend Lord Clement-Jones, which calls for people’s views on those services commissioned by the board, whether locally or nationally, to be taken into consideration. I need to make a declaration, because I am chairman of the Specialised Healthcare Alliance. When she sums up, will my noble friend the Minister try to give some assurance that those with rare and complex conditions, services for whom will be commissioned by the board, will be included in all consultations by local healthwatch organisations and by HealthWatch England?
I have some general remarks about HealthWatch, which is to be the voice of the patient both nationally and locally. I want to tease out what it is all about, where it should be and who should be doing it. HealthWatch has to do far more than its name suggests—it has to do more than just watch. Clearly, it needs to listen. I totally support the amendments of the noble Lords, Lord Rooker and Lord Harris of Haringey, who are pushing the idea that HealthWatch should be able to recommend. This is not just a tacit thing: it has to be very much more proactive, to push things back. Whether it is pushing it back to the Secretary of State, CQC, local authority boards, NICE or even clinical commissioning groups, it is critical that that should be seen as part of HealthWatch’s role. “No decision about me without me”—well, we will not know about that unless the recommendation amendment is actually woven in.
The amendment of my noble friend Lady Cumberlege is about local healthwatch organisations. Local healthwatch organisations will have an opinion on clinical commissioning groups’ commissioning plans, and that opinion should go to the board.
Where should healthwatch organisations be placed? We have said it before in this Committee and I suspect we shall have to say it again on Report: we on these Benches are not convinced that the role for HealthWatch England is with the CQC—as a sub-committee of the CQC—or that the role locally should be with local authorities. One of the things that these organisations will have to do, whether nationally or locally, is to be quite critical of their hosts. It is very difficult to be critical of your host, so it is perhaps not appropriate that they should be their host.
Along with the question of where healthwatch organisations should sit, another issue—certainly, this is an issue at local level—is funding. Funding is currently held by local authorities for LINk organisations. I suspect that many of us who have been involved in this Committee have been receiving letters from LINk organisations saying that their funding is being cut and they cannot possibly manage. That needs to be taken into consideration. I understand that, currently, the pot of funding for local healthwatch is going to be given to a local authority. Should we be unsuccessful in moving local healthwatch out of the local authority, I would like the Government to give some thought as to how that money might be ring-fenced. I know that they are not happy about ring-fencing money, but should money be ring-fenced and be part of, for the sake of argument, the public health budget? If local healthwatch organisations have to remain with local government, then the funding needs some sort of protection.
Who should be involved with HealthWatch? I support the amendment of, I think, the noble Lord, Lord Beecham, that there should be locally elected delegates. HealthWatch England would be far stronger if there were local voices from local healthwatches. Now that we will have not strategic health authorities but sub-national areas, perhaps there should be two members from each sub-national area to represent their patch who could give the views of local healthwatch organisations to HealthWatch England. Perhaps that might be appropriate.
The local healthwatch organisations—LINks and their immediate predecessor organisations—have had problems with who actually forms part of these organisations locally. Some have been very good, but some have been less than effective. The members of these groups have just happened to be whoever was interested and keen at the time. Sometimes the groups were positive, but sometimes they really did not work at all. There might be shades of the past here: I wondered if there was any mileage in suggesting that the local healthwatch should be composed of someone from the local authority, someone from the voluntary sector and, of course, someone representing the patients, so that you weave into the local group some professional expertise in order to help with some of the strategic work.
I pass on apologies from my noble friend Lady Tyler, who was going to speak about children—she had her name down to Amendment 311ZA. Children need to be heard. When you talk about the views of children, you might have a mental picture of very little children, but in this context children go up to the age of 18. A lot of interesting services are currently available for teenage children, teenage individuals, young people or young citizens. It is critical that their views, needs and experiences are sought so that they can be fed into the mix.
I have probably said enough now about HealthWatch for the three groups so I shall sit down and not stand up again, but it is critical that we do this right in the Bill. I look forward to seeing what comes out on Report and to seeing where we need to move on to from there.
Baroness Pitkeathley
My Lords, my contribution in support of the amendments is simple and brief: it is to ask that the Minister ensures that we learn the lessons of history and do not repeat the mistakes of the past when it comes to patient involvement. As we know, there is a huge evidence base about the benefits of patient involvement in health outcomes, and I am sure that the mantra of “No decision about me without me” is something that all noble Lords will accept.
While successive Governments have been committed to patient and public involvement, the history of it has not been a happy one. Some of us can go right back to 1974 when CHCs were first set up. Like my noble friend Lord Harris, I believe that this Government are committed to putting patients at the heart of the NHS, but let us look at why the previous attempts to do so have not been successful. In summary, I suggest that the reasons are these: the efforts have not been sufficiently well funded; they have not been seen as sufficiently independent and therefore have had conflicts of interest; they have not had enough status; and there has not been seen to be enough communication between national and local bits of the set-up.
I leave aside the current problems of the CQC, although I agree with noble Lords who have spoken about that, but the very idea of making the new body a sub-committee of anything seems to me to ensure that we are in fact going straight down the route where we have made so many mistakes before. I remind the Committee that those who do not learn from history are doomed to repeat it.
Nursing
Baroness Jolly Excerpts(12 years, 5 months ago)
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Baroness Jolly
My Lords, I thank the noble Baroness, Lady Emerton, for inspiring this debate. Hers is one of the most respected voices in your Lordships’ House, and when she speaks on this subject we all listen and learn. I am also delighted to see here in the Public Gallery nurses who have come to listen to the debate.
What is the front line? All but a few of the 600,000-odd nurses are working right there, delivering world-class care to their patients. Some will be in key management positions in our trusts and a few are top civil servants advising the department and strategic health authorities. They are members of clinical networks, and I hope that in the new world they will be advising the NHS boards and should be on clinical senates.
If you were to talk to a focus group of the general public and ask them to close their eyes and think of a nurse, what would they say? In all probability they would think of a woman. Depending on their age, they might put that nurse in a frilly starched cap, and almost certainly in a hospital at the sharp end of acute medicine—including theatre, A&E, intensive care and neonatal nursing—although those with recent experience of the NHS might have a more modern, nuanced view. Of course, that picture is not accurate. Many nurses are men, and in the days of infection control frilly caps have gone. This focus group might be surprised that it is a graduate profession and that there are many specialist nurses with the equivalent of masters’ degrees in their specialism. This situation is completely unrecognisable from that of 20 years ago. Let us be completely clear—here I totally agree with the noble Baroness, Lady Warwick—that, despite much red-top protestations to the contrary, all but a very few nurses do their jobs with utmost professionalism, as they fit into a multidisciplinary team based around patient care.
I shall focus my remarks today on the nurses whose front line is the local community and who work in community settings, in the home and in community hospitals. They are largely unsung but play a vital role in patient care. They give the patients what they want—personal care at home or close to home. Their role is vital in keeping patients out of the acute setting wherever possible and in taking tasks from doctors, who are thus freed up for diagnostic work. We should be in no doubt that this is not only good news for the patient but, incidentally, delivers considerable savings to the NHS.
What roles might nurses take in community care? They are involved with cancer, continence, COPD, diabetes, district and community nursing, end-of-life care, learning disability, mental health, midwifery, minor injury nursing, multiple sclerosis, older people, practice nursing, prescribing, renal, school nursing, smoking cessation, stroke and substance misuse. My list is not exhaustive, and I apologise unreservedly for any areas that I have omitted. These nurses are quietly innovative. The way that they work improves the care of their patients. They are collaborative and forge links with GPs, acute care, charitable sector providers and local authorities. They were designing informal packages of care and pathways before those terms were in common parlance. They act, while others plan and strategise.
In the history of community specialist nurses, midwives get the earliest mention in literature, in Exodus, delivering babies as the tribes of Israel fled from Egypt—if anyone can go back more than 6,000 years, I am happy to hear of it. This is a far cry from the world that my noble friend Lady Cumberlege spoke about on Monday in Committee on the Health and Social Care Bill. I should like to highlight two areas of outstanding care. Your Lordships will know that I worked for Macmillan Cancer Support, and I should like to explain its work in the community, and the role of minor injury nurses.
Last Sunday, I attended a service in Exeter cathedral to celebrate 100 years of Macmillan Cancer Support, which was established by Douglas Macmillan in response to his father’s death from cancer. There are now thousands of Macmillan-trained nurses in the community, offering services such as chemotherapy at home, wherever possible, and helping the whole family deal with end of life, where necessary. At present, only a quarter of patients are able to die in their own beds, and 24/7 community nursing is critical to helping cancer patients die at home. These front-line nurses prevent crisis situations from occurring, so that patients are not transferred into hospital and hence reduce costs to the NHS in the longer term. However, half of PCTs are not providing this vital service. The palliative care funding review recognised that a relatively small investment in 24/7 community services would enable commissioners to deliver improved outcomes for patients and ensure that palliative and end-of-life care services are delivered in the most cost-effective way. The new draft end-of-life care quality standard also supports the need for 24/7 community nursing, and Macmillan would like to see the standard implemented effectively and as quickly as possible. Macmillan is also supporting those living beyond cancer. Macmillan nurses help families link into specialist benefits advisers—either Macmillan's own or those trained by Macmillan and now working in CABs across the country—who work through and around the system for the patient and their carers. That is true personalisation.
On minor injury nurses, every week millions of people go to A&E or their own doctor for conditions that are minor—neither an accident nor an emergency. They go because A&E is easily accessible, but they waste the time of trauma teams. Two highly skilled specialist nurses in a community hospital or within an A&E department can run a minor injuries unit. They have access to advice from the A&E department as and when required. These units are able to treat a range of conditions: cuts, bruises, burns, simple fractures —even broken bones, as long as the skin has not been broken and the bone does not stick through—as well as sprains, strains and head injuries. Saturday afternoons see them full of sportsmen and women. In one year in Cornwall, 900,000 patients attended a Cornish minor injury unit. This prevented nearly 1 million attendances at A&E. By anyone's reckoning, that is an impressive record. If we visit their websites, praise for their service is fulsome. Holiday-makers visiting Cornwall, in Newquay, St Ives or Bude, leave messages on the websites to say how impressed they are by the services and asking why they are not offered locally.
I would like to move on to two general points about specialist nursing. Changes to the workforce need to be patient-centred and must not be undertaken simply as a cost-cutting exercise. There is anecdotal evidence that, in some cases, services are downgrading roles simply to save money without analysing the needs of patients. Changes to the workforce need to be thought out and patient-centred, mapping needs against skills. Macmillan is looking at how cancer patients can be given one-to-one support by a team of different professionals so that they receive support from the right person at the right time. In particular, Macmillan is looking at how support workers can be used to release capacity for specialists so that they can concentrate on tasks that make best use of and develop their skills, thereby improving the productivity and efficiency of teams.
I would like to echo remarks made by the noble Baroness, Lady Emerton, the noble Viscount, Lord Bridgeman, and the noble Baroness, Lady Warwick. I suspect that the speakers who follow might agree, although I dare not anticipate your Lordships’ speeches. Education and training must be protected if we are to ensure a high-quality future nursing workforce. I am extremely concerned that under the current financial constraints, education and training budgets are being cut. In addition, there is not the capacity or funding to free up professionals to attend such training. Neglecting the continued education of professionals hampers their ability to advance their knowledge to meet the new and emerging needs of patients and threatens the future supply of specialist nurses. I would welcome assurance from the Minister on this subject.
This has been a very interesting and important debate. Its timing within the Committee stage of the Health and Social Care Bill is really useful. We must do all we can to advance the nursing profession and in particular those specialist nurses who add so much to patient care.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 5 months ago)
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Baroness Finlay of Llandaff
My Lords, I apologise to the House for missing the noble Baroness, Lady Bakewell’s opening remarks. I simply point out that we have an Older People’s Commissioner for Wales, Ruth Marks. In March 2010 she led an inquiry into care in hospitals, called Dignified Care? By November this year, she was satisfied that the 12 recommendations from its in-depth and hard-hitting report had been met. She is now using her powers to drive forward additional adult protection legislation and a nursing home review. It is only with legal powers and leadership that we can really turn care round. I believe that such a post is more than cost-effective. I really recommend that the Government look hard at having an older people’s commissioner for England because we know that there is a big problem there. Such a post will more than save its cost.
Baroness Jolly
My Lords, I support the noble Baroness, Lady Bakewell, in her plea for a commissioner for older people. As she indicated, it has been a long-standing commitment of our party, which was put into party policy last September. Prior to the general election, we had a spokesman in the other place on older people’s issues, and there was a general election manifesto commitment. So we were right there and, as the noble Baroness has indicated, she has form in this regard too.
The Welsh commissioner for older people actually started life in your Lordships’ House before going to the other place, and the appointment was made in 2008. I have talked to Welsh colleagues over the last week and they have been really enthusiastic about the work that has been done and the progress made in Wales. So if it can happen in Wales, maybe we need to think about England too. The Welsh ambassador has similar responsibilities to those in the noble Baroness’s amendment. The role also has powers of investigation, entry and interview. I wish that we could be more ambitious with this older persons’ commissioner and extend the scope. As the noble Baroness said, there are so many issues that worry old people. Health and social care are clearly at the top of the list, but there are also pensions, housing, transport, leisure, even banking. Clearly there is a need for some sort of signposting centre for old people which somebody has to grasp and make it work.
The Government start a consultation on social care in the new year, and I know that my honourable friend Paul Burstow, the Minister for social care, is also keen on this particular issue, so I am really pleased to support this. Could my noble friend the Minister clarify whether an older person’s commissioner, or something similar, would be on the list of possibles, probables or definites for the next Bill?
Baroness Jolly
My Lords, I have supported the idea of coterminosity from when I first saw the Bill in January. It struck me as being straightforward and sensible that if health and social care were put together, the health boundaries would be aligned with the social care boundaries. That clearly happened in the middle of the last decade, when PCTs were grouped together to be coterminous with social care boundaries. There are all sorts of issues. If you have a large clinical commissioning group, then there is a capacity issue in that you have one clinical commissioning group that might need to work with several local authorities’ health and well-being boards, directors of public health, healthwatches or whatever. If you have a small group, then you have many CCGs working with all those bodies. It struck me that if there were a direct fit, everything would look quite neat and hunky-dory. I parked the thought in my mind that everything was fine.
Then I started to look at what was happening around me locally in the south-west. Torbay has been mentioned many times in your Lordships’ House. It provided a care trust—health and social care together. One of the areas they are really anxious about is that if they become part of Devon, an awful lot might get lost. So there are special circumstances around that integration. They know that they are small and they are trying to look at making themselves bigger by working with other parts of Devon, all of which take their acute services from one DGH. The same sort of thing is happening in Plymouth. Noble Lords will remember from the Bill about constituency boundaries in January that there was a huge big deal about Cornwall being all on its own. Cornish patients, believe it or not, actually do cross the Tamar in order to go to hospital in Plymouth. A fifth of Cornish hospital patients actually do that, so a whole group of Cornish GPs who face that way, along with some in south-west Devon who face that way, along with Plymouth, have discussed the possibility of working together as a group, simply because they all face one DGH. It was a common bond, if you like.
Therefore, we have a county or a district or a borough seen as one possible common bond. We have an idea that commissioning groups who commission from a particular hospital, trying to work together in a pathfinder mode, is not peculiar to the south-west; a lot people seem to think it would be a good idea. There are lots of issues, so how do we solve this? I still think that, for an awful lot of situations, co-terminosity is the right answer. The test really has to be: what actually can be deemed to be in the interest of the patient? The whole thing has to be taken in the round; it has to include care providers and health providers and there has to be an element of size capacity. My head—and my heart—say coterminosity, but then I look at certain other areas where there are groups that have—
Lord Hunt of Kings Heath
Would the noble Baroness give way? She has raised an interesting point. Could I describe the situation in Birmingham? My understanding is that although there will be more than one clinical commissioning group, there will clearly be one HWB group and the membership has now reached 25. There is one place for providers on it. One gets the feeling that there is a risk that it will become a talking shop. Secondly—and I declare my interest as chair of an NHS foundation trust in Birmingham—if you exclude the providers from those key discussions, you will not get a buy-in. Think of patient discharge and the relationship between reducing length of stay, preventing admissions and the support that social services needs to give packages of care. One worries that you reach a situation where the whole thing is so unwieldy that it will not really work.
Lord James of Blackheath
My Lords, could I ask the Minister a question that is definitely not medical and about which he might wish to take note for further advice later? In a cluster, does each component maintain its own solvency or do they have a collective solvency? If there is an imbalance in the size of those components and a marginally solvent large component, you run the risk of creating insolvency for the two smaller ones. That would be a severe risk for the trustees of those components.
Baroness Jolly
I have lost my thread. We are talking about Birmingham, which is humongous, and presumably any large city would have exactly the same sort of issues. Is the noble Lord arguing for coterminous clinical commissioning groups?
Lord Hunt of Kings Heath
My point is that my amendment was a probing amendment to get some information from the Government about their intent regarding boundaries. Clearly, one of the problems that we are discussing is size and the larger you make clinical commissioning groups, the less influence GPs will have on their deliberations. The whole point about clinical commissioning groups was to put GPs in the driving seat. I do not know if Ministers know how much pressure within the system is being put upon potential clinical commissioning groups, but they are being told that they have to get large. The numbers who put themselves forward at the beginning were basically told that there was no way that they would get approval, so they have been forced into big marriages.
I simply point out that even if you take Birmingham, where there will be very big clinical commissioning groups, you will still end up with an unwieldy health and well-being board. One has to think through the implications of this if you are then trying to get a cohesive strategy on public health and on joint commissioning that pulls all of the players together—while still excluding the providers from those discussions. We started from an original prospectus that was going to give GPs real control over commissioning. That is gone. I agree with the noble Lord, Lord Mawhinney. I do not think that there is now any chance in the system that is being forced upon the service, that individual GPs will have any influence. As with the noble Lord, Lord Mawhinney, it is clear that GPs are realising this now, and that the prospectus is a false one.
Baroness Jolly
I think that the noble Lord’s point is well made. The noble Baroness, Lady Finlay, however, talked about the element of size and back office, which needs to be quite large. Small CCGs will need to share a back office, simply because that is the way it is. There will need to be shared commissioning arrangements. I think that the noble Earl, Lord Warner, was saying much the same thing: these things will not work if they are tiny but might if they are larger. I remember primary care groups, which became primary care trusts, which became bigger primary care trusts. What is a reasonable size to make all those linkages work? What we do not want is for all of these organisations to spend their days going to meetings. If we are not careful and clinical commissioning groups go over local authority boundaries then they will have to serve more than one health and well-being board.
The ideal would be to have some co-terminosity but clearly it will not work in really enormous situations. My background and experience is in rural areas, where it strikes me as the most obvious way forward. Even if that is not how it starts, that is how it probably should end up. As for the Torbay example, the PCTs are very small. However, they are also perfectly formed and have done a really good job. They are desperate to keep what they did, and did well, but they are being pressured to join a Devon PCT—which also has pressure on Plymouth, which is also part of the Devon PCT. So it is not a straightforward picture. When clinical commissioning groups put their case to the board, there needs to be some sort of nuancing in application.
Baroness Murphy
My Lords, is not the whole point of the formation of clinical commissioning groups that it should be a local solution that fits the configuration of a particular urban or rural area and that it should be decided locally with the Commissioning Board what the best fit is? I take the point made by the noble Lord, Lord Warner, that size is an important issue as to whether one is favouring individual GP commissioning of a personal family health service or whether one is going for the much bigger purchasing of population services. Surely the big difference with this Bill is that PCTs had no real central support for developing commissioning in the way that clinical commissioning groups will have very explicit support from the Commissioning Board. I can see that the noble Lord, Lord Warner, is shaking his head, but I think that makes a huge difference because we have seen the concentration of emphasis by the Department of Health on the acute sector, and to get a way towards having much greater leadership from the centre in developing commissioning seems to me a very positive thing.
The noble Lord, Lord Hunt of Kings Heath, asks why is it only GPs—why do all professionals not get involved? All local primary care clinical professionals should have an input to the groups’ deliberations, but surely the obvious answer is that it is GPs who specifically use resources for their patients from secondary care. They actually determine the costs in secondary care through their use of secondary care hospitals; they intervene to stop secondary care—they have the possibility of doing it through provision of primary care; and they have enormous control over the funding, potentially, of the hospital system. It seems absolutely obvious that it should be GPs. The input of local dental practitioners, opticians and pharmacists is vital but they do not play the same financial role and that is why it seems to me it has to be GPs.
We cannot in this Chamber fix this Bill to lay down rules for the development of clinical commissioning groups. It would be absurd. The Commissioning Board and local people who are going to contribute to it have to make that decision. They have to be the ones to make it work. If they need to come together to commission services for rare conditions, that is fine.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 5 months ago)
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Baroness Jolly
Baroness Jolly
I will be brief so perhaps we can make a little more progress this evening. These four amendments come as a group; originally they were in two groups of two, but actually they hang together as a suite. They are probing amendments, and I thank the Royal College of Paediatrics and Child Health for its help with them. These amendments are intended to arrange for the organisation of carer children and young people, particularly young people who are vulnerable, and are about guaranteeing their safety and well-being and safeguarding them. When I was rereading the amendments earlier and making my notes I realised that they are not in the context of children necessarily and thought that they might just as easily apply to vulnerable adults, but certainly the intention was around children.
Successive Governments have tried without an awful lot of visible success—or perhaps there have been successes, but with some high-level and visible failures—to integrate services for young people. From Victoria Climbié to Baby P, there are still issues around silos not talking to each other. We have not got integration absolutely right.
In many ways, the Bill does not help streamline services for young people: if you are under five and going to be looked after by health visitors it is the responsibility of the board; if you are over five, school nurses come under the auspices of the health and well-being boards; primary services, local services, mental health and acute services are all under clinical commissioning groups. Within the Bill there are several different organisations responsible for delivering services to young people.
I will very quickly go through the meaning of all the amendments. Amendment 135AA concerns the general duties of the board in promoting integration. The wording of the Bill encourages commissioning groups to enter into Section 75 arrangements with local authorities. The amendment suggests that we move to mandating—and it occurs to me that somebody really should produce for this House a sliding scale of verbs from “may” right up to “mandate” so that we can work out exactly where they all sit within the hierarchy. Certainly this is a probing amendment, however, so I am using the verb “to mandate”. We are talking about Section 75 arrangements involving pooled, shared budgets. Shared budgets will give you shared ownership and shared solutions to problems. With shared solutions one will get shared decision-making. For this vulnerable group, we need shared decision-making.
Amendment 197BA concerns the general duties of clinical commissioning groups. It covers the duty to obtain appropriate advice. The intention of the amendment is to add in experts in maltreatment. Nobody could gainsay that. Whether it needs to be in the Bill, I do not know. We would appreciate some indication from the Minister on this.
The third amendment in the group concerns the establishment of health and well-being boards. It would add to the board a representative who is a health professional, for safeguarding. The final amendment in the group, Amendment 331AB, concerns the function of health and well-being boards and the duty to encourage integrated working. Again, it uses the word “mandate”, which I appreciate is at the top of the scale. It mandates people who work in health and social care to work in an integrated manner.
I do not apologise for the verb, because the situation is very serious. Young people who need the most care run the risk of falling into holes where there is nothing joined up. We are saying that the Bill puts the patient first and we talk about integration running all the way through the Bill. Sadly, it does not look like this will happen in children's services. The amendments in the group try to make it happen. Perhaps the Minister will offer clarity on the level of detail—which clearly is not in the Bill—that will be in secondary legislation to help with this. Successive Governments have tried to get this right but it has not always worked on the ground. This is an opportunity to rectify that. I beg to move.
Lord Beecham
My Lords, I sympathise with the motives of the noble Baroness who tabled the amendments but I am not sure whether they are persuasive. Mandating is not necessarily the right approach. It is certainly not the correct approach for health and well-being boards, because they are not executive decision-making bodies. We hope that the boards will produce joint strategic needs assessments, to which the clinical commissioning groups will have to have regard. There will certainly be joint working there, but the boards will not be in a position to mandate anybody. Therefore, while the aspiration is noble—appropriately—the phraseology does not necessarily achieve what is intended.
I expect the Minister to say that he envisages that the precise object that the noble Baroness is pursuing will be taken into consideration and acted on by the relevant parties: in this case clinical commissioning groups in particular. Obviously these are probing amendments. They should not be reflected in a substantive amendment put to the vote—unless of course the noble Earl departs from his usual practice and accepts them.
Baroness Jolly
I thank the Minister very much for his reply. I am more than happy to withdraw my amendment.
Lord Warner
My Lords, would the noble Baroness accept from me, as someone who was this great centraliser sitting in Richmond House, that we actually set up these capacity-building capabilities for social enterprise in the voluntary sector, in response to those sectors’ concerns about their inability to make headway locally and enter the market to provide services in those areas? That was not a centralising tendency on our part. It was actually a response to people saying to us that we needed more capacity-building capability at the centre because it was not being provided at the local level.
Baroness Jolly
My Lords, I can give an example of where it has been provided. Today I have been talking to the operations director of Peninsula Health Care. That was the provider arm for the Cornwall PCT which was providing community hospitals and community services, and which is now a community interest company as of 1 October 2011. It has already brought across all the arrangements that it has with its local authority; Section 75 and so on, shared budgets for equipment, and all sorts of innovative work alongside.
The whole thrust of the amendment of the noble Lord, Lord Rooker, was part of our manifesto, it was part of the coalition agreement, and I feel quite comfortable about supporting it.
Lord Mawson
My Lords, I am very sympathetic to the amendment of the noble Lord, Lord Rooker, for very practical reasons. I am building a street at the moment in Tower Hamlets, and part of that street is not only a new school but a new health centre, which has been under development for five years. The health centre proposals were begun in the previous Government’s time in office. It is true that the Bromley-by-Bow Centre, when competing for that practice, was not on a level playing field. It is very difficult to compete with a multinational company that could undercut the price per patient to £75 per head, when I, having run an integrated health centre for 20-odd years, knew that the real costs were probably around £119 per patient and that the £75 per patient was not sustainable. It was very interesting going through the whole of that process, of proper competition and then losing the competition, to three years later, when I was approached by that company which admitted that the business plan did not work and asked whether we could help rescue the situation, which we have now done, and the multinational business has now withdrawn. I know that there is a problem here that we need to get our heads round, and I know and believe that the Government are serious about wanting the social enterprise sector and the voluntary sector to play their full role. It is a practical problem that needs to be got hold of.
The other thing that I know from experience is that bureaucracies like to talk to bureaucracies. I know that large government departments often find it easier to talk to large businesses. Indeed, we have seen this happen over many years. I am in favour of the private sector. We work a lot with the private sector, and I do not think that it is a case of one of the other. However, I have noticed how easily civil servants translate across into large companies, with the bureaucracy carrying on under other names, and organisations that are leaner and more innovative sometimes find it very difficult to break in. Therefore, if the Government are really serious about allowing some of us who do this work but are smaller in scale to break into this market and grow in capacity, then something will need to happen here to help that.
I also know from experience that one way in which we have grown in capacity is by forming relationships with one or two businesses. They have got to know what we are about and we have got to know what they are about, and we have formed partnerships and grown opportunities together. As I mentioned earlier, a £35 million LIFT company has now built 10 health centres. When we formed that relationship, which is a bit like a marriage, we got to know about each other’s worlds. We are now in a social enterprise with that business carrying out landscape work on 26 school sites. Therefore, there are things that government can do.
In my experience, some businesses are becoming more intelligent about this, although some businesses are not. The Government should be using their muscle to encourage businesses to form these local partnerships. If they do not do that, the danger will be that the profits made in poorer communities will be sucked out of the area, rather than there being virtuous circles around the areas creating more jobs and opportunities in local contexts. Therefore, I am sympathetic to the amendment. I would encourage the Government to look again at some of the practical issues and how they work in practice on the ground.
Health: Flu Vaccine Research
Baroness Jolly Excerpts(12 years, 5 months ago)
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Earl Howe
The noble Baroness is quite right. The Chief Medical Officer wrote to the NHS on 25 May, citing four studies that provide strong evidence of the benefit of influenza vaccination for front-line healthcare workers. These studies show clearly that healthcare workers can transmit influenza to patients, that vaccination of healthcare workers can prevent that transmission and that vaccination of healthcare workers can lead to better health outcomes in the vulnerable patients with whom they very often deal.
Baroness Jolly
My Lords, can my noble friend confirm that there is a problem with supplying the H1N1 vaccine? If that is the case, how is it proposed to target it more effectively and what steps will be taken to make sure that vulnerable people are targeted first?
Earl Howe
My Lords, there were supply problems last winter, but my advice is that there are none this winter. Indeed, the quantity of vaccine that has been ordered for this winter’s anticipated flu outbreak is considerably larger than was the case last year. The Government also have a reserve stock of vaccine to be deployed in the event of local shortages.
NHS: Waiting Times
Baroness Jolly Excerpts(12 years, 5 months ago)
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Lord Naseby
My Lords, is it not strange that the figures show that certain hospitals consistently get nowhere near meeting the 18-week target? What action are the Government going to take to help those hospitals ensure that they perform like the average?
Earl Howe
My Lords, we believe that the safeguards are already in place, but the figure I cited in my original Answer is very similar to the figure we have seen over the past two and a half years. Little progress has been made over that time. We do not think that that is satisfactory, so we are broadening the operational standard to ensure that more patients are treated in a timely way. I am sure all noble Lords would wish to see that.
Baroness Jolly
My Lords, approaching 250,000 patients have been waiting for more than 18 weeks and I expect that they would like to know why, as would the House. Can the Minister give us any indication, apart from the five hospitals mentioned earlier, of whether there is a regional pattern to this—while we still have regions—or of whether it is the result of financial pressures, clinical management issues or maybe a combination of all three?
Earl Howe
It does seem to be a combination of all three, although it is clear that in certain areas there is a shortage of the necessary specialist consultants. Sir Bruce Keogh, the NHS medical director, is addressing this urgently with the British Orthopaedic Association in particular. That is expected to result in a solutions paper being put to the NHS Operations Executive in the new year.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 5 months ago)
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Lord Patel
In response to the amount of funding, as I understand it—I am sure the noble Baroness, Lady Northover, will correct me if I am wrong—the Bill suggests that the funding for HealthWatch England will be a grant in aid provided by the department to the CQC.
Baroness Jolly
My Lords, they say that too many cooks spoil the broth, but I think this is an occasion where that probably has not happened. Many hands might make light work. I ask the Minister to take these amendments away because there is an awful lot of good to be found in each of them, but not in each together, as it were.
Amendment 318C, tabled by the noble Lord, Lord Whitty, inserts a new clause and subsection (2)(a) of the new clause is about complaints. It is a nice idea that complaints could be taken to HealthWatch England. Complaints are a big issue to which we will be returning on Amendment 108.
The noble Baroness, Lady Cumberlege, raised the relationship between local and national healthwatches. It is critical. We would support the election of local healthwatch representatives to the national body.
Finally, on independence and finance, I believe very strongly that it is very difficult to criticise and challenge an organisation if you sit within it. I understand the point about the benefits, but if you are local, and you sit within your local health authority or nationally you sit within the CQC, generally the feeling that you are monitoring the organisation that is your host is never a good place to start. Similarly, I, too, have had letters from people who were CHIPs and then LINks about budgets being not just cut a little bit but absolutely hacked away. I would be really uncomfortable if, for example, locally the healthwatch was going to be located within the principal local authority that held the budget. We have had it already today. Intentions will be good and then somebody will come along and say, “We really need a bit more just for this”. It will happen in a meeting where they are not present and, all of a sudden, there will be another slice taken. We have seen it before with lots of other things. You could look at it from a negative point of view and say these are like curate’s eggs and bad in parts or good in parts, but I think too many cooks will not spoil this broth. Many hands will make light work. I ask my noble friend to take this away and have a look at it.
Baroness Northover
My Lords, I sympathise with the noble Lord, Lord Patel. He is forgiven for being subject to the beatings of the noble Lord, Lord Harris. When I made my maiden speech, the noble Lord, Lord Harris, gave me a very interesting and less than usual tribute. Noble Lords will see that we have a slight history.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 5 months ago)
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Lord Rea
My Lords, I support all those noble Lords who have spoken so far and I agree with everything they have said; there is hardly anything for me to add. I just want to emphasise that a public health specialist will have had special experience and training in dealing with the massive amount of health data that comes into a health authority or, in this case, to the NHS Commissioning Board; it will be a huge amount. Public health specialists are trained in statistics and in epidemiology, and have other skills needed to handle this information and to help the board to make the correct decisions. I would like to emphasise the point made by my noble friend Lord Warner that very often this can be extremely helpful when certain services are deemed no longer appropriate. They may save a lot of money by giving backing to decommissioning and reconfiguring certain services, ensuring that populations are best served with the resources that are available.
Baroness Jolly
My Lords, it sounds as though there is a considerable level of agreement on this. I, too, believe that we should have a public health specialist sitting on the board. Members of the faculty have said that if there is not going to be such a specialist on the board by right, there should at least be one where the CMO is not a public health specialist. This Bill has put public health at its core and at every level.
I shall not say any more about the public health appointment but I will talk a little about the involvement of the patient. The patient is also meant to be fundamental to this Bill: “no decision about me without me.” Again, we have the patient involved through local government and the local commissioning groups but not necessarily on the board. I think that whoever is chair of HealthWatch England should have a seat on the board.
What would both of these positions bring to the board? They would bring a level of expertise that nobody else has. I understand the Government’s reluctance to be specific, and I know that lists are problematic. I also know that with these things there is a tendency to request that every man and his dog, or all and sundry, sit around the board table. However, it is a board table and not a representative council, so I would put those two people there for one distinct reason: they add a dimension that the board does not know it misses. Decisions made without them will be made in a vacuum and will be all the poorer for it. Somebody put it to me earlier today—your Lordships will have to excuse me for this—that the board knows what it knows, it knows what it does not know, and it does not know what it does not know.
Baroness Jolly
Apparently there was a Persian poet who got there even before him, but whether Donald Rumsfeld was a reader of Persian poetry, I know not. The point is that you do not know what you do not know. Both those voices would bring to the board serious added value.
I have another four or five amendments in this group which relate not to the composition of the board but to its work. Every year, the board is tasked with producing a three-year business plan on how it is going to discharge its functions. We have a Secretary of State who produces a mandate for the board. We are all in total agreement that the board has huge powers to shape the NHS. New Section 13S of the 1996 Act indicates that there should be an ability to revise the plan. It talks about a “revised plan” but says nothing about the process of revision. The Bill is silent also on the operational plans of the board. I am slightly curious as to which comes first—the mandate or the plan.
How might a conversation with patients and other stakeholders be managed to revise the draft plan? Clearly, we have to start with a draft and then it will be revised. To what extent does the Minister envisage the plan being amended? Might the details on board membership and business plan consultation be included in guidance to the board? One half of my amendments is about board composition; the others are about business planning. It will be interesting to hear the Minister’s response to the latter because it will give us some indication of the way that the board plans to work or it is planned that it should work.
Lord Hunt of Kings Heath
My Lords, I have a series of amendments in this group concerning membership of the national Commissioning Board and its cost. There is common consent that getting the board’s membership right is important.
My Amendment 52A would ensure that the chair could be appointed only with the consent of the Health Select Committee. I fully acknowledge that Professor Grant, the chair of the NCB, went before the Health Select Committee; I have already referred to the transcript. It is clear that the process ensured proper and effective scrutiny. However, I should just like to put the matter beyond doubt and make sure that the procedure will always be followed in future, and I hope that the Minister will agree to my amendment. I should say that I followed the legislation which established the Office for Budget Responsibility, so we have a precedent for ensuring that a Select Committee of the other place has an important role to play in such appointments in the future.
My Amendment 52B is simply a matter of good governance to ensure that a lay vice-chair is appointed, which I am sure I am right to assume is the Government’s intention.
On the composition of the board, my Amendments 54 and 56 are intended partly to probe and partly to make a point. It would be helpful if the Minister could give some indication of the likely make-up of the board, both executive and non-executive, and perhaps some details about how non-executives are to be appointed. My specific point is to encourage the Minister to ensure that, on the executive side, a medical director, a nursing director and a finance director are always appointed. To be frank, my main focus is in relation to a nursing director. I have no doubt that there will always be a finance director and a medical director; I want to ensure, and I want the Minister to give an absolute assurance, that there will always be a nursing director on the national Commissioning Board. I go back to 1991, when NHS trusts were first appointed. Some noble Lords here will recall that some rather foolish chairs of those trusts did not want to appoint a nurse to their board. They were forced to do so, I am glad to say, through the intervention of a Secretary of State at the time. I have no doubt that it is the intention of the Government to ensure that there is a director of nursing on the board, but I should like to make sure that it always happens.
I understand that getting a range of expertise on the non-executive side will always be difficult. As the noble Baroness, Lady Jolly, said, the risk is that Parliament will always seek to legislate for a list of backgrounds, which we know is not a practical way to ensure that a fairly small board is appointed. My amendments seek to ensure that there are at least some non-executives on the NCB who have some experience of the National Health Service. While the temptation will always be to appoint people from other sectors because of the experience that they can bring, there is something unique about the National Health Service. I think that non-executives find it helpful if, among their number, they have people who know the business and help them to challenge the executives. One of the risks of the fashion—my own Government were as guilty of it as any other—of thinking that what the health service most needs is outside business expertise is that, when it comes to issues of safety and quality, you do not have anyone on the non-executive side who can effectively challenge the executives. I urge the Government to ensure that there are non-executives on the board who have real experience of the National Health Service and how it works in order to enable a proper challenge to be put to the executive directors.
Amendments 52D and 54A are probing amendments, designed to tease out the place of public health on the national Commissioning Board. I support the comments already made by noble Lords. On my proposal that the Chief Medical Officer be a member of the board, the Minister may say that he thinks it more appropriate for the Government’s chief medical adviser to be seen purely as part of the department than to be on the national Commissioning Board. I sympathise with that point. I suspect that the answer to the question of the noble Baroness, Lady Jolly, in relation to HealthWatch is that there is always a problem if people are appointed because of their other positions. The problem is that they then have to take responsibility for the corporate decision-making of the NCB. I can therefore assure the Minister that my amendment to place the CMO on the NCB is probing, designed to enable us to hear how the public health function will be given sufficient prominence within the national Commissioning Board.
My Amendment 55 would remove the requirement for the appointment of the chief executive to be approved by the Secretary of State. I have no problem with paragraph 3(4) of Schedule 1, which provides for the first chief executive to be appointed by the Secretary of State. This is normal practice and is entirely sensible in view of the need to get the national Commissioning Board up and running. However, my question is why the Secretary of State needs those powers in relation to subsequent appointments. After all, the Minister has waxed lyrical about the need for there to be distance and for the Secretary of State no longer to intervene, so why on earth does he have to approve the appointment of a chief executive? Surely that is for the board to do. Surely it is for the Secretary of State to nominate the chairman of the board to go through the necessary parliamentary scrutiny. For the Secretary of State to actually have to approve the appointment of the chief executive is ambiguous. The department has not sorted out the real relationship between the Secretary of State and the national Commissioning Board. On the one hand, there is the desire to give the NCB as much freedom as possible; on the other hand, one knows that in these clauses there is a desire to control it. I should have thought that the fact that the Secretary of State has a veto over the chief executive appointment is an example of that. I hope that we can see that go between now and the conclusion of our proceedings on the Bill.
Health and Social Care Bill
Baroness Jolly Excerpts(12 years, 5 months ago)
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Lord Hunt of Kings Heath
My Lords, I also have an amendment in this group. I say to the noble Lord, Lord Patel, that he anticipated the remarks of his noble friend Lord Walton remarkably well.
Having argued against bureaucracy in the previous group of amendments, I am now about to argue in favour of putting senates on a statutory basis. I shall explain why. First, this was a very good outcome of the listening exercise. I think that because I am concerned at the Government’s decision to abolish the strategic health authorities. It is what I call the Hagley Road issue. In 1948, the Birmingham Regional Hospital Board was established; its offices were in Hagley Road and throughout 60 years there has always been something there. It may have been a regional health authority, a regional hospital board, a strategic health authority—call it what you will—but there has always been a regional outpost of the department acting essentially as a leader, with a positive role in looking at the region as a whole, ensuring that its services were cohesive and had proper direction and that, by and large, it was self-sufficient. That is to be removed and we are going to get large SHA clusters which will cover a much larger part of the country. Although we do not know the size of the clinical commissioning groups, they will clearly cover much smaller population areas.
I believe that there is still a need for a mechanism whereby strategic leadership can be given over a region, and I see the clinical senates as being the best approach to that. Noble Lords have spent at least two days debating reconfiguration and are concerned that these difficult decisions often have intervention from the centre. Clinical commissioning groups will be too small to take on the kind of strategic leadership that is required. When you are trying to establish in a region where the super specialty and tertiary services should be and trying to come to a view about how many A&E and emergency departments you need, you require a body that can take a strategic overview. The clinical commissioning groups are too small to do that. They could, of course, possibly come together in a kind of federated meeting to try to resolve those kinds of issues, but that could prove to be very difficult. Therefore, the senates could have an important role in setting some of the parameters and giving strategic leadership to a region.
However, as the Government intend them at the moment, these will be informal groups of people who could easily be ignored by the clinical commissioning groups, by the health and well-being boards, by the deaneries and by all the organisations that have an influence on the way in which the health service is going. My amendment is designed to set out a more structured approach to ensure that clinical senates are created as bodies corporate, that they are properly accountable to the national Commissioning Board and that they have the ability to give strategic leadership and have some oversight of the work of clinical commissioning groups.
I suspect that my amendment will not find favour with the noble Earl but the point about the need for strategic leadership in a region is important. I fear that the super SHA clusters will be too large to do that and the clinical commissioning groups will be too small.
Baroness Jolly
My Lords, I would like to speak to Amendments 51 and 84, but before I do, I have an interest to declare. I am chair of the Specialised Healthcare Alliance, an organisation campaigning for those with rare and complex conditions. The move to commissioned services for this particular group of patients by the NHS board is really welcome. It is the first time that there will be a common standard across England under the auspices of the board. However, we are not totally clear about the composition of the senates or their roles. I am not sure that the amendment of the noble Lord, Lord Walton—who is not in his place at the moment—actually gets to the meat of this. There is concern that specialised services within senates might get lost. If a specialised senate with expertise and integration were set up, that might be useful to this group of patients, but more often than not networks are where the specialised services go to for the expertise. We welcome the commitment to ensure that networks stay as they are and possibly expand. Maybe a network could set up a task and finish group to look at the problems around specific conditions. I would be grateful if the Minister would make the role of the senates clear. Would they have a role in specialised commissioning? Similarly, I would be grateful if he would shed some light on the ways in which the board will commission specialised services in general.
Baroness Jolly
“(1A) The Secretary of State must make provision for a procedure whereby complaints about health and social care providers in England can be brought before the Board.”
Baroness Jolly
My Lords, Amendment 57A is to do with reporting complaints to the NHS Commissioning Board. There are two distinct areas for complaints: complaints related to commissioning and those related to care or service delivery. In fact, they would filter through the board, clinical commissioning groups and local authorities. I include local authorities because, if we are talking about complaints about possible integrated services, we cannot decouple clinical commissioning groups from local authorities.
Baroness Jolly
I thank the noble Earl for his reply, the noble Baroness, Lady Wheeler, for her commitment to quality and the noble Lord, Lord Whitty, for the patient voice input. I beg leave to withdraw the amendment.
Baroness Jolly
My Lords, I think I am the last Member of the Committee to speak on the amendments in this group and I promise I will be brief.
I have two amendments in this group. One concerns a public health specialist on the clinical commissioning groups. We have been around the houses with this and my noble friend Lady Williams has spoken most eloquently on this matter so I will not emphasise the points again. My second amendment is to do with the recruitment and remuneration of lay members of clinical commissioning groups. The Committee has rehearsed the arguments that there is a lot of silence around clinical commissioning groups and their governance. This just underpins that. There is a bit of a Catch-22 with this situation because the Bill makes provision for an audit committee and a remuneration committee and also for a lay member to chair each of the two groups. Therefore, you could argue that a remuneration committee might play a part in deciding how much a lay person would be remunerated for sitting on the group. However, we do not yet have the lay person to chair the group and take the decision, so who will take the first decision about the appointment of these two lay members? They will also need remuneration; who will take that decision?
The other big issue that has been discussed by the Committee this evening is that of transparency within the governance of clinical commissioning groups. I expect the noble Earl hopes to wind up soon. When he does, I hope he will be able to give us a steer on the Government’s thinking on this.
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.