My Lords, we come to a second large group of amendments concerned with clinical commissioning groups and the way they do business. They also relate to responsibility for primary medical services and also relationships with the other healthcare professions. Amendment 176B adds to the responsibility stated in 14O(1)(b), page 35, lines 40-1, "““to promote awareness of the NHS Constitution among patients, staff and members of the public””."
I would have thought a good basis for the promotion of awareness of the constitution might be to assure that GPs themselves were knowledgeable about the NHS Constitution and hence my amendment to promote awareness among GPs by clinical commissioning groups.
The noble Earl has got two answers to any issue raised as to how the Secretary of State will ensure that there is comprehensive provision. One is the mandate and the other is the NHS Constitution. Given that, and given that he puts so much store by the NHS Constitution, which is very welcome, it would be nice to know that general practitioners had some knowledge of it and some understanding of their responsibilities under it as commissioners.
One of the most important responsibilities laid upon clinical commissioning groups is to promote the involvement of each patient in decisions about the provision of health services to patients. However in 14T(2), on page 36, it is surprising that while the board may publish guidance to clinical commissioning groups on this, it is not required to. Equally surprising is in 14T(3) that the clinical commissioning group is only required to have regard to such guidance. My Amendments 194A and 194B require the board to publish guidance and require clinical commissioning groups to implement the guidance. I hope the noble Earl will be able to accept that involvement of the public is of such importance that it ought to be a mandatory requirement.
Amendment 197ZA concerns patient choice. Clause 14U, page 36, line 40, states that each clinical commissioning group must act with a view to enabling patients to make choices with respect to aspects of health services provided to them. That, I am sure, is worthy of support by all noble Lords, but I take it that this applies to the commissioning of services. What about GP services themselves? The noble Earl will know that there has been a long-standing issue with patients often finding it difficult to change GP practices. It would have been sensible to have given clinical commissioning groups some remit to encourage choice within primary medical services. We have a situation where clinical commissioning groups can decide to place large contracts with themselves as GP providers. We have already discussed the issue of conflict of interest. One is looking for some comfort that somewhere in this system there is going to be some proper performance management of the quality of primary medical services. Again, I would be interested in the noble Earl’s views on that.
On the same basis, my Amendment 207A returns us to public involvement and consultation by CCGs set out in clause 14Z(2) on page 38 of the Bill. I would just stress the importance of ensuring that if CCGs are consulting about commissioning decisions, why should they not also consult on the provision of primary medical services? The noble Earl may say that it is inappropriate for CCGs to do this, because of potential conflicts of interest, and the fact that they do not actually hold the contract of GPs. That is going to be held by the National Commissioning Board. I understand that, but I do say to him that if the Government propose to establish local field offices of the board to hold those GP contracts, it is a much more complicated picture which could well undermine the prospects of integration of primary medical services with commissioning.
My Amendment 208ZA concerns the voluntary sector. I know that on Monday your Lordships had a long debate at the end of the evening on issues about the voluntary sector and supporting it. I do not intend to say anything more about it at the moment, save that the much-maligned primary care trusts have given a lot of support to third sector organisations. I would particularly mention some of the support they have given to organisations in relation to public health, or to organisations that have perhaps provided support for patients in their own homes in the community enabling discharge of patients from hospital. Can we have some assurance that clinical commissioning groups will at the very least be encouraged to give support to these kinds of programmes in the future?
Amendment 197D continues with the theme of clinical commissioning groups’ consultation, but particularly stressing the need for other professional groups, the non-GPs, to be consulted. I heard what the noble Earl said earlier about the reason why professions such as dentistry were not to be given equal status with GPs. I think there will be issues about the relationship between GPs and the other contractor professions given that GPs are going to have so much commissioning responsibility. It will be very important to ensure that there is a confidence-building exercise among those professions, so they do not feel excluded from the work of clinical commissioning groups. He did not answer my question on rural dispensing and the conflicts and tension between the pharmacists and the GPs who dispense rurally. I do not really expect him to do so tonight, but I would just point out to him that he knows that there is a real tension here. It is something in rural clinical commissioning groups that will need to be watched carefully.
My Amendments 216ZZA and 216ZA continue the theme in relation to commissioning plans. They are intended to ensure that the agreement of all individuals for whom the CCG has responsibility for ensuring comprehensive service provision, and of the health and wellbeing board, should be required to agree to a commissioning plan or revision of a plan. My Amendment 216ZBA follows the same theme and also suggests if there is a disagreement between the clinical commissioning group and the health and wellbeing board, then the national commissioning board should decide how that will be dealt with.
I do not think this new system has any chance of working unless the health and wellbeing boards are seen to be a core focus for pulling together public health, commissioning and social care and the integration of services. How can we make it effective? It is not unreasonable actually to give the health and wellbeing board some right of veto over the commissioning plan of CCGs within the local authority area to ensure the two come together.
Amendment 216ZB is consequential to 216ZBA. My Amendment 220 concerns performance assessment. Currently, on page 44, line 38, the Bill says that the board must publish a summary of performance assessment of CCGs. I wonder why the board would not publish the whole assessment: again, there seems to be a disparity of treatment. The way the Department of Health is working is that it has very tight control of all elements of the health service, but suddenly GPs within CCGs are going to have this light-touch mechanism. It is a continuing puzzle to me what it is about GPs that they suddenly deserve such special treatment. Unless we sort out the issues to do with conflict of interest, I can assure the noble Earl that there is going to be trouble ahead. With all our experience of allowing great power to individuals without proper and effective corporate governance, we know that this is going to end up in big trouble.
Finally, I come to my Amendment 245A, which is of interest to the pharmaceutical profession. In the Bill, there is a reference on page 289, line 30, to a substitution of Section 2 of the NHS Act 2006 to say: "““The Secretary of State, the Board or a clinical commissioning group may do anything which is calculated to facilitate, or is conducive or incidental to, the discharge of any function conferred on that person by this Act””."
This is a substitute for the general power in the current 2006 legislation, which says: "““(1) The Secretary of State may—""(a) provide such services as he considers appropriate for the purpose of discharging any duty imposed on him by this Act, and""(b) do anything else which is calculated to facilitate, or is conducive or incidental to, the discharge of such a duty.""(2) Subsection (1) does not affect—""(a) the Secretary of State’s powers apart from this section, and""(b) Chapter 1 of Part 7 (pharmaceutical services)””."
In the course of substituting Section 2, the safeguarding of pharmaceutical services in Chapter 1 of Part 7 of the NHS Act is removed by virtue of the removal of 2(2)(b). Perhaps the noble Earl would like to write to me about that, but there certainly seems to be a concern among the pharmaceutical service negotiating committee that a point may have been missed there. I beg to move.
Health and Social Care Bill
Proceeding contribution from
Lord Hunt of Kings Heath
(Labour)
in the House of Lords on Wednesday, 30 November 2011.
It occurred during Committee of the Whole House (HL)
and
Debate on bills on Health and Social Care Bill.
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