Health and Social Care Bill

My Lords, in responding to these amendments, I begin by highlighting one basic point. Our intention is that the relationship between the NHS Commissioning Board and CCGs should be mutually supportive. Of course, the board will have responsibility for overseeing the system of CCGs, authorising them and making any subsequent changes to their constitution, as well as for assessing their performance each year. In addition, the Bill gives the board clear powers of intervention. We should recognise, without the need to change the heading of new Section 14Z19, as Amendment 220ZA would do, that the intervention powers of the board are expressly designed for circumstances in which the CCG is at significant risk of failing, is failing, or has failed, to exercise its functions. However, the board is also there to provide effective support to CCGs beyond the allocation to them of commissioning budgets. On this topic, while supportive of the principle behind Amendment 220C concerning transparency in how the board determines its allocations to CCGs, we should be cautious in our consideration of amendments on the specifics of how the board performs its functions, which would be better suited to the Secretary of State’s mandate. The Bill contains provisions to equip the board to act as a supportive partner to CCGs in the exercise of their functions. These provisions are flexible and proportionate, and I would urge that they stand unchanged. The board has the power to provide direct support to a CCG if it requests it, by taking on the specific commissioning function of a group. That is to say, if a CCG needed support in exercising its ability to commission care to meet the needs of its population, as set out in these proposed new sections, the board could, at its request, step in and undertake the commissioning function on a temporary basis. This is a sensible power to give to the board and CCGs, and it would be unwise to remove it. CCGs would only make such requests where they felt they needed the support of the board—that is obvious—and the use of this power would prevent deterioration in a CCG’s ability to exercise a commissioning function, with its attendant threat to patient outcomes. It might be valuable, in particular, where a CCG or CCGs were finding it difficult to effectively commission for more specialised services across a much wider area than that covered by individual, or small groups of, CCGs. There is no question of CCGs using this power to delegate their legal responsibilities for their patients. Even where the CCG requested that the board should support it by exercising a function on its behalf, the CCG would retain legal responsibility for the exercise of the function. That could not be delegated. The board, similarly, could not arrogate CCG functions. A CCG must expressly request that the board undertakes a function on its behalf. Noble Lords should also note that the power in new Section 14Z7 may be limited by the Secretary of State in regulations so as to ensure, should it be necessary, that certain functions of the CCG cannot be so delegated to the board. Likewise, Amendment 213B is not necessary. I emphasise that the support or assistance that the board can supply would be in order to build CCG capability. This is unequivocally one of the reasons why the board would provide resources, or employees, or financial assistance to a CCG, so I fully support it. The amendment is slightly out of place as it adds to the list of ways in which the board would provide support, but is in fact an outcome of those inputs. I worry that it may lead the board to give undue weight to that outcome when we do not want to imply that board support should be limited to that objective. Clearly, without this amendment, the board has perfect freedom within the provisions of this section to support CCGs in building their capacity and capability. I hope, therefore, that this will be sufficient for the noble Baroness. Some of these amendments would change the relationship between CCGs and providers of primary medical services and pharmaceutical services. CCGs must support the board in discharging its duty under Section 13E in relation to securing continuous improvement in the quality of primary medical services. It is right that this duty is expressed in terms of quality improvement. Amendment 185 would place a duty on CCGs to support the NHS Commissioning Board in securing continuous improvement in primary medical services by monitoring the performance of individual primary care practitioners in their area and reporting their findings to the board. I support the concern of the noble Lord, Lord Kakkar, to ensure that CCGs are effective in supporting the board on the quality of primary care. As the noble Lord rightly said, quality in primary care is absolutely key to the success of the NHS, not least in managing chronic conditions. A great deal of work is currently going on in the Department of Health to construct meaningful quality metrics for primary care, including patient-reported outcomes, combined with plans to ensure the transparency of general practice performance. Our information strategy, which we will publish in a few months, will say a lot more about that. However, I fear that stipulating what activity CCGs should undertake in exercising this function would be to impose too specific a requirement on them in the performance of their duty under new Section 14R. The philosophy of the Bill is very much to limit processes and instead focus on outcomes. The Commissioning Board will performance-manage contracts with providers of primary medical services, although it may ask CCGs to carry out on its behalf some aspects of the work involved. That could include promoting reviewing practice performance and ensuring clinical governance. However, it must be the board’s decision as to how it wishes to performance-manage its contracts with providers, and how it should be supported in that by CCGs. The CCG will similarly want flexibility in its approach to how, as a peer group, it ensures the quality of the care provided by individual practitioners and practices. In this regard, the experiences of GPs as commissioners under practice-based commissioning will be invaluable in identifying ways to strengthen the relationship between practice and commissioner. There have been a lot of very useful lessons learnt from practice-based commissioning, which must not go by the board. In general, clinical commissioning groups will play a systematic role in helping to monitor, benchmark and improve the quality of primary medical services for the practices within their membership. This will include the use of clinical governance and clinical audit. Armed with the right information systems, clinical commissioning groups will be well placed to spot potential issues of poor performance at an early stage, to identify the root causes of the problems and to work with the board or the Care Quality Commission and other agencies as necessary to support practices and practitioners in improving performance. I see it as a mutually supportive arrangement. We have already had proof of this, as I say, in many practice-based commissioning consortia. Local medical committees will also have a role to play here. I very much recognise the important role played by LMCs in relation to the local provision of primary medical services. We want this to continue, which is why the Health and Social Care Bill continues to provide a legal framework within which local medical committees may operate. The proposed amendments to Section 97 of the NHS Act 2006, which are set out in paragraph 42 of Schedule 4 to the Health and Social Care Bill, fully preserve the existing primary legislative provisions, with references to primary care trusts being replaced by references to the NHS Commissioning Board. This is a straightforward consequence of the proposal that the NHS Commissioning Board should take on statutory responsibility for the commissioning of primary medical services from PCTs. Under the Bill, the NHS Commissioning Board will be able to arrange for clinical commissioning groups to undertake some of the board’s functions relating to primary medical services. Where these functions include a duty on the board to take certain actions with regard to LMCs, the delegation of a function will not alter this duty. As well as protecting the existing legislative framework, I very much wish to encourage both the board and emerging clinical commissioning groups to identify ways in which they can work with LMCs for the greater good. I believe that this important task will be more successful if it is not constrained by further primary legislation. After all, local relationships have been shown to flourish within the existing primary legislative framework, which we are maintaining. The noble Lord, Lord Hunt, asked, ““Why GPs?””, and contended that the Government had never explained why GPs should be given the responsibility for commissioning. I found that a rather extraordinary statement. He may recall that his right honourable friend Andy Burnham was very keen on GP commissioning—and I hope still is. In May 2006 in another place he said: "““We are introducing practice-based commissioning. That change will put power in the hands of local GPs to drive improvements in their area, so it should give more power to their elbow than they have at present””.—[Official Report, Commons, 16/5/06; cols. 861-2.]" That is an endorsement of the principle if ever there was one.