With this it will be convenient to discuss the following:
Amendment 363, in clause 179, page 152, line 34, leave out ‘encourage’ and insert ‘ensure’.
Amendment 364, in clause 179, page 152, line 37, leave out ‘encourage’ and insert ‘ensure’.
I do not apologise for returning to a recurring theme. Yet again, we have a duty, relating to integrated working, and a weasel word. The duty is to encourage integrated working. The health and well-being boards seem to have very few functions, even though clause 179 comes under the heading “Health and Wellbeing Boards: functions”. What are the functions? They seem to be a “Duty to encourage integrated working”—there does not seem to be any other sub-heading. As it is such an important part of their functions—the main one, really—why can they not ensure integrated working instead of just encouraging it?
Given that integrated working is such an important policy thrust and that the Government and the Opposition agree that we must have more integrated working and services, if the health and well-being board has a role, it is to bring all parties together and ensure that. Encouraging it is not sufficient. “Encourage” is a weasel word. Let us ensure integrated working. If health and well-being boards cannot ensure it, nobody can.
Amendment 372 would change subsection (2), which provides for
“arrangements under section 75 of the National Health Service Act 2006 in connection with the provision of such services”,
to read “integrated services”. The whole purpose of the clause is to ensure integrated working. Those are my arguments for the amendments. I will speak further on clause stand part, Mr Hancock.
I start by reflecting on the fact that, for the best part of 13 years, the question of how we better deliver integrated services was one that I raised, in opposition, in relation to various pieces of legislation. Interestingly, I was always told that the duties provided through the NHS flexibilities would be sufficient. Of course, one reason why they have not proved sufficient is the absence of the right collaborative behaviours and working relationships in many parts of the country, which has got in the way of that happening. To drive that forward is one reason why we have crafted the Bill as we have, conceived the idea of a health and well-being board, and placed the duties in respect of joint strategic needs assessments and joint health and well-being strategies in the Bill in the way we have.
Let me address directly the suggestion from the hon. Member for Islington South and Finsbury that we should move from the language currently in the Bill, “encourage”, to “ensure”. The issue for us is the fear of the law of unintended consequences—unintended consequences that would follow from the amendment. There are areas of NHS activity—services that the NHS provides—in which integration with social care would never be appropriate. Specialist health services may have very little overlap, or indeed none, with social care, so requiring them to integrate would have very little benefit, and would in fact be an unnecessary burden placed on the NHS. We are trying to achieve a proportionate and appropriate framing of the legislation, requiring the health and well-being boards to drive forward integration where it is appropriate. That is what this is all about.
Would the Minister be kind enough to clarify another aspect of this? How is “encourage” to be defined in the legislation? What criteria are envisaged as suitable to assess whether the duty to encourage has been met? Given that it is so important, how do we know whether a health and well-being board has been successful? We must consider that the success of a health and well-being board will lie in its ability and capacity to create a culture of consensus across its membership. How do we know whether it is doing its job properly? How do we define “encourage” and how do we assess whether health and well-being boards have been successful?
That question feels like the old style of top-down process targets which we became familiar, but to answer it, one way in which we would see evidence that integration was becoming more the norm would be the increased use of the NHS flexibilities that are available and which the Bill says the NHS commissioning board should promote actively to consortia. In addition, the responsibility for encouraging their use is placed on health and well-being boards. That would be a tangible and obvious way in which we could see clearly that commissioning was being undertaken in the form of lead commissioning, use of pooled budgets and so on. That is the intention behind the measure, and I think that it will provide opportunities for local authorities, in collaboration with the NHS, to join up services where that is appropriate, particularly in respect of care of older people but in other areas as well.
I draw the Minister’s attention to an example of such integrated working in my county of Staffordshire, where the local authority and the NHS are setting up a joint trust to provide precisely the kind of integrated working that is being discussed. Clearly, they have responded to encouragement and have not needed to be forced into doing it. That is a good model.
I certainly agree. I now want to draw attention to amendment 372. Again, I fear an unintended consequence of the amendment, because it would not do what the hon. Member for Islington South and Finsbury intends. An amended clause 179 would be limited to health and well-being boards providing advice, assistance or other support for the purpose of encouraging section 75 arrangements only in relation to already integrated services, rather than health and social care services. Inserting the word “integrated” would have that unintended and unfortunate consequence; it would narrow the scope of the clause. I hope, therefore, that the hon. Lady will not press that amendment or the others.
Finally, let me define the word “encourage”. In the absence of an express definition in the Bill, “encourage” will have its ordinary dictionary meaning, as in, for example, what will be done by boards by way of encouragement. In other words, I refer the hon. Lady to the Oxford English Dictionary for the necessary definition. I am sure she will be delighted about that because she has advanced the need for plain English in our legislation. I hope she will withdraw the amendment.
I do not wish to delay the Committee for too long. I support the aims of the clause, but I want to try to find out a little more about how things are going to work on the ground.
Clearly, the current sub-structure within primary care trusts in respect of local pharmacies—I declare an interest as chair of the all-party pharmacy group—and of dentistry, and to some extent of ophthalmics as well, is pretty well known. I have had several meetings over the years with the local medical committee, whose influence, I assume, will be greatly strengthened because of how commissioning is going to change. It is going to be GP-led, but I wonder where the local pharmaceutical committee and dentist forum will sit in the new structure.
The clause is about integration, which I support. For far too long, the health service has delivered down stovepipes and has not looked at integrated care for individuals, particularly people with long-term conditions. Hopefully, the Bill will allow that to happen.
On the establishment of health and well-being boards, I accept entirely that they have the power to appoint such additional persons to be members of the board as they think appropriate. If we look at pharmacy, we see that all of us will have a very similar pattern, although some may not because of the differences between urban and rural areas. There are big players in my local pharmacy sector—the Co-op, Lloyds, Boots—but there are also regional players and some individuals as well.
I hope the Minister can reassure me, because I am worried that health and well-being boards might say, “We will have somebody who is representative of pharmacy on our board, so that they will be there all the time.” I accept that that is their choice and that it is probably a good thing, given the role that pharmacy plays now in the population’s health, looking after individuals who sometimes do not see doctors. But I am deeply worried that the big players could say, “We will put somebody on that. It will be at no cost.” They have the money to be able to take something to the table, potentially, whereas small, independent pharmacies, which are well known in their communities, may get their head turned away and decide, “We will have a pharmacies rep and that’s it.” Will the Minister give some assurance that that is unlikely to be the case?
I agree that we do not want to be too descriptive on these bodies, because flexibility is needed. I would hate to think that only the big players in the primary medical services were having the say in the community, rather than all the players. That will apply to some extent to dentistry, although it tends to be someone who has two or three practices as opposed to a big dental player like there are in cities, where companies are set up. I would like some reassurance that that will be heard and that we will not see local people—who are often described as members of the NHS family—who are effectively given a service by a contractor on occasion, having their nose shoved out of joint in being represented on local health and well-being boards.
I can reassure the right hon. Gentleman that it is not our intention to exclude the very people he has just talked about—it is not how the Bill is drafted. I can also add, for the interest and information of the Committee, that earlier today we considered, albeit briefly, clause 190, which deals with the transfer of the responsibility for pharmaceutical needs assessments to local authorities. In discharging that responsibility, local authorities will, of course, want to engage with local pharmaceutical committees to ensure that they have access to the relevant insight, experience and expertise. That will be one of the places they will go to in discharging that responsibility, among others. That will play an important part going forward in how the commissioning board discharges its responsibilities as well. I hope that I have been able to say enough to reassure the right hon. Gentleman, and with that I hope that the clause can stand part of the Bill.
As I said earlier, the Government have talked a great deal about health and well-being boards and what a panacea they are going to be, yet when one looks at the legislation one realises how little their function will be. They have the duty to—weasel word—“encourage” integrated working, but little else. That is a great concern. I hear a certain amount of groaning from the Government side when I speak in these terms, but how many Government Members were watching television a few weeks ago at 9 o’clock on a Sunday morning, when the Secretary of State was being interviewed?
He said some things of interest. This is another example of how over-excited the Government Front Benchers can be, how far they can fly in flights of fantasy, and how far they can be from the ball sometimes. I understood, from what the Secretary of State said, that health and well-being boards would be allowed to agree commissioning plans. That was what was reported in the press. When I look at the Bill, I cannot see anything that says that health and well-being boards will sign off commissioning plans of GP consortia—far from it. The public need to understand how little power health and well-being boards have, compared with GP consortia and how little accountability there is of GP consortia compared with the supposed accountability of health and well-being boards.
The Government response to the White Paper makes it clear that the Government have considered whether health and well-being boards should have formal decision-making powers over GP consortia on their commissioning plan. I read that with some interest. I refer Government Members to page 98 of the Department of Health’s response to the White Paper, in the chapter titled “Local democratic legitimacy”—they cannot stop themselves can they?—which has an interesting passage that states:
“Sutton and Merton PCT reflected the views of many respondents when seeking clarity on what ‘health and wellbeing boards are accountable for and how that accountability sits with clinical commissioning consortia’s accountability to the NHS Commissioning Board’.”
I am sure that the Minister knows the argument well. The answer to that was:
“Formal approval rights for health and wellbeing boards would put them in a more powerful position than the NHS Commissioning Board, to whom the consortia are primarily accountable”.
We have given double the amount of money that we spend on defence to GP consortia, and they are not primarily accountable to health and well-being boards. The Government have said it themselves. GP consortia are primarily accountable to the NHS commissioning board, who are the faceless bureaucrats from Whitehall and are supposed to be the enemy of the Minister. Nevertheless, he has said time and time again that he wants to shine the light of democracy on all corners of the national health service and other phrases of that nature—I am afraid that I do not know them off the top of my head. The point is that if the Bill is to give health and well-being boards any power, such as signing off the commissioning plans of GP consortia, clause 179 is the time to do it. However, in many ways, it is an empty clause, which is such a shame, because it is a missed opportunity. We want to focus on the many things that are wrong with the Bill, and this provision is certainly wrong.
Another section in the Department of Health’s response to the White Paper states:
“The Government is also clear that it cannot grant authority without responsibility: it would contravene the principles of financial accountability to give local authorities the ability to make NHS commissioning decisions that could commit additional expenditure from GP consortia, without local authorities having to take responsibility for that expenditure.”
That, however, is the whole point. I thought that the whole point was that local people would start taking responsibility for the NHS. It was going to be accountable. We were going to be able to work in partnership. There was going to be “no decision made about me without me” and all the other associated flights of fancy that we have heard from Government Members. When it comes down to it, however, they are exposed when they say that GP consortia will be primarily accountable to the NHS commissioning board and not to health and well-being boards, which is why health and well-being boards cannot sign off the commissioning plans. There we are. That is why the clause is as short, weak and disappointing as it is.