My Lords, we come to a very important matter-the role and function of the national Commissioning Board. It is almost as important as the previous debate on the responsibilities of the Secretary of State.
In a telling intervention last week, the noble Lord, Lord Marks, spoke of the tension in the Bill between the proposed duty to promote autonomy on the one hand and the fulfilment of the Secretary of State's overall responsibility for securing the provision of services on the other. I suspect there is a similar tension built into the Bill in terms of the relationship between the Secretary of State and the national Commissioning Board.
At the heart of this debate have been concerns about the alleged micromanagement by the Secretary of State into the affairs of the National Health Service and specifically with regard to reconfiguration decisions. I sympathise with those in the NHS who can feel frustrated if hard-worked-through proposals are held up or rejected by Ministers or the service is constrained by too many interventions and targets from the centre. To think that this can simply be waved away in the new structure may prove to be optimistic. I suspect that a confusion of responsibilities between the Secretary of State and the national Commissioning Board and the plethora of organisations the Government have established or proposed to set up may well add to the burdens of the NHS.
Why is there political intervention in the health service? Surely there is political intervention because the NHS is one of the most important services that the Government are called upon to deliver to the public. Surely there is political intervention because, in the end, the public require it. In our debate last Wednesday the noble Lord, Lord Mawhinney, said that the public, for whom the NHS exist and who pay the NHS bill, expect politicians to intervene on their behalf. Indeed, democracy may be a messy process but I prefer a messy process to rule by quango or even an unaccountable group of clinicians.
Even if you succeed in removing the Secretary of State from the picture, is it likely that local NHS organisations will simply be left to get on with life without external interference? The public will certainly not go away and nor will their representatives, Members of Parliament. They will still encourage the Secretary of State to intervene in the health service. Even if the Secretary of State courageously resists that pressure, it will then fall on the national Commissioning Board. I doubt that the regulators, the CQC and Monitor, will be immune. Nor, I suspect will clinical senates, the health and well-being boards that will be established or the commissioning support units that are apparently to emerge up and down the country. Certainly, clinical commissioning groups themselves will not be immune.
The idea that if you remove the Secretary of State from reconfiguration proposals all will be sweetness and light, with rational bodies making rational decisions and a grateful public acquiescing to those decisions, does not seem to be in the real world. Is it really suggested that £120 billion of public money does not require full accountability of Ministers to Parliament? By full accountability I mean sole accountability, rather than the construct of this Bill, which quite remarkably gives the Secretary of State and a quango-the national Commissioning Board-concurrent powers in relation to the crucial duty in Clause 1. It is so important that the Secretary of State is solely accountable because that is probably the best protection of the overriding mission of the health service to provide comprehensive services to all.
I recently read the transcript of the evidence that the chairman of the national Commissioning Board, Professor Grant, gave to the Health Select Committee, which is very interesting. Professor Grant disarmingly described the Bill as "unintelligible" but we know that all Bills, on the face of it, look rather unintelligible. He went on to make much of the Secretary of State's responsibility for delivering, as he put it, a comprehensive NHS. He then laid great stress on the mandate set for the board by the Secretary of State. He suggested that it should be for three years, rather than an annual mandate as laid down by the Bill. He made it clear that if,
"the matter is within the mandate of the Board, it is not within the jurisdiction of the Secretary of State, except that he has power to revise the mandate with the consent of the Board or ... in exceptional circumstances", he can intervene. The professor concluded that,
"ultimate political accountability ... remains secure, but it requires a Secretary of State to define upfront what he or she wants the Board to be accountable for and to hold the Board accountable for it".
I found that, from the chair of the NCB, eminently sensible and I have no criticism to make of the points that he put forward. However, does that reflect the real world? Things happen, reports are published and crises occur. The Secretary of State cannot simply wash his hands of responsibility. There will be occasions when, mandate or no mandate, he will want to intervene.
A number of today's newspapers carried stories that indicate that the Secretary of State is prepared to sack PCT chairs if they continue to save money by rationing treatments or making patients wait longer for operations. I do not know whether that is true but I say to the noble Earl that I certainly make no complaint about Mr Lansley's actions. It seems entirely appropriate for the Secretary of State to wish to intervene in that kind of event. However, what would happen if the Bill were to be enacted? Let us say that continuing financial pressures led clinical commissioning groups to implement a 15-week wait for non-urgent treatment, or that patient choice was restricted to ensure that sufficient money flowed into the local hospital to ensure its continued viability. Assume then that MPs raised complaints about that in Parliament to the Secretary of State, and that the Secretary of State wanted to intervene. How? Would he call in the chair of the national Commissioning Board? Would the chair say, "I'm afraid that's an operational matter-nothing to do with you, Secretary of State. It's not in the mandate". In any case, the chairman of the national Commissioning Board might go on to say, "You set the NCB one of its main goals, which is to balance the books of the health service. If we take action in the way you want, the books won't be balanced". What happens then? I suspect that there will be a huge tension and tussle, with real confusion in the NHS and among the public as to who is in charge.
Coming back to my Home Office brief, in the past two weeks we have seen some of the problems that can arise between a Secretary of State and an executive agency such as the UK Border Agency. There is absolutely no question that the UKBA is a subordinate agency of the Home Office. Therefore, there is no question over the Home Secretary's right of intervention. Whether she intervened correctly is, of course, another matter. How much more confusion will there be if you establish a hugely powerful quango and give that body the same, concurrent duties as the Secretary of State in relation to the crucial duty set out in Clause 1?
I wish Lord Marsh was still here to talk about his experience in the nationalised industries. He was both Minister for and chairman of British Rail. Those of us who can recall those heady days will remember the inevitable tension between the Minister and the chairman of the nationalised industry. We certainly saw day-to-day intervention by Ministers in rail, steel and the other industries. We also saw a great deal of resentment on behalf of the chairmen of the boards of those industries. My suggestion is that the same is likely to happen over the NHS between the Secretary of State and the national Commissioning Board. That is why the relationship between the NCB and the Secretary of State is so important. Amendment 48 goes to the heart of this by removing the proposal in Clause 6 that the Commissioning Board should have concurrent powers with the Secretary of State in relation to Clause 1. I know that the Government have invited noble Lords to withdraw all their amendments to Clause 1 to allow for further discussions. I hope that the noble Earl will agree to do the same in relation to Clause 6.
The NHS Commissioning Board, however well led and powerful it is, ought not to be given the same, concurrent powers as the Secretary of State. There should be a clear hierarchy and the hierarchy should be the clear accountability of the Secretary of State. In Clause 1, clear responsibility should be given solely to the Secretary of State. That would therefore mean that the Secretary of State would have full power of direction over the national Commissioning Board. That would establish a sensible priority and ensure that clear accountability to Parliament through the Secretary of State is maintained. Above all, it would give clarity to the National Health Service. I beg to move.