Health and Care Bill – in a Public Bill Committee at 3:30 pm on 14th September 2021.
I beg to move amendment 48, in schedule 2, page 119, line 18, at end insert—
“(c) the process by which any proposed changes to the policies of the clinical commissioning groups within the area for which the integrated care board is established will be consulted upon and agreed.”
This amendment would require ICBs to be clear about how they would make changes in clinical policies and established models of care that have already been established and are applicable to patients in the area for which the integrated care board takes responsibility.
We are certainly getting a good workout this afternoon, Ms Elliott—hopefully the Minister will now be able to catch his breath.
As the hon. Member for Eddisbury suggested earlier, we have seen a rapid reduction in the number of CCGs in Cheshire and Merseyside—there are now nine, but there were more than that not so long ago—and it is one of the biggest ICSs, if not the biggest, in the country. I am not going to take the Committee through the angst on that again, but even with sensible coterminous boundaries, quite a lot of ICSs will have more than one progenitor CCG.
Under the old regime, every CCG had its own plans, policies, care pathways and models of care. For example, many had different rules about gluten-free products being available on prescription, and most Members will be acutely aware of the manifest unfairness of the postcode lottery for IVF treatment. The number of cycles people were entitled to and how old they had to be to access treatment all depended very much on where in the country they lived. It is tempting to say that, rather than having all that variation, we should just level up—the Government’s catchphrase of the day—but that of course will not always be possible, and there will be variations in CCG policy that we cannot easily equate into one optimum outcome or standard, so how do we go about moving the many into the one?
The amendment would add a requirement that, in drawing up the initial constitution CCGs, which of course should be aware of the issues, make a start on place-based approaches, but there is an important job to do on harmonisation at the outset, and that is important for patients and the public. It will be contentious. We can all imagine the outrage if something that is offered in one CCG but not another is then removed from everyone in the process of forming an ICB. These are possible changes that we will see over the next 12 to 18 months, and they will be a real test of how responsive and engaged ICBs are in their local communities. We may indeed see people holding banners with ICBs on them if things are not handled well.
In the amendment, we say that the process of harmonisation or variation should be arrived at only after proper consultation. That fits in with the duty, which we have talked about already, on harmonisation, public involvement and consultation. It also highlights a gap in the specification for the job of producing the initial constitution for each ICB, which is given to the relevant CCG. As I have pointed out, it is very much up to them to decide who they consider it appropriate to consult. We want a much stronger and clearer commitment to consultation on changes that might affect patient care on the face of the Bill.
As ever, I am grateful to the shadow Minister for tabling the amendment in order to air this issue in Committee. I fear that I may have to disappoint him once again; it seems I am getting into a habit, although perhaps at some point I will suddenly surprise him.
We agree that it is right that there is appropriate consultation when making decisions about commissioning policies and care. The shadow Minister set out very clearly, as he always does, some of the reasons for that. I hope that I can give him some reassurance that the Bill already provides for much of what he is seeking in terms of outcomes. In clause 19, new section 14Z44 of the National Health Service Act 2006 already places a duty on integrated care boards to involve and consult the public in respect of the planning of commissioning arrangements, including on any planned changes. That would include, for example, plans by an ICB to change the range of health services available to the public or the manner in which they are delivered. This will ensure that the voices of residents, patients and those who access care and support, as well as their carers and representatives, are properly embedded in ICB decision making.
Schedule 2, which concerns the constitutions of integrated care boards, states that ICB constitutions must specify how the ICB plans to exercise its functions, including the duty to involve and consult the public. ICB constitutions must, moreover, specify the arrangements that the ICB will make to ensure transparency in that decision making. NHS England will ensure that they are appropriate and include the relevant provisions.
Under clause 13, and new section 14Z25 of the National Health Service Act 2006, NHS England will need to approve the constitution and make an establishment order for the ICB. In that respect, new section 14Z26 goes on to make it clear that NHS England can reject a proposed constitution if it is inappropriate. I hope that that offers some reassurance to the shadow Minister, and helps underline our commitment to ICBs being as transparent and as involving of patients and the public as possible. I encourage him not to press his amendment.
Unless anyone wishes to move amendment 1, we now come to amendment 31.
I beg to move amendment 31, in page 119, line 28, leave out from “for” to end of line 29 and insert
“an initial chair to be appointed by NHS England, with the approval of the Secretary of State, for a period of no more than 2 years and for subsequent chairs to be elected by the voters in the area for which the integrated care board is established in accordance with regulations made by the Secretary of State for that purpose.”
This amendment would require the first Chair of each Integrated Care Board to be appointed by NHS England, with the approval of the Secretary of State for a period of no more than 2 years and for subsequent chairs to be chosen through local election.
With this it will be convenient to discuss the following:
Amendment 50, in page 119, line 29, leave out
“, with the approval of the Secretary of State”.
Amendment 51, in page 119, line 29, at end insert—
“4A The constitution must provide for all members of the integrated care board to be consulted, and for any views expressed to be taken into account, before a chair is appointed.”
Amendment 52, in page 120, line 2, at end insert—
‘(1A) The constitution must provide for all members of the integrated care board and of the integrated care partnership to be consulted, and for any views expressed to be taken into account, before a chief executive is appointed.”
This amendment would ensure the involvement of the integrated care board and the integrated care partnership in the appointment of the ICB chief executive.
Amendment 31 is about the ICB having an elected chair. Amendment 50 relates to the Secretary of State’s approval to remove the chair from the ICB, amendment 51 relates to consultation on an ICB chair’s appointment and amendment 52 relates to ICB and ICP members and consultation on the ICB chief executive’s appointment. I hope there were not too many “ICB”s and “ICP”s in that statement, but I will now set out some detail on the intention behind each of the amendments.
I would like to make some general points about integrated care boards. I would also like to put some specific amendments to a vote—unless, of course, the Minister does surprise me, and concedes on some of these points. Many things have been said about ICSs, ICBs and ICPs that do not appear in the Bill. In discussing this matter, some care has to be taken in distinguishing between what is actually in the Bill as it stands and what is not. In particular, the NHS document on the ICS design framework came out in July. Is anything in that document to be regarded as interpretation of the Bill? Perhaps more pertinently, is anything in the design framework ruled out by the Bill or inconsistent with it? There is a huge contradiction in all this. Many actions have already been taken, such as fixing boundaries and appointing chairs, that presume that this Committee does not have a say—that this Committee is not going to change anything. That is almost contempt of Parliament, but we are where we are. No doubt the Minister will be able to justify why he feels it necessary to instruct the NHS to get on with these things before legislation has been passed. To be fair to him, that is what they have been doing for the past five years as they have been trying to avoid Lansley, but we are in a different world now.
For us, the most significant issues are ICB composition, ICB constitutions generally, and the vexed issue of what people on an ICB actually take responsibility for. In each of those areas, we have tabled specific amendments. As we know, ICBs are the latest in a long line of commissioning models: we have had GPs, PCGs, PCTs, larger PCTs, cluster PCTs, CCGs, merged CCGs, and now ICBs. Just maybe, if we do not get this right first time—if we have to keep reinventing the wheel—the problem here is that it is always the NHS making decisions about itself. Various retrospectives have shown that CCGs and PCTs have had virtually no impact on the design of services, or in terms of innovation or better allocation of resources based on need, and it is certainly difficult to show that they have had much impact on outputs. It is worth pointing out that in some cases, these ICBs will be allocating billions of pounds of public money—in theory, at least—so when we are talking about a multi-billion-pound venture, it has to be free of vested interests. It has to be open and transparent in a way that, I am afraid to say, has not been a hallmark of the Department in recent years.
We know that many of the NHS witnesses said in their evidence that they did not want more prescription. As we have already touched on, we are probably going to have some debate about where on the spectrum we land in terms of prescription, with one end being a totally prescriptive environment and the other being a totally permissive one. As it stands, the Bill is too close to the permissive end, in this area at least; as I have already said, we do get some prescription when it suits the Department in other areas. We consider that prescription is not an imposition: it is a vital safeguard to make sure that things are done correctly, and that there is proper accountability of roles and positions. Legislating for the removal of conflicts of interest to ensure that these bodies are more representative and accountable is not a frivolous or minor matter. These are not optional matters: they are fundamental in a democratic society. We should take this opportunity to widen public and patient involvement and end what is increasingly looking like a much more internal model than perhaps was envisaged when the White Paper came out—a pattern, I have to say, that is possibly being set from the top.
In our view, each ICB should have an elected chair so we are going to push amendment 31 to a vote, because we believe it is a really important principle that we should be exploring further. There are two justifications for that, the first of which is negative: we simply do not trust those who make these appointments. We have seen far too many family members and friends appointed within the wider NHS who, it would be fair to say, have not come with CVs that obviously lend themselves to being part of the NHS family. In fact, the NHS has already announced who the chairs will be for two thirds of these ICSs, showing a complete disregard for the work of this Committee, particularly when it was decided that councillors did not even need to apply. There are a number of former councillors on this Committee, not least myself, the shadow Minister, and the Minister himself. Perhaps we might not be the best people to judge who could go on those bodies as chairs, but I certainly think that councillors have a legitimate claim to be suitable people in a number of circumstances. We need to take control of this; we need to have a democratic system.
The positive argument for electing someone is that it signifies that there is some accountability. It also speaks to a trend that we want to see continue moving forward, improving genuine representation of the public and of patients. We have elected police and crime commissioners, and we increasingly see Mayors and other elected figureheads having growing powers over services in defined geographies. We have already touched on how ICSs may not mean much to people in the street, but if there is someone at the top who has been elected by the people of an area, that gives everyone a sense of ownership and identity—there is a tangible body there that they have some stake in.
Let us take the example of Cheshire again, as it is the one I am familiar with. The annual budget for the police authority is in the region of £200 million. We of course do not have sight of the equivalent for the ICS at the moment, but let us say it will be significantly more. Cheshire CCG’s budget is about six times that at the moment, and we have to throw in the whole of Merseyside on top. To my mind, we will have a rather unsatisfactory situation where someone is directly elected to represent our interests in police and crime, but no equivalent in health, where billions and billions more is spent.
We recognise that this is a departure from what has been worked on in the NHS to date, which is why the amendment would allow for a period of two years from the initial ICB appointment to enable the Government and probably the Minister to work through the detail of how elections would work, and the precise role and powers of a democratically elected chair.
As a country, we are being told constantly that we are taking back control. That should be put into practice. Local communities should be given a real say in who runs their health services. Throughout the evidence sessions, it was far from clear with which individual the buck stops.
Amendments 50, 51 and 52 reflect our concerns about the frankly arrogant way that the membership of ICBs has been formed to date. If we do not get our wish for a directly elected chair, we still think there is a clear need for more local accountability for the appointment and removal of ICB chairs. As the Bill stands, there is a danger that the chairs are answerable only to the Secretary of State—not to the partnership, not to the community and not to the patients.
Why does the Secretary of State need to approve the chair? Is the chair there to represent the Secretary of State or to represent the ICB? As we have already covered, there is a less than glorious record on appointments by the Secretary of State. Let us take him out of the equation and ensure, as amendment 51 would do, that members of the board are consulted and their views taken into account before any chairs are appointed. After all, we would not want them to be appointed and then not have the confidence of the other board members. One of the questions that is hanging in the air is what would happen in the situation where the chair does not have the confidence of the board. There does not seem to be any clear mechanism for dealing with that situation, which we hope would not be a regular occurrence.
We could have the absurd situation where all those who work with the chair on a daily basis simply did not think that the chair was leading the organisation as they should, but because the chair retained the confidence of the Secretary of State—someone who might meet the chair once a year, if they were lucky—they remain in post. I think we can all see that that would be a very unsatisfactory situation. What does the Minister say should happen in that scenario? What would happen if members of an ICB or ICP clearly object to the appointment of a chief executive? If the Minister does not have an answer to those questions, perhaps he could support our amendments, although I may be tempting fate in even suggesting that.
Will the Minister at least set out what role his Department will have in such situations? What does he define as failure for an ICS? In what circumstances would NHS England terminate the appointment of a chief executive? How will removing the chief executive lead to improvements if, for example, the reason for “failure” is systemic issues around workforce and funding, which we will be coming on to later on? Let us make sure that the system works properly from the outset and that the leaders in it have the confidence of all those who work within it.
I will speak mainly to amendments 31 and 50. The case for an elected chair of an ICB is very strong. As my hon. Friend said, if we accept the need for an elected police and fire commissioner, why not for health? The amounts of money we are talking about and the influence on people’s daily life dwarf those even of my local council. That is what people on the boards will be responsible for. Social care is still provided through a democratically accountable local authority, so why not healthcare?
We are moving towards the NHS budget overall accounting for up to 40% of general Government spend—that is what we are looking at for the next few years. It seems to go against the grain of everything else—elected Mayors, devolution and so on—for Conservative Members to allow that quantity of Government funding from the taxpayer to be out in communities without any kind of more local democratic control. There would also be a lot more confidence that the days of crony contracts favouring friends, families and donors had been well and truly left behind were there independent heads of the ICBs. I do not know if the Secretary of State has as many close friends as the last one, but letting him make the appointments is not something that Conservative Members will want to defend.
We should therefore be electing a local health commissioner. The amendment reasonably allows a two-year period for the organisations to get established—they have enough to do at the moment—but it would then start to take away some of the problems that the Government will get into with their proposals for the integrated care board chairs. On the make-up of the boards, too, the Bill is a good opportunity, should they wish to take it, for the Government to move away from the terrible scenarios of the past few years in particular. That argument was made cogently this morning by the Minister himself, in terms of NHS England having non-executive directors, people of independence and so on as part of its board, and it can well and truly be made about these new local bodies.
We do not need to go back to the 1990s, when trusts were first invented. Friends and families were put on to those bodies, which were stuffed with worthies, with business people favoured over local people with strong links to the community. Surely we can learn from the past 20-odd years and from the past couple of years in particular. Place is central to what the Government are trying to achieve and is the general policy direction of the Minister’s Department and many others, so it has to mean something and it has to be accountable.
We will come later to some of my amendments on a good governance commission, for which I hope to gain Government support; on having fit and proper tests for people to be scrutinised as suitable to come on to the boards; and, without wanting to throw back to the past, on bringing people in from the community to make the ICBs reflect their local community. In all seriousness, in our sad political situation, most ICBs will be headed up not by people are particularly sympathetic to Labour, so this is not a partisan point. It is, as the Minister started to say about NHS England itself this morning, about having people with the right qualifications—some clinical, some not. Let us have some clear criteria for how we want the boards to be governed and the sorts of people we want on them.
As I said earlier, the Government have got themselves into a real mess with accountability and with how much work the Secretary of State is doing, given how much is put on his desk—this sort of circular NHS accountability thing—so the amendments are trying to offer the Government a way through that follows their general policy direction. That was raised by NHS Providers in its written evidence
“to make crystal clear the relationship between trusts and ICBs, and how the statutory accountabilities of trusts, foundation trusts and ICBs align. There also needs to be clarity within the legislation on how the roles and responsibilities of the current NHS England and NHS Improvement…regions, ICBs, ICPs, trusts, foundation trusts, health and wellbeing boards…places, provider collaboratives, neighbourhoods and primary care networks…will all fit together.”
We would all like to understand how that works, even those of us who follow such things.
I am not suggesting that an all-powerful elected chair will get that, but at least that skilled person bringing together the multiplicity of organisations, groups and people for the local community would be a figurehead who needs to understand and grapple with the issues. The chairs would need to be trusted and highly skilled. In that way, there can be further accountability back up the national system, either through NHS England or the Minister. Let us take all that away from the Secretary of State’s desk—he is going to be a terribly busy man over the next few years. Let us help him out.
The Government should support this and similar amendments to try to bring local accountability much more to the fore. That, in turn, would allow local people, who are expected to spend huge quantities of their taxes on health—increasingly so over the next few years—to be very clear about what the money funds, what they get for their money and how they can hold people accountable.
The shadow Minister, the hon. Member for Ellesmere Port and Neston, said that his amendments would give me two years to work through this, if necessary. I am grateful for his confidence in my longevity in this post—only time will tell.
I am grateful for the opportunity to address amendments 31, 50, 51 and 52, which were tabled by the shadow Minister. I fear that I may not surprise him on this set of amendments. Under the Bill as drafted, the chair of the integrated care board will be appointed by NHS England, as he and other Members have highlighted. It is therefore rather disingenuous to suggest that friends and cronies will be appointed. This is an NHS England appointment, with approval from the Secretary of State. I am not quite sure what is being suggested about those at NHS England, but I suspect it is rather unfair.
The chair will be appointed by NHS England, with approval from the Secretary of State. That reflects the fact that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, this House. That goes to the heart of the comments made by the hon. Member for Bristol South on the balance to be struck between having local flexibility and accountability, and recognising that this is a national health service and the way in which it has evolved. The accountability mechanisms are also national to reflect that.
In answer to the hon. Lady’s questioning, the chief executive of the NHS, Amanda Pritchard, said very clearly of the ICBs:
“In the proposed future structure, they would be accountable to a combined NHS England and NHS Improvement structure. At the moment, we operate that through seven regions, and then through to the national NHSEI executive. We are, in turn, accountable to Parliament.”––[Official Report, Health and Care Public Bill Committee,
Amanda Pritchard was very clear that it is the integrated care board that carries that national statutory responsibility on behalf of the NHS, hence why we have structured the accountability requirements as we have.
That chain of accountability has been at the heart of the NHS since its inception. There is a difference, which I know all Members recognise, between the DNA—for want of a better way of putting it—of social care provision, which has evolved through the link to local authorities, and the NHS, which has a more vertical, national structure. That goes to the heart of the different DNA of those two complementary—vitally complementary—parts of the system. We have to remember that history.
That is reflected in the clear belief, which is shared across both sides of the House, that in various ways the Secretary of State is ultimately accountable to this House and, through that, to the public for the performance of the NHS. It is therefore only right that once NHS England has made the appointment, the Secretary of State, who is ultimately accountable, should give final approval for the appointment of the chair. It is an important role in the ICB, as I am sure all Members would agree, and it is right and proper that the Secretary of State ensures that the appointment is appropriate. That is why, I fear, we cannot accept amendment 50, which would remove that mechanism.
At this point, it might be helpful to address the shadow Minister’s point about councillors. We need to draw a distinction between their role on ICPs and on ICBs. ICBs are the NHS accountable body for the spending of public money. As is already the case, the NHS is clear that it does not approve of dual accountability, so when someone is directly accountable for the spending of NHS money, they are required to have that as their role and to not have multiple roles. That applies to the chair and the chief exec, as is consistent with current practice. I discussed that at some length with the chief executive of the NHS when she was chief operating officer. Quite rightly, given my background and the shadow Minister’s, I sought her guidance and that is the conclusion we reached.
Amendment 31 suggests that the chair of the ICB should be appointed via local elections. That brings in a new element to the accountability relationship, which, again, could give rise to the perception of conflicting accountability routes, given that the genesis of how the NHS is currently structured has been as a national health service. The amendment risks introducing a degree of tension into that relationship. Given the importance, as the hon. Member for Bristol South rightly said, of having the right, highly skilled and able people in all these roles, it is appropriate that the mechanism we propose seeks to balance local knowledge and national accountability.
The shadow Minister or perhaps the hon. Member for Bristol South—forgive me if it was—asked what happens if there is discord within an ICB or challenges to the authority, capacity or capability of an individual chair. Essentially, we come down to the constitution of the ICB. Paragraph 8 of schedule 2 sets out how that would work, and NHS England will be producing guidance. Ultimately, NHS England will have the power to remove a chair should issues arise that necessitate that, but there will be further guidance on how that would work and what thresholds there might be.
The hon. Member for Ellesmere Port and Neston raised an important point: what is the mechanism in the hopefully unlikely event that that should occur? Chairs are subject to normal recruitment processes, and NHS England’s approach to appointments has been to work with the existing ICSs, including both NHS providers and local authorities, to ensure that the chairs appointed are high quality, credible and have the confidence of their local systems. Similarly, to ensure democratic involvement, ICBs have strong duties in relation to public and patient involvement, and local authorities must appoint, by right, a representative to the ICB.
Before I turn to amendments 51 and 52, the hon. Gentleman raised some challenge about the design document, its status and whether it appeared to prejudge the House’s deliberations. I want to reassure him: the key word in terms of that document is that it is in “draft” form—it is not formalised, and it is not the final document, because he is right. However, it does allows the non-statutory ICSs to be given a degree of guidance to continue their evolution, rather than all work stopping while we deliberate. Should the House pass the legislation that means ICSs become statutory, that document would have greater force. However, we are not seeking to pre-empt or pre-judge the will of the House. In fact, even with that caveat, the hon. Gentleman will be aware that we did not publish the document in draft until after Second Reading. That recognised again that we wanted the House to have a say on the principles before we even published documents in draft form and that we are cognisant of the need to show respect to the House’s democratic processes.
Amendment 51 would mandate that NHS England consult with the board before appointing a chair, and amendment 52 would require the chair to consult with both the board and the integrated care partnership before appointing a chief executive. We fully accept the importance of both the chair and the chief executive having credibility among system leaders and the population they serve. That is why NHS England is working closely with local authorities, NHS bodies and others in the appointment process.
The Bill, at its heart—again, we will come to the question of balance—aims to strip out needless bureaucracy by removing processes that we believe add little in terms of ensuring high-quality or safe care and that could get in the way of collaborative, smooth decision making. The amendment to formally require consultation on the appointment of the chief executive would create an unnecessary formal requirement, as well as potentially duplicative work, given that we would anticipate this happening informally anyway, and having due regard to that.
We believe that the approach taken in the Bill ensures both patients and the public have a strong voice on ICBs while also ensuring that the accountability arrangements set out by the chief executive in her oral evidence are maintained upwards as well, to the House and the Secretary of State. I therefore ask the shadow Minister to consider not pressing all his amendments to a vote.
We have had an interesting debate, and I think we have seen the stark differences in approach. Certainly, Labour colleagues see the proposal as an obvious thing to do. As my hon. Friend the Member for Bristol South said, the NHS will account for about 40% of all Government expenditure, so it seems obvious to want some kind of accountability for how it is spent on a local basis. The Government have decided to split the NHS up into 42 areas, so this seems an obvious thing to do, but I appreciate that the Minister comes at this from a completely different perspective. It might say something about the culture of the NHS and perhaps the insularity in how it does things.
When the Minister talked about not being here in two years’ time, he was of course referring to the inevitable promotion that he is due. Perhaps he will be promoted to the Home Office, in which case he will be dealing with police and crime commissioners. Perhaps at that point he will be persuaded of the benefit of having locally elected individuals responsible for services. Of course, we did not have police and crime commissioners until the coalition Government decided to import them from America, and although there is certainly a degree of scepticism about them, if they are a good thing for policing, I see no reason why the NHS should not embark on a similar route.
I envisage some tension between those who sit on an ICB who have some democratic mandate, perhaps from the local authority, and those who do not. Would they be seen to have greater legitimacy? Would their vote carry more weight than other ICB members, because it could be argued that, in the eyes of the public, it would? I think that we are storing up problems for further down the line. If we are to see this levelling up—this renaissance of place—in towns and cities up and down the country, we will need a focal point in all our public services, and none is more important than health and social care.
The Minister suggested that those involved in NHS England might not be appointing people in the most straightforward manner. I was certainly not implying that in my comments, because, as he conceded—this makes me wonder why he is not prepared to support amendment 50—all these appointments still require the approval of the Secretary of State. That is the bottom line. If that is not necessary and the Minister has full confidence in NHS England to make the right appointments, we do not need the Secretary of State’s approval, so the Minister can support amendment 50.
Turning back to amendment 31, which I will press to a vote, we think that a focal point of local accountability is vital. When something goes wrong, when decisions are made that people are unhappy about, or when people just want answers, they need a figurehead that they can go to. They need someone they can hold to account at the ballot box, as is our democratic tradition in this country. I do not think that they will get that with ICBs. If the Minister does not support the amendment, I really think this will be a missed opportunity, and I hope that in future years he will think again on this point.
I beg to move amendment 32, page 120, line 26, in schedule 2, at end insert—
“(d) at least one member nominated by the mental health trust or trusts that provide mental health services within the integrated care board’s area;
(e) at least one member nominated by the Directors of Public Health that serve each local authority within the integrated care board’s area;
(f) at least one member nominated jointly by any NHS trust, NHS foundation trust and local authority that provides social care services within the integrated care board’s area;
(g) at least one member nominated by the trade unions representing the health and social care workforce that serves the integrated care board’s area;
(h) at least one member appointed to represent the voice of patients in the integrated care board’s area.”
This amendment would require integrated care boards to have members nominated by Directors of Public Health, mental health trusts, social care providers and trade union representatives and a member representing patients.
The amendment seeks to enhance the prescribed members of the integrated care board. We have not been able to move the Minister on the chairing, but I hope we might be able to do a bit better on the board members.
These are exceptionally important roles. The decisions that these bodies make will shape communities and lives. As we have heard, the boards will be accountable for spending hundreds of billions of pounds of public money. We are banking on their leaders taking good care of that very profound responsibility, and taking integration from an academic concept, or something that is seen in some places, to a real-world idea across the country. That is a big ask, and we need the very best people on the boards and the best range of voices.
Prior to coming to this place, I was a system leader in my local health system. I chaired my health and wellbeing board for a number of years and led my council’s health and care functions. That dual responsibility is hard, because our every instinct is to think “system first”—certainly in local government, because we know that the best prize and the best step changes in the wellbeing of the community come when organisations work together. We know that, but we also butt up against the grinding realities of one-year budget cycles and diminishing financial resources, so we find ourselves in one meeting—a board meeting perhaps—where we are desperately trying to move forward the cause of integration, or the common cause of the shared vision in a community, but we know that when we get back we have to meet finance colleagues in local government, and there is a reality to that.
That duality is really hard. I always likened it—people rolled their eyes in my health and wellbeing boards, and they may roll their eyes in this Committee too—to playing for an international football team, because people come from their clubs, but they come together for a common purpose. They wear a different shirt. The reason that matters is that they do not forget who they were previously—none of that goes away—but in that moment, they are trying to work in a common cause and put aside any of the parochial or local differences they have. That worked best with a balanced and diverse set of voices and experiences around the table, and I do not think that the Bill supports the appointment and assembly of a balanced and diverse set of voices.
The more I have listened to the Minister, the more concerned I have become about that issue, because on two occasions he has characterised integrated care boards as essentially NHS fund-holding bodies that therefore sit within the NHS accountability structures. I absolutely agree that that is true, certainly in this schedule, but in that case, is this not just a bigger CCG with an integrated care partnership moored to it? What really is different here?
We have said throughout—and have been told that we are wrong, and perhaps overly cynical in saying so—that this is an NHS reorganisation Bill, not an integration Bill. I am afraid that the Prime Minister rather weakened Ministers’ arguments by saying that there needs to be an integration White Paper, which I thought was an extraordinary indictment of this legislation. If this is a Bill regarding integration, who is integrating with who? There do not seem to be multiple parties; there seems to be a single party, perhaps with different elements and slightly different email addresses, but still with broadly the same accountability structures. At this point, this does not feel like integration.
In the previous sitting, the Minister described the current composition of the boards as a de minimis one, and said that there could be more members. I hope there is an expectation—he might address this when he replies—that generally, there would be more than the five people currently set out. Paragraphs 3 to 7 of schedule 2 set out the minimum of five members who will form the integrated care boards: the chair and the chief executive—there must be two of them—and then one member to represent all the NHS trusts, one person to represent primary care, and one person to represent all the local authorities in the area. The first time I read about those three ordinary members, I thought, “Those poor people.” One person to represent all the trusts in an area? One to represent all the local authorities in an area? Goodness me, that is a challenge.
I understand that the Minister is not keen to be overly prescriptive beyond what is in the Bill, and that there is a desire to strike a balance between being permissive and being prescriptive—trust me, nobody gets more frustrated with people in London telling people in Nottingham what to do than I do. However, given what is in the rest of schedule 2, I think the Minister is in danger of undermining that argument.
As we have heard, paragraph 4 says that only NHS England can choose the chair; paragraph 5 says that only NHS England can remove the chair; paragraph 14(2)(a) says that NHS England can vary the constitution of a local integrated care board; and paragraph 14(2)(b) says that NHS England can stop any other amendments to that constitution. We should not give too much succour to the idea that this part of the Bill is going to be particularly permissive, and that there is not going to be prescription in there. Of course there is, because we want local communities to shape their planning and their approaches, but we also think that there are minimums—I think we could find a level of commonality relatively easily—and we want to establish them as a backstop. Obviously, we have five here, but I think we ought to go a bit further.
As such, my amendment suggests five other members, the first of whom would be a representative of a mental health trust or similar. Again, if the Minister thinks I am wrong or that I have misunderstood this, I would be keen to hear from him, but I think it is exceptionally unlikely that the ordinary member chosen to fill the role described in paragraph 7(2)(a) on behalf of NHS trusts in a particular integrated care board footprint would not be from the biggest acute trust in that patch, or at least from one of its acute trusts. Our big hospitals are the gravitational centres of a local health system. They are totemic to a local population, they are massive financially, and they are exceptionally powerful in terms of soft power in a community. That means that there is one place and that place is gone, so once again, there is nothing for mental health.
We talk so often in this place about the need for parity of esteem between mental and physical health, but this is an opportunity to demonstrate that in practice, and we are not taking it. Beyond the fact that we ought to be putting mental and physical health on an equal footing, so many of the knotty issues that we will want local health systems to tackle will be rooted in issues relating to mental ill health, so I think there needs to be a voice at that table that can give balance to the decision making.
I am grateful to the hon. Gentleman for giving way, and I understand his desire to try to push the agenda of some very important parts of our healthcare system, including mental health. Is he cognisant of the evidence that we heard from Dame Gill Morgan, who has already set up an ICS and who has perhaps done some of the testing for us on what works best? She said:
“In our case, we will have mental health and social care around the table, not because we are told to but because we could not imagine how we could do our work at a local level without having those people feeling that they are full partners and sitting around the table.”––[Official Report, Health and Care Public Bill Committee,
Does the hon. Gentleman think it is important that we listen and learn from the experience to date in order to ensure that—to use the hon. Gentleman’s football analogy—we do not have too many people on the pitch? The analogy falls down, because it is possible to have only 11 on a football pitch. The danger is that we end up with too many people, which is unworkable and unmanageable.
I am grateful for that intervention—I am going to stop at 10. That evidence actually supports the point the I am making. When we heard that evidence, the witness said that it was automatic to them, but of course we would want someone from a mental health background and someone from a social care background. I completely agree. What I am saying is that if that is so clear and obvious, which I believe it is, why on earth would we not put it in the Bill? It was clear and obvious enough that we wanted to have someone on behalf of local authorities, and that we wanted someone on behalf of primary care. If it is clear and obvious in those cases, it is clear and obvious in these, too. That was my reasoning, and it was obviously echoed in the evidence submitted by the Royal College of Psychiatrists and the Mental Health Foundation. That is the first thing I want to say about the amendment.
The second relates to a director of public health drawn from that patch. Goodness me—as my hon. Friend the Member for Ellesmere Port and Neston said this morning, if anyone has proven themselves under fire over the last 18 months, it is our incredible DPHs. With a unique combination of knowledge, training, local insight and cross-system relationships, they have done an extraordinary job for us in pulling together our approach to the pandemic. We should be using that to pull together our approach to all sorts of big issues that we face in our local communities.
The DPHs are the human embodiment of our communities’ joint strategic needs assessment. They bring that to life, and they could bring that to the table. If we want our system leaders to go beyond their organisational concerns when they go into their integrated care board meeting, who better than the person who develops the insight into system need? The DPH is exactly the right person. They also provide an invaluable director-level connection to all the departments of the local authority that have such a profound impact on the wider determinants of health—housing, leisure and planning. What a wealth of knowledge, and what connections, they would bring to the table.
Thirdly, the amendment provides for a designated social care representative. The stated aim of the Bill is to drive integration and to foster collaboration between health and care partners. I really want that to be the case, rather than this being just a reorganisation Bill. It is a 135-clause Bill, and two of the clauses are about social care, so it is not unreasonable to say that perhaps there is an imbalance. Rather like the much-hyped social care reform and funding plan that the Government are discussing downstairs at the moment, the clauses in the Bill neither reform nor, in the main part, fund social care. Again, social care is left trailing behind. It has been battered for 11 years and, as a result, we see rationed care, dreadful terms and conditions for staff, and services that are just not fit for what they were supposed do. If the Bill really is about fostering collaboration, social care ought to be explicitly represented.
I am conscious that there is a nominated local authority representative under paragraph 7(2)(c) of schedule 2, but that person will already have quite a lot on their plate. They will have to represent the broader views of the entire local government family. Nottingham and Nottinghamshire is probably one of the simpler planning footprints in the country, but it is still 11 counties, and representing all those views at once is very difficult. It is too much—and not credible—to represent not only 11 council chief executives, but 11 directors of adult social care and children’s social care, as well as all the other functions of the local authority. A social care lead, who convenes the social care leads in the given geography, would give the ICBs the specialist knowledge and insight to create and foster the environment for a true partnership between health and care.
Fourthly and penultimately, amendment 32 would replace the staff voice through recognised trade unions. As has already been mentioned, our health and social care services are well served with amazing staff. They are our experts. They are the people who feel things on the frontline and who know, when they go, “Here we go—here’s a new initiative”, whether it is practical and rooted in real-world experience. They have that very direct experience of population health and how it is changing over time.
The staff are the ones telling us about the fractures in the health and care system that make their jobs harder—the fractures we are supposed to be dealing with. They were the ones—boy, should we have listened to them then!—who told the Government very clearly what the impact of the 2012 reforms would be on the system and about the greater fracturing of the system. They were not listened to then, but they should have been and they should be now.
Prior to coming here, I was a union organiser. I know one thing for sure: senior management always think they can speak for the staff, but I am afraid they generally cannot. That is not a criticism; their lives at work are very different. The health and care family is better served when all aspects are covered, rather than some speaking for others. If we are going to develop really significant plans at these boards, the discussion would be incredibly enriched if the voice of the frontline was there, to sense-check things, to highlight things that are working already and the workarounds that staff develop as time goes on, and to assist on planning as well. There is an awful lot they could contribute.
Finally, and crucially, let us have a representative of the patient voice. The whole reason why any of us come to this place is that we want to give communities a voice. We think that is important. The key way we do that is to listen to people. If we do not, we do not do very well for very long.
We want our communities to have brilliant health and care services, but sometimes we make it harder for them to tell us what they want. We have tremendous mechanisms for finding out. The evidence of Sir Robert Francis from Healthwatch was particularly pertinent on not just using numbers, but the wealth of qualitative information. Let us have someone who is an expert by experience and who can draw on and bring that with them, and speak for thousands of other experts by experience. We must believe that they have as much to contribute as senior leaders. Not only would they bring insight, but it would give legitimacy to decision making, which is something that we have real concerns about, as we have said on discussion on multiple groups of amendments.
Those are the extra five members we are suggesting. If anyone listening at home is keeping score, that means five members—the chair, the chief executive, the acute lead, the primary care lead and the mental health lead—who owe their employment fundamentally to the NHS, and five—the local authority lead, the DPH, the social care representative, the staff representative and the patient representative—who do not.
If the Bill is about integrating and not about a restructure and reorganisation that involves the big acutes taking on the rest of the system, that might be quite an elegant balance. Of course, local systems could seek to augment that, which would be a matter for them, but this would be a very solid foundation, which I think enriches the board. I look forward to the Minister’s response.
I, too, rise to support the amendment. This is probably one of the most important amendments so far. In the witness discussion, we came back time and again to which voices would be on the ICB and would be able to influence. I agree that, with all the talk of parity of esteem, it seems incredible that there would not be a voice representing the importance of mental health on the board. Similarly, with the talk of moving to population health and wellbeing, there is a need for directors of public health to agree policy and to feed in information about the underlying health inequalities, life expectancy and so on in the local population. Not to have a social care voice when what the Government say is that they are trying to integrate the NHS with social care seems quite bizarre.
The NHS and social care are both services delivered by people for people and having both the workforce and staff voice, and the patient voice, is therefore important. On the staff voice, the “Learning from Scotland’s NHS” report from the Nuffield Trust highlights that the success of both the Scottish patient safety programme and the Scottish quality improvement standards was driven by the fact that frontline staff were involved as drivers, champions and developers from the word go. These programmes have been able to run over years, building on experience that is then shared with other sectors and specialities. It is important to get this part of the Bill right, or else priority will not be given to integration, population health or wellbeing. Of all the things that have been discussed so far in Committee, and through the witness statements, this amendment is one of the most important.
This is an important amendment because it goes to the heart of the debate we have been having about permissive versus prescriptive, and where the appropriate balance is. I suspect we slightly disagree on that—perhaps a little less than one might suppose—but I am grateful to the shadow Minister, the hon. Member for Nottingham North, for bringing this amendment forward. It gives us the opportunity to start getting into that permissive versus prescriptive debate. At the outset he raised the recent announcement by the Prime Minister about integration; it will not surprise him when I say that I believe this creates the foundations of that integration, on which we can continue to build in the coming years.
In respect of the specifics of the amendment, schedule 2 sets out minimum membership of the integrated care board. That is the key element here. It will need to include members nominated by trusts, foundation trusts, persons who provide primary medical services in the ICB area and local authorities. As we heard in the witness sessions, this is very much de minimis—it is not what will happen; it is the baseline, above which each system can go if it wishes to reflect local needs and priorities. We have heard the quote from Dame Gill Morgan about how she is approaching it, but we have also heard from Richard Murray of the King’s Fund, who said:
“You could easily criticise the degree of permissiveness; you could criticise the degree of direction in there. The question should be, ‘Can anyone come up with a better one?’ We have not been able to do so, so I think it is a balance well drawn.”––[Official Report, Health and Social Care Public Bill Committee,
I appreciate that shadow Ministers may take a different view because they feel they have come up with a better balance. However, I highlight that evidence before I go into my answer.
Obviously, Dame Gill Morgan is quoted as saying that no one could evenly remotely think of setting up an ICS without primary care voices—and these other voices. Are all interim ICSs that have developed so far following the same model as she is? Is this totally intuitive, and therefore to be relied on, or should it actually be laid down? The voices listed in this amendment are central.
The hon. Lady and I have spoken about “Learning from Scotland’s NHS” before; as she will know, we are not dogmatic and are always happy to learn from Scotland’s NHS—as, I am sure, it is happy to learn from England’s NHS. That is to the benefit of everyone, and I am very grateful to her for inviting me on Second Reading to come and visit Scotland and see it on the ground, which I hope to do.
The reality is that the ICSs at the moment, on a non-statutory footing, are at different stages of development, different stages of evolution and reflect different approaches. One of the things we are seeking to do here is to put a non-restrictive degree of prescription around this—if that is possible—to get a degree of consistency, but not to be too prescriptive.
Dame Gill Morgan leads one of the more developed ICSs. I do not think what she is saying would be unrepresentative of the attitudes and approaches adopted by ICSs more broadly. I should say ICBs, as the hon. Member for Bristol South rightly highlighted the importance of reflecting careful use of the terminology in the evidence sessions—she caught my eye, and I have corrected myself now. I think we strike the appropriate balance here, and I suspect we will see ICBs going further in their membership, but that flexibility is able to reflect local circumstances.
I wonder whether my hon. Friend the Minister could assist the Committee with a question on the evidence given by Louise Patten from the ICS Network, who said that, on top of the five mandated board positions in the Bill,
“a further five will be in the mandated guidance from NHS England.”––[Official Report, Health and Care Public Bill Committee,
Is that something that the Minister has been sighted on? If so, do we know what those positions are? I fear that the hon. Member for Nottingham North might have to start to move to a substitutes bench to get enough people around the table, based on his amendment.
I am pleased that I do not see any signs of the hon. Member for Nottingham North moving to the substitutes bench any time soon. However, my hon. Friend is absolutely right. I do not want to pre-empt the detail of the guidance, but, as Louise Patten said, the whole purpose of this is to provide the ability to further supplement what is on the face of the legislation with guidance that the ICBs will have regard to.
Perhaps the Minister can help me. When I read the guidance, I understood that it meant that there would be at least 10 individuals on any ICB. Does the Minister think that is the correct number?
The key focus for this amendment is what the legislation sets out in this clause, and that is the five positions—that is what we want to specify on the face of the legislation. I will come to the detailed guidance, but first I will go through a few of the remarks from the hon. Member for Nottingham North in support of his amendment.
At the heart of the issue is our desire for the provisions of the Bill not to be too prescriptive regarding the membership requirement, beyond that proposed statutory minimum. The guidance is a different matter from what is in the actual legislation; we want the statute to specify that de minimis. We believe that it gives the right approach and balance, having key voices and local flexibility to add voices—including those the hon. Member has proposed, but others as well—and that it reflects the evidence given by Martin Marshall, who said that the boards have to be kept to a workable size to be able to make decisions effectively. Again, that is permissive.
I come back to the point that local ICBs can appoint more members, should they wish to do so. They can go significantly beyond the legislative minimum requirements if they so choose. Therefore, we do not believe that prescribing further membership is necessary. Of course, schedule 2 states that ICBs will need to publish details of their membership in their constitutions. Under clause 13, proposed new section 14Z25 of the National Health Service Act 2006, NHS England will need to approve the constitution proposed by each ICB. Again, we come back to that approval process.
Of course, the evidence from the Gloucestershire ICS was that of course those individuals—some of whom are included in our amendment—would be on the ICB. From our perspective, it is clear that all the individuals we have named are critical players in any local health system. Could the Minister set out which of those included in our list, if any, he does not think would be appropriate to sit on an ICB?
I think that all add value, but equally, in some circumstances, we see different local arrangements; in some localities, some people fulfil more than one role or sit in different places.
The hon. Gentleman asked me to cover his specific point about the guidance before I conclude: the guidance will not prescribe additional roles in the same way that legislation prescribes or mandates, but it does seek to set out best practice, highlighting what would be deemed to be best practice—drawing on experiences such as Dame Gill’s, I suspect. We would expect that ICBs would pay due heed to that guidance, alongside their de minimis legal and statutory obligations.
If in time, when those ICBs are up and running, it becomes clear that that approach needs strengthening and that we need to add further requirements, regulation-making powers in schedule 2 will allow the Secretary of State to do so at a later point. We believe that it is right to start at this de minimis point in the Bill. It reflects our view, which I have articulated throughout, that we must not attempt to over-legislate at this stage on the composition of ICBs, letting them evolve as effective local entities, to reflect local needs. It may not fully reassure the hon. Gentleman, but there is a mechanism whereby further changes could be made in future, although we do not believe that will be necessary.
The amendment takes a different approach, which is essentially more prescriptive and less permissive. I do not dispute the sincerity of that approach, but it comes down to a matter of where we feel the appropriate balance should be struck. I fear that, although the shadow Minister and I are quite close to one another in our region of the east midlands, we are slightly more distant in respect of the amendment, but I am grateful to him for affording the Committee the ability to debate a key point of principle in the approach to the Bill.
I am grateful to the hon. Member for Central Ayrshire for her contribution and for sponsoring our amendment. She spoke about the way staff have not only improved patient safety and the quality improvement programmes, but made them stand the test of time. We are sometimes in danger—the Bill is a good example—of building things that do not stand the test of time and keep being changed, and she went through all the various situations. If we pass any test, it should be that one. The amendment is certainly one way of improving our chances on that.
I am grateful to the Minister for his comments, too. I understand the de minimis point, but I still cannot envisage a scenario in which we would not want a mental health rep on the board. I live in undoubtedly the best place in England—in Nottingham—but we still have mental health problems and need mental health leaders. If we need mental health reps, and we certainly do, I think that everybody probably does.
The Minister’s response did not quite address the point about balance. The balance of the five members is four NHS and one non-NHS. The whole business maxim is no mergers, only takeovers. If the provision is really about integration and partners coming together on an equal footing to improve the population’s health, everything that we have heard so far does not fit with that. What we have heard so far is about organising this round with the terms of reference that NHS England wants, and if local communities and local authorities wish to be part of that and know their role within it, that is absolutely fine. I think we should aspire to do better, so I will press the amendment to a Division.
I beg to move amendment 30, in schedule 2, page 120, line 26 at end insert—
“(2A) The constitution must prohibit representatives of GP practices with active Alternative Provider Medical Services contracts from becoming members.”
This amendment would mean that the only GPs able to participate in integrated care boards would be those whose practices are on the standard General Medical Services (GMS) contract.
With this it will be convenient to discuss the following:
Amendment 33, in schedule 2, page 120, line 26, at end insert—
“(2B) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care boards.”
This amendment prevents private providers of healthcare services from becoming members of integrated care boards.
Amendment 27, in clause 20, page 29, line 9, at end insert—
“(4) Representatives of private providers of healthcare services, other than general practitioners who hold a contract for the provision of primary medical services in the area, may not be appointed to integrated care partnerships.”
This amendment prevents private providers of healthcare services from becoming members of Integrated Care Partnerships.
We have not had success with chairs, and we have not had success with who should be on the board, so we move on to who should not be on the board. Let us see whether this alternative tack might prize the Minister away from not giving us his support.
The amendment would mean that representatives of GP practices with alternative provider medical services, or APMS, contracts were prohibited from participating in integrated care boards. That would mean that, under schedule 2, they could not provide that primary care representative.
Let me briefly explain the context. The vast majority of practices—nearly 70%—operate under the general medical services, or GMS, model. That is the standard contract and the most usual model of partnership whereby a CCG or NHS England contracts with a local general practice. Another quarter or so operate on personal medical services, or PMS, models. There is a little more flexibility for commissioners to tailor to local need—this is not agreed as a standard contract like the GMS at national level—and again the arrangement is with a local practice. However, these are not particularly en vogue; they are being phased out, I understand.
That leaves the remaining portion, which is on APMS. That is a much more flexible contracting model and very much a child of the previous decade. Here, commissioners can contract with organisations other than GPs or GP partnerships, and can contract, for example, with private companies.
APMS contracts—without that GP requirement and with shorter durations—offer the easiest way for large private companies to take over practices. Those are companies motivated by profits, rather than their patients, and their having a voice on the board would run contrary to what I am sure Members on both sides of the Committee seek to achieve. I would say it was contrary to the triple aim of the Bill.
However, this is a model on the march and one that could change general practice beyond recognition. My colleagues and I do not think it should exist, but we will make our case on that when we deal with clause 16 and amendments 28 and 29, so I shall have to keep the Committee in suspense. The amendment would mean that a representative from such an APMS partnership could not be part of the ICB and could not fill that place.
As my colleagues and I have made clear previously, we think it paramount that the Bill put patients front and centre. For many patients, using the health service begins and ends with their GP for big parts of their life. The GP is someone they have known for years, someone they can trust and someone who plays an active role in and knows their community.
The pandemic has created some access issues, but the care that people have received is still exceptional. The latest GP survey found that 89% of patients said that the healthcare professional they last saw was good at listening to them and giving them enough time, 88% said that that healthcare professional was good at treating them with concern, and 93% said they were involved as much as they wanted to be in decisions about their care and treatment. Our local GPs are really good and do the job really well. It is not much of a stretch to think that those are the sort of people that the public want speaking for them in these ICB structures. That would be very welcome.
We also know that, whether my supposition that the ICBs are going to be really big CCGs is right or not, CCGs had significant involvement from primary care clinicians and the ICBs will have less. That is definitely a point beyond contention, but there is still a reserved place on the board. However, this is a perfect opportunity for local GP leaders to fill that space, and with regard to APMS contracts, I do not think that those representatives will provide that same involvement.
I appreciate that the numbers will be relatively small—indeed, this might be quite unlikely to happen—but we should bear it in mind that APMS contracts do not require a GP to be a contract holder. They do not offer the same benefits to an ICB as a general or personal medical services contract holder, who is contractually required to be a GP. That is a significant difference. This position on the board should bring important perspective; it should not be wasted.
This is about two things: first, showing the best possible voice and secondly, putting a stop on creeping privatisation. Ministers have been at great pains earlier in the process, and certainly on Second Reading, to say that this is not about privatisation. Well, this is a very good chance to prove that.
I would like to speak to amendment 33, which is grouped with amendment 30. I will try to address the real concerns that were so eloquently described by the British Medical Association. It said that there are huge risks and absolutely no benefits from having out and out private companies sitting on integrated care boards. Nothing in the Bill remedies that conflict to allow those companies to sit on integrated care boards at the same as allowing them to comply with their statutory duty to their shareholders in manner that anyone could feel comfortable about.
We know that spending in the private sector before the pandemic in 2019-20 was £9.7 billion. I accept that those figures before the pandemic are probably the fairest to cite, but that sum is still double what it was a decade earlier under the last Labour Government. We have seen the creep from the private sector in recent years and we need to put an end to that.
Amendment 33 is not about the amount spent on private providers but about who runs the NHS, not just who profits from it. For us, there is a complete and utter incompatibility between the aim of a private company and what we say should be the aims of the NHS and ICBs. I can do no better than refer to the evidence of Dr Chaand Nagpaul, who last week said:
“We forget at our peril the added value, the accountability, the loyalty and the good will that the NHS provides. We really do.
We only have to look back at the last year. Compare the vaccination programme run by the NHS and delivered by NHS staff to Test and Trace. Even with Test and Trace, compare the £400 million that Public Health England had to the billions that went to the private sector, and local public health teams reached 97% of contacts compared to 60% for the others. I am saying that it does matter. Your local acute trust is not there on a 10-year contract, willing to walk away after two years. It is there for your population; it cannot walk away.” ––[Official Report, Health and Care Public Bill Committee,
Those final words sum up our concerns perfectly. Put a company on the board and their interests last as long as their contract. Of course, their interests may not be the same as the NHS’s during that period anyway. With that clear and, we believe, unanswerable concern about conflicts of interest there must be a solution in the Bill. As it stands, there is not, and that is what amendment 33 seeks to remedy. We hope that the Minister recognises the opportunity that this presents and goes one step beyond his colleague, Lord Bethell, who said in response to a written question:
“We do not expect independent providers to have seats on the ICB.”—[Official Report, House of Lords,
What he expects and what is actually in the legislation is not the same.
We have already seen in the south-west private providers lining themselves up to have a big say in how local NHS systems are run. If it is the Government’s position that they do not expect private companies to sit on the board, do they say that because they do not believe it will happen, or because they do not want it to happen? If they do not want that to happen, they should support the amendment. If they do not support it, and if they refuse to join us in trying to legislate to stop private companies getting involved in the running of the NHS, all the people who believed that the Government were determined to increase private sector involvement in the NHS will be entitled to say, “We must be right.”
When presented with the opportunity to put a halt to further private involvement, not only did the Government not support the proposals from Labour, but they actively voted against them. All the words about what the Government expect will count for nothing because when it comes to the crunch, the Government will have sided with the private companies, some of which, let us not forget, have actually sued the NHS when they have not got their own way. Is that the kind of collaboration and integration that we want to see in ICBs? Remember when Circle walked away from Hinchingbrooke because the contract was too tough. Was that in the spirit of joint working? No, it was not. We should be absolutely clear in this Committee and support the amendment that says that private companies should not be running or having a say in the running of ICBs.
Although this was described as an evolutionary piece of legislation that would not involve a lot of upheaval for the NHS, it actually does. It is a significant piece of legislation, but it represents a missed opportunity to go back to a unified public NHS with integrated care bodies as the main structure. They are responsible for spending billions of pounds of public money, but the system will still be a transactional one based on a purchaser-provider split and tariffs. We will talk further about how can inhibit development.
If we are to have a purchaser-provider split, we have to have a split. We cannot get away from the conflict of interest inherent in having private providers who seek contracts to deliver care sitting on the very board that makes those decisions, or on the partnership board that will develop the strategy. That is a conflict of interest. It should be resolved, and the amendment should be supported.
With your indulgence, Ms Elliott, I will turn to amendment 33 first. Integrated care boards will be NHS bodies, whose membership consists, at a minimum, of individuals appointed by NHS providers, providers of GP services and local authorities that coincide with the ICB. Any perceived risk of privatisation through the ICB membership provisions is, I believe, entirely unfounded—and, I feel bound to add, potentially unfair to the many public servants in the NHS who work for ICBs. Although service provision—I emphasise the word “provision”—by the independent and voluntary sectors has been, and continues to be, an important and valuable feature of this country’s healthcare system under successive Governments of all political complexions, it was never the intention for independent providers, as corporate entities, to sit on integrated care boards, nor for an individual to be appointed there to be a representative of such an interest in any capacity.
People must therefore be assured that the work of integrated care boards is driven by health outcomes, not by profits, and I am sure that there will be a consensus on that principle across this Committee. That is why there are already safeguards in place to ensure that the interests of the public and the NHS are always put first. The ICB chair has the power to veto members of the board if they are unsuitable, and NHSE has the power to issue guidance to ICBs in relation to appointments as part of its general guidance-making power. That sits alongside the robust requirements on ICBs to manage conflicts of interests, and NHSE’s wider duty to issue guidance to ICBs.
I turn to amendment 30, which seeks to exclude individuals whose GP practice holds an alternative provider medical services contract from being made a member of an ICB. APMS contractors include some private and third-sector organisations, but also some GP partnerships. These contractors include, for example, social enterprises and partnerships that provide services to homeless people and asylum seekers. This amendment would potentially prevent some individuals from being on ICBs, on the basis of the type of NHS GP contract that their practice holds.
I do appreciate the intent behind the amendments, namely the desire to avoid the appearance, and potentially even the risk, of privatisation and conflicts of interest. However, the effect would be to limit the ability of primary medical service providers to appoint an ICB member who might best meet the requirements of the local population, by reducing the diversity of GPs who could be appointed. While I can understand the intent behind them, I fear that these amendments do not do what they seek to do, and they would have unintended consequences. I will turn to those shortly.
We recognise that the involvement of the private sector, in all its forms, in ICBs is a matter of significant concern to Members in the House, and we are keen to put the point beyond doubt. However, having taken appropriate advice, I am afraid that that these amendments would not cover a number of scenarios—for example, lobbyists for private providers, or those with a strong ideological commitment to the private sector—and they would therefore not be watertight
As it stands, these amendments may well not offer the robust assurance that perhaps hon. Members intended. Therefore—this is where I may surprise the hon. Member for Ellesmere Port and Neston—to put this matter beyond doubt, we propose to bring forward a Government amendment on Report to protect the independence of ICBs by preventing individuals with significant interests in private healthcare from sitting on them.
As hon. Members will know from their attempts to draft these amendments, avoiding unintended consequences is not a simple matter. If appropriate, I would be happy to engage with either the hon. Member for Nottingham North or the hon. Member for Ellesmere Port and Neston in advance of Report. We may not reach a consensus, but, as they both know, I am always happy to have a conversation with them.
The Government are firmly committed to the founding principles of the NHS. We recognise the importance of its values, and the public service ethos that animates it. It is by no means our intention to allow private sector providers to influence, or to make, decisions on spending on the commissioning board—the ICB—and the spending of public money. The Bill does not allow that, but we will look to see whether we can find a way to put that unfounded fear to bed once and for all with an appropriately worded amendment that does not have unintended consequences.
Although I appreciate that much the same motive underpins amendment 27, it is worth considering why the integrated care board and the integrated care partnership are different bodies. The decision to create integrated care partnerships came from discussions with a number of stakeholders who revealed a strong case for the creation of a committee to consider strategically not only the health needs but the broader social care and public health needs of a population. It is not a body like the ICP, as we have heard, which will be directly accountable for the spending of NHS monies.
We therefore do not intend to specify membership for the ICP in the Bill, as we want local areas to be able to appoint members as they think appropriate. To support that, we have recently been working with NHS England and the Local Government Association to publish an ICP engagement document setting out the role of integrated care partnerships and supporting local authorities, integrated care boards and other key stakeholders to consider what arrangements might work best in their areas.
We would expect members of the ICP to be drawn from a very wide variety of sources and backgrounds, including the health and wellbeing boards within the system; partner organisations with an interest in health and care, such as Healthwatch; and potentially voluntary and independent sector partners and social care providers at that level, as well as organisations with wider interests in local priorities, such as housing providers.
To exclude independent providers from both the ICB and the ICP would, I fear, risk severely reducing the extent to which all parts of the broader health and care ecosystem could be drawn upon in the ICP context. It would exclude valuable expertise and would, for example, prevent social care providers who provide a small amount of domiciliary care to the NHS from sitting on the ICP. Furthermore, the ICP will not make commissioning decisions or enter into contractual arrangements that are binding, or make decisions about who gets funding allocations. Those are functions conferred on the ICB, hence the distinction that I make.
I therefore believe that membership of individuals from independent providers on the ICP does not present a conflict of interest in the way that hon. Members have asserted, certainly in the context of the ICB. I suspect that we may debate that further in the coming weeks, but taken with the ICB and the comments that I have made, we believe that this provides the right balance between recognising the distinctive accountabilities and responsibilities of the NHS, local authorities and other partners, and strongly encouraging areas to go further in developing joint working.
I hope that what I have said provides some reassurance to Opposition Members, and that they will be willing—I see them nodding—to engage with me to see whether we might find a greater degree of consensus. I should also say that I will obviously speak to the Scottish National party spokesperson on this as well, as I have done throughout. I addressed my remarks to the shadow Minister, but of course I extend that offer to her. I hope that on that basis, the Opposition Front-Bench spokesman will consider withdrawing the amendment.
If the Bill is about collaboration, we ought to model that here. Given that very gracious offer, I am very happy to beg to ask leave to withdraw the amendment.
We now come to amendment 33 to schedule 2, which has just been debated. Justin Madders, do you wish to move the amendment formally?
HCB60 Mental Health Policy Group
HCB61 Royal College of General Practitioners
HCB62 Royal College of Physicians
HCB63 National Pensioners Convention
HCB64 First 1001 Days Movement
HCB65 Urology Trade Association
HCB66 Faculty of Sexual and Reproductive Healthcare (FSRH) and Royal College of Obstetricians and Gynaecologists (RCOG) (joint submission)
HCB67 Cancer Research UK
HCB68 NHS Providers
HCB69 The British Medical Association, British Dental Association, Pharmaceutical Services Negotiating Committee, Optometric Fees Negotiating Committee and National Community Hearing Association, on behalf of NHS Primary Care (joint submission)
HCB70 Centre for Governance and Scrutiny