New Clause 8 - NHS Good Governance Commission

Health and Care Bill – in a Public Bill Committee at 2:00 pm on 27th October 2021.

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“(1) Regulations must provide for the establishment of an NHS Good Governance Commission as a Special Health Authority.

(2) The Commission has responsibility for ensuring that anyone appointed to, or elected into, a non-executive role on an NHS body—

(a) is a fit and proper person for that role; and

(b) has been appointed or elected by a process that the Commission considers appropriate.

(3) For the purposes of subsection (2) a Chair or ordinary member of an Integrated Care Board must be considered to be a non-executive role.

(4) NHS England may publish guidance, which must be approved by the Commission, about how appointments are made to NHS bodies.

(5) The Commission must publish an annual assessment of diversity and inclusion in decision-making by NHS bodies and in appointments to executive and non-executive roles in NHS bodies.

(6) For the purposes of subsection (2) an NHS body is—

(a) NHS England;

(b) an Integrated Care Board;

(c) an NHS Trust;

(d) an NHS Foundations Trust; and

(e) a Special Health Authority.”—

This new clause returns to the position prior to 2012 by recreating a body with independent oversight of important NHS appointments.

Brought up, and read the First time.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

I beg to move, That the clause be read a Second time.

At the risk of my career, I am again trying to be helpful to the Government. During the debate, we have come round in a circular way about the lack of accountability in the Bill and the quite astonishing levels of power taken directly by the Secretary of State. Those may be two separate things, but, in terms of the culture that we want to embed in the health system, they are really quite worrying.

The Bill puts into law the organisational changes of the last few years—based on what the NHS, I agree, has been asking for—on a population basis, not on competition or autonomy. Most of us genuinely welcome that: we want to see better population health, people working together, and services rooted in the community; we want to empower local people and guarantee service levels locally. We want to ensure transparency on funding to see if one area is funded more favourably than another. Historically, there have been problems with that and we want to understand that. We want to know why certain services operate in one area and not another.

Opposition Members often talk about a postcode lottery. I do not always agree with that terminology because if the population shows that it needs different levels of services in different parts of the country, then the local NHS needs to reflect that. My own city, Bristol, is a very young city; we have a very small population of over-85s. Further to the south-west, in nearby Torquay and Torbay, that situation is reversed. I would expect to see different population levels of healthcare in Bristol and Torbay.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

When we talk about a postcode lottery—something I have worked against my entire career—it does not really refer to the area of the postcode, but the access of individuals. At the end of the day, 85-year-olds in Bristol should get the same service as 85-year-olds in Torbay, even if there are fewer of them. Everyone should get the mandate of the service both health and social care deliver, even if it is delivered in a different way because of geography or demographics.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

I thank the hon. Lady for her intervention, and I do not disagree. The terms are bandied around and people often do not know what we mean by them, which is why, without going back into the past too much, I was a strong supporter when we were in Government of the national service frameworks and certainly of guaranteeing a level of care and access, as she says.

However, it is the case that different health systems will have different demands on them, and therefore should respond differently. On that basis, my point is that that local difference should be reflected: it should make the system accountable to and understandable by local people, and should involve them in the decisions made on their behalf. That seems self-evident.

We often hear in this Committee about the Minister’s, the shadow Minister’s and my other colleagues’ experiences in local government, but I think people would agree that the experiences of people involved in local government and people involved in the health service are so far apart as to be completely unrecognisable, in terms of the national accountability that the health service seems to have and the local accountability that local government has.

These bodies are deeply troubling. I have called them local cartels, in their form as integrated care boards. They have no accountability to the local people they serve, or nationally through Parliament. We have heard that the chair and chief executive are to be chosen in London according to criteria we know not, with all power vested in the Secretary of State and some promise of further detail in secondary legislation.

However, the logical conclusion of the Bill, and the way out of the problem for the Government, is a system, as we have tried to suggest, of elected chairs akin to the police and crime commissioners or metro Mayors. Elsewhere in the debate, my hon. Friend the Member for Ellesmere Port and Neston and I have highlighted the vast discrepancy in money and powers that exists between police and crime commissioners, or even my local Mayor, and the health service. Health service spending dwarfs both of them.

I will not press the new clause to a Division, because I would like to see it picked up elsewhere in the debate as the Bill progresses through this place, and I would like to leave it as something helpful for the Government to keep considering. If the Government do not want to go down the election route, and we heard the reasons from the Minister, bringing back some form of the Appointments Commission, which disappeared in the coalition’s bonfire of the quangos, would be very helpful. There, we had clear role descriptions and person specifications for people who sit on those bodies, a transparent recruitment and interview process, and performance oversight and accountability. I was subject to that when I was a member of the primary care trust in Bristol North some time ago.

The other vital change is to try to bring in some genuine openness and transparency and some independent oversight of the process of appointment. The new boards and integrated care systems are a radical departure from the past 30 years. Earlier in the Committee, I made us pause momentarily as we saw off section 75, autonomy and competition. This is a big moment, and the new systems will need very highly skilled and experienced people to develop them to their potential, because, as we have heard, it is not clear how they are to be run.

The Government keep talking about permissiveness. The systems will be run by people on the ground, and the sort of people we want in charge must be imbued from the off with the culture that we want to see. The hon. Member for Central Ayrshire talked the other day about the safety board being strangled at birth, and there is a danger that these bodies, some of which have been operating quite well, will not fulfil their potential and will be strangled at birth, because that culture of feeding up accountability just to NHS England and not to local populations will make them not work in the way they should, and certainly will make them not work well with local government.

This huge culture change is a culture change for clinical leaders as well as managers. There are some great opportunities here for population-based health, but we are asking clinical leaders—clinical leadership is already a real problem in these bodies—not to look to their own departments in the first instance and their own institutions in the second, but to look outwith their institutions, working with clinicians across the primary-secondary interface, and at a population-based approach rather than their own specialty-based approach. Again, that is a massive sea change for them. Having the clinical leaders doing that at the board level and giving them the support they need to do that in their specialities requires people who are highly skilled and who will be respected locally for their experience and skills, and for, I would argue, their independence from not being hand-picked by the Secretary of State.

The Government continue to lurch from one cronyism charge to another. A transparent process would help them get over that problem—again, I kindly offer the Government some help through their difficulties. The NHS should be seen as an exemplar for appointments and recruitment. The NHS has a terrible problem with diversity. Yesterday, I chaired a meeting of the all-party parliamentary group on social mobility on the work the civil service is trying to do around improving recruitment, particularly at the higher levels, of people from lower socio-economic backgrounds and black and minority ethnic backgrounds. The NHS has also failed that test over many years, and I believe that a more representative local selection—I would like it to be elected, but it could be selected through an appointments process— would help.

The key aim of the last 30 years was to have local responsibility for financial performance as close to the patient as possible. We need to understand clearly where the money went for the population as locally as possible. It does seem counter-intuitive that a Tory Government are completely abandoning that aim with these new organisations and not going down a route of a locally elected and accountable chair. The new clause offers a good governance commission, and I do not know anyone who could disagree with good governance given what we have gone through in the last year. A good governance commission would be based on clear transparent criteria to start building a better culture in the NHS and make our local NHS more accountable to local people.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care) 2:15 pm, 27th October 2021

It is a pleasure to follow my hon. Friend the Member for Bristol South, who gave a superb analysis of why the new clause is important and she picked up on many of the themes that we have already debated. The topicality of NHS senior management is there for all to see, with some of the recent headlines being orchestrated to divert from the growing waiting list crisis in the NHS.

Our view is that NHS senior management cannot be all that bad because they have seriously outperformed the private sector on efficiency for nearly a decade. If the NHS is one of the most efficient services in the world as many international studies have demonstrated, that is a credit to the managers who form a relatively small proportion of the overall workforce. I hope the Minister will join us in congratulating NHS managers, along with all the other brilliant staff, who have got us through the pandemic over the last 18 months—although, as we know, we are not through it yet. The contrast with some of the political decisions made has been exposed recently by the joint report by the Health and Social Care Committee and the Science and Technology Committee.

As we have discussed on a number of occasions, the Bill seems to specialise in the centralisation of power, with more and more being explicitly given to the Secretary of State. Do we want the Secretary of State appointing every chair, non-executive and chief executive, even in bodies that are meant to be independent from the Department? Amendment 18, which we debated earlier, would have gone some way to addressing that: alas, it was not to be. This is a serious issue that needs tackling. My hon. Friend is an expert on these matters through her own knowledge and experience, and I absolutely support what she has said.

While good governance might sound a little cheesy, I am sure that we could spend a lot of time discussing what exactly this new clause should be called.

I think we can all understand what good governance means and what it should look like, because we have certainly seen what it does not look like in how the Department operates at the moment. As my hon. Friend said, there was something similar in place previously, before it was burned in the bonfire of quangos under the coalition Government. Something should be in place, be it a revitalised appointments commission or even some independent standing committee or panel—something that has independent oversight of these very senior positions.

As we have said before, we would like more direct democracy in our integrated care boards. We are not going to get that, by the looks of it, but we would at least like some independence in appointments. When my ICB chair is finally appointed, I want him or her—it is a “him” at the moment, and it is an interim position—to be looking outwards, not upwards to NHS England all the time. That is something that a good governance panel would help facilitate.

A fit and proper person test should be applied independently, even to get on a shortlist, and there should be some process for removing those who should not be on there. This needs to be applied by people who are independent and competent, and not people who are already on the lists or making the appointment decisions. Perhaps we should even have some people who have oversight of how people in senior positions are appraised, trained and supported. There is a lot of experience and expertise out there that we could harness. I hope that, whatever this body ends up looking like, it can assist the NHS in dealing better with issues such as diversity, succession planning and leadership—all areas on which we can always strive to do better.

I hope that nobody mentions bureaucracy or cost as an excuse to leave things as they are. We know from published NHS experience that having an appointments commission was not really an overhead; in fact, it was a valuable resource that, in the end, saved money. We know how much it costs to replace someone who has proved unsuitable, and to undo the mistakes that they made. Appointing the right people in the first place is the best solution. The Minister will, of course, be aware of the importance of recruitment and retention across the whole NHS. I think that we can do more in respect of senior leadership roles.

As my hon. Friend the Member for Bristol South said, transparency is key throughout the systems. Where the funding goes is a key question that will become even more key as we move into the ICBs, with larger areas and different funding streams merging into one. Transparency will be important there. Of course, there will be local differences, as she said, but there should still be accountability to someone for where that money goes and who is taking those decisions. We have what we have described as a permissive approach to running ICBs at the moment, but that does not mean that we cannot have transparency and accountability. That is why we support the new clause.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

It is nice to see you back in the Chair, Mr McCabe. I am grateful to the hon. Member for Bristol South. Although we may not fully agree, again I take the new clause in the spirit in which she tabled it. I will reflect on what she said, but I will also set out why I cannot accept what she is proposing. I will always reflect on what she says and proposes; when she proposes things, they are well thought out. We may come to different conclusions, but the points she made are certainly deserving of reflection. I can give her that assurance up front.

As in our oral evidence sessions, I join the hon. Lady and the shadow Minister in paying tribute to those in our amazing NHS and care workforce. It is also important that we recognise, as I think she said during questioning of witnesses, that the complexity of the organisations we are talking about—the complexity of an acute trust, for example—means that strong and effective leadership, both financial and administrative, are hugely important to the overall success of the enterprise of our NHS. I therefore join her in paying tribute to those staff who often find themselves, particularly in media commentary and similar shorthand critiques, on the receiving end of criticism. People may ask, “What are they there for?”. They are hugely valuable—just as much as frontline clinicians, nursing staff and those who work in the canteens or clean the wards. It is a team.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

I will give way to the hon. Lady, as I am sure she will amplify this point. She has worked in clinical settings and will know that a whole team is needed to make things work.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care), Shadow SNP Spokesperson (Europe)

I cannot resist the opportunity to amplify that point. Having spent over three decades working in hospitals as a surgeon, I know that it is a team sport that depends on everyone. Sometimes when cuts are made we hear the definition of “frontline” or “back-room” services. If I am in a clinic on my own without the patient records, the patient or the laboratory results, I am a complete waste of space. It is critical to recognise that. To get all the moving parts working well, really good managers are worth their weight in gold. They are part of the team and should be valued as such.

We heard with reference to fit and proper persons that the Kark review did not go far enough and should have suggested suggest registration or licensing of senior managers. Sometimes when the system does not work, we see the same people move out of one place and into another in this kind of revolving door manner.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

Although I do not always agree with the hon. Lady, I find myself in complete agreement with her. She made a couple of points that referred back to those made by the hon. Member for Bristol South. The hon. Lady is absolutely right that the system needs high-calibre, high-quality people with the right skills, particularly given what we are seeking to do with integrated care systems. We must foster an environment in which those high skills are valued, continually reinforced and refreshed.

On the point about the Kark review, the hon. Member for Central Ayrshire is right. How should I phrase this delicately? People may move on, or be moved on, from posts because it was not a success for whatever reason; I will phrase it like that. We need to look at the challenge posed by those people suddenly reappearing in another equivalent senior post in a different part of the country. There may be a reason why someone has not been a success that is not due to particular circumstances or something beyond their control, and we need to look at the recycling of those people who have not been found to have hit the mark. We need to look at that carefully.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

I see the look on the shadow Minister’s face, which makes me wonder what is coming.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

I am not trying to catch the Minister out. I can think of a specific example where what he mentioned has happened. I am, frankly, angry that this individual has been able to do that. What does the Minister think can be done to ensure that the revolving door is shut on those whom it deserves to be shut on?

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

The shadow Minister is right. It is a challenge, and it is something I continually reflect on, because it intersects with legal employment rights, the nature of the terms on which someone leaves, how these matters work and the fact that NHS trusts around the country are individual. It is not a simple issue. It is one that I continue to reflect on. I hasten to add that it is not just the shadow Minister but Members from both sides of the House who have, on occasion, raised the issue. It requires further thought and reflection.

New clause 8 would involve creating a new special health authority, effectively, to provide independent oversight of NHS appointments. I recognise the importance of such appointments, and everyone would agree that good governance arrangements should and must be in place for managing them. Appointments to NHS trusts, NHS England and special health authorities are public appointments; they are managed in line with the principles of the governance code for public appointments and are regulated by the Commissioner for Public Appointments. The chair of an ICB would be appointed by NHS England, with the approval of the Secretary of State. That reflects a point that has been considered on a number of occasions during the passage of the Bill, namely that the ICB is accountable to NHS England and, through it, to the Secretary of State and, ultimately, Parliament, as part of a national health service.

I acknowledge what the hon. Member for Bristol South said about the need for people to be answerable and responsive to their local community. The counter-challenge is avoiding the fragmentation of the national health service and the vertical arrangement. She mentioned police and crime commissioners, and although our police forces operate in a similar way, the difference is that we have never had a national police force. Each force is based on a county—or a city, in the case of the Metropolitan Police Service—and works on a locality basis, as local authorities do.

The national health service has, since its inception in 1948—the legislation was in 1946—moved in a different direction. It moved away from local, voluntary and local government arrangements for the provision of health services, patchy as they were, and towards a national model. That is the tension that we have wrestled with when we considered different clauses of the Bill.

With regard to NHS foundation trusts, it is for the council of governors at a general meeting of the council to appoint or remove the chair and the other non-executive directors. Governors are under a legal duty to represent the interests of the trust and the public, and must discharge this duty when making decisions on appointments. Foundation trusts must be assured that the decisions they make and their performance can stand up to public scrutiny on the grounds of public interest and quality of care. We believe that those existing provisions and processes provide Ministers, Parliament and the public with the necessary assurances when making appointments that good governance expectations are being met.

The process by which different appointments are made to the boards of NHS bodies has now been made public, and NHS England will continue to ensure that the process remains transparent. For appointments to NHS boards, such as those managing NHS trusts, or indeed to NHSE’s own board, NHS England will continue to assess diversity data and promote diversity and inclusion.

The hon. Lady made a valid point in that context. When I took over responsibility for workforce a few weeks ago, on top of my other responsibilities, I undertook the exercise of asking about, among other things, the gender split and the black, Asian and minority ethnic proportions at chief executive officer level. It will not surprise the hon. Lady to know that the answer was not clear cut, because then there was the challenge, “Ah, but what’s a CEO versus a managing director? What counts and what doesn’t?”. There is still a little bit of to-ing and fro-ing over definitions. However, I think the hon. Lady will be encouraged to learn that at the CEO level, the gender balance is very good compared with swathes of the public sector. On my preliminary assessment, however, there is a lot more work to do in terms of diversity and inclusion, so she raises an important point.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care) 2:30 pm, 27th October 2021

This is a slightly cheekier question than my last one. Has the Minister conducted a similar exercise in his own Department?

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

In respect of Ministers or senior civil servants? When it comes to Ministers, though I suspect that is not the point he wishes to push—

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care)

I think we can see who the Ministers are, at least this week. I was referring more to the senior civil servants.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

I like to think that I am a constant in the Department, this week and in previous weeks. It is piece of work that we have done. If one looks at the very senior civil servants—the directors general and permanent secretaries—there is a good gender balance. He is absolutely right, however; having assumed responsibility for workforce more broadly a few weeks ago, it is a piece of work that I want to do. I was responsible for the implementation of the Lammy review and race disparity audit when I was at the Ministry of Justice, and it is an interest that I have taken with me to my new Department. The last year has been a little bit busy, but it is something of which I have not lost sight.

I do not believe that it is necessary to create a new body to oversee appointments, given that good governance arrangements are already in place. I therefore remain unconvinced by the argument. As ever, and as behoves me when the hon. Lady proposes something, I will continue to reflect on it carefully.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

I am grateful for the Minister’s comments. I will not press the new clause to a Division, but I hope to see this matter further debated during the passage of the Bill. I say gently to the Minister that the gender split for CEOs and managing directors in the health service may be 50:50, but the workforce, and certainly managerial post holders, are overwhelmingly women; however, that is not reflected further up.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

The hon. Lady makes a point that I should have made earlier. When I was looking at this matter in the Ministry of Justice, I was not just looking at prison governors. We need to look at the layers below, the succession plan, and the mix coming up through the system—the next generation of leaders. She is right to highlight that; forgive me for not having mentioned it.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

I am afraid that these bodies have not proven themselves good at doing that, and it is not good to have them police themselves, so we need to progress the debate. On the national/local question, I am generally more Morrison than Bevan, so I will continue to plough that furrow, but this is also about being seen to do things properly for local people. My fundamental point remains that as we ask people to spend more money—we are talking about a huge proportion of our GDP, and it will be increasingly so under any Government—we need to be able to demonstrate to them what is done with it, and how and why it is done, and we need to involve the public.

That is my view of the future of the health service, and that is why I will continue to pursue this argument. When it comes to cost, it is a moot point whether this is done quietly in the corridors of NHS England; whether it is done by the Secretary of State; whether names mysteriously appear in the local economy; or whether there is due process. I am not saying that the old system was perfect. It is quite hard to recruit people to these bodies, but they are powerful people, spending billions of pounds of local money in the local economy. They need to be more representative and accountable, and we need to know who they are. As I said, I will not pursue the matter now, but I would like to see it debated further over the passage of the Bill, and we will come back to it another time. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.