Committee (6th Day)
Relevant documents: 15th and 16th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee
Clause 20: General functions
106: Clause 20, page 20, leave out lines 20 to 43
My Lords, Amendment 106 is in my name and those of my noble friend Lady Walmsley and the noble Baroness, Lady Thornton. I am very grateful for their support.
Two months ago, two of our Select Committees, the DPRRC and the SLSC, published simultaneous and collaborative reports. The DPRRC report is entitled Democracy Denied? The urgent need to rebalance power between Parliament and the Executive, and the SLSC report is called Government by Diktat: A call to return power to Parliament. It would be very hard to exaggerate the importance of these reports, and I congratulate both committees on a very timely and disturbing reminder of the Government’s habit of trying to bypass Parliament and avoid effective scrutiny, as they do again in this Bill.
Both the reports focused on the long-standing abuse of the use of delegated powers legislation, and the DPRRC concluded:
“The abuse of delegated powers is in effect an abuse of Parliament and an abuse of democracy, and this report will, we hope, be a prompt to strengthen Parliament in the coming years.”
We can make a start on that hope with this Bill.
The DPRRC noted in its report of 15 December that the Bill contains 155 substantive provisions and 156 delegated powers. It concluded:
“The Health and Care Bill is a clear and disturbing illustration of how much disguised legislation a Bill can contain and offends against the democratic principles of parliamentary scrutiny.”
The report examines some of the Bill’s clauses in some detail, including the insertion via Clause 20 of a new Section 14Z48 into the National Health Service Act 2006. Essentially, the new section gives a Minister the power to make law by simply publishing “a document”. The department tries to justify the lack of any parliamentary procedure associated with the publication of a document on the grounds that the power is concerned with operational and administrative matters. However, the DPRRC goes on to say:
“Such a power is very unusual. If used in a context other than one involving public sector health bodies, it might give grave cause for concern and set an extraordinary precedent. Statutory liabilities should be imposed transparently, subject to clear legal conditions and parliamentary scrutiny.”
I should point out here the force of the word “unusual” in the committee’s comments. This is the highest form of disapprobation used by committees, and for good reason. This proposed new section is a blatant, transparent and disgraceful attempt to avoid any parliamentary scrutiny whatever.
The DPRRC’s conclusion is damning. It says:
“The power to impose a legal liability by merely publishing a document, without any parliamentary scrutiny, is a striking example of disguised legislation. We regard it as an inappropriate delegation of power, which should be removed from the Bill.”
In its report on the Bill of 7 January, the Constitution Committee agreed with the DPRRC’s recommendation to remove the new section from the Bill. I agree strongly, and that is what our amendment would do. I suggest to the Minister that if he wants to retain the powers set out in proposed new Section 14Z48, he rework them between now and Report so that they at least involve scrutiny by the affirmative procedure. If not, he can certainly expect us to return to this serious abuse of delegated powers on Report. I beg to move.
My Lords, we have just heard a very powerful contribution from my noble friend Lord Sharkey, reminding Ministers and your Lordships’ House of the importance of the problem of Ministers taking delegated powers, stopping Parliament doing its job properly. I support his amendments.
Amendments 133, 139 and 161 in this group, from the noble Baroness, Lady Greengross, are on continuing healthcare and I can think of no better person in your Lordships’ House to speak about the importance of that. I look forward to her speech. I am pleased to support her amendments and will speak to them now. The NHS definition says:
“Some people with long-term complex health needs qualify for free social care arranged and funded solely by the NHS. This is known as NHS continuing healthcare.”
The full continuing healthcare assessment and the toolkit for updating assessments are absolutely vital for any multidisciplinary team and, at least in theory, these amendments put them on a formal footing as part of the smooth package of care that individuals need. The amendments establish a duty to fund and assess continuing healthcare, which needs to be visible, not least because of the abuses in the current system.
The principles of continuing healthcare in current legislation are fine, but unfortunately, as money has got tighter, there are problems with how they work in practice. There are many reports of CCG assessors and social workers having disruptive and degrading discussions, sometimes with family members present, about whether a particular issue is a continuing healthcare or a personal care need, which would be funded by the patient or their local authority, or the NHS. I personally witnessed a debate about the percentage split of continuing care versus personal care concerning the incontinence of a family member. It was not about the patient; it was solely about money and who would pay.
On the use of the toolkit, Beacon’s website states:
“When the Decision Support Tool has been completed and considered by the Multidisciplinary Team, they should have a genuine and meaningful discussion about whether they feel the individual has a primary health need. This is a role for the entire MDT, not just the CCG’s coordinating assessor and the social worker.”
“Not just” is an interesting phrase to use. The actual power is entirely in the hands of the parties who have the funding—in this case, either the CCG or the social worker; of course, the social worker acts on behalf of either the patient or their local authority. The reality is that it becomes a negotiation about who pays and can, as I said, end up as a haggle over percentages. It can feel as though the patient’s needs were long dispensed with. That is why these amendments are so important.
Amendment 133 states that ICBs’ annual reports must cover
“all commissioned services, including NHS continuing healthcare”.
I believe that this requirement will bring more focused attention on the assessments and the negotiations. Amendment 139 would require a performance assessment of continuing healthcare assessments, their results and their consequences. Finally, Amendment 161 would ensure regular reviews and performance assessments of continuing healthcare assessments, their results and their consequences.
The Government say that this is the Bill that will transform the commissioning of health and social care. In a perfect world, they would be a seamless service, both properly funded to deliver what the patient needs. By adding continuing healthcare to the Bill, it will be strengthened, and that golden thread between the NHS and the social care sector will run all the way through it. I hope the Minister will accept these three amendments, which would help to deliver exactly the change the Government want.
My Lords, I will speak to Amendments 133, 139 and 161 in my name, and to Amendments 143 and 144 in the name of the noble Baroness, Lady Finlay, to which I have added my name.
Amendments 133, 139 and 161 are intended to clarify the role that continuing healthcare—CHC—will play, along with other commissioned services. The Continuing Healthcare Alliance has raised concerns about the provision of NHS continuing healthcare. The package of care is there to support people with ongoing and substantial needs in England. Examples of conditions for which someone may qualify for CHC include Parkinson’s, motor neurone disease and dementia, but there are many others as well.
Amendments 143 and 144 would strengthen the power of NHS England to give directions to integrated care boards. They would help to ensure national consistency of CHC services, which, sadly, is not always the case at present. When the Bill was debated in the other place, the Minister, Edward Argar, responded to a similar amendment as follows:
“It is right that clinical commissioning groups, as they are currently called, are held accountable for NHS continuing healthcare within their local health and social care economy. That will also be the case with the national move to integrated care boards, where the board will discharge those duties and be accountable for NHS continuing healthcare as part of its NHS commissioning responsibilities.”—[Official Report, Commons, Health and Care Bill Committee, 28/10/21; col. 825.]
Given this earlier response, I believe that it is the intention of the Government to improve the national delivery of continuing healthcare and to ensure more consistent delivery throughout England. The intention of this group of amendments is to clarify that in the Bill, so I commend Amendments 133, 139 and 161.
My Lords, I added my name to Amendments 133, 139 and 161, which were so ably introduced by the noble Baroness, Lady Greengross, and others. I also have Amendments 143 and 144 in my name. All the amendments aim to tackle the accountability gap: the inconsistency of provision of continuing healthcare across different parts of England.
The noble Baroness, Lady Greengross, alluded to some diseases, but this goes much wider. There are people with spinal injuries and long-term multiple sclerosis and there are people who have had strokes. They all need ongoing long-term healthcare at a high level—way above the level that can be provided by social care.
The problem is that the accountability gap exists and there is inconsistency in the quality of provision, with eligibility criteria being interpreted differently in different areas. Amendments 143 and 144 aim to strengthen the powers of NHS England in the Bill to give direction to integrated care boards, with the particular aim of closing this accountability gap. Within the existing system, NHS England is responsible for holding clinical commissioning groups accountable for their discharge of continuing healthcare and functions.
In the reformed system proposed by the Bill, NHS England will hold these boards accountable in a similar way, but I question whether it has adequate authority both in the current system and the proposed system and whether the levers available to it to act meaningfully are adequate. While the intention prior to the Lansley reforms was to give NHS England powers to intervene to create meaningful change in practice, the powers were restricted to high-level interventions where there was a failure of governance at the highest level, rather than interventions where a CCG was failing to implement good practice or to adhere to national policy.
The 2018 report by the Public Accounts Committee in the other place supported these concerns and stated:
“NHS England is not adequately carrying out its responsibility to ensure CCGs are complying with the legal requirement to provide continuing healthcare to those that are eligible.”
There are limited accountability mechanisms and there is inadequate data collection at present. These amendments seek clarification and would drive long-overdue improvements in the quality and, importantly, the consistency of the way that continuing healthcare decisions are made and the process is administered, with the aim of improving outcomes and reducing the strain of applying for continuing healthcare for people who live with complex health needs and for their loved ones, in particular their family and carers.
My Lords, I very much support the noble Baroness, Lady Greengross, in her amendments. We should be clear that continuing health needs are ignored by assessors because of the issue of who will pay. I have experienced this twice with neighbours and friends. It was clear to me that both patients had complex needs, mentioned by the noble Baroness, Lady Finlay, and had undeniable continuing care needs, so I was puzzled as to why the families were working out how to fund places for their relatives. They had never been told of the possibility of continuing NHS funding. I suggested that they quote the legislation back to the assessors and of course when they did so they found that funding would be provided—and some years later it is still being provided. Without this chance encounter with me, and asking the right questions, those families would have been denied the funding that is their right.
My Lords, as ever, it is a great pleasure to row in behind my former boss at Age Concern—the inspirational leader of Age Concern for so many years—to return to an issue that Age Concern and its successor body Age UK have for decades raised with successive Governments during successive NHS reorganisations.
It is important, at the outset of this debate, that we understand the true importance of NHS continuing care. On one level, an individual level, it is about enabling people who have long-term conditions to live dignified lives in the community. At a strategic level, in terms of healthcare planning, it is about keeping people out of acute hospitals, which is the most expensive form of care.
The reason why it is right, again, that we seek to put these amendments on to the face of the Bill is that, at an organisational level within the NHS, there has never been a full accountability path for NHS continuing care. That means that, when it comes to individual decision-making on the part of members of staff in relation to individual patients, the decisions fall down. We have not just wide variation between different organisations but wide variation between particular practitioners, who sometimes resort to using non-standard checklists to make decisions, with inconsistent decision-making.
As a result of that, it is hardly surprising, but a real condemnation of a long-term failure of the NHS, that there is a need for an organisation such as Beacon to exist. It is a social enterprise set up by the main charities that gives information to older people and their carers. It should not have to exist. The fact that it does, and that it is a profitable social enterprise business, is testimony to the extent to which older people and their relatives are being badly let down on this.
I hope that in raising this yet again we have shone a light on a part of the NHS system that goes to the heart of what this Bill is supposed to be about. If we do not make this an express responsibility of the NHS in the Bill, yet again it is just not going to happen.
My Lords, I, too, support the noble Baronesses, Lady Greengross and Lady Finlay. It is right that people should have the cost-effective continuing care to which they have a right. I have my name on the amendment tabled by the noble Lord, Lord Sharkey, and I intend to make some very brief comments about that, although I make the point that the need for us to be brief is the Government’s own fault, because they have not given us enough days in Committee—fewer in fact that in another place.
On the amendment, we refer to the 15th report of the Delegated Powers and Regulatory Reform Committee. I have rarely read such a hard-hitting report by this highly respected committee. One of the worst of the Henry VIII measures that it mentions is allowing zero scrutiny on allowing NHS England, merely by the publication of a document, to impose a financial liability on an ICB. It specifies the circumstances in which an ICB is legally liable to make payments to a provider under arrangements commissioned by another ICB. The Government claim that this is an operational matter. However, if you believe that an ICB should be in total control of deciding how its funds are spent in its area in order to fulfil its duties, you might think that this is an important thing—a legal liability to pay for something that another organisation has decided to commission is quite a serious matter. The DPRRC thinks so and so does the Constitution Committee.
In their response to the DPRRC, as quoted in Appendix 1 of the committee’s 16th report, the Government said that they
“recognise that the Bill contains a significant number of guidance making powers, powers to publish documents and powers of direction.”
They suggest that
“these are appropriate because they reflect the often complex operational details, which are better illustrated by examples and guidance rather than legislation.”
The Government go on to say that there is currently a precedent in the powers of the clinical commissioning groups.
I do not believe that Parliament is unable to grasp technically complex matters, nor to understand them, when illustrated by examples given by a Minister at the Dispatch Box introducing a regulation. I suggest that that is what the Government should do instead of publishing a document; they should explain and give examples. It is patronising to Parliament to suggest that it cannot grasp these issues. The Government have gone too far. It is a power grab and I suggest that the Government withdraw and do exactly what my noble friend Lord Sharkey suggests.
My Lords, I thank the noble Lord, Lord Sharkey, for opening this important group and moving Amendment 106, to which my noble friend Lady Thornton added her name. As he explained, the substance of this amendment was singled out by the Constitution Committee and highlighted by the Delegated Powers and Regulatory Reform Committee. I reinforce the Constitution Committee’s endorsement of the DPRRC’s recommending the removal from Clause 20 of the imposition of legal liability merely by publishing a document. We agree with the two committees that this is a necessary amendment, and I look forward to hearing from the Minister how these concerns will be addressed.
Somewhat paradoxically, Amendments 143 and 144 strengthen the powers of NHS England in its quest for top-down management and imposition. However, they sit within the wider context of describing how NHS England would be able to give directions to integrated care boards under Clause 20 and improve these provisions, so we support them.
The remaining amendments on NHS Continuing Healthcare underline how vital it is to address this urgent issue, although it is not central to the intentions of the Bill. I thank the noble Baroness, Lady Greengross, for ensuring this focus in the debate and for Amendments 133 and 139, which ensure that this crucial issue is specified under the ICB’s duties and included in its annual report and performance review accountabilities.
Today, we heard in detail about the widespread concern about and scale of the problems with the way in which the NHS Continuing Healthcare scheme works and is funded, and the arguments it leads to about who pays for what, as a shared responsibility between the NHS and local government. Patients and their carers feel they are the sideshow, not the central focus of concern, and are deeply traumatised and upset by the whole experience.
As a carer of a disabled adult myself, like my noble friend Lady Pitkeathley, I know, from meeting many other carers and their loved ones, their deep concern about this. The three things that cause most concern and upset, which one hears time and again, are, first, the huge problems with inadequately funded social care packages—or their absence—to meet basic care needs, and deep worries and anxieties about how the care cap will operate; secondly, the trauma of the discharge-from-hospital process for carers and their loved ones, which we will discuss later; and thirdly, NHS Continuing Healthcare, the postcode lottery of whether your loved one receives it or not, the huge bureaucracy around the application and allocation process, the long wait for a response and being stuck in the middle of an NHS local authority fight over funding. As the noble Baroness, Lady Finlay, stressed, there is an urgent need to tackle the accountability gap in this process.
NHS Continuing Healthcare is the absolute manifestation of what our Economic Affairs Committee report on the “national scandal” of social care funding called the “condition lottery”—in other words, the wide disparity between health conditions for which people receive healthcare that is free at the point of use and those for which users usually have to make a substantial contribution with “catastrophic costs”, in the committee’s words. As we heard today, dementia is the condition most cited in this regard, but many of us know of cases where people with motor neurone, Parkinson’s and other degenerative diseases have struggled to get NHS Continuing Healthcare funding, either for home care or support in residential homes.
We support Amendment 161, which ensures that the Care Quality Commission reviews must include this issue. However, I am unclear—and may well learn in a minute from the Minister—what role the CQC currently has in looking into all continuing care matters which traverse NHS and local authority boundaries. However, we support its involvement.
The amendment would also ensure that the CQC reviews include looking in depth at how NHS Continuing Healthcare is working under each ICB. That will mean that at last we can begin to develop the much needed strategic overview of this crucial area for thousands of people in desperate need of care and support.
My Lords, I thank the noble Lord, Lord Sharkey, and the noble Baronesses, Lady Finlay and Lady Greengross, for bringing this group of amendments.
I understand the intention behind Amendment 106, on payment to providers, which is to remove new Section 14Z48 in its entirety, but the section will allow NHS England to specify the circumstances in which an ICB is liable to make payments to a provider for services commissioned by another ICB.
The Government are committed to ensuring that delegated powers in the Bill use the most appropriate procedure, so that Parliament has due oversight of their use. We recognise that the Bill contains a significant number of guidance-making powers and powers to publish documents. However, we believe that they are appropriate because, as the noble Baroness, Lady Walmsley, said, they reflect the often complex operational details and the importance of ensuring that the guidance keeps up with best practice, especially as the system flexes and evolves. I understand the noble Baroness’s point about Parliament, but the issue here is whether, every time the system flexes, Parliament has to have another debate. The ICBs will be reading the guidance, not Hansard, and the guidance should reflect that.
Nor is it our intention to interfere unduly in the financial affairs of ICBs. Instead, the intention is to resolve specific circumstances, such as emergency services. The legislation makes it clear that each ICB has to arrange for urgent care services to be available for all people physically present in the area, not just for the people who are its core responsibility by virtue of their GP registration. I am sure noble Lords will agree that it would be neither fair nor in the best interests of promoting an efficient health service for the ICB to both arrange and cover the cost of all additional emergency treatment brought by visitors to the area, particularly in areas with high visitor numbers. A number of noble Lords referred to that principle in debates last week.
Instead, this provision allows NHS England to mandate a different payment rule for those services, ensuring that, where necessary, the ICB where a patient is registered will pay, rather than the ICB where they receive treatment. This ensures that the financial impact is felt in the right commissioning organisation and eliminates the risk of some ICBs having unreasonable financial demands placed on them—for example, during the holiday season.
The wording of this provision replicates almost exactly the National Health Service Act 2006 as amended in 2012, but it is updated to reflect the new ICB structure. As my noble friend Lord Howe mentioned to me, we had a massive debate about this 10 years ago, but the provision seems to have worked effectively in the CCGs, and we wish to continue that with the ICBs.
Amendments 143 and 144, in the name of the noble Baroness, Lady Finlay, are about NHS England directing ICBs. I understand the interest in ensuring that NHS England has the necessary tools to intervene in ICBs where necessary. However, we believe that NHS England already has sufficient powers to direct ICBs. NHS England already has certain powers to direct an ICB under Section 14Z59(2), and powers to intervene over ICBs in order to prevent failure and to ensure that the lines of accountability from ICBs through NHS England to Parliament are strong.
However, this power has a threshold in that it can be used only if NHS England deems an ICB to be failing to discharge a function or at risk of failing to do so. The threshold removes the possibility of NHS England overdirecting the system while retaining the power for use if necessary. This balances the need to prevent failure and to support accountability with allowing ICBs the autonomy they need to operate effectively.
Amendments 133, 139 and 161 expressly require that ICB annual reports and NHS England performance assessments of ICBs include specific consideration of commissioned services, including NHS Continuing Healthcare, which noble Lords have spoken about, and that the CQC reviews of ICSs include specific consideration of that. We agree with the principle, but we believe that it is already covered in the Bill. NHS England already has a key role in overseeing ICBs. For example, the Bill requires NHS England to assess the performance of each ICB every year, and ICBs are required to provide NHS England with their annual report. These reports will include an assessment of ICB commissioning duties, which would encompass any arrangements for NHS Continuing Healthcare.
In addition, as noble Lords are aware, Clause 26 gives the CQC a duty to assess integrated care systems, including the provision of relevant healthcare and adult social care within the area of each ICB. This would include the provision of NHS Continuing Healthcare. We intend the CQC to pilot and develop its approach to these reviews in collaboration with NHS England, but also with other partners in the system. This should ensure that the methodology does not duplicate or conflict with any existing system oversight roles.
With this in mind, we believe that these amendments are not necessary, because commissioned services, which we would expect to encompass NHS Continuing Healthcare, are already included in these clauses. I hope that I have been able to somewhat reassure your Lordships. For these reasons, I ask noble Lords not to press their amendments.
My Lords, it is clear that new Section 14Z48 is an unambiguous abuse of delegated powers. It provides for a law to be created by the simple issuing of a paper. There is no real possibility of a coherent defence of this procedure and the Minister did not provide one, relying as he did on special pleading and the extraordinary notion that Parliament cannot handle complexity.
As the Bill stands, Parliament is bypassed and scrutiny is avoided. I remind the Committee that the DPRRC and the Constitution Committee have recommended the removal of this section. I again suggest to the Minister that if he wants to retain the powers set out in Section 14Z48, he should rework them between now and Report at least to involve scrutiny by Parliament via the affirmative procedure. If he does not, we will return to this issue on Report. In the meantime, I beg leave to withdraw the amendment.
Amendment 106 withdrawn.
Amendments 107 to 144 not moved.
145: Clause 20, page 27, line 43, at end insert—
“(3) Subsections (1) and (2) do not have effect if the information involves the personal data of patients.”Member’s explanatory statement
The amendment is aimed at ensuring that the power to disclose information should exclude personal data on patients and is a probing amendment to see what purpose the Government thinks the power in the clause may be used for.
My Lords, my amendment concerns patient data. I want to probe the meaning of new Clause 14Z61, proposed by Clause 20(2), which relates to the permitted disclosure of information by integrated care boards. It sets out, on page 27 of the Bill, a number of conditions under which disclosure can be made. They include when
“the information has previously been … disclosed to the public”
“the disclosure is made in accordance with any enactment or court order”.
That seems perfectly sensible. However, proposed new subsection (1)(f) contains a catch-all condition under which a disclosure can also be
“made for the purpose of facilitating the exercise of any of the integrated care board’s functions”.
That seems remarkably open-ended. My amendment seeks an assurance that this power excludes the personal data of patients.
We have already had one go at the issue of data and digital transformation, and I have told the House that I am right behind the efforts of the NHS and the Minister’s department to encourage the digital transformation of the NHS. The potential is clearly enormous. However, public confidence depends on the integrity of the system and having embedded in it a guarantee that every use of data will be consensual, safe and transparent.
The recent Laura Wade-Gery review, on which a number of noble Lords have commented, acknowledged some of those concerns. As she said:
“The field of data science is undergoing a revolution as new tools such as machine learning transform our ability to gain insights and improve outcomes. These advances, combined with the explosion of new data driven commercial business models, have caused citizens to be concerned about the privacy of their individual health data and the controls in place over its dissemination and use.”
There may be situations where a patient does not want a doctor—by the way, just for the Chief Whip’s reassurance, I have not spoken for 37 minutes as the clock says—to tell another doctor something about them, yet this can be ignored by those who want to copy records across a lifetime. Modern communications have created the capacity to copy medical records on a scale that can shatter medical confidentiality.
The experience of Care.data is surely a lesson for us. The decision to axe the scheme followed the publication of two reports that supported far greater transparency over what happens to the information, and opt-outs for patients who want their data seen only by those directly caring for them. A review by the late Dame Fiona Caldicott, and a second by the Care Quality Commission, recommended tougher measures to keep people’s medical information confidential. The Caldicott review said that there needs to be much more extensive dialogue with the public as to how their information can be used. As she said:
“Citizens have a right to know how their data is safeguarded. They should be included in conversations about the potential benefits that responsible use of their information can bring. They must be offered a clear choice about whether they want to allow their information to be part of this.”
This was brought home to me recently by NHS England’s announcement that it is to give trusts, as employers, access to the Covid and flu NHS vaccination records of their staff. I am fully behind the vaccination drive and sympathetic to the Government’s mandating of vaccines, but the announcement said:
“To assist Trusts with understanding the vaccination status of their workforce, we are providing a solution for Trusts to view the vaccination status of staff who are on the Electronic Staff Record … system. To do this, we are undertaking an exercise on Trusts’ behalf, to match ESR data, using NHS numbers, with vaccination data held in the National Immunisations Management System … which includes data drawn from all point of care vaccination systems. Following a successful import of ESR data into NIMS, a dashboard will be provided to each Trust detailing their workforce Covid and Flu vaccination uptake, drilled down to employee-level.”
Let me be clear: I support the vaccination drive, as I said, but am I the only one to worry about the access to confidential data that is being given? I recognise that we are talking here about electronic staff records as opposed to electronic patient records, but the principle of releasing patient data is the same.
I would like to hear some assurance from the Minister about the use of this clause and the open-ended nature of new Section 14Z61(1)(f), because, as I think we will shortly hear from the noble Baroness, Lady Brinton, such an open-ended disclosure provision in other legislation would be looked at with very great concern. Having said that, and having taken up 44 seconds, according to the Clock, I beg to move.
My Lords, I have failed in my duty, and not for the first time. I should have stated before calling Amendment 145 that the noble Baronesses, Lady Brinton and Lady Harris of Richmond, will be taking part remotely. May I apologise, and invite the noble Baroness, Lady Brinton, to speak?
My Lords, this probing amendment from the noble Lord, Lord Hunt, is essential, because it protects confidential patient data from being given out by an ICB in contravention of the ethics rules of the General Medical Council and other regulatory bodies.
When the Police, Crime, Sentencing and Courts Bill arrived in your Lordships’ House in the autumn, it had clauses in it that gave the police, probation and prison services access to a patient’s confidential medical data as part of their role to reduce and prevent serious violence. As originally drafted, that Bill would have required GPs, CCGs and their staff to hand over that data. This was not just about those under suspicion; it could have been anybody involved in serious violence.
I had extreme concerns about this, and I tabled an amendment not dissimilar to Amendment 145. I was grateful for the support of the noble Lords, Lord Patel and Lord Ribeiro, the General Medical Council, the BMA and others in Committee on that Bill. We had meetings between Committee and Report with officials from the Department of Health and the Home Office, meaning that by the time we got to Report the Government had laid amendments to ensure that a patient’s personal data could not be demanded by the police, probation and prison services. It is now recognised that the medical regulators—the GMC, the Nursing and Midwifery Council and other bodies—actually have the responsibility and the excellent ethical standards by which their members are expected to judge what they should do if they are asked for personal data.
The amendment from the noble Lord, Lord Hunt, would address what data an ICB may disclose by adding a subsection to protect the Government in the same way as happened in the police Bill, so that the personal data of patients should not be disclosed. This is a vital amendment. The Government have already accepted in this Parliament that a patient’s personal data must not be accessible by those other than clinical and clerical staff dealing with it, who must abide by the confidentiality rules of their regulatory body or by their employment contract.
This is even more necessary, because the Bill says in new Section 14Z61(1)(g), on permitted disclosures of information, that
“the disclosure is made in connection with the investigation of a criminal offence”.
That is even broader than in the original police Bill. Patient confidentiality is a fundamental ethical duty. It is crucial to upholding the trust that lies at the heart of the doctor-patient relationship. The new section will give the ICB the right to override that.
New paragraph (e) is also more far-reaching than the investigation of any crime. It says that
“the disclosure is made to any person in circumstances where it is necessary or expedient for the person to have the information for the purpose of exercising functions of that person under any enactment”.
So it is not the doctor or the ICB that has the choice about disclosing that information; they must take the word of the person making that request. That is total free access for anyone who says that it is necessary or expedient for them to have that information. Where is the protection of a patient’s individual and confidential data?
It also removes the decision from GPs, despite GPs having very clear and effective guidance from the GMC on when, in exceptional circumstances, they can give out data. I will not quote the whole of the guidance, because we do not have time, but there are two vital points that a GP must consider: the patient must consent, whether implicitly or explicitly; and disclosure must be permitted or must have been approved under a statutory process that sets aside the common-law duty of confidentiality. The doctor also has a duty, even when they have made their decision, to use anonymised information if practicable, and they must be satisfied that the patient has ready access to information explaining how their personal information will be used. It goes on, but I will not quote the rest.
One might hope that Ministers assumed when drafting the clause that confidential patient data would never be included, other than for the treatment of the patient. However, paragraphs (e), (g), (h) and (f), as the noble Lord, Lord Hunt, outlined, put paid to that. If the argument is that the clause is needed because the ICB might have to share data with, for example, care providers or social workers carrying out assessments, that needs to be made clear, and it would be permissible. But, as drawn, it is far too brief.
The amendment from the noble Lord, Lord Hunt, at least protects the personal data of patients. It is very straightforward and provides the protection that every doctor, nurse and patient would expect. So I hope the Minister will say today that he is happy to accept the amendment. If he is not, please will he agree to a meeting with those who have spoken in this debate, and invite the GMC and the BMA? If progress is not made on this, I will lay an amendment on Report and am likely to press it to a Division.
My Lords, the noble Baroness, Lady Harris of Richmond, is also taking part remotely and I invite her to speak.
My Lords, having spoken on just about every police Bill in this House for the past 23 years, I am afraid that I could not let this amendment pass without comment. I refer your Lordships to my policing interests in the register.
As my noble friend Lady Brinton has just said, the Police, Crime, Sentencing and Courts Bill, which has just gone through this House, had provisions that gave the police and other criminal justice bodies investigating possible serious violence, or plans to produce serious violence, the power to demand the confidential medical data of individuals. As drafted, unspecified police officers —that means any police officer, not just a senior ranking officer—could make requests to a GP’s surgery or a CCG, or their staff, to hand over the data.
What I found chilling was that the police would not be required to explain to the patient’s GP why they wanted the information, or whether the patient concerned was a potential criminal or possible victim—or even someone associated with the investigation, for example a possible witness or family member. After discussions with Peers, the General Medical Council, Ministers and the British Medical Association, the Government made their own amendments, making it clear that the police would not have this universal access to patient data. Instead, they would have to use the current, traditional method of approaching a patient’s GP directly and asking for the data, with the decision being made by the GP under the GMC code of ethics, as my noble friend Lady Brinton explained.
New Section 14Z61 gives the new integrated commissioning boards a duty to hand over personal medical data to a wide range of bodies that request them. However, I will focus on paragraphs (g) and (h), which are about police requests for data when they are undertaking criminal investigations. It is even more extraordinary that a health Bill is proposing to give the police even wider powers than in the recent police Bill. At least that Bill originally limited access to cases of serious violence. I will quote my noble friend from 25 October 2021, in debate on the Police, Crime, Sentencing and Courts Bill:
“It is quite extraordinary that this Bill proposes that any Home Secretary can, at will, demand that doctors and other healthcare professionals breach patient confidentiality, over and above their responsibilities of confidentiality to their patients and their commitments to their regulatory body.”—[Official Report, 25/10/21; col. 551.]
This Bill proposes giving police those powers for any criminal investigation. It is absolutely wrong. I refer your Lordships to recent police cases of sexual assault, where we know they have also trawled victims’ telephones and computer data for any information they can find. Would these clauses allow similar fishing expeditions on their private and confidential medical data? Would they also apply to those who might be loosely associated with potential criminals? What about family members? Is it intended that their data be similarly trawled? Where does this end? This entire clause breaches an individual’s right to their medical data being kept confidential, other than in exceptional circumstances. It removes the power from the individual’s GP to make such a decision in exceptional circumstances. Worse, it enables commissioning staff and directors at an ICB to be required to hand over data to the police without the knowledge of the GP. It is totally unacceptable, and I entirely support this amendment.
My Lords, I support the amendment in the name of the noble Lord, Lord Hunt, to which I have added my name. He is not the only one to be concerned about this part of the Bill. My noble friends Lady Brinton and Lady Harris have delivered powerful support and a demonstration of why we have to be absolutely vigilant about access to, and sharing of, personal data, as they were so successfully on the police Bill. We must not repeat those experiences.
We will talk further and more comprehensively about data later in Committee. In the meantime, Amendment 145, as the noble Lord, Lord Hunt, explained, tries to illicit from Government their intention behind these disclosure powers for ICBs in new Section 14Z61 in Clause 20 with regard to information, whether personal data is involved and what the safeguards are. New Section 14Z61 sets out the provisions whereby
“An integrated care board may disclose information obtained by it”
in the exercise of its power. As the noble Lord, Lord Hunt, said, the catch-all condition in new Section 14Z61(1)(f) under which disclosure can be made
“for the purposes of facilitating the exercise of any of the integrated board’s functions”
seems remarkably open-ended. My noble friends have also pointed out the sheer width of paragraphs (e), (g) and (h), which go even further than those originally proposed in the police Bill and raise crucial questions for the Minister to answer.
Amendment 145 aims to ensure that an ICB cannot disclose information where this is patients’ personal data. In my last intervention on the group headed by Amendment 26, I, like the noble Lord, Lord Hunt, expressed my support for the NHS’s digital transformation programme. It is clear, as the noble Lord says, that there is great potential growth in new technologies using data such as AI and machine learning. However, there is an absolute imperative to have the right safeguards in place in relation to duties and data. This is very much aligned with transparency in public information and engagement, particularly in this context. Transparency, choice and consent are crucial, as the noble Lord, Lord Hunt, says.
We have all looked forward to the Goldacre review, but I am not convinced that it will range wide enough and cover the governance arrangements needed to preserve and enhance public trust in the sharing and use of health data, but we will see. I look forward to the debate towards the end of Committee when we discuss the wider aspects of the Bill, when we will produce further illustrations of the rather cavalier way in which the Government, the department and the NHS have treated personal data. Not least of these is what has been called the attempted GP data grab of last year. In the meantime, I hope the Minister will be able to give assurances that the powers in Section 14Z61 will be very limited.
My Lords, from the perspective of a clinician, I support this amendment very strongly. If it is not adopted, I can see it being imperative, in any doctor’s consultation, to warn the patient that their data could be accessible and to be very careful about what is recorded in the clinical record. Very often, patients come to see a doctor, possibly at a very early stage of slightly disordered thinking or because they have undertaken a potentially high-risk activity, often in the sexual domain, and are worried that they may have contracted some condition or other. If you inhibit that ability to see a doctor early, you will further drive people into whatever condition is beginning to emerge, so it will not be known about until later. That applies particularly in mental health, where early intervention might prevent a condition from escalating.
I can see that, without an amendment such as the one proposed by the noble Lord, Lord Hunt of Kings Heath, every clinical consultation will have to be conducted with extreme caution, because of potential access to data.
My Lords, I an enormously grateful for this debate, because this clause and related clauses are critical both to achieving the digital transformation aims of the NHS, referred to by the noble Lord, Lord Clement-Jones, and to getting the healthcare system to work better together.
I am also grateful for the humanity and testimony of several noble Lords, exemplified by the noble Baroness, Lady Finlay, who spoke movingly about the practicalities of patients going to see their doctors. I know from my own life and from my family how important it is to protect those relationships.
That is why I would like to hear a little from the Minister about what protections there are, because health data is and should be treated as a special category of data. What additional protections are there in the use of health data, including in the common law duty of confidentiality, the role of the National Data Guardian, the way the Caldicott principles will be used and the national data opt-out? What reassurances do we have that those special considerations will apply to this clause and its related components?
My Lords, I agree with my noble friend Lord Hunt and those speakers who expressed their concern about the open-endedness of what is in the Bill at the moment and the lack of protection for patient data. I look forward to the Minister’s reply on this.
My Lords, I am grateful to the noble Lord, Lord Hunt, particularly for his brief and, as always when he speaks, his clear understanding of the amendment. It makes it so much easier for us to know where the noble Lord is coming from.
I am grateful to all other noble Lords who spoke on this issue, and I understand the interest in the integrated care boards’ power to disclose information that is personal data. As the noble Lord, Lord Hunt, mentioned, public trust is essential in this and individuals’ data will be used lawfully and with respect, and held securely with the right safeguards in place. It will need to be proportionate, transparent and subject to individuals’ rights to access and correct information in use.
Let me further explain how we will make sure this happens. I assure noble Lords that the clause already restricts integrated care boards’ powers to disclose information by limiting these to the specific circumstances set out in the clause. Further, all use of personal data is subject to data protection legislation, including the UK general data protection regulation and the Data Protection Act 2018. This legislation provides several key protections and safeguards for the use of an individual’s data, including strict rules and key data-protection principles for the sharing of personal data.
Under the UK GDPR, health data has to be treated as a special category. This data requires additional protections due to its obvious sensitivity. For this type of data to be lawfully processed, a further condition must be met, in addition to identifying a lawful basis, as set out in the GDPR and the Data Protection Act.
This data protection legislation applies to the use of all personal data and provides robust safeguards in relation to information and disclosure. Importantly, there are additional protections on the use of health data, including the common-law duty of confidentiality, along with the role of the National Data Guardian, who advises and challenges the health and care system to help ensure that the public’s confidential information is safeguarded securely and used properly. As the noble Lord, Lord Hunt, mentioned, there are also the Caldicott principles; there are seven of these, which I am sure noble Lords are aware of, so I will not go through them all now. They provide guidance to health and care organisations on the use of confidential information. Along with this, there is also the national data opt-out.
I remind the Committee that new Section 14Z61 will apply, which provides when an ICB may disclose information obtained by it in the exercising of its functions. I emphasise that maintaining trust that healthcare data is being used properly is paramount. Individuals’ data will be used lawfully and with respect, held securely and have the right safeguards in place. None of the changes we are making will remove the duties of organisations to comply with the requirement of data protection legislation. Along with that, we are working with the Home Office to ensure that the protection and confidentiality of patient information is upheld within the Police, Crime, Sentencing and Courts Bill. Appropriate safeguards are in place and the Bill makes it clear that information can be shared only in accordance with data protection laws.
I am concerned that this amendment could cut across the different pieces of relevant legislation, preventing the ICB from effectively discharging its functions where it may be necessary to disclose information, which may include personal patient data. This would include investigating complaints, making safeguarding referrals for patients whose welfare is at risk, complying with court orders and assisting criminal investigations. It would also risk a confusing data-sharing system, with different rules applying to different organisations.
I know that my noble friend the Minister, the noble Lord, Lord Kamall, has agreed to talk about this further with the noble Lords, Lord Hunt and Lord Clement-Jones. He wants to meet civil liberties organisations, along with them, to discuss this subject further. However, I regret that the Government cannot accept this amendment. I hope that I have given the noble Lord some reassurance and that he will feel able to withdraw the amendment.
My Lords, I am of course grateful to the noble Baroness but I am not sure that she has entirely dealt with the concerns expressed. Because the noble Baroness, Lady Brinton, referred a lot to the GMC, I should just say that, although I am a member of its board, I am not acting here on behalf of the GMC at all.
The noble Lord, Lord Clement-Jones, and I signed the amendment and we both start from the basis of supporting digital transformation in the NHS, but we have always seen that it has to go hand in hand with the safeguards. That is why this debate is so important. We have heard powerful interventions from the noble Baronesses, Lady Brinton and Lady Harris, about why the police Bill had to be amended in relation to police access to patient information. The noble Baroness, Lady Finlay, referred to the issues for clinicians if they did not feel that the integrity of the patient confidentiality system was sufficiently safeguarded.
The Minister has basically said that we need not worry, because the NHS will only deal with information lawfully, and she went through some of the protections, including the fact that in the Bill there are conditions before the integrated care board can release the information. She referred to the data protection legislation, the GDPR, the special category given to health data about patients and the Caldicott principles. She went on to say essentially that my amendment would cause problems, because it would get in the way of legitimate information being given by the ICB, which might have an impact on patient care quality.
I do not pretend that my amendment is perfect in any way; I have always seen it as a probing amendment. But my concerns remain, and the contrast between the conditions put into the police Bill as compared with the health Bill seem, on the face of it, puzzling and need to be explored further. The Minister has kindly offered me a meeting. I hope that the noble Baronesses, Lady Brinton and Lady Harris, and perhaps the noble Baroness, Lady Finlay, could also be invited, because they clearly have insights into this. But I am grateful for the offer of the meeting. Obviously we will want to return to this on Report. In the meantime, I beg leave to withdraw the amendment.
Amendment 145 withdrawn.
Clause 20 agreed.
Amendment 146 not moved.
Clause 21: Integrated care partnerships and strategies
147: Clause 21, page 29, line 19, at end insert—
“(ba) members appointed by each of the local medical, dental, pharmaceutical and optical Committees, and”Member’s explanatory statement
This amendment would ensure that primary care professions would have mandated roles within Integrated Care Partnerships with a member appointed by each of the practitioner committees.
My Lords, Amendment 147 concerns the establishment of integrated care partnerships. Although the amendment is specifically about the membership of ICPs, I think that it is appropriate that I comment more generally on ICPs and their role. As I see it, the proposals on integrated care partnerships can be seen as an attempt to try to bind the NHS more closely into a wider system that delivers much wider services contributing to care and well-being.
Particularly at issue is the relationship between the NHS and its partner local authorities. If there is to be a genuine generational shift in thinking that moves the NHS from being a sickness service to one that contributes to the overall well-being of the public, that must be welcomed. Of course, there is a lot to do. At the heart of the issue must be who decides how the money is spent. Who sets the priorities and allocates funding down to place or to service line? If it is just the NHS itself through integrated care boards, that will not work. We have to widen the decision-making to ensure that other voices are heard.
What is missing is some assurance that integrated care partnerships are to have some focus not just on wider well-being but on the need to reduce inequalities and to leverage maximum social value for the area covered. Here, the skeletal nature of the Bill once again gives rise to many more questions than it answers. How are integrated care partnerships to be performance-managed? Will there be an executive? Where will the funding come from? Can the ICP actually deliver any services? Could ICPs be the hub for shared services across the NHS and local authorities?
We have so far heard very little about ICPs; there has been much more emphasis on integrated care boards. Many noble Lords have remarked that the Bill is too focused on the NHS. It is clear that, so far, much energy has been put into the establishment of ICBs and much less into the establishment of integrated care partnerships, which are due to be set up jointly between the NHS and the relevant local authority or authorities. That shows that the building blocks are flawed, because essentially local authorities should have been equal partners in the establishment of integrated care boards. If this was really an integrated Bill about the NHS and adult social care, surely local authorities would be equal partners with the integrated care partnerships on the integrated care boards.
I do not want to go over old ground, but the very fact that NHS England is excluding local authority councillors from the integrated care boards means that it does not want a serious NHS contribution on ICBs from local authorities. I can only take that as the reason for wanting to exclude local authority councillors.
Finally, I will make a general comment about ICPs. The noble Lord, Lord Lansley, raised this earlier. I fail to understand why health and well-being boards are continuing in parallel with the integrated care partnerships. I hope that we might at some stage get an explanation.
That brings me to my amendment. I have concerns about the neglect of primary care and I think that local representative committees have been an important part of the NHS since its foundation. I see no reason why they cannot be assured of some kind of presence on the new integrated care partnerships.
We had a very good debate last week, led by the noble Lord, Lord Crisp, on the role of primary care generally in these arrangements. The Minister said that it was important to consult the relevant primary care local representative committees, and that was why there was a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts considered appropriate when preparing the forward plan. But underlying my amendment is a concern expressed by the noble Lord, Lord Warner, who on Thursday asked whether the Minister was aware that the influence on key decision-making in the NHS was diminishing for primary care in general and GPs in particular.
In response, the Minister was clearly sympathetic to making sure that primary care was better represented and not dominated by acute trusts. He said that he was open to further discussions in this area and I hope that he will extend those discussions to the membership of ICPs as much as integrated care boards.
The Minister may say that ICP membership is best left to the local level, but I do not think that that is sufficient. We are fully entitled to agree the framework of the new arrangements. Primary care is at risk of being marginalised and that cannot be left to local discretion. I beg to move.
My Lords, as the noble Lord, Lord Hunt, said, Clause 21 is about representation on the integrated care partnerships, and new Section 116ZA specifies who should be on the committee of the partnership. The Bill currently specifies that one member of the ICP should be appointed by the ICB and one by each of the local authorities. The partnership is also free to appoint others. My Amendment 148 requires that one of these additional members must have responsibility for public health—and in that I include public mental health—and one must demonstrate that he or she can represent local voluntary organisations.
It is tempting in a Bill such as this to assume that all the members of these very influential committees should be from the major health organisations or local authorities in the area. However, there are many small community organisations run by charities or not-for-profit groups that play a very valuable role in providing services to local communities in a very cost-effective manner. Unless they are represented at ICP level, it is quite possible that their survival will be threatened by the new arrangements—and we heard in previous debates that they already do feel threatened. I am sure that the Government do not want that.
Similarly, public health has a major role to play in addressing many of the preventable diseases that contribute to health inequalities—and it looks after the tracing of communicative diseases. We saw the value of that recently when it was a great deal more effective than the national test and trace service at tracing the contacts of Covid-positive patients.
So, the work of both groups is very cost effective. If the ICB and the ICP are to use their resources efficiently and fulfil their duties to level up health inequalities, it is important that both groups are represented on the integrated care partnership. I echo the comments from the noble Lord, Lord Hunt: the Bill is quiet on the structure of and representation on the integrated health partnership. Given the duties that it is being asked to perform, it is perfectly reasonable for us to suggest that some of those important duties are properly covered in representation.
My Lords, in speaking in support of my Amendment 150, the issue is simple. We have much to learn about ICPs; I associate myself with the remarks of my noble friend Lord Hunt.
My proposal is that the rules determining the membership of ICPs should be consistent with the rules for membership of ICBs. As the Committee will be aware, it has been agreed, with the amendment made in the House of Commons, that ICBs will not and cannot be controlled by the private sector, in any way. I believe that the Health Minister, Edward Argar, made the point of principle clear when speaking during the Commons Report stage. He said that
“ICBs will not and cannot be controlled in any way by the private sector, as NHS-accountable bodies guided by the NHS constitution and with NHS values at their heart.”
Let us just remind ourselves that the requirement added by the Government to Schedule 2 is that an ICB’s constitution “must prohibit” a candidate being appointed to it if the person making the appointment considers, in the Government’s words in the amendment,
“that the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise.”—[Official Report, Commons, 22/11/21; cols. 119-61.]
We might not agree with the wording adopted by the Government, as previously discussed, but the principle is accepted on all sides.
So, as with ICBs, we should have a parallel provision for ICPs. In this, I am simply following what the Minister said in relation to ICBs: he wanted
“to put the matter even further beyond doubt.”—[Official Report, Commons, 22/11/21; col. 116.]
I emphasise “even further”. The debate here is not really about the precise wording of any amendment; it is about the principle of extending to ICPs the same protection that, as has already been agreed, should be extended to ICBs.
I look forward to the Minister’s reply. It is possible that, given the way in which ICPs are appointed—on the one hand, by ICBs, which are already protected by the Government’s amendment to Schedule 2, and on the other hand, by local authorities—it might be suggested that the issue simply does not arise and that protection is already there. However, if only to put the matter even further beyond doubt, why not accept my amendment?
My Lords, my noble friend Lord Hunt and the noble Baroness, Lady Walmsley, started what I hoped was going to be a discussion about ICPs.
My first question is this: who was consulted on the structure, membership and role of ICPs? This question has hung over all our debates from the beginning. The Minister has said several times that this is what the NHS wants—well, which bit of the NHS? Who was consulted? As far as we can see, in the role proposed in the Bill, it is not at all clear who was consulted on how ICPs should operate. Indeed, in a previous debate, we asked how this will work with the role of health and well-being boards. That has still not been answered. It is not at all clear why both things are needed; that is the first point. My noble friend Lord Hunt is right that, at the moment, the Bill raises more questions than it answers.
In particular, the idea that local councillors cannot be members is ridiculous and slightly offensive, because the role of the ICPs is to discuss strategy and local health infrastructure and delivery. Their role is absolutely vital.
My noble friend raises a very important point, because councillors can presumably go on integrated care partnerships and health and well-being boards but cannot go on the integrated care boards—but one of their officers can. What is the logic? Can my noble friend help me? So far the Government have given no answer whatever as to why. I know I am going on about this, but it is a fundamental issue: why are local authority councillors not seen as core partners on integrated care? It makes a mockery of the integration. There is no integration: they are setting up two separate boards. I do not know why they are not setting up one integrated board to cover the NHS and the partnership. It defies understanding. Why have they come up with this complicated arrangement and are continuing with health and well-being boards? Can my noble friend help me?
I certainly cannot help my noble friend, but I live in hope that the Minister can. It smacks of a fix. The Minister might not be prepared to say on the Floor of the House what exactly the fix was between the various bits of NHS England and various bits and other parts of the machinery. I suspect that the noble Lord, Lord Lansley, might know better than the rest of us what that fix was.
I will comment on my noble friend Lord Davies’s amendment. The problem with it is that, as the ICPs are proposed in the Bill at the moment, they will not be spending any money or commissioning services. It is also important that they include the various important parts of our local health delivery systems, including pharmacists, dentists, GPs, social enterprises and the voluntary sector. As I read it, this amendment would exclude hospices, for example—which would be a ridiculous thing to do. So my noble friend might want to rethink that amendment, because it does not necessarily serve the intended interests of the ICPs.
I thank all noble Lords, especially the noble Lord, Lord Hunt, for the points they have raised. ICPs will play an important role in co-ordinating services, planning in a way that improves population health and reduces inequalities between different groups. It is right that we consider the best conditions for their success. I was asked where the idea for ICPs came from. It originated from the Local Government Association. We have had extensive consultation with both the LGA and NHS England. To be clear, councillors can sit on ICPs.
They were. Good. I got the answer just in time.
I will turn to Amendment 147, which would mandate a role for a member drawn from each area of primary care. With all amendments relating to the ICP membership, we want to be careful to give space for local areas to find a model of membership that works best for them. As the noble Lord, Lord Stevens of Birmingham, raised at Second Reading, it is right that in a country as large and diverse as ours, one size will not fit all. Therefore, it is right that local areas should be able to determine the model and membership that best represent their area.
We fully expect primary care professionals to be involved in the work of ICPs. Each partnership will need to involve a wide range of organisations and representatives from across the system, including professionals from primary medical, dental, pharmaceutical and optical backgrounds as they prepare their strategy. The department has published a draft list of representatives for ICPs to consider involving, which includes clinical and professional experts, including those from medical, dental, pharmaceutical and ophthalmic settings. The mechanism of how this is done will be down to local discretion. For example, one ICP may wish to formally appoint certain members, whereas a neighbouring ICP may wish to have an extensive range of consultees, and a third may decide to invite primary care representatives to join a subcommittee instead. We believe it is right that local areas are able to determine the model of partnership that best works for them, and this amendment would prevent that from happening.
A similar argument applies to Amendment 148. While we welcome the contribution of directors of public health and the voluntary, charity and social enterprise sector, I do think that we risk limiting the flexibility of ICPs. We expect public health experts to play a significant role, especially given their role in developing the joint strategic needs assessments that are crucial to guiding all planning, and their role in supporting, informing and guiding approaches to population health management.
Similarly, we expect appropriate representation from the voluntary, charity and social enterprise sectors, which will be able to contribute in respect of a number of different interests and perspectives. A number of noble Lords have spoken very eloquently about the reasons we should involve these sectors. We believe it would not be prudent, for example, to suggest that it may be appropriate for only one person to represent the local voluntary sector on a partnership, given the diversity of their involvement in health and social care.
I turn to Amendment 150, tabled by the noble Lord, Lord Davies of Brixton, and I also thank the noble Baroness, Lady Thornton, for her advice on that. I appreciate that the noble Lord might want to prevent anyone who works for, represents, or has a financial interest in a private health and care company, from being a member of an ICP. However, I would draw the noble Lord’s attention specifically to the recent experience of coronavirus, which showed that independent and voluntary providers were a vital part of the health and care picture. This amendment could exclude a significant part of the health and care sector, as the noble Baroness, Lady Thornton, rightly said. Given their scale and the central role they play, adult social care providers in particular would be potentially useful members of an ICP. It also risks leaving out, for example, dentists, pharmacists, opticians and many others working in primary care, and doctors other than GPs who work both in the NHS and privately.
We expect every ICP to have robust measures to ensure that formal conflicts of interest are managed carefully and transparently. It is also important to note that ICPs, as the noble Baroness, Lady Thornton, says, are not commissioners, and so will not be making decisions on the allocation of funds. Fundamentally, the ICP is working solely for the interests of people in the area. The experience of the health and well-being boards is helpful here, as they have similar flexibility in membership, and there have not been significant issues with conflicts of interest as they have developed their plans. We really expect the ICP strategy to be rooted in the people and communities they serve, and to be directly informed by the health and well-being boards and the joint strategic needs assessments. We are refreshing the health and well-being boards’ guidance to ensure that there are strong foundations in place at neighbourhood levels that the ICP can consult and build on.
Having said this, I thank noble Lords for their contributions on this important matter. However, as I have explained, we believe that these amendments run contrary to the principles of flexibility and subsidiarity that the Bill is based on, and therefore I hope that noble Lords will not press them.
I am grateful to the Minister. First, I thank my noble friend Lord Davies for his amendment. I think, notwithstanding what the Minister said about some of the technical details, the principle that he put forward is absolutely right: clearly, the consistency with ICBs that he mentioned is really important. I am also very sympathetic with the noble Baroness, Lady Walmsley, and her amendment on the importance of public health and voluntary organisations.
We come here to the principle that some of us continue to be puzzled by the architecture we see before us. The Minister says that this was consulted on and the Local Government Association is fine and dandy about it but, with respect, that is not sufficient in terms of your Lordships and the rigour and scrutiny that we need to put into this legislation. Frankly, as my noble friend Lady Thornton suggests, it looks much more like a fix between representative institutions to preserve the current arrangements as much as possible.
I remain somewhat confused about the structure. The Minister said that health and well-being boards will feed into ICPs, but why? Think about what he said about the role of integrated care partnerships; it sounded to me like the role of the health and well-being boards. I just do not understand the differences. I understand that, in some parts of the country where the ICP will cover a lot of local authorities, there is an argument that you should continue with health and well-being boards at the local level, but I do not see why they cannot be sub-committees of the integrated care partnerships; the Minister referred to that. Why on earth do we in Birmingham need a health and well-being board as well as an ICP? I simply do not understand it.
If the Minister believes that this should all be set out at the local level, why can people decide locally not to have a health and well-being board? He may say, “Ah no, you need a framework”. Our argument is that you need a framework in relation to membership as well. The compromise here might be to set out in legislation, as we will want to do, certain conditions around local governance and then leave it up to the local level. In relation to ICPs, however, we cannot leave it as it is. Having said that, I beg leave to withdraw my amendment.
Amendment 147 withdrawn.
Amendments 148 to 153 not moved.
154: Clause 21, page 30, line 1, leave out “may” and insert “must”
Member’s explanatory statement
This amendment and others to Clause 21 and Schedule 4 in the name of Lord Farmer would specify that integrated care partnerships consider how to integrate family help services into the provision of health and social care services, as relationships are recognised by research as a 'health asset'. ‘Family help’ is defined in accordance with the Independent Care Review’s starting definition. ‘Family hubs’ are named as key potential sites for delivering integrated paediatric health and family help.
My Lords, I will speak to all four amendments in this group in my name. I remind the Committee that I have already declared my interests, especially as regards integrated care and family hubs.
In Committee in the other place, the Minister, my honourable friend Edward Argar, recognised
“that the system has been calling for two different and important types of integration: integration within and across the NHS to deliver healthcare services within a defined locality, and integration between the NHS and local government and wider partners.”
He went on to say:
“The ICP is intended to bring together health, social care and public health to develop a strategy to address the needs of the area also covered by the integrated care board. If”—
I emphasise “if”—
“the ICP wants to go further, it can also involve representatives from the wider system, where appropriate, such as voluntary and community groups, and social care or housing providers. That will be up to the ICP, and we will welcome locally driven innovation to reflect local circumstances.”—[Official Report, Commons, Health and Care Bill Committee, 16/9/21; col. 332.]
I, too, welcome locally driven innovation to reflect local circumstances, as I will emphasise shortly. However, I am genuinely mystified as to why integration between the NHS and local government and wider partners is voluntaristic in the Bill. My Amendment 154 would exchange “may” for “must” and require integrated care partnerships to include in their strategy a statement of how health-related services could be more closely integrated with health and social care.
My Amendment 155 would specify “family help” as a required subset of health-related services, access to which would include through family hubs. This wording avoids prescribing hubs as the sole means of delivery of and access to services. That said, I have been talking to seasoned health leaders in the Newcastle area who say that the current system is simply not working for vulnerable families. Parents need help navigating what is out there; the community-based access point of a family hub would be a game-changer. The Supporting Families programme, appropriately based in the Department for Levelling Up, Housing and Communities, recommends hubs in its systems guide for this reason. Moreover, the Government have invested significantly—around £130 million to 2024-25 —to develop this badly needed infrastructure and fulfil their 2019 manifesto promise to
“champion Family Hubs to serve vulnerable families with the intensive, integrated support they need to care for children—from the early years and throughout their lives.”
The second action area in the DHSC’s The Best Start for Life strategy ensures that families have access to the support they need through a welcoming family hub. As I have already said in this Committee, as well as perinatal and early years healthcare, local authorities in Essex are delivering more extensive paediatric health services to meet the same need for co-ordination identified in Newcastle. Continence, speech and language, and allergy services, among others, are provided in community settings close to families through their integrated family hubs.
Many such health needs are psychosocial and practical. Addressing them needs a whole-family approach, often through early help commissioned by local authorities. This is what integration should look like. I have always insisted that the design of these family hubs should be flexibly and locally determined, not centrally imposed. but flexibility must be geared towards meeting families’ and children’s needs. One key lesson from children’s centres was that health should be fully integrated from the start.
How that is done should be locally decided, including through consultation with local people. Also, the hub is not the place where everything happens—that would need a vast building—but it is the place through which families can access everything. Other government departments are joining up, integrating their policy goals with those of health, by actively citing the delivery of their priorities in and through family hubs. I could give many examples but, for the sake of time, I will limit myself to a couple.
The Department for Work and Pensions is keen to run its reducing parental conflict programme in family hubs, making access to couple relationship support far easier and less stigmatising for low-income families. The Ministry of Justice is funding a pilot family hub in Bournemouth, which will include a specialist family justice programme that links closely to the family court. Separating parents will be encouraged, early in the process, to use the family hub rather than go down a costly and adversarial court route.
The lack of community-based support is one of the reasons why the promise of the 1989 Children Act has not yet been fully realised, as many pointed out in publications to mark its recent 30-year anniversary. I will return to this. I need to keep emphasising that family help, particularly with relationships, is not at all niche but is erroneously treated as such, hence the need for it to be specified in the Bill. The social determinants of health have already been referred to by other noble Lords, and family-level factors in particular can make or break clinical efforts by healthcare professionals. The US Centers for Disease Control and Prevention says that children need “safe, stable, nurturing relationships” to thrive, and UK research, including from UCL, recognises healthy, well-functioning relationships as a “health asset”.
With my Amendments 158 and 167, “family help” in the Bill would mean
“services which improve children’s lives through supporting the family unit and strengthening family relationships to enable children to thrive and keep families together”.
I quote, but in a heavily truncated form, the independent care review’s starting definition, which can be read in its entirety in lead reviewer Josh MacAlister’s The Case for Change. He teases apart how this phrase differs from “family support” in local authority usage, and refers back to Professor Eileen Munro’s 2011 social work reform recommendations and the 2003 and 2009 reviews by the noble Lord, Lord Laming. Both emphasise the need for easily accessible, early help for families if outcomes for children are to improve markedly and tragedies are to be averted in more cases.
I would go even further back than that. In the earliest days of the welfare state, it was recognised that poor family functioning threatens the effectiveness of its other pillars. The ability of health, education and state financial support for families to transform the life chances of children is fundamentally undermined if parents fail to nurture their children emotionally and materially. In 1949, in acknowledgement of this uncomfortable truth, Michael Young, one of the architects of the welfare state, called for child welfare centres. These would, he said, fulfil Beveridge’s principle of the preservation of parental responsibility and deal with the emotional cost to children of high post-war levels of family breakdown.
These began to emerge as family centres in the 1980s. Many were opened by voluntary organisations such as the National Children’s Home, now Action for Children, and many had significant local authority and social services involvement. They helped parents of children of all ages, mainly in disadvantaged areas, ideally before and to prevent the involvement of social services. Family centres were included in legislation—symbolically, given today’s Bill—as part of the then Department of Health and Social Security’s contribution to the Children Act 1989. As family help was a health emphasis in that landmark law, a health Bill is a highly appropriate updating vehicle.
As an aside, in 1994, the National Audit Office, then the Audit Commission, proposed a central role for family centres in developing a more proactive partnership with parents. The commission reported that Section 27 of the 1989 Children Act—the duty to co-operate—was still not progressing well, and emphasised the need for a single point of entry to a range of multiagency support services. Plus ça change, plus c’est la même chose. We can wait until family hubs spread slowly across the country before acknowledging the need for them in legislation, or we can update the Children Act by making it reflect more accurately where more than 30 years of policy-making since then have brought us to.
There is an argument that family hubs are as yet untested, hence the Government funding rollout in only 75 local authorities. However, as I said, the principles that they are based on rest on decades of learning about what families need. We can, and must, refine the model, but hubs—somewhere families can go where someone will be able to help—are a vital missing pillar of our welfare state. I believe that, in time, they will be as indispensable as primary care and schools, because they make such a valuable contribution to their successful functioning.
As it currently stands, the Children Act 1989 is out of date in how it refers to family help in infrastructure. Paragraph 9 of Schedule 2 states that local authorities
“shall provide such family centres as they consider appropriate in relation to children within their area.”
The name “family centres” is too suggestive of a single building, while the phrase “family hub” expresses that this is an access point. It is descriptive, not prescriptive. Many family hubs refer to themselves as children’s centres. Others, such as those in Doncaster, want to shift the culture away from an exclusive focus on the early years, so they do call themselves family hubs.
Moreover, other aspects of paragraph 9 are inappropriate now. Paragraph (c), for example, refers to the family centre being a place where someone will be provided with accommodation while receiving advice, guidance or counselling. That does not happen, hence my rewording to reflect better what the hubs actually do without being overdeterminative. Local needs decided, as I said, in consultation with those who will use them, as well as in the context of integrated care partnership discussions, must be the priority.
Finally, it is with humility that I propose amending the Children Act 1989. Internationally, it is highly respected and much copied. However, the intention of my amendments is to fulfil its key principles: the emphasis on prevention, on keeping children with their families wherever possible and on ensuring that help is available for parents who struggle to nurture their children or provide a safe and stable environment in which they can thrive. I commend these amendments to the Committee.
My Lords, I lend my voice to this important group of amendments. I will explain very briefly why family hubs are so important to many of the big themes that we have been discussing in the Bill so far: prevention, early help and integration in particular.
Family hubs have a very important role to play in improving early intervention services and helping with integration and data sharing, as we discussed earlier, among public services and the voluntary sector. Importantly, as the noble Lord, Lord Farmer, explained, the range of services available in family hubs often includes important services such as children’s health services, which are better delivered in a community setting and integrated with other family health services, rather than delivered in a hospital or somewhere that has a much greater focus on acute care.
The Public Services Committee, on which I served until very recently, produced what I thought was a very important report on vulnerable children recently. It put a national rollout of family hubs at the very core of a national strategy for child vulnerability, proposing that the most deprived communities be prioritised in the early stages of any such expansion. In our report, we set out what fundamental characteristics we thought should be at the heart of every family hub, including employing full-time family co-ordinators, offering addiction and domestic violence services, providing support for parents with poor mental health and organising parenting classes. I say that, because I hope that it illustrates the point I made about integration between health services and broader family support services.
I had the privilege as a committee member—I think the noble Lord, Lord Hunt, was with me—to visit Westminster family hub. I sat down and talked to a young mother with two young children who had a lot of very difficult issues that they were dealing with. The mother explained how the help and support she was getting through the family hub, both with her health issues and those of her children, as well as a wider range of issues, were helping her to keep her head above water. I was so impressed with that family hub and the help and support it was giving, and the way it was integrating statutory services and the voluntary sector.
I will make two other brief but important points. First, family hubs will be working with children from birth to 19. I see that as important, because families face challenges at any time, not just when children are very young, and focusing solely on early years and not helping families with older children does not have the same sort of holistic approach. So it is extremely helpful if, during early years, families build up these trusted relationships with people they meet in family support hubs of the type I have described, rather than sever that relationship when the child reaches the age of five. Parents can continue to contact a familiar team and access that trusted source of information and advice.
My final point to emphasise is the importance of family relationships and relationship support. One key thing about family hubs that is very important is the work they do to prioritise help with relationships—it might be couple relationships, parent-child relationships or even sibling relationships. By being able to deliver counselling and various other programmes to address some of the conflict and breakdown that often affects families in these difficult situations, they often help avoid the whole family reaching crisis point, particularly to the extent that parents have to access the courts to resolve disputes. For all these reasons, I very much support the amendments.
My Lords, I support my noble friend Lord Farmer. I declare my interest as a non-executive member of the board of Ofsted. I apologise for not being able to speak at Second Reading for my own family reasons. I echo everything that the noble Baroness, Lady Tyler, said. It was a real pleasure to serve with her on the Public Services Committee.
I will praise the Government first, which is always wise. They are showing great commitment to family hubs and I believe that they are committed to the rollout. What concerned me when the committee took evidence from certain members of the Government was a sense of a lack of urgency. Everybody agreed that this was a brilliant idea, but different people from different departments had different ideas about how they should work.
We also took evidence from families, in private and in public. The stories we heard over and again were, as others have alluded to, that, “This could have been prevented if it had been addressed in a joined-up way”. We particularly heard from young children, “I had to tell my story over and again.” Imagine the trauma. This could have been prevented under a different model. These situations did not have to happen.
We have the building blocks to make sure that these situations do not happen, but I do not think the legislative framework is in place to help us to address that. For that reason, I am persuaded by my noble friend Lord Farmer and I am happy to support his amendment.
My Lords, I am very supportive of what the noble Lord, Lord Farmer, said. My colleagues and I have been in this space for 37 years and we have built rather a lot of things in it. It has been very interesting to watch what happened in east London, when this new scheme from a new Government arrived in the middle of a group of communities that already had well-established relationships with very vulnerable families, with a whole range of opportunities emerging. I am sure it was unintentional—it is part of the danger of being overinfluenced by the idea that local authorities will sort this stuff out in the same old usual way that they have tried to before—but it was very disruptive for the social enterprise sector, which was already doing this stuff very effectively, with all the numbers to show it. I will not go into the detail now, but when you look at the detail of what actually happened, the present facilities cost £100,000 more than those being delivered by the social enterprise sector.
These ideas are really important. I am happy to take the noble Lord into this in a lot more detail. I encourage him to spend more time in the detail in some real places to look at the unintended consequences of what happens when new government programmes arrive in communities, with the best will in the world, with an overconfidence in what they think the state can deliver. I am very happy to have a further conversation with the noble Lord, but the detail of the long-term relationships with these families really matters.
My Lords, briefly, I support these amendments, partly from my own experience as a director of social services and Children’s Commissioner, but also because of the points that the noble Lord, Lord Mawson, raised.
I have three key points from history. As a director of social services in the 1980s and 1990s, I offloaded my local authority family centres to the voluntary sector because a survey of parents suggested that they would not come to a service run by the organisation that was likely to take away their children. That was a perfectly rational position and we should listen to what people say about that.
Fast forward to 1999 and parenting orders under the Crime and Disorder Act. We find that compulsion brought parents to the party but, when they actually attended, they found—not so much men but women—that they were being treated and given skills that enabled them to manage children, largely teenage children, much better than they had been. It was a great shame that we used the criminal justice system to bring people to a parenting tuition experience that they should have been given many years before.
This is a final point from history. Michael Gove made me—this was madness on my part, as well as his—children’s commissioner for the failing Birmingham City Council children’s services. Ofsted report after Ofsted report had been telling them of their deficiencies. We found that the group they could not handle, for which they had no effective responses, was teenagers. If we are to make any progress in helping people to help the family unit, we need to address the support given to parents during the teenage years, because they are really struggling, particularly mums.
My Lords, I will briefly say that I am extremely optimistic about family hubs. They answer the challenge to solve the complexity around integration incredibly well. My noble friend Lord Farmer made the point that one cannot think of a better example of what integration looks like than family hubs. The noble Baroness, Lady Tyler, talked clearly and persuasively about the journey they have been on.
My noble friend has made the case for these amendments. Other noble Lords have made the case for updating the legislative framework. I ask the Minister to look carefully at what can be done to bring these laws up to date so that family hubs can thrive, as I believe they will.
My Lords, I am grateful to the noble Lord, Lord Farmer, for introducing this important debate and to other noble Lords who have supported the amendments before us and spoken about how we can improve the support that families will receive through this Bill. As the Family Hubs Network rightly observes,
“prevention is simply listed in the Bill as one of several commissioning requirements of ICBs with no broad mention of children’s health”.
This group of amendments gives us the opportunity to sharpen this.
As we have heard, the issues that families face, in whatever form or shape, do not exist in isolation. In addition to the impact of financial, housing, social and other pressures, the physical and mental health of a child or young person affects the physical and mental health of not just their parents, but their wider family, and vice versa. It makes common sense to facilitate a healthcare system that is designed and resourced to actively take a holistic approach to the many issues that face children and those who care for them.
I cannot help but feel that the points raised today are not new. We have the experience of Sure Start to show us how effective properly integrated family services can be. As the Institute for Fiscal Studies confirmed:
“By bringing together a wide range of early years services for children under 5, Sure Start centres dramatically improved children’s health even through their teenage years.”
Early investment is crucial.
I hope the Minister will be keen to embed change in this Bill to replicate the success that we saw through Sure Start. The first step towards doing this is to make sure that integrated care partnerships are properly required to consider how family help services can be thoroughly integrated into our health and care system, so that family members—no matter what form those families take—are seen as both individuals and groups who have an effect on each other.
I thank my noble friend Lord Farmer and all noble Lords who spoke about their experiences. The creation of integrated care boards represents a huge opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people.
Before I go into the specific amendments, I make it quite clear, as my noble friend said, that the Government set out in their manifesto a commitment to championing family hubs. We want to see them across the country, but at the same time we must give democratically elected councils the choice to shape how services are delivered, bearing in mind some of the points made by the noble Lords, Lord Mawson and Lord Warner, whom I thank for their experience on this.
The Government agree that it is vital to ensure that ICPs work closely with a range of organisations and services to consider the whole needs of a family when providing health and care support. In preparing the integrated care strategy, the integrated care partnership must involve local Healthwatch and the people who live or work in the area. We are working with NHS England and NHS Improvement on bespoke draft guidance, which will set out the measures that ICBs and ICPs should take to ensure they deliver for babies, children and young people. This will cover services that my noble friend considers part of family help.
In addition, the independent review of children’s social care is still considering its definition of “family help”, and the definition published in The Case for Change may well be further refined as a result of ongoing consultation. It would be inappropriate to define the term in legislation at this stage, pre-empting the full findings of the review and the Government’s response to it. Also, it is important that there should be a degree of local determination as to what should be included in the strategies of ICBs and ICPs. In order for them to deliver for their local populations, a permissive approach is critical.
On Amendment 167, we agree that family hubs are a wonderful innovation in service organisation and delivery for families. The great thing about them is how they emerged organically from local councils over the last decade. I pay tribute to my noble friend for the key role he has played in advocating family hubs and bringing this innovation to the heart of government. The Government strongly support and champion the move but we are clear that they have to be effective and successful—they need to be able to adapt to local needs and circumstances. They also need to be able to operate affordably, making use of a diverse range of local and central funding streams.
In both these regards, local democratically elected councils should hold the ultimate decision-making power over whether to adopt a family hub model and how it should function. As such, I regret that we cannot support the amendment, which would place too much prescription on the decisions and actions of local authorities and risk imposing significant new financial burdens. For this reason, I ask my noble friend to consider withdrawing his amendment.
My Lords, I thank the Minister for his rather disappointing reply and those who supported these amendments, particularly the noble Baroness, Lady Tyler, and my noble friend Lady Wyld, for giving such clear definition to the services and the advantages of family hubs. I take to heart the advice from the noble Lord, Lord Mawson, about unintended consequences. I would quite happily talk to him about this. I also take the point from the noble Lord, Lord Warner, that it is nought to 19, not nought to five. Families have so many problems with teenagers, as we see on the streets today, and family hubs can be a non-stigmatising place where help can be got.
I agree with the noble Baroness, Lady Merron, about Sure Start. In a way, I have always said that family hubs are building on Labour’s Sure Start centres. However, it is not nought to five but nought to 19—in fact, nought to 25 for children who come out of the care system, et cetera, with special needs.
There might be concern that my amendments attempt inappropriately to set in concrete the policy of family hubs when it is constantly progressing. However, the changes I have described are not just about bringing the latest policy idea into the Bill. Absent of these references to places where families know that they can access help and be connected to the full gamut of local services and support, the Bill will not reflect the overarching direction of travel. Their inclusion requires health to be fully on board, which has not happened in the past, to the detriment of the success of previous policies.
My amendments represent unfinished business from the founding of the welfare state. The family help that they mandate is also essential to the success of the levelling-up agenda and the build back better agenda, which is what this Government will be judged on. I hope that I might be able to speak further with the Minister before Report but, in the meantime, I beg leave to withdraw my amendment.
Amendment 154 withdrawn.
Amendments 155 to 159 not moved.
Clause 21 agreed.
Clause 22: NHS England’s financial responsibilities
159A: Clause 22, page 32, line 29, at end insert—
“223CZA Financial duties of NHS England: the principle of subsidiarity(1) NHS England must exercise its functions in accordance with the principle of subsidiarity, and must promote the principle throughout the integrated care system in particular by ensuring that integrated care boards observe the principle.(2) The principle of subsidiarity is that responsibility for deciding how and where to use resources is as far as possible to be delegated to local areas in order to meet local needs and to promote local groups working collaboratively.(3) In doing so, the process and timing of procurement should take account of the benefits of long-term relationships and stable partnerships in delivering sustainable integrated solutions to local health issues.”
My Lords, I have listened carefully to the debate taking place in Committee over the last few weeks with great interest and noted the growing consensus that now exists across this Chamber for transformation and change. These debates have shown the House at its best. It is clear that the Government now have before them an opportunity to transform not only the NHS, its culture and its ways of working but the public sector, much of which is not fit for purpose in this century. People inside and outside these systems know this—listen to those who are leaving for early retirement.
As well as listening, I have been talking to colleagues around the country: those inside the NHS systems; those responsible for the development of the ICSs; and those outside who seek to transform the health and care world and who wish to partner with these systems. I will share a few concerns that I have heard, because they relate to my two amendments, Amendment 159A and 210A.
First, colleagues both inside and outside NHS systems have heard fine words from Governments before about change and transformation in health and care, but they are sceptical. They know that the Civil Service and government systems and mindsets are not fully fit for purpose. The Civil Service’s culture and mindset need to transform; it needs to get interested in what is happening among young entrepreneurs in Bradford, for example. The voluntary and social enterprise sectors need the Government to go beyond fine words and deal with, for example, the situation that my colleagues at the Bromley by Bow Centre have to deal with every day as they navigate—as the noble Baroness, Lady Cumberlege, mentioned last week—41 different funding streams coming up the silos from the Treasury, at enormous cost and wastage of time, as they try to deliver integrated services. If we are to build a more integrated health and care programme, these practical issues are going to get worse—not just in east London but across the country—unless we address this now.
Many years ago, we had a secondee from the Treasury in Bromley who told us how all tax revenue was paid into one bank account. How much does it cost to then spread this out across 41 government departments and programmes, only for it all to be brought back together to address the multiple, complex and interlocking issues that somewhere like Bromley by Bow faces? How much cost does all this add? No one knows. Is it 20%, 30% or more? No wonder we have a productivity crises.
The Single Regeneration Budget programme was an early attempt, some years ago now, by the Civil Service and the Government to bring funding streams together. What lessons have been learned in government and the Treasury from it? I suspect there is no memory of this programme in the system.
There is also a danger of the NHS and public sector culture imposing itself on the voluntary and social enterprise sectors, as they try to innovate and generate new ways of working—what I call putting old men in new clothes. I have seen this in the housing association movement, which I was involved with in the very early days, and in what happened to children’s centres, which were launched in Bromley-by-Bow by a Labour Government, which then unwittingly undermined our integrated model and ways of working with local families.
My colleagues in parts of the country can already see the NHS centrally trying to impose its old processes on them as they innovate, at the very moment there needs to be a two-way street and real learning taking place. The centre needs to learn from the micro, from the innovation platforms we have created, not impose its outdated systems on them. Government needs now to show a clear resolve to transform the culture of the NHS or people will become even more cynical. The whole system and culture desperately needs change, and the way into this is via the micro and practical details.
Yes, it will take time, but first we must be clear about why we are taking these initial early steps and where we are trying to get to. There is a real danger of our Civil Service systems unwittingly deepening poor-quality outcomes and a dependency culture. The centre should see these innovation platforms as a place that can teach the centre, not the other way around. I declare my interests here. We need new behaviours from NHS England, not last-minute processes that want everything tomorrow. The macro needs to learn from the micro; the whole system needs to return to first principles and create an environment which encourages healthy communities.
Levelling up is surely about addressing the UK’s productivity gap, especially in marginalised communities, and one way of doing that is via a healthy and thriving population. It is also the only way to stop the NHS taking an ever-greater percentage of the UK’s GDP. I suggest health is now everybody’s business.
My two amendments fit within this mindset and suggest some first steps that could be taken along this road. Let me now deal with my first amendment, Amendment 159A. True subsidiarity cannot be achieved without delegation of resources and the authority to allocate in a way which will achieve the intended and agreed objectives. For example, systems may wish to ensure that discretionary local services such as community centres, community transport, struggling family support and meals on wheels should be prioritised and sustained ahead of further spend on health capacity, given their key role in supporting ongoing independence and social cohesion and preventing the need for health services.
Place systems may choose to pool delegated resources in order to commission collaborative services at scale, where they jointly agree that they are not best placed to provide such services, and such discussions are already taking place in mature systems. For example, in north-west Surrey we have agreed to jointly commission dermatology services across two place systems. The point is that delegation to place does not work against the development of services at a wider scale where that is appropriate, but the recognition of this needs to come from the place level.
True transformation—true to the spirit of the Bill and the long-term plan and to achieving the intended benefits of integration—cannot be achieved without the freedom to invest those resources in a way which can unlock long-term benefits. This may require speculative investment in some cases, as well as investment in preventive services which do not offer rapid returns but are essential to maintaining the ongoing sustainability of services. We would not expect any of this to be done without due diligence on the capability of place-based partnerships and appropriate levels of holding to account for achievement of improvements and results. The ICS will have a key role in not only ensuring that funds are delegated appropriately but supporting place-based systems to build the capability to manage delegated funds effectively.
We need to make leaps in how health services are now delivered through integrated services and offers to populations, by thinking radically about who can support people best, and in what way, to keep them healthy, look after them at home where possible and provide services which understand people as individuals and meet their needs holistically.
This degree of change in public health, prevention and provision of services needs innovative and broad-based collaborations and partnerships between organisations—health organisations, local authority organisations, VCSE and business—tailored to fit the needs of the place. These relationships are not quick to build; they take time and effort. The work takes years and the impact can be seen only through long-term relationships and stable partnerships. For this to succeed, the ICS will need to embrace the principle of subsidiarity, delegating meaningful responsibilities and accompanying budgetary responsibility to place level. This may mean that standard procurement cycles and processes do not immediately bring the outcomes that the Bill envisages. More innovative processes and timings may be needed to ensure that the benefits brought through long-term relationships and stable partnerships are given time to be achieved.
Let me now deal with Amendment 210A. In general, NHS bodies do not currently make best use of their local voluntary community, social enterprise and faith sectors when procuring services to achieve key health outcomes, especially in prevention and early intervention services. This is all well understood but, somehow, we never seem to get beyond one-off experiments or short-term, time-limited initiatives. By contrast, the best local authorities have been procuring and partnering with their VCFS for many years, though this has become more difficult with recent funding pressures. There is an opportunity, therefore, for health colleagues to learn from their local authority colleagues in the ICS on best practice in this regard.
With NHS vacancy rates at their highest levels, together with waiting lists for treatment, now is the time to take a whole-system approach and look more collaboratively across the local community. There is also a strong value-for-money argument. Simply waiting for people to become seriously ill, which is what is happening in practice at the moment with regard to many mental health services—but not by design—and could equally be applied to services for struggling families, leads to very poor outcomes and is very expensive. Using VCFS organisations and others, with a combination of staff and local volunteers to create a coherent health-oriented rather than illness-oriented approach, will pay dividends, but only if there is real intention and focus over a sustained period of time. This is a long-term play, not a quick win, but vital none the less.
Traditional models are not working for the groups which can offer most value. Local charities and social enterprises tend to be funded on a hand-to-mouth basis using grants, so most cannot permanently invest in their services. This is despite a huge growth in charitable giving from the public, directed in the main at the NHS.
In north-west Surrey, we are looking at how we can give similar prominence to local charities supporting areas of deprivation and communities in need, but more needs to be done to enable charities and voluntary sector groups to be assured of ongoing funding to provide core services. Keeping such VCS groups active is essential to achieve insight into the needs of communities. There are innovative approaches such as Tribe, a platform developed by a technology business- person, Richard Howells, simply because he had become so frustrated by the inabilities of the NHS and care services to deal with his own mother’s care needs. Richard did not write a research paper; he created a practical solution, which is pretty impressive. When he shared this practical solution with the NHS centrally, there was a lot of interest and fine words but, in actual detail, no follow through.
We now need to allow these insights at the most granular level to inform the commissioning and targeting of services. Without this, we will not be able effectively to respond to specific areas of inequality or health risks, leading to ill health and pressure on services. The existing models of voluntary sector support need to be developed to enable and promote micro- enterprise creation on a far greater scale. This both protects the quality of services and enables individuals to gain training, support and income. It has the potential to open up a currently untapped resource of care support, which is critical in places such as north-west Surrey, where community care staff vacancies run at around 40%.
Employment and volunteering are themselves key determinants of well-being. Place-based systems will wish to use their spending power to leverage this benefit and invest directly in local employment, where it can be demonstrated to be the most effective use of resources. In north-west Surrey, we have achieved a virtuous cycle of supporting furloughed airline workers during lockdown through recruiting them into the hospital workforce, supporting the delivery of services and well-being of clinical staff, and reducing the risk of those individuals developing physical or mental health problems through inactivity and stress.
I can see that I am being told that I am running out of time, but I need to share two final things about the digital world. I am sorry about this, but I think it is important.
Richard Howells, who I have mentioned, is a successful data engineering entrepreneur, who, as I said, found it hard to arrange care for his elderly mother. I suggest that the Government need to action the NHS to look in detail at what Richard Howells is doing. His project has recently been awarded £23 million in funding from UK Research and Innovation. A second data platform has been developed by Amir Hussain of Yeme Architects in Bradford. It uses the internet to get people off internally focused social media platforms and brings them together in communities to do things.
I tabled these amendments and have put this on the record because they are about the detail and practicality. The opportunity is there for transformation, but the worry out in our communities is: will this Government, like others before them, be serious about transformation or will it be about old men in new clothes?
I now call the noble Lord, Lord Howarth of Newport, who will be taking part remotely.
My Lords, I support the spirit of these amendments. The noble Lord, Lord Mawson, in his working life at Bromley-by-Bow and more recently in north-west Surrey, and in his very full speech, has demonstrated the significance to healthcare of the principle of subsidiarity, the freedom to innovate and the mobilisation of community resources. If ICSs are to mobilise the full power of place this must indeed be a governing principle.
Although there might be definitional issues to clarify, I particularly applaud the ambition expressed in Amendment 159A that resources should be used at local discretion to promote collaboration by local groups, and that the procurement processes should take account of the benefits of stable partnerships. How could anyone dissent from that? Yet, the experience of so many non-clinical and VCSE organisations is of chronic financial instability and of promising work being aborted because of policy discontinuity.
I will give one instance of damaging discontinuity of funding. The Alchemy Project used dance as a form of early intervention in psychosis. The project was developed jointly by Dance United, South London and Maudsley, and King’s College London. Two cohorts of participants were drawn from young people in south London boroughs where the rate of psychosis is very high. With no previous experience of dance, after four weeks they performed a specially commissioned piece at the Shaw Theatre and Sadler’s Wells. Academic evaluation demonstrated clinically significant improvements in well-being, communication, concentration and focus, trust in others and team working. The project helped participants to develop relationships with their peers and restore relationships with their families. The Alchemy Project had to be abandoned, however, when a fragile consortium of funders did not renew its funding. ICBs and ICPs will need to be less fickle and less prodigal, bolder in supporting innovation, and more consistent and farsighted in their relationships with their providers and communities.
My Lords, I also support these amendments. Earlier in Committee, I described the noble Lord, Lord Mawson, as
“a man of infinite resource and sagacity, an entrepreneur and … a great achiever”.—[Official Report, 18/1/22; col. 1575.]
I am sure that, if noble Lords are not convinced, these amendments will further endorse my description.
I now add that the noble Lord is a very determined reformer. He has told us how the present systems serving the public are not fit for purpose. The Government are trying through this Bill to remedy that through greater integration and other measures. It was Edmund Burke who said that, if you want to preserve something important, you need to be prepared to reform it. Our systems are important and need reforming.
Amendment 159A is about the financial duties of the NHS in England and solidarity. In the previous debate, I mentioned Bromley by Bow, as the noble Lords, Lord Mawson and Lord Howarth, said. Bromley by Bow was the forerunner of other imaginative, ground-breaking and huge entrepreneurial schemes in the north of England, London and Surrey. The examples are breathtaking but they cost energy, hard work, original thinking and money. It is sad that these scarce resources are dissipated by the convoluted systems that we, the nation and the Government impose on burgeoning and, at the beginning, fragile schemes. However, Bromley by Bow is not one of these. It is well established but not secure due to having to navigate 41 different funding schemes, as the noble Lord, Lord Mawson, said. Huge effort and wasted time are spent trying to integrate these schemes for the use of a single neighbourhood centre.
I strongly support Amendment 210A. The noble Lord is right: he paints a compelling picture of the future, which will be realised only if our public health, prevention and provision of services collaborate in partnership with local organisations. They understand the history, dynamics and strengths that permeate their local place—their neighbourhood. The noble Lord is also right that, to thrive, ICSs will have to embrace the principle of solidarity, which is the essence of a successful project; that includes the financial duties of NHS England.
I have lived in my community from the age of five. In another debate, I said that my father, a GP, knew his patients inside and out. I, too, know my villagers inside and out in a different way. I treasure the relationships I have made with local organisations. We fight for every shop and organisation that is threatened. We welcome newcomers. We have produced a pocket list of 45 organisations with a mantra on the front saying, “Newick”—my village—“is here for you”. It goes on to say that there is so much going on in our village and there is something for everyone, whether you would like a new hobby, to make new friends or just give something back to the community. Get active, get involved and get happy.
I strongly support Amendment 210A, which urges local providers in particular to be prioritised. I certainly support that. This is not about get-rich-quick developers, who have no regard for the nature of the community in which they are going to build, building bricks and mortar. In our village, we fight for employment, which is absolutely critical in local communities. It reduces traffic problems and helps to mitigate global warming. Above all, it goes some way to generating happy communities. It generates the Government’s intention to make place an important component of a stable community. Surely that is what we all want.
My Lords, we on these Benches said everything we needed to say on this matter in support of the noble Lord, Lord Mawson, when we had the substantial debate. I do not know when it was—last week, I think. These two amendments flow from that. We probably could have taken them then, but I am sure that the Minister will have useful things to say.
My Lords, we return to the very important theme of subsidiarity, to which the noble Lord, Lord Mawson, has brought us in both his amendments and his powerful speech, born of his immense experience in the real world.
I will begin with Amendment 159A, if I may. One of the main reasons for introducing this Bill was to ensure that existing collaboration and partnership working across the NHS, local authorities and other partners was built on and strengthened. This relates especially to the framing and monitoring of assessments and strategies. We intend for these assessments and strategies to be a central part of the decision-making of ICBs and local authorities. That is why we are extending an existing duty to ICBs and local authorities to have regard to the relevant local assessments and strategies. Furthermore, the integrated care board and local authorities will both be directly involved in the production of these strategies and assessments through their involvement with both the integrated care partnership and the health and well-being boards. As a result, they have a clear interest in the smooth working of the ICP.
More widely, there are already several mechanisms to ensure that ICBs and local authorities will have regard to the assessments and strategies being developed in their areas. First, health and well-being boards have the right to be consulted by ICBs and give NHS England and ICBs their opinion on whether the joint forward plans take account of the joint local health and well-being strategy. Likewise, as part of its annual assessment of ICBs, NHS England must consult each health and well-being board on how well the ICBs have implemented the relevant joint local health and well-being strategies.
There are what one might call insurance policies embedded in these arrangements. Each ICB must also include in its annual report a review of the steps it has taken to implement any relevant joint local health and well-being strategy. It must also consult the health and well-being board when undertaking that review. Finally, NHS England has formal powers of intervention if an ICB is not complying with its duties in any regard. Putting all this together, we think that it is sufficient to ensure that ICBs will have regard to both ICP and health and well-being board plans.
The emphasis is on collaboration. Implicit in that concept is the two-way street on the sharing of ideas and exemplars that the noble Lord, Lord Mawson, called for and illustrated in his examples. Given the strong collaborative measures in the Bill and the strong foundations of collaborative and partnership working across the NHS, local authorities and other partners on which this Bill is built, we do not think that further provision is required. We would expect an ICP to resolve disagreements through discussion and joint working rather than additional, potentially burdensome procedures.
Amendment 210A brings us once again to the role of non-statutory organisations in helping to create and sustain healthy communities. I want to stress straightaway that the Government hugely value the contributions of the voluntary, community and social enterprise sectors to the health and well-being of the nation. We recognise their important role in supporting the health and care system.
The Government fully expect that commissioners will also recognise this contribution and role going forward. This role will be particularly important in efforts to recover performance and move beyond a purely reactive service to building a sustainable and personalised health and care system, something the non-statutory sector is uniquely placed to offer. I think the lessons learned, so well described by the noble Lord, Lord Warner, in the previous set of amendments, are widely accepted nowadays.
NHS England and NHS Improvement recently published the proposed ICS Implementation Guidance on Partnerships with the Voluntary, Community and Social Enterprise Sector, which outlines the importance of the VCSE sector as a key strategic partner for ICBs and provides proposed guidance on how VCSE partnerships should be embedded once the new system is in place.
Membership of the ICP is flexible, as we have previously discussed, and could well include organisations from the voluntary, community and social enterprise sector. We expect many will. The integrated care partnership will be tasked with developing a strategy to address the health, social care and public health needs of its system, which will be another important way to bring the voluntary, community and social enterprise sector in. That is why I am confident in saying to the noble Lord, Lord Mawson, that I do not think this amendment is necessary.
It is our intention that the provider selection regime will allow commissioners greater flexibility to arrange services in a way that adds value for the patient, taxpayer and local population. One of the predominant aims of the provider selection regime is to allow commissioners and providers greater certainty and continuity of service provision to improve partnerships between providers, reduce disruption and promote sustainable long-term and integrated collaborations between providers from across the system.
As part of NHS England’s consultation and development of the provider selection regime proposals, it set out suggested key criteria for decision-making which a relevant authority would need to take into account. We intend to include them in the new regime. They will include, among other things, the importance of innovation, social value, the sustainability of services, access to healthcare and reducing inequalities.
More broadly, we recognise the importance of places. We expect each integrated care board to agree its place-based structures as part of the process of agreeing its constitution. The integrated care board will also have to work closely with health and well-being boards as they have the experience as place-based planners. The integrated care board will be required to have regard to their assessments and strategies.
This has been a helpful debate on an important matter. I hope I have been able to reassure noble Lords that we are already taking a sensible approach in the provisions in the Bill and that making amendments to it is not necessary. I therefore hope the noble Lord, Lord Mawson, will feel able to withdraw his Amendment 159A and not to move Amendment 210A when it is reached.
My Lords, I thank the Minister for those helpful thoughts and reflections. First, on NHS England, we need to be very sure that a two-way street is established, because I worry that systems such as this are not learning organisations—we know this from experience—and they now need to become such if they are really to embrace an environment that is about innovation and more entrepreneurial activity. I put that on the record. We will watch what happens; I am sharing with noble Lords what is actually happening now, live, in some of these services around the country as they try to establish new ways of working.
I pass on apologies from the noble Baroness, Lady Andrews, and the noble Lord, Lord Clement-Jones. They have supported these amendments but, because of the change in the timetable, were not able to be with us today. This debate is being watched around the country, and I am aware of a very interesting dialogue going on with people both inside and outside the system. We should all be encouraged by that and should build on it.
With regard to the Report stage and to these two amendments and my earlier amendment, my colleagues and I, with others in the system, will reflect on these discussions. We will, I hope, talk further with the Minister and other colleagues and think about what the next steps might be. For now, I beg leave to withdraw my amendment.
Amendment 159A withdrawn.
Clause 22 agreed.
Amendment 160 not moved.
Clauses 23 to 25 agreed.
Clause 26: Care Quality Commission reviews etc of integrated care system
Amendments 161 and 162 not moved.