Health and Social Care Bill

My Lords, the amendment tabled by the noble Baroness, Lady Gibson, and all the amendments in this group, highlight the importance of ensuring that neither rural nor urban areas are affected by health inequalities. I quite understand the noble Baroness’s concerns—especially given that rural areas have unique circumstances that affect their health needs, such as a diffuse population and long travelling times for patients. I therefore acknowledge that some significant issues face rural and urban areas, as was highlighted by the Marmot review. In particular, there are concentrations of shorter life expectancy and greater illness, and these tend to occur in some of the poorest areas of England, most of which are urban areas of deprivation. There are particular challenges with the provision of services in rural areas due to the higher cost of delivering services in more locations and the greater sparsity of rural communities. However, although I am very sympathetic to the noble Baroness’s intentions, I do not feel that the amendments are the most effective way to achieve her aims. Existing reference to ““England”” or ““its area”” in the Bill already includes every type of population, including rural and urban populations. The responsibilities for commissioning are absolute across all the communities and individuals for whom they have responsibility. There is no discrimination between different areas. That principle runs throughout the legislation. Moreover, the fundamental and unique change we are making to commissioning is to give local GPs responsibility for securing services for their patients. That vital principle, above all others, will make a decisive break from the past by ensuring that the needs of much smaller groups of patients can be taken into account by the commissioners. A CCG will be exercising its statutory functions appropriately only if it is meeting the reasonable needs of all the people for whom it is responsible, not just those in particular demographic areas. The guidance on commissioning which the board must issue under the power in new Section 14Z6 could, of course, cover issues relating to commissioning in rural and urban areas. Although the noble Baroness’s amendments are unnecessary, they could also be damaging. That is because there is the potential under some of the amendments, however inadvertently, to limit the scope of the responsibilities which the Bill places on CCGs. Amendments 188 and 114 could limit the effect of the scope of the duty on reducing inequalities to a duty only in relation to reducing inequalities and access between rural and urban areas. That would not include the duty to tackle the variety of factors which can affect a person's ability to access the care that they need, such as socioeconomic background and ethnicity. The changes proposed to the Secretary of State's duty in new Subsection 1B are particularly problematic in their impact. The Secretary of State may no longer have regard to the need to reduce inequalities between the people of England but only between people in urban and rural areas. Similarly, Amendment 190 could limit the duties regarding reducing inequalities in outcomes to inequalities in outcomes between patients in rural and urban areas only. So I have concerns about the limitations that the amendments may impose. Despite all that, I hope that I can reassure the noble Baroness that the Bill adequately provides for her worthy intentions—due, in particular, to its coverage of the whole of England. With that in mind, she may consider withdrawing the amendment.