Health and Social Care Bill

My Lords, I shall speak to Amendments 169, 171 and 174 in my name and that of the noble Lord, Lord Patel. I very much endorse the remarks made earlier by the noble Lords, Lord Kakkar and Lord Patel, and my noble friend Lord Hunt. There has been a huge amount of concern about the governance and accountability of clinical commissioning groups since they were launched upon a slightly unsuspecting world. That is not to say that it was a bad idea to have them, but a large number of questions have been legitimately asked about how they will be held to account for large sums of public money and how they will govern themselves, given in particular that they are a new type of public body. We have been unsure from the beginning precisely how many of them will emerge. It seems that there are now in the order of 200, or 250 or something like that, but we are not quite sure how many there will be eventually. Some of them are quite small and some will be quite big, so they are quite variable in their scale of operation. The conflict of interest issue has come up repeatedly. I cannot remember how many events I have been to where that issue has been expressed. There is also the fact that these bodies are untested. They are different in kind from many other public bodies that there have been. The theme running through my three amendments is about trying to improve the governance and accountability of clinical commissioning groups, given the large amount of public money that they will be spending—the collective expenditure of these particular groups runs into tens of billions a year. Amendment 169 seeks to ensure that a clinical commissioning group not only has a governing body but has, "““an accountable officer who is the most suitable senior””—" I emphasis ““senior””— "““employee of the group””." I can appreciate how difficult it may be for a group of clinicians to agree who should be the chief executive. I also have no wish to impose an overly rigid management structure on clinical commissioning groups, particularly in their early days. However, I am old-fashioned enough to believe that public bodies handling large sums of public money should have a senior accountable officer who, knowing that he or she may be held publicly accountable, can speak the truth to colleagues when they are tempted to duck responsibility. It is an important principle of the way in which we have run public bodies that there is a senior accountable officer who can internally, as well as externally, give strong advice and leadership on propriety in the way that public money is spent. This amendment would ensure that the governing bodies of clinical commissioning groups had a person who could perform that function. Amendment 171 attempts to strengthen the provision on standards of governance for clinical commissioning groups in new Section 14L(2)(b). At present the Bill requires the governing board of clinical commissioning groups to have, "““such generally accepted principles of good governance as are relevant to it””." As I have said, clinical commissioning groups are a new kind of organisation, spending large sums of public money. There has been much debate about the adequacy of the Government’s wraparound of these bodies. I share that concern and I believe that, as worded, the Bill does not go far enough. It tends to leave these groups to look around for a governance model that they deem to be relevant to them. They might find this a rather difficult proposition it its own right. There is a very strong likelihood that they will have very divergent governance arrangements for such large sums of public body money. We do not expect PCTs or local authorities to have that level of governance divergence in the way in which they conduct their affairs. That is why Amendment 171 attempts to increase the rigour and reduce the variation in the governance arrangements for clinical commissioning groups. It requires them to meet the standards of good governance of any elected or appointed public body authorised by Parliament. That seems to me to be the standard that we should be looking for, and we should expect these groups at least to be able to point to a governance system that is no worse than that of local authorities or PCTs. If this wording can be improved further, or if other noble Lords have ideas for improving that governance, I am happy to go along with any proposition that strengthens the Bill in its governance requirements and produces an outcome that is likely to mean less divergence between individual clinical commissioning groups in the type of governance that they produce for the running of their affairs. Amendment 174 has a different theme. It attempts to address the key issue of information that enables a public body, such as a clinical commissioning group, to discharge its public accountability in a way that enables comparisons to be made with other similar bodies within, in this case, the NHS. It is one thing to give clinical commissioning groups a lot of flexibility in the way in which they organise themselves. I see no reason why we should allow a thousand flowers to bloom in the way in which these groups choose to render public accounts for their work and expenditure decisions. I also struggle to see how the national Commissioning Board can itself review the performance of clinical commissioning groups without some template setting out how it would do so. It would not be able to shrug its shoulders when asked about groups perceived to be performing poorly. It will need some evidence that it can make public about that inadequate performance. Why should that evidence vary dramatically from clinical commissioning group to clinical commissioning group? If that is to be the case, we should be clear from the outset that there will be a more standardised system of minimum financial performance information that these groups are required to publish annually. That is in the interests not only of the good governance of these bodies but of the public understanding what they are getting for their money from those groups. It is critical that any such system has a good weighting of financial and cost data. Healthcare systems here and overseas are very good at putting into the public arena data about what they have produced that are often disconnected from how much they have cost to produce. We need a clear obligation in statute on the national Commissioning Board to require more data in this area from this rather diverse group of clinical commissioning groups. I lived through the process of dealing with financial meltdown in the NHS in 2005-06. One of the main causes of that meltdown was that the NHS could explain to hardly anybody collectively the relationship between the level of activity and the cost of that activity. It had two streams of data—one about money and one about activity—and they were not related to each other. If we repeat that approach in clinical commissioning groups, we will end up in the same place as we ended up in 2005-06.