Health and Social Care Bill

My Lords, when I spoke to the amendments concerning the NHS Commissioning Board, I said that the arrangements for governance, membership and the like were skeletal. In the absence of the most reverend Primate, I am probably safe to say that these arrangements for clinical commissioning groups are, by comparison, words made flesh. There is currently virtually nothing in the Bill that indicates how these commissioning groups would be constructed, what their membership would be and indeed what they should do. Clause 22 contains provisions to make changes to the 2006 Act to provide for regulations as to the governing bodies of clinical commissioning groups. It is disappointing that nearly a year after the Bill was first produced we are debating the formation of clinical commissioning groups without any clarity at all—for example, in the form of draft regulations, if they are to be prescribed by regulation rather than the Bill itself—about how these groups should be composed. It is quite unsatisfactory. Clearly tonight we are not going to be voting on anything—these are probing amendments—but I hope that before we get to Report we can have sight of draft regulations to see what is in the Government’s mind and what changes might be necessary for the composition of these bodies. I have some sympathy with Amendment 101A, tabled by the noble Baroness, Lady Williams, but that assumes that it would be the function of the NHS Commissioning Board to ensure the composition of the commissioning groups. That does not necessarily follow and presumably we will not know until we see what the draft regulations contain. A number of your Lordships have referred to the issue of coterminosity. In principle, it sounds fairly straightforward although in practice it looks a little less straightforward. There are different types of coterminosity. As I have said before, in my home town of Newcastle we have two clinical commissioning groups. In one sense they are coterminous because they are within the boundary, but on the other hand there are two of them. What if they do not agree? What if there are competing, conflicting ideas about what should be commissioned from the service in Newcastle? That assumes that you can treat the services within the city as confined to the city, but of course that is not the case. There are facilities in the city that are widely used across the region. Some of them are specifically regional centres. It may be that some of these services would be commissioned by the NHS Commissioning Board, but others would not. In this era of patient choice and the like—and one understands and supports that—there will be interest from other commissioning groups around the region in what goes on in the city, so coterminosity takes on a different flavour in that respect. In some parts of the country geography could make it difficult to envisage coterminosity. In a county like Cornwall or Devon, commissioning groups based primarily on general practitioners would be less likely to find it easy to work on the basis of coterminosity across the county area. In previous debates the Minister referred to the possibility of groups working together. This needs to be fostered. It may be that the commissioning board would have a role in that, or this matter could be covered by regulations to provide for the opportunity for groups to cluster effectively to replicate the pattern of primary care trusts. As matters stand, however, it does not seem that is likely. There are issues of a different kind about coterminosity because some, in particular GP consortia, may have interests in different areas. The Haxby Group in York, which has been mentioned in your Lordships’ House before—the general practitioners’ group which on NHS-headed paper advertised effectively a private service, though that is not the point I am making—also operates in Hull. That is in a different area. Hull is a unitary authority and York, which is also a unitary authority, is in North Yorkshire. They are two quite distinct areas. The practice, however, operates in both. I am not sure how a practice like that fits into the scheme of commissioning groups. Will it be present on two commissioning groups? Maybe and maybe not. Maybe it creates a difficulty; maybe it does not. It needs looking into. I agree with the noble Lord, Lord Greaves, in commending my noble friend Lord Hunt’s proposals around some district council representation. We will revert to this later when we are talking about health and well-being boards, where there is a more obvious role. Nevertheless, there is a potential role for district councils, with the services and responsibilities to which both noble Lords have referred, to have some place in commissioning groups. There is certainly, judging by the tenor of the previous debate, a clear role for either the director of public health or at least his or her representative to sit on commissioning groups. Again, if there is simple coterminosity—one local authority and one commissioning group—there is no problem. If you have, however, a number of commissioning groups within the area served by a principal authority, with someone running around from one group to another, it would not work but they could be represented. That should be looked at. There seem to be a number of unanswered questions and this late in the day, in every sense, we cannot take them much further tonight. I hope, however, that the Minister can assure us that there will be an opportunity to have draft regulations and responses to all the issues that have been raised tonight in good time for the House, which has different concerns across the divide here, to consider them carefully, in order that we can take a clear view about how to close the gaps in the Bill on the basis of clear proposals expressed where necessary in the form of the draft regulations which will apparently be heading our way at some indefinite point in the future.