Health and Social Care Bill

My Lords, CCGs will be under a duty to arrange for services to meet the reasonable requirements of patients for whom they are responsible. This is the language of the current duty on the Secretary of State in Section 3 of the 2006 Act and will remain one of the fundamental principles in the future. Additionally, under their discretionary power in new Section 3A inserted by Clause 11, CCGs will have the power to arrange the provision of services and facilities for the people for whom they are responsible where that will improve physical and mental health or improve the prevention, diagnosis and treatment of illness in those people. However, CCGs do not have commissioning responsibility for all services—for instance, those that the NHS Commissioning Board will commission. For that reason, Amendment 60A would be inappropriate. However, the Bill is already expressly designed to ensure that the comprehensive health service is maintained and that patients’ needs are meet. Amendments 76 to 78 seek to revise the commissioning responsibilities of CCGs, as set out in Clauses 10 and 11. In effect, Amendment 76 would give each CCG responsibility for commissioning for everyone normally resident in its area, removing the link between the provider of primary medical services with whom a person is registered and the CCG responsible for commissioning services for them. We think it is important to maintain this link. PCT responsibilities currently include people who may be registered with a GP in that area but who live outside the geographic boundaries of the PCT, so this is not something new. Clause 10 also includes some necessary provisions for the Secretary of State to clarify the responsibilities of CCGs in regulations—for example, when a CCG has ongoing responsibility for a patient’s care even if they are no longer a registered patient of a member of that CCG, which is an important element of the policy of continuing healthcare, and when somebody might be excluded from their responsibility, which might apply to patients registered with a GP in England but living in another part of the United Kingdom. Amendment 78 would change the discretionary power that CCGs would have under new Section 3A into an obligation. That would go much further than the current discretionary powers of the Secretary of State. It would place CCGs in the situation of being legally obliged to arrange any services that it felt were appropriate to meet a patient’s needs. This would conflict with their duty under Section 14P to exercise their functions effectively, efficiently and economically, and could leave them open to challenge. These are judgments that commissioners, as now, need to be able to weigh up themselves in order to achieve the best possible services for their patients with the resources that they have available. The same arguments apply to Amendments 177 and 178. On the latter, the noble Baroness, Lady Murphy, made an excellent point about the key role that the voluntary sector can play in providing high-quality and cost-effective services. The noble Earl, Lord Sandwich, is a great advocate of services for those addicted to prescription drugs. I pay tribute to his work, about which I have spoken to him, and I hope he will be reassured that this area of care is not forgotten and that the voluntary sector has a major role to play. If I had to single out one area where I expect to see a step change in the quality of care delivered to NHS patients as a result of the creation of CCGs, it would be long-term conditions. However, it is unnecessary, as Amendment 79 proposes, to emphasise that the power in new Section 3A applies to securing improvement in the health of persons with long-term conditions, because the new section covers all those for whom a CCG has responsibility, regardless of their health needs. Neither is it necessary to make additional provision for integration, important though that is. New Section 14Y in Clause 23 would require CCGs to exercise their functions with a view to securing integration. We covered integration in earlier debates. Rather than focusing on integration as an end in itself, the duty under new Section 14Y rightly focuses on the outcomes that we want to deliver through the provision of integrated services. When that duty is considered in conjunction with the power of CCGs to do anything calculated to facilitate the discharge of any function conferred on them, it is clear that the Bill already achieves the intention behind the amendment. I fully agree with the noble Lords, Lord Ramsbotham, Lord Kakkar and Lord Hunt of Kings Heath, that the services covered by Amendments 80, 81B, 82 and 83 should be commissioned by the NHS Commissioning Board. It would be very difficult for me to take issue with the powerful points that they advanced for the care of those in the criminal justice system, Armed Forces veterans and those with rare and specialised conditions. However, it is our firm view that it is better to provide this detail through regulations, which will give the Secretary of State flexibility, as the services that the board commissions and the settings in which they are provided will no doubt change over time. This will also provide greater flexibility over when the board takes on these responsibilities, to allow co-ordination with the other agencies involved. The noble Lord, Lord Kakkar, made an extremely compelling speech about amputee veterans. The Government accepted the recommendation in Dr Andrew Murrison’s report, A Better Deal for Military Amputees, that Ministers should take appropriate steps to provide for the national commissioning of specialist prosthetic and rehabilitation services for amputee veterans. Clause 12 already includes provision for the Secretary of State to require in regulations made under new Section 3B of the 2006 Act that the NHS Commissioning Board should commission certain other services not specified in the Bill. I confirm today for the first time that we intend to make provision for amputee veterans under those regulations. In the context of Amendment 82, the noble Lord, Lord Hunt, asked how the board would involve health and well-being awards in its commissioning plans. The NHS Commissioning Board will be required to appoint a representative to attend local health and well-being boards in certain circumstances. It will thus have an active role in the preparation and development of joint strategic needs assessments and joint health and well-being strategies. It will have a duty to have regard to those strategies in exercising its commissioning responsibilities. However, it would not be appropriate to require commissioning plans to agree with health and well-being boards, or for the boards to have a right of veto. The Local Government Association agrees with us on this. Clearly it is also important that the board develops its responsibilities in a way that complements and supports other local health and social care commissioning. As I have said, the board will have regard to joint health and well-being strategies. It would confuse lines of accountability, and would actually be unworkable, if we forced a duty on the board to agree its commissioning plans with health and well-being boards. Clause 20 also enables the Secretary of State to specify in the mandate to the board matters by reference to which he will assess the board’s performance, including in the services it will commission. The noble Lord, Lord Hunt, asked how the board will be able to manage its primary care responsibilities effectively. Sir David Nicholson has set out his expectation that the NHS Commissioning Board will have a local field force, which is likely to be based—at least to begin with—on the areas covered by the PCT clusters. The field force would manage those aspects of primary care commissioning that require local expertise. There is a very informative section in the document, Developing the NHS Commissioning Board, published a while ago, which talks about this. It refers to Sir David’s aim to have, "““dedicated teams performing the range of functions””," that make up the relationship with clinical commissioning groups. I direct the noble Lord’s attention to page 23 of that document, and hope that he will find it helpful. The noble Lord also asked me what would happen if a CCG refused to commission a service. I reassure your Lordships that, first of all, CCGs will be under a statutory obligation to arrange for the provision of care to meet the reasonable requirements of the people for whom they have responsibility. I have covered that point. The board will have a duty to perform an annual assessment of how well each CCG has fulfilled its duties in the previous financial year, and that will include in particular an assessment of how well it has taken account of assessments and strategies under new Section 116B(1) of the Local Government and Public Involvement in Health Act 2007, inserted by Clause 190. It is intended that the NHS Commissioning Board, supported by NICE, will develop a commissioning outcomes framework so that there is clear, publically available information on the quality of healthcare services commissioned by CCGs, and CCGs must have regard to the commissioning guidance that must be published by the NHS Commissioning Board. Where a CCG chooses not to commission a service, it would have to be satisfied that it was not necessary to do so in order to meet the reasonable requirements of the patient population. My noble friend Lord Greaves asked about the role of CCGs in setting up new services. I wish to be clear; CCGs will commission services. They will not provide services. A key commissioning function for CCGs will be securing the provision of services in their area to ensure effective provision of such services. If a new service is required, a CCG could choose to factor capital costs into the contract when commissioning the services.