Health and Social Care Bill

My Lords, the noble Lord is quite right, and my understanding is that we are doing that as well. Meanwhile, I can tell my noble friend Lord Marks that we will consider the provisions highlighted by Amendments 153ZZA and 153ZZB as part of this process. My noble friend also raised the issue of inequalities. In earlier debates I highlighted the very significant departure made in the Bill that, for the first time ever in this country, the Secretary of State will be legally obliged to have regard to the specific need to reduce health inequalities, whatever their root cause. The board and the CCGs will also have this duty, which clearly emphasises our commitment to equity and fairness across the health service. We believe that the phrase ““have regard to”” completely captures the intention of the legislation; that is, that the board and the CCGs must consider the need to reduce inequalities in every decision they take. That, I hope, addresses the essence of Amendment 118. This is consistent, as I think it should be, with the public sector equality duty, which is phrased in exactly the same way. As the board already has a responsibility for all patients in the population, its general duty on inequalities also applies this widely. Under Amendment 119, the board would have to have regard to the duty on inequalities in allocating resources to CCGs. We recognise fully the importance of ensuring that allocations give CCGs the resources to meet the distinctive needs of their local population. Again, our preference is not to place particular weight on one factor or set of factors in legislation. In fulfilling this duty, the board will also need to work in collaboration with health and well-being boards and local authorities. We have already debated the various duties on the board to participate in certain activities of health and well-being boards. On Amendment 137A, of course it will be important to ensure that all providers contribute to the fulfilment of these duties. Some public sector duties, such as the duties under the Equality Act, already apply to anyone exercising a public function, which includes private providers who supply NHS services. The specific duties in the Bill are placed on the board and CCGs, and they remain responsible for exercising them even when they contract with another body to provide services. It is, therefore, incumbent on them to ensure that these commissioning arrangements, and the ongoing monitoring of services provided under them, support the fulfilment of their duties. I am not sure whether the noble Baroness, Lady Royall, spoke to her Amendment 343A, but if I cover it briefly, it may be helpful to her. The amendment probes how long it will take NICE to produce the full range of quality standards. As the noble Baroness probably knows, the ambition is to create a core library of NICE quality standards that covers the majority of NHS activity, and supports the NHS delivering against the outcomes in the outcomes framework. The programme is ideally placed to deliver a steady stream of quality standards over the agreed timescales and this will lead to a comprehensive library of quality standards within, we hope, about five years. Therefore, I am afraid the timescale envisaged in her amendment is too short. I turn now to the group of amendments introduced by my noble friend Lady Cumberlege on maternity services. I am grateful to her and, indeed, the noble Baroness, Lady Thornton, for giving us the opportunity to consider this question. I hope I can provide some reassurance that the new commissioning arrangements will provide a very secure basis for quality improvement in these services. Women should always expect—and always receive—excellent maternity services that focus on the best outcomes for them and their babies, and which optimise women’s experience of care. Getting maternity care right from the start can help tackle the negative impact of health inequalities and begin to improve the health and well-being of mother and baby. We are committed to improving outcomes for women and babies, and for women’s experience of care. Three of the improvement areas in the NHS Outcomes Framework for 2011-12 focus on improving maternity services, by reducing perinatal mortality, by reducing admissions of full-term babies to neonatal units and by improving the experience of women and families of maternity services. My noble friend spoke of variation in services and that was the theme of the very powerful speech by the noble Lord, Lord Mawson. We are committed to ensuring consistency in the quality of maternity services. From April 2012, a maternity experience indicator will be introduced as part of the NHS outcomes framework. It will allow us to chart a woman’s experience of care through antenatal care, labour, delivery and postnatal care. To support the NHS in improving outcomes in pregnancy, labour and immediately after birth, the National Institute for Health and Clinical Excellence is developing new quality standards based on the best available evidence on antenatal care, intrapartum care and postnatal care. It is outcomes and quality that matter, and the NHS Commissioning Board will be publishing a commissioning outcomes framework for clinical commissioning groups. The commissioning outcomes framework will rely on the national outcomes framework set for the board and NICE quality standards. On top of that, the NHS Commissioning Board could decide to include guidance on the matter in the commissioning guidance that it must publish for CCGs and to which CCGs must have regard. Women tell us that being able to make informed choices that enable them to personalise their maternity care is important and that the choice of where to give birth is most important. The birthplace in England study published last week provides evidence for the first time that women with straightforward pregnancies can choose whether they would like to give birth in a hospital obstetric unit, a midwifery unit or at home, knowing that giving birth is generally very safe. But there are some important differences between these birth settings in benefits and risks for mother and baby. This study will help NHS organisations around the country to design excellent maternity services based on what women want and need. We made extending choice of maternity services a key priority for the NHS, as reflected in the operating framework, so that women have access to a full range of services close to home. As recommended by the NHS Future Forum, the Secretary of State’s mandate to the NHS Commissioning Board will set clear expectations about offering patients choice—a choice mandate. This could include expectations relating specifically to choice in maternity services. Finally on maternity networks, we heartily endorse the important role that clinical advice will play in supporting the board to fulfil its duties and carry out its functions effectively. We will explore with the NHS Commissioning Board over the coming weeks how to ensure that maternity networks can provide the expert clinical advice that commissioners will need in a flexible way, responsive to local arrangements. I would, of course, be happy to write to my noble friend with further detail on that subject. My noble friend asked about indemnity in relation to independent midwives. Current membership of the NHSLA schemes is open only to NHS bodies. We are currently looking at reforming NHS indemnity arrangements in the context of this Bill. We remain committed to ensuring that all providers of NHS care have access to NHS indemnity arrangements in future and are pleased that One To One (North West) Ltd has secured indemnity for independent midwives. We hope that this solution will work for other groups of independent midwives as well. On the question of maternal request for caesarean section, NICE guidance makes it clear that caesarean section is a major operation and that women who request it should consider all risks with the healthcare professionals, including midwives, obstetricians, anaesthetists and others, if appropriate. If, after having advice, a woman still wants a caesarean, her request should be honoured. I turn to Amendment 299C, in the name of the noble Baroness, Lady Finlay. I shall of course consider the points that she made, as I always do. However, for elective services, patients already choose their NHS services—or NHS care in a private provider, if that is what they want—before they even attend as out-patients. It is a little hard for me to see how they could be poached by foundation trust staff for private work; there would be no incentive for patients to pay for something which they are already in line to receive on the NHS. Using NHS business to recruit private patient business would be against accepted professional practice; it could lead to a charge of misconduct, handled by the profession’s regulator, which would put professional practice in jeopardy. Foundation trusts could also view such practice as a breach of contract, since poaching their patients would lose them money. On the issue of conflict of interest in referrals by GPs, we will not allow a situation to arise where profits can be made at the expense of patient care or choice. Clinical commissioning groups will not be directly responsible for commissioning services that GPs themselves provide—that will be the responsibility of the board. CCGs will be commissioning organisations; they will not be able to provide services in their own right. The NHS Commissioning Board will be responsible for commissioning primary medical care and holding contracts with individual GP practices in their role as providers. Through GMC guidance doctors will be, as they are now, under a duty that any commercial interest that a GP may have in a company must not affect the way that they refer or prescribe for a patient. The proposed reforms to NHS commissioning arrangements do not in any way alter the existing duties of GPs, as clinicians, to provide high-quality primary medical care to meet the needs of their patients, as required under their contracts. My noble friend Lady Williams asked what the destination was for these reforms. I reassure her that the destination for our modernisation of the NHS is to safeguard the values and principles that the NHS is based on. That is the case now; it has always been the case and will remain so. On my noble friend’s specific point about commissioning support, clinical commissioning groups will not be able to delegate their commissioning function but they will need support. Commissioning support is the assistance which commissioners, both CCGs and the board, can draw on to help them deliver their functions. Good commissioning support will help CCGs and the board to concentrate better on the clinical and locally sensitive aspects of commissioning to make the best use of resources available to the NHS. That support could come from the talents of their own employed staff or, if they choose, from outside bodies. We are talking here about things such as data analysis, back-office functions and other areas. It is important to recognise that PCTs can and do currently hire independent sector support for their commissioning functions. That is not commercialisation or privatisation of commissioning but using the available resources to get the best support. It will be for GPs and their colleagues to decide which commissioning activities they do for themselves and which, if any, they choose to buy in from external organisations. It is entirely up to them. I hope that what I have said provides additional clarity and, indeed, reassures the two noble Lords, and that it will enable the noble Lord, Lord Butler, and my noble friend Lord Newton, in particular, to withdraw their amendments.