Health and Social Care Bill

My Lords, this group of amendments and this debate has focused on conflicts of interest. For clinical commissioning groups, conflict of interest will arise where the leaders of the groups have financial interests, but also where private companies which may have separate provider arms competing as a qualified provider are contracted to provide commissioning support. The other area of conflict which has not been addressed is where quality rewards for commissioning are linked to financial performance of clinical commissioning groups. Further, there are cases where local medical committee officers are key officials in a clinical commissioning group. The clinical commissioning group is meant to represent the constituent practices. Indeed, there have been articles in the press about commissioning support and commissioning support organisations. Many of those have raised alarm among clinicians who have become increasingly concerned by the talk revealed in the press about the profit to be made by commissioning support organisations. There has also been a realisation that profit going to the commissioning support organisations will reduce the amount of money going into the provision of core NHS services at any level—whether in the community or in secondary care and the hospital sector. Several amendments are tabled here. The amendment in the name of the noble Lord, Lord Hunt, is very comprehensive and deals with an area which the other amendments do not. There is also an amendment, on which my name is the first, regarding conflict of interest. I can see that Amendment 79A is more detailed than the amendment which I have tabled, and therefore goes further and would be better. However, I am concerned that it does not go quite as far as the amendment in the name of the noble Lord, Lord Hunt, and that some of the principles in there need to be incorporated into Amendment 79A if the Government are minded to accept that amendment. We may have to come back to amend the amendment should it be accepted and incorporated. My Amendment 102 in this group addresses a quite different aspect of the commissioning process. It aims to ensure that the registered secondary care specialist who is to be included on the governing board of each clinical commissioning group can be someone working within the area that the clinical commissioning group covers, the reason being that a person working in an area will be able to establish integrated care across that area far better than someone who comes from outside. In Teams without Walls—a document on which the Royal College of Physicians led but which was written in conjunction with the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health—it was made very clear that the complementary skills of the different groups need to be integrated. There has been quite a lot of concern at the suggestion that the secondary care specialist should not be employed by a local provider and should therefore come from outside the area or even be a retired person. That concern arises because there will be nobody in the local community who understands that community, who knows the clinicians across the community and, indeed, who has an interest in the patient services for that community. Furthermore, if it is a rural area, such a clinician may be relatively disadvantaged in having to travel many miles to attend meetings and in not being embedded in the healthcare delivery system. It seems to go counter to a localism agenda to insist on taking somebody from outside the area. Therefore, the amendment is designed to allow a clinical commissioning group to take the best person, whether they are from within or from just outside the area, to drive forward integration and collaborative working. One would hope that a representative from primary care would also be invited on to the trust board within an area so that there was a degree of reciprocity—again, to build bridges rather than to create a division between the primary and secondary care sectors. Conflicts of interest will have to be declared at every stage, and obviously the secondary care doctor will have no right of veto. The argument that the secondary care doctor from within an area would argue only in favour of their own discipline or trust is fallacious. I have not seen a strong evidence-base for that, given that medical directors and others currently work in an area representing different disciplines. A criterion of the person's job description, appointment and regular appraisal could be that they are seen to represent all providers within an area so that trust is built up across all the providers with which a clinical commissioning group enters into some form of contract. We have a group of amendments here covering a wide range of aspects of the structure and functioning of clinical commissioning groups. I hope that we will shortly find that a declaration of interests is included in the Bill, in whatever form, and that the Minister will be amenable to revising the rigid stance taken over insisting that the secondary care representative and nurse come from outside the area.