Health and Social Care Bill

My Lords, as we near the end of our deliberations on Report, I hope to set out the case for changing not the policy but the pace of implementation. We have discussed extensively the policy background and the legal and other implications of this Bill. We have agreed on some things and disagreed on others. The case for Amendments 300A and 300B is simply that we have learnt a great deal in the past 13 months since my noble friend Lady Wheeler and I asked 18 other noble Lords to join us in organising seminars about this Bill because we felt that the House needed to understand it better. I have to say that 13 months later I am not sure whether we do understand it any better. However, what is quite clear from those seminars and our discussions since the autumn is that there are risks involved in this Bill. There are credible claims that detrimental consequences brought about by the scale of change are already being felt. There are some extreme assertions, such as from regional risk registers, that patient care could be seriously impacted. In these remarks I am really only going to assert what we know. We know what is in those risk registers, we know the risks that we have discussed and we know that this is the largest reorganisation that the NHS has ever undergone, including the one that set it up. The evidence that we collected in our seminars raised the scale of those risks. During our debates risks have been mentioned time and again—risks to children, to older people and to people with long-term conditions. The Health Select Committee and the Public Accounts Committee have both added weight to those expressing concerns about the scale and pace of change, and that is the point of these amendments. We still do not know what the key risks are in the risk register, which is a grave disappointment, but that may actually add to our concerns. Our concerns should also be heightened by the poor track record of the Department of Health to oversee and manage change on this scale. The wisdom of ex-Ministers in this House is such that they know very well how hard change is to manage within our NHS. Added to this particular programme is one of the worst impact assessments that I have ever seen and, one suspects, a deficient risk management process. The level of organisational change was acknowledged when the coalition agreement specifically ruled out any such major programme. In adding to the risk inherent with the implementation of this Bill, we have put forward an amendment that is intended to ensure that part of the Bill is deferred and the major part of the Bill is proceeded with. That is what this amendment is about, and I think it has advantages. First, we have to allow time and bring about some stability for the Nicholson challenge, as it has been called, to deliver the savings. We know that economic regulation is not a key factor in delivering those savings, as evidence to the Health Select Committee demonstrated. Reforms in both commissioning and provision can continue as now in advance of economic regulation in the full market. That is the first reason. The Nicholson challenge and the savings need time to embed themselves and to work their way through the system. Secondly, many in this House and outside have expressed concerns that the role of Monitor as the independent regulator of foundation trusts should not be weakened. To some extent that has already been acknowledged in the changes made to the Bill, but the addition of new rules and duties to Monitor is, we believe, in itself a risk. Under our amendment, Monitor would complete its role in authorising foundation trusts and be well on its way to moving to a light-touch regulation, so that the inevitable conflicts of interest, which many noble Lords have raised during the course of this Bill and outside the Chamber, would be lessened. The pipeline of expectant foundation trusts is still long and will not decrease any time soon. It seems that there is a job of work for Monitor to do in managing things such as mergers, takeovers, and franchising for laggards. That process, of itself, is enough, and we want to reduce the risks of failure in those processes. It also seems that developing and building the capacity and capabilities required in a wholly new regulatory regime will and should take time. There is much to do, and we think that undue haste brings with it its own risks. The emerging clinical commissioning groups will be commissioning with billions of pounds of public money, yet they are young organisations with only light governance. They will need time to grow and to build capacity, capability and experience before they have the additional complexities of market regulation, and this amendment allows for that. The most compelling reason for sequencing—a term that I openly acknowledge I first picked up from the noble Baroness, Lady Williams—is that it will give time to work with those who have to implement the changes, as opposed to forcing those changes upon them. Even those in the Government and on the Liberal Democrat Benches cannot really pretend that the widespread opposition to this Bill and the arguments for it to be reconsidered are all part of some Labour plot, as has been suggested. Would that it were that the Labour Party had such influence and strength. I do not think that is the case, but calling distinguished academics and leaders of professional bodies Labour stooges is both offensive and counterproductive. There is widespread opposition to and fear of the risks that this Bill brings. They are not borne of ignorance and ideology but based on knowledge, evidence and experience, so the Government would be wise to take time to win people over to what they want to achieve. As the Prime Minister himself said last year, he would not wish to move forward with these reforms without the support and commitment of the National Health Service's staff and patients. My final point is about the consequences of sequencing. At the outset, we heard claims that the NHS was in urgent need of competition to drive through reforms to improve outcomes, but evidence has been compiled to show that while our NHS is far from perfect—and indeed may need reform—it is still arguably up there with the best in the world. Where we lag behind, we are closing the gap, which is testimony to our support and investment in the NHS. We believe that there is no urgent reason for implementing Part 3 of this Bill, either for clinical or financial reasons. On the positive side, we are not suggesting any delay in developing other aspects that have wider support, such as clinically informed commissioning, health and well-being boards, HealthWatch and much else. These changes need not be delayed if our amendment were passed—indeed, they are pretty much going ahead anyway—but could proceed with less risk. By sequencing the changes, the risks posed to patients can be lessened and the prospects of delivering the Nicholson challenge increased. While other parts of the Bill bed in and foundation trusts can be regulated and registered as far as possible, it seems to me that May 2016 is the right time to implement Part 3 of the Bill. At some point in this Bill, the Government had set that date for getting foundation trusts set up, as far as they could be. That will be when all the other work has been done and is bedded in, and has perhaps built up some support with less fear and hostility than it does at the moment. I beg to move.