My Lords, in moving Amendment 25, I will speak to other amendments in this group, which follows on from the previous group and the last comments made by the noble Baroness, Lady Walmsley. On day two in Committee, we had an interesting discussion about the composition of integrated care boards. My noble friend Lady Thornton and other noble Lords argued for specifying in some detail the composition of ICBs, including having representation from mental health trusts, public health, staff and the patient’s voice.
Equally, the noble Lord, Lord Mawson, discussed the problems that arise when members on committees are seen to represent what he called “other agendas”. The noble Baroness, Lady Harding, was supportive of that view, although she argued that
“we should think more about what we want the integrated care boards to do”.—[Official Report, 13/1/22; col. 1303.]
and how we will measure this, rather than exactly who is on them. I see the force of that argument; I for one am pretty uncertain about what exactly these integrated care boards are all about.
The noble Lord, Lord Hunt of Wirral, went to the heart of this when he raised an issue that has troubled me right from the beginning: the provision that NHS trusts and foundation trusts are to be members of the integrated care boards. As he said:
“Organisations that provide the bulk of NHS services”
are therefore brought into the work of commissioning. The current system is one where commissioners—CCGs—hold providers to account
“objectively determining whether they are best placed to provide a service and assessing their performance”
and, as he said, the question then arises as to how the new integrated care boards can
“continue to perform that role.”
He felt that the membership of provider appointees on those boards at least created a risk of
“a conflict of interest between the roles of those individuals on the board and any roles they may hold with provider organisations”.—[Official Report, 13/1/22; col. 1297.]
In response, the Minister said that
“each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore”—
this is a very relevant point—
“each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB”.—[Official Report, 13/1/22; col. 1308.]
Up to a point, Lord Copper. I am now totally confused as to what ICBs are. I must admit that I thought that reason for having all the key local players around the table was to brokerage deals, sort out the flows of money and keep the show on the road, but the Minister’s vision seems to be for a rather more rarefied forum, where members of the ICBs have to leave their interests behind them and think Olympian thoughts in the interests of the greater good. However, when you think of an ICB, with members of a major trust sitting around the table, and local authorities represented not by their political leadership but by officers, how on earth can they leave their principal interests behind them? Surely the responsibility of the
CEO of a trust or presumably of a local authority or the director of adult social care is to represent the interests of the organisations on that board.
I will give a couple of examples. On page 21, the Bill states in relation to new Section 14Z50 on the joint forward plans for an integrated care board and its partners that
“an integrated care board and its partner NHS trusts and NHS foundation trusts must prepare a plan setting out how they propose to exercise their functions in the next five years.”
That is fine, because that is probably one of the most important things that they have to do, but what are the trusts’ chief executives on the ICB expected to do? Are they expected to sit there and declare that it is a conflict of interests and therefore take no part in the discussion, or are they there to represent the interests of their trust, because the forward plan is very important to the success or otherwise of their organisation? It would be the same with the local authority representative, even though that representative, because they are an officer, will have to report back all the time to their political leaders to get the green light to what they have to agree to within the ICB board, which is why it is so stupid to keep local authority councillors off that board.
The Minister says, “Oh well, if it all goes wrong, we can use regulation powers to put it right”. But we are at the beginning of this process, and we need to get it right now. I very much ask the Minister to think again about the structure of ICBs and how on earth you can expect them to operate if the large trusts that they are supposed to commission serve round the table. It is really a nonsense in governance terms. Only NHS managers could have come up with this—and, oh dear, it was NHS managers who came up with it. Much though I love them and have represented their interests, I agree with the noble Lord, Lord Scriven, that accountability and democracy do not come very easily to them, and you can see that in the complete mess that we see before us today.
We then come to the question of whether these ICBs are accountable at all locally. I see no evidence of that at all; they are clearly part of a top-down managed hierarchy. How can you explain the reasons for the chair being appointed by NHS England and not by the board itself? How can the chair be removed from office only by NHS England? The chair should hold office at the confidence of the board. It should be the board that decides whether the chair is competent to continue, subject to external regulatory interventions, as of now, where that is necessary.
Secondly, why does the appointment of the ICB members have to be approved by the ICB chair? I am sorry that the noble Lord, Lord Scriven, is not here. If I, as leader of Birmingham City Council, for instance, decided that my director of adult social care should go on to the board of the Birmingham and Solihull ICB, what right does the chair have to give their approval or not to that appointment?
We have already discussed the nonsense of local authority councillors being left off, but let me just make one other point. If you were the chief executive of the local authority appointed to an ICB, where you are making big decisions about finance, does the Minister imagine that that officer will do it off their own bat, or
does he think that every step of the way they will report back to the leader of the council and the cabinet member for social care? Of course they will.
The problem is that NHS managers think local government is run in the way the NHS is run; they think the officers are in charge. But they are not, because you have political, democratic leadership. It is the same with Ministers in government, which it seems is why they have got themselves into such a mess in relation to this governance.
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The ICB does not even appoint its own chief executive officer. The CEO is appointed by the chair, with the approval of our old friends NHS England. Again, why? Surely, the chief executive should be appointed by the board of the ICB through a proper appointments process. What we can see is, first, that these ICBs will basically be the tools of NHS England, because the chair and the chief executive officer owe their continued existence to that quango. Secondly, we see that they have built a huge conflict of interest into the structure.
When taking evidence last year, the Health and Care Select Committee concluded that it was
“vital that local populations have confidence in the boards of the NHS Body … and transparency in the appointment process for those boards will be a key factor”.
I agree. The argument I put forward, particularly in my first amendment, is that there must be some independent process or scrutiny of the appointments of ICBs. When the composition of NHS England was debated on the first day in Committee, the noble Earl, Lord Howe, said he agreed that
“robust governance arrangements are absolutely necessary to oversee public appointments, particularly to NHS England”.—[Official Report, 11/1/22; col. 987.]
He then qualified it by saying that it did not apply to ICB boards. He was absolutely right, because the one thing they do not have is a robust independent appointments process. I put this point to the Committee: why can we not put a proper appointments process in? Why do we not resurrect an independent NHS Appointments Commission to do the job properly, make sure that the governance arrangements are fit for purpose, and ensure there is much more local confidence in these ICBs and what they are there to do?
The board should appoint the chair; the chair and the board should appoint the chief executive officer. They should stay in those positions at the disposal of the boards, and those members should be appointed through an independent process which should include local authority councillors nominated by the principal local authorities within the ICB board region. ICBs cannot be expected to carry any weight locally, given the way they have been constructed at the moment.
I urge the Government to think again about this. They may want to push on and have it accepted with a fait accompli but, in the end, it is their decision in Parliament as to how these bodies operate. Unless we do this, it is pretty clear that we will be coming back within the next year or two with another NHS restructuring Bill. We have already heard about the ludicrous decision to keep health and well-being boards at the same time as having ICBs. We all know that,
looking at it, this structure will not keep. It would be better if the Government started to sort it out now. I beg to move.