My Lords, I did not originally intend to contribute to this debate. However, I would like to thank the noble Lord, Lord Mawson, for his Amendment 41A, which, although modest in scope, has initiated an extremely useful debate and raised a lot of important issues. I do not want to add a lot of material to the debate, but I want to focus on the questions that have emerged from it.
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It will not surprise noble Lords to know that I have been to Bromley by Bow, as shadow Secretary of State, and as Secretary of State in the company of Sam Everington, now Sir Sam, who was and is an advocate for clinical commissioning. I put on the record that we must not lose sight of the value of clinically-led commissioning in delivering best-quality outcomes in healthcare. I do not think it is the Government’s intention to lose that, but we need to make sure it is not lost sight of.
Taking the example of Bromley by Bow, where did it get to? It had the Tower Hamlets clinical commissioning group, which was once CCG of the year, an exemplar in this field. That CCG and others eventually came together in a large conglomerate operation—I think the noble Lord, Lord Kakkar, will know it very well—the seven CCGs in north-east London. A population of about 2 million eventually came together in one large organisation.
We started out with clinical commissioning groups whose understanding was that they need to work with local authorities through the health and well-being boards. They needed additional powers for the integration, which is absolutely fine. But as I said on Second Reading, we have ended up with the NHS and its management getting themselves in a terrible twist in terms of organisational structures and geography. The noble Lord, Lord Mawson, talked about place-based partnerships with a population of half a million. The noble Baroness, Lady Cumberlege, talked about place and localities with a 50,000 population. My point is that the 2012 legislation, even if it did not achieve what was intended, at least said that clinical commissioning groups could determine whatever population they like—they could set it at whatever level made sense. They ended up with about 300,000, on average, but the range goes from 30,000 to 800,000.
I do not think we should get obsessed with geography. We should still, even at this late stage, be letting the ICS achieve what it needs to by being a relatively large organisation with the capacity to do population health management and to manage commissioning at a higher level. Going back to what my noble friend Lord Hunt of Wirral said, it should be bigger—this is the key to why size matters—in the jungle than the big provider trusts, making sure that conflicts of interest do not arise and the providers do not run the commissioning. But then, if you have a big ICS, there is a big gap. How is place and local leadership going to be incorporated? The noble Lord, Lord Mawson, rightly talks about it being represented on the integrated care board. But where is it in the Bill? I know that NHS England, NHS Improvement and the Local Government Association have produced guidance and referred to place-based partnerships being an integral factor in the Bill. But I do not see it in the Bill. It is not there. How are we going to put it in the Bill? How are we are going to make sure it happens? How are we going to achieve the objective that the integrated care boards genuinely integrate health, social care and the whole range of those services, which in my view is what they should do, in order to deliver health?
The integrated care partnership, incorporating health and well-being boards, should be about achieving the social determinants of health. I depart from the noble Lord, Lord Kakkar, in that I do not think it is the job of the health system to deliver the social determinants of health. It is the job of government to deliver the improvement in well-being and health that is implied by moving in the right direction on the social determinants. The integrated care partnership is where that should happen.
I see no reason why the clinical commissioning groups cannot be a place-based, clinically led basis for creating place—they are going to be abolished, but in that sense, why are we doing that, since they already exist? Secondly—to repeat a point—health and well-being boards to my mind are the basis for creating an integrated care partnership that is the essence of well-being. That seems to me a much simpler structure. I was accused a decade ago of making it all too complicated; it is now at risk of becoming even more complicated. Let us at least start with what we have, which is exactly what they did in north-east London. They came together
and said, “Look, for the three boroughs of Newham, Tower Hamlets and Waltham Forest we can create something that is large enough to work, and inside it we have the borough-based relationships which are the method that we ourselves apply locally to deliver the health and well-being that we hope to achieve”.
So I ask my noble friend, at this stage—as we are just starting out on this—whether he would be kind enough to show us where in the Bill the essential element of place is to be inserted. Then we can debate it further and put it into the Bill in its right form.