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I will deal with the question posed by my noble friend Lord Marks. Why should we use the word "significant"? The clear aim of its use is, exactly as my noble friend suggested, to stop Ministers intervening in inconsequential matters. There is no case law on the meaning of "significant failure". The Secretary of State will need to decide whether a failure is significant. However, cases have considered the meaning of "significant" in other contexts and have taken the approach that, while a dictionary definition of "significant"-

is not to substitute a different expression for the statute, it remains a helpful indication of what the term means. There is a degree of flexibility inherent in the term "significant", and I believe that that is helpful in the context of the arguments put forward by the noble Lord, Lord Owen-who is not in his place-and my noble friend Lord Mawhinney.

I will first deal with Amendment 152. I respectfully suggest that there is a gap between that amendment and that of my noble friends Lord Marks and Lady Williams. Amendment 152 seeks to amend the Bill to give the Secretary of State wide powers to direct the board and clinical commissioning groups in how they carry out their functions. I said "wide powers", and that fundamentally cuts across the vision of a health service free from political micromanagement. It therefore gets us back into exactly the territory that we want to get away from.

Of course it is important, as I have said, that there are intervention powers if things go wrong and those powers are in the Bill. The Bill also sets out a robust system by which the board will hold CCGs to account. I will come on to that in a moment. Creating a sweeping power of direction would seriously undermine the autonomy of the board and local commissioning groups and allow Ministers to use directions or indeed the threat of directions to second-guess operational decisions. In addition, any direct power over CCGs would duplicate and undermine the role of the board which is responsible for overseeing local commissioning.



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Amendment 153 makes a more subtle point. It seeks to enable the Secretary of State to direct the board should he consider it to be failing to carry out its functions in the best interests of the health service. Let me reassure my noble friend of what I am sure he does not need to be told. We would always expect the board to act in a way that is consistent with the interests of the health service. This is made clear by the duty on the board to promote the NHS constitution and the duty set out by proposed new Section 1E(2), which ensures that the board is also subject to the duty to promote the comprehensive health service. If the board were acting in a way that was not consistent with those duties, then it would be acting unlawfully. That may constitute a significant failure by the board to exercise its functions properly or indeed at all in relation to which the Secretary of State would consider intervening.

Lord Marks of Henley-on-Thames: My Lords, I am sorry to intervene at this stage but does my noble friend the Minister not accept that there may well be two divergent views of what the best interests of the health service are, and that the board may hold one view, the Secretary of State an entirely different view-or, on the other hand, CCGs may hold one view and the board an entirely different view-and that undermines any notion of accountability if the Secretary of State has to stand up in Parliament and say, "I do not believe what the board has done is in the interests of the health service but the board does and I cannot do anything about it"? That is the mischief at which these amendments are directed.

Earl Howe: I take the point but I hope my noble friend will agree that I have an answer. The crucial point is that, while we would expect the board to have a clear shared understanding of what the interests of the health service are, the Secretary of State has mechanisms over the board which he can use if necessary to clearly set out what these interests are. He can do that by setting objectives and he can hold the board to account for those. So he has other levers.

Amendment 277, also in the name of my noble friend Lady Williams, would prevent the Secretary of State from intervening in specific cases where he considers that Monitor has failed or is failing to perform its functions. We believe that it is important for the Secretary of State to be able to intervene in the event of a significant failure by Monitor to perform its functions. That intervention power does not exist at all under current legislation, and we believe it should. We do not believe Ministers should have the power to intervene in individual cases. Such a power would risk politically motivated interference and undermine the independence of the regulator. That point is extremely important.

However, there is an important exception to this rule in relation to the continuity of services. Amendments introduced in another place allow the Secretary of State to intervene in relation to proposals for securing access to services where a provider has become unsustainable. The Secretary of State would be able to exercise a veto if Monitor and clinical commissioning groups have failed to discharge their functions, to follow the proper procedures or to secure access to services.



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We are clear that the wording of the clause as it stands strikes the right balance, enabling the Secretary of State to intervene when necessary to address systemic failure, while ensuring that Monitor is able to carry out its functions free from potentially time-consuming and politically motivated interventions relating to individual cases. The NHS Commissioning Board will also have powers of intervention, as set out in new Section 14Z19, to support CCGs and take action where necessary if there is evidence that they are not meeting their statutory duties or that there is a significant risk of them failing to do so.

I recognise that the intention behind Amendments 220ZAA and 220ZAB, which look to ensure that the board only intervenes in a CCG when it is satisfied that the CCG is failing, or is at significant risk of failing, is to exercise a function in the best interests of the NHS. However, as the Bill is drafted, the board can determine when a CCG is not exercising its functions properly and that is surely the better approach. We are giving the board discretion to determine when intervention is necessary, based on the terms of each statutory function that CCGs have, not in relation to a separate criterion. The amendment would actually narrow the grounds on which the board would have power to intervene, which I do not think would be at all helpful.

Finally, I would like to address the point put to me by the noble Lord, Lord Hunt, about waiting time objectives. The noble Lord implies that Ministers would be powerless in the face of waiting times. That is simply not the case. Ministers' main weapons on this issue would be the standing rules and the NHS constitution. Current contractual requirements relating to waiting times, such as 18 weeks, are covered by the constitution through the handbook and will form a key feature of the standing rules pending passage of this Bill. If the Secretary of State wanted to act on a new waiting time issue, the option is there for the NHS constitution handbook to be revised and the standing rules updated accordingly.

I hope that I have provided enough detail on these clauses to enable my noble friend to withdraw the amendments.

Baroness Armstrong of Hill Top: Will there be issues around the National Health Service that Members of Parliament will not be able to question Ministers about or to get clear answers from Ministers on? I have listened very carefully to the Minister, but I am still very confused about the accountability to Parliament and what the Minister will answer questions on and what he will say is the responsibility of Monitor, the NCB or whatever.

Earl Howe: There are no areas that will be out of bounds to parliamentarians in the sense that the noble Baroness has said. What may happen is that the Secretary of State or other Ministers may respond directly, or in a way that draws upon advice that they have received from, let us imagine, the NHS Commissioning Board; they may quote what the board has said and say that this is the advice that they have received, or they may, as with some agencies at the moment, refer the parliamentarian to that body directly. It will vary. The

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main question that the noble Baroness asks is whether parliamentarians will be inhibited in some way. The answer is no.

Baroness Williams of Crosby: I should like to add a few words before considering whether or not to withdraw this amendment. The noble Earl, Lord Howe, has obviously made the best possible case he can, but given the very extensive doubts on all sides of the House, I feel that he ought to be asked to address this issue very clearly. It is bound up in many ways with the whole issue of the responsibilities and accountability of the Secretary of State which is under discussion at the present time. I will withdraw the amendment on the understanding that it will come back on Report when we have had an opportunity to see how this fits into the whole structure of responsibilities of the Secretary of State.

Perhaps the most simple answer to the question that was asked by the noble Baroness, Lady Wheeler, is that on the basis of Amendment 153 it would be impossible for the Secretary of State to say, "Not me, guv" in response to the point made by the noble Lord, Lord Newton of Braintree. This is so central, and so serious, that in withdrawing the amendment I make it absolutely clear that I do so in order to give an opportunity to the department and to the Minister to consider how this may be best fitted in to the responsibilities and accountabilities of the Secretary of State over the whole of the health service. I beg leave to withdraw the amendment.

Amendment 153 withdrawn.

Amendments 153ZZA to 153ZA not moved.

Clause 20 agreed.

6.15 pm

Clause 21 : Financial arrangements for the Board

Amendments 153A and 153B not moved.

Clause 21 agreed.

Clause 22 : Clinical commissioning groups: establishment etc.

Amendment 154

Moved by Lord Hunt of Kings Heath

154: Clause 22, page 29, line 2, after "services" insert ", primary dental services, primary pharmaceutical service, primary ophthalmic services and primary nursing services"

Lord Hunt of Kings Heath: My Lords, my Amendment 154 brings us to a group of amendments which consider a number of interesting points about clinical commissioning groups and their relationship with GPs, other contractor services and local authorities. They also allow us an early canter at probing exactly where the Government's policy on clinical commissioning groups currently is.



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My first Amendment 154 is partly probing, but it is also to ask why membership of a clinical commissioning group is only confined to general practitioners or, in the jargon of the Bill, providers of primary medical services. What about the other contractor professions within primary care: the dentists, the pharmacists and the ophthalmologists? What about primary and community nurses? I would not in any way seek to undermine the potential leadership role of general practitioners, but they are part of a primary care team. It is rather unfortunate that other members of the primary care team were not considered worthy of membership of a clinical commissioning group.

I must say that I have yet to hear any rational explanation as to why GPs only have been singled out for this exalted membership of a clinical commissioning group. It would have been perfectly possible to have brought all the contractor professions and, I would hope, primary care nurses, into membership of a clinical commissioning group, and then to have a governance structure which none the less recognised the pivotal role of GPs but did not exclude the other professions. One could have had a weighted voting system or some other way of reflecting that yes, GPs are clearly a very important profession in primary health care, but they are not the only one.

I am curious to know why the Government did not adapt that approach, and how they expect clinical commissioning groups to really relate to the other professions. How can they bring them on board? I think of rural clinical commissioning groups and rural dispensing, and how there can be terrible tensions between GPs who dispense in rural areas and community pharmacists in those areas. If I were a community pharmacist, I would be rather concerned that the rural clinical commissioning group is not at all going to act in the interest of community pharmacy. It is almost bound to act in the interest of rural dispensing general practitioners.

I would be interested therefore, if the noble Earl, Lord Howe, could give some further explanation as to the construct of clinical commissioning groups. I should say to him that, having talked to dentists and community pharmacists, they are really concerned that they will be excluded from the decision-making process within clinical commissioning groups, and that it will be purely GP-dominated. Some of the people most concerned, and quite rightly, are primary care nurses, whose voice should be heard. One fears that the traditional approach will be to exclude them from those discussions when they have an enormous amount of expertise to bring to the table.

Amendment 158 is a probing amendment. It relates to the areas of clinical commissioning groups and argues that clinical commissioning groups ought to be coterminous with the boundaries of a local authority or contiguous group of local authorities.

I stress to the noble Earl, Lord Howe, that this is a probe. If health and well-being boards are to work well, there clearly needs to be an integration of public health and commissioning between the various groups at local level to make sure that they come together in a cohesive plan and at interventions. It is very important

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that clinical commissioning group areas at least do not go over into other local authority boundaries. There is an argument for coterminosity, but of course I do accept that in some areas that would make the clinical commissioning groups far too large and that is why I stress to the noble Earl that this is a probing amendment.

In the county, non-metropolitan district areas where you still have a two-tier system, I would have thought there is some concern about the involvement of the non-metropolitan district councils in the arrangements for liaison between local government and clinical commissioning groups. While it does not strictly come within the remit of this amendment, it is a matter to which I suspect we will want to return at Report stage.

Beyond that, this is a good opportunity to ask some serious questions about clinical group commissioning. It seems to be clear that there is now increasing anxiety among GPs that the likelihood of them having significant control of commissioning is becoming remoter by the day. The noble Earl will be aware of the BMA's decision to come out decisively against the Bill. But I have also noted with great interest a press release by the NHS Alliance, which of course has been very much a flag waver for the Government, in which it complained about bullying taking place by the system in relation to clinical commissioning groups. The headline is that doctors leading the NHS reform changes report coercion and bullying in the way the organisations are being set up, which followed a survey of a number of pathfinder clinical commissioning groups. The survey asked: "Do you believe that your clinical commissioning group is being coerced or bullied in how you are setting up in ways that conflict with what you feel would benefit your local population?" Out of the 67 clinical commissioning groups surveyed, 60 per cent answered yes. So much for this hands-off approach that we have been promised. Clearly things have changed. When this started the assumption was that we would have a large number of clinical commissioning groups covering fairly small areas where GPs would actively be involved around the table in commissioning decisions. It has been made abundantly clear that CCGs would not be authorised unless they merged into much larger organisations covering very large population bases.

I wonder whether the noble Earl could perhaps say how many clinical commissioning groups he now expects to be informed. Can he also confirm that they are going to be forced to obtain external commissioning support? Indeed, they have been promised the delight of a bureaucratic procurement process for that support lasting, I understand, up to 12 months. So they are also clearly being leaned upon to use the private sector for such support and they are being forced also to merge commissioning for large-scale commissioning projects. No wonder some GPs are beginning to wonder what this is really all about and whether one beast is being replaced by another. Today Dr Michael Dixon, the chair of the NHS Alliance, told the annual conference about the challenges ahead for clinical commissioning groups or, as he called them, the nation's future clinical commissioners. He said that they will be confronted by the demons of self-interest, factional politics, ignorance, laziness and raw emotion. They will be hated by all of those who have fed from the gravy train of the current system.



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I am a longstanding admirer of Dr Dixon, not least because of his pressure when I was in government to give support to complementary medicine, which I suspect that noble Earl, Lord Howe, now enjoys as well. But I think he made those remarks because he knows, deep in his heart, that the game is up. Whatever one thinks of the Government's reforms and whatever changes have been made as a consequence of the listening exercises, I had always clung to the thought that the Government were serious about giving GPs control of commissioning. It has become abundantly clear that this is not the case. GPs have been sold a dupe and so too has Parliament, I fear. I beg to move.

Lord Warner: I speak to Amendment 157 which is aimed at containing the number of clinical commissioning groups and their total operating costs. I have some sympathy with the remarks made by my noble friend, but before I go into the detail of these particular amendments, I want to give a little context.

My Lords, there has been a great deal of concern expressed by many people who are well versed in the background and activities of the NHS about the number and small size of clinical commissioning groups that might emerge. I do not condone bullying, but we have a problem. The smallest population size for a CCG that I have come across is 18,000 for Radlett, near Watford. I asked the Minister for the Government's latest estimate of the number of clinical commissioning groups likely to be operational in April 2013. In his answer to me on 9 November, he said:

"It is too soon to estimate the number of clinical commissioning groups that will be operational in April 2013. There are, however, currently 266 pathfinder CCGs covering 95% of GP practices in England".-[Official Report, 9/11/11; col. WA 58.]

So it is possible that there could be about 280 clinical commissioning groups when all practices are covered. This is far too many to be effective, for reasons I will explain in a moment. We are getting into an extraordinary position. It seems almost an article of faith, or really bold ministerial courage, for the Government to be embarking on this massive NHS reorganisation, at a time of great financial challenge, without knowing, 16 months before they go live, how many clinical commissioning groups-the bodies that will be handling large chunks of this money-will be in place. That seems a pretty racy way to live with a national icon like the NHS.

We will come to the competency tests for CCGs in later amendments. If those competency tests are to mean anything, a significant number of these groups could, presumably, flunk them. Or will all the geese suddenly become swans? What light can the Minister throw on the likely failure rate for clinical commissioning group applicants? When will we have more reliable data on how many clinical commissioning groups we are likely to end up with? For the purposes of discussing the amendment, I will assume that the Government anticipate having something of the order of 250 clinical commissioning groups by April 2013. For many of us, this would seem far too many, and totally fails to learn the lessons of history. As someone who had to learn the lessons of history in the area of commissioning the hard way, I want to share some of that experience with the House.



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In 2002, the previous Government set up 302 primary care trusts to undertake commissioning. To some extent, in doing this, it was following the course that this Government are trying to pursue-of getting commissioning closer to local populations. That was one of the arguments for doing it and it is not one which I would quarrel with, in principle. But, like clinical commissioning groups, small PCTs were expected to be able to carry out most of the functions of a commissioner. They needed to have all the skills to undertake commissioning, they needed to be effective demand managers, they had to have the muscle to stop acute hospitals gobbling up too much of the money and they had to be able to secure a more appropriate balance between community-based and hospital-based services in their delivery. They failed, and their failures were shown by a number of reports by the Health Select Committee in the House of Commons. They failed because many of them were simply too small and there were too many of them for the commissioning capability nationally available to be able to staff and run that number of bodies. We are heading down exactly the same path with clinical commissioning groups. The manifestation of the failure of the PCTs was the financial meltdown of the NHS in 2005-06. This meltdown occurred after several years of 5 per cent real terms growth in NHS expenditure and in the middle of a financial year with 5 to 6 per cent real terms growth. This is not the situation that clinical commissioning groups will be faced with.

6.30 pm

After the 2005 election I tried to reduce the number of PCTs. We got down to 150; we should have got down to many fewer. We have now ended up in a position where there are, effectively, 51 clusters of PCTs running commissioning in this country. So we have actually ended up, after rather a painful journey, at roughly the right number of bodies that have the effective capability to run a commissioning of services for this country. We are going to throw that away and have a go at doing it with clinicians-whose increased engagement I support-but starting all over again with a number which could be four to five times the number of the PCT clusters. That is a pretty risky strategy in current financial circumstances.

Amendment 157 is an attempt to persuade the Government to have another look at all this and to get real about a credible, effective and affordable number of clinical commissioning groups. It is certainly not 250; it is probably not 150; it is probably nearer the number of PCT clusters that we currently have; it could be even smaller if you wanted to align them more with health and wellbeing boards. The amendment only caps the number at the number of PCTs, but it does enable the Secretary of State to go lower which, in my view, he would be wise to do. If the Government do not get real, we will end up over the next few years -I am in the business of forecasting this afternoon-with a blizzard of mergers and failures, simply because we will not be able to run and operate that number of bodies. Fantasy football management is great fun, but there is no case for extending its approach to NHS commissioning which, on the whole, lacks an adequate supply of star strikers and defenders to keep 250 teams going.



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The second part of Amendment 157 tries to contain the overall management costs of clinical commissioning groups to that of PCTs less 20 per cent, with an NAO audit of the figures. This approach would also curb the enthusiasm for an excess of clinical commissioning groups. The Government seem to be struggling to establish what the management costs of clinical commissioning groups will be. In his Written Answer of 9 November, to which I referred earlier, the Minister told me that CCGs' management allowance,

That is a pretty wide range and it could have significant budgetary implications. How would those range figures compare with current PCT costs and when will we have firmer figures and a clear global sum for the running costs of CCGs? I hope the Government will not simply brush aside amendments of this kind. It will give me no pleasure to say "I told you so" in a few years' time.

Lord Newton of Braintree: My Lords, perhaps I may chip in once again in seeking that my noble friend should at least listen very carefully to what has been said by the noble Lord, Lord Warner. I probably ought to declare a sort of interest in that my wife is currently a member of a PCT board. I would like some clarity about just what the situation is in this respect. As the noble Lord, Lord Warner, indicated towards the end of his remarks, the contrast between what is being put in place at the moment and what is prospectively going to be put in place is even greater than the actual number of PCTs at present because of what has been done about clustering. At the moment-I do not know the exact figure on clusters-there is an even bigger contrast between, as I say, the number of clusters and the potential number of clinical commissioning groups, with all the costs, potential fragmentation and the rest of it that that might entail.

There is another issue and I just want to find out exactly how the Minister sees the position. Clustering has been achieved not by abolishing or merging PCTs but by appointing the same people to the boards of several PCTs. I think that the House should be clear about that. I want to know from the Minister exactly what is the number of PCTs at the moment; whether that number has in any way been affected by clustering; and whether the PCTs, which still exist as legal entities alongside the clusters which are not legal entities, continue to have all the responsibilities and duties that are assigned to them under the statutory basis on which they were set up in the first instance. PCTs remain the statutory entities. The clusters have no statutory basis at all, and we need to be absolutely clear what the situation is, how many PCTs we have and what their responsibilities are.

Baroness Finlay of Llandaff: My Lords, I have an amendment in this group. At first sight the group might seem loosely hung together but there is a common theme running through all this, and that is: how much is all this going to cost? The back-office functions for commissioning are not inconsiderable, and the more that clinical commissioning groups come together, the

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more some of those back-office functions can be merged and cost-savings made-or at least the more that expenditure can be decreased, because it is not really cost-saving. The document Developing Commissioning Support is quite interesting because it reveals the complexity of many of the back-office support functions that clinical commissioning groups will certainly need. Indeed, GPs themselves are independent contractors to the NHS. In many ways, that is why the amendment in the name of the noble Lord, Lord Hunt, is so sensible. Many of the other people working in the community are actually salaried, so they do not get any financial gain from contributing to a clinical commissioning group, whereas there are financial incentives for general practitioners in different ways of commissioning. For example, they often run out-of-hours services and may effectively be commissioning those from themselves within a particular area.

I want to draw the Committee's attention to the need for collaboration in commissioning for those patients and groups of patients who have relatively rare but not terribly rare conditions. I shall take motor neurone disease as an example. In Nottingham, there is a properly commissioned neurological network that works across different PCTs with a lead PCT and the patients with motor neurone disease are able to access a pathway of care-a complete package of care-that is consistent with the Motor Neurone Disease Association's own Year of Care pathway, which it developed to inform commissioning some time ago.

In another area, Southampton, no end-of-life care has been commissioned for motor neurone disease patients over the past five years. That means that patients even have to move to other areas, such as Gloucester, simply to access specialist palliative care when they are aware that they are going to need it at the end of life. That cannot be right. We know perfectly well that when you provide good integrated care, the quality of patients' lives as their disease progresses can be improved by appropriate interventions. However, without it, it is a council of despair. The PCTs in that area have refused to fund end-of-life care for motor neurone disease patients, and it is an ongoing problem. Recently, two of the commissioners in the PCT were so concerned that they made a business case, but it was not backed by the PCT on financial grounds, because it is short of funding.

There is another problem, and another reason that clinical commissioning groups need to come together and collaborate. Quite a few seem to be looking at using the map of medicine as a basis to inform their commissioning decisions, but the map of medicine was not devised and written to guide commissioning. It was meant to guide clinical decision-making, and it is not complete in any one sector. You need to put the different parts of it together. For example, if you take chronic obstructive pulmonary disease, it does not have end-of-life care within its module. So if you use that module, you will not get the complete package that patients need. You also have to go to the end-of-life care module. Some of us who have looked at it in detail do not think that it is an appropriate template to use for comprehensive commissioning of services integrating processes early in the disease and right on through.



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The commissioning groups are going to be on a very steep learning curve. They are going to find things very difficult, and with many small groups, the cost of them trying to do the commissioning will go up, and that is before they have used their funding to actually commission the services for patients that they have responsibility for.

These are very important amendments. This group and the next one get right into the heart of some of the problems that are beginning to emerge over the way that clinical commissioning groups are defined in the Bill.

Lord Mawhinney: My Lords, the noble Baroness, Lady Finlay, was right when she said that these are important amendments because they get to the heart of one of the big issues of the Bill. They pose a problem that only the Government can help us to understand and resolve. The noble Lord, Lord Warner, introduced us to the concept of clusters. Although I am deeply tempted-for I agree with what my noble friend Lord Newton of Braintree said about them-as we are supposed to be brief, I shall resist expressing my views on clusters until we get to the amendments that I have put down to Schedule 6, which deals with these issues, save to say that, at that point, the House is unlikely to be confused about what I think.

The noble Lord, Lord Warner, pinpointed the issue. From my Second Reading speech and also from conversations which he and I have had, my noble friend will know that I am enthusiastic about this Bill because it introduces GP commissioning. I have strong memories of the great advantage that GP fundholding presented to those patients who were the patients of GP fundholders. So I was drawn to be supportive, because I understood that the groups were going to be relatively small. They would benefit from the inter-reaction of GPs and patients, and nobody in the health service knows better than GPs what is in the best interest of their patients.

On the other hand, I recognise the point made by the noble Lord, Lord Warner, that if you have too many of them-as the noble Baroness, Lady Finlay, has pointed out-you run into other difficulties. Were we to wind up with a smaller number of large bodies, then clinical commissioning starts to mean something entirely different from what those of us who were supportive of the Bill believed to be the case initially. The noble Lord, Lord Warner, said there was a danger in all of this and a number of GPs would wind up being very disappointed. I have to say to my noble friend that if we get in to big organisations, there will be more than a few GPs who will be disappointed at the direction of government-policy travel.

6.45 pm

Baroness Jolly: My Lords, I have supported the idea of coterminosity from when I first saw the Bill in January. It struck me as being straightforward and sensible that if health and social care were put together, the health boundaries would be aligned with the social care boundaries. That clearly happened in the middle of the last decade, when PCTs were grouped together to be coterminous with social care boundaries. There are all sorts of issues. If you have a large clinical

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commissioning group, then there is a capacity issue in that you have one clinical commissioning group that might need to work with several local authorities' health and well-being boards, directors of public health, healthwatches or whatever. If you have a small group, then you have many CCGs working with all those bodies. It struck me that if there were a direct fit, everything would look quite neat and hunky-dory. I parked the thought in my mind that everything was fine.

Then I started to look at what was happening around me locally in the south-west. Torbay has been mentioned many times in your Lordships' House. It provided a care trust-health and social care together. One of the areas they are really anxious about is that if they become part of Devon, an awful lot might get lost. So there are special circumstances around that integration. They know that they are small and they are trying to look at making themselves bigger by working with other parts of Devon, all of which take their acute services from one DGH. The same sort of thing is happening in Plymouth. Noble Lords will remember from the Bill about constituency boundaries in January that there was a huge big deal about Cornwall being all on its own. Cornish patients, believe it or not, actually do cross the Tamar in order to go to hospital in Plymouth. A fifth of Cornish hospital patients actually do that, so a whole group of Cornish GPs who face that way, along with some in south-west Devon who face that way, along with Plymouth, have discussed the possibility of working together as a group, simply because they all face one DGH. It was a common bond, if you like.

Therefore, we have a county or a district or a borough seen as one possible common bond. We have an idea that commissioning groups who commission from a particular hospital, trying to work together in a pathfinder mode, is not peculiar to the south-west; a lot people seem to think it would be a good idea. There are lots of issues, so how do we solve this? I still think that, for an awful lot of situations, co-terminosity is the right answer. The test really has to be: what actually can be deemed to be in the interest of the patient? The whole thing has to be taken in the round; it has to include care providers and health providers and there has to be an element of size capacity. My head-and my heart-say coterminosity, but then I look at certain other areas where there are groups that have-

Lord Hunt of Kings Heath: Would the noble Baroness give way? She has raised an interesting point. Could I describe the situation in Birmingham? My understanding is that although there will be more than one clinical commissioning group, there will clearly be one HWB group and the membership has now reached 25. There is one place for providers on it. One gets the feeling that there is a risk that it will become a talking shop. Secondly-and I declare my interest as chair of an NHS foundation trust in Birmingham-if you exclude the providers from those key discussions, you will not get a buy-in. Think of patient discharge and the relationship between reducing length of stay, preventing admissions and the support that social services needs to give packages of care. One worries that you reach a situation where the whole thing is so unwieldy that it will not really work.



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Lord James of Blackheath: My Lords, could I ask the Minister a question that is definitely not medical and about which he might wish to take note for further advice later? In a cluster, does each component maintain its own solvency or do they have a collective solvency? If there is an imbalance in the size of those components and a marginally solvent large component, you run the risk of creating insolvency for the two smaller ones. That would be a severe risk for the trustees of those components.

Baroness Jolly: I have lost my thread. We are talking about Birmingham, which is humongous, and presumably any large city would have exactly the same sort of issues. Is the noble Lord arguing for coterminous clinical commissioning groups?

Lord Hunt of Kings Heath: My point is that my amendment was a probing amendment to get some information from the Government about their intent regarding boundaries. Clearly, one of the problems that we are discussing is size and the larger you make clinical commissioning groups, the less influence GPs will have on their deliberations. The whole point about clinical commissioning groups was to put GPs in the driving seat. I do not know if Ministers know how much pressure within the system is being put upon potential clinical commissioning groups, but they are being told that they have to get large. The numbers who put themselves forward at the beginning were basically told that there was no way that they would get approval, so they have been forced into big marriages.

I simply point out that even if you take Birmingham, where there will be very big clinical commissioning groups, you will still end up with an unwieldy health and well-being board. One has to think through the implications of this if you are then trying to get a cohesive strategy on public health and on joint commissioning that pulls all of the players together-while still excluding the providers from those discussions. We started from an original prospectus that was going to give GPs real control over commissioning. That is gone. I agree with the noble Lord, Lord Mawhinney. I do not think that there is now any chance in the system that is being forced upon the service, that individual GPs will have any influence. As with the noble Lord, Lord Mawhinney, it is clear that GPs are realising this now, and that the prospectus is a false one.

Baroness Jolly: I think that the noble Lord's point is well made. The noble Baroness, Lady Finlay, however, talked about the element of size and back office, which needs to be quite large. Small CCGs will need to share a back office, simply because that is the way it is. There will need to be shared commissioning arrangements. I think that the noble Earl, Lord Warner, was saying much the same thing: these things will not work if they are tiny but might if they are larger. I remember primary care groups, which became primary care trusts, which became bigger primary care trusts. What is a reasonable size to make all those linkages work? What we do not want is for all of these organisations to spend their days going to meetings. If we are not careful and clinical commissioning groups go over local authority boundaries then they will have to serve more than one health and well-being board.



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The ideal would be to have some co-terminosity but clearly it will not work in really enormous situations. My background and experience is in rural areas, where it strikes me as the most obvious way forward. Even if that is not how it starts, that is how it probably should end up. As for the Torbay example, the PCTs are very small. However, they are also perfectly formed and have done a really good job. They are desperate to keep what they did, and did well, but they are being pressured to join a Devon PCT-which also has pressure on Plymouth, which is also part of the Devon PCT. So it is not a straightforward picture. When clinical commissioning groups put their case to the board, there needs to be some sort of nuancing in application.

Baroness Murphy: My Lords, is not the whole point of the formation of clinical commissioning groups that it should be a local solution that fits the configuration of a particular urban or rural area and that it should be decided locally with the Commissioning Board what the best fit is? I take the point made by the noble Lord, Lord Warner, that size is an important issue as to whether one is favouring individual GP commissioning of a personal family health service or whether one is going for the much bigger purchasing of population services. Surely the big difference with this Bill is that PCTs had no real central support for developing commissioning in the way that clinical commissioning groups will have very explicit support from the Commissioning Board. I can see that the noble Lord, Lord Warner, is shaking his head, but I think that makes a huge difference because we have seen the concentration of emphasis by the Department of Health on the acute sector, and to get a way towards having much greater leadership from the centre in developing commissioning seems to me a very positive thing.

The noble Lord, Lord Hunt of Kings Heath, asks why is it only GPs-why do all professionals not get involved? All local primary care clinical professionals should have an input to the groups' deliberations, but surely the obvious answer is that it is GPs who specifically use resources for their patients from secondary care. They actually determine the costs in secondary care through their use of secondary care hospitals; they intervene to stop secondary care-they have the possibility of doing it through provision of primary care; and they have enormous control over the funding, potentially, of the hospital system. It seems absolutely obvious that it should be GPs. The input of local dental practitioners, opticians and pharmacists is vital but they do not play the same financial role and that is why it seems to me it has to be GPs.

We cannot in this Chamber fix this Bill to lay down rules for the development of clinical commissioning groups. It would be absurd. The Commissioning Board and local people who are going to contribute to it have to make that decision. They have to be the ones to make it work. If they need to come together to commission services for rare conditions, that is fine.

Lord Warner: There are very few things in health policy on which I disagree with the noble Baroness. However, this House needs to look at what the evidence base from GP fundholding and practice-based commissioning shows us. The evidence base shows

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that GPs did quite well in commissioning some services. However, their actual impact on reshaping services out of acute hospitals was virtually zero. There have been some very good evaluations of GP fundholding and some less good evidence from practice-based commissioning. These showed that GPs got very close to their patients, understood what they wanted and reshaped some services. The transaction costs were seriously high in GP fundholding, which demonstrated that doing good commissioning requires a lot of data collection and analysis, which does not come cheap.

We need to understand the issue of muscle. People like the Nuffield Trust have done some good work on this. At the end of the day, the GP commissioners we have had so far were not strong enough and did not have big enough budgets or the analytical capabilities to call the shots with acute hospitals. That is the bottom line. I strongly support GP commissioning in principle. However, we are in danger of repeating the mistakes of the past and not learning from those experiences.

Baroness Murphy: I do not disagree with the noble Lord, Lord Warner. It is absolutely true that there is a balance and that size is important. Nevertheless, at the moment we are going back to a size that is approximately the same as the old district health authorities that we had between 1983 and 1992. They survived for quite a long time-

Lord Patel: Too small.

Baroness Murphy: I agree; they were too small. However, if you want to get that balance and that advantage of the clinical commissioning, it seems that, with a different sort of central support, it would be possible. With some local responses and reconfiguring of commissioning groups and the old PCTs, it can work. I do not feel quite as depressed about the clinical commissioning groups as other people.

Lord Greaves: I was going to make merely a brief intervention on this group on the question of coterminosity. However, this has extended into a much more important debate, which is coming down to some very fundamental issues in relation to clinical commissioning groups. The noble Lord, Lord Hunt, is to be congratulated on introducing this debate because it is absolutely crucial. We have to have it some time-if we are having it on this amendment, fine.

The noble Lord said in passing that the same issues keep coming round at different stages of the Bill. On this Bill the same issues keep coming round in different sessions in Committee. This is the second time we have talked about coterminosity. I think previously it was on an amendment from his colleague, the noble Baroness, Lady Thornton. I will not repeat everything that I said then, except to say that there has to be some flexibility. There are very good arguments for saying that CCGs should not cross local social care authority boundaries. However, the point I made previously was that in very large counties, like Lancashire or North Yorkshire or, if I think about the south of England-which I force myself to do occasionally-Hampshire and Kent perhaps, at the very least they ought to have the ability to not have a very large CCG forced on them that covers a whole county, which would be very remote indeed.



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We have heard about Cornwall and Devon from my noble friend. We have heard about Birmingham. I am going to say a few things about Lancashire. I am very interested to know whether there are any noble Lords in Committee today who are very clear about what is happening in relation to setting up CCGs in their own areas, how it will work and what will come out of it. Asking colleagues on the Liberal Democrat Benches while this debate has been going on, nobody seems to know; chaos and confusion seem to be the impression. I am not saying that it is chaos and confusion, but as far as ordinary members of the public are concerned, let alone other people like myself who try to take a more direct interest, it is not very clear at all what is happening, or if what is happening is clear, it is not clear why and how it is happening. This comes back to the points raised by the noble Lord, Lord Hunt, about the fact that there are very clear pressures from above that are moulding the system that is going to take place. I very much take the point from the noble Baroness, Lady Murphy, that there ought to be local discretion and local decision-making here. However, that is not happening. People are being forced into decisions, and that goes against what she was saying.

Let me tell you about where I live, in east Lancashire. At the moment there are two PCTs. There is a Blackburn with Darwen PCT, because Blackburn with Darwen escaped from Lancashire County Council at some stage in the past and became a small unitary authority, so it has its own PCT. The other five districts, which are part of Lancashire County Council, have an East Lancashire PCT which, as the noble Baroness pointed out, had been formed by amalgamations over the years. There is one East Lancashire Hospitals NHS Trust that effectively covers the two PCTs, so there are two PCTs and one hospital trust at the moment. The PCTs have been combined with the rest of Lancashire into a county-wide cluster, but the East Lancashire PCT still exists.

I have recently been given a whole set of minutes and agenda papers, a great big thick file, from a relatively recent meeting-in the last few weeks-of the East Lancashire PCT. Although they find it increasingly difficult to keep going because all their chief officers have gone, there are still functions taking place at the PCT level; there are functions taking place at the cluster level, and for somebody like me who takes an interest in but is not directly involved in the health service nowadays-I used to be on a district health authority, an area health authority and a community health council, but am not now-I find it very difficult to find out where the decision-making is taking place.

Back when CCGs came along, the original idea was that they would be quite small, as the noble Lord, Lord Mawhinney, quite rightly said. They would be groups of GP practices within a recognisably local area. Whether that was a good or a bad idea-and in many ways it was an attractive idea-that has clearly now gone by the wayside. People were told that the minimum that you could get away with in east Lancashire was district-wide-that is the lower tier-so people were getting together and forming proto-CCGs at the district level.



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In terms of population, Rossendale is about 70,000 and Pendle is probably the biggest of the five at about 90,000; it is that sort of range. The doctors who were getting together and working on these CCGs-and certainly in both Burnley and Pendle they were working closely with the district authorities to share back-room services and so on when they were set up-were told that this will not do any more. I am not at all clear who told them, but it has been made absolutely clear that there now has to be a new CCG covering the five districts, an area of 450,000 people. It is a very significantly different proposition, however you define significant, from groups of local practices, where the whole thing started off.

Blackburn and Darwen, because it is a unitary authority, is insisting that as far it is concerned, it will have its own CCG, which will be coterminous with the relatively small unitary authority, which has a population of around 140,000.

Lord Hunt of Kings Heath: Has that potential CCG been told that it will not get authorised? I would think that that is the way in which the system will force it into a larger merger.

Lord Greaves: I assume so, but I have no personal knowledge of the processes that are leading to these outcomes. All I hear about-from talking to people who are professionals and politicians involved in these systems and through the normal bush telegraph-is the outcome. The outcome is that there is almost certainly going to be a CCG 450,000 bigger, as I understand it, than any of the doctors involved would really like, and there have to be far fewer doctors involved from each of the districts. In my own district, it was going to be a Pendle-wide organisation where all the doctors involved would be known to a lot of people in Pendle, but now there will be just a small number from Pendle and some from Rossendale and some from far-flung parts of the Ribble valley. Meanwhile in west Lancashire, along the Fylde coast, where there is a string of small holiday towns with Blackpool in the middle and then a large area of countryside, are the two districts of Fylde and Wyre while Blackpool itself, the main town of the Fylde coast, is a unitary authority. What we understand is going to happen there-I have no direct evidence of this, it has come through the bush telegraph-is a CCG of Fylde and Wyre, a relatively smaller one, with Blackpool on its own. Of course all the hospital services and everything else are mainly in Blackpool. There does not seem to be any logic about what is going on, even though it is being defined by local authority boundaries.

I ask the Government to provide some clarity over what is happening in two ways. First it would be very helpful to have clarity on what is actually happening in each area, and for this whole process to be taking place in a much more public way. But it is not. It is all taking place out of the public gaze, and unless there are local journalists who are particularly interested in it and try to research it, nobody has the slightest idea what is going on, whether or not it is being decided locally.



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More importantly, I accept what the noble Baroness, Lady Murphy, says, but I think that we need an understanding of the sort of pattern which is going to result from this Bill once it is enacted and the CCGs are set up. We want a clarity of vision from the Government. What sort of number are they talking about? What range of size will be thought to be permissible? If they are saying that it could stretch from areas of 15,000 right up to a major city of half a million or so, and that sort of thing will be left to some sort of diffuse local decision-making, then that is okay, but we need to understand that. If, on the other hand the Government are saying that a lot of the groups that have been looking at this are far too small and they have to be much larger, then they are really moving towards what I might call the Lord Warner position, and again we need to understand that. We have a right to know what the outcomes of this legislation are likely to be before we allow it to go forward.

Baroness Wall of New Barnet: My Lords, the noble Baroness, Lady Jolly, has made a very strong argument for what might happen in her part of the world. However for London it is very different, and I want to remind noble Lords that this is about health and social care, and relate what happened in my area.

My trust is part of north central London and that cluster is now going to be merged with north east London. The cluster has been a great improvement on the separate PCTs, not just because of the way they do things, but in the whole vision they have of the health economy. One of the things that we suffered from in Barnet and Chase Farm and North Middlesex was that we were all separate, independently operating providers. We just took notice of what we were providing and what was happening around us. The BEH-Barnet, Enfield and Haringey strategy-made us look beyond that at the whole health economy. The evidence is that we have been failing in not providing social care or community care because each individual provider was looking at what was happening for them and its importance to them.

I can only share the experience that is happening in London. My view is, and our experience as a trust is, that the bigger the cluster has been and the bigger the cluster will become, the more opportunity there is to ensure that the whole health economy of the people that we serve is going to be taken into account, rather than that minuscule Barnet PCT, Enfield PCT or Haringey PCT. I know that they are much closer than Lancashire, and I come from Lancashire, so I recognise some of those areas. People are questioning what is happening in London, and it is very different. The smaller the groups, the worse it is, in my experience, because we are not addressing the whole economy.

I believe, as the noble Lord, Lord Warner, has said, that we need a much broader and wider experience in the sense of the numbers that we might have. I do not know how big is big or how good is big. What I do know is the difference that it has made, in my experience, across London, that the bigger we have got in the sense of the clusters, the better the service has been and the more able we have been to take our eye away from just acute providers to looking at what is going

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on in the community. We have failed to do that, and all the debates that we have been hearing in the House during the passage of the Bill have identified how much we have been failing. Most of the social care issues that we have discussed are about how we failed. In my view, as a chair of an acute trust, it is about us being focused on patients coming in to hospital rather than patients being able to have their provision elsewhere. From my experience in London, we need less of them, so that we get a complete health economy view.

7.15 pm

Lord Greaves: What the noble Baroness, Lady Wall, says is very interesting. Does she understand what the future pattern of CCGs in that area is going to be in relation to the borough PCTs and the clusters that she is talking about?

Baroness Wall of New Barnet: In my experience, the PCTs, in a sense, do not exist any more, in my part of London; I am not sure about elsewhere. Contrary to what the noble Lord, Lord Newton, suggested, it has not happened in London. All the PCTs have not been absorbed into the cluster. The chair of each of the PCTs that were in place before the cluster and the growth of the cluster has been seconded as chair of their particular PCT. For me, the important thing is who is making the decisions about the commissioning and what view they have. What is the panorama that they are looking at, rather than the closeness of the individual boundaries? Certainly from the PCTs in London, the clusters are taking over the way that is going more and more; and their relationship with the GP commissioners is much closer than it ever was in separate PCTs, and that has been part of the issue.

Lord Greaves: I am really impressed by the enthusiasm shown by the noble Baroness. I understand exactly what she said. The way in which the clusters have been put together is exactly the same, as I understand it, as in Lancashire. What I am trying to get her to tell us, if she knows, is how many CCGs there will be in the area of her cluster once the clusters have disappeared.

Baroness Wall of New Barnet: I cannot answer for the whole of London. I really do not know. What I do know is that the more the clusters emerge, obviously the more those PCTs will be absorbed into them. My noble friend will be much more able to give you more detail about that.

What is happening in real life in north central London is that the PCTs are being absorbed into the cluster. Contrary to the experience of the noble Lord, Lord Newton, the clusters have not just taken over the whole PCTs, including staff and everything else; they have not. In fact, the chief executive of the cluster in north central London did not come from north London at all. So that is very different, I think, from some of the experiences that other people have. However, I cannot give you the view of the whole of London because I really do not have that knowledge.

Lord Hunt of Kings Heath: My Lords, perhaps I could intervene to say that I echo everything that my noble friend said about the work of the clusters.

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They are covering, in my case, some 1.3 million and clearly are trying to get to grips with the strategic leadership that is required on the whole issue of reconfiguration of bed numbers and all the things that have been put off for so long. My understanding is that they go on as local field offices of the NHS Commissioning Board. That is the whole point. The question that then comes back, and where I am completely puzzled, is where on earth is GP commissioning in this? It is abundantly clear that the clinical commissioning groups are going to have very little influence. When you come to the issue of the individual GP, which was what this was all about, it is very hard to see what on earth they will be doing in terms of commissioning.

Lord MacKenzie of Culkein: May I intervene briefly, as I have my name down to Amendment 168? This has been a very important debate, and I want to return briefly to the issue of collaboration. Whatever the outcomes in size of the clinical commissioning groups, there will be a need for joint commissioning. I refer particularly, as the noble Baroness, Lady Finlay, has said, to some of the rare conditions, such as many of the neurological conditions, which will require a population, as I understand it, of some 250,000. For motor neurone disease this will be a population of some 500,000. It is vital that we have in the Bill something about joint commissioning for long-term illnesses. We will come back to that issue in a later group of amendments, but I want to emphasise its importance.

Baroness Tonge: My Lords, before the Minister gets up, I would like to ask him a very simple question. Noble Lords will have all realised by now that I have no faith in this Bill whatever, and never have had. I think it is totally unnecessary in the current economic circumstances, let alone other circumstances. Will the Minister tell us honestly what the reason was for clinical commissioning groups? Why could we not have kept the PCTs in whatever clusters they have formed together, and put clinicians, GPs, dentists and nurses into those groups to lead the commissioning process? Why did we have to have this massive upheaval to achieve what, according to what most of the speakers here tonight think, is not going to be achieved anyway, as the GPs will not have much input? Perhaps he could explain.

Lord Newton of Braintree: My Lords, I apologise for intervening a second time. I want to link with things I raised the first time, because I have been left in some confusion by the noble Baroness, Lady Wall-which is not her fault-said about what has been happening in London. My understanding is that at the beginning of the year the department issued a document suggesting four possible ways of doing clustering. One was along the lines that the noble Baroness spoke about. I forget what all four were, but one was that PCTs should informally group in clusters, create an informal board, and have one of the chairs, perhaps a rotating chair in some cases, who would oversee the informal cluster board. The legally existing boards would continue.

At the back end of September, the department, at least as interpreted in the east of England, issued an edict saying that there were no longer four options.

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There was to be one, and it would be clustering, based on appointing the same people to more than one PCT board. That raises a number of issues, as my noble friend Lord Mawhinney has indicated with unmistakeable clarity, to which he and possibly I might wish to return later. Meanwhile, how many legally separate PCT boards exist at the moment, who is on them, and were different policies pursued by the department in different parts of the country? What the noble Baroness-my noble friend-Lady Wall said suggested that a different policy had been pursued in London-not for the first time, I may say-than was being pursued in the east of England at least, and possibly everywhere else. We need some clarity, not just on what the future is going to be, but what the present is.

Earl Howe: My Lords, the principle behind clinical commissioning is that decisions about local services should be made as close to patients as possible by those who best understand their health needs. This is why the membership of CCGs should comprise GP providers, rather than other primary care providers, such as dentists, opticians and pharmacists who do not have the same relationship with patients or responsibility for a registered list. I hope this answers the question posed by the noble Lord, Lord Hunt, in his Amendment 154. However, of course effective commissioning will require the full range of clinical and professional input.

Although the members of clinical commissioning groups will be GP practices, the groups will be required to obtain advice appropriate for enabling them to effectively discharge their functions from a broad range of healthcare professionals. So this is not a matter of other professions being shut out; quite the opposite. Other professionals may also be invited by the CCG to be members of the CCG governing body and, as regards nurses, regulations may require that governing bodies include certain healthcare professionals, such as a nurse and hospital doctor. Also, other clinicians could be directly involved in influencing the decision-making of the CCG through, for example, membership of a committee of the CCG, without needing to be members. The basic point is that the function of clinical commissioning is directly linked to the function of the general practitioner and we should not risk diluting the effectiveness of the proposed approach.

The noble Lord, Lord Hunt, suggested that CCGs will not be led by clinicians. I am surprised to hear the noble Lord say that, especially as he has been paying tribute to the work of the NHS Alliance and Dr Mike Dixon for whom I, too, have a high regard. I understand that when Dr Dixon spoke at the NHS Alliance Conference this morning he said that we stand close to liberation of clinicians on a grand scale. That indicates to me that he believes that this is a huge opportunity for primary care clinicians.

My noble friend Lady Tonge asked what this is all about. The philosophy behind these new organisations is different from what we currently have. Clinical commissioning is about placing the financial power to change health services into the hands of those NHS professionals whom the public trust most and giving GPs the flexibility within the legislative framework to

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The Bill sets out high-level requirements for working together, including at new Section 14Z1 in Clause 23 provision for CCGs to enter into arrangements with other CCGs to exercise their commissioning functions. That addresses the point that was made earlier about commissioning for groups of patients who are smaller in number in a small area. One has to commission at the right level. These can include both joint and lead commissioning arrangements and this may be a topic which the board chooses to cover in its commissioning guidance.

The process of the local development of commissioning organisations is well under way, with pathfinders-emerging CCGs-coming together to begin to explore approaches to commissioning and building up their organisations, supported by the PCT clusters, about which I will talk in a moment. The board will be responsible for undertaking a rigorous assessment of all prospective CCGs, prior to authorisation, to ensure, for instance, that they are of an appropriate size, that they cover an appropriate area and have put the appropriate arrangements in place to be effective commissioners. I would say to my noble friend Lady Jolly that there will be a presumption in favour of coterminosity with local authority boundaries. But as we have previously discussed, and as advised by the Future Forum, local flexibility must include, in exceptional circumstances, the flexibility to cross a local authority boundary where that is appropriate to patient flows.

I am afraid that I do not agree that we should place arbitrary constraints on the number of CCGs or on their budgets as Amendment 157 would do. I appreciate the keenness of noble Lord, Lord Warner to ensure that the maximum resources available are devoted to patient care. The Government share that concern, but the way to do this is to ensure appropriate controls over administration costs and ensure good governance on how that money is spent and the outcomes that it delivers.

Lord Mawhinney: My noble friend said that they would have to decide on the appropriate size. Does he know what that size is approximately likely to be, and if so could he share it with us? Or is that something that is still to be determined?

Earl Howe: I am grateful to my noble friend and I was coming on to that very point, which was a question posed by the noble Lord, Lord Warner and others-my noble friend Lord Greaves expatiated on that theme. Our starting point is this: we do not wish to be unduly prescriptive about the size of clinical commissioning groups. There have been widespread variations in the size and population coverage of PCTs and there is no evidence to suggest that there is a single right size. If one looks at the history of the National Health Service over the last 20 years it has been an attempt by successive Governments to find a right size and we never quite succeeded. It is important that solutions develop from the bottom up and are not imposed from above.



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Lord Greaves: I apologise for intervening, but if that is the case can my noble friend the Minister tell me who told the group of GPs in Pendle, who had been developing proposals for a CCG, that they would have to go in with the other four districts in East Lancashire?

Earl Howe: My Lords, in those instances, and they are very few, where a pathfinder CCG is of a manifestly unviable size, then it is right that they should receive advice to that effect at an early juncture. Advice is the word. The initial thinking is simply suggesting that emerging groups should be considering the impact of their proposed configurations on their organisational viability and the degree of sharing roles and functions or the use of commissioning support that they might need.

Lord Greaves: Is my noble friend, therefore telling me that a well defined borough with a population of 90,000 is manifestly unviable for this purpose?

Earl Howe: No my Lords, I am not aware of the specific circumstances that my noble friend refers to and of course I will find out and give him greater chapter and verse if I can.

Lord Warner: I thought I would get my question in before the noble Lord gets warmed up again. He said there is no indication from the evidence from the past of what the right size for a PCT was, but there is some evidence from the past. I do not think that there was ever constructed a PCT of under 100,000 population, which compares with 18,000 in Radlett for a CCG. If you actually look at what happened when we asked PCTs and SHAs to work together and engage in local consultation in 2005-06 on reformulating PCTs, the general thrust of what they came forward with was twofold: it was to be bigger in size and to be a better match with the boundaries of the upper-tier local authorities, which were the social services authorities. So there was some evidence that people themselves, when engaged in an exercise of reorganisation, moved towards bigger organisations and coterminosity with social care authorities.

Earl Howe: Earlier on I noted that the noble Lord drew parallels between CCGs and his attempts when he was a Minister to reduce the number of PCTs. I do feel there is a critical difference. The decision to establish a certain number of PCTs was taken in Richmond House by Ministers. I am not saying those decisions were arbitrary-of course they were not-but they certainly were not bottom-up. With CCGs, the onus is on GP practices to determine the most appropriate size and configuration for their local population. As I have said, the board will then rigorously assess whether this proposal will result in the CCG being able to fulfil its functions. That is a judgment, but it is a proper fitness for purpose test which PCTs never had to go through. I simply do not accept that, come April 2013, there is likely to be a raft of CCGs failing. If a CCG's proposed constitution is not robust, then it will not receive full authorisation.

Lord Hunt of Kings Heath: I do not think that is quite fair, since I was involved in setting up PCTs. I accept the strictures of my noble friend about whether

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we made them too small. As for the idea that Ministers came up with PCTs, it was of course the service which, basically, came and made recommendations. Frankly, the same tiers are deciding on CCGs as decided on PCTs. There has been huge pressure on CCGs to come together and merge. Yes, it started as a bottom-up idea, but I have to put it to the Minister that the reason why I quoted Dr Mike Dixon is because he, like many people, knows that the "forces of bureaucracy", as the noble Earl, Lord Howe, likes to put it, have been very strong and have basically said to CCGs that they will not get anywhere unless they merge.

Earl Howe: Yes, the noble Lord, Lord Hunt, suggested earlier that there was a process of shoe-horning CCGs into certain shapes and sizes, forcing them to take up external support and merge commissioning functions. I emphasise that CCGs will not be forced to take up external support or merge functions. What is happening at the moment is a process of advice and information from the centre. Obviously, the board will not authorise the establishment of any CCG which could not satisfy the board of its ability to discharge its functions and be an effective commissioner. We want to ensure that the process is not too bureaucratic or cumbersome. The noble Lord suggested that it was likely to be, but I do not accept that. We are working with stakeholders to ensure that emerging CCGs can articulate their requirements for commissioning support. I do not accept the picture that he has painted.

My noble friend Lord Newton spoke about the clustering of PCTs. Clusters bring together PCTs to prepare for and support the transition to clinical commissioning. Until PCT abolition in April 2013, they continue to exercise their functions and remain statutorily responsible for their functions until abolition. Pathfinders, or emerging CCGs, can act as sub-committees of PCTs until this time. The role of PCT clusters during the transition is to support clinical commissioning groups, not dictate how they operate. For the reasons that I have stated, it is important that CCGs have the freedom to develop their own solutions from the bottom up and that they are fully supported in doing so. The latest operating framework for the NHS emphasises this and we will see that it is acted upon.

My noble friend Lord James queried the legal arrangements. The process of clustering has been open and transparent. If it is acceptable to noble Lords, I can provide a written update on the latest position, giving the numbers, locations and so on, to save time.

Lord Greaves: If a CCG pathfinder can operate in the mean time as a committee of the PCT, will it act as a sub-committee of the PCT or of the cluster?

Earl Howe: Of the PCT, because the cluster has no legal standing.

Lord Hunt of Kings Heath: My Lords, I thank the noble Earl, Lord Howe, for his response. This has been a really good debate, which has gone to the heart of the Bill and the Government's intentions. I would like to come back to a point that the noble Baroness, Lady Murphy, made when she reminded us of the central tenet of the Secretary of State. Essentially it is that

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GPs are responsible, like GPs the world over, for most expenditure in the NHS, either through their referrals or through their prescribing decisions. The clear intent was to put budgetary responsibility with referral and prescribing responsibility, in the hope that it would lead to a more cost-effective system. I think the issue that many noble Lords have is that in the way this has emerged and in the guidance that has been given by the board and the department it is becoming clear that the influence of the individual GPs within this huge structure that is being established is likely to be very limited. On the other hand my Lords, because of the mantra of the Bill and the reforms, patients are likely to believe that it is their GPs who are making the commissioning decisions. Therein lies trouble, because I think the GPs are going to be in a very unenvious position. We as patients will hold them to account for commissioning decisions in a way they have never been held account before, but their influence on commissioning is going to be very limited indeed. I think this has been a very good debate, I beg to withdraw my amendment.

Amendment 154 withdrawn.

House resumed. Committee to begin again not before 8.41 pm.

Prevent Strategy

Question for Short Debate

7.41 pm

Asked By Lord Noon

Baroness Stowell of Beeston: My Lords, I hope noble Lords will find it helpful if I remind the House that the next debate is a time-limited debate and, with the exception of the noble Lord, Lord Noon and my noble friend the Minister, speeches are limited to four minutes. The right reverend Prelate the Bishop of Hereford has also requested to speak in the gap.

Lord Noon: My Lords, the Government's revised Prevent strategy was presented to Parliament in June this year. It is an integral part of the broader fight against terrorism and I welcome the opportunity to have this short debate about the implications of this strategy, and of extremism and integration. The thinking behind Prevent was that there needed to be a proactive response to the threat of so-called home-grown terrorists. I do not want to speak about the merits or failure of the original strategy. Other noble Lords, including my noble friend Lord Carlile, who provided the important independent oversight for the review of Prevent, are much more of an authority on this issue than me.

I am not a policy man, I am a businessman and I like to speak my mind in a straightforward way, which, in business as in life, is usually the best way. You may be aware that I have been a victim of deadly terrorist attack not once but twice. The extreme fear that I and my family experienced, the shocking uncertainty of

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being sandwiched between life and death, brought home forcefully the grief and devastation of the families who suddenly, unexpectedly lose loved ones. We have seen this horror here in the UK with the 7 July terrorist attacks in London. What is worse is that the 7/7 attack was carried out by young men born and brought up in the UK. The Prevent strategy is supposed to stop people from ever going down this path. It is about confronting people at an early point so that they do not become extremists.

Christians, Jews, Muslims, Hindus, Sikhs, Jains and Buddhists all have the right to practise their religion freely in Great Britain. The strong civil rights movement here ensures that we can express our religious and political beliefs freely. At the same time, there is a thousand years of tradition of the supremacy of the law-we must abide by the law even as we practise in private the faith of our choice. What has gone wrong is that a tiny minority refuse to accept that. Instead they wish to impose their beliefs on the majority. Noble Lords will agree with me that the majority of Muslims are law-abiding, peaceful and patriotic citizens, as was reported in the Sunday Times on 20 November. I see no conflict between practising Islam and abiding by the rules of the law of this country, and I speak as a Muslim.

I have expressed my views many times, in speech as well as in print. People who do not accept the British way of life should find another acceptable country where they can live happily, and leave us alone. Often they come here as economic migrants and then oppose our common values. In many cases, they are running away from harsh regimes that do not permit dissent. I am a staunch supporter of the British values of democracy, decency, fairness and integration. I say, live and let live. We should give a robust retort to those who oppose integration: we cannot have small, independent enclaves within our country that are a law unto themselves. I agree with the Prime Minister's words in Munich earlier this year that we have not done enough in standing up to those who oppose our way of life.

I find it confusing that the Prevent strategy makes a distinction between two things. On one hand, the strategy says that having a strong sense of belonging and citizenship makes people more resilient to extremism. Then, on the other hand, it states:

"Policy and programmes to deal with extremism and with extremist organisations more widely are not part of Prevent and will be co-ordinated from the Department for Communities and Local Government".

Could the Minister tell me what these wider policies and programmes are that are not part of Prevent? Surely these are things that promote cohesion, interfaith dialogue and citizenship. If the success of the programme depends on our sense of belonging-which is what I call integration-then how could this not be a part of Prevent? By separating integration and extremism, the Prevent strategy will create its own pitfalls. How do local councillors know what to do? Where is the guidance that explains how to know the difference between an extremist acting against our country and others who need support and direction to become more integrated? Where is the line drawn between dealing with extremists and promoting integration? Surely these are two sides of the same coin.



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What about young people? How will the youth worker or the teacher know what to do? We need a strong initiative for the youth; after all, it is the youth who get lured into extremism at youth clubs and universities. The hunting fields for fresh recruits to terrorism are the stamping grounds of young people. That is where we need to be: to reorient them into a life of decency; to give them a sense of belonging; to make them proud to be British; and to make them see that using religion as an excuse for violence goes against its very tenets.

What about the police? I often speak to them on this issue. I ask them why individuals or groups who are violently opposed to our way of life and the laws of this country are allowed to be here. The police say that their hands are tied; they often have no case. It seems that the human rights of criminals outweigh those of the rest of us law-abiding citizens. Even when they manage to bring such a person to court, the Crown Prosecution Service tells the police that the criminal is the one who needs protection. It strikes me that in trying to make Prevent more focused, the Government have risked making it less effective. Even more seriously, I believe that this fudge makes things much worse. It risks further alienating those communities that feel the most stigmatised and targeted by Prevent, especially the Muslim community.

The danger of focusing only on a certain religious group was made clearer to us by the terrible events in Norway in July this year, when a right-wing extremist not only set off a bomb in the city, killing eight people, but then went on to shoot and kill 69 innocent children and young people who were taking part in a summer school. Such acts of extreme violence are not restricted to ideology, whether religious or political. Rather, these terrible acts are born of hatred, racism and ignorance. We ignore these risks at our peril.

In summary, I have a very simple bottom line, which is that preventing terrorism depends on strengthening integration. In my straightforward way of looking at things, there is definitely a problem because the strategy actually causes confusion about this issue. I welcome the idea that we need to confront people more when they express extreme ideas such as threatening to burn poppies, abusing our brave soldiers returning home from the front line in Basra or asking for Sharia law in this country. Let us not forget honour killing, although I do not know what honour there is in killing. Surely this is not acceptable. We need to go further. We need to ensure that we not only confront these people but that we actually deal with them in order to protect the citizens of this country. We need to be clear that this is about anyone who opposes our way of life, anyone who does not clearly stand up for democracy and freedom of choice. Integration is our greatest strength and we must not allow our resolve to protect it to be weakened by a muddled approach to extremism.

I am sure that noble Lords will have many further issues that they wish to bring to this debate, and I look forward to hearing them.

7.51 pm

Lord Ahmad of Wimbledon: My Lords, first, I thank the noble Lord, Lord Noon, for initiating this debate.



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9/11 and 7/7 changed Britain and the world. From London to Lahore, from New York to New Delhi, terrorism cannot be ignored. A new kind of terror emerged with 9/11, as we saw on 7/7, attacking the very basis and basics of British society-a society enriched by its secular democracy, multitude of faiths and diversity of communities. The terrorists used the ultimate weapon, destroying their own lives to take the lives of others. They sought legitimacy then, as they do now, 10 years on, by cloaking their vile and heinous acts in the name of religion-of Islam. Yet these criminal acts are far removed from the principles of Islam which, not only in its teachings but in the essence of its very name, stands for peace. Islam unreservedly and totally rejects all forms of terrorism and violence. Islam-indeed, all religions-cannot sanction violence and bloodshed of innocent men, women and children in the name of God. However, the reality is that there are some who seek to hijack noble religions and principles, to perversely interpret them and through their misguided actions, often fuelled by extremist preachers, seek to bring about terror. As 9/11 and 7/7 demonstrated, they succeed in carrying out such acts.

Against this backdrop of real and present danger which surfaced 10 years ago and continues to this day, we need to take action on prevention and, more importantly, a permanent and lasting solution to eradicating this evil from our society. Therefore, I welcome the new Prevent strategy, for it recognises the need to tackle the ideological challenge and the threat from those who promote terror and extremism. It is not aimed at those with legitimate religious beliefs. As my right honourable friend the Prime Minister has said, to be devout in faith should not be equated to extremism; indeed, if you are truly devout about faith you are anything but an extremist.

Prevent deals with all forms of terrorism, but I seek my noble friend the Minister's assurance that, while wider programmes dealing with extremism and its implications do not fall under the regime of Prevent-they are co-ordinated by the Department for Communities and Local Government-there is no disconnect between the two, as the noble Lord, Lord Noon, has said. I would further ask that educational programmes aimed at curbing the rise of extremism in our future generations-such as the excellent 9/11 Education Programme, launched nationally in September this year and already rolled out to 20 schools, supported by many, including my noble friend Lord Fink-are also co-ordinated with a more cohesive programme. I would also seek the Minister's assurance that stringent steps are taken to eradicate these extremist preachers who come to our shores to preach hate. There should be a simple message sent to them: they are not welcome.

Prevention of terrorism, integration of communities -as the noble Lord, Lord Noon has said-and education of our future generations are all part of the same equation. They are three essential components which form the basis of eradicating extremism, protecting the deep-rooted and long-established traditions of our country and providing the lasting solution we all greatly desire.



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7.55 pm

Baroness Hamwee: My Lords, the noble Lord, Lord Noon, has asked a most important question. In the short time available I want to focus on integration and make one point. I wonder whether the answer to the noble Lord's question is partly characterised by the speakers list that we have tonight-10 speakers. How many of us are what my late noble friend Lord Jenkins termed "ancient Britons"? I think it is a fair bet that the eighth Baron Henley is. I do not want to make assumptions about the noble Lord, Lord Rosser, but excluding the Government and Opposition Front Benches, look at our names. Mine is because my family, not very long ago, came from Hama in Syria-a place where I am very glad not to be.

Is it that our speakers tonight feel a particular responsibility to take part, and should it rest only on their shoulders? Beyond this House, have we made assumptions about who should integrate with whom, about who needs to take active steps and who can sit back and dissociate themselves from the issue? Have we made assumptions about "us" and "them"? Have we made assumptions about what Britain today is or should be? It is not the same as when I was born. It is not the same as when Victorians ruled the world-and on that subject I have said before in the context of immigration that I find the term, "the brightest and the best", whom we are seeking to attract, very difficult because of its implications. It takes us to the question of what we think is the Britain into which we are seeking integration. Integration, of itself, does not secure loyalty to a set of values or instil patriotism; they are more than learnt behaviours. It is about a view of society and one's place in it, and perhaps we should be talking more about social cohesion in a wider sense.

I know that far more is going on than just the Prevent strategy. Both noble Lords who have spoken have referred to this, but I think it is important not to do anything to consolidate the widespread view that a particular ethnic background or a particular faith and terrorism are in any way synonymous.

7.57 pm

Baroness Prashar: My Lords, I, too, want to thank the noble Lord, Lord Noon, for initiating this debate. The new Prevent strategy states that a clear distinction between counterterrorism work and integration strategy is necessary if it is to succeed and that the two must not be confused but, as has already been said, there is a fundamental link between fighting home-grown terrorism and creating a more integrated society. While the government strategy recognises that, we do not have a clearly understood and clearly articulated policy on how to develop a sense of belonging, how to create support for our core values or how to encourage integration. If anything, it is rather muddled.

Britishness was seized upon as a way of building a cohesive society, and multiculturalism was seen as divisive, but cultural diversity and pluralism do not threaten cohesiveness; inequality does. They are in fact the essence of Britishness. For a plural society to be successful, we need shared respect for and loyalty to the law of the land. In seeking to promote diversity, we

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must not stifle robust discussion or debate on issues that are of legitimate public concern, no matter how unpalatable they are. We need more, not less, freedom of speech to combat the propaganda promoted by extremism. We need open, frank dialogue and debate to enhance understanding between different communities and religious groups. We need to cherish diversity without undermining our common bonds of citizenship and respect for the law, thus helping what I call the evolution of a plural society through democratic processes. We need to work to inculcate this in our citizens, particularly the young. The Prevent strategy recognises the need to work with sectors and institutions where there is a risk of verticalisation. Universities are such institutions, not just as informers, though that may be necessary, but as promoters of free speech. Universities are reluctant, for they fear to be seen as curbing freedom of speech. Propaganda machinery must not be allowed to hide behind the pretence of freedom of speech and claims of human rights. Distorted and loaded messages that manipulate the young must not go unchallenged. Universities are well placed both to challenge propaganda designed to radicalise students, and also to provide experience of rational debate in safe spaces. As John Ruskin said,

"Education does not mean teaching people to know what they do not know-it means teaching them to behave as they do not behave",

as members of the family, of the community, of the nation and of the world. To succeed in the long run we need to challenge and deal with those promoting extreme ideology, but also to provide safe spaces like universities and other educational institutions, where learning about citizenship can take place. We also need to develop a consistent narrative about what a vibrant, diverse and integrated society is. I hope the Government will promote that.

8.01 pm

Lord Sheikh: My Lords, this coalition Government spent over a year reviewing the Prevent strategy and produced a clear, focused strategy on tackling extremism, as well as focusing resources on key institutions like universities, prisons, schools and colleges. This strategy looks at countering the ideology rather than just the violent action of extremists. This is the fundamental difference between the previous Government and this one.

People who espouse extremist views may be more prone and susceptible to being primed and moulded towards extremism, especially if they live in segregated communities and have little interaction with other communities. Extremism is also based on people being excluded and separated, and these are ideas that we should not allow in our communities whether they are al-Qaeda inspired, or whether they are far right or EDL-inspired. Separation and segregation have no part to play in our modern state. These phenomena have been rejected globally and they must equally be rejected here. There is a link between extremism and a lack of integration, and we need to acknowledge this.

However we must be more nuanced in our understanding and approach towards communities. We must acknowledge that there are groups of individuals

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who are integrated in every sense of the word. They work, they speak English, and they are living quiet and happy lives in different parts of our country. Yet they choose not to engage with other communities and they may also feel aggrieved and angry at what is taking place regarding international or domestic issues that affect their fellow brothers and sisters. These people cannot be viewed as being non-integrationist, but they may hold extreme views. They may, however, not be patriotic about this country, though that is different from not being integrated. The link between extremism and a lack of integration is not clear in these cases, and we must be aware that there are a set of competing circumstances affecting different communities. I firmly believe that we have moved in the right direction in terms of the Prevent work, which is now being undertaken, which is much more focused on interventions and countering extremist ideology. There is no simple solution around integration, and we need to look at situations in different parts of the country and with different generational groups, through multiple lenses and not through one single lens of understanding. Yet a lack of integration may leave some persons more susceptible to manipulation and thereby be used to promote extremist ideology. Sometimes the lack of integration can be self-imposed and the individual concerned may be completely devoid of extremist narratives and ideologies. Yet we can all agree that communities need to celebrate being part of their local areas and do all they can to make these areas places where they feel that they have a future.

At the very least this is the healthiest option we can take. I would like to end by saying there was a survey published in the Sunday Times a few weeks ago which found that Muslims are more patriotic than the rest of the population. This shows Muslims have gone a long way towards integrating with society and shows Muslims in a different light compared with what is being portrayed in the media. Islam is a religion of peace and this philosophy is shown visually in my coat of arms.

8.05 pm

Lord Patel of Bradford: My Lords, I am most grateful to my noble friend, Lord Noon, for having introduced this debate. Prevent is a very important strategy and one that I am very familiar with, having been asked by the previous Secretary of State for Committees and Local Government to undertake a rapid review of the original Prevent strategy. Over a period of several weeks, I visited 12 local authority areas and spoke to more than 700 people about their experiences of and attitudes to the Prevent strategy. The confidential report that I produced for the Secretary of State outlined a number of areas where I thought there needed to be improvements. Some of these issues have been addressed in the current revised strategy, which on the whole I welcome, but there are two particular issues which I believe need further clarification. Firstly, how are people, especially young people, engaged in Prevent? Secondly, how are professionals and elected officials being given the skills and confidence they need to challenge extremism and the way in which this causes further segregation between communities?



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I shall speak first about the engagement of young people, and as the chairman of an organisation called the International Forum for Community Innovations, otherwise known as TIFCI. TIFCI works with a wide range of community groups across the country and has just finished a piece of work on extremism and the risks for young people from radicalisation. The work explored the issues for young people and the particular risks they face from radicalisation and extremism. During the course of the work TIFCI spoke directly to over 130 young people and children of both sexes, from a wide range of ethnic, religious and cultural backgrounds. In the first place, the risk they most strongly identified was that from the far right, particularly the EDL, which they perceived to be causing disruption and harm to their sense of belonging and community cohesion. We very clearly should not take our focus off the threats posed by the far right. But what struck me even more strongly was the near universal view that, as young people-a key group who are identified as being most at risk-they were not actively consulted or involved in finding solutions and strategies to deal with the problems. Many of them said, when commenting on the work programme of TIFCI, that it was the first time anyone had even asked them about this issue. Does the Minister agree that young people, especially those at risk, should, wherever possible, be involved in and actively engaged with any work undertaken in this area and could he say something about what is being done to encourage this?

From my experience, including the work that I did reviewing the previous Prevent strategy, I believe that the second key issue concerns the skills and confidence among professionals and elected officials on the ground and their ability to challenge people and to address some of the issues that divide our communities. I strongly believe that they have not been adequately equipped to do this. Sadly-I have seen evidence of this many times in my work on community engagement -there remain deep divisions in our society and too many communities live separate lives, having little or no contact with their neighbouring communities even within their same town or ward. I agree with my noble friend Lord Noon that it is this division, the lack of community cohesion integration that is the greatest threat to our security. It is in this failure to have people meeting and interacting with each other outside their immediate family and community networks that the greatest risks of extremism and radicalisation take hold. If we recognise this then we can start to move away from thinking simply about one religious group or another and begin to work with whole communities and finding solutions that truly promote integration and challenge extremism. This is going to take high quality training for professionals and elected officials and at local levels we need to see clear implementation plans that provide direction and leadership. I would be very grateful if the Minister in his closing remarks could explain what plans are being developed to implement training and capacity building for professionals, youth workers, social workers, and very importantly, elected officials, to ensure that they can take the leadership on addressing these important issues at a local level.



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8.09 pm

Lord Hameed: My Lords, I convey my tribute to the noble Lord, Lord Noon, for introducing this subject this evening. In 2011 we live in a world of extraordinary progress and opportunity and yet it is a world in which 1 in 5 people lives in abject poverty. One in 6 children never reaches their fifth birthday and 115 million children worldwide do not even go to primary school; and with poverty comes a multitude of other bad things. And yet, it is nothing like the only reason why one group resents another, but it is a big reason.

Poverty is also a reason for our concern about terror, and the real and perceived threat of violence, locally, nationally and internationally from radicalised or marginalised people. Their route to terrorism can be found in many things: in faith, ethnicity, culture, nationality, poverty, economic and political causes, and more. A lot of people readily associate terror with religious fundamentalism. Any religion can be vilified, and indeed in this country we have known militant Christianity and militant Islam. The great contradiction of fundamental politics-its epic flow-is that it cannot deliver on the greatest problem that provokes its rise, which is economic deprivation.

Rage is not an economic policy. Violence is not the antidote to economic progress. It can succeed at moments of high social stress, or public rage. Ordinary people hunger for bread, not guns. This is what keeps the overwhelming majority away from fundamentalism. The bad news is that it takes less than 1 per cent to wreak havoc upon us.

We have here in the United Kingdom a multi-religious and multiethnic society. Here dialogue is the only way forward for addressing our differences. We ought to celebrate our commonality and discuss our differences based on mutual respect and trust in each other. It is imperative that we engage in a continuing dialogue. This dialogue is no longer the luxury of a few well-meaning individuals. It has become a necessity, demanding action, without which only catastrophe stares us in the face.

The other message that should go out from us is that Islam, like other faiths, prohibits not only the killing of innocent people, but is most severe on the act of suicide. There is a clear Koranic instruction against taking one's own life. Therefore, let me state clearly, for all to hear, that exploding bombs and firing bullets in an act of suicide, with the intent to kill, is totally un-Islamic and against the teachings of the Koran. All Muslims must therefore do everything to stop this evil depravity.

The 1.5 billion Muslims who live in this world are peaceful and law-abiding. They also make good neighbours and exercise responsible citizenship, and resent being stigmatised with negative religious profiling, which is inflammatory.

Finally, many Muslims believe that the savage cruelty and cynicism mirrored in the abuse at Abu Ghraib prison, Guantanamo Bay and at Bagram in Afghanistan, as well as rendition flights, waterboarding, and other methods of interrogation are not helpful in our pursuit

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to harmonise the radicalisation of young people because, more than anything, they are the best recruitment ground for the terrorists.

8.14 pm

Baroness Flather: My Lords, may I first thank the noble Lord, Lord Noon, for giving us this opportunity to say how we feel about this issue? It is a very important issue, and I have given it much thought, over a long period of time. There are now cities in this country with areas where no white people live and no white people go, and usually they are Muslim areas. It is very sad, because in fact the people who live there have no desire to mix with the white people. There is of course a reason for it, and I think the noble Lord, Lord Hameed, has very properly touched on it.

They feel they are disliked by us. The Muslims now feel that people of this country think of every Muslim as a terrorist. That has had a very important and negative effect on relationships. We all know, of course, what Islam is like, but do they know what Islam is like? I am surprised that none of your Lordships has mentioned what happens in mosques, which are the crucial areas where recruitment and extremisation of people takes place.

Lord Sheikh: You have made a statement about mosques. Where is your evidence?

Baroness Flather: I will get you evidence, but I do not have it to hand at the moment. I hope you realise that it is happening. Schoolchildren go to mosques every day; they have no time to do their homework and they are falling behind in education. What is wrong with seeing that the imams are properly educated, that they can speak English and that they know what Islam teaches? One of the most important aspects of starting integration is making sure that people who go to a mosque are taught Islam in the proper way, as has been spoken about in this Chamber. I am sorry to say this is not happening.

The second point, which I am very keen on, is that the young-young men in particular-are not skilled in anything. It is time we started programmes for skilling them. Education is important, and they are lagging behind in it, but if we can give them a skill to earn their living, we might see a change in their lives. We do not want young people to not get jobs, to live on benefits all their lives and then start the trend again. Their fathers may be on benefits, they are going to be on benefits, their children will be on benefits. This is what happened in Northern Ireland. We must stop this somewhere. We have to start doing programmes, we have to skill them, and we have to make sure that they are capable of holding proper jobs. This will give them self-respect and respect from other people as well, which is very important. I repeat that we must make sure the imams in the mosques are properly educated and are teaching the people proper Islam, not what they think is Islam. If you talk to young Muslim people, they do not think like that. They do not say "Islam is a religion of peace". They say that they want this country to become Islamic; they want to change this country into an Islamic country.



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I am also very concerned about the advent of Sharia, particularly because it is discriminatory against women. That is not the way we live in this country. We have an Equality Act, yet we allow Sharia, which is totally discriminatory to women, to deal with family situations. No boy over seven is given to the mother-he automatically goes to the father. Property rights are not respected. I hope that your Lordships, especially those of you who are Muslims, will do your best to change these things.

8.18 pm

The Lord Bishop of Hereford: My Lords, I am grateful for the opportunity to contribute to this debate. The first objective in the Prevent strategy is,

It slightly surprised me that the word "ideology" is used in the singular, when, as other noble Lords have said, there are-sadly and tragically-many ideologies that, in their own different ways, support terrorism. The counter to any bad ideology, whichever it may be, is not no ideology but good ideology. The report refers to core values. The counter to bad core values is not no core values but good core values. The counter to bad religion is not no religion but good religion.

This begs questions for us: how do we learn our good ideologies and our good religion? As we know, these things are not just taught but caught. Therefore, the approach has to be surely one that covers the areas that the report refers to: education, and all the aspects of that to which reference has already been made, but I would also love to see a greater emphasis on the sense of relationship, community-building and integration to which the noble Lord, Lord Noon, and others have referred. There is the need for us to make sure that not only are good ideology and good vision caught, but there are plenty of examples and that people have the opportunity to catch them because they see them and hear them. I also endorse the truth in the report that this is about process. The catching and the teaching are always about the process, not single steps or single actions. This therefore also emphasises to me the need for integration and cohesion, to which reference has been made by many noble Lords.

Isolation in all its forms needs to be countered. Where individuals or small groups of people are cut off from others, it can help contribute to and provide a soil in which extremism, and the distorted thinking that goes with any kind of extremism, whether it leads to terrorism or in any other way, can more easily flourish and grow. Again I would totally endorse the comments that have been made about the way in which poverty, among other social ills, provides that isolation.

One strategy does not stand alone. I would be delighted to hear the Minister talk about the way in which this strategy sits alongside other strategies and work on community cohesion, the development, building -up and strengthening of our communities and the avoidance of those social ills that cause the very divisions that can further isolate. A strategy like this has to be put within a total context that helps us to strengthen the relationships within communities. As others will

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know, a research project was undertaken by Vivien Lowndes and Leila Thorp on the Prevent strategy. They identified a community safety focus, a community cohesion focus and a community development focus in three different cities. All of these are about developing community.

Again, the Minister may wish to comment on those insights and help us to understand more about how the Government are working to overcome people's isolation, identify those most at risk to stop them being isolated and stop the unemployment and the other things that help fuel the isolation so that the integration-the interfaith and Muslim forums and so on-can all play their stronger part in helping stronger communities and cohesion and therefore community safety for us all.

8.23 pm

Lord Rosser: My Lords, I add my thanks to my noble friend Lord Noon on securing this debate and for speaking in such a forthright way about his personal experiences and his strong concerns and reservations. Following the bombings in London in July 2005, much work was done on the development of Prevent-work which was largely breaking new ground since it was needed to disrupt the process of radicalisation when there was no previous experience to draw on. The strategy was launched in 2007 and its objective was to seek to stop people becoming terrorists or supporting terrorism both in the UK and overseas. It was the preventative strand of the then Government's counter-terrorism strategy.

In view of the fact that it was breaking new ground, there was clearly going to be a need to review and update the Prevent strategy in the light of experience, including experience of the different approaches adopted. This Government have undertaken such a review as part of their wider review of counterterrorism. An independent oversight of the Prevent review was provided by the noble Lord, Lord Carlile of Berriew. In his preface to the Government's Prevent strategy, the noble Lord said, among other things, that generally, Prevent had been productive.

The Government have said that their Prevent strategy will involve work with sectors and institutions where there are perceived to be risks of radicalisation which need to be addressed. On this point, perhaps the Minister could say what has happened since the review was published in June. We know that the Secretary of State has healthcare providers and universities in mind, so what is she expecting the NHS and universities to do that they have not previously been doing? What has been their response, bearing in mind previously expressed views by Universities UK and the BMA on this issue?

Last June, the Secretary of State said that Prevent was about acting on information from the police, security and intelligence agencies, local authorities and community organisations to help those specifically at risk of turning towards terrorism. Since it involves the security and intelligence agencies, can the Minister say whether the Intelligence and Security Committee will be involved in evaluating the effectiveness of the Prevent strategy? Could he also say against what criteria and objectives will the Government assess the effectiveness or otherwise of the Prevent strategy?



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The Government have said that Prevent depends on a successful integration strategy, which will be the responsibility of the Department for Communities and Local Government. What kind of financial resources will be available next year and in future years, since there have already been significant cuts from the Prevent funding for local councils this year and there appear to be further cuts to come? Police budgets and numbers are also being cut. What kind of priority have police forces committed themselves to give to the Government's Prevent strategy, since the Government have said that Prevent is about acting on information from the police?

The Government have also said that public funding for Prevent must be rigorously prioritised and comprehensively audited. What does that statement mean in terms of the amount of funding for Prevent-not least on training and personnel-that will be provided in future from the Home Office and other departments? Will funding be going up or will it go down? What link-up will there be between the Home Office initiatives and the DCLG integration strategy to ensure that they complement each other? In the House of Commons on 7 June, the Home Secretary said that the Government's Prevent strategy,

Note that the Home Secretary did not say that the strategy was designed to achieve those objectives, or that it would make an important contribution to achieving them. She said it would achieve those objectives. If it remains the Government's view that their Prevent strategy will single-handedly and without doubt achieve those objectives in full, then I fear that the Government have underestimated the complexity and difficulty of what they are quite rightly seeking to achieve, or that they are as interested in rhetoric as they are in seeking to build on, develop and update in a consensual way the work that has already been done under the Prevent strategy.

8.28 pm

The Minister of State, Home Office (Lord Henley): My Lords, before I deal with the major part of this debate, there are three points I want to make. The first is that my noble friend Lady Hamwee, looking at the names on the list of speakers, possibly said that I was a very ancient Briton. The important thing to explain at this stage is not that I am an ancient Briton, but I am about as Anglo-Saxon as you can get. I will go on to say that I live in a village which I think has a Norse name; my nearest town, the county town of Carlisle, has an old British name; and I live in the county of Cumbria. As the late Lord Cledwyn of Penrhos-a great friend of mine and of noble Lords opposite-always reminded me, Cumbria is exactly the same word as Cymru. They are of the same etymological origin.

I make this point not for any flippant reasons, but to point out that in the United Kingdom we have experienced immigration of one sort or another for many, many years. We have adapted and have place names that reflect the vast array of different people who have come here at different stages and different

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times. We have gone on accepting immigrants from year to year and over the years. This is something that we should be proud of: the Huguenots who came here, the Jews who had been expelled, and others such as the Normans who came here under rather different circumstances. Possibly we objected to that at the time, but we got used to it later on. These things have been going on for some time. We are all mongrels in this country, and it is something that possibly we should all be proud of. I hope that we can all continue to integrate in the best possible way.

The second point that I want to make before I get on to the substance of the debate relates to the remarks made by the noble Baroness, Lady Prashar, about the need for more freedom of speech, particularly in universities. This touched me particularly as a former spokesman for higher education in this House, both quite recently and before 1997. I certainly agree with her that at times the universities should be faintly embarrassed by what they have or have not allowed to happen in terms of freedom of speech. We should all take note of that point, and I am very grateful to the noble Baroness for reminding us of it.

The third introductory point that I want to make refers to the opening remarks of the noble Lord, Lord Noon, when he talked about that 1,000-year tradition of the rule of law. Whether it is a 1,000-year tradition I am not sure. Sometimes that has wavered a bit, and there have been weaknesses here and errors there. However, I think that he is right to point out that there is something that we can be proud of, something that we should sing about and shout about, and something that, certainly in promoting this country and everything that goes with it, we should talk about and be proud about.

The substance of the debate from the noble Lord, Lord Noon, is on integration and extremism and how they will be affected by the Prevent strategy. There is good evidence that, by international standards, the United Kingdom has a relatively well integrated strategy. That is why I wanted to start with what might have seemed flippant remarks about where I lived in Cumbria and the mixed nature of that over the last 1,000 years; that will happen again in the future. We are told that 92 per cent of people across all ethnic groups say that they feel part of British society; 86 per cent feel that people from different backgrounds get on well in their area; 88 per cent say that they get on well with their neighbours; and 97 per cent agree that it is everybody's responsibility to obey the law. These figures show that we have much to be thankful for and that the Government's approach to integration is building on solid foundations that, again, we can be proud of in the citizenship of this country.

Of course, those figures do not tell the whole story. There are differences from area to area and within areas. For example, a high proportion of people in country towns are likely to say that they get on well with their neighbours, but in some inner-city boroughs the proportion can fall below half. Again, that obviously needs to be addressed. It is in those areas with a lower level of integration that the greatest challenges have to be faced.



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It is also in these less well integrated areas that the advocates of extremism are often most active. Groups like the English Defence League and the recently proscribed Muslims Against Crusades seek to spread fear and mistrust in order to generate and perpetuate division and separation rather than integration. Successful policies to promote integration must also, therefore, be capable of countering extremism, in non-violent as well as violent forms.

My right honourable friend the Secretary of State for Communities and Local Government plans to make a Statement to Parliament and publish a document setting out the Government's approach to integration later this year. I hope that the noble Lord, Lord Rosser, will be able to wait for that Statement. In the mean time, the elements of that approach are beginning to take shape. It will be an approach that emphasises what we have in common rather than what is different; draws out the responsibilities that we have to each other and to society; enables people to realise their potential to get on in life; gives people opportunities to work together and to take decisions for themselves; and ensures a firm response to threats to integration like discrimination, extremism and disorder.

These objectives cannot be achieved by top-down design by the Government. Government can create the conditions which enable integration but it is for people themselves in neighbourhoods and in voluntary and community organisations to take responsibility for making it happen in their areas.

To illustrate what Government are doing to create the conditions that support integration, let me give three examples, which have also been touched on by a number of other noble Lords in this debate. First, without a common language, integration will always be constrained and so we are looking at what additional support we can offer to local areas to help isolated women in particular and other priority groups to learn English. Secondly, understanding and co-operation between people of different faiths is pivotal to integration and that is why the Government awarded £5 million to the Church Urban Fund's Near Neighbours scheme, which fosters precisely these ends. Thirdly, we have made integration one of the three objectives of the National Citizen Service. In 2012 this will enable up to 30,000 16 year-olds from different backgrounds to meet each other, to break down the misconceptions that put up barriers between them and to get on together.

As I have said, intolerance and extremism are a threat to integration and to initiatives that support it, such as those I have described. Therefore we must challenge extremism in all its forms, both violent and non-violent, and whether manifested through propaganda, public disorder or incitement to hatred and violence.

If extremists break the law they will feel the force of the law, but even if they keep within the law we shall not stand by. Extremists will be challenged if they use public spaces to promote their ideology and if they publish offensive material on the internet members of the public will be able to ask the police to investigate.

Integration and the Prevent strategy are not the same thing. They are linked but distinct. In the past the distinction between them became blurred and that

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is partly why the Government initiated a review of the Prevent strategy late last year. The review found that the old Prevent strategy was too far-reaching. It confused counter-terrorism with social cohesion and "securitised" social policy. It was in danger of stigmatising Muslims-a point made by various noble Lords-and reinforced a misperception that all Muslims could be extremists. It created division between Muslims and other communities. It was unfocussed and wasteful of resources. It was concerned only with Islamist terrorism and not other forms. It generated allegations of being a cover for spying on communities. It treated some extremists as allies rather than as part of the problem. It was unable to show that it was effective in preventing terrorism.

The new strategy published in June this year deals with these shortcomings by reaffirming Prevent's place within CONTEST, as part of the United Kingdom's counter-terrorism strategy. In common with the rest of CONTEST, Prevent now deals with all forms of terrorism and extremism, whether violent or non-violent, that contribute to support for terrorism. This includes extreme right-wing and Northern Ireland-related as well as al-Qaeda-inspired terrorism. At the same time, the Department for Communities and Local Government has taken responsibility for integration and non-terrorist related extremism.

These changes mean that Prevent should no longer be seen as "securitising" integration. Rather than ranging far and wide, as it did previously, it is now more tightly focused, proportionate and prioritised. It is a national programme concentrated on certain localities and sectors, concerned with extremism conducive to terrorism, including non-violent forms as well as terrorism itself, is based on allocation of resources according to risk and will use law enforcement, regulation, civil challenge and support as appropriate.

I will conclude, as my Whip is beginning to kick my legs to indicate that time is running out. Although they are linked, we make it quite clear that integration and prevention of terrorism must not be conflated. With the new Prevent strategy the Government have taken decisive action to ensure that they are not. Prevent is now able to concentrate on what it is supposed to do, to stop people from becoming or supporting terrorists, while the Department for Communities and Local Government is enabled to get on with creating the conditions in which integration can grow and extremism can be challenged and reduced.

Health and Social Care Bill

Committee (9th Day) (Continued)

8.41 pm

Amendment 156

Moved by Baroness Thornton

156: Clause 22, page 29, line 2, at end insert-

"( ) Subsection (1) shall not apply to any providers who have any financial interest, directly or indirectly, in the provision of any service that the clinical commissioning group may be required to commission."



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Baroness Thornton: My Lords, I also speak to my other amendments in this group. Over supper my noble friend reminded me that the late lamented Lord Carter, a previous Government Chief Whip, used to say to Ministers and others that if we needed to save time, the thing to do was to speak only from every other page and see if anybody noticed. What I intend to do is to try and speak from every other paragraph.

These issues deal with the serious potential conflicts of interest that GPs will face in their new role as commissioners of health services. When this group of amendments first started out it contained only two amendments but it has now, quite rightly, grown substantially to address the major concerns of transparency, integrity and patient confidence and the issue of trust that must be addressed in their new role. In passing, I would say that the publication of the Government's recent draft guidance on commissioning, Developing Commissioning Support: Towards Service Excellence, in effect decrees that by 2016 the real work of CCGs will be outsourced, presumably to large private providers, which makes me start to question what is left for CCGs to worry about. However, the issue that these amendments deal with is a fundamental issue of the Bill.

We all have high regard for our GPs and we trust them as experts and advisors. We know from the evidence that they do a cost-effective and good job. Our national system of GPs may be quirky, half in and half out of the NHS, but it works. At its best, it is the very best system in the world.

We are concerned that the Bill endangers the trust that patients have for their GPs and, essentially, these amendments seek to explore and to test that. GPs are going to be decision-makers across the whole breadth of commissioning, making decisions about priorities and standards, things that may often be unpopular, and reconfigurations of service. They will handle huge amounts of money, own budgets and get bonuses for good financial performance. So patients need to be assured that they can continue to trust their GP and that their GP will always act in the patient's best interest. This concern has been flagged up by the BMA and the Royal College of General Practitioners, so I hope that the Minister can tell the House how we will be able to protect the image and reputation of our GPs after the first CCG goes wrong. Amendment 156 starts with the obvious necessary safeguard that providers of primary medical services who have a direct or indirect financial interest in the provision of services that a CCG is required to provide must not be members of the CCG. Amendment 161 is also key in requiring the Secretary of State to issue guidance which must be incorporated into CCG constitutions on how conflicts of interest must be dealt with by consortia as part of their decision-making. Transparency and clarity about how potential conflicts of interest would be managed is essential if the confidence of the public is to be maintained.

Openness and transparency are supported by Amendment 176A, requiring CCGs to maintain a publicly accessible register of all potential conflicts of interest of individuals involved in any part of their commissioning process. Taken together, Amendments 176A and 224 reinforce this, and call for regulations to

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stipulate that no provider should be a member of a CCG if they have any financial interest in the provision of any service the CCG is required to commission; in other words, open book accounting.

We do not think it is enough, as Amendment 228 proposes, for a CCG member merely to declare their financial interest in a commissioning decision being taken by their CCG, or absent themselves from decision making on that provider. We expect our councillors to operate under this regime. We should expect other people responsible for public money to do the same. Indeed, this transparency and openness, and the declaration of interests, should be extended to their families, in the same way that it is for other public servants.

Finally, I want to underline that we recognise that extending GP commissioning and setting up CCGs has the potential to give GPs freedom to innovate, improve services and use commissioning to develop new models of care in the interests of the communities they serve. The safeguards against conflicts of interest proposed in these amendments are not designed to shackle CCGs. As I have said, the Department of Health commissioning guidance already does that. The safeguards will ensure that they abide by the reasonable rules, regulations and codes of practice that we would expect of any statutory body responsible for taxpayers' money worth millions of pounds.

The public needs to be assured that robust governance arrangements are in place for commissioning consortia, and that conflicts of interest will be managed effectively. I beg to move.

Baroness Williams of Crosby: My Lords, I have a great deal of sympathy with the intention behind this amendment. Noble Lords will remember that from the very beginning of the discussion about this Bill, there has been a great deal of concern about the conflict of interest that could so easily arise. Many of us recognise that the relationship between patients and general practitioners crucially depends upon that relationship being one of trust. The same will apply, if the commissioning groups work well, to the relationship between them and the patients who are within the practices of which they are part. So I sympathise very much with what the noble Baroness, Lady Thornton, has proposed, and also with what the noble Baroness, Lady Finlay, has proposed in Amendment 161.

Our concerns on this side of the House are not with the whole motivation behind this. We believe that that is extremely important and we completely share it. It is our feeling, rather, that the remedies are not adequate to the scale. We feel, for example, that one of the weaknesses of both amendments is the lack of any effective sanctions against those who breach what would be a relationship of trust. At the moment there is not provision within the Bill for effective sanctions, which can be used to ensure that these high-minded and perfectly proper principles are lived by.

The Nolan principles have been very effective in local government-as we all know-and increasingly effective in national Government. There are references to those in the course of the Bill, but there is no specific determination that members of the partnership

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groups or the CCGs would be dealt with, if they were in breach of the requirement that they should not ever put their own interests ahead of those of their patients.

I suggest to the noble Baronesses, Lady Thornton and Lady Finlay, and her associates in moving these various amendments, that they would look at the amendment we have put down-and I suggest this with due humility-which effectively brings into practice powerful sanctions. We believe these will be effective in ensuring that this relationship of trust is upheld, and also that powerful requirements lie on every CCG, as well as on the board itself, that it would be absolutely clear that all interests must be declared publicly.

These will ensure that once people's names are on the register, and they have made a declaration of the appropriate kind about their own interest never being put forward as the reason for a decision, there are then effective measures that will enable the whole issue to be dealt with in detail, with appropriate requirements of sanctions and of effective punishment for those who breach them. We believe this to be absolutely central to the working of the clinical commissioning groups and to the whole relationship of doctors to their patients.

So, with those few words, I hope I can persuade the noble Baronesses, Lady Thornton and Lady Finlay, to have a look at the proposals that we have put forward, which, I am pleased to say, have at least to some extent the support of the noble Baroness, Lady Finlay.

Baroness Finlay of Llandaff: My Lords, I certainly support the amendments tabled by the noble Baroness, Lady Williams, who has just spoken, and they go further than the amendments to which I have added my name. I would just draw the attention of the House to the conflicts of interest guidance from the General Medical Council, which makes it quite clear that doctors,

It goes on to say:

"If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest".

I would also remind the House that the ultimate sanction is to be struck off, and that if you are struck off, you lose your livelihood. I have a concern that when it comes to the implementation, warnings may actually be issued rather than stronger sanctions taken against those who might breach such guidance, because this is guidance, and it is therefore subject to interpretation.

This whole group of amendments has really gone to the heart of the problem of conflicts of interest, both for the individual general practitioner, who would be on a clinical commissioning group, but also their families and all those others around. It may be friends of theirs, who they know really well, with whom they are inclined to place some commissioning contract, or enter into some arrangement. There is a really fine line between having a personal interest, and going to that person because professionally you think that they are the best person to do the job.

Of course, I will say as a doctor, we all know the doctors that we would like to be referred to, and we all know the people who we want to work with in our

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teams. That is human nature. It is a mixture of competence and attitude, but there is also something about having a shared set of values, and so on, because you tend to gravitate towards people who share the same set of values as yourself. The highest principles and values would of course fall, I would hope, outside of the conflicts of interest, but financial interest is a really difficult one.

While I would suggest that none of these amendments are absolutely perfect, this group of amendments illustrates the fact that we need to come back to this at Report with a definitive amendment that really crystallises the whole problem around conflict of interest in commissioning.

Lord Greaves: My Lords, I spoke on an earlier amendment this afternoon about issues that come round and round, and this one comes round across Bills. We had a great deal of quite difficult discussion on these matters in the Localism Bill-now the Localism Act-and achieved what we hoped will be a satisfactory compromise in the Bill.

It is all about standards in public life and the importance of all bodies that deal with public funds and public functions being part of the regime of standards in public life. I assume that clinical commissioning groups, while not part of local government, are certainly part of local governance, or they will be part of local governance as far as the health service is concerned. They will deal with a lot of authorities that have the standards of public life regime as part of their own practice. I wanted to go very quickly through the basic principles that need to be established in my view before this Bill is finished. First of all there have to be clear rules. In The Localism Act they are set out in Part 1, Chapter 7, across 11 pages and in parts of the schedules. There need to be set out on the face of the Bill so that everybody knows where we are.

There needs to be a code of conduct, whatever it is called, which is based on the Nolan principles. We came to the view in the Localism Bill, now the Act, that those principles needed to be set out again on the face of the Act: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. In my view they ought to be set out on the face of this Bill.

There needs to be a system which members of commissioning groups have to register appropriate interests and again in the Localism Act some of these were pecuniary interests, going back to the old wording which is now on the face of the new Act. There are interests other than pecuniary interests which also need to be registered even if they do not debar people from taking part in decisions. If we are going to be open about what interests people have, then they ought to be there on record. There needs to be a register of interests-there is no point in registering if there is not an open public register. Then there needs to be a system in which people taking decisions and taking part in decision-making meetings have to declare interests at the point of that decision, as in the system that we have in your Lordships' House. As the noble Baroness said, it needs to involve close families and partners as well as the individuals concerned.



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Then there is no point in having that unless you have a system of dealing with complaints. It needs to be very clear what the system is, how such complaints are investigated and what penalties there are for breaching the rules. There may be different penalties for different rules. Clearly breaching the system in relation to financial pecuniary interests is much more serious than breaching one for non-pecuniary interests.

The penalties need to be clear and understood and the system for judging on them needs to be clear. The whole system has to be in the public domain. The system itself has to be open and transparent and all the actions taken under the system, whether it is just registering an interest or dealing with a complaint and the results of that complaint, have to be open, transparent and in the public domain. It seems to me that those are the principles. The details will quite rightly differ according to different organisations and different contexts. I am not suggesting the details of the local government scheme, although the amendment of my noble friend Lady Williams picks up some of the wording from the Localism Act, I think. Clearly CCGs are different from local authorities, but they are not sufficiently different that the basic principles should not apply, or the basic rules and regulations about avoiding conflicts of interest and declaring those interests when they exist and enforcing those interests within the framework of a broad code of conduct. That in my view has to apply and I hope that when the Bill leaves this House, it will incorporate sufficient detail to give those assurances.

9 pm

Lord Warner: My Lords, I just wanted to make a couple of observations and ask the Minister a question on this group of amendments. First, this is a not a new area that we are getting into. The same issues arose with GP fundholding and with practice-based commissioning. We have managed, as I recall, to sail through those two areas where we have involved GPs in the commissioning of services where there was potential for conflicts of interest without any great scandals. Has the department looked at the experience on this issue of conflicts of interest with practice-based commissioning and GP fundholding and seen whether there was a major issue? My recollection of all this from the research on GP fundholding was that there was not an issue and it was handled perfectly sensibly.

Secondly, if we actually have bigger clinical commissioning groups-and I promise the Minister I am not going to reopen the debate we have already had, no doubt to much relief in your Lordships' House-the smaller the risk, I would suggest, of conflicts of interest. There is a different set of considerations if you have got a clinical commissioning group for a population of 18,000, where inevitably there is going to be much greater potential for a conflict of interest, to one in which you are commissioning for 400,000. There is a different order of magnitude and I wonder whether that is an issue that the Government have looked at.

Thirdly, if there is concern about sanctions, the thing which really counts with doctors is the prospect of being reported to their professional bodies. It is the

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GMC and professional misconduct which is the big issue. We should not invent a system which is based too much on local government. It should be bedded into the professional body and the misconduct issues, because that is likely to be the way that it will have most effect with doctors involved in commissioning.

Lord Marks of Henley-on-Thames: My Lords, I rise to speak to Amendments 175E, 176AA to AD, 213C and 220A, all in the names of my noble friend Lady Williams, the noble Lord, Lord Patel and myself, and in the case of 220A in the additional name of my noble friend Lord Clement-Jones. The purposes of these amendments are first to secure on the face of the Bill a thoroughly robust regime to avoid conflicts of interest sullying the commissioning process, and secondly to ensure transparency in the commissioning process to the greatest extent that is commercially possible. Taking the point made by the noble Lord, Lord Warner, a moment ago, that this is not an entirely new area, I suggest that the arrangements for commissioning proposed in this Bill risk raising the threat level from conflicts of interest in the commissioning process from "moderate" to "severe", if I may use the intelligence services' scale. That is because of the greater involvement of practitioners in the commissioning process, which is of course to be welcomed for many reasons, and the increased likelihood that many practitioners may also be providers of other healthcare services or have interests in such providers.

Our task is to reduce the threat at least to "substantial", and then to manage the threat in such a way as to avoid commissioning decisions ever being skewed by the private interests of those making the decisions. Much of what we propose ought to be uncontroversial, and merely represents good practice, but we suggest, and in this I agree with my noble friend Lord Greaves, that it is important that our commitment to best practice is made clear on the face of the Bill. Amendment 220A would impose on any provider of medical services who is also a member of a CCG a duty to declare any financial interest in a commissioning decision-a bare minimum proposal, I suggest. Amendment 213C would impose on the NHS Commissioning Board a duty to refer a member of a CCG to his or her relevant professional body for material breach of the provisions or of the guidelines we propose. I entirely agree with the further point made by the noble Lord, Lord Warner, that this is an appropriate way of dealing with offending by practitioners. It should not be for the board to act as, or to set up, a disciplinary tribunal, but it is sensible and a greater deterrent, I suggest, for the professional bodies to do so.

However, the meat of our proposals is in Amendments 176AA to 176AD. We propose a thoroughly transparent regime as the best and most effective way of protecting commissioning from the insidious effects of conflicts of interest. I say insidious-and this is a point in which I pick up on what was said by the noble Baroness, Lady Finlay-because it is not only when a public decision-maker acts deliberately to favour his private personal interests that conflicts arise and threaten the system. It is also when the decision-maker at least persuades himself that his interests and the public's interests coincide. It is only public scrutiny of the process that can properly test that.



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The provisions in the Bill permitting some public access to the meetings of governing bodies of commissioning groups are, I suggest, over-cautious and too limited. The system should be made more open. The public should not be excluded from governing body meetings during the all-important discussions involving a choice between potential providers. I entirely accept that that would involve a new openness about commercial transactions and decision-making. However, these decisions are about choices between providers at public expense; I question the need for meetings to be held behind closed doors in relation to them.

Secondly, in the case of other decisions where the public are excluded from governing body meetings in the public interest, then a record of decisions made should at least be published, and quickly. That is the subject of Amendment 176A.

Our amendments set out a code for dealing with conflicts of interest in new paragraphs to go into the schedule. There would be a requirement for a register of interests of all CCG members. That register should be kept up to date. It should be kept available for public inspection. Then there would be a provision to exclude from the governing body of any CCG a director of a healthcare organisation or anyone with a significant financial interest in such an organisation if there is a contract in existence between that CCG and that organisation.

Thirdly, there would be a provision to ensure that a member of such a governing body who would be excluded if such a contract came into existence would have to stand down from the governing body while any negotiations for such a contract were in progress.

Finally, our amendments import the admirable guidelines produced by the General Medical Council, entitled Good Medical Practice. Those are the guidelines to which the noble Baroness, Lady Finlay, referred. I am grateful to the GMC for producing a document of such clarity and for welcoming our use of it in these amendments. The emphasis of the guidelines is on honesty and openness; that is what we are trying to achieve in this Bill. I believe it is what the Government are trying to achieve in this Bill. These are probing amendments, intended to give the Government an opportunity to consider how they might import such guidelines into the Bill at Report stage. However, our central point is this: we believe that the present provisions of the Bill do not display the seriousness, the clarity or the robustness that are required to meet the risks posed by the new arrangements. I suggest that the Bill cries out for a code in this area such as the one we have proposed.

Baroness Finlay of Llandaff: My Lords, there is an additional area which I think means that the provisions in this Bill have to be different from other previous legislation. We face a huge financial challenge across the whole of healthcare, with budgets squeezed in a way they have not been squeezed before. So the potential for conflict of interest will go up as very difficult decisions are made. One can envisage the situation where somebody on the governing body of a clinical commissioning group will have a relative with a certain condition-and I refer back to the example I used previously, motor neurone disease. Say that person

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needs end-of-life care, and say that is a clinical commissioning group that has decided that it is not commissioning it in its area. There would be a direct personal conflict of interest, because that person would obviously want that care for their relative, but they would need to stand back. With the financial stringencies, the proposed amendments become even more important. While they are probing amendments, I hope the Minister in responding will recognise the importance of this area and agree to come back to it-hopefully, with a Government amendment-at a later stage.

Lord Greaves: My Lords, in brief response to the noble Lord, Lord Warner, I am not suggesting in any way that the regime should be identical to the local government regime, but that the decision-making body in clinical commissioning groups will be the board. Under the new Section 14A, the board will include lay members and possibly other people. So merely relying upon professional standards and professional systems of discipline will not be sufficient.

Baroness Masham of Ilton: My Lords, I spoke on Second Reading of the need for safeguards. These are important amendments. They are safeguards which are necessary. Many people are worried about the conflict of interest.

Earl Howe: My Lords, I know full well that noble Lords have some concerns about the potential for conflict of interest in a system of clinical commissioning groups. Those are natural concerns, but I hope to show that the approach that we are advocating has some very specific and robust safeguards within it, which meet the intentions of the amendments in this group.

The CCG constitution provides for dealing with conflicts of interest and specifies arrangements for securing transparency about the decisions of the CCG and its governing body. The governing body must in turn ensure that the group has arrangements in place to ensure adherence to relevant principles of good governance. The CCG's governing body will have responsibility for ensuring that the CCG adheres to relevant principles of good governance. The Secretary of State can also make regulations for CCGs under Clause 71 of the Bill, which are designed to ensure that in commissioning, CCGs adhere to good procurement practice. These regulations may impose requirements relating to,

These regulations can also confer on Monitor powers to investigate suspected non-compliance. These are the safeguards that the Bill puts in place. My view is that it is unnecessary and indeed undesirable to go further.

Requiring CCGs to adhere to examples of good practice in managing conflicts of interest, such as declarations of interest; or maintaining a register of interests; or the monitoring or registration of hospitality received by members is a temptation, but one that should be resisted. We have got to be very careful about encumbering the Bill and CCGs with inflexible prescriptions as to how CCGs should operate within the statutory framework, or procedure about how they

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specifically manage potential conflicts of interest. This does not mean that these are not reasonable safeguards. Requiring the governing body to discuss in public choices between potential providers, or publish any decisions made in camera, for example, would remove a necessary discretion around ensuring that sensitive issues, either relating to contract values or performance, or staff matters, were given the appropriate level of confidentiality. I would urge in particular that we do not-as proposed in Amendment 175CC-put restrictions on those from whom a CCG can commission services. Given the importance we attach to ensuring that services are delivered in an integrated way, we cannot afford to cut CCGs off from being able to commission services from local GPs with a special interest, for example, who could deliver secondary care services in a community-based setting.

Baroness Thornton: Will the noble Earl acknowledge that there is a conflict of interest there? There must be a potential conflict of interest there. How does the Bill mitigate that? How does the Bill deal with that? I cannot see from what the noble Earl has said so far that that is going to happen.

9.15 pm

Baroness Finlay of Llandaff: Before the Minister responds, I wonder if he could also explain why clinical commissioning groups would not necessarily have to have a register of hospitality, conflicts of interest and so on? Those of us who work for NHS trusts certainly have to complete a register, and if we receive hospitality above a minimum amount or major gifts, not only do we have to declare them, but we actually have to decline them. I think we would be subject to severe discipline if we breached that code.

Earl Howe: I do not disagree with any of these principles, but I am not sure whether the noble Baroness understood what I said earlier: there have to be arrangements for securing transparency about the decisions of CCGs, and governing bodies have to ensure that CCGs adhere to relevant principles of good governance-think of the Nolan principles, for example, and many other ways in which good governance can take place-but there is no need to specify all this in the way these amendments suggest because the arrangements provided for in the Bill will cover these things. As the noble Lord, Lord Warner, said we are not in new territory here. There are very well established procedures for tackling conflicts of interest when they arise. There might very well be a conflict of interest in the kind of situation to which the noble Baroness, Lady Thornton, has alluded, but there are ways of addressing and coping with that.


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