Essential amendments

Summary of essential amendments to the Health and Social Care Bill required to implement the Liberal Democrat Conference Motion


Please sign our statement if you agree.


[Note:The Social Liberal Forum is hosting this petition for the movers of the amendment at Conference]

Substantial amendments are needed to the Health and Social Care Bill in four areas:

• The role of the Secretary of State;
• The nature and accountability of Commissioning Consortia;
• The functioning of the “market” created by the Bill;
• The implementation programme

Role of the Secretary of State

1. Restoration of the duty on the Secretary of State to provide or secure a comprehensive health service, not just to promote one.
2. Reaffirm that only the Secretary of State, subject to parliament, can impose new or higher charges for NHS services.
3. Secretary of State to remain responsible for the final decision, if needed, when major service changes are opposed by local democratic scrutiny bodies on behalf of their community.

Nature and accountability of Commissioning Bodies (i.e. GP Commissioning Consortia or any new term)

4. Local commissioning bodies to be public authorities required to adhere to the full standards of conduct and transparency that this implies.
5. Membership of local commissioning bodies to include a substantial proportion of elected councillors as per Coalition Agreement to improve transparency and accountability.
6. Local commissioning bodies to have responsibility for clearly defined geographical populations and to be funded on the basis of relative need as now.
7. Local commissioning bodies to be co-terminous with local authorities which commission social services
8. The commissioning function (i.e. not back office functions) to be carried out directly by public authorities rather than subcontracted to non-public bodies; using public sector staff and employing the skills of existing PCT staff
9. Unless Commissioning bodies have a majority of councillors, there must be scrutiny of all commissioning decisions by local elected councillors either through the local authority, Overview and Scrutiny Committees, or Health and Wellbeing boards (which must have a majority of councillors to fulfill this role)
10. The scrutiny body above to have powers to provide for full scrutiny, including the power to require attendance of all organisations in the local health economy funded by public money, including Foundation Trusts and any external support for commissioning consortia.
11. Where the local authority scrutiny body objects to a commissioning proposal or to a significant service change consequent upon it, and no local agreement is subsequently reached, there must be provision for public consultation and if still no agreement for plans to be referred to the National Commissioning Board and – if needed – to the Secretary of State for final decision.
12. Amendments to restrict additional freedoms only to Foundation Trusts that successfully engage substantial proportions of their local populations as active members
13. Foundation Trusts to retain their current status in UK and EU competition law

Constraints on the operation of the market

14. Commissioning to be governed by a requirement/duty on Commissioners, when considering contracting with any new provider – or offering the choice of a new provider – to be satisfied that broader service stability is safeguarded and that cherry-picking and cream-skimming are avoided:
The matters which must be safeguarded are
a) The financial viability of remaining NHS services (unless there is an explicit transparent proposal to close a service)
b) Adequate case-load to maintain clinical competence and effective organisation of care for any remaining NHS services including emergency services, rescue services, complex cases, education and training needs, and clinical research capacity
c) The maintenance and promotion of clinical networks.
d) The integration of care pathways and the integration of health and social care

The requirement/duty must also apply to the National Commissioning Board.

15. Commissioners to have freedom, in their approach to contracting and commissioning, to – for example – “bundle” tariffs and contract for whole care pathways, applying broader “Best value standards” learning from local authority experience.

16. Complete ruling out of any competition based on price for tariff-based services
(and not just at the point of referral or the point of patient choice);

17. For services not subject to the tariff to ensure that procurement is based on both best value with minimum quality standards by placing this duty on local commissioning bodies, the National Commissioning Boards and Monitor.

18. The role of monitor to include the promotion of equity/fairness in respect of access to health services

19. Provide that no Commissioning body act in a way, or be required to act in a way that leads them to be considered undertakings for the purposes of competition law.

20. Statutory provision to ensure that provision of clinical services to the NHS is not governed by current EU and UK competition law to a greater extent than is the case now. In particular to provide that vertical integration of services is not impeded by competition law.

21. Robust arrangements to manage the conflicts of interest inherent in commissioning so that no-one can be in a position to make a decision to place a contract if that person, whether GP, employee or external consultant, has any link financial, commercial or through family with a provider which might benefit from the placing of that contract.

Properly managed implementation

22. The changes to commissioning to be piloted and evaluated before full roll-out

23. The introduction of the new structures should be rolled out in a staged manner, retaining (albeit in slimmed down or eventually shadow form) PCT clusters and SHAs until it is clear that the new system is working properly, in particular as regards to financial control, workforce, patient safety and strategic service change. The amendment could put a sunrise clause in the bill dependent on success in these respects.

Charles West, Graham Winyard Version 4, 29.3.2011

To be read with briefings (in pdf format) by Evan Harris:

9 comments on “Essential amendments
  1. Dr Michael Taylor says:

    I support all of this except the demand that the Secretary of State having power to overrule local democratic health bodies.

    If you believe in devolution of power – and as a life-long Liberal/Liberal Democrat I do – then you have to accept that local people will make the decision and you cannot centralise final decisions in the way you suggest. Why should health be any different from the Scottish Parliament, the Welsh Assembly or local councils? Once you devolve power you have to take the risk of democracy!

  2. Richard says:

    I think these proposed changes are sensible. However, I wonder whether it would be less disruptive and less costly to retain existing PCTs. The PCTs should be reconstituted with clinical and public representation on their board so that they are properly accountable. They could also be made co-terminus where that isn’t already the case.

  3. Sally Brearley says:

    I agree with all of this and . . . we need to go further to ensure that Foundation Trusts are properly accountable. Not just by restricting freedoms if they don’t have enough members but by ensuring that the FT Board meets in public – many of them do not at present – and removing the requirement that the Chair of the Trust Board is also Chair of the Council of Governors (because this was introduced, and has been used, to keep the Governors under the Board’s control). Also, we need to make sure Monitor is publicly accountable. What about: democratic representation on the Board of Monitor, ensuring it meets in public, and that it properly involves patients and the public in the same way that the NHS is required to do. Contested decisions about service change or reconfiguration of FTs have to be referred to Monitor but it seems Monitor has, to date, refused to accept referrals properly made to it by local authority health overview and scrutiny committees. With Monitor being given extensive new powers, this doesn’t bode well for the future unless we close these loop holes.

  4. I am relieved that there is opp to the Tory plans for the N.H.S. An importent addition to other amendments is the one of the waste of money n paying members of boards/trusts. The shoul only get expenses……. I was a member of a board in England before Health boards became trusts and grew like topsie. Wedid not get paid . The amount of public momey wasted over the years since the creation of trusts is in billions of pounds.

  5. Pat Jones says:

    If we asked patients, I believe they would not want GPs taken away from their clinical roles to undertake commissioning. Management of minor illness and injury has been revolutionised with the advent of walk in centres and development of nurse prescribing and nurse led care. GPs in co-operation with other health professionals, could contribute a lot more to planned clinical care of patients with long term and complex conditions. This would reduce emergency admissions and allow GPs to practice what they have spent many, expensive, years studying to do. Of course they should be able to contribute to commissioning decisions but it takes a lot more than clinical and local knowledge to configure efficient, cost effective and patient centred services. Systems and processes need to be put in place and for this the NHS needs those villainous managers that everybody seems to love to hate. I agree with Sally-Foundation trusts should hold their board meetings in public and their councils of governors should be chaired differently to achieve accountability.

  6. Evan Harris says:

    @Dr Michael Taylor – Under Lib Dem policy, you would be right. Health, like social services, would be locally commissioned with no scope for direct SoS interference. But the NHS currently, or under the reforms proposed (even with our amendments) is not Lib Dem policy but still has a major role for unelected commissioners and the National Commissioning Board. Under that scheme, there needs to be a way to – ultimately – resolve dispute between Local Authority and commissioners. Without our amendments there would not even be a right of local authority to challenge and the Sec of State would wash his hands of these matters leaving it entirely to the unelected.

    @Richard – I agree with you, but we are seeking to compromise with the Govt here. If the Coalition Agreement policy of more GP commissioning is implemented in the way envisaged – by new consortia and public health moved to local authorities (LD policy) then there is no role for PCTs. Also the Govt needs to save money from making cuts in management which cant be done with GP commissioning and PCTS. Having said that if our approach of elected members of the commissioning body is combined with the Select Cttee proposal to put other healthcare professionals and patients on the commissioning bodies you essentially have a PCT again!

    @Sally Brearley. I agree with you. I sought a separate vote on the line in amendment 2 relating to FTs but FCC did not allow it. The list of amendments here are only those which are consequent on the Sheffield motion. I will ensure your points are passed on, but you should write to John Pugh MP directly.

    @dolores phelan Please pass this on to John Pugh MP directly.

    @Pat Jones I agree with you, but GP commissioning was in the Coalition Agreement so that compromise was already made.

  7. Dr Anthony Lynch says:

    I’ll vote for this IF it is the best that can be done.
    But what I really want to see is the whole disasterous Lansley’s Bill thrown out. Then we could start again with the best changes for the benefit of patients put in front.
    I think the fact that Lansley went ahead with the changes – salaries for commissioner chairs and so forth – all at the tax payers expense – and without a word in the Coalition agreement is an abhominable cheat.
    Anthony

  8. Mike Cooper says:

    Regarding the proposed amendments to the Health Bill as printed on the Social Liberal Forum site.

    I agree that most of what they are asking for is very sensible. But there is one specific point that they have got wrong, in clause 9.

    Commissioning bodies need to be subject to independent scrutiny, regardless of the composition of the boards themselves; and Health and Wellbeing Boards cannot provide that effective scrutiny – they are part of the executive function, and they themselves should be subject to independent scrutiny.

    The key principle is that decisions on all publicly funded commissioning and provision should be taken by publicly accountable and open bodies, and should be subject to local authority scrutiny.

    This has been recognised by the government in their response to the consultation on the Health White Paper, where they have now committed to making both commissioning bodies and Health and Wellbeing Boards subject to scrutiny by local authority scrutiny committees.

    And engagement needs to be much broader than having a few councillors and a representative of HealthWatch on the board.

    There is a need for proper governance and transparency of commissioning consortia and of Health and Wellbeing Boards, with membership including elected councillors and representatives of local patients and the public; but regardless of who is made members of these bodies, there is still a need for separate and independent scrutiny of both commissioning consortia and Health and Wellbeing Boards, by local authority scrutiny bodies.

    It is a key strength and advantage of scrutiny that it is separate from the strategy and commissioning decisions, and is not responsible for taking the decisions or the delivery of services, so it does not need to be defensive of those decisions, and it does not have cover everything, but can focus on what it thinks is important for its local community.

    I think that strategy, as proposed for Health and Wellbeing Boards, commissioning as proposed for commissioning consortia, scrutiny by local authority scrutiny committees, and engagement with the community through HealthWatch are all valid and distinct roles, and it is helpful to have different bodies with different members and perspectives undertaking them.

    The boards of commissioning bodies should have non-executive members, like PCTs have, and these should include elected councilors, but elected councillors need not make up the majority; and they should also have representatives of other health professions, not just GPs.

    I agree with the suggestion that Health and Wellbeing Boards should follow the local authority model, with ‘members’ of the boards being appointed representatives of board of the commissioning bodies and local Councillors; and officers of the council and commissioning professionals should act as officer support and not be ‘members’.

    Distinctive engagement of patients and the public needs to take place at each level.

    The role of HealthWatch on behalf of the wider community, and in particular in commissioning and strategy, does not remove the need for individual commissioners and providers to establish effective engagement mechanisms, like ppi forums, that can inform decisions and service provision, and be a more effective way for those interested in particular services and for patients and carers groups to become involved.

  9. Edward Hill says:

    I too have signed, but I really want the whole Bill scrapped.

    Many Lib Dem MPs seem poorly informed. Please can the Social Liberal Forum send them copies of 3 books, + links to 3 media articles?

    1. The PLOT by commercial companies over many years to take over the NHS
    Book 1: The Plot Against the NHS by Colin Leys 2010
    Quick article: http://www.renewal.org.uk/articles/the-plot-against-the-nhs/

    2. The DISHONESTY of the poised American health insurers whose pursuit of profits leads them to LIE and CHEAT, REFUSE INSURANCE COVER, and commit FRAUD
    Book 2: Deadly Spin by Wendell Potter 2010
    An insurance company insider describes the dishonest methods of corporate US healthcare
    Quick article: http://www.guardian.co.uk/commentisfree/2011/jul/12/nhs-reform-lansley-warning

    3. The EVIDENCE that there could be a different strategy for the NHS without privatisation.
    Book 3: NHS plc by Allyson Pollock 2005
    Quick article: http://www.guardian.co.uk/commentisfree/2011/jun/16/nhs-fear-tory-reforms-competition

    (Book 4: The Political Economy of Healthcare. Julian Tudor Hart. In-depth clinical perspective.)

    Edward Hill, Greenwich Lib Dems

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