Yesterday was the seventh day of the Committee Stage of the health and Social Care Bill. In theory this should be the half-way point of the discussions, but the Committee has only got up to Clause 20 and there are another 323 Clauses to go.
One of the debates yesterday centred on the “mandate” (crazy word, crazy Bill) that the Secretary of State will give to the National Commissioning Board (this is the biggest quango in the known universe and it will effectively run the NHS). The “mandate” is essentially the Government’s instructions to the Board, but as they are claiming that they are giving away all responsibilities to the Board (and thereby absolving Ministers from taking responsibility for what happens to the NHS as the budget is cut) the content of this “mandate” is really rather important. How detailed will it be and will it be subject to proper Parliamentary scrutiny?
I am afraid the Government’s attitude brought out the normally-hidden (!) cynic in me:
“My Lords, I confess that I am something of a cynic about some of the proposals in the Bill. I am a great believer in the principle of localism, the local determination of services and local decision-making. Therefore, in principle I would applaud any Government-even this Government-who desire to devolve responsibility for various things to local authorities and, in this case, local commissioning groups.
However, my cynicism kicks in because what I suspect is happening here-I suspect that it will happen in other service areas-is that Ministers are cynically saying, “We are leaving these responsibilities to you, the local bodies concerned. We are very happy for you to make all these decisions. The snag is that we will not provide you with the resources to meet all the expectations that the public, who rely on those services, might legitimately have hoped to be provided. However, we are not taking these decisions. We will not be involved. It is a matter for local determination”. To be honest, I think that is what underpins much of the localism, devolution or autonomy agenda that we are seeing.
However, the experience of all previous experiments of localism is that while Ministers say, “Yes, this is a wonderful idea. We want to do it”, pressure starts to be applied to particular things. They want to have a mechanism whereby they can say, “It is, of course, your decision. However, we want you to make sure that these things happen”. Gradually, the list of the things that must happen gets longer and longer and the list of areas of discretion gets shorter and shorter.
When I saw the proposal for a mandate to be in the Bill, I thought that that was the mechanism whereby on the one hand Ministers will proclaim that they have no involvement in these decisions and say that they are all local decisions, but on the other hand this will enable them to ensure that certain things still happen because they are being subjected, as elected politicians, to pressure to make sure that they happen. That is why the amendment of my noble friend Lord Warner, which would restrict the extent to which this could be done, is very important. If we do not have an amendment of that sort in the Bill, I can tell you now what will happen; every single pressure group, voluntary organisation and lobby will say, “We want included in the mandate”, which is being issued to the national Commissioning Board, “the following service. We will want to see it there.”
For any sensible Minister the simple answer to all this is to write an extremely long mandate that covers all those points rather than sticks to them. If they were
obliged to be limited to just five or six or another small number of issues, that would be extremely salutary. It would stop the creep that would happen. However, I suspect that the Government are not going to say suddenly, “My goodness, the noble Lord, Lord Warner, has come up with an excellent idea. Why didn’t we think of that? We must accept it, of course”, because unfortunately that is not always the way in which government Ministers react. They will stick to the letter of the Bill without those specifications. They will say, “Well, why five? Why not 10? Why not 12? What about three?”. All these different things will be argued as an excuse for not doing it. You will then get the drift and the pressure to say that more and more things must be added.
Amendment 100A is so important because there must be parliamentary scrutiny of what is happening, because this will be the mechanism that drives decision-making in the NHS. It is not going to be a pure version of devolution, localism and autonomy; this is going to be done through the mandate. The mandate is then going to be the most important document that drives the NHS at any one moment. That is why parliamentary scrutiny is essential. Parliament must have the opportunity not just to see it and to know what is being done in the name of the public but to comment, amend, or put forward amendments and have the Government respond to them.
I therefore hope that when the Minister responds he will accept not only the principle of my noble friend Lord Warner’s amendment but the principle of detailed parliamentary involvement in this process in the amendment of my noble friend Lord Hunt of Kings Heath.”
The full debate is here.