National Health Service Reform and Health Care Professions Bill

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Mr. Heald: All the amendments are to the same effect. They would change the name of strategic health authorities to area health authorities. Their purpose is not simply to concentrate on the name, but to ascertain whether such authorities are properly designated as strategic. We want to examine the functions that the Government intend for them, and whether it is right to describe those functions as strategic. We might go further and ask whether those bodies have a role to play.

As I understand it, the Government propose to reallocate responsibilities in the NHS so that PCTs will become the bodies that assess need, plan for it and commission services, and as such will be the main budget-holders; I do not use the word ``purchaser'', of course. There are to be about 30 new health authorities, covering about 1.5 million residents each, although I have heard that, in certain areas, the Government are prepared to accept far larger numbers of residents.

Will the Minister explain why it is necessary to have strategic health authorities and what is strategic about them? The research paper says that they will provide

    ``support to PCTs and NHS trusts to help them . . . improve the quality of the services they provide through their `clinical governance' arrangements''.

What does that actually mean? The paper goes on to refer to developing

    ``appropriate links with patients and the public as a whole, to ensure that services become genuinely patient-centred''.

We seem to be developing a massive structure of overarching and underlapping bodies to do what the community health councils used to do. Is it really necessary to have another set of bodies developing links and ensuring that patients have a role? Can the Minister justify the claim that those bodies are genuinely strategic?

The research paper says that SHAs will

    ``play a part in the wider public health agenda so that they contribute to general strategies to promote good health''.

What does that involve? Does the Minister really believe that a strategic role is called for? If so, how will the system operate in terms of the relationship between SHAs and PCTs?

The BMA asserts that the new structures should include a role for public health doctors. Does the Minister intend the high-level appointment of a public health doctor in each area? Would that be part of improving the quality of services within a clinical governance arrangement? I do not think so. Would it assist in developing a link with patients? Probably not. However, it might play a part in the wider public health agenda. Is part of the strategic purpose of SHAs the appointment of public health doctors? The BMA thinks that that is important. It says:

    ``The BMA is concerned that with such flexibility of appointment to these key public health posts at PCT and SHA level, potentially some areas of the country may be without the expertise of a public health doctor.''

The Royal National Institute for the Blind has commented on the role of sight loss and eye health promotion. Will the Minister explain whether that is a strategic issue that plays a part in the wider public health agenda, or is it the kind of thing that PCTs will deal with? Will he also respond to the RNIB's observation that the NHS and local authorities should work more closely to ensure effective service delivery in terms of sight loss and eye health promotion?

In other words, what does it all mean? [Interruption.] I ask that not in an entirely philosophical sense; I was hoping instead that the Minister might give a little detail and explain what the strategy is, why we need strategic health authorities, and why they should be called that rather than area health authorities.

12.30 pm

Mr. Hutton: I am encouraged to have an opportunity so soon in our debate to respond to the points raised by the hon. Gentleman. On noticing page after page of amendments, I thought that we would be discussing them for some time. I am grateful to him for spelling out that his amendments are essentially probing and that he is simply trying to establish what the function of these bodies should be.

The hon. Gentleman asked several questions about the public health function, which the hon. Member for Westbury also mentioned on Second Reading. Both hon. Gentlemen are rightly concerned about where the public health function will go and whether the reforms will weaken it, but in my view they will strengthen its delivery in the NHS. Given the present climate, that is one of the most important things that we must get right. All hon. Members and their constituents are aware of the growing menace of international terrorism and of the role of public health specialists in helping the NHS to cope with it effectively. I shall return to that subject in a moment, but I should first make it clear that the proposed reforms will not diminish the important role of public health in the NHS; indeed, I very much hope that they will strengthen it.

The rather quixotic desire was expressed for a seminar on the activities of SHAs, but ``Shifting the Balance'' and other documents provided for the Committee offer an almost exhaustive description of their role and functions. First and foremost, SHAs will have the key performance management role across the NHS. If the hon. Member for North-East Hertfordshire has talked to people in the NHS, he will know that the regional offices are too far away from the front line to carry out that role in the way that many in the service would like.

Again, this is an area in which we must make a judgment call. The Bill and the background documents show that the performance management function must be effective, but not too distant or bureaucratic, and the function must be close enough to the front line to ensure that genuine performance management responsibilities can be discharged, without creating for the sake of it—this is perhaps the hon. Gentleman's worry—another tier of bureaucracy in the NHS. Such a further tier is not what we are proposing.

The hon. Gentleman also referred to other responsibilities of the strategic health authorities, particularly their leading strategic development of services and ensuring that all parts of the NHS work together effectively. In a sense, that issue touches on another that was raised by the hon. Member for Billericay when we considered a previous group of amendments. We need a devolved NHS where as many resources and as much control and responsibility as possible are given to the front line, but where the back office functions—for want of a better expression—are properly identified and supporting arrangements established. That is a sensible balance, and although the line is perhaps not drawn in a place with which the hon. Gentleman is happy, there will certainly be significantly fewer authorities than the current 90-odd area health authorities in England to which he referred.

Mr. Heald: A lot of people say that all that the Government are doing is moving deckchairs. At the moment, there are two basic tiers—regional directors and health authorities—but we will end up with three: PCTs and SHAs, both of which have a health authority role, and regional directors. There will be a lot more PCTs than there ever were health authorities, so we will end up with more bodies. Is that really necessary?

Mr. Hutton: As I understand it, the hon. Gentleman's amendment would leave us with exactly the structure that I have just proposed—it would simply brand the bodies with a different name.

Mr. Heald: That is why it is a probing amendment.

Mr. Hutton: On this occasion, I do not feel particularly probed by the hon. Gentleman. Perhaps he will do better with later amendments. I accept that he wants a better and fuller description of the rationale behind the changes, but it is only fair to point out that the amendment would result in exactly the structure that we are proposing.

The fundamental change relates to the functions of health authorities and SHAs—that is the core of ``Shifting the Balance''. On reading the Bill, it is obvious that some health authority functions will remain in a different place in the NHS firmament, but most will move to PCTs. As we have made clear in numerous arguments on Second Reading and elsewhere, that is the right way to achieve our principal objective of finding a new and different system that properly confers responsibility and thereby grants the freedom to be innovative and enterprising. Those should be the hallmarks of a modern, dynamic public service. We must give those powers and opportunities to the people on the front line who actually make a difference, know their communities well and understand where the problems and pressure points are in the system, so that they have the tools to do the job more effectively.

It is important to call strategic health authorities by that name because it emphasises that their function should differ from that of the area health authorities to which the hon. Gentleman wants to revert. We should remember that area health authorities were commissioning bodies. Strategic health authorities will have a completely different role.

Mr. Heald: No one is suggesting that we go back.

Mr. Hutton: That is what the hon. Gentleman is suggesting—he is proposing that we establish area health authorities rather than strategic health authorities.

Mr. Heald: No I am not.

Mr. Hutton: With the greatest of respect, that is precisely what the amendment proposes. Most people in the NHS remember what area health authorities used to do, as will the hon. Member for Westbury, who is very fond of old NHS structures but has no fondness for the new ones. It would serve no purpose to allow confusion about the new health authority. The Bill needs to make crystal-clear the concept of a strategic responsibility and role, and that is what it will do in relation to the functions that strategic health authorities will discharge.

I have talked a lot about striking a balance, and it is important to make such matters clear. The system must devolve, decentralise, innovate and encourage change at a local level, but it must also be effectively managed, so that two parts do not do opposite things and thereby create the free-for-all that was characteristic of some of the hon. Gentleman's party's early reforms. Such a free-for-all does not enhance care or encourage the co-operation between different parts of the NHS that is so important if it is to be efficient and effective and to do what our constituents want: to improve access and quality of care, and make the best use of the resources at our disposal.

The challenge for us all, which we have tried to take on through these reforms, is to get right the balance between devolving and decentralising—that is what we want to do—and ensuring that the all parts of the service can work together closely, still plan sensibly for the future and secure the results that we all desire.

I have looked at the past functions of the area health authorities to which the hon. Gentleman's amendment harks back, and set out the obvious responsibilities of the strategic health authorities, and there is no obvious comparison between the two. The strategic functions of the new health authorities will be clearer and more defined. As I have said, under our proposals the new strategic health authorities will take a step backwards from service planning and commissioning. They will lead strategic development of local health services, and performance-manage PCTs and NHS trusts.

The hon. Member for Westbury made a point about public health, which also came up on Second Reading. I apologise to him because I did not get a chance to respond fully to his points then. Should the day ever dawn when he has the chance to wind up debates, he will know how difficult it can be to respond fully to all the points made by hon. Members. I did not intend him any discourtesy in not dealing fully with his points about public health.

We plan that every PCT will have a director of public health and an appropriate support team. Those directors will be board-level appointments, which is an important step forward. They will focus their activity on local neighbourhoods and communities, and on programmes to improve health and reduce inequalities. We want them to play a powerful role in forging partnerships with, and influencing, all local agencies to ensure the widest possible participation in health and the health care agenda. That generation of directors of public health will be from a variety of backgrounds, not only medical as at present.

The new strategic health authorities established by the NHS reforms will also need a doctor with appropriate strategic management skills. The SHAs will also have responsibility for the performance management of the public health function of primary care trusts. It makes absolute sense for public health doctors to fulfil that role. A successful SHA will lead and performance-manage that area to ensure that each organisation for which it is responsible has vibrant clinical governance arrangements and powerful, effective clinical networks.

I do not think that there is a substantive argument behind the amendment.

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Prepared 27 November 2001