Standing Committee A
Tuesday 27 November 2001
[Miss Ann Widdecombe in the Chair]
English Health Authorities: change of name
Amendment moved [this day]: No. 84, in page 2, line 3, at end insert
`provided that such area has an adult population of more than 2 million people.'.[Mr. Burns.]
The Chairman: Before I ask Mr. Burns to conclude his comments, I remind members of the Committee that all mobiles and pagers should be set on silent, or should not be on at all.
Mr. Simon Burns (West Chelmsford): May I be the first, Miss Widdecombe, to say what a pleasure it is to have you as co-Chairperson of our proceedings?
As I was saying when we adjourned for lunch, amendment No. 84 is purely a probing amendment by which we are seeking to find out more about the Minister's views on the composition of the strategic health authorities in terms of the average number of people that each will represent, and to tease out of him more information about how he thinks that SHAs will work.
Dr. Andrew Murrison (Westbury): It is a fairly fundamental law of physics that large bodies tend to consume small ones, and one of my concerns about SHAs relates to their size. As far as we are able to tell, they will be of diverse size. One of the stringencies placed upon those deciding on their boundaries is that the authorities should relate to a tertiary centre, such as a major teaching centre or major hospital. My own area of the south-west provides an example of where the proposals fall well short of that. The minnow that is Somerset and DorsetI mean that in the nicest possible wayrelates at best to Taunton, which is not a major centre. That will leave Devon and Cornwall looking towards the Peninsula medical school and Plymouth, which is a major tertiary centre. The remaining area of Avon, Gloucestershire and Wiltshire will look towards Bristol royal infirmary and the Bristol teaching hospitals.
That creates real instability. It is likely that there will be some mergers as time goes by. In the south-west, the three SHAs will probably reduce to two, with Somerset and Dorset being split between the SHA for the far west and Avon, Gloucestershire and Wiltshire. Such changes bring more uncertainty for those who work in the service. We should be able to anticipate that to ensure from the outset that SHAs can plan for the long term in a period of some stability. Members of the Committee have commented on the importance of stability in the national health service, which has undergone almost perpetual change since 1974. This is one area where the Government can give a steer by offering the prospect of stability at SHA level.
Of course, reducing the number of SHAs in the south-west from three to two and repeating that across the country would strip out a layer of bureaucracy and associated costs, as well as giving many of them much more cogency. I urge the Minister to think in terms of reducing the number of SHAs, perhaps by increasing the numbers of people that they will serve.
Dr. Richard Taylor (Wyre Forest): I was delighted that in the letter from the Secretary of State for Health that was circulated with the White Paper, ``Shifting the Balance'', he emphasised that consultation would take place according to boundaries. Natural geographical boundaries for health care seem to be the most sensible way of deciding the constituent members of strategic health authorities. Will the Minister confirm that the authorities will not be rigidly bound by numbers, whether too small or too great, but that the natural geographical boundaries, whether they have tertiary centres or not, will be used?
I have a natural geographical area in my part of the country that has long been known as West Mercia, which is an example of an ideal grouping without a tertiary centre. I make a plea for geographical boundaries and not boundaries based on absolute numbers.
Mr. John Baron (Billericay): Will the Minister consider another issue concerning the boundaries of strategic health authorities pertaining to existing clinical networks? The Government have stated that SHAs would be coterminous with an aggregate of local authorities and that the boundaries would not cut across Government office boundaries. That is fine, but existing clinical networks do not always align with local or central government boundaries. Securing delivery of health care must be the overriding determining factor when resolving difficulties, so consideration must be given to the role of the clinical networks. I hope that the Minister will forgive me if I refer to the BMA again, but it suggested that an appropriate solution might be to manage any lack of coterminosity at the new regional director of health and social care level instead of with the 28 SHAs to ensure that such decisions are taken at the appropriate strategic level. That would give weight to existing clinical network boundaries instead of historical administrative boundaries, which are largely based on geographical features. Will the Minister consider that point, because existing clinical networks are important to the overall functioning of health services at local level?
Mr. Oliver Heald (North-East Hertfordshire): I join in the welcome to you, Miss Widdecombe, as our co-Chairman.
I want to add one or two points to those of my hon. Friend the Member for West Chelmsford (Mr. Burns). To have a guideline of 1.5 million residents as the basic unit for a strategic health authority is acceptable, although we could argue about what the number of residents should be. However, some flexibility is required from the Minister if it is to work well. My understanding is that, in some city areas, it is proposed that strategic health authorities should be much larger than 1.5 million residents. I should be grateful if the Minister would tell us whether that is right and give us some idea of the scale of difference that is acceptable to the Government.
In my area, it has been suggested at regional level that Hertfordshire should be combined with Bedfordshire to achieve a unit of approximately 1.5 million; a similar size to Essex, to which my hon. Friend the Member for West Chelmsford referred. That is a convenient way of dealing with the matter and would meet some of the clinical networks, but if there were no constraint in terms of having to use local government units to build strategic health authorities, or by the 1.5 million figure, some of the other issues could be considered. For example, to the east of the county, many patients go to Addenbrooke's hospital in Cambridge. Further down the east side of the county, many residents go to Harlow in Essex for hospital treatment. To the south of the county, Mount Vernon is the cancer centre, as the Minister knows, and many of its patients come from north London.
Everyone at regional level, and everyone else involved, is doing their best to come up with a solution for a strategic authority that will work. Will the Minister explain why the figure should be 1.5 million, because a larger number would give greater flexibility?
What is the thinking on having coterminosity with local government areas? Would that be convenient where social services and the NHS were working together? Does the Minister hope that there will be joint working with mental health services? If that is necessary, what is his response to the submission by the Democratic Health Network, a body set up by the Local Government Information Unit? It states that
``the Government has given no clear rationale for the number of the proposed new SHAs. We would wish to see much closer working between health and local government at both regional and sub-regional level. It will not be helpful that the proposed new SHAs will not be co-terminous with other government regional or sub-regional structures.''
The Minister will know that I am not a great one for regions. However, the network has 100 members from local government; it is a body with a voice. It has asked that question. Will he respond to it? This is not something that I would favour, but it is the Opposition's job to put forward submissions when bodies of importance issue them.
The Democratic Health Network goes on to say:
``If the main role of Strategic Health Authorities is performance management, we do not understand why up to 30 SHAs are necessary and why they cannot be made co-terminous with the English regions . . . which would make it much easier to co-ordinate regional health policy with other areas of regional policy and with political and administrative structures at regional level.''
One can see what it means. The Minister accepts that in parts of the country where there are cities and great urban areas, there should be larger SHAs that fit in with the sub-regional pattern.
I should like the Minister to explain whether this is a patchwork with big SHAs on the one hand and little ones on the other. What is the meaning of the guidance figure of 1.5 million? It obviously means something in Hertfordshire because that region has said that 1.5 million is an important guideline. If something totally different is happening in the west midlands or Yorkshire, how will he reconcile the one with the other? Will the Minister give us a clearer picture of what is going on?
The Minister of State, Department of Health (Mr. John Hutton): May I say how pleased we are to see you in the Chair, Miss Widdecombe? My Front-Bench colleagues and I would rather you were in the Chair than on the Opposition Front Bench.
Mr. Heald: Does the Minister accept that I would always be happy to vacate this slot should my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) want to return to the fray?
Mr. Hutton: You would rule me out of order if I started to argue the merits or otherwise of appointments to the Opposition Front Bench, Miss Widdecombe. I do not intend to go there, and I notice you no longer intend to go there either.
The debate on amendment No. 84 has raised two questions. First, where do we draw the lines in relation to the boundaries of SHAs? The hon. Members for Wyre Forest (Dr. Taylor) and for Billericay (Mr. Baron) have referred to that matter. Secondly, what criteria do we use to draw the lines? The hon. Member for North-East Hertfordshire will be aware from his experience as a Minister that such lines are difficult things to get right. We are putting the structures in place; they are our creation. However, drawing precise boundaries and lines across the map of England is necessarily complicated, and raises issues such as those that the hon. Member for Westbury (Dr. Murrison) mentioned about local perceptions of where boundaries are, and what affinities local people feel with the communities around them.
Opposition Members ask me where we are drawing the lines; we are consulting on that. I hope that all Opposition Members will want to add their views to the consultation process that we have initiated, and some have already. I am sure that the hon. Member for Wyre Forest has, because he is that sort of man. It is up to hon. Members, if they feel concern about such issues, to input into the consultation process. That is the melting pot out of which final decisions come.
The criteria to which Opposition Members have referredthe existence of clinical networks, the importance of coterminosity with local authority boundaries and the issue of regional office boundariesare important in making decisions about where the boundaries of SHAs should be fixed.
The reference in the consultation document to a guideline population basis of 1.5 million peoplenot simply adults, to which the amendment refers, but including childrenis also important. Of course we need flexibility in such areas when coming to sensible decisions and, wherever we can, we will refer to the weight of local opinion that emerges through the consultation exercise.
We will not make final decisions through an arbitrary approach to those criteria, but the amendment would force us into doing that. We have issued a document referring to the criteria, and I will return in a minute to Opposition Members' concerns about those criteria. The hon. Member for North-East Hertfordshire said that we need flexibility to make the proposals work well. His amendment, by design, removes from the Bill the flexibility that he wants to ensure is a principle underpinning the decision-making process about the boundaries of SHAs. I accept that the amendment was designed to illuminate and inform the debate, but we must look at the proposed words. I have to tell my hon. Friends that it would be a mistake to go down that road.
Important issues have surfaced, such as observing coterminosity with local authority boundaries wherever we can. The amendment would compromise our ability to do that. I am sure that it is obvious to hon. Members that we want coterminosity because health and social care, the two key pillars of our care system, have developed historically as two separate tribes that do not always work well together. We see the consequences of that in various areas in the NHS. Delayed discharge is the obvious example; another is the problem in accessing mental health services. NHS and social care providers need to work together as closely as possible there because mental health lends itself to such a solution. People with mental health problems have a high degree of dependence on social care services. If the NHS is to do its job properly in delivering effective care, those two great pillars of the welfare society must work more closely together.
The principle of coterminosity between the boundaries of SHAs and those of local authorities fits with the strategic development of services that we want to see. That would be difficult to achieve if the boundaries of SHAs cut a big swathe across the boundaries of social service authorities, so that the same social service authority provided services to a range of PCTs in different SHAs. That would not be the sort of strategic development and coherence that we want, and that SHAs are intended to facilitate and promote.
The argument, as in earlier debates, comes down to how we juggle the various criteria, which most hon. Members recognise as important, in a framework that does not twist the Secretary of State's arm, forcing him to make decisions on arbitrary criteria in the Bill that he has no power to waive. If one takes that to its logical conclusion, the difficulty would be presented in stark terms; the hon. Gentleman's amendment would not allow the Secretary of State to constitute an area with a population two short of 2 million as an area that could have a SHA. With respect to the hon. Gentleman, that does not make sense and would contradict the principle of flexibility that I am sure we share.
I was asked a number of pertinent questions about the guideline of 1.5 million in the consultation exercise. The document makes it clear that we have attempted to provide flexibly. He asked me for a guide for the range of populations that could come within the boundaries of a single SHA. It is clear in the proposal for Durham and Tees valley in the north east that if Ministers decided to set up an SHA there, the population that would be served would be 1.2 million.
Another example is in the east midlands. The proposed boundaries for mid-Trent would include Lincolnshire, north and southern Derbyshire, north Nottinghamshire and Nottingham, making a substantial population of nearly 2.7 million. It is obvious that, in ``Shifting the Balance''and with the consultation under waythere is flexibility over the size of populations that need to be served and serviced by the SHAs. That reflects the important point made by hon. Members about the importance of clinical networks, and the point about tertiary centres made by the hon. Member for Westbury.
We are trying to juggle a number of criteria, which we have set out clearly. We have made no secret about the criteria that we intend to use. We want the proposals to command as much support as possible from the local communities that they will serve. Opposing views are forming part of the consultation process and they will be drawn to Ministers' attention as important arbiters of local opinion. As many hon. Members recognise, we then need to make the judgment of Solomon and are unlikely to be able to keep 100 per cent. of people happy. However, the criteria will be transparent and powerfully informed by the strength of local support for the proposals. Ministers will try to approach the task flexibly with a clear view of the end game. That is not a monstrosity of bureaucracy that cuts across obvious boundaries, but a new system for the NHS that complements the framework of the responsibilities on local authorities and regional officers of government.