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From my parochial point of view, I continue to ask myself—and anyone else who is listening—how local issues that I have been able to pursue with a PCT with good local knowledge will be resolved in future. I shall reflect and echo the comments made by the hon. Member for Wellingborough (Mr. Bone). To whom do I speak—and will they have a grasp of the issues in the locality when I contact them—about problems or concerns relating to GP practices, such as the need for new or developing premises? To whom do I speak about local dental provision? My area has been consistently defunded over the years by the exodus of dentists from the NHS. Even though that defunding is being stopped by the retention of funding at local level, where will the funding for re-provision go once we have a pan-Leeds PCT?
My colleagues and I have made a number of other points that are effectively expressed in the Select Committee report. The consultation, for example, had no real tangible substance other than the proposal to move from five PCTs to one. Even that was in the context of a broader document that covered the whole of the west Yorkshire region.
We share the concerns expressed by other Members about the need to retain strong public health functions at local and city level. Of course, we are going from having five teams to having one centralised team within Leeds. Public involvement in health provision at all levels must be promoted. The forums in our city—I am sure that this is the experience elsewhere—have only just begun to find their feet but, as a result of the reorganisation, we have a completely new ballgame.
We must ensure that the present levels of service provision, particularly at local level, are strengthened and enhanced. On that point, we were disturbed to learn that the savings from the reconfiguration in Leeds would not necessarily be recycled into the Leeds health economy. That is totally unacceptable. Leeds faces major challenges in addressing the historical imbalance between community and hospital services. We have two major teaching hospitals, which, over time, have soaked up most of the NHS resources. As a result, we have relatively weak community services, we hospitalise too many people and we keep them in hospital too long. We are also conscious that in the immediate future the acute sector faces major challenges which may require additional resources.
Those are crucial issues and there is precious little time to get them right in the helter-skelter process that hon. Members have described. I sincerely hope that my hon. Friend the Minister will be able to give me some grounds for optimism in his response to the points that I and other hon. Members have raised.
4.25 pm
Steve Webb (Northavon) (LD): I am sure that all hon. Members agree that debates such as this are valuable occasions. We owe a debt of gratitude to the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron), and its members, some of whom are with us this afternoon, for a valuable and hard-hitting report. This morning, I refreshed my memory by rereading sections of the report and was struck by the forthright language in which it was couched, to which the right hon. Gentleman referred, which conveys a lot of the anger that was felt at the time. The letter appeared and although there was some precedent, it still felt like a bolt from the blue and was much firmer than anyone expected. It came at came at precisely the wrong time in the parliamentary cycle and at the wrong time for any meaningful consultation to take place. Although things have moved on, it remains an important document and our debate this afternoon has highlighted some of the issues that need to be considered as we go forward.
Something that strikes me from what I have heard from colleagues around the country is how different everyone’s local case is. My perspective is coloured by coming from an area with a relatively small unitary authority. In our case, to argue for coterminosity was also to argue for localism, and we got it, albeit not under the original proposals. Other hon. Members have referred to wanting a PCT that understands local issues and is coterminous with the social services authority. I was arguing for the same things, but I fully appreciate—the debate has helped me to understand the point—that for some colleagues those two things were in tension.
That leads me to the first key point arising from the debate. It could not be more apparent from the debate that such decisions must be local decisions. I was interested in the comments of the hon. Member for Staffordshire, Moorlands (Charlotte Atkins), who said that she is a great advocate of local decision making, but then implied that because there may be conflicts within an area, there should be some sort of external, independent arbitration. With all due respect, that seems to be entirely misconceived. Local government exists for that purpose—to reconcile the competing claims of different sub-parts of an area. We do not say that just because a county has one bit that wants one thing and another bit that wants another, we need an independent third body to tell it what to do. We resolve the matter through open, local, democratic procedures in the local area.
Charlotte Atkins: If that had happened in Staffordshire we would have been lumbered with a Staffordshire-wide PCT because the county council was determined from the start to be completely undemocratic and perverse and to ignore not only the population in Staffordshire, but its own elected councillors and post-holders.
Steve Webb: That comment opens a whole can of worms. If we are saying that elected people are not listening to their electorate—
Charlotte Atkins: It was worse than that.
Steve Webb: If elected people are not listening to their electorate, any hope of local democratic accountability becomes problematic.
Charlotte Atkins: It was not the elected members who did not listen to their electorate; it was the officers of the county who did not listen even to its own elected members.
Steve Webb: I am not an authority on what happened in Staffordshire, but that suggests to me that the elected members should get a grip.
Charlotte Atkins: Absolutely.
Steve Webb: The answer to the problem of tensions within a local area, it seems to me, is more democratic accountability, not external independent arbitration by a quango. I cannot follow that logic at all. If the existing democratic structures would not have produced the outcome that the hon. Lady wants, that suggests that the democratically elected people should have been doing their jobs more effectively. That seems to be logical.
The idea seems to be, in essence, that we all have to go cap in hand to the Secretary of State. Opposition Members do not have the same access to Ministers—I do not say that with side, but it is true. I have often heard Government Members say “I had a meeting with the Minister about this or that,” but it can prove very difficult for Opposition Members to do that. That is a statement of fact. I had a local reconfiguration issue about a hospital. After six weeks of trying to see the Secretary of State, I was eventually offered a meeting with one of the junior Ministers. I phoned her office and was told that she was too busy, but I could have a phone call to the Secretary of State two weeks later. Then, the Secretary of State said to me, “Why didn’t you raise this eight weeks ago?”
There is a more profound issue, which is that these matters are being decided in the wrong place anyway. The Secretary of State is an elected person, but she is not elected by anybody in Staffordshire, or Wellingborough or Leeds, so why are we having to go to her for a decision to be made? Clearly, there are some things that have to be done nationally and strategically, with an overview. However, decisions about local health configuration should be taken at an appropriately local level.
To continue the theme, the
right hon. Member for Rother Valley talked about those with the biggest
voice. What was interesting was that I heard something different to
what he was saying. He was, I think, referring to some cases where it
is difficult rationally to justify the outcome and there is some
suspicion that a former Health Secretary, or whoever it may have been
in a particular case, had undue influence. That is another reason why
one vocal person, whoever he or she may be, should not determine such
matters. Whoever it is, the decision should be a community decision,
made locally and democratically. I agree with the right hon.
Gentleman—it should not be just one loud voice that counts.
However, I think that the voices that are heard should be elected
voices; that is what I was trying to get across. In the Avon area, we
had the
surreal situation in which everybody who had ever put their name on a
ballot paper and got elected to anything had a common view, but they
were going to be overridden by the unelected. That was what I found
unacceptable.
We had an interesting exchange about why some of the strategic health authorities appeared to come to conclusions that were different from the widespread community view. There was an interesting exchange about the reasons for that and some suggestion that it was the result of looking to the future, or perhaps empire-building. I have a slightly different theory, which is that the power of the acute trusts has been underestimated. There is a close working relationship between the strategic health authorities and the big hospital trusts. I know perfectly well that my local hospital trust did not want to deal with lots of small PCTs. Its life would be easier if it were dealing with a smaller number of commissioners. It had a very loud voice, so when we went to see the strategic health authority, it made it clear that the acute trusts’ preference for fewer commissioners was weighing strongly with it. That is one reason why the health authorities were saying something different to what the communities were saying. Again, it is a case of the unelected being very powerful: in this case, the chief executives of the acute trusts had a big say.
Dr. Stoate: I am listening to the hon. Gentleman’s argument very carefully, but it does not entirely stack up. As we move towards practice-based commissioning, there will be far more commissioners in future, so the PCT’s role in commissioning will be significantly diminished. I am not sure how that squares with his argument.
Steve Webb: The hon. Gentleman highlights one of the many inconsistencies in the Government’s whole approach to health policy. On the one hand, he says that we will have practice-based commissioning—if we believe that—and on the other, we have “Commissioning a patient-led NHS”, which was all about PCTs commissioning, not providing. Practices are to commission, but PCTs are to commission, too, and individual patients are going to make individual choices that somebody is going to have to provide for, so in fact patients will determine the pattern of demand. Those three things cannot all be true at the same time. I have no idea—nor do the Government, I think—where we are going with that.
Dr. Stoate: Perhaps I can help the hon. Gentleman. They will be commissioning different things. The PCTs will be commissioning certain services, such as district nursing and the provision of regional services. Practices will be commissioning much more locally based things and most referrals to hospital which, as the hon. Gentleman rightly says, will ultimately be decided by patients who work through choose and book.
Steve Webb: That is an elegant characterisation; if only I believed that the process was as carefully worked out as that.
The hon.
Gentleman has highlighted the sense that, throughout this experience of
reforming PCTs, the Government have been making it up as they go
along—abolishing county-wide health authorities, but
replacing them three years later with merged PCTs that cover the same
area and do similar things. I find that the most worrying aspect of
all. To have a 10-year NHS plan, with strategic direction that sets out
where we are going so that everyone knows where they stand and can plan
on that basis, is an excellent idea, but to produce an NHS plan for 10
years in 2000 but then to rewrite the whole thing every six months
seems to be the opposite of what we want.
A number of hon. Members have mentioned the importance of continuity. An hon. Member briefs a PCT about an issue and gets to the point of something being about to happen, but then the PCT disappears and the whole thing has to start again. We need continuity and stability—not stick in the mud-ness or dinosaur-ness, if I may use those words—rather than constant turmoil.
The hon. Member for Wyre Forest (Dr. Taylor) quite properly pointed out the so-called distraction effect on managers. I am so pleased that the day after the Minister made the announcement, my local PCT chief executive could get on with planning health services for south Gloucestershire, instead of wondering whether she would have a job in six months or having to organise the winding down of the organisation. I cannot believe that what is happening is a rational way to proceed.
The hon. Gentleman talked about consultation and the statutory duty to consult on such changes. I am sure that he is right factually, but for the Department of Health to write and say, “We don’t need to consult,” is the wrong way round. Surely one would wish the Department’s instincts to lead it to say, “We want to consult.” It should not say, “No, it’s all right, we don’t have to—we’re just going to get on with it.” The Department should want to hear what people say before it makes decisions. The default position should be for the Department to consult unless there is a pretty good reason not to, but so seldom do things happen that way.
The hon. Gentleman mentioned Professor Ashton. Nobody could say that his resignation was politically motivated or a party political gesture, because he expressed political sympathy for the governing party of the day and wanted to enter into politics. However, he also highlighted the constant reorganisation and its debilitating effect on health services.
The hon.
Member for Dartford (Dr. Stoate) mentioned PCT planning blight, which
is a helpful phrase. He also flagged up the idea of directly elected
members of PCT boards, which I am interested in, but then said that
perhaps we could work with the foundation trust board model. I have to
say that the foundation trust board model is a complete farce, with
small numbers of people, often self-appointed, notionally representing
huge numbers of people. I have come across plenty of governors and
members of such bodies—I do not think that they are called
boards—whom the foundation trust often sees as its cheerleaders.
The trust is often a commercial organisation trying to get business and
succeed, and wants those people not to hold it to account but to go out
and promote it. That is a very different role, so I am not sure that
the foundation trust precedent is a happy one. Foundation trust
governance came about because
the Government do not trust local government and therefore invented a
proxy for local accountability, which has not worked.
The hon. Member for Southend, West (Mr. Amess), who has just rejoined us, asked to be remembered for something. I assure him that he will be remembered; or rather—he knows what I am going to say—that his smile will be remembered. It was his smile in 1992 that brought me into politics. His joy at what had happened in Basildon did not, it would be fair to say, coincide with my feelings. I decided at that point that a political career was necessary and I am grateful to him for that.
The hon. Gentleman raised an interesting question: what happens when a PCT is created that straddles local authority boundaries, such as county boundaries and unitary authority boundaries? By the sound of it, what happens is a dog’s breakfast. Probably influenced by experience in my area, I am a great believer in coterminosity wherever possible. The idea of creating something that is not truly local, but not coterminous either, horrifies me, as does the thought of how the joint working will take place in the set-up that the hon. Gentleman described. What is proposed does not look like a sustainable long-term solution, so I would not be astonished if the Essex PCTs ended up being reorganised again, which I suspect horrifies him as much as everybody else.
The hon. Member for Staffordshire, Moorlands was absolutely right to highlight the impact on public health of all these changes, as it has been a neglected area. Several hon. Members made that point.
The hon. Member for Wellingborough (Mr. Bone) was right repeatedly to stress the importance of local accountability. That is where I come in on this whole issue. We are talking about the public’s national health service. We are not only consumers who shop around, whose voice in health care provision should be exercised only when we are ill. We are citizens who pay our taxes and who should have a say, as citizens, in the way that our health service is structured.
The phrase “sham consultation” was used by the hon. Member for Southend, West and others, and it was interesting that the Minister appeared to be genuinely puzzled by it, as if such things do not happen. Now he is looking at me with a puzzled expression. [Interruption.] Perhaps I misunderstood him. However, there is widespread public dismay about the consultation.
I said the other day that never have so many people been consulted about so much to no effect. There is a sense that we are either not talked to at all or that, when they do talk to us, people do not listen to what we say. Record amounts of consultation go on. I spoke to the Secretary of State about a local issue on my patch, and she said that there had been citizens’ juries. Yes, there had been citizens’ juries in one bit of the patch that wanted one thing, and they got what they wanted, but the other bit of the patch was not asked and did not get what it wanted.
The
critical point about consultation is that it needs to happen before the
decision is made. That might sound blindingly obvious, but it would be
nice if it happened. It needs to happen early, while people still
have open minds. If people consult when they already know the answer, it
just spreads cynicism. We need to consult when minds are still open,
when issues are still there to be addressed, when the contribution of
the public as citizens can still add something. We do not need
consultation that is a rubber stamp or a process that generates
disillusionment. The consultation on changes to primary care trusts has
been a case study in how not to do it. I hope that the Minister has
listened to Members across the House this afternoon and that future
changes will be made in a genuinely consultative, local and accountable
way.
4.42 pm
Mr. Stephen O'Brien (Eddisbury) (Con): I, too, welcome the Minister to his new position. He and I have had the chance to meet across the Dispatch Box from time to time but in different roles, and it is a great pleasure to have an opportunity to debate with him today what is unquestionably of the greatest importance to all constituents in all constituencies, namely, their current and potential health care.
Equally, I pay tribute to the Chairman of the Health Committee. He has presided over an important and timely contribution, which is not always easy to arrange in Select Committee affairs, to what has, in effect, been one side of the great argument on health care; that is, how much does patient care come out of structures and how much does it come out of the professional application of clinical and management approaches?
The report is highly influential. Notwithstanding the fact that some time has elapsed and that one could argue that the debate has been somewhat overtaken by events, the report stands well, despite the risk that it always carried. The members of the Committee are to be congratulated on their combined efforts in producing it, and I join in congratulating the secretariat that supported its work.
In an informed and sincerely articulated debate by Members across the House, we have heard powerful points about the manner of genuine consultation and commitment to it. We have heard about appropriateness and accountability and how health care services can best be configured structurally for delivery, whether according to geography or to some form of local arrangement. We have heard, notably, from the hon. Member for Wyre Forest (Dr. Taylor) about the distraction effect. The point is powerful coming from him, as somebody who has worked at the front end of the health service and no doubt knows what it is like to be on the receiving end when politicians, including Administrations of a different political hue, come up with grand designs and the professionals have to down scalpels and deal with political directions.
Dr. Richard Taylor: May I point out that one of the huge problems that I faced was when organisations for which I was working were called to be involved in pilot trials that were scrubbed before we had got half way through them? That is most off-putting.
Mr.
O'Brien: I am grateful for that contribution. As it
happens, I strongly believe that the Government should pilot and trial
most things that they implement,
but they should see the trials through so that proper conclusions and
assessment can be made in the light of experience. So much can be
learned by that
method.
I wish to concentrate my remarks on taking forward the lessons of the report and also focus on the Government’s response to it, which is equally part of the debate. Their response to one of the Committee’s most critical reports—at the time it felt damning—typifies their approach to our NHS: a recital of soundbites and phrases, and saying that throwing a lot of money at the NHS is somehow an immediate answer to criticism. It is incumbent on the Government to look out for a tone that strikes many—I will not be the only one who has heard this opinion expressed in his constituency—as suggesting that an ungrateful nation is failing to thank the Government for throwing money at the NHS. That money has been welcomed, but it is no wonder that the public do not give thanks if the money is not accompanied by the necessary financial and general competence required to ensure that it is best used and deployed.
We are in a time of the worst crisis of deficits and job cuts in the NHS in living memory. Another restructuring of PCTs, more or less returning the NHS to the structure that the Government inherited nine years ago on taking office, seems like a monumental lost opportunity. The 100 health authorities were abolished in 1998 and primary care groups formed. They were duly removed in favour of the 303 PCTs, which are now being meddled with and reduced to an indicated 152. The hon. Member for Pudsey (Mr. Truswell) made the important point that the reduction did not seem to carry with it a sense of having been designed with a resonance to his area’s needs or any analysis of what accountability was needed locally. It was a fair and well argued point.
There have been nine years of what can fairly be argued to be mismanagement, under a constantly changing cast of Ministers—I do not necessarily consider the Minister himself to be primarily in the frame, although he is currently accountable. The result has been that productivity in the NHS has declined by up to 1.3 per cent. every year. There is a question whether taxpayers, our constituents, are getting genuine value for the vast amounts of money that we have all put in. That money was recently described by Nicholas Timmins of the Financial Times as “an opportunity squandered.”
The Government have failed to point out that there has been haemorrhaging of staff across the NHS, due to poor financial management. Notably, this week two surgeons at the Oxford Radcliffe hospitals have had to leave their jobs. The Independent reports today that at least 20 NHS trusts are considering making consultants redundant. Money has been haemorrhaged on PFI deals, particularly through the Secretary of State delaying the Barts and The London project and the poor transfer of risk in the Norfolk and Norwich PFI project. Such matters ought to have been highlighted if the Government are genuinely seeking to be accountable for the effect that their expenditure is having on front-line patient care, which is sometimes to diminish it.
In emergency care,
the Government have severely limited the capacity and quality of
out-of-hours provision across the country through their questionable
approach to negotiating the GP contract. They are now
having to pay to undo some of the problems of that negotiation by
directly enhanced services, and they are driving deficits up with
overly stringent targets in accident and emergency departments that
deliver little clinical benefit to
patients.
On page 3 of their response, the Government say that the rationale for the changes is to
“commission better services for patients, work more closely with local government, and ensure that we get the best value for money from the system.”
Increasing patient choice and driving up standards will require stronger commissioning—that is something on which we all agree. The Health Committee, however, remained unconvinced that instigating large-scale reform was the best way to retrench commissioning expertise. The Committee rebuked the Government for not strengthening commissioning when it strengthened the provider sector, thereby leading to a market imbalance in the service. The current proposals for practice-based commissioning are looking increasingly unrealisable in totality. There are only meagre benefits—if any—for GPs in holding merely indicative budgets, particularly as the Government are inclined to be sluggish over things. Lord Warner, the Minister, said in another place that he was “relaxed” about how quickly practice-based commissioning was implemented. Not only will that not strengthen commissioning sufficiently, but the Government have yet to ensure that we secure best value for money.
One of the Health Committee’s sternest criticisms was of the clumsy and cavalier approach that had been taken. In the case of establishing new PCTs as commissioning or provider bodies, it amounted to making policy on the hoof. Under pressure from many people—not only from Conservative and other Opposition Members but from Members on their own side, the Government claim to have clarified matters. However, to use the words of the Select Committee Chairman, it is fair to say that the “direction of travel” remains unclear, and that there is still uncertainty around the purpose—let alone the true job expectations—of those who are charged to deliver.
According to the Government view on provider status, decisions on local provision will be left to local PCTs. The PCT will decide whether it has to divest itself of provider function. There is a requirement to consult, but no timetable within with that must be done. The Government have said that if PCTs keep provider functions, they will need appropriate clinical governance arrangements, but they have given absolutely no guidelines. Bob Ricketts, the Department of Health director on demand-side reform, has said that commissioning has not worked for 10 years, and that this time it really has to be a success. Leaving aside practice-based commissioning, “Our health, our care, our say” gave a greater commissioning role to the Department of Health. Will the Minister provide greater clarity on that point?
PCTs have not
proved themselves to be adept at commissioning. It must be argued that
the rise in sexually transmitted diseases, for instance, is linked to
shortfalls in funding for genito-urinary medicine clinics, as PCTs try
desperately to claw back money. When I asked my local PCTs about the
situation, Central Cheshire Primary Care Trust, which is well managed
and has good clinical and management leadership, and which is broadly
in balance, replied that
it was extremely concerned, but that the programme was on hold until
“prudent fiscal management” could
find
“the necessary investment from savings in other PCT budgets”.
Cheshire West Primary Care Trust, one of the disasters of the country, has a turnaround team. My local newspaper has reported that it now has £20 million to make up the terrible shortfall, although there was no mention of the MP who has campaigned about it. There are consultants at the trust, while the people who were meant to do the job are still employed—£20,000 a day is being spent on the consultants while the trust still has £20,000 employment costs for those who should have done the job in the first place. It is an absolute basket case. Constituents are now losing front-line patient services, such as the Parkinson’s nurse specialist, who has gone—the job was cut. That is happening with front-line services, not just with the reorganisation as the background. Nevertheless, Cheshire West would say only that it had established a team to develop strategy.
The reduction in the number of child immunisations is another example. It is due to the Government having moved responsibility out to the PCTs under the new GP contract, with cash-strapped PCTs failing to commission immunisation from GPs.
If the Government are moving toward practice-based commissioning for the commissioning side of health care, and are also seeking to divest PCTs of their provider functions, what does the Minister actually see as the future of PCTs? That question was raised a moment ago by the spokesman for the Liberal Democrats. Surely those questions should have been answered before yet another restructuring and moral-sapping reorganisation, as it was described by the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) in her fine speech.
The reorganisation does little to help close the gap between health and social care. Indeed, this restructuring comes soon after the last one, which was off the back of six others, as has been indicated. The price of raising coterminosity to 80 per cent. is that once again relationships painstakingly built up between the two sectors are rendered worthless, and professionals on both sides are forced to return to square one.
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