Examination of Witnesses
Health and Social Care(Re-Committed) Bill
4:00 pm
Jimmy Hood (Lanark and Hamilton East, Labour)
Good afternoon, gentlemen. I welcome Dr Hamish Meldrum who is video-linked to us from Cardiff; Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing; Sir Richard Thompson, president of the Royal College of Physicians; and Professor Sir Neil Douglas, chairman of the Academy of Medical Royal Colleges. We have a video link, but we will run the evidence session as though Dr Meldrum was sitting in his chair, and for all intents and purposes that is exactly where he is sitting.
Emily Thornberry (Islington South and Finsbury, Labour)
It is nice to speak to you, Dr Meldrum. Can you see us?
Emily Thornberry (Islington South and Finsbury, Labour)
I shall begin with a question to all four witnesses that is similar to the one I asked first thing this morning. Although there might be pressure to get on with the changes and it might be regarded as important for the national health service to be able to move on, do you believe that the timetable that has been set out for all of us, and particularly for you, has been sufficient to enable you to go through the 180 amendments, compare the new document with the original Bill, consider the suggestions from the Future Forum and the Government’s response, and then look at whether the clauses reflect the promised changes? Do you think that you are in a position to represent fully your views and the views of your members in the time you have been given?
Dr Carter: The straight answer is no. We have had two full working days, and by anyone’s standards 180 amendments is a huge quantity. We are working on it. We are prepared to go ahead with it, but forensically going into these amendments in that time scale is virtually impossible. As far as talking with our members goes, the honest answer is no, because we have not had the time. However, we are where we are and we want to get on with it.
Sir Richard Thompson: I think the timetable is very short. The Irish person would say, “I wouldn’t start from here,” but we are here. There are bigger problems outside this room, to do with money and improving care in the health service, and we must get on with that. A senior politician said to me, “We’ve lost a year arguing about these things.”
Professor Sir Neil Douglas: The 48 hours was ridiculous, but there are so many disadvantages in delaying that we have to get on with it to the best of our ability now. We will not be able to give you definitive answers on detailed questions because our members have not had a chance to respond, but we will do our best and we believe that we should be going forward at the moment.
Emily Thornberry (Islington South and Finsbury, Labour)
Dr Meldrum, I think some of us may have received by e-mail about 10 minutes ago some form of response from the BMA, but you will forgive us if not all of us have been able to read it in some detail. We promise that we will. Could you give us a response to whether you feel that you have had a sufficient timetable?
Dr Meldrum: It has certainly been extremely rushed and challenging. I repeat how grateful I am for you allowing me to join via video link because I am at our annual conference in Cardiff. Interestingly enough, we had a very full and quite passionate debate on the Bill this morning. One of the problems that many members pointed out was that they were finding it very difficult to work out how the amendments fit into the current Bill. They feel that the degree of complexity is really quite immense. Any judgment we make at the moment has to be predicated on the view that we will want more time to study the amendments to see how they fit in with the overall situation. I echo what others have said about the uncertainty in the service also causing problems.
John Pugh (Southport, Liberal Democrat)
Can I direct both of my questions to Hamish? I, too, received some communication during the lunch hour on a resolution passed by the BMA, and it would be helpful, Dr Meldrum, if you were able to amplify a little bit on it. Can I just take the resolution in reverse order? I understand that the BMA wants the Bill withdrawn, and three or four reasons are given there. One reason is that it imposes a duty on commissioners to promote choice as a higher priority than tackling fair access and health inequalities. An awful lot of the amendments are about tackling fair access and health equalities and, indeed, some are about promoting choice. Is your reading of the Bill that it promotes choice as a higher priority than tackling fair access and health inequalities?
Dr Meldrum: Our understanding of the amendments as they are at the moment is that that might well be the case. I have always said that we are not against patient choice but, in a social solidarity model of health care, there always has to be a balance on how much individual choice impacts on the choice of others and the potential destabilisation of other services. First and foremost, we want to ensure that there is comprehensive, fair provision of health services to all. I think the reason that the conference asked for the Bill to be withdrawn is what I said earlier about the increasing complexity and the difficulty people were having finding out what it actually all means. There was another option, which was defeated, that opposed the Bill in its entirety, so there are still aspects of what the Government are trying to do that the BMA would continue to support.
John Pugh (Southport, Liberal Democrat)
I can entirely understand your difficulty in getting clear about what all the legislation means in the round. What I am trying to do is clarify the BMA’s present position. The second reason is that you believe that Monitor, the CQC and the NHS commissioning board should have a legal duty to act and to avoid the undermining of existing NHS services. That is something that you would hope that everybody in the NHS would seek to do—avoid undermining services. According to the BMA, what would it involve any of those bodies doing that they do not currently do and are not mandated to do by legislation?
Dr Meldrum: It goes back to my answer about the position of choice and the focus on that rather than, in some cases, there not being enough focus on the provision of stable, integrated services. It is about getting that balance right in allowing appropriate choice but not doing it in a way that undermines the system.
John Pugh (Southport, Liberal Democrat)
It is about getting the balance right between integration and choice. I will not go into the issue about the duty of the Secretary of State for Health because we will have him here quite soon. The other reason given is in regard to the function of Monitor to promote competition in the provision of health services. We had an interesting debate this morning as to whether preventing anti-competitive behaviour, which is what the actual amendment states, is the same as promoting competition. Your members are presumably aware that that particular phrase does not occur?
Dr Meldrum: Yes, but clarity is getting increasingly difficult. This was already quite a complex piece of legislation and it is now being very significantly amended. In many ways, it is being amended in ways that we approve of and have suggested, but we could end up with something that I would call almost a legislative morass, which is quite difficult to find one’s way through and work out what it will all mean in practice. Of course there are other areas, such as the relationship with the NHS commissioning board and the role of clinical practitioners which add to the confusion.
Owen Smith (Pontypridd, Labour)
I will put my question to the people in the room, starting with Sir Richard. When you gave evidence to us previously, you were not sanguine at all about the changes that the Bill was going to introduce into the health service. Are you reassured by the amendments that we have seen, albeit at very late notice?
Sir Richard Thompson: The amendments are improvement. There are still things that I worry about, but the amendments, such as the one about putting a secondary care doctor on each clinical commissioning group, are a step forward. If there is one good thing in the reforms, it is forcing integration between primary and secondary care and getting rid of that barrier—commissioning without walls, we would call it. One thing that we suggested but no one has picked up is that there should also be a GP on the foundation trust board as well, to encourage integration between both sides of the patch.
Owen Smith (Pontypridd, Labour)
One of the issues that we discussed this morning was the extent to which Monitor’s powers remain effectively the same. It has powers to promote competition; it has words relating to integration but no powers to compel or to encourage integration. Are you still concerned that we will see more competition and that that will play against further integration in the NHS?
Sir Richard Thompson: I am worried. I know that the chairman of Monitor has changed what he said previously, when he was interviewed by Mr Timmins. Hopefully, that is a real change and he does not have the same financial competition in mind that he seemed to have then. Clearly, if there is going to be choice, there will be some type of competition. I prefer the word “choice”, as I think Nick Clegg does, so I will stick to that. I am worried about Monitor and it must be watched carefully. I am not technically minded, so I do not know how you can write these things in. You have to leave some flexibility. Yes, though, I am still worried about it.
Owen Smith (Pontypridd, Labour)
Dr Carter, do you feel that the balance between integration and competition is better struck?
Dr Carter: It is right to say publicly that the listening exercise was a real exercise and we are pleased that many of the things that we asked for have been taken on board, but we have serious reservations about Monitor. Sir Richard has already mentioned some of the comments that were made by David Bennett when he was first appointed—likening the NHS to gas and utilities and saying it was ripe for significant change. Ideologically, we do not believe that getting component parts of the health service to compete with each other is a sensible way forward. We would prefer a model where people are tasked to collaborate with each other and to co-operate, where there is more integration of services, and where services sort out who is best placed to do what. We are worried that Monitor will focus on cost at the expense of quality, which is something we will have to watch in the coming period.
Professor Sir Neil Douglas: I agree entirely with what Richard and Peter have said. I welcome the involvement of a hospital doctor and a nurse on the clinical commissioning groups, although it is unfortunate that there is no firm recommendation that a public health doctor should be there too, because driving down health inequalities is really a public health role. One of the roles of the commissioning group is to drive down inequality, so I would like to see that there.
I also am very disappointed that although the involvement of the medical royal colleges in such things as the NHS commissioning board has been welcomed, recommendation 3.25 in the clinical advice and leadership report of the Future Forum of a requirement on NHS employers to release people to do work for the greater good of the NHS, be that for the colleges and thus the commissioning board, for the National Institute for Health and Clinical Excellence or for any other group, has not been taken up. The fact that foundation trusts do not wish to release people for the greater good of the service is a real problem for the colleges at present, and we would very much like to see that embedded in the Bill.
Sir Richard Thompson: Could I follow on the topic of public health, because that is one of our faculties? We are worried that public health will not be strong enough when it is embedded in local authorities and health and well-being boards. After all, as David Cameron has said, public health must be our future; if public health does not win through, we will be destroyed economically trying to run the health service. I think it should be more prominent not only on the clinical commissioning groups but in advising the NCB and the local clinical commissioning groups.
Steve Brine (Winchester, Conservative)
This is a question for any of you, but let us start with Cardiff. Dr Meldrum, thank you very much for joining us. I know that the BMA union has had its run-ins with Government over the years—some would say right from the start—and that has certainly been the case recently. Can I ask you two questions? First, I know that the BMA has made its position clear today, as is being reported, but what do you personally like in the new Health and Social Care Bill?
Secondly—the other gentlemen may be able to answer this as well—I am interested in probing the representative voice a bit. Obviously, the views of your organisations about this Bill have been well reported in recent months, but I am wondering what ongoing surveying of membership takes place. How many members do you have, and how many have answered your calls for responses about the Bill?
Steve Brine (Winchester, Conservative)
Sorry to interrupt you, but let us just be clear. You asked your members not to support the withdrawal of Bill motion today, so presumably you were arguing a slightly different case from them. I tend to be a rather positive person, so I am asking you what you like in the Bill.
Dr Meldrum: I am a positive person, too, and I am a pragmatic person. I like to try to work out and talk out differences, and I did not really feel that suggesting the withdrawal of the Bill—whether that would be practical or not—was the best way to achieve that.
We obviously like the underpinning principles, which are greater clinical involvement in the decisions about how services will be provided, more patient engagement and a focus on quality. However, many of us, myself included, felt that a lot of those could have been achieved without recourse to legislation, or certainly with much simpler legislation than this Bill. Instead, we have this whole additional layer of legislation, which led to the worry that it was actually going to destabilise services and widen the split between primary and secondary care, and that it was not going to encourage collaboration. We wanted to see something that would actually change that position. However, the basic principle is fine. Certain aspects about getting rid of certain elements of bureaucracy are fine, although one wonders whether, with these amendments, we are replacing it with another layer of bureaucracy.
On getting members’ opinions, we have had meetings around the country, we have had our annual meeting, we have had the conference of GPs, and we have done surveys. Even among GPs, whom you might expect to be the most positive, many, even though they are getting quite actively involved in commissioning groups, still have severe reservations about certain aspects of the Bill.
Liz Kendall (Leicester West, Labour)
Thanks to everyone for joining us, here and from afar. I want to come back to a point made right at the beginning about what is happening now out in the services. The NHS Confederation managed to get us a briefing on the amendments to the Bill. It says:
“The new system could make it more difficult to make urgent decisions about reconfiguring local services when this will improve the quality of care for patients”.
It also stated that
“the reforms do not sufficiently focus on the big challenges facing the NHS: making £20 billion of efficiencies over four years”.
I want to ask each of the four witnesses whether, from what you understand that the Government are now saying, you think that those difficult decisions are going to be easier or harder.
Sir Richard Thompson: I think that improving the quality of care and saving money, which is desperately important, are separate. I came back from Nottingham to be with you today, and I hear that there are tremendous problems in secondary care everywhere, which is obviously my business. I think that that is separate from the reforms, which are altering the structure of the NHS. I see them as two separate things.
Liz Kendall (Leicester West, Labour)
You do not think that any of these changes help to deal with the problems that we face?
Sir Richard Thompson: The only thing that is really good is encouraging integration between primary and secondary care, which may lead—I hope it does—to improvement in the way that patients receive care and possibly to savings. Reconfiguration is a separate matter, and I would not see it as particularly affected by the reforms.
Liz Kendall (Leicester West, Labour)
Neither the need to make current savings nor the need to reconfigure services is affected by the reforms?
Dr Carter: Because we are still not clear about how these various structures are going to work, it is difficult to make an informed comment. I downloaded something just today that is a byzantine maze of structures, and we are hoping to get very quickly from the Government further understanding about how it all wires up and links together, because it is not readily apparent now.
On the £20 billion, it has been said many times before that that on its own would be a huge challenge for the NHS at the best of times. Doing it now, coupled with this major reorganisation, makes it that much more difficult. As we go around the country, we see hugely differing approaches. Some people are applying some intelligent and imaginative thinking, but sadly there are many examples of people carrying out short-term cuts that will soon stack up as problems both financially, because we do not think that they are properly thought through, and, more importantly, for patient care. We are seeing waiting lists go up in a way that I believe will soon become unacceptable. Why are we keen to work with the Government to get this on board? We need to get some coherence and stability in the system. We need to find a way of getting through the financial crisis that is facing the NHS in a way that does not further destabilise it.
Dr Meldrum: There are two aspects to Liz Kendall’s question. One is whether the reforms themselves will help to achieve the savings and achieve the reconfiguration or better help to do that. We have concerns about the original legislation, for some of the reasons I have mentioned, such as not encouraging co-operation, not encouraging that good partnership working between clinicians of all types and patients, which will be vital if we are to buy into reconfiguration and provide more cost-effective services.
The other aspect of the reforms is the disruption that a major reorganisation creates, with people more interested in looking after their jobs or finding their next job than in doing their day-to-day work. There is no doubt that, even at the moment, we are seeing the destabilisation of primary care trusts and strategic health authorities. That is why there is a real dilemma: do we try to move on more quickly and get over this process of reorganisation or reform, or do we take our time to get it right? Difficult though it may be, we have to do as much of both as we can.
Professor Sir Neil Douglas: One of the deeply disappointing aspects of the Bill is that it does not read like a logical attack, or a logical approach to solving the problems, namely the ageing population, chronic illness, reconfiguration and integration. Having said that, we are where we are, and as I have already said we need to proceed as best we can to come up with some clear answers. I have no doubt that the Bill has been improved to a significant extent during the pause.
Dan Byles (North Warwickshire, Conservative)
I have two questions, one of the entire panel and one of Dr Meldrum. First, you stated that you have perhaps not had as much time as you might have liked to look at the amendments. However, I would suggest that you have had plenty of time to look at the NHS Future Forum report, which this morning Professor Field said he was extremely pleased about, and that it was remarkable how the Government had responded to it in such a positive way. He felt that the vast majority of what had been recommended is reflected in the amendments. [ Interruption. ] You can read it in Hansard tomorrow. I think you will find that he did. Based on the NHS Future Forum report, which you have had time to read, I am curious to know whether you are satisfied that, if the Government amendments are to reflect accurately the Future Forum recommendations, it is the right move and will take us forward in the right direction.
Dr Meldrum: Certainly, the Future Forum took a significantly better direction than we had been going in previously. We still have some issues with aspects of the Future Forum report, but what counts in practice and will count with the service on the ground is how the recommendations are delivered in legislation. As I said earlier, it was already a very complex piece of legislation; it is now potentially more complicated. Besides Professor Field’s comments that you reported, we still need to study the detail of the legislation, see how it all fits together, and to see whether, in trying to deliver the Future Forum recommendations, it does so and does not have other perverse consequences.
Sir Richard Thompson: I agree, it was very carefully written. We all met them several times; they tried extremely hard. A lot of the suggestions have been picked up by the Government. We are probably not discussing the work force section, but we are strongly against that. We are very worried about that, but it is probably not being discussed. One thing they did not pick up was the question of allowing NHS doctors to do national work, such as working in colleges—to give them definite time off to do that. Now, with the increased stress as I have found in Derby and Nottingham in the past two days, there is enormous difficulty in getting time off from an increased clinical work load to do work for the colleges, or even to go out and meet GPs, I am told. Yes, I think they have achieved quite a lot and I welcome a lot of their suggestions, but not on the work force.
Dr Carter: We, too, have said that we feel it was a real exercise. Steve Field and his colleagues came down to the RCN, and we had a very good half day. Our members throughout the country participated at a host of events. Many of the things we asked for have been achieved.
In relation to Mr Brine’s question, I hope I will complement what you are asking. We have consistently said that we sign up to the key principles. One thing we had always been concerned about in the NHS was that there were far too many bodies, far too many primary care trusts. In addition, far too many primary care trusts did not do what they were set up to do—that is, commission. They had a provider arm, and that really muddied the waters.
Therefore, when the reforms were first announced, we were encouraged by the fact that we were to see a reduction in some of those structures. We were to get more clinical involvement—and we mean “clinical” in a generic sense. We also felt it was a very healthy and sensible thing to do to put GPs right at the heart of things, because in many respects they had felt alienated and on the periphery. There was lots of good stuff in the reforms.
However, the reforms lacked detail. We put this to the Future Forum. In the meeting that some of us went to with the Prime Minister and others, we made the point that even at this stage in what are now known as clinical commissioning groups, we still do not have the architecture, we do not have the detail and we do not know who will chair those groups, who will appoint them and what their term of office will be. What is the failure regime? It is naive to think that every group will be a success. When money was being poured into the NHS, trusts still got into financial difficulties. We are kind of being asked to sign a blank cheque, and what we say is that it would not be unreasonable at this stage, nearly a year on, to have had answers to some of those quite elementary questions about the governance of those groups.
I know that was a bit of a walk-around, but I was keen to come back on Mr Brine’s question. I hope that has helped.
Professor Sir Neil Douglas: Broadly, the Future Forum did a very good job, but the devil, as Hamish has said, is in the detail of the Bill. That is where we have had problems. I am the chairman of 16 different colleges, which each have to report back to me their views. However, I am speaking for myself at the moment, largely.
Dan Byles (North Warwickshire, Conservative)
Dr Meldrum, picking up on my colleague Mr Brine’s question, I am very interested that the BMA has voted the way it has today, because it seems to be at odds with the way quite a lot of doctors in my constituency whom I speak with say that they feel. Can you tell me what the total membership of the BMA is and how many people are present at the conference and voted today?
Kevin Barron (Rother Valley, Labour)
I declare my interest again as an honorary fellow of the Royal College of Physicians. I have just two questions. One is to Dr Hamish Meldrum. Dr Meldrum, I will quote from your speech yesterday:
“There is a huge difference between adapt and change and slash and burn, between carefully planned reorganisations and knee-jerk closures and redundancies, between partnership working amongst health professionals, managers and patients and imposed, top-down, politically motivated diktat.”
Clearly, you are shy with words, Dr Meldrum, but could you put that quote in some context for the Committee this afternoon?
Dr Meldrum: Thank you for the compliment, Kevin. Obviously, speeches are a time for trying to use words effectively, but we are getting reports from people that they feel that the co-operative working that I talked about earlier, whereby you get all the people together and decide what you will do about difficult situations, is not happening, particularly in the current financial situation. That quote was in relation to the need to make or identify £20 billion of savings, rather than in the context of the Health and Social Care Bill. The need to identify those savings is leading to short-term thinking and immediate, rushed reactions that are having bad effects for staff and, consequently, for patients.
We realise that time and money are tight and that we will not be able to do everything that in an ideal world we would like to do. However, there is a way about the process, which to some extent is a legacy of the way things worked in the past, that seems to militate against good-quality planning and decision making. That is unhelpful. Of course, the only aspect of the immediate impact of the Bill is the destabilisation I talked about earlier.
There is an added aspect, although again we are grateful for some of the changes. I do not want to sound like a latter-day Oliver Twist from the BMA, always coming back asking for more. We are grateful for some of the changes that have been made, and one of them was the relaxation of the foundation trust pipeline, but even in relation to that, a lot of managers and people from hospitals who were at the conference were reporting that they still feel a pressure to meet very tight financial deadlines and financial standards, rather than focusing on patient deadlines and patient standards.
Kevin Barron (Rother Valley, Labour)
One further question to the panel. We had it confirmed from Monitor this morning that mergers between national health service trusts and between NHS trusts and other bodies could become a matter for the Office of Fair Trading and the Competition Commission. I wanted to ask all four of you whether you as individuals are happy with that. Do you think your members would be happy with that?
Dr Carter: I have not seen those comments but that concerns us. I assume that it was Mr Bennett who gave that evidence. We would need to understand more what he means by that. We simply do not see that mergers are necessarily something that will take the health service forward, but there needs to be intelligent service redesign and it means making difficult decisions that at times are politically very contentious. We feel that that is the only logical way forward. I would need to study more what Mr Bennett said, but it gives me some concern.
Sir Richard Thompson: I understand that if there were mergers, it might be considered to be anti-competitive and that worries me. We have to move towards fewer and larger hospitals. I am reassured about the European law by Nick Clegg and that that has been sorted out, but I have not seen that in print.
Kevin Barron (Rother Valley, Labour)
I am talking specifically about clause 65, which remains unamended. Professor Douglas?
Dr Meldrum: Yes, I also have concerns remaining. Mergers should take place for good clinical reasons. Certainly, you have to consider cost-effectiveness but they should not just be done for financial reasons. I am afraid that I never like to personalise things, but it is another comment from the head of Monitor that has not been exactly helpful in reassuring people that the real purpose behind Monitor has changed and that we are seeing a move much more to collaboration and appropriate choice, rather than focusing on competition as an end in itself and not just one of many means to an end.
Daniel Poulter (Central Suffolk and North Ipswich, Conservative)
There has rightly been a focus on integration of services. I know, Dr Thompson, that when you were here last time that was one of your concerns, particularly given our ageing population and the fact that many people now are living with multiple medical co-morbidities. It is obviously a key challenge. This morning we heard from Sonia Brown and David Bennett of Monitor that the key focus of Monitor now would be on promoting integrated care. I want to get your views on that. Monitor would be looking to achieve value for the NHS, and value for the NHS is also value for patients; which meant, from further questions, that it would be better looking after patients in the community to prevent inappropriate hospital admissions, which is good for patients and good financially. Would you welcome that sort of thing in our focus from Monitor?
Sir Richard Thompson: Absolutely. I just hope that the leopard can change its spots. If it does, that is fantastic. I would not entirely say that everything is done out in the community. Obviously, patients like things done at home but it can be done more cheaply. The evidence, as you probably know, is very divided in the studies that have been done. In principle, yes, I support that.
Dr Carter: You need a mixed economy of provision. You do not want to lurch from one extreme to the other. What is undoubtedly the case is that far too many people are coming into hospital with long-term conditions, and if you had adequate community infrastructure you could prevent those admissions. Equally, you have the challenge of delayed discharges because of a lack of infrastructure out there. That is why we were hoping that these reforms would free up resources, and you would be able to switch to get those sorts of things that prevent unnecessary admissions.
Daniel Poulter (Central Suffolk and North Ipswich, Conservative)
So you very much welcome that Monitor said this morning that it was taking that into account in its involvement in securing provision?
Daniel Poulter (Central Suffolk and North Ipswich, Conservative)
I do not think it was saying it was the driver, but that it saw that its role was to help to promote integration, and we heard that very clearly this morning.
Daniel Poulter (Central Suffolk and North Ipswich, Conservative)
Indeed. Very good. Do you think that it is none the less a welcome direction of travel for Monitor?
Dr Meldrum: I agree. It is a welcome direction. I would like to see the context in which the quote was made. We want to see care appropriately delivered closer to home. It is not always the cheaper option. Of course, the other thing that we do, which we have clearly mentioned, is the administration of health and social care. Again, we hope that there are measures within the legislation that help to achieve that, because that is really going to help with the longer-term management of these long-term conditions.
Tom Blenkinsop (Middlesbrough South and East Cleveland, Labour)
I address this question directly to Dr Meldrum. You said today that the BMA discussed the Future Forum document and the Government’s proposed amendments, and you said to the BMA conference that the Government response on the issue of competition largely addressed the BMA’s concerns, but members today clearly rejected your view and advice, and the Bill. Why do you think they did that?
Dr Meldrum: I obviously have the advantage of having had time to study, with the help of very learned colleagues, some of the detailed amendments, and I am therefore probably better placed than others to read other people’s interpretations. You would obviously have to ask my individual members why they were not as cognisant as I was that the issues had been addressed, but I think that one reason is the fact that the Bill very much started out to promote competition, as was mentioned in some of the comments from Monitor and others that we referred to earlier. Therefore, there is still a concern that although there has been some improvement, the issues have not been totally addressed. Some of the comments that have been made by Ministers, to the private sector for example, reassuring them that there is not too much change, have not helped with that.
Tom Blenkinsop (Middlesbrough South and East Cleveland, Labour)
Dr Meldrum, I would imagine that your members are of average and above-average intelligence.
Tom Blenkinsop (Middlesbrough South and East Cleveland, Labour)
Given that there are no amendments to clauses 60, 64 and 65, which are a substantial part of the Bill with regards to competition law, would you not say that that might be one of a few reasons why your members voted against the Bill?
Dr Meldrum: Yes, absolutely. Just in case my personal position is being misrepresented here, what I said both yesterday and today is that there has been movement in the right direction. It has not gone as far as we would have wanted it to in many places. What I am anxious to do as the leader—this is one of the reasons I am sitting here—is to still be in a position in which I can negotiate with some credibility, not wanting to sound totally curmudgeonly and negative. Some of the way in which people will interpret some of the notions might not help with that process. I have quite a lot of sympathy with the strength of feeling, and if you had been in the hall, you would have felt the passion behind the statements that were made. I have never said that the changes are absolutely great and that we are completely happy with them all. We still need to work on the detail.
On the question of intelligence, I hope that I am of above-average intelligence, but I have to rely on people who are skilled in parliamentary drafting to tell me exactly what the words mean in practical terms.
Liz Kendall (Leicester West, Labour)
I think everyone supports the idea that commissioning should engage the full range of clinicians, but what do you think of the fact that clinical senates and clinical networks will be run by the national commissioning board and that the legislation gives the board the power to tell commissioning groups how they get their guidance?
Jimmy Hood (Lanark and Hamilton East, Labour)
Order. We had time for the question, but unfortunately we do not have time for the answer. I would like to thank our guests for coming along. It was an interesting video link. [ Interruption. ] I think it is a first for a Public Bill Committee, but Select Committees may have tried it before.