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My Lords, I am grateful to the noble Lord, Lord Turnberg, for giving us an early run at one of the key questions coming out from the Government's proposals-a question which I might rephrase as: will they work where it really matters, at the front line? I, too, congratulate the noble Baroness, Lady Jolly, for giving us such an eloquent description of why they matter.
There is a great deal to be said for the Government's proposals-not least the continuation of a 20-plus year policy for a primary care-led NHS and for decentralisation, although, as some noble Lords have pointed out, there need to be limits to both of those. There are of course risks. It will be no surprise that I shall concentrate on the more managerial issues. The Minister knows, but I should say for the record, that I was chief executive of the NHS and Permanent Secretary of the Department of Health for six years; so I am afraid that I know a bit about reorganisations and may be seen by some of my clinical friends in the House as one of the villains of the piece.
I read the Command Paper that came out before Christmas with great interest, particularly where it talked about how to manage the transition. It was well written, as I would expect from former colleagues in the Department of Health, but there were some fundamental gaps that are fundamental risks. I will mention three of them.
The first is the capability of consortia. I have no doubt that there any many good, talented and skilled GPs and people working in primary care who can and will take the lead in this area. I did not find anything in the paper that described how the capabilities of those consortia to discharge that role would be in any way tested. Your Lordships will no doubt know that foundation trusts and NHS trusts go through a critical scrutiny as to whether they are capable of discharging their functions, and that is to be continued under these proposals. As an NHS trust chief executive 15 years ago, I remember going through just such a tough process where people from outside the organisation tested whether our ambition to do something was matched by reality. The optimism of our will to do it was tested against the pessimism of whether we could actually deliver-were we up to the job? I do not know why that is not being put forward here for GPs unless the Government are too eager to get the GPs involved and do not want to frighten them off at that stage. It is important that some testing is done to secure the success of what is intended here. How will the department test the capability of consortia before they are given free reign?
Secondly, as a subset of that, I was again interested to know how consortia would be accountable. I see in the text that there is somebody called an accounting officer who is not really defined other than as the person who will account to the NHS commissioning board and then upwards to Parliament for the expenditure of the consortium. It need not be a doctor, we understand, but there is a question about what their responsibilities and powers are. In some ways it looks like going back to the old system of consensus management that we had 25 years ago where you basically had a doctor and an administrator in charge and you had to get the two of them to agree to get any change going. This was the sort of situation of which Roy Griffiths, in a report for the Conservative Government of the 1980s, said that, were Florence Nightingale back today, she would be wandering the corridors of the hospital wondering who was in charge. That question is still there. How will that arrangement work for accountability?
The third gap, to which my noble friend Lady Finlay alluded, is that these consortia will turn for expertise to private sector organisations, some of which will be from abroad. We know that GPs are saying that, and that it is already happening. They will, for example, turn to people with experience in insurance systems. We have a social contract system: we expect to be able to go to our doctor and know that they will do their best for us, looking at a comprehensive care with some exceptions rather than an insurance system that too often specifies what you can have. There is a big difference between the two. My worry is that there will be a change in the attitude of mind and behaviour in that relationship.
I have one positive suggestion here which the Minister may or may not like. Although there are pathfinders and there is preparation under way, I have not seen anything that suggests there will be any large-scale simulation of these proposals-getting people together and, over a period, encouraging them to play out the various roles to see what will happen. That has been done in the past, and it is an effective way. The question need not be whether these proposals will work but what you need to do to make sure they work as effectively as possible. Can the noble Earl say whether the Government propose to do any such simulation of these proposals before bringing them fully into effect?