Thank you very much, Professor Field, for the work that you have done. During the two working days that you were given, do you think that you had sufficient time to compare your recommendations with the Government’s oral and written responses to those recommendations and, perhaps most importantly, to see whether they have been implemented in the 180 amendments that the Government have tabled?
Professor Field: I do not understand the term “working days”, but yes, I do. Despite the fact that I was poorly, I spent the weekend looking through the amendments and cross-checking. This is so important for the NHS that it is worth giving all our waking time to it, which is what we did during the eight or nine weeks of the listening period as well.
Professor Field: I have been through it very carefully. In some areas the Government have gone further than we suggested in our five parts of the report, and in some areas they have not gone as far as we suggested. I can understand why, but generally I am extremely pleased at the way Government have responded. Particularly in areas such as cherry-picking, people have come up with lots of suggestions. We did not believe that it was our job to go through the Bill as part of the listening exercise and look at each section and provide amendments ourselves; we thought that that was your job. Our job was to listen to thousands of people out there in the NHS speaking not only about their concerns but about where they were happy with the Bill.
On my question about which of your recommendations had been left out of the amendments, are you able to particularise perhaps the top three that have not been included?
Professor Field: First—off the top of my head—looking at the openness of board meetings, I believe that there should be a level playing field for all providers of health care. I strongly believe that, as a taxpayer, I should know where my money is being spent, and that was the feeling that people gave back to us in the listening period. Open foundation trust board meetings have been accepted, but I believe that private providers of NHS services should also be on the same level playing field as foundation trusts. I can understand why that cannot be put in an amendment to the Bill, but it does say that ways, through contracting or whatever, can be explored, so that is really a minor issue. The vast majority of the paper has been accepted in its entirety.
In one particular area about demonstration sites for some integrated care between health and social care, the wording is slightly different from what we suggested. However, as a global answer to your question, it is remarkable how the Government have listened to what are a lot of recommendations from us and have come back with more ideas and suggestions in the amendments than we had asked for. We are pleased with that, and Kathy would probably agree.
Professor Field: We believe that personal health budgets are important, and we wanted a time frame so that they would be pushed forward quickly to give patients more control. There is no mention of the time frame in the paper. There was a lot about public health and establishing Public Health England as an independent organisation. That has been accepted, but the Government have said to us that more work needs to be done looking at public health in the NHS. That has been suggested for us to carry on with during the listening exercise over the next 12 to 16 weeks. Where the Government have not followed what we suggested, I believe it is for legitimate reasons, and extra work has been suggested to help them. If you read the original Bill, which you all know well, it is remarkable how the Government have responded in such a constructive way to what were quite challenging recommendations.
Hello and thank you very much for coming. I am sorry that you had to go in and out of the room.
I want to ask Professor Field a question and then Dr McLean. In your report, Professor Field, you recommend the establishment of clinical senates and a stronger role for clinical networks, and the Government have said that they will be run by the NHS commissioning board. Is that a good idea?
Dr McLean: Clinical networks and senates were recommended in response to what we heard about the need to involve a broad range of multi-professional people and clinicians in the advice to commissioners and the design of clinical services. In terms of whether the commissioning board actually leads those, that is around their being both hosted by the commissioning board and supported by the clinical commissioning groups.
Dr McLean: In order to have something that actually functions and exists, it needs some support in terms of somewhere to do administration, someone to make arrangements and so on and so forth, and you obviously need a body that will do that. The commissioning board, spread out into the country, would support the networks. At the moment, the clinical networks are supported as they exist, and the proposal would take things forward and allow them to continue and develop. It is similar for the senates, too.
Dr McLean: No. That would be for discussion. One thing that has been made clear in the recommendations is that the development of the exact detail needs to happen now, so we need to look at that in detail. I would anticipate a fairly lean approach, so that you have a small number of people supporting a number of networks and senates. We have to agree at what level—
Dr McLean: We have a well established system of networks for, say, cancer, stroke, cardiac and so on. They are largely based around either a single disease area or a single client group, such as mental health or children. A senate brings together the different areas into one group, so you might have the leads for various areas such as urgent care networks, end of life or children coming together in a group so they can provide cross-cutting advice.
But as you understand it—Professor Field said that he was pleased that the Government had done everything that you said—who has the final say about how services change?
We have argued that there should be lots of other clinical advice put in, and quite a lot of people are confused about how the bodies will run. I wanted to ask you, Dr McLean, about one of the big recommendations in your specific report—something I am very interested in—which is a concern about leads for safeguarding children. As far as I can see, nothing in any of the amendments specifies where that responsibility will lie. Where do you think it should lie? Where should the safeguarding lead be?
I will ask two very brief questions, if I may, because I know that time is pressing. They are directed more to Professor Field. First, I want to summarise what I think you said in your opening remarks. Is it fair to say that following the very impressive listening exercise that you and the Future Forum did, you feel that the recommendations that you put forward, which have been predominantly accepted by the Government, address what you consider the legitimate concerns expressed to you during the listening exercise?
Marvellous. Thank you for that very concise answer. Secondly, I would like briefly to quote one line—I do not know whether they are your words or the forum’s words—from the summary of your document:
“It was right to pause and reflect. It has, however, been a destabilising period for the NHS and an unsettling time for staff and for patients. It is time for the pause to end.”
Do you consider that it is quite important that we do not spend too long now chasing our tail over what to do next, and that we get on, get behind these reforms and get moving?
Professor Field, in the report you referred to the fact that you no longer wanted Monitor to be an economic regulator, and that you wanted choice to be emphasised and competition to be played down. Are you not disappointed, therefore, that part 3 of the Bill, which relates to competition, is still called “Economic regulation of health and adult social care services”? Are you not also slightly concerned that the shift of emphasis in the wording of the amendments from promoting competition to preventing anti-competition, which I contend is pretty much the same duty, is a very minimal change?
Professor Field: Thank you. Monitor and the role of Monitor probably caused more discussion than any other part of the Bill during our listening exercise. We are pleased with how the Government have responded in the proposed amendments to the Bill. You have read out one part of it. There are a lot more. If you take them all in context, our belief is that competition, as Stephen Budd would say if he were here, is not a disease. Competition is needed in the NHS. Indeed, it has been there right the way from the start of the NHS over 60 years ago. General practices are competitive, as are dentistry, pharmacies and hospitals. Competition is not a bad thing. What we did not want to see was promoting competition being the main role of Monitor. On the one hand we believe that choice is important and through our choice mandate we also believed that creating a market in some circumstances is important as well. So we are satisfied with how the amendments are laid.
Professor Field: The emphasis on the words is completely the opposite, is it not? Anti-competition—there needs to be choice in the market. There is choice even in Scotland where they profess to have a different health system from us in England. Turning Point provides brilliant services for substance misuse and learning disabilities. It has done that here for many years. We want to encourage patient choices. We do not want to close down competition, but we do not believe that Monitor’s prime aim should be to promote competition. It should be about encouraging the best quality, most efficient, effective health care possible. In some cases that will encourage integrated care between health and social care. In other areas it will be about suggesting that more competition should be there. I think the wording changes completely the emphasis on that and needs protecting.
May I question you further on that? My understanding was that you recommended that Monitor should be stripped of the competition issue altogether and also be stripped of its economic regulator role. Correct me if I am wrong, but it will still remain an economic regulator. Really the question I should be posing to you is this: what is the difference, if any, between a sector regulator and an economic regulator? What does this mean?
Professor Field: We had long discussions with people out there in the NHS, with Monitor, and with the people who wrote the original part of the Bill, and we discussed the issues of a sector regulator and how that sector regulator’s role should be just about health and not about a broad group of utilities. We felt it was wrong that in the early discussions Monitor was described as a utility regulator like that for water. We felt that set the wrong tone. We felt that there should be a regulator that looked at competition, but also encouraged choice and integration. The wording we suggested there was about sector regulation. It was about removing the initial promoting of competition. It was about inserting words about collaboration and choice. So we wanted to say that we felt Monitor should exist, but should not have promoting competition as its prime aim. It should be there and it would have an important role to play.
Professor Field: We heard a number of arguments about the OFT. We had a lot of discussion about European law and we even asked for opinions about what was happening in Holland now over competition, because that might be a precursor to what happens here. Our feeling was that in a way having Monitor as a specific sector regulator protects you from the OFT, because the alternative would be to let the OFT take on responsibility for everything, and perhaps it would never get round to health because it was so busy. We felt that being explicit and tying Monitor down to doing what we wanted it to do was the best course of action.
I would like to follow along on the same theme. The concern on the Opposition side of the Committee has been about Monitor as a potential Trojan horse for introducing competition into the heart of the NHS. One of the NHS Future Forum’s recommendations was about raising concerns about promoting competition as an end in itself, which was set out in the original Bill. You recommended that Monitor be stripped of the competition duties and no longer be an economic regulator. I am surprised that you said that looking at the Government amendments you were not concerned that there is no provision to remove the role of Monitor as the economic regulator.
I want to consider the costs of Monitor because the Minister of State, the right hon. Member for Chelmsford, indicated in evidence to the original Bill Committee that the costs of Monitor would be between £40 million and £130 million a year. It is a huge bureaucratic machine. Given that its powers are being diluted, is there an argument for asking why we need it? Could its powers not be transferred to the Care Quality Commission, HealthWatch England or another organisation in the new architecture that the Bill establishes?
Professor Field: Thank you. On the final point first, some people suggested that we should have one regulator that included the CQC, but the overwhelming number of people we spoke to when that was raised felt that the CQC should do its job properly as its prime directive, rather being merged with Monitor. Merging two organisations certainly would not help now when the CQC has a lot of difficult issues on its plate, so when we discussed it with people the feeling was that Monitor should be separate.
We do not believe that competition is bad; it can be bad, as can integrating a health care service and fossilising it, so that the service quality decreases. Choice can improve quality of care. There needs to be some mechanism for managing those issues, and therefore, from a regulation point of view, there is a role for Monitor. We did not believe that the prime role was about promoting competition. Clearly, it does have a role there.
The costs, Mr Hood, are not incidental. Over the lifetime of a Parliament, they equate to the cuts in social care for elderly people, highlighted only yesterday in a report published by Age Concern—it is around £600 million in total.
Could you comment on another recommendation of the NHS Future Forum, which is the system for designation that allows services to close without consultation? My understanding is that the NHS Future Forum indicated that it would like that changed, but as yet that change does not seem to be among the 180 amendments the Government have tabled.
Professor Field: Unfortunately, difficult decisions will have to be made in the NHS and those decisions have been dodged for many years. Those of us who work as GPs understand the difficult nature of reconfiguration of services. Two or three years ago, I chaired a reconfiguration panel in the south of England, and our opinion was overturned nationally. Someone will have to make those difficult decisions. There is enough in the Bill, as it stands, to allow consortia, the commissioning groups or the commissioning board to have a view, and to allow the system to be there to make those decisions. The critical period will be over the next two years, because we have to meet the financial and productivity challenge.
Professor Field, I welcomed your remarks at the beginning when you said that it was worth giving all of our waking time to consideration of the Government’s amendments, and I want to reassure you that at least some of us feel the same way.
Can I ask about the cap on private patients in foundation trust hospitals? What representations and submissions did you receive about that?
Professor Field: We talked about it a little bit, and we did not put as much in our report as perhaps we could have done. In fact, it was one area, having re-read the paper at the end, that we might have been stronger on, but, because the feedback was so mixed, I did not feel that we could actually make a strong recommendation.
On one hand, many of the foundations trusts were saying that the private patient cap was unreasonable. One strong representation was from University hospital Birmingham, which is capped at around 1%, whereas the Royal Marsden is capped at around 30%, so University hospital Birmingham could not bring money in that would actually help its NHS services. On the other hand, if you opened the cap, it made you more likely to be under attack from EU law, competition and Monitor, so when we weighed up the proposals and the problems that might arise, we chose not to go into any great detail.
If you wanted a gut feeling for what was happening in the listening, the feeling was that the private cap should actually stay, because people felt that that would provide a protection. However, it should be reviewed and set at a reasonable level, whereas it is unreasonable in some areas at the moment. We felt that that probably was not worth putting in the document, because it was divided.
Can I ask a quick question about Monitor? I am new to this Bill Committee—I was not part of the previous one—and I am thinking about patients being at the centre of this and about explaining to them the difference in the wording between a positive statement about competition and a double negative one. What could have happened under the previous Bill that cannot now happen under the recommitted Bill? Is there an example that you could give patients today?
Professor Field: Most of the feedback that we had was about fears of competition and of big American companies coming in and taking over the local hospital and stripping it of services and money for profit. We wanted to ensure that Monitor had a role in competition, but that it was not the end in itself.
Professor Field: When we spoke to the Government and when we spoke to most of the people who were involved—we spoke to a lot of senior staff at the Department of Health—we did not, at any time, pick up any feeling that anyone wanted a free open market where people could come in and privatise the NHS, as some people have said in the press.
Professor Field: No. We believe that it actually makes it clear that the prime role of Monitor is not to pursue competition as an end in itself but rather to be there to encourage collaboration and integration, as well as competition where it is needed. That actually gives a safeguarding. We do not believe that any individual actually believed that there would be an open market, but there was an overwhelming fear that the way that the Bill was written would cause problems.
The key issue that we have picked up on is about the integration of services, competition and patient choice. We have talked also about reconfiguring services, which you mentioned briefly. Do you now feel that the Bill is well suited to doing that? Obviously, there are different challenges in different parts of the country; perhaps better integrating adult social care with NHS care is a challenge where there are more elderly populations with health and services issues. In the Bill as it now stands, how do you see Monitor’s role in promoting that sort of integrated working?
Professor Field: We saw Monitor as being part of a more complex system. Monitor is described as an economic regulator in the title of part 3, but when you read further down that section the amendments talk about promoting collaboration and so on. It is part of Monitor’s role to make sure that that happens, and if you read some of the other amendments to do with the commissioning board they also talk about integration and services around the patient. We talk about health and well-being boards and their important role, and we talk about pilots locally to try to bring everything together.
What we were trying to do in our paper was to encourage the integration of care around the needs of the individual patient and make sure that the system as a whole encourages that, while not getting rid of the need for competition if that was needed in a particular area. You can still have choice within an integrated pathway. That might be competition between optometrists or between pharmacists, for example, in a more tied-in, integrated system.
Do you see the Bill as promoting a greater community focus with services being provided more around the patient in the community? Do you feel that the Bill supports a move in that direction in health care?
Professor Field: It remains an economic regulator in the title of part 3, but when you read through the amendments, look at the original Bill and put them together with our recommendations, Monitor no longer has a prime directive of pursuing competition. It is not the be-all and end-all, and it is not an end in itself; competition is part of that.
Professor Field: It is exactly as I have stated to you. It is a sector regulator, yes, but there are amendments all the way through around integrated care about improving quality and efficiency. It is unfair to take out just one thing and pursue it, on economic regulation, when Monitor is the sum of the amendments that have been tabled to the original Bill.
Professor Field: I said:
“Competition should be used as a tool for supporting choice, promoting integration and improving quality and must never be pursued as an end in itself.”
That is quite clear, I would have thought. I also stated:
“Monitor’s role in relation to competition should be significantly diluted in the bill.”
The amendments, as far as I read them, do that. I also recommended that
“Its primary duty to ‘promote’ competition should be removed and the bill should be amended to require Monitor to support choice, collaboration and integration.”
In the amendments, cherry-picking and tackling abuses are also talked about. As they are written, they adequately answer what we have recommended in our paper.
Can I take you back to a remark that you made earlier? One thing that you thought had not quite been embodied in the legislation and that was demanded by some contributors to the listening exercise was a demand for greater transparency with regard to private sector providers. The Government have the laudable intention of trying to secure a level playing field, but clearly, without financial transparency, you could get a private provider behaving in a predatory way—trade at a tariff but at a loss for a period of time to remove a hospital unit that is thought to be fragile, or whatever. Is that a problem that people wanted TO be addressed? Were there any obvious solutions coming from the Future Forum, or that have been, as you can see, embodied in the legislation to deal with that issue? It is obviously a tricky problem, because private firms are not very good at letting people know precisely how their finances stack up.
Professor Field: It was quite complex. The question that we posed was about transparency, and overwhelmingly, the feedback was that foundation trusts should have open board meetings, consortia should have open meetings, and all the minutes should be published. Nurses, doctors and patients also wanted those providing NHS services, which might be the third sector or a hospital, to have more transparency. Many said that open board meetings would be a good thing, because that would create a level playing field with NHS providers. It is difficult legally to make that happen. You might do it through the commissioning process, by writing it into contracts. I can fully understand why the Government did not go as far as we were suggesting, because it is very difficult in law, I gather, to make that happen. There are other parts of the Government’s response that reassured me, and I knew that I was pushing harder than I might get an answer for.
I am trying to get to the spirit of the input that the Future Forum received, so this is a general question to finish. Many representations that have been made to me in the past few months regretted the unsightly political football match that had taken place. In the summary to your report, you said that things became polarised; on one hand, the Bill was about all-out privatisation of the NHS—we will call that option A—and on the other, reform was the only way to safeguard the principles of the NHS that we all hold dear. We will call that option B. Were most of the tens of thousands of people who contacted you coming from position A, position B, or somewhere more moderate in between?
Professor Field: It was more complex than that. Most of the public face was “Save the NHS from being privatised”. That was in the press. When we met with organisations and individuals, and once you got past the privatisation and talked about the detail, there was a genuine understanding from lots of people that the NHS had to change. When we talked about the reasons for change, such as the ageing population, or the cost of fantastic medical advances that the NHS has brought about, people genuinely felt that the NHS had to move on from where we are now, which is hospital-based, to something more community-based and preventative. When we started to ask questions about the principles underlying the Bill, there was overwhelming support for the principles of clinical leadership, which had not been apparent in many of the PCTs in the past—that led to stagnation and a lack of development of commissioning, and all of that is on record—as well as for more meaningful patient and public engagement, and for the outcomes framework, building on Lord Darzi’s brilliant work on quality. Therefore, it was more complex. It quickly became apparent that those people who were aware of the NHS constitution and its first words owned the NHS almost like a religion and wanted us to safeguard the constitution.