Clause 16 - Commissioning primary care services etc

Health and Care Bill – in a Public Bill Committee at 2:00 pm on 16th September 2021.

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Question proposed, That the clause stand part of the Bill.

Photo of Julie Elliott Julie Elliott Labour, Sunderland Central

With this it will be convenient to discuss the following:

Amendment 28, in schedule 3, page 126, line 28, leave out “person” and insert

“general practitioner, GP partnership or social enterprise providing primary medical services”.

This amendment would prevent an integrated care board from entering into or renewing any Alternative Provider Medical Services (APMS) contract.

Amendment 29, page 126, line 32, leave out “person” and insert

“general practitioner, GP partnership or social enterprise providing primary medical services”.

This amendment would prevent NHS England from entering into or renewing any Alternative Provider Medical Services (APMS) contract.

That schedule 3 be the Third schedule to the Bill.

Clause 17 stand part.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

With your permission, Ms Elliott, I will first turn to clause 16 and schedule 3, and then discuss amendments 28 and 29, before concluding with clause 17.

Clause 16 gives effect to schedule 3, which makes provision for integrated care boards to take on responsibility for primary care services. The schedule allows for the conferral of functions relating to the commissioning of primary medical, dental and ophthalmic services on ICBs and contains related amendments. NHS England is currently responsible for arranging these services, but in future, once ICBs are fully established and ready to take on these functions, we intend for ICBs to hold the majority of them. This approach will ensure that decisions about services are made closer to the patient and in line with local population needs.

The schedule introduces a number of provisions to enable the transfer of these functions. The schedule includes equivalent provisions relating to primary medical, dental and ophthalmic services. That is to ensure flexibility, as it allows the different services to be conferred on ICBs over a period of time if that is deemed the most effective and efficient approach. The Bill is designed for the future, and we want to work with the system to support it to move at the right pace and offer patients the best care at all times.

The schedule provides for regulations to define which services should be regarded as primary medical, dental and ophthalmic services for the purposes of the Bill. The services that are classed as primary care services may vary over time and so these powers allow the Secretary of State to react to any such changes. The powers restate similar powers that are currently found in the National Health Service Act 2006. This provision places a duty on ICBs to provide primary medical, dental and ophthalmic services for those people for whom the ICB is responsible and allows ICBs to enter into the necessary arrangements in order to do so. To date, NHS England has always been responsible for dental and ophthalmic services, but the commissioning of primary medical services has been successfully delegated to clinical commissioning groups for some time. These provisions will ensure that primary care continues to be at the centre of delivering joined-up care to local communities—many members of the Committee have highlighted that—in partnership with wider health and care services in the area.

The schedule requires each ICB and NHS England to publish any information that may be prescribed in regulations concerning the provision of primary medical, dental and ophthalmic services. To ensure that appropriate safeguards are in place once these responsibilities are transferred, NHS England will have powers to direct ICBs as to how they should exercise their primary medical, dental and ophthalmic care functions.

In addition to primary care services, the Secretary of State will have powers to require NHS England to exercise pharmaceutical services, which can, in turn, be delegated to the integrated care boards. NHS pharmaceutical services are generally not directly commissioned, and the schedule continues to allow for that consistent approach to be followed.

The schedule makes provision for the necessary technical and consequential amendments to reflect the new provisions within it relating to primary care services. It is crucial for establishing ICBs as the key commissioners for the NHS in England in the future.

I am grateful for the opportunity to debate amendments 28 and 29. I will address what I read into them at this stage and if I have misrepresented them, I will of course seek at the end, as appropriate, to address any misapprehensions I may have set out. I fear that the amendments would prevent an ICB from entering or renewing a contract with some private and third-sector organisations for the provision of primary medical services. Although the explanatory note for the amendment says this will

“prevent an integrated care board from entering into or renewing any Alternative Provider Medical Services (APMS) contract”,

I have been advised that it would actually go much further than that limited objective, as limited companies can currently also hold general medical services and personal medical services contracts. The amendment would bar some of those companies from doing so, which would have a potentially devastating effect on primary care at a moment when the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Bury St Edmunds, is working flat out to build capacity in primary care.

My constituency neighbour, Jonathan Ashworth, has accused the Government of allowing, in his words, the “stealth privatisation” of primary care and thereby undermining patient care. However, primary care commissioners have long had a choice to commission services from a range of primary care providers. Prior to the introduction of CCGs, primary care trusts had a long-standing power under section 23 of the National Health Service Act 1977, which was introduced by the Labour party, to purchase services from the independent and voluntary sector. If I recall correctly, it was the Labour party that, in 2004, first allowed GP out-of-hours services to be contracted to private companies.

It is crucial that commissioners have the flexibility to commission partnerships, individuals, and private and third-sector organisations to deliver NHS GP services to meet the specific healthcare needs of their populations. Private and third-sector providers play a vital role in the delivery of services to meet those needs, and they must adhere to the same quality and safety standards as any other form of GP contractor. The Labour Front-Bench team will know that we have moved to have further discussions with them on ICBs—hopefully, that will be a positive step forward—but in this case, we cannot support the amendments.

Let me say a few words about APMS contracts. Such contracts offer greater flexibility than either GMS or PMS contracts, for the benefit of both commissioner and provider. APMS contracts are time-limited and can be locally negotiated and used to commission other types of primary care service beyond core general practice. Because of their flexibility, APMS contracts allow commissioners to commission specific primary medical care services in response to specific local need. I fear that the amendment would undermine commissioners’ ability to commission services fully to meet the needs of their local populations in a flexible way at, as I said, exactly the same time as the Under-Secretary of State for Health and Social Care is working to encourage them to go further in the development and design of high-quality primary care services.

I suspect that the shadow Minister, the hon. Member for Nottingham North, will clarify matters if I have misunderstood some elements of his proposals, but I have set out my current misapprehensions on the basis of what is in front of me. I hope he will rethink and consider not pressing the amendments to a Division, given our concerns about the potential negative impact on the provision of primary care.

Finally, let me turn briefly to clause 17 which, importantly, provides a power to make transfer schemes in preparation for the time when ICBs take on primary care functions, by enabling NHS England to transfer property rights and liabilities to ICBs. The rights and liabilities that can be transferred under the clause include those in relation to a contract of employment, thereby ensuring a smooth transition to the new commissioning arrangements. Without the clause, we would risk the creation of instability for NHS staff and the possibility that ICBs could lack the necessary rights, staff and property effectively to commission primary medical, dental and ophthalmic care. I therefore commend clauses 16 and 17 and schedule 3 to the Committee.

Photo of Alex Norris Alex Norris Shadow Minister (Health and Social Care) 2:15 pm, 16th September 2021

It is a pleasure to serve with you in the Chair, Ms Elliott. I wish to speak to amendments 28 and 29, and will also briefly address a couple of brief points relating to the clause.

I am grateful for the Minister’s response—it is handy to know in advance the likely arguments against the amendments. I referred to the amendments late on Tuesday afternoon, with regard to private company involvement in integrated care boards. We are heartened to hear what the Minister said about that and look forward to having those conversations. My original notes said that the amendments go a little further and might be a little rich for the Committee’s blood, and that may well be the case, but they are nevertheless important.

As I said the other day, the vast majority—around 70% —of GP services are provided on the general medical services contracting model, between local and national commissioners and a GP or GPs and their practice. A little more than a quarter of services are on the personal medical services terms, which allow greater local flexibility, although I understand that the intention is to phase them out. There is a small but growing number of APMSs, which we are debating. APMSs allow bespoke contracting with private companies, with no obligation for a GP behind them. The Minister mentioned their being time-limited as an asset; I am not sure that that is necessarily true. Of course, there has to be flexibility for commissioners to meet need, but my argument is that this is being misused and is operating as a loophole for private companies to enter the market and cream off profits in a way that I do not think is generally the direction that service users in the NHS want. Colleagues should not think that, because the model currently provides just over 2.5% of contracts, this is in some way small beer. The largest provider of GP services in this country is wholly owned by a US megacorporation and has 500,000 patients on its books. I do not think that is what our constituents want from their national health service in England, and I do not think that is what they expect it to look like either.

Therefore, it is reasonable to use the Bill to try to do something about it, because this will be the model. It will grow at pace unless it is checked, and there are many reasons to tackle the issue. It is not just because I find the model distasteful, which I do. First, such contracts are poor value for money. For a registered patient, the mean payment to an APMS provider is 11% greater than that to a GMS provider. Of course, the Minister made the argument on Tuesday that such practices often serve the hardest cohorts, so perhaps that could account for the difference, but that is not the case either. When patients are weighted according to need, the mean payment is actually 16% greater on APMS contracts—it gets worse. If we read that across the entire patient list across the country, it would be the equivalent of £1.5 billion. That is the risk, if this grows to be the dominant model. Such contracts also provide less satisfactory care, with a 2017 survey of nearly 1 million patients finding that APMS services generated lower levels of satisfaction.

Finally, the contracts are easier to walk away from. Within the NHS, we already know that when it stops working for private providers corporately, they are willing to just walk away from contracts and hand them straight back. I strongly say to the Minister that such arrangements are a distortion of the health service’s founding principles. They are costly, they are of lesser quality and they are less reliable.

Amendment 28 is designed to stop integrated care boards entering or renewing such contacts, and amendment 29 would do the same for NHS England. I fear that the Minister may have slightly catastrophised the impact of that, because if this was accepted today, there would be GP services that could no longer operate tomorrow. For a start, the Bill has an awful long way to go, and I gently say that if there is anxiety about health organisations working in advance and presupposing that this will become law at some point and will be operational in April, I am afraid that the Government started that a very long time ago and have already started to fill places in shadow. I do not think there should be any anxiety about getting prepared in this way, so that there would not be a cliff edge.

I am willing to take the argument that perhaps there is a better and more elegant way of drafting this, and I would happily accept an amendment in lieu, but what I cannot accept is nothing at all. Again, the Minister’s point on Tuesday was very good, because sometimes there will need to be a way to provide flexibility for very bespoke services. I think the example he used was services for street homeless people. Of course, that might be a very different model from that of the GPs on my estate. I would accept that as a principle, but the corporation that has the biggest patient list, at 500,000, is a bricks-and-mortar primary care service in my community. That is not a use of flexibility; it is using that as a loophole.

I do not think that can be right, and I do not think the answer can be that the provision needs to exist and therefore we must open this space for that sort of distortion. We are either saying, “There needs to be flexibility, and here is the best way of having a flexible system. Don’t worry—we’ll make sure it is not misused,” or we are saying that we are happy with such organisations entering the market. The Government need to say which one is their preference.

I will make a point about primary care networks before I move on to clause stand part. Obviously, primary care networks are not in the Bill, but I put quite a lot of stock in them. I think that, locally, they will be a very important unit of organisation of care services in our community. I want them to work, and I am playing an active role in the primary care network in my constituency. I think they have real potential. However, who will lead them if we lose our GP practices to those who do not have an interest in our community? The model will become much more distant and uninterested, based on finances rather than the local population. I believe that would be a very, very bad thing indeed. As I say, the amendments may not offer the best way to close that loophole, but I have not heard a better one, or indeed a desire to close it, so I wish to press the amendments to a Division.

Finally, a couple of quick points on schedule 3, which we do not intend to press to a Division. We have had quite a lot of discussion—the Minister touched on this in the previous stand part debate—about the arrangement of integrated care systems, such as they exist. At the moment, we know that NHS England holds certain responsibilities, the regional teams hold certain responsibilities and CCGs hold certain responsibilities at a local level. It is possible, after these reforms, that CCGs will be replaced by ICBs and the previous arrangements and responsibilities will remain unchanged, with NHS England nationally doing the same things, the regional teams doing the same things and ICBs picking up the responsibilities of their predecessors. I suspect, however, that that is not the intention, so I want to press the Minister a little bit on that.

The explanatory notes, on page 59, paragraph 286, state that the functions relating to medical, dental and ophthalmic primary care sit with NHS England, but that

“The intention is that Integrated Care Boards will hold the majority of these functions…in the future.”

Will the Minister expand on that? Does a “majority” mean two out of the three in a different area? Does he intend—again, we touched on this the other day—that this should all be devolved to the 42 ICBs at the same time, or will there be a sense of when each system is ready to pick up those important services? If so, what criteria will that be based on?

Finally, in case we do not come back to this topic—I do not expect the Minister to have an exhaustive list to hand—what is the thinking on other NHS England national and regional functions? Are they likely to be devolved to ICBs? Can he give an example of what sorts of things might be retained? He mentioned that we would want to retain specialist commissioning at a national level. The final question is this: is it ICB by default unless there is a very good reason why it cannot and therefore it has to be done at a national level, or is it at a national level unless it is proven that ICBs are competent to take it on? The answer may be a bit of a mixed economy, but if that is the case, I am keen to know what criteria he will use, or the Secretary of State will use, to make those decisions.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

I rise to support my hon. Friend the Member for Nottingham North, who made an excellent case for amendments 28 and 29. While on a primary care trust board, I commissioned APMS contracts under a previous magnificent Government—I am not saying this one’s not magnificent, but—because they offered flexibility. Then, as now, they were a sign of a failure of the system and the model of primary care contracting to deliver, particularly in areas of high deprivation. To provide flexibility in Bristol, for example, we had an 8 am to 8 pm service in the city centre to allow better access for people in the city centre, partly to drive down demand on emergency care services, which is a circle that we just keep on going round. Whether they worked or not is a bit of moot point, but it is a model and it is clear that something is needed—I would certainly concede that—so I understand the Government’s difficulty here with having something that is flexible.

I was slightly concerned when the Minister said that the APMS model would be developed further. I wonder if he wants to come back on that. We have to accept that they are problematic at the moment and we would like to see them go because of that. They are now being used as a back door, a very unfortunate one, for large private companies to start hoovering up general practices, which is, yet again, a sign of failure as to why they cannot survive in their environment. If they are going to be developed further, that is something we would like to hear more about. If not now, perhaps the Minister responsible could come back to us on that. Patients are always surprised when they find out that their GP is a private contractor. I accept that this is a difficult area to be completely black and white on. We are certainly in favour of flexibility in developing services in areas of high demand where, for reasons around capital or the type of contract, a GP might enter into partnerships. We know that the workforce is changing rapidly and the model of partnerships is not as attractive and is not recruiting people into the service. It is—not to overuse the word—a crisis.

I am sure we have all been contacted by various bodies representing GPs in our own constituencies. They are fearful not just about the current pressures, but the future attractiveness of primary care. We are not going to get into the future model of the contract today, but I always pity the poor Minister who has to negotiate the contract.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

It is not a negotiation that anyone looks forward to with relish, but we need to take a good, strong look at the model now. This policy is not the route, and my hon. Friend the Member for Nottingham North has described perfectly why it is not. It is of deep concern. These large organisations are not part of the local community. It is completely against the thrust of this Bill, which is about place-based, locally accountable systems. The Government would be wise to take his advice and perhaps come back with something else. We seek assurance that this policy is not being developed further, because that would be of even greater concern.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

I can reassure the hon. Member for Bristol South. I fear she misheard me when I was saying that we were encouraging primary care commissioners to go further in developing primary care provision—that was not necessarily this model. Forgive me if I was unclear on that, and I hope that gives her a little reassurance on that point.

To address a number of the other points that the shadow Minister primarily made, I suspect his fears are not borne out in reality. I suspect he will none the less, as we cannot accept his amendment, press it to a vote to highlight the issue, and that is his prerogative. I come back to the point that flexibility in this space is hugely important. The examples given by the hon. Member for Bristol South about the challenges in primary care provision are a good argument for why we need this flexibility. We know that some practices, which are GPs’ private businesses contracted to the NHS, on occasion will collapse or a partner will retire and a surgery will cease to operate, especially if no one wishes to take it over. Therefore it is important that these flexibilities are available to commissioners to ensure GP practice coverage.

Photo of Karin Smyth Karin Smyth Labour, Bristol South

Just to be clear—my apologies for mishearing the Minister previously—such closures are a sign of failure. The answer is to negotiate the contract better and to modernise a clear contract, not to use this vehicle. That was my very clear point.

Photo of Edward Argar Edward Argar Minister of State (Department of Health and Social Care)

I take the hon. Lady’s point, but it would be a sign of failure not to build flexibility for all eventualities into the arrangements we have at the disposal of commissioners and into what my hon. Friend the Member for Bury St Edmunds is trying to do to build resilience into the system. I very much hope that she will continue to do so, or will ascend in the next few hours to something else. That is why flexibility is at the heart of this measure and why we cannot support the amendment of the hon. Member for Nottingham North.

I will try to address a couple of points that the hon. Gentleman made. We envisage PCNs continuing to play a hugely important role locally in the provision of primary care services. My GP is actively involved in the local PCN in Leicestershire. I know, whenever I speak to him, just how much it has done, particularly in the past 18 months, to build resilience into the system and make sure it works. I know the value of those PCNs more broadly in, for want of a better way of putting it, more normal times.

The final thing the hon. Gentleman asked about was the delegation of currently nationally commissioned functions down to ICBs. The short answer is that he was right in his supposition that this is not a binary, one-size-fits-all measure. The reality is that NHS England will be looking at which ICBs and ICS areas are sufficiently developed that they can take on additional commissioning responsibilities. If he and I sat down, we would probably have a fair sense of which ones were already well advanced. It may be some where there is a mayoralty and there is already a significant amount of devolution in one or two areas. It may be others. We heard from Dame Gill Morgan in Gloucestershire, who clearly has a highly developed ICS in that area. I would be reticent about setting a black-and-white thing on meeting some criteria. There is a degree of subjectivity, which is why we will be reliant on the expert advice of our colleagues in NHS England, and they will make these decisions in the appropriate way.

I hope that gives the hon. Gentleman some reassurance on the broader clauses and schedule stand part. I fear I have not persuaded him in respect of his amendments, but it was worth a try.

Question put and agreed to.

Clause 16 accordingly ordered to stand part of the Bill.