May I first welcome the Under-Secretary of State for Health, my hon. Friend Mr. Lewis. This is his first debate as a Minister in the Department of Health in which I have taken part. Clearly, he will be able to throw up his hands in the air later and say, "It was nothing to do with me, guv", as most of the issues before us this afternoon predate his entry into the Department. I thank members of the Health Committee who are here today for taking evidence and for drawing up the report. I am the chair of the Committee, which has been doing good work over many years.
The report was instigated effectively by the Department's letter on
Some of our criticisms of the letter and the subsequent debate were sharp in tone and quite deliberate. The English language, on which I am not the greatest expert in the world, can draw attention to different matters just by the use of the right types of words in reports. The Government thought that some of what we said was a little over the top. In one of our recommendations, we said that the reforms were poorly conceived, rushed and badly implemented, that there was no clear evidence base for them and that the consultation process was inadequate. The Government defended themselves. We put in the report that they had developed the reforms on the hoof, in response to which they said that that was not the case. They stressed that strategic health authorities had been asked to engage with local partners in developing proposals prior to a 14-week formal consultation period.
The essence of the letter of
We found that, because of the general election, matters slowed down; the letter of
The right hon. Gentleman has made an interesting point that I had not anticipated making, which was that his Committee had identified a lesson that is worth learning. For fundamental change, particularly when consultation is both valuable and required, it must be in the Government's best interests not to issue documents either on the last day of term or at the beginning of a recess. That happened in respect of the NHS 10-year plan, which reported that there had been consultation about the axing of community health councils, which was found not to be the case. That is another example of what he has just said.
I agree and am sure that by the end of August last year those lessons had been firmly learnt from what was going around in the media. In terms of what people felt, that feeling increased when we as a House got back in October.
I think it was. I will want to say something about the transparency issues of that consultation and what we were promised; something that has not yet been delivered to the House.
I suggested earlier that the Government rejected our suggestions about patient care and that patient care would suffer as a result of the disruptions caused by the changes or the potential of the changes. The Government commented that a more evolutionary approach to the changes would have benefited some organisations but have been prejudicial to others.
That was an interesting comment. If that was the case and given that we were not drawing up statutes here—although I know that my hon. Friend was not in post then—we must ask why we did not look at the issues of SHAs or PCTs on a geographical basis. My own borough of Rotherham has had one PCT for the past three years. In the neighbouring three constituencies, two of which are represented by health Ministers, they have had three PCTs in the same years. Socially and economically that borough of Doncaster is the same as Rotherham. Why did they have three PCTs three years ago, when nothing was laid down about what they should or should not have? Maybe that was when something should have been laid down. With very little acrimony, as far as I know, they are now moving to the one PCT model for their borough, coterminous with local government and everything else, which makes sense.
Of course that could have happened without the
As for the SHA in my part of Yorkshire, that has changed and we now have one big one that covers the same area as the regional ministerial office. Although we have that, there was little or no voice for the public as to whether or not that was the wrong thing to do. Most of the debate that we had after
The Government have not stated clearly whether or how PCTs would divest themselves of their provider functions. SHAs are therefore being asked to design organisations without an understanding of their ultimate purpose. I thought that that criticism was rightly made. If one was to change providing and commissioning at primary care level, then the shape of the primary care side would be crucial. We lost that, in my belief. The Government's response made it clear that PCTs would not be instructed to stop providing services, but that PCTs would be required to review all the services that they commissioned in 2007, including those provided directly. The Government will issue a fitness-for-purpose tool for the new PCTs in the summer of 2006. I accept that, but again think that the Committee found a weakness in the system when looking at that particular area, which should have been thought out a lot more.
Also, we said that the reduction in the number of PCTs would lead to a loss of local contact and responsiveness, which we believed was one of the main arguments for the previous configuration of PCTs. The Government's response argued that larger organisations could still engage effectively with the local population. The Government commented that the development of effective, professional executive committees would be central to ensuring effective local engagement. They also commented that the roll-out of practice-based commissioning would make services more localised. Over time that might probably be the case, but nobody thinks for one minute that at this stage, while we change the reconfiguration of PCTs, we will have practice-based commissioning at any level at all. We also had concerns that the reforms were cyclical in nature because the new PCTs will be similar in size to the scope of the old health authorities that were only disbanded in 2002.
One can imagine what it was like; people sat before the Committee and said that they remembered the changes that they had to make to get into that new structure. They said that it seemed as if we were rolling back into an old structure, which was just a few years down the road. We had to be critical, given what we were confronted with, when we were taking evidence in that area.
The Government argued that the NHS had changed radically since PCTs were created and that
"reforms, such as Practice-Based commission and Payment by Results make it especially important that the roles of PCTs are adjusted and strengthened."
They went on to argue that the reforms do not represent a "change for change's sake"; that many PCTs had already begun to merge or worked collaboratively with the neighbours prior to the
It seems to me that we are in a position of waiting to see exactly whether the Government are right in that analysis or whether there is an 18-month disruption when you do go to having these types of changes inside our health care system. Jill Morgan, from the NHS Confederation, brought that to our attention early on in the inquiry.
We commented on the fact that the reforms were largely motivated by financial, rather than service, considerations. We were led to believe that there were going to be savings around the £250 million mark. The most savings with the reconfiguration that we could find was somewhere between £60 million and £80 million.
However, it might be that those types of savings do take place. It does not give me any great pleasure to say that the £250 million tag was in the Labour party manifesto. Yet, when we were taking evidence, it was initially denied that that was the reason why those reconfigurations were about to take place. Consequentially, we had to probe it even more.
Two hundred and fifty million pounds represents, or will shortly, about one day's spend in the NHS. It is possible that the manifesto was right that savings of that kind are available within the NHS. However, to tackle the basic structure in such a hurried way was highly likely to lead to no savings whatever. We shall not know for four, five or six years. The Minister replying today may be forming his own Administration at a period when we shall be able to look back with some accuracy on this matter. I hope that that will be the point at which he will re-count.
I would suggest that the future will tell us exactly about the rights and the wrongs of that. We have had some movement in that area since the Government's response. Presumably, Committee members will have been involved in some of the consultation that has been taking place on PCT reconfigurations.
In May of this year, the Government published the fitness for purpose tools for new PCTs. A document of more than 500 pages was sent out to them; I am sure that they will greatly appreciate that. On
May I take up three or four outstanding matters? One matter is the approach to change. In response to our concerns, the Government have clearly modified the approach that they took in the
Equally, some explicit decisions regarding local PCT boundaries have been adjusted in response to local pressure. The Government have acknowledged that the top-down, one-size-fits-all approach to change is not the one that is required. That is shown by both the current significant variations and those that will be coming into being in October of this year. The new Hartlepool PCT covers a population of just 90,000, but Hampshire PCT covers a population of more than 1.25 million.
My right hon. Friend is making a powerful case. I recognise the pressures that he described, but does he agree that the impact of the reform process on individual PCTs is to some extent dependent on the way in which those PCTs are managed? An effective PCT is much better able to respond to the opportunities of change. In Swindon, we have an effective, well-managed PCT that has taken advantage of the changes that the Government are driving forward to look at innovative ways of servicing delivery. That is driven not primarily by financial considerations, as my right hon. Friend said, but, for example, by integrating the work of the PCT with social services and housing services to provide a total care provision that is imaginative and will significantly improve what we can offer to the people of Swindon. That is possible only because of the managerial competence of that PCT.
I entirely agree and perhaps when PCTs amalgamate, the best management will take over the helm of the one at the top. That could be grounds for great improvement in the service that people receive. The health community talked to us about the disruption and so on, but there may be positive changes in our communities 18 months on. At this stage, we are trying to second-guess that.
On decision making, the Government appointed an independent, expert panel to advise on which proposals submitted by SHAs should be accepted. The Health Service Journal reported on
Similarly, in County Durham and Tees Valley the panel supported the SHA's recommendations that its 10 PCTs be reduced to two. In response to pressure from local MPs, I understand that six PCTs were retained, not two. Again, I am not sure that that is how we should deal with reconfiguration of our health care service.
The Avon, Gloucestershire and Wiltshire SHA is in my area and the difference between three or seven PCTs is that the four unitaries in the former Avon area wanted a coterminous PCT with their unitaries. That is what every MP of every party and all the local authorities argued for. If the right hon. Gentleman is saying that despite everyone who has ever been elected anywhere in the entire country having one view, the Government should have gone in the other direction, I do not agree.
Perhaps the consultation process should have taken place much earlier and involved people on the ground, including Members of Parliament, who certainly have a role to play. I do not know the details, but in terms of health service planning I am not sure that those with the loudest voice should prevail. I am not saying that that is what happened; it may be the best reconfiguration to improve health services. If that is the case, I am happy, but when I see reports about people with the loudest voice and political debates resulting in more PCTs than the initial plan suggested, I oppose it. That is a matter that all Members of Parliament should consider.
As it happens, the Government are to be commended for listening during the Cheshire consultation with the Minister's predecessor, with whom I had a number of discussions. The Conservative-controlled Cheshire county council, under its new post-1974 configuration, wanted coterminosity of the four PCTs of Ellesmere Port, Cheshire West, Central Cheshire and Cheshire East and indeed the SHA. In the end, my hon. Friends the Members for Macclesfield (Sir Nicholas Winterton) and for Congleton (Ann Winterton) and myself were able to persuade the Government that the health economies that would really be best kept as a localised focus were the combinations of central with east and of west with Ellesmere Port. The added advantage was that the Cheshire West PCT, which has just received a £20 million bail-out, would therefore not be able to disguise its dysfunctionality by combining with others and has therefore been held accountable.
Again, I am grateful for the fact that there has been local consultation. Clearly, the Government need to take this into account. My hon. Friend the Minister will be pleased that the hon. Member for Eddisbury has complimented the Government on what they have been doing in the Cheshire area in that short intervention. It is pleasing that the Government have followed the Committee's advice in taking a more consultative approach and that in some areas they have listened to the wishes of local communities. However, the Government have not published the advice they received from the expert panel. This leads to the accusations that this form of consultation was not transparent.
Lord Warner gave us a commitment to publish all information submitted to the external panel as soon as possible. We are now at the end of June and we still have not got to that stage. It may be historical, but there may be lessons to be learned from what the expert panel wanted to do and what the reconfiguration ended up with. That is something that I would like to look at.
I now move on to the other area of provider functions. The Government have responded to the Committee's concerns by stating quite categorically that they will not instruct PCTs to divest themselves of service provision, and
"nor will we impose any timetable."—[Hansard, 10 January 2006; Vol. 441, c. 598W.]
However the White Paper "Our health, our care, our say", published in January 2006, instructs PCTs to review all its services in 2007 and says that where services are not sufficiently qualitative, PCTs will be expected to look for alternative providers, including private sector organisations. That is on pages 172 and 174 of the White Paper.
There are concerns that PCTs will be pressurised into tendering out some services which they currently provide directly in order to stimulate competition in the primary care sector. Further assurance is required that PCTs will be allowed to make independent decisions about the future provision of primary and community service.
When we first talked about the implications of moving from working for an NHS provider to an independent provider, we asked some fundamental questions. First, we asked Lord Warner about what happens to someone's pension. I do not want to get into a debate about local government pensions or NHS pensions today as we seem to be doing that every other day in this place, but it is a fundamental issue. If I were changing my employment—certainly at this point in my life—I would want to know exactly what was going to happen to my pension. Many other people would too. In the first session we took with Lord Warner and a senior civil servant, they were unable to convince us that they had looked at this in any way at all. They said that it may be covered by TUPE or that it may not.
As a member of the Liaison Committee, I asked the Prime Minister what would happen to people's NHS pensions under these circumstances. It was only when I received a letter from him that we eventually came to know the truth.
This will be an issue if we are to see this method of travel succeed; we were told by Ministers that providing would travel further out into the independent sector than it does now. As I suggested earlier, the Committee did not look at that; we did not say whether it was a good or bad thing. I have discussed this with other organisations as we were told it would be a road of travel. Issues such as terms and conditions and in particular, pensions, are also important.
I talk a lot to the independent sector now—not just in Westminster, but on visits to where my PCT gets its independent sector care from; the charitable sector. If one considers the interaction with the national health service, there is no longevity in terms of contracts or anything else. If that is the preferred route, there will be a lot of debate in this country about how such a route could be travelled. The Government may think that they can just contract with providers in constituencies such as mine, but there are very few independent providers in such constituencies.
We were taking evidence earlier today in the Health Committee when I was explaining that even the NHS has not been a brilliant provider of services in my constituency. Doctor-patient ratios have been some of the highest in England and Wales for many years; in fact, for decades. Health inequalities are massively greater than in quite a lot of other constituencies, yet, in my personal view, the NHS on the ground is not at the level it should be. If we are going down that road, that is fine, but the Government need to ensure that people will be travelling down that road with them as well.
You will be pleased to know that I am going to stop now, Miss Begg. I know that other people want to talk about the specifics of what has been happening and what is likely to happen in October this year in terms of the reconfiguration of PCTs and SHAs. We will obviously be keeping a watch on how that affects, or may affect, health care in our communities, in the months to come.
It is crucial that when we go down roads such as this, particularly given the reaction from the NHS in July of this year, we get it right and we improve health care. On occasions, the two Front Benches might agree, and it is good that they have done so on this matter. I have said this before, but it is a fool's dream to think that we are going to stop the NHS being a political football in this place. However, it would be better for the health service and for our constituents if we did.
I am very honoured to be called so early in this debate, and revel in the luxury. It is a pleasure to follow the esteemed Chair of the Health Committee, and to see a new Minister in his place. I always regard a new Minister as, possibly, a new broom. As he was not involved with the report or the response to the report at all, I hope that he will take back some of our criticisms of the report and of the way things were done.
I want, first, to talk a little about consultation, because it figured quite largely in our report. The Department of Health considered that as the changes were only managerial, there was no need for formal section 11 consultation. I was really quite bothered about that, because when one thinks about what PCTs provide, such as community hospitals, community nurses, intermediate care beds, and GP beds in other hospitals, it strikes that me that there is quite a big provision element as well. I wrote to the Secretary of State, from whom I received a letter in March, which said:
However, she followed it up with a very powerful, important paragraph:
"However, if there are any proposals to make changes to service provision put forward in the future by the newly reconfigured organisations, there will be a duty on those organisations to involve and consult patients and the public on those proposals under section 11".
In the Government's response to the Select Committee report, that was repeated. They said:
"Commissioning a patient-led NHS is not about changes to local services. Our policy is clear: decisions about service provision will be a matter for the PCTs to determine locally."
So, thank goodness the PCTs are absolutely committed to consult on some of the changes that some of us are very worried about.
The lack of section 11 consultation was extremely significant because it meant that even if overview and scrutiny committees put in a response, that response had no effect. Under section 11, the response is passed to the Secretary of State for a final decision. If she is not happy, it can go to the independent reconfiguration panel. In my county, all the forums and the overview and scrutiny committee objected strongly. That had no effect at all, I am afraid. I rather fear for the future that the Department of Health will always have the let-out that the definition of management can be rather wide.
I have just learned, rather to my horror, that without any form of consultation, because it is possible in the future only if there is a management change, the Department has just placed adverts in the supplement of the Official Journal of the European Union inviting bids from companies that wish to appear on a Government-approved list of suppliers of management services to PCTs, presumably for cases in which a PCT's management is perceived to fail. It is fairly significant that that came a day or two after the Derbyshire judgment, which, although it did not go in favour of local people, was incredibly helpful in that the judge recognised the wide obligations to consult on NHS bodies that flow from section 11.
Still on the subject of consultation, the Government response to our recommendation 9 quoted a letter from John Bacon, sent to all SHAs on
"Responsibility for approving PCT consultations, ensuring they reflect the conditionality set out in my
The huge problem is that if the option that local people want more than any other is not even on the list, where does one go from there? We in Worcestershire were completely floored, because we were told that the size of the PCT was absolutely crucial. We have three PCTs with populations of 110,000, 170,000 and 260,000. We were not even allowed to consider the continuation of those three PCTs, or even two PCTs, despite the fact that that was what all local people wanted.
The consultation document sent round by the West Midlands South strategic health authority contained the phrase:
"The lack of 'critical mass' within these small organisations also compromises the management of financial risk and, in general, reduces the scope for achievement of operational efficiency and value for money. These models would also perpetuate the current high management overheads seen in the PCT sector. This option was not short listed on this basis."
That leads me to reflect on some of the comments made by Mr. Barron. If we consider the small PCTs that preserved their autonomy, 10 had populations below 150,000, which is tiny. Eight of those were in Government-held constituencies and the two smallest, with populations below 100,000, were Darlington and Hartlepool. They may be coterminous, but it looks as though there is a bit of political influence.
I was absolutely delighted to hear from some Opposition Members that they felt that they had influenced things. We in my patch were completely unable to influence things, and we are very upset about that.
I can reassure the hon. Gentleman. Charnwood and North West Leicestershire is one of the larger PCTs, and it strikes the right balance for size. It is big enough to be efficient in delivering services and small enough to be accountable, with a population of about 250,000. It is working really well, and people from all parts of the political spectrum supported it.
Despite the collective efforts of three Members of Parliament, two of us Labour and one not—myself, Mr. Reed and the former Secretary of State for Health, Mr. Dorrell—what is happening? We are becoming part of an enormous untested structure of 750,000 people, a doughnut wrapped around the city of Leicester. It is not necessarily politically driven.
I am grateful to the hon. Gentleman, who is always helpful in putting me straight.
The external panel's response has been mentioned. We said in our report:
"It is essential that the external panel's responses are made public also."
The Minister at the time did not say that he would publish the response. He said that he would publish the information given to the panel, which is remarkably different and not what we want at all. We need to see that response. We want to know what the external panel felt about the PCTs that were affected politically or non-politically.
I move to the issue of distraction. We were bothered by evidence that told us quite clearly that such a major reorganisation put the local work force back by two years and required another 18 months for them to catch up. Witnesses at this morning's Health Committee bore that out. It takes an awful lot of time for people to catch up. We must add to that the fact that under this particular reorganisation, people who will no longer have their jobs are planning for what happens afterwards. As I have said before, I do not think that that is like turkeys planning for Christmas. It is not the best plan. That has been borne out graphically.
Professor John Ashton in the north-west was a well-known, outspoken director of public health for many years. I remember him saying a long time ago that when public health doctors became directors of strategic health authorities and primary care trusts, they would immediately lose their independence and ability to represent patients. Having been in his job for 13 years, he resigned in frustration at the prospect of a fifth Government-inspired departmental reorganisation. He said:
"I have just finished building up a team from the last reorganisation. This is what they do—constantly reorganise. You have to ask questions if they don't get it right this time."
Professor Ashton is well known to me and in the north-west. The point that he is particularly and rightly concerned about is the diminution of commitment to public health, something that I shall address later on. It is important to put it on the record that public health has suffered as a result of so many reconfigurations.
The report on PCT mergers reassured us that public health doctors would not be affected by the £250 million economy. We asked a public health doctor this morning. Obviously, she could not give us a categorical denial that it had happened. We must watch what happens to public health.
Savings have been mentioned. One of the objections of my local overview and scrutiny committee in Worcestershire was that there had been no attempt at a business case before the mergers were worked out. The Health Committee report queried those savings. The Government response confirmed that they would be £250 million, but then said:
"These plans will be firmed up once reconfiguration plans are approved."
So they were very much guessing at what would happen.
If SHAs are reduced from 28 to 10 and PCTs from 303 to 152, there will have to be many redundancies among senior staff, who are the most highly paid people. I wonder whether that has been calculated accurately, and also whether driving out high-powered executives will help our competitors. We know of at least one chief executive who left to run one of the private sector companies that are organising the independent sector treatment centres.
That is the end of my gripes. I shall briefly discuss the future and how we can make what we have work. Sadly, we cannot undo the changes. One thing that we expressed concern about in the report, that people are worried about and that has been mentioned today, is the local focus. With a local PCT, there is a local director of public health who participates in the local strategic partnership, a local professional executive committee, a local patient forum and local non-executive directors.
There are three completely separate localities with separate characteristics, needs and health service provision in my county, yet we have gone back to the days of the county-wide health authority and a total lack of county-wide medical leadership. That is one of the many reasons why I am here. If there had been effective county-wide medical leadership at the time, what happened to put me here might not have happened in the same way.
The local focus is crucial. The Select Committee picked up on that in recommendation 21:
"Whatever the size of future PCTs, it is essential that structures to ensure clinical engagement and, most crucially, patient and public engagement are retained at their current levels, covering each natural community."
The Government response states:
"The Government agrees with the Committee that it is important that structures for engaging with clinicians and patients are not lost through this reconfiguration process."
Can the Minister absolutely assure us that the local focus will remain? How will that happen? How will clinicians reflect the needs of their local area? Will there still be public health doctors?
We are in complete confusion about what will happen to patient forums. The expert panel that reviewed them reported to Ministers and we are waiting with bated breath to hear what it said. My patient forum really works. It has been a vital method of feeding local people's comments and needs into the PCT, and it has held the PCT to account. We need to know that forums will be resourced and that they will be independent from the NHS bodies with which they deal.
I feel strongly about non-executive directors. A whole-county health authority existed at the time my hospital was downgraded. There was a vacancy on the authority during the whole of the consultation and—surprise, surprise—it was for the representative from the north-west of the county. We have just lost the person from that part of the county on the county-wide acute trust board, and now we are to have a county-wide PCT.
I wrote to the NHS Appointments Commission, but because it is so keen not to have any political influence at all, it rarely writes to MPs. I made the point that if there is one PCT for a large county, it is essential to reserve positions on the board not only for representatives with expertise in accountancy, management and so on but for those who live in the different parts of the area. If the Minister is allowed to, will he put pressure on the NHS Appointments Commission so that, as a general rule, if there are not applicants for non-executive director posts who reflect the interests of the whole area, the commission should not make an appointment but seek to find applicants who do reflect those interests?
We are saddled with the mergers. Some areas have escaped but, remembering how small some of the PCTs are, I wonder whether they will succeed. I hope that the Minister will tell us in particular how local focus will be retained from the point of view of public health, the board membership and clinical, patient and public involvement. Even in a county such as mine and others in which various organisations have been merged into one, fair shares of resources and representation for all localities must be maintained.
Primary care trusts evolved from primary care groups, which replaced health authorities. They were introduced precisely because it was hoped that that would strengthen the local focus of the NHS and improve clinician and patient engagement in the planning and commissioning of health care. In my constituency, however, the latest decision is to replace Dartford, Gravesham and Swanley PCT with a PCT covering the whole of west Kent, which looks remarkably like the health authority area that was originally replaced.
The decision could threaten the successful working relationships that managers and the professional executive committee of the PCT have been able to build up with individual clinicians throughout the PCT area. The close working relationship between the PCT and Dartford and Gravesham's 120 GPs has been helpful in ensuring that the introduction of some of the challenging and potentially contentious changes, such as choose and book and practice-based commissioning, happens as smoothly as possible. The relationship has enabled individual clinicians to become involved at an early stage in the implementation of the reforms and to take ownership of them in a way that would be much more difficult with a larger PCT that was less rooted in the various communities that it served.
The only way to ensure that that consensual approach is maintained is to ensure that all the professional executive committees—PECs—that are about to become redundant are replaced by strong practice-based commissioning groups that have the necessary resources and management support to function effectively. Without bodies of that nature, which are capable of championing the interests of local practitioners at PCT level and maintaining clinical engagement in the reform process, we will jeopardise much of the progress made in the past few years since the PCTs were set up. The presence of effective locality practice-based commissioning groups will also help to provide a mechanism whereby examples of best practice can be fed through the system and shared among local practitioners.
My worry, which many local practitioners to whom I have spoken share, is that very little has been done to prepare for the launch of the new PCT, which is to take place in October. With only three months to go, no one has any idea what management structures and what arrangements for liaising with front-line professionals will be put in place. All that is known for certain is that some PCT jobs will go. Not unnaturally, that has created a great deal of uncertainty and pessimism at local level about what the future might hold. That needs to be addressed, and quickly.
Aside from the possible loss of local clinical engagement, my major concern is how the new PCTs will manage to reconcile the competing clinical priorities of each former PCT area. Dartford, Gravesham and Swanley PCT has a clear sense of the particular health care needs of the local population and has been able to put in place a wide range of strategies tailored to the needs of that population. Life expectancy in the area, which is 76.5 years for men and 80.5 for women, is among the lowest in the county. The area has a significantly higher percentage of people with a limiting long-term illness than any other area in Kent except Swale and Ashford. Levels of cancer, coronary heart disease, mental illness and teenage pregnancy are also higher in my area than in other districts in the county.
Dartford and Gravesham, situated in a major part of Kent Thameside, not only have similar health care needs, but face considerable development pressures. There are plans to build 20,000 new homes over the next 20 years. That is unlike what is happening in any other area coming into the new PCT. As a local organisation with strong links to each of the major development partners operating in the area, the present PCT is well placed to influence the design of those new communities and to ensure that the health care needs of new residents are given appropriate consideration. In amalgamating Dartford, Gravesham and Swanley PCT with PCTs serving Sevenoaks, Tonbridge and Malling, Tunbridge Wells and Maidstone, all of which have very different health care needs from those of Dartford and Gravesham, there is a risk that the local focus will be lost. That could mean that some of the key strategic issues affecting Kent Thameside will not get the priority that they deserve at PCT level.
There is also a risk of planning blight in the run-up to the introduction of the new PCTs later this year, as PCT boards, in their twilight period, shy away from making some of the more difficult decisions about service development, which have become necessary as a result of the "Agenda for Change" programme and the introduction of payment by results and practice-based commissioning. Reconfiguration will also prove a significant distraction for PCTs in the next 12 to 18 months, absorbing a great deal of management time and resources at a time when many are grappling with major financial and strategic challenges. The uncertainty caused by reconfiguration is also likely to unsettle medical and managerial staff, leading some to seek posts elsewhere. It is vital that we try to prevent the loss of key personnel with experience of the local health care market and the health needs of the local population.
Although PCTs are now responsible for spending 80 per cent. of the NHS budget and have considerable freedom to decide which services should be commissioned and how they should be delivered, that increase in resources and power has not been matched by an equivalent increase in the level of accountability to the communities that they serve. Unlike local education authorities, which are at least politically accountable, PCTs are in no way accountable to the communities for whose health care they are responsible. Anyone who approached the Department of Health, for example, with concerns about the way in which a local service was being provided would simply be told that it was a local matter and that Ministers and civil servants could not possibly intervene. They would probably be referred back to the patient and public involvement forum for the PCT, which has some input into the decision-making process, as well as a scrutiny role, but that is an appointed body and is not directly accountable to the public.
At present, the local focus of PCTs and the fact that most key executive and non-executive board members and members of the PEC live or work in the area have helped to ensure that they are at least receptive to the views of local community bodies and patients. Once the newly configured PCTs have been created, however, that local connection is likely to be lost. Although the board of each newly configured PCT will contain non-executive directors who, between them, will have some experience of the health care system in each locality, it is inevitable that the voice of each locality will become less prominent at board level, whatever the NHS Appointments Commission tries to do to balance the situation.
The only way to overcome the problem, and at the same time to address the accountability gap that has always affected PCTs, is to include some directly elected members on PCT boards. At the very least, we should introduce a system along the lines of that used by foundation trusts, whereby trust members, who are patients and other members of the public in the area, are given the opportunity to elect the majority of representatives who serve on the trust's board of governors. The board of governors helps to set the trust's strategic direction and ensure that it operates in a way that is consistent with its terms of authorisation. In addition, its elected members must put themselves up for re-election every three years if they wish to continue to serve on the board. Foundation trusts therefore have an element of accountability that PCTs continue to lack. The presence of a group of directly elected individuals on the board of governors, which would operate in parallel to the board of directors, as in the case of new foundation trusts, would certainly help to assuage my constituents' understandable concerns about the remoteness and lack of accountability of the new PCTs.
I also want to talk about the involvement of pharmacists in PCTs. As part of the reconfiguration process, I should like community pharmacists to be given a much greater strategic role in the management of local PCTs. At the moment, it is quite rare to find pharmacists involved in the decision-making process at PCT level. As a result, they lack any real say in defining local health care and clinical priorities. The mandatory appointment of community pharmacists to PCT executive committees, for example, would be a great way of ensuring that the voice of pharmacy is heard at executive level. Increased PCT liaison with local pharmaceutical committees would also ensure that PCTs made the best use of the skills of community pharmacists. Finally, new PCTs should be encouraged to commission and properly fund new primary care services from pharmacists. The Government have made it clear that they want community pharmacy to play a key role in the delivery of primary care services in the future, and such commissioning and funding would be an important way of achieving that.
The new White Paper "Our health, our care, our say" emphasises the need to make greater use of community pharmacy services and refers to the strong support for them among the public. According to the consultation that was carried out prior to publication of the White Paper, the public want pharmacists to have an increased role in providing support, information and health care in future. In addition, the Government strategy for reducing health inequalities highlighted the important contribution that pharmacists can make to reducing obesity, improving sexual health and helping people to quit smoking.
Although some PCTs have used their commissioning powers to great effect and have committed themselves to expanding the range of primary care services available to patients, others have been very slow to grasp the new strategic responsibilities. I want to make sure that that is addressed as a matter of urgency in future.
I have pointed out that there are some benefits in the PCT reform. However, I do not believe that the reform has been properly thought through, and I share some of the concerns that the Chairman of the Health Committee voiced in his opening remarks that some of the process seems to have been rushed. I do not believe that there has been enough consultation or involvement, nor do I believe that there has been sufficiently careful examination of the long-term implications.
I share many of the hon. Gentleman's concerns. The Minister came to the House on
Obviously I cannot comment on the hon. Gentleman's individual circumstances, but I have to agree that that seems to be an example of rushed thinking. It seems to have taken place at the last minute and smacks of the back of an envelope.
In conclusion, I believe some of the reforms have been to great advantage. I believe that in some parts of the country the reforms will turn out to be very beneficial and that they will lead to improved communication and improved service delivery. However, I have real concerns on some of the issues that have emerged from the reform. I certainly believe that my own part of Kent would have been better served by a Kent Thameside primary care trust area that would at least have covered the whole of north Kent and would have had a degree of demographic coherence that is lacking in the proposed new west Kent primary care trust.
I welcome the Minister and I congratulate him on his position. He was not merely an adornment to the Health Committee when he was a member of it; he was a hard-working and effective colleague, and stories of his exploits abroad are certainly well worth listening to.
Much has been made of the letter of
To cut to the chase, there is no doubt at all that the whole exercise was embarked upon to save money—though we can argue about how much was actually saved. As my hon. Friend Dr. Richard Taylor said, there were undoubtedly some political shenanigans going on the background—shenanigans that had mixed success.
"Commissioning a patient-led NHS", the document published by the Government on
The Health Committee report on changes to PCTs acknowledges that, as has been said, the reforms are necessary. However, it highlights several key concerns on which I shall dwell, particularly the concerns about the way in which the consultation on the Government's proposals was conducted. As all hon. Members, or certainly those on the Opposition Benches, know, these so-called consultation exercises are becoming utterly meaningless. I also wish to touch on how the proposals will affect local health service delivery and public health, which are crucial.
It would be nice for each of us, when we are no longer Members of Parliament, to have a quotation by which we will be remembered. We are always quoting the remarks of famous political figures. In April 1999, when I was a member of the Standing Committee—I believe that it was in this room—on the Health Bill that abolished GP fundholding to create PCTs, I said that it was a "truly socialist Bill." It was legislation that was intended to centralise health care provision commissioning away from clinical professionals and towards central Government. The reconfiguration of PCTs will take centralisation one step further through the creation of fewer and larger PCTs. For example, we in Essex have 13 PCTs, but later this year we will have five. Among Essex MPs there is great concern about that.
Is my hon. Friend sure that he is getting five PCTs? We were told that we were getting two in Hertfordshire, but really we are getting one. He has been told that he is getting five, but he might in fact be getting four, three or two. Has he checked the numbers and who will be running the PCTs?
My hon. Friend makes a valid point. I was giving Her Majesty's Government the benefit of the doubt, which I might now retract.
I argued in Committee on the Health Bill in 1999 that GP fundholding was being abolished too quickly and with little debate on the structures that would replace it. We are in a similar situation now. The Government took only 11 weeks to put together the reconfiguration proposals and the 14-week consultation period was certainly not adequate to get sufficient feedback on many aspects of them.
In 1999, many medical and professional groups voiced concerns about the rationale behind the structural changes. For example, in my speech on the Health Bill on
"The Bill heralds yet more structural change for doctors after nearly a decade of major upheavals in the National Health Service. The BMA will work with Government to try to make these changes work but would ask for no more changes for some time after this. We need a period of stability now in which doctors can concentrate on quality of service to patients rather than structural reorganisation."
There have been 23 major reconfigurations in the NHS since 1974, and the reconfiguration of PCTs is another significant upheaval that negates the request for stability and continuity from the NHS and health care professionals.
The general consensus of the Health Committee and those who gave evidence to our inquiry was that the consultation process was insufficient and flawed, to say the least. Not only was the consultation period too short, but it was conducted in a very top-down manner, pushing the Government's centralising agenda without taking into account the local solutions currently being pursued by PCTs on their own initiative to improve their operating procedures. For example, in its response to the Committee's report, the BMA stated that many PCTs had reported that they were rushed into the merger process, with little or no consultation with local stakeholders. In addition, although strategic health authorities were invited to contribute to the consultation, professional groups and patient representatives were not. For any transition to be successful, it must have all the professionals and patient groups on board at the local level.
As has been said, the Government response acknowledges that in many places the NHS is already working collaboratively to commission the best local services in the most effective manner. So why reconfigure PCTs, when the evidence shows that smaller trusts are taking the initiative where collaboration is sensible and right? Not all PCTs are operating optimally, but there are better ways of spreading best practice than imposing uniformity across the board. As the Committee's report made clear, there is no perfect size for a PCT, and one size certainly does not fit all.
In my constituency, Southend-on-Sea PCT will be merged with Castle Point and Rochford PCT on
Southend-on-Sea PCT already works closely with the surrounding trusts and Southend-on-Sea borough council to bring together commissioning functions and provider services in joint health and social service teams. However, although 70 per cent. of new PCT areas will mirror local authority boundaries, the new south-east Essex PCT will be a much more complex organisation, operating across Southend-on-Sea unitary authority and Essex county council, which brings new collaborative challenges. I know that the staff in Southend-on-Sea PCT will work hard to build on the successes that they have already achieved, but that is not to say that the structural upheaval is welcomed; it is not.
The Health Committee has estimated that the reconfiguration of PCTs will put the service back 18 months and undermine much of the progress made since PCTs were created in 2002. Clinical, public and patient engagements with each natural community were seen as priorities in the establishment of PCTs four years ago, but the reconfiguration brings those relationships into question. Clearly the non-executive directors, patient and public involvement forums, and professional executive committees of local clinicians that operate around each PCT have a cost, but they are increasingly proving their value, by making PCTs more inclusive in their working.
A major way in which the NHS will be destabilised by the reconfiguration of PCTs is, as has been said, through the impact on staff. The Government response to our report informed us that there would be a national primary care trust development programme that would support trusts throughout the transition. Southend has already begun preparing for the changeover, with the first meeting of the primary care trust transition board being held on
Paragraph 21 of the Government response, which has already been mentioned, outlines how staff will be supported, as set out in the human resources framework, which was published in 2005. I would be grateful if the Minister could say what steps are being taken in that respect. What has been the outcome of the proposed consultation under TUPE—the Transfer of Undertakings (Protection of Employment) Regulations 1981—with staff and trade unions on how the restructuring will affect them?
The Health Service Journal reported in February 2006 that, according to data submitted by 17 of the 28 SHAs last October, the reconfiguration of PCTs, SHAs and ambulance services could equate to 2,143 job losses. If those figures are calculated for all SHAs, there could be as many as 3,350 job losses, of which 1,307 will be from PCTs in both the provision and the commissioning sides of the service. Once again it seems that cost-cutting has been put before strategic reform with a target of £158 million to be cut in the running of PCTs. As has been said, there is also the question of what retirement protection deals will be available to NHS staff who lose their jobs in the restructuring. In Southend-on-Sea PCT, substantive employment contracts have been guaranteed until June 2007 only, which creates uncertainty about employment in the work force.
In its response to the Health Committee inquiry, the BMA argues that there should be more effective management in the NHS. However, as it also points out, it is unclear how that will happen while the reconfiguration focuses on a 15 per cent. cut in management costs rather than takes a more strategic view of how including clinicians in management can help to strengthen the NHS.
One point that was emphasised throughout the Health Committee inquiry was that PCTs' commissioning functions could be strengthened considerably by trusts working with local professionals and engaging with local clinicians. Clearly, the involvement of general practitioners in practice- based commissioning is essential, and other consultants in a range of specialist areas must not be overlooked.
Clearly, the balance between the provision and the commissioning functions of PCTs needs to be readdressed with a view to whether the divestment of services from the former could lead to the strengthening of the latter. To what extent will those improvements be brought about by the large-scale structural reforms aimed at recentering commissioning skills in the larger PCTs, and by spending £250 million less a year on that function? I would be interested to hear the Minister's response to that. The Government maintain that PCTs' commissioning functions will be strengthened, but they have not outlined how that will be achieved at the same time as giving better value for taxpayers.
In his letter to SHAs on
"PCTs are no longer required to stop providing services directly. Instead from 2007 they are required to review the services they commission (including service they provide themselves) to ensure they are delivering value for money, quality and equity".
The concluding recommendation of the Health Committee report was that the Government should allow PCTs to develop organically, sharing best practice and collaborating on their own initiative with other trusts on commissioning and service provision. That recommendation has not been heeded.
Unfortunately, this debate on changes to PCTs comes a little too late to be useful as the decision to reconfigure the organisations has been made and plans have been put in place for the transition. However, having contributed to the 1999 Health Bill that created PCTs and to the report on changes to them now, I know that the underlying message from health professionals then and now is that continual structural change is damaging to service provision and should not be undertaken lightly.
The Health Committee report on changes to primary care trusts was extremely timely. It was published on
The Health Committee told Ministers that the consultation had been a top-down process. I feared the worst—that local needs would be overruled after a sham consultation. We called for the rest of the consultation process to be made much more transparent and to offer local people a genuine choice about how local health services could most effectively be restructured.
In my constituency, the Shropshire and Staffordshire strategic health authority was determined to force through its plan for a huge, remote primary care trust, which would gobble up six other PCTs for the whole of Staffordshire. The SHA colluded with Staffordshire county council to ignore the wishes of local people, including a 300-strong public meeting at Leek in my constituency, where a unanimous vote was taken in favour of a more local primary care trust.
I am glad to say that Ministers forced the strategic health authority to consult on a local PCT that would combine just two PCTs—the option that local people really wanted. When the SHA completely ignored the overwhelming local support of clinicians, the voluntary sector, patients and councils for that local option, Ministers again overruled them. Their undemocratic and perverse decision was completely rejected.
That happened not just in Staffordshire but all over the country. When the Minister of State, my hon. Friend Andy Burnham, gave his statement on reconfiguration to the House on
The hon. Lady makes an important point. However the ministerial team as it then was dealt with representations that came from all quarters; we had exactly the same problem in Cheshire. What does she think drove the local SHA, and often the county representatives, in a certain direction? Was it to do with envisaging their role or their purpose as an SHA? That had not previously been articulated properly or decided in advance of the reconfiguration proposals. Or was it because of anxiety about the continuation of various jobs and roles that people wanted to preserve?
As the hon. Gentleman hints, I think that it was complete self-interest. I do not think that it was a matter of reconfiguration only with respect to health matters. It was looking forward to a local government review, which was behind it.
The public consultation, which appeared to be a sham, was transformed into a far more transparent process. I am particularly grateful to Lord Warner, but some credit must also be given to the external panel. When I met him, he said that he viewed the external panel as a good, diverse body that represented a number of stakeholders in the NHS. The panel used its NHS experience to recognise that the approach that local stakeholders and local consultations brought to Ministers was right.
It is, to some extent. In fact, we had the same debate; some people in south Staffordshire wanted Cannock Chase primary care trust to stand on its own. There must be independent decision making; however it is up to the people of Staffordshire to ensure that points are put forward.
I hope that we can build on the new, more transparent process. We must ensure that the appointment of the new chairs and chief executives is seen to be fair and based on independent professional assessment of candidates' abilities. All too often in the national health service, it appears that people who are displaced through reorganisation, of whom there have been too many, are slotted into new jobs even when they are not very competent. It is like musical chairs without taking away the chairs.
I want able candidates filling the new jobs. It is crucial, because they will be vital to leading desperately needed NHS reform. Mr. Walker made the point that Ministers must ensure that the appointed people deliver on ministerial decisions, as indicated to local communities, about reconfiguration. Rumours are already circulating, possibly based on the hon. Gentleman's experience, that some people are working to undermine those political decisions by, for instance, forcing new PCTs to share a chief executive or management board. I hope that Ministers are alert to such manoeuvres and that they stamp on them. I hope also that the Minister assures me today that no such back-door mergers will take place.
I am delighted that Staffordshire Moorlands primary care trust in my constituency is already working with Newcastle-under-Lyme primary care trust, with which it will merge, to get things up and running in time for
However, we still need to get the PCTs' commissioning function working effectively. In north Staffordshire, the new Stoke-on-Trent and North Staffordshire primary care trusts must work together more effectively, perhaps on a north Staffordshire commissioning board, to hold the acute sector to account. It is vital that PCTs are not left to sink or swim, and that best practice is shared more widely, through either a central change agency, as the Committee recommended, or a more pro-active role for strategic health authorities. Where necessary, specific support should be provided to the poorest-performing PCTs to get their commissioning role right.
The Committee identified another neglected area: the changes to PCTs' vital public health function. It was concerned that there was no consultation with public health professionals prior to the publication of "Commissioning a Patient-Led NHS". That is particularly worrying, as public health can be seen as an easy target when finance is tight. That was reinforced by a 2005 survey by the Faculty of Public Health that showed that there were 17 per cent. fewer public health consultants in 2005 than in 2003. It would be fine if those posts were replaced by public health posts in the community. However, having said that, 36 per cent. of PCTs in England believe that they do not have the capacity to deliver their public health programme effectively.
With a new configuration of PCTs and a local engagement of clinicians with the voluntary sector and local authorities, there is a real opportunity for primary care sectors to address public health matters across artificial geographical boundaries by focusing on the problems and finding the best way of delivering public health programmes.
In my own area, it would make sense for that public health remit to stretch right across north Staffordshire and bring directors of public health, consultants and particularly, community health professionals to all work together. However, with PCT deficits, there is a risk that public health will be a casualty of cost-savings.
What are the Government doing to ensure that public health is kept at the forefront of local health priorities? The PCT reconfiguration has been immensely time consuming, distracting and a morale-sapping experience. PCTs have been put in limbo. Now that decisions have been made, it is vital that we focus on best practice and develop the potential of our PCTs working in local partnership.
My Staffordshire PCT has been leading the way. For instance, they have been working with Sure Start, the programme for early-years youngsters. It helps to sustain a project called "Special Matters", a unique combination of local parents in a relatively rural area with special needs children. It meets to help steer health professionals to provide a quality and comprehensive service for all those families, not just the ones covered by Sure Start. They all have children with special needs. The project has recently won a national childcare champion award. It is unique and it is parent-led and its activities are targeted towards the whole family. It is fantastic.
However, they are doing other fantastic work using community matrons to manage patients who are at risk of emergency admission. They have reduced the emergency admissions massively. They have introduced a highly acclaimed falls programme that ensures that those people who are at risk of falls are managed in such a way as to prevent falls and to make sure that they are not admitted to hospital again.
Staffordshire Moorlands PCT has the joint highest uptake of first and second measles, mumps and rubella doses by the child's fifth birthday. It has also set up "Physio Direct" so that if you have back, neck, joint or muscular problems, you can use a dedicated phone line to contact a qualified physiotherapist straight away for advice or treatment. You do not have to go through a GP.
The hon. Lady has been generous in giving way to me for a second time. I congratulate her on a genuinely fine speech. In an important way, she has laid bare the fallacy of seeking to arrange those services from the centre on a geographic basis—for the convenience of Whitehall—rather than sectorally focused on local need and demand.
I remember our debates when no one has stood up for her local ambulance service, which was among the first responders. She has just been doing the same thing. I want to put it on record that the example of Staffordshire—and her part of Staffordshire—demonstrates how silly it is to approach those on a rather crude geographic basis rather than on a needs and demand basis.
I agree absolutely with that. That is why it is important that the Government must always listen to local stakeholders, whoever they might be. It is vital, particularly in relation to the Staffordshire ambulance service, which was a fantastic local victory. It will continue to serve me and my family and the whole of Staffordshire rather well. That PCT's work is extremely valuable, and we must ensure that it is not put at risk by lack of staff or inadequate staff training.
The Health Committee received evidence this morning that the primary care work force is somewhat neglected as far as training is concerned. One of our witnesses said that primary care workers desperately need proper career pathways and ring-fenced money to train staff. If we want to expand primary care, we must do so with well-trained and well-prepared staff. That is vital if we are to achieve Government objectives of shifting the balance of health care from the acute sector to the primary sector. I hope that the Minister will give me some assurance today that the Government's priorities for moving care into the community and the primary care sector will be backed up by financial support for staff training and the development of proper career structures.
It is a great honour to follow Charlotte Atkins, who made an excellent and powerful speech. I shall come to the issue of local accountability, which was also raised by Dr. Stoate when he suggested directly elected PCT members, which seemed to have a lot of merit.
One of the problems that I have had as a new Member of Parliament is getting NHS matters sorted out. I complain to the Minister, who writes me a very nice letter saying that it is the PCT's responsibility, but when I write to the PCT, it tells me that it is the Government's fault, because the PCT is underfunded. The Chairman of the Health Committee mentioned the issue in his powerful opening remarks about independent providers.
My PCT, Northamptonshire Heartlands, had a problem when on
The Government are right to try to get the best combination for health care. The only question to be answered is: does this improve health care for patients in my area? In Northamptonshire, we have a slight problem. We were bolted on to the bottom of the East Midlands strategic health authority—a huge, not really geographical area. We are part of the worst funded SHA in the country, and we are at the bottom geographically, so we lose out.
But at least we had a PCT that covered my part of the county. There were three PCTs in Northamptonshire, which divides neatly into two. When the Government considered police forces, they decided that Northamptonshire should have two basic command units. When they considered local development, they decided that it should have two development agencies, given that we are required to build 167,000 new homes during the next few years. It seems strange that we have one PCT for the whole county when everything else has been done on a natural north-and-south basis. That failure in local accountability is at the heart of our problems in Northamptonshire.
As a new Member, I was drawn into a lot of meetings about the proposed PCT mergers. There were lots of cross-party meetings with Labour and Conservative Members. I went to my local hospital, managers came up here and we had lots of briefings. It suddenly dawned on me that it must be costing an absolute fortune, not only because of the actual cost of the meetings but because of the time taken from the PCT managers, who should have been focusing their resources on health care in my area. It then struck me that we have had ongoing problems in Rushton, where there are three local NHS health care units on three sites, when they should have been brought together on one site. For more than five years, efforts have been made to sort that out but, of course, it went by the by. No one wanted to talk about it, only about what would happen when the PCTs merged. My fear is that, when we have one PCT, the Rushton project will disappear for another five years. It will not be of interest to anyone.
In the run-up to the election, one of the matters that I campaigned on and which came out top through our local listening to Wellingborough and Rushton surveys was the need for a local community hospital. The Government have said rightly that they are in favour of community hospitals. Both my acute hospitals are outside the constituency, so people must travel for half an hour or more to reach them. I have just been successful in getting Heartlands PCT to recognise that that would be a good idea when it is about to be abolished. I now have to go through the whole process again, without local accountability. To a certain extent, I regard matters as change for the sake of change in a quick period. I believe that change should have been made over a period on the basis of what was best for each area. Clearly, we should not have had three PCTs in Northamptonshire, but two. However, there seemed to be an overall plan in the east midlands, at least, that there would be county-wide PCTs. Perhaps the Government had that design in mind before they went into the project.
Many hon. Members have protested, as a result of which their area was altered. Unfortunately, perhaps the new hon. Members who represent parts of Northamptonshire—there was more than one—did not have the clout that some previous hon. Members had or did not know how to get the decision changed. If we are to have a proper consultation, it should not require people afterwards with the biggest stick or the most influence to change things. I know that the Government thought that what they were doing was in the interests of the NHS, but I consider that they failed in Northamptonshire.
I received an e-mail today. It said:
"I have just returned from my local dentist's surgery after my 6-monthly checkup. I was absolutely horrified and disgusted to be told that because of the Dept of Health's changes in the provision of NHS dentists, he would be going private in September. This means that the price for a routine checkup (assuming nothing is wrong) is increasing by almost three times. The quality of service will remain the same so the Dept of Health changes will certainly not improve patient care."
I read that out in relation to the PCT because the two towns of Wellingborough and Rushton adjoin each other. There is no NHS provision in Wellingborough and the PCT has just managed to obtain some new NHS provision in Rushton. Unfortunately, that dental surgery is already full. Appointments cannot be made before December.
Luckily, a local dentist, Dr. Chan, had a Polish dentist available with experience of the NHS because he has been here for a while. He wanted to work in Rushton for the NHS. That would have solved not only Rushton's problems but those of Wellingborough. I had a chance with my partner's PCT to argue that, in that regard, Wellingborough and Rushton were the same place. If the PCT were based in Northamptonshire, and the strategic health authority covers the whole of the east midlands, it would not even know that Wellingborough and Rushton were joined together, so there would be no chance of more NHS provision in my area.
Unfortunately, I have just received a letter from the local Heartlands PCT to say that no funding is available. Can the Minister explain that dilemma to me? I complained to the Secretary of State for Health, and a meeting was arranged with the Minister of State, Department of Health, Ms Winterton. I complained in November, but like many people in the NHS, I had to wait, only to have my appointment cancelled and then cancelled again. It was only six months later that I actually had the meeting, and the Minister argued with some clarity that it was for the PCT to decide whether to provide NHS dental services in my constituency, but the PCT says that the Government will not fund those services. How, therefore, are Members of Parliament to get somebody to do something about a situation in which there is a Polish dentist available to work in the NHS, but there is no NHS provision in the constituency?
Let me now move from dentistry to what is, in many ways, a more serious issue and give just one example of the problem that we face locally. Our local hospitals are very efficient—the NHS standard is 100, and they work at 85—but our area is underfunded, even by Government standards. We are underfunded by 4.5 per cent., and it is argued that that is because other areas are overfunded. That might sound very neat, but there is a real and serious problem for the patients.
A five-year-old child in my constituency—with your permission, Miss Begg, I will not identify him—had an operation in February 2005. During the operation, three surgical procedures should have been carried out, but one was not. That has meant that that little boy has had to wait in pain for a considerable time. This month, the consultant agreed that the case should be urgent, but despite the fact the little boy is in urgent need of treatment, the consultant said that he could not be treated for five months because of the PCT's ruling that it had no funding. The consultant opened his diary and showed all the dates when he could have done the operation, but he cannot do it, because the PCT will not allow it. When that argument is put to the PCT, it says that it is because of Government funding and targets. It has been told that everybody must have an NHS operation within six months, so urgent cases are being put back five months to allow everybody to meet the six-month target.
Such an arrangement cannot be right, and it certainly is not the way to achieve local accountability. Indeed, to conclude, the real issue with which I should like the Minister to deal is the local accountability of PCTs as they are now and as they will be in the future.
I am grateful for the opportunity to intrude on the debate as a non-member of the Select Committee. I appreciate that its report was a snapshot in time and I am sure that my hon. Friend the Minister will tell us just how far we have progressed since. Despite the passage of time and events, however, the report remains extremely topical and relevant to people's experience in Leeds.
As we know, a tablet of stone dropped from the lofty heights of the Department of Health at the end of July. It contained two commandments: "Thou shalt reduce the number of PCTs" and "Thou shalt divest thyself of services". To a degree, the second commandment has been withdrawn, although how far remains the subject of debate. In my area, for example, the initial requirement for PCTs to divest themselves of services has led people to spend considerable time looking at various options, some of which would have obvious attractions to staff who wanted to avoid the threat of outsourcing. My fear is that some of those options might be pursued further out of fear and uncertainty about the future and about change, rather than primarily on the basis of what is in the best interests of patients and services.
The proposals that were submitted for reconfiguration in Leeds need to be viewed in the light of the flawed top-down process that the Select Committee report so accurately described, irrespective of the Government's emollient words in response. They were not carefully considered plans for the improvement and commissioning of services. They were an acquiescent response to the first of the commandments that I referred to a couple of minutes ago. That remains of major concern to us, because in Leeds we have generally found that the PCTs have been a success. They adopted commissioning approaches based on the needs of their communities. They have taken a particularly robust line with the local acute trust. They developed services to meet needs, very much in the way that my hon. Friend Charlotte Atkins described in her area. Indeed, community services were transferred from the then community and mental health trust to the PCT as a means of improving them.
In my constituency, for example, the Leeds West PCT developed a whole range of services responding to local needs, including rapid response teams to prevent unnecessary admission of older people to hospital, thereby addressing a major challenge in Leeds, which is that we hospitalise too many people and keep them there for far too long. A respiratory team has been established to advance the care of patients with certain respiratory conditions. Advanced special practitioners, who are basically senior nurses, are working with patients who have had experience of multiple hospital admissions over a year and regularly require the assistance of their GP, again to address the issue of unnecessary admission.
Our profound hope is that with the reconfiguration such innovation and good practice can continue and be disseminated in a much larger PCT area. In Leeds we are talking about moving from five PCTs, the largest of which serves a population of just under 200,000, to a single PCT serving a population of more than 720,000.
I would not expect the hon. Gentleman to know the answer in detail, but can he compare the actions being taken in his native city of Leeds and the bold way they have gone about merging the PCTs with the absolute lack of commitment and timidity of the Government with the PCTs in London?
My hon. Friend is absolutely correct to anticipate that I cannot answer that question, but I am sure that his intervention will have found its mark.
In fairness, my Leeds colleagues and I were not opposed in principle to the changes—we would not take a luddite approach—nor to the proposal to reduce from five PCTs to one. On the basis, however, of the sparse information placed before us in the so-called consultation exercise, we could not support the proposal as it stood. The picture of how the new PCT would look and function was and, I am afraid to say, remains far too unclear. We were conscious that the proposals were not the result of an organic process but were initiated directly and exclusively as a result of Sir Nigel Crisp's letter of
Like the Select Committee, we appreciate that savings released from reducing administrative cost can be reinvested in patient care. We understand the frustrations of the many voluntary organisations in our city that have to deal with five separate commissioners, although there was a degree of lead authority work taking place to address some of those problems. We recognise the problems of working closely with partners such as the local authority and its relevant departments.
In our response to the SHA consultation we stressed what we wanted to see coming out of the reconfiguration. The points are reflected in a number of the recommendations made in the Select Committee on Health report. I do not intend to take up time reiterating them, because they have been covered by a number of other hon. Members.
It goes without saying that the reconfiguration must maintain and build upon the achievements of our existing PCTs, especially in developing strong local focus and initiatives to meet the needs of our communities. We raised our concerns about whether the move from five PCTs to one could achieve that in a meeting with our right hon. Friend the Secretary of State in the autumn. As a result of our representations, we were pleased that John Bacon's letter of
"Concerns have been expressed about the risk of losing a strong local focus, particularly in Leeds, and it is therefore essential that the consultation document explains how you will sustain this focus within a larger PCT."
We were therefore hugely disappointed that the consultation document contained just a few glib sentences on that point. In subsequent discussions with Mr. Farrar, he made a number of positive assertions regarding that and other aspects of the issue that we discussed. He asked us to trust him, and we might well have done so. He is an extremely good and effective officer. Unfortunately, and inexcusably for a Yorkshireman, he has now disappeared over the Pennines to become the chief executive in the north west.
We now have a new chief executive of the SHA and a new chair. They, of course, have a much larger area to deal with, not only West Yorkshire but the whole of Yorkshire and Humberside. It seems likely, without wanting to pre-empt the process, that the new PCT chief executive will come from outside the area. We also await the appointment of a chair. The Select Committee's concerns on the issues of continuity and responsibility were, I believe, well-founded from the point of view of our experience in Leeds.
At PCT level, it feels as though there is a centrifugal force pulling the emphasis from localities towards the centre and, at SHA level, pulling it from the west Yorkshire area to a Yorkshire and Humberside level. Whether practice-based commissioning will provide a countervailing centripetal force is totally unclear to us at the moment. There has been precious little in the consultation process, or since, to demonstrate how that would work. The Select Committee's comments on that point remain entirely valid, from our point of view.
From my parochial point of view, I continue to ask myself—and anyone else who is listening—how local issues that I have been able to pursue with a PCT with good local knowledge will be resolved in future. I shall reflect and echo the comments made by Mr. Bone. To whom do I speak—and will they have a grasp of the issues in the locality when I contact them—about problems or concerns relating to GP practices, such as the need for new or developing premises? To whom do I speak about local dental provision? My area has been consistently defunded over the years by the exodus of dentists from the NHS. Even though that defunding is being stopped by the retention of funding at local level, where will the funding for re-provision go once we have a pan-Leeds PCT?
My colleagues and I have made a number of other points that are effectively expressed in the Select Committee report. The consultation, for example, had no real tangible substance other than the proposal to move from five PCTs to one. Even that was in the context of a broader document that covered the whole of the west Yorkshire region.
We share the concerns expressed by other Members about the need to retain strong public health functions at local and city level. Of course, we are going from having five teams to having one centralised team within Leeds. Public involvement in health provision at all levels must be promoted. The forums in our city—I am sure that this is the experience elsewhere—have only just begun to find their feet but, as a result of the reorganisation, we have a completely new ballgame.
We must ensure that the present levels of service provision, particularly at local level, are strengthened and enhanced. On that point, we were disturbed to learn that the savings from the reconfiguration in Leeds would not necessarily be recycled into the Leeds health economy. That is totally unacceptable. Leeds faces major challenges in addressing the historical imbalance between community and hospital services. We have two major teaching hospitals, which, over time, have soaked up most of the NHS resources. As a result, we have relatively weak community services, we hospitalise too many people and we keep them in hospital too long. We are also conscious that in the immediate future the acute sector faces major challenges which may require additional resources.
Those are crucial issues and there is precious little time to get them right in the helter-skelter process that hon. Members have described. I sincerely hope that my hon. Friend the Minister will be able to give me some grounds for optimism in his response to the points that I and other hon. Members have raised.
I am sure that all hon. Members agree that debates such as this are valuable occasions. We owe a debt of gratitude to the Chairman of the Select Committee, Mr. Barron, and its members, some of whom are with us this afternoon, for a valuable and hard-hitting report. This morning, I refreshed my memory by rereading sections of the report and was struck by the forthright language in which it was couched, to which the right hon. Gentleman referred, which conveys a lot of the anger that was felt at the time. The letter appeared and although there was some precedent, it still felt like a bolt from the blue and was much firmer than anyone expected. It came at precisely the wrong time in the parliamentary cycle and at the wrong time for any meaningful consultation to take place. Although things have moved on, it remains an important document and our debate this afternoon has highlighted some of the issues that need to be considered as we go forward.
Something that strikes me from what I have heard from colleagues around the country is how different everyone's local case is. My perspective is coloured by coming from an area with a relatively small unitary authority. In our case, to argue for coterminosity was also to argue for localism, and we got it, albeit not under the original proposals. Other hon. Members have referred to wanting a PCT that understands local issues and is coterminous with the social services authority. I was arguing for the same things, but I fully appreciate—the debate has helped me to understand the point—that for some colleagues those two things were in tension.
That leads me to the first key point arising from the debate. It could not be more apparent from the debate that such decisions must be local decisions. I was interested in the comments of Charlotte Atkins, who said that she is a great advocate of local decision making, but then implied that because there may be conflicts within an area, there should be some sort of external, independent arbitration. With all due respect, that seems to be entirely misconceived. Local government exists for that purpose—to reconcile the competing claims of different sub-parts of an area. We do not say that just because a county has one bit that wants one thing and another bit that wants another, we need an independent third body to tell it what to do. We resolve the matter through open, local, democratic procedures in the local area.
If that had happened in Staffordshire we would have been lumbered with a Staffordshire-wide PCT because the county council was determined from the start to be completely undemocratic and perverse and to ignore not only the population in Staffordshire, but its own elected councillors and post-holders.
It was not the elected members who did not listen to their electorate; it was the officers of the county who did not listen even to their own elected members.
The answer to the problem of tensions within a local area, it seems to me, is more democratic accountability, not external independent arbitration by a quango. I cannot follow that logic at all. If the existing democratic structures would not have produced the outcome that the hon. Lady wants, that suggests that the democratically elected people should have been doing their jobs more effectively. That seems to be logical.
The idea seems to be, in essence, that we all have to go cap in hand to the Secretary of State. Opposition Members do not have the same access to Ministers—I do not say that with side, but it is true. I have often heard Government Members say, "I had a meeting with the Minister about this or that," but it can prove very difficult for Opposition Members to do that. That is a statement of fact. I had a local reconfiguration issue about a hospital. After six weeks of trying to see the Secretary of State, I was eventually offered a meeting with one of the junior Ministers. I phoned her office and was told that she was too busy, but I could have a phone call to the Secretary of State two weeks later. Then, the Secretary of State said to me, "Why didn't you raise this eight weeks ago?"
There is a more profound issue, which is that these matters are being decided in the wrong place anyway. The Secretary of State is an elected person, but she is not elected by anybody in Staffordshire, or Wellingborough or Leeds, so why are we having to go to her for a decision to be made? Clearly, there are some things that have to be done nationally and strategically, with an overview. However, decisions about local health configuration should be taken at an appropriately local level.
To continue the theme, the right hon. Member for Rother Valley talked about those with the biggest voice. What was interesting was that I heard something different to what he was saying. He was, I think, referring to some cases on which it is difficult rationally to justify the outcome and there is some suspicion that a former Health Secretary, or whoever it may have been in a particular case, had undue influence. That is another reason why one vocal person, whoever he or she may be, should not determine such matters. Whoever it is, the decision should be a community decision, made locally and democratically. I agree with the right hon. Gentleman—it should not be just one loud voice that counts. However, I think that the voices that are heard should be elected voices; that is what I was trying to get across. In the Avon area, we had the surreal situation in which everybody who had ever put their name on a ballot paper and got elected to anything had a common view, but they were going to be overridden by the unelected. That was what I found unacceptable.
We had an interesting exchange about why some of the strategic health authorities appeared to come to conclusions that were different from the widespread community view. There was an interesting exchange about the reasons for that and some suggestion that it was the result of looking to the future, or perhaps empire-building. I have a slightly different theory, which is that the power of the acute trusts has been underestimated. There is a close working relationship between the strategic health authorities and the big hospital trusts. I know perfectly well that my local hospital trust did not want to deal with lots of small PCTs. Its life would be easier if it were dealing with a smaller number of commissioners. It had a very loud voice, so when we went to see the strategic health authority, it made it clear that the acute trusts' preference for fewer commissioners was weighing strongly with it. That is one reason why the health authorities were saying something different to what the communities were saying. Again, it is a case of the unelected being very powerful: in this case, the chief executives of the acute trusts had a big say.
I am listening to the hon. Gentleman's argument very carefully, but it does not entirely stack up. As we move towards practice-based commissioning, there will be far more commissioners in future, so the PCT's role in commissioning will be significantly diminished. I am not sure how that squares with his argument.
The hon. Gentleman highlights one of the many inconsistencies in the Government's whole approach to health policy. On the one hand, he says that we will have practice-based commissioning— if we believe that—and on the other, we have "Commissioning a patient-led NHS", which was all about PCTs commissioning, not providing. Practices are to commission, but PCTs are to commission, too, and individual patients are going to make individual choices that somebody is going to have to provide for, so in fact patients will determine the pattern of demand. Those three things cannot all be true at the same time. I have no idea—nor do the Government, I think—where we are going with that.
Perhaps I can help the hon. Gentleman. They will be commissioning different things. The PCTs will be commissioning certain services, such as district nursing and the provision of regional services. Practices will be commissioning much more locally based things and most referrals to hospital which, as the hon. Gentleman rightly says, will ultimately be decided by patients who work through choose and book.
That is an elegant characterisation; if only I believed that the process was as carefully worked out as that.
The hon. Gentleman has highlighted the sense that, throughout this experience of reforming PCTs, the Government have been making it up as they go along—abolishing county-wide health authorities, but replacing them three years later with merged PCTs that cover the same area and do similar things. I find that the most worrying aspect of all. To have a 10-year NHS plan, with strategic direction that sets out where we are going so that everyone knows where they stand and can plan on that basis, is an excellent idea, but to produce an NHS plan for 10 years in 2000 but then to rewrite the whole thing every six months seems to be the opposite of what we want.
A number of hon. Members have mentioned the importance of continuity. An hon. Member briefs a PCT about an issue and gets to the point of something being about to happen, but then the PCT disappears and the whole thing has to start again. We need continuity and stability—not stick in the mud-ness or dinosaur-ness, if I may use those words—rather than constant turmoil.
Dr. Taylor quite properly pointed out the so-called distraction effect on managers. I am so pleased that the day after the Minister made the announcement, my local PCT chief executive could get on with planning health services for south Gloucestershire, instead of wondering whether she would have a job in six months or having to organise the winding down of the organisation. I cannot believe that what is happening is a rational way to proceed.
The hon. Gentleman talked about consultation and the statutory duty to consult on such changes. I am sure that he is right factually, but for the Department of Health to write and say, "We don't need to consult," is the wrong way round. Surely one would wish the Department's instincts to lead it to say, "We want to consult." It should not say, "No, it's all right, we don't have to—we're just going to get on with it." The Department should want to hear what people say before it makes decisions. The default position should be for the Department to consult unless there is a pretty good reason not to, but so seldom do things happen that way.
The hon. Gentleman mentioned Professor Ashton. Nobody could say that his resignation was politically motivated or a party political gesture, because he expressed political sympathy for the governing party of the day and wanted to enter into politics. However, he also highlighted the constant reorganisation and its debilitating effect on health services.
Dr. Stoate mentioned PCT planning blight, which is a helpful phrase. He also flagged up the idea of directly elected members of PCT boards, which I am interested in, but then said that perhaps we could work with the foundation trust board model. I have to say that the foundation trust board model is a complete farce, with small numbers of people, often self-appointed, notionally representing huge numbers of people. I have come across plenty of governors and members of such bodies—I do not think that they are called boards—whom the foundation trust often sees as its cheerleaders. The trust is often a commercial organisation trying to get business and succeed, and wants those people not to hold it to account but to go out and promote it. That is a very different role, so I am not sure that the foundation trust precedent is a happy one. Foundation trust governance came about because the Government do not trust local government and therefore invented a proxy for local accountability, which has not worked.
Mr. Amess, who has just rejoined us, asked to be remembered for something. I assure him that he will be remembered; or rather—he knows what I am going to say—that his smile will be remembered. It was his smile in 1992 that brought me into politics. His joy at what had happened in Basildon did not, it would be fair to say, coincide with my feelings. I decided at that point that a political career was necessary and I am grateful to him for that.
The hon. Gentleman raised an interesting question: what happens when a PCT is created that straddles local authority boundaries, such as county boundaries and unitary authority boundaries? By the sound of it, what happens is a dog's breakfast. Probably influenced by experience in my area, I am a great believer in coterminosity wherever possible. The idea of creating something that is not truly local, but not coterminous either, horrifies me, as does the thought of how the joint working will take place in the set-up that the hon. Gentleman described. What is proposed does not look like a sustainable long-term solution, so I would not be astonished if the Essex PCTs ended up being reorganised again, which I suspect horrifies him as much as everybody else.
The hon. Member for Staffordshire, Moorlands was absolutely right to highlight the impact on public health of all these changes, as it has been a neglected area. Several hon. Members made that point.
Mr. Bone was right repeatedly to stress the importance of local accountability. That is where I come in on this whole issue. We are talking about the public's national health service. We are not only consumers who shop around, whose voice in health care provision should be exercised only when we are ill. We are citizens who pay our taxes and who should have a say, as citizens, in the way our health service is structured.
The phrase "sham consultation" was used by the hon. Member for Southend, West and others, and it was interesting that the Minister appeared to be genuinely puzzled by it, as if such things do not happen. Now he is looking at me with a puzzled expression. [Interruption.] Perhaps I misunderstood him. However, there is widespread public dismay about the consultation.
I said the other day that never have so many people been consulted about so much to no effect. There is a sense that we are either not talked to at all or that, when they do talk to us, people do not listen to what we say. Record amounts of consultation go on. I spoke to the Secretary of State about a local issue on my patch, and she said that there had been citizens' juries. Yes, there had been citizens' juries in one bit of the patch that wanted one thing, and they got what they wanted, but the other bit of the patch was not asked and did not get what it wanted.
The critical point about consultation is that it needs to happen before the decision is made. That might sound blindingly obvious, but it would be nice if it happened. It needs to happen early, while people still have open minds. If people consult when they already know the answer, it just spreads cynicism. We need to consult when minds are still open, when issues are still there to be addressed, when the contribution of the public as citizens can still add something. We do not need consultation that is a rubber stamp or a process that generates disillusionment. The consultation on changes to primary care trusts has been a case study in how not to do it. I hope that the Minister has listened to Members across the House this afternoon and that future changes will be made in a genuinely consultative, local and accountable way.
I, too, welcome the Minister to his new position. He and I have had the chance to meet across the Dispatch Box from time to time but in different roles, and it is a great pleasure to have an opportunity to debate with him today what is unquestionably of the greatest importance to all constituents in all constituencies, namely, their current and potential health care.
Equally, I pay tribute to the Chairman of the Health Committee. He has presided over an important and timely contribution, which is not always easy to arrange in Select Committee affairs, to what has, in effect, been one side of the great argument on health care; that is, how much does patient care come out of structures and how much does it come out of the professional application of clinical and management approaches?
The report is highly influential. Notwithstanding the fact that some time has elapsed and that one could argue that the debate has been somewhat overtaken by events, the report stands well, despite the risk that it always carried. The members of the Committee are to be congratulated on their combined efforts in producing it, and I join in congratulating the secretariat that supported its work.
In an informed and sincerely articulated debate by Members across the House, we have heard powerful points about the manner of genuine consultation and commitment to it. We have heard about appropriateness and accountability and how health care services can best be configured structurally for delivery, whether according to geography or to some form of local arrangement. We have heard, notably, from Dr. Taylor about the distraction effect. The point is powerful coming from him, as somebody who has worked at the front end of the health service and no doubt knows what it is like to be on the receiving end when politicians, including Administrations of a different political hue, come up with grand designs and the professionals have to down scalpels and deal with political directions.
May I point out that one of the huge problems that I faced was when organisations for which I was working were called to be involved in pilot trials that were scrubbed before we had got half way through them? That is most off-putting.
I am grateful for that contribution. As it happens, I strongly believe that the Government should pilot and trial most things that they implement, but they should see the trials through so that proper conclusions and assessment can be made in the light of experience. So much can be learned by that method.
I wish to concentrate my remarks on taking forward the lessons of the report and also focus on the Government's response to it, which is equally part of the debate. Their response to one of the Committee's most critical reports—at the time it felt damning—typifies their approach to our NHS: a recital of soundbites and phrases, and saying that throwing a lot of money at the NHS is somehow an immediate answer to criticism. It is incumbent on the Government to look out for a tone that strikes many—I will not be the only one who has heard this opinion expressed in his constituency—as suggesting that an ungrateful nation is failing to thank the Government for throwing money at the NHS. That money has been welcomed, but it is no wonder that the public do not give thanks if the money is not accompanied by the necessary financial and general competence required to ensure that it is best used and deployed.
We are in a time of the worst crisis of deficits and job cuts in the NHS in living memory. Another restructuring of PCTs, more or less returning the NHS to the structure that the Government inherited nine years ago on taking office, seems like a monumental lost opportunity. The 100 health authorities were abolished in 1998 and primary care groups formed. They were duly removed in favour of the 303 PCTs, which are now being meddled with and reduced to an indicated 152. Mr. Truswell made the important point that the reduction did not seem to carry with it a sense of having been designed with a resonance to his area's needs or any analysis of what accountability was needed locally. It was a fair and well argued point.
There have been nine years of what can fairly be argued to be mismanagement, under a constantly changing cast of Ministers—I do not necessarily consider the Minister himself to be primarily in the frame, although he is currently accountable. The result has been that productivity in the NHS has declined by up to 1.3 per cent. every year. There is a question whether taxpayers, our constituents, are getting genuine value for the vast amounts of money that we have all put in. That money was recently described by Nicholas Timmins of the Financial Times as "an opportunity squandered."
The Government have failed to point out that there has been haemorrhaging of staff across the NHS, due to poor financial management. Notably, this week two surgeons at the Oxford Radcliffe hospitals have had to leave their jobs. The Independent reports today that at least 20 NHS trusts are considering making consultants redundant. Money has been haemorrhaged on PFI deals, particularly through the Secretary of State delaying the Barts and The London project and the poor transfer of risk in the Norfolk and Norwich PFI project. Such matters ought to have been highlighted if the Government are genuinely seeking to be accountable for the effect that their expenditure is having on front-line patient care, which is sometimes to diminish it.
In emergency care, the Government have severely limited the capacity and quality of out-of-hours provision across the country through their questionable approach to negotiating the GP contract. They are now having to pay to undo some of the problems of that negotiation by directly enhanced services, and they are driving deficits up with overly stringent targets in accident and emergency departments that deliver little clinical benefit to patients.
On page 3 of their response, the Government say that the rationale for the changes is to
"commission better services for patients, work more closely with local government, and ensure that we get the best value for money from the system."
Increasing patient choice and driving up standards will require stronger commissioning—that is something on which we all agree. The Health Committee, however, remained unconvinced that instigating large-scale reform was the best way to retrench commissioning expertise. The Committee rebuked the Government for not strengthening commissioning when it strengthened the provider sector, thereby leading to a market imbalance in the service. The current proposals for practice-based commissioning are looking increasingly unrealisable in totality. There are only meagre benefits—if any—for GPs in holding merely indicative budgets, particularly as the Government are inclined to be sluggish over things. Lord Warner, the Minister, said in another place that he was "relaxed" about how quickly practice-based commissioning was implemented. Not only will that not strengthen commissioning sufficiently, but the Government have yet to ensure that we secure best value for money.
One of the Health Committee's sternest criticisms was of the clumsy and cavalier approach that had been taken. In the case of establishing new PCTs as commissioning or provider bodies, it amounted to making policy on the hoof. Under pressure from many people—not only from Conservative and other Opposition Members but from Members on their own side, the Government claim to have clarified matters. However, to use the words of the Select Committee Chairman, it is fair to say that the "direction of travel" remains unclear, and that there is still uncertainty around the purpose—let alone the true job expectations—of those who are charged to deliver.
According to the Government view on provider status, decisions on local provision will be left to local PCTs. The PCT will decide whether it has to divest itself of provider function. There is a requirement to consult, but no timetable within with that must be done. The Government have said that if PCTs keep provider functions, they will need appropriate clinical governance arrangements, but they have given absolutely no guidelines. Bob Ricketts, the Department of Health director on demand-side reform, has said that commissioning has not worked for 10 years, and that this time it really has to be a success. Leaving aside practice-based commissioning, "Our health, our care, our say" gave a greater commissioning role to the Department of Health. Will the Minister provide greater clarity on that point?
PCTs have not proved themselves to be adept at commissioning. It must be argued that the rise in sexually transmitted diseases, for instance, is linked to shortfalls in funding for genito-urinary medicine clinics, as PCTs try desperately to claw back money. When I asked my local PCTs about the situation, Central Cheshire Primary Care Trust, which is well managed and has good clinical and management leadership, and which is broadly in balance, replied that it was extremely concerned, but that the programme was on hold until "prudent fiscal management" could find
"the necessary investment from savings in other PCT budgets".
Cheshire West Primary Care Trust, one of the disasters of the country, has a turnaround team. My local newspaper has reported that it now has £20 million to make up the terrible shortfall, although there was no mention of the MP who has campaigned about it. There are consultants at the trust, while the people who were meant to do the job are still employed—£20,000 a day is being spent on the consultants while the trust still has £20,000 employment costs for those who should have done the job in the first place. It is an absolute basket case. Constituents are now losing front-line patient services, such as the Parkinson's nurse specialist, who has gone—the job was cut. That is happening with front-line services, not just with the reorganisation as the background. Nevertheless, Cheshire West would say only that it had established a team to develop strategy.
The reduction in the number of child immunisations is another example. It is due to the Government having moved responsibility out to the PCTs under the new GP contract, with cash-strapped PCTs failing to commission immunisation from GPs.
If the Government are moving toward practice-based commissioning for the commissioning side of health care, and are also seeking to divest PCTs of their provider functions, what does the Minister actually see as the future of PCTs? That question was raised a moment ago by the spokesman for the Liberal Democrats. Surely those questions should have been answered before yet another restructuring and morale-sapping reorganisation, as it was described by Charlotte Atkins in her fine speech.
The reorganisation does little to help close the gap between health and social care. Indeed, this restructuring comes soon after the last one, which was off the back of six others, as has been indicated. The price of raising coterminosity to 80 per cent. is that once again relationships painstakingly built up between the two sectors are rendered worthless, and professionals on both sides are forced to return to square one.
We must remember that the Health Committee report says that it will take 18 months for organisations to recover from reorganisation and a further 18 months for any benefits to emerge. That will create uncertainty when, for instance, subtracting the necessary extra investment such as for the important local improvement finance trusts, which rightly want the chance to become the real agents of change and improvement. The Committee report stated:
"There are also well-founded concerns that patient care will suffer as a direct result of the distraction caused by these reforms".
The national infertility awareness campaign is concerned that the PCTs' implementation of NICE guidelines on infertility will be further delayed by the restructuring—as it is, that implementation is considerably varied. I hope that the Minister will take this opportunity to give a specific commitment on that. I dare say that other Members have received a briefing from the campaign group as well.
In relation to the hon. Gentleman's comments, I have had deep concerns since I first raised the question with the Prime Minister in February of last year. As currently arranged, PCTs have not been delivering one third of what NICE said we should have, as far as IVF and infertility treatment is concerned.
I am grateful to the Chairman of the Health Committee for placing that on the record here, as he has done on the Floor of the House with no less an authority than the Prime Minister. I hope that that will urge the necessary responsiveness, let alone response, required to meet what is unquestionably, in my view, a health right, let alone need.
I shall tackle the public health issue, which I promised to come on to when I intervened on the hon. Member for Staffordshire, Moorlands. I hope that the Minister will explain why, prior to the publication of "Commissioning a Patient-led NHS", there was no consultation with public health officials on its potential impact on PCTs' crucial public health functions. The hon. Lady was not the only Member to mention that—I think that it was raised also by my hon. Friend Mr. Bone and others.
According to the BMA, in the next few months, more than 150 directors of public health will lose their jobs. There are now fewer than 1,000 public health doctors. Among other things, the Government have presided over an explosion in sexually transmitted diseases, a crisis of confidence in child immunisations and a failure of readiness to protect the country against pandemic flu. More generally, they have been cavalier in their planning for public health. I believe that the absence of consultation on public health throws up the Government's ignorance when it comes to supporting closer working relationships between local authorities and health organisations.
The Government have defended the restructuring against the Health Committee's charge that organic change would be better by denying that it is change for change's sake. However, this meddling gives the lie to the Government's claim that they are presiding over a decentralised NHS. Central credit, local blame appears to be the order of the day with constant micro-management from the centre. The NHS should be freed up to change organically and to trust front-line professionals to develop an effective health care system. Change should not be continually imposed from the centre.
Ministers continue to promise an efficiency saving of £250 million a year from 2008, despite the Health Committee's assertion that it is more likely to be between £160 million and £135 million. That point was raised noticeably in the excellent contribution made by my hon. Friend Mr. Amess. That promise comes from Ministers who have presided over the largest deficit—two and a half times bigger than the Secretary of State's estimate as recently as
The Health Committee report deemed it essential that structures to ensure clinical engagement and, most crucially, patient and public involvement were retained at their current levels covering each natural community. Does the Minister agree? If so, why have the Government adopted what I think is a Stalinist approach to public involvement in the NHS? The Government have desperately mismanaged public and patient involvement. They split up the structures of individual patient advocacy, complaints investigation and collective patient representation. Patient and public involvement forums have been the creatures of NHS management. They have lacked independence—which is vital for trust and credibility—have had inadequate specialist staff input and have lacked any influence over the consultations on service configuration throughout the country. The Commission for Patient and Public Involvement in Health had been functioning for only six months when the Government announced its proposed abolition.
After the loss of volunteer expertise and independence with the abolition of community health councils—many will remember that I had quite a hand in the campaign and argument against abolition, and we did achieve a stay of execution for a year—patient forums have had a turnover of 62 per cent. in just three years. Too many good independent people who want to help their local NHS have been turned off by poor training, bureaucratic interference and a lack of real influence.
One reason given for abolishing CHCs was that the volunteers who staffed them were not representative of the general public. On
"The commission will go out into communities and hear those different voices and draw in those socially excluded groups and marginalised communities."—[Hansard, 15 January 2002; Vol. 378, c. 226.]
I hope that this Minister is ready today, given that the issue is part of the Health Committee's report, to tell us what evidence he can show for the CPPIH having had any success in recruiting and training people from hard-to-reach groups.
The Minister will know that the Conservatives fought tooth and nail against the abolition of CHCs, trying to protect patients and keep the Government accountable. It is important that none of us is afraid of having effective accountability structures in the NHS, and it is doubly important that patients and professionals are trusted, because the alternative—centrally micro-managing everything—is patently causing a diminution in morale and trust. The Health Committee said that the Minister's view that practice-based commissioning would improve patient and public involvement in health care was not firmly based in any evidence. I hope that the Minister can make such evidence immediately available.
I hope that the Minister will also clarify the impact of PCT mergers on resource allocations. In some areas of the country, PCTs serving more deprived areas have merged with PCTs serving less deprived areas. That is one reason why we managed to resist Cheshire West PCT going into an organisation covering the whole of the rest of Cheshire. Apart from anything else, it would have lost its accountability for the disaster that it had created. How will the Government ensure that, within the new structure, the more deprived areas continue to receive the funding that they need, without creating large sub-bureaucracies in the new PCTs and masking accountability? My hon. Friend the Member for Wellingborough made that point very effectively, among others, in relation to the Rushton example.
I seek an assurance from the Minister that when the Government say "Separate PCTs", they mean separate PCTs in every case, with separate boards, chairmen, chief executives and secretariats. As he has today, my hon. Friend Mr. Walker raised that in a point of order on
The changes to primary care trusts are the result of a rushed, centralised and, in large part, predetermined consultation and have thrown up a vast number of concerns relating to public health, patient and public involvement, resource allocation and the very future of PCTs. The Government have done little to clarify the grey areas in their policy or to address our concerns or those of the Health Committee over the past six months.
Most tellingly, the Health Committee report recommended that a central change agency be established. Surely the agency responsible for strategic oversight of the NHS is the Department of Health. I dare say that the Committee might not have called for such an agency had it felt that the Department of Health was functioning appropriately. The Department and its Ministers have been too busy micro-managing the NHS and, I fear, chasing headlines to concentrate on a coherent policy that puts patients, the public, in each of their recognised localities, and front-line health care professionals in our NHS first.
I congratulate my right hon. Friend Mr. Barron on introducing this important Adjournment debate. I also pay tribute to the work of the Select Committee. Its report was very significant in the influence that it had on the reconfiguration process, and the quality of today's debate has, on the whole, been very high.
The starting point for considering why the reconfiguration was deemed necessary is how, in the end, we add most value to patient care. I made the point, as soon as I came into this job in the Department of Health, that everything we do is ultimately about supporting the interaction between the people providing the service on the ground and the people receiving that service—whether it be NHS or social care provision.
The Government felt that, based on the ever-changing needs of the health service and the necessary reforms that we have started to put in place, the reorganisation of PCTs was essential to further that reform agenda in a positive way that is consistent with our aspirations for excellent patient care.
I also believe that in the context of my own responsibilities it is crucial that we achieve an integration of health, social and community care in this country in a way that we have not been able to do previously. That is particularly important in relation to joint commissioning. Therefore, the greater level of coterminosity that has been achieved as a consequence of these change is to be welcomed on the whole. That does not mean that coterminosity has been achieved in every area, but system-wide there is a greater level of coterminosity than has previously been the case.
I understand concerns expressed by those who argue that there is too much restructuring and reorganisation, but one has to look at the specific reconfiguration and make a judgment as to whether at this time, in the development of our NHS reform programme, it was the right thing to do. In time—such matters can be proved only over time—the judgment will be that, on the whole, it was the right thing to do.
I wish to spend most of my contribution responding directly to the many contributions that hon. Members have made. My right hon. Friend raised an important issue about the question of pensions for staff and reassuring staff in that area. I agree entirely that we need to give greater clarity and greater assurances and produce clear guidance for employers and staff in this respect. It is important and we will be doing that as soon as we possibly can. With regard to the question of savings, we expect—I know that there is a difference of opinion on this and that the Select Committee found a different figure from that of the Department—that there will be a recurrent annual saving of £250 million as a consequence of these changes. The important thing about that is the transferral of those resources to front-line services.
Dr. Taylor, who has a tremendous amount of personal knowledge and experience in these areas, asked a number of questions that are worthy of consideration. One of the issues was about publishing the external panel's response. A number of hon. Members raised this issue. We have published this in the Library only this week in a variety of forms: the external panel advice from Michael O'Higgins to Lord Warner; a table setting out the various decisions that had been made; and the rationale of Ministers' decisions on PCT configuration. I suggest that the hon. Gentleman consults the Library. He may find that the information is not as complete as he wants it to be and he can come back to me on that point. But, consistent with the commitments that the Minister of State, Department of Health, my hon. Friend Andy Burnham made when this statement was first made in the House, that information has been placed in the Library this week.
The hon. Gentleman also raised, as did other hon. Members, the question of local focus. Of course, we have made it absolutely clear that in terms of practice-based commissioning there will inevitably be a greater level of local focus than there has been historically. We have also made it clear to each PCT that, post-reconfiguration, we expect them to take account of the different localities that form component parts of the trust. They must be sensitive to the distinct needs of those communities—the health inequalities that may exist and the differences that undoubtedly will. It will be partially about us holding those PCTs to account in that respect, but it will also be for local hon. Members to hold PCTs to account and to make sure that those commitments are honoured.
Mr. O'Brien raised the question of patient forums and patient involvement in the NHS. Hon. Members are aware that we are due to come forward with some proposals in this area. Dr. Taylor used the term "well resourced and independent", and I hope that when we introduce those proposals we can demonstrate that they are properly resourced, with a significant element of independence to reassure hon. Members.
As for the NHS Appointments Commission, as a Minister I would sometimes wonder about its autonomy; however, it has tremendous autonomy. Parliament took that decision for good or for bad. Criteria have been applied for making appointments, and they pay particular regard to ensuring that local appointments reflect local communities. An independent appointments commission, by its very nature, guards fiercely its right to retain its independence.
My hon. Friend Dr. Stoate, who speaks with great knowledge about these issues, raised several important points, such as localism and planning blight. He asked whether the reconfigurations cause a period of blight. We have professional people running the organisations, and most of the agenda, which has been in place for a long time, has not changed as a consequence of the reconfiguration proposals. I do not see why there should be significant planning blight as a consequence of the reorganisation, but the proof of the pudding will be in the eating.
My hon. Friend was also concerned about professional executive committees. We made it clear that we expect high-quality, high-calibre committees to be elected in every PCT area, so perhaps we can discuss at a later stage how we go about that.
My hon. Friend also raised the question about the vital role of community pharmacists in primary care. If I am honest, we have a long way to go towards creating a more central role for them. I suspect that if we looked throughout the country, we would find that there was a patchiness—the new word—in the extent to which PCTs put the role of community pharmacists at the centre of their planning and commissioning. I agree that we should think far more seriously about it.
I am not sure to which international travels my old friend, Mr. Amess was referring; he has a better memory than some. He referred to political shenanigans and the meaninglessness of consultation, too, and I must say to him and to other hon. Members who have made that point, that when the first letter was issued there was a case for saying that a number of things could have been done differently. I would be the first to acknowledge that. I guess I can, because I was not part of the team at the time. However, many changes were made as a consequence of listening to the Committee and to Members. They demonstrate that the Government have listened and taken seriously the views of people on the ground, who are democratically accountable and understand the needs of their communities, when health service managers and bureaucrats have not acted in accordance with local needs and preferences.
The Government can be proud of being not too proud—sometimes Governments are—to say where it was appropriate to make changes to the original proposals. I accept that not all hon. Members are satisfied, but in many cases, those changes were made. Based even on today's debate, there is considerable evidence that those changes were not made on a party political basis, because people of all political persuasions have today been able to point to changes that were made as a consequence of their representations on behalf of their constituents. It is disingenuous of the hon. Gentleman to say that there was no listening process and that somehow there were political shenanigans. I shall leave it to my hon. Friends to determine whether they like the phrase "truly socialist Bill". I imagine that many of my hon. Friends would be pleased if that title were attributed to a health Bill.
The hon. Gentleman is right when he says that it is very important in the context of reorganisation and restructuring that we reassure front-line staff. It is disingenuous when talking about organisational change to suggest that staff will not be anxious and insecure. They will be. Good management and good leadership are about managing that process on a local level.
Again, the word "patchiness" springs to mind. There are excellent examples of organisations that manage change and deal with the insecurities and anxieties of the people who work there. There are other examples in which the concerns of staff are not taken nearly seriously enough. That has consequences for morale and in other areas. It is about good management.
On the question of the PCT's continued role as a service provider, we have made it clear that we expect PCTs to continue providing services but that they have the right to consider bringing into the market new providers that may be in a better position to provide those services in a more responsive and high-quality way. There will be no edict or instruction from Government to PCTs to stop providing services, but we need to focus on the best shared outcomes that we can achieve for local populations, and that might sometimes mean bringing in other providers that have not historically been involved.
I spent my entire working life before coming to this place in the voluntary sector. The voluntary sector could do things in terms of responsiveness to user and carer need that statutory services frankly could not and cannot do. It is not a new concept or phenomenon, but it must not be ideologically driven. It must be about shared outcomes and high quality and responsive services.
My hon. Friend Charlotte Atkins felt that despite some of her early frustrations the Government had listened. She also made a point about the centrality of area commissioning, which is one of my responsibilities in a sense. We have not sorted commissioning of health and social care in this country. We need an integrated approach and commissioners who are willing to get their hands dirty by getting close to users and carers as they make decisions about the nature of the services that should be commissioned.
Being a commissioner in a modern health service in a social care setting is a skill. Maybe we need to do a lot more thinking about the kind of support and development that we offer to people who end up in commissioning roles in such organisations, because the nature of the commissioning can often determine the quality and responsiveness of NHS and social care.
I agree with my hon. Friend about the importance of public health. The Government will continue to stress PCTs' responsibility for focusing on public health. We want to see a continued shift where appropriate from hospital care to community care and primary care. In some areas that is more advanced than in others, but it is important that we keep our eye on the ball and ensure that we are spending more money, time and energy on preventive support than on reacting when we could have done better in the first place.
I pay tribute to my hon. Friend's parent-led Sure Start scheme, an example of an innovative local project that is making a difference, probably more than anything because it is parent-led. On the question of staff training and primary care, I agree entirely with her that staff training and development are important. I do not have any figures to hand, but if she wishes me to write to her on the issue, I shall be happy to do so.
I want to reassure Mr. Bone on the question of community hospitals. He is right. The Government are committed to a new and exciting role for community hospitals, and I hope that that will help him in his discussions with his PCT. Just because the management arrangements have changed does not mean, if we are talking about reflecting and meeting the needs of local communities, that the commitment to community hospitals should change. I hasten to add from the Department of Health that it is not for me to dictate to the PCTs the nature of the projects that they should support. [Interruption.] I will give way to the hon. Member for Eddisbury in a moment.
The hon. Member for Wellingborough raised the question of the five-year-old child. It would be wrong for me to comment on an individual case, but it is slightly contradictory that Ministers are asked to make judgments about individual cases at that level when we have devolved resources to the PCTs and asked them to make decisions about priorities. I do not know the level of pain that that child is in right now. That should be important in determining the decision-making process. However, I cannot intervene directly in that individual case.
I shall be brief. It may be a point that the Chairman might want to consider by way of intervention if he catches your eye for any final remarks, Miss Begg. I note that on page 69 of its report, the Select Committee put to Lord Warner the point about the possible proposal to put out to tender the commissioning function in Oxfordshire. He assured them that that would not be allowed to happen.
However, an article has just been passed to me that appears in today's Health Service Journal in which it says that the Department of Health is doing precisely that by asking for bids and tendering-out processes. I was wondering whether the Minister would like to take the opportunity to comment on that.
I would say to the hon. Gentleman that we give the PCT a significant amount of resource. We give them a major amount of autonomy. Yes, it also has priorities and targets that are set by Government. However, as I understand it the situation is that a five-year-old child is in pain. If it is as clear as the hon. Gentleman has reported it during the debate, he is right to pursue the question whether that child's treatment could not be provided in a more accelerated way. That is all that I can say to the hon. Gentleman. I cannot comment on whether the PCT and management's view, that that is a question of priorities, is a reasonable one. All I can say to the hon. Gentleman is that in any weighing of priorities, the pain of a five-year-old child should be given significant weight. However, I cannot go any further than that. I have probably gone too far as it is.
My hon. Friend, Mr. Truswell is obviously frustrated, to say the least, about some of the changes that have been made in his area and some of the ways they have been approached. He expressed support for some of the innovative services that have been provided in recent times and concern that they may be detrimentally affected by those changes.
All I will say to my hon. Friend is that it is important, not to debate decisions that have already been made, but to ensure that the new structure delivers in the way that the Government intended. I am happy to engage in a constant dialogue with hon. Members, including my hon. Friend, to make sure that any fears or concerns that they have will not be borne out. That is not the end of the matter.
One of the matters that is legitimate in the debate is for right hon. and hon. Members to play a role in holding their local PCTs and other health organisations to account on how services are delivered at a local level. That need not be in a formal way, but it is an entirely proper part of a Member of the House's responsibilities to ensure that local delivery organisations meet the needs of their constituents, and, if they do not, to bring that to the attention of the management of those organisations and, ultimately, to that of Ministers.
The significant thrust of what Steve Webb was saying was that consultations were sometimes of a sham nature. He said that I looked disapproving at that statement. I did not actually. My experience of consultations, across the board in all services, is that sometimes managers issue consultation documents—not just in the health service, but across the piece—and they know exactly the decision that they have already made. They know the outcome that they want. The consultation is there to justify the decision that they have already made. Any hon. Member who would not acknowledge having had such an experience at one stage or another, in one consultation or another, would not be living in the real world. Such consultation is not acceptable, and should not be, to the Government or to locally or nationally elected representatives.
I do not think that the hon. Gentleman can describe the consultation as a sham. There is a lot of evidence that major listening took place. The evidence is in the changes that were made as a consequence of the listening. If the consultation were a sham and the Government wanted to drive the changes through on a one-size-fits-all basis, as we have been accused of, we would not necessarily have listened and we would not have made changes, so I do not think that that was entirely fair.
The hon. Gentleman talked about decisions being made locally. That was a big thrust of his argument. The strategic health authorities of course oversaw all of the consultations, not the Department of Health at a national level. However, there comes a point when there has to be some level of arbitration or mediation in making final judgments. Significant differences of opinion are always going to have to have an ultimate arbiter or mediator who comes up with a solution. That solution will not always be acceptable, either to local people or to other stakeholders. In some way there will always have to be somebody who makes a decision. There were very disparate and diverse views as to the best way forward. Obviously, the Government have to create a mechanism to arbitrate and mediate in such a circumstance.
Turning to the contribution of the hon. Member for Eddisbury, the argument that the Conservative Opposition tend to throw at the Government is that all we have done is to throw lots of money at the health service and as a consequence have not seen real improvements. Frankly, that is disingenuous. First of all, we have always made the case for reform alongside investment. That has been the mantra from day one in the way that we have sought to improve our health and social care services. Secondly, it is disingenuous to pretend that there has not been tangible improvement in many of our front-line services as a consequence of the Government's investment and reform programme. I believe that many members of the public—it is not a question of an ungrateful nation—would acknowledge that.
The hon. Gentleman described the financial challenges of the year as the worst crisis in the NHS's history, but I would say that the worst crisis in the NHS's history developed during 1979 to 1997. One of the primary reasons why the Major Government were thrown out of office to the extent that they were was because of the public belief that the health service had been so starved of resources, particularly during the latter years of the Major Government. The Conservative party paid the political price. That was a real crisis. I remember the bed-blocking stories every year—year after year. They were almost accepted as an inevitable part of what was happening in the national health service. One only needs to remember from a professional point of view, as well as from a patient point of view, the reality of those years.
The hon. Gentleman also raised questions about commissioning. I agree entirely with his belief in the centrality and importance of getting the commissioning right. The question is not just of commissioning at a practice level within the NHS, but also about how we can integrate commissioning in social and community care, as well as those commissioning functions currently under the national health service.
The hon. Gentleman also raised the question of health inequalities and making sure that, under the new configuration, we do not neglect or allow to become invisible again some of the most deprived and disadvantaged communities. In my view we have to make sure that post-reconfiguration we continue to target resources on those most disadvantaged, in areas where health inequalities are at their starkest.
The hon. Gentleman also raised the question of the NICE guidelines on infertility. I know there is a fear among some of the organisations involved, but I do not believe that the reconfiguration per se will be a problem for the NICE guidelines. I want to reiterate that we do not believe that the reconfiguration of primary care trusts should lead to that situation—
It being half-past Five o'clock, the motion for the Adjournment of the sitting lapsed, without Question put.