NHS Reform and Health Care Professions Bill

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Mr. Hutton: I am following the hon. Gentleman's arguments closely, and they have a certain familiarity. Given his many concerns, where are his amendments to the clause?

Mr. Burns: As the Minister probably knows, because I am sure that he reads the Order Paper—or, at least, his parliamentary staff does—there are two amendments to clause 2 on the Order Paper. The first seeks to postpone the introduction of PCTs until 1 April 2003; the second concerns the order-making powers. As the Minister also knows—and as I heard many of his colleagues say when his party was in opposition—the joys of Opposition spokesmen in not having the Rolls-Royce facilities of a first-class civil service really tax their ingenuity. The Minister will know that the amendments are starred and that, in their wisdom, Miss Widdecombe and Mr. Hurst have, rightly, not selected them.

Mr. Hutton: I hear the hon. Gentleman's points, and I have some sympathy with them, but can I ask where all the Short money is going? He has £3 million of it.

Mr. Burns: I think that you would chastise me quickly, Miss Widdecombe, were I to seek to answer that question.

The Chairman: I would.

Mr. Burns: I hope that you agree, Miss Widdecombe, that the Minister gets full marks for trying it on but, sadly, he will not be successful tonight.

Dr. Harris: I think that the Conservatives' decision not to table amendments to the clause is right, because they have the same approach as me. On reflection, they may have tabled some amendments that were starred, but they are quite right if they have decided that the clause is so flawed that it needs to be opposed in its entirety. The clause is unamendable and unimprovable if one is opposed to the measures for reorganisation that the Government are taking. I welcome the fact that the Conservatives also take that view.

Mr. Burns: I heard the hon. Gentlemen's comments with interest. I am grateful to him for contributing at this stage in my speech and thank him for his comment. I will not detain the Committee any longer because, as the hon. Gentleman said, the clause is important. We have serious concerns because we believe that the Government are mistaken in seeking to rush the matter. I am sure that many of my hon. Friends wish to raise important points about their concerns.

Dr. Richard Taylor: I have one brief question. I am relieved to hear that the establishment of PCTs will be delayed until October 2002 and fully implemented in April 2003, but I am very concerned about the possible transition vacuum. What will happen when health authorities have gone, SHAs are in place and PCTs are not yet established?

Mr. Baron: I add to the valid concerns expressed by my hon. Friend the Member for West Chelmsford my concern at the speed with which PCTs are being introduced. I question whether PCGs and PCTs are ready for the reforms. I think that the changes in the Bill, especially in relation to the establishment of PCTs, will divert activity and resources away from front-line patient care when it is most needed. It seems that the remaining 130-odd PCGs will be rushed into becoming PCTs whether they like it or not, and some existing PCTs are struggling.

6.45 pm

I draw the Committee's attention to a study undertaken by the National Primary Care Research and Development Centre in collaboration with the King's Fund, which was supported by the Department of Health. The second national tracker survey of 71 primary care groups and trusts, to which reference has been made, concluded:

    ``Progress in commissioning, health improvement and partnership working is slower. Lack of reliable and timely information and insufficient managerial capacity remain problems.''

Professor David Wilkin, project director of the survey, said that

    ``there is a real danger the management of the organisational changes is going to divert attention from the core functions of improving care.''

He also said that the pace of change is being dictated by Government timetables rather than by a

    ``process of learning and building on experience''.

It is easy to dismiss such observations, but the fact is that this group, which has the backing of the Department of Health, has severe reservations about the speed at which PCTs are being brought into existence.

I have two further concerns about the introduction of PCTs, one of which relates to skills and the other to funding. On skills, Professor Wilkin pointed out that resolving this issue is a question not of extra resources, but of getting managers with the right skills and experience into the system. Managers from trusts and health authorities can be, and indeed are being, taken on, but they do not necessarily have the skills needed to cope with the additional roles and functions that PCTs will be taking on. In my view, that will cause some concern and disruption to the delivery of care.

PCTs are already experiencing difficulties in recruiting clinical staff who are competent, willing and able to participate, but the problem is not just with such staff. There are also other areas of management for which PCTs are struggling to find recruits. Finance directors play a crucial role, bearing in mind that, by 2004, PCTs will have under their control some 75 per cent. of national health service expenditure. Yet at the moment, a good number of PCTs cannot find finance directors, let alone ones with competent experience relevant to taking on the new roles. I would welcome the Minister's views on that.

I should also like the Minister to deal with the issue of funding. Will PCTs be saddled with health authorities' outstanding deficits as part of the devolution process? If so, PCTs could be left without the resources to implement their devolved responsibilities, let alone to achieve the Government targets on which much of their funding depends. With ever-increasing central directives and no additional resources, there will be arguably little opportunity to improve provision of health care over and above that which has been supplanted. I ask the Minister to clarify the precise funding requirements and relationships, so that we can ensure that PCTs are able to deliver the health care that we expect from them.

Whether in terms of skills or funding, we return to the central concern that PCTs are being rushed. As someone who, I admit, believed that the deadline was April 2002, I am obviously pleased to hear that it is October 2002. However, I have spoken to the two PCTs that cover my constituency, and the Minister might be surprised to learn that they were under the impression that the deadline was April. Moreover, their chairmen and chief executives have told me that they are worried about a management skills shortage.

In conclusion, I can only reiterate the view expressed by many members of the Committee; we should reconsider the timetable that the Government are forcing through, and contemplate introducing the April 2003 deadline.

Dr. Harris: I am conscious of the time and the fact that it would be convenient for us to hear the Minister's reply shortly, so I shall not detain the Committee. We oppose the proposals on imposing PCT status and imposing upon PCTs the transfer of powers from health authorities and we intend to vote against the clause.

I should like the Minister to clarify a couple of points. I echo the comments of the hon. Member for Wyre Forest about the vacuum that will be caused by a delay between the compulsory abolition of health authorities and the establishment of the remaining PCTs capable of taking on this huge range of additional responsibilities.

At what point in the interregnum between the publication of the NHS plan and the press opportunity of 21 April 2001 did the Government decide to change their position of allowing PCGs to choose PCT status and take this measure to impose PCT status on them?

Do the Government recognise the contradictions in their position? I shall try to cover this in less confrontational terms than those used on Second Reading. The Government have an agenda to end what they describe as the postcode lottery of prescription and the provision of treatment. I accept that my party has previously used those descriptors in expressing concern about the situation, but I have never been convinced that local decision making about priorities in a cash-limited system is always a bad thing. Indeed, it need not be local at the commissioning level; it could be local at the prescribing level. Does the Minister appreciate that any system that does not have completely centralised control will involve some geographical variation in the provision of services and the availability of treatments? He cannot say that he wants to devolve power, budgets and responsibility locally while at the same time seeking to abolish, or at least bear down on, geographical variations in the provision of treatment—what he calls the unacceptable variations of the postcode lottery.

Mr. Hutton: I am genuinely puzzled by the hon. Gentleman's comments. The logical conclusion of his argument is that there should be centralised control of the NHS, yet that is clearly not his view.

Dr. Harris: I have written articles, which I would send to the Minister if I thought that he would read them, arguing that one cannot in all honesty say that there should be an end to geographical variations in the provision of treatment, or what some people lazily call the postcode lottery. Such decisions are not made in a lottery fashion, but after due deliberation by hard-pressed commissioners with limited budgets and a sense of guilt that they cannot fund everything that they wish to. The Government cannot bear down on that at the same time as saying that there will be devolution of real power, budgets and responsibility to the health authority or PCT.

Organisations such as the BMA should be cautious before accepting the Government's offer of all this responsibility and a budget to spend, because they will at the same time either centralise decision making to clamp down on what they describe as unacceptable geographical variations or use the opportunity of this apparent devolution to ensure that the blame for the inability to provide services in the postcode lottery is placed on PCTs, as was previously the case with health authorities. There are two different positions, and I am not clear which one the Government are adopting. I urge organisations such as the BMA to hold fire on deciding whether they think that this is a good thing until they understand whether what is being devolved on them is blame or the ability to make rationing decisions within a capped budget.

Unless the Government clarify which way they will go, the accusation will stand that they seek merely to decentralise the blame for rationing. This is going wider than PCTs, and I can remember having many debates around the subject of rationing with you, Miss Widdecombe, in which we shared a common view that we must be up front about the issue and then discuss the degree of rationing of additional funds.

Finally, I should like the Government to address the concern that they claim that these changes will save money in management terms. There are many who argue that if managers can be found to do the work, creating more commissioning authorities while still having SHAs that need people in responsible jobs who are being paid the going rate will increase, or at least maintain, the degree of management. It is hard to understand how the Government can have it both ways. They claim that their new system will not be under-managed, but the new bodies will receive a series of extra powers although they will have little experience, no option to opt in—the enthusiasm is not there—and will simultaneously be asked to deliver huge savings in management costs.

I asked on Second Reading, and I shall ask again today, whether the Government will be willing to subject their claims of management savings in this reorganisation, and others, to the scrutiny of an independent audit body, which the Government could propose and we could discuss? The Government must decide their answers to those questions, which illustrate the confusion that exists. I am concerned that the proposals mean significant upheaval and change, which is not the main priority for the NHS at the moment.

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Prepared 27 November 2001