NHS Reform and Health Care

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Dr. Harris: I direct the Minister to the explanatory note, which specifies that the extension is a new provision. That might mean ``new'' in the sense that everything in the Bill is new, but I am not sure why that would be so. I agree with the Minister's comment, and the Library briefing, that the proposal is a continuation of the health authority approach.

Mr. Hutton: The hon. Gentleman is right. The extension of powers is a new provision in a new Bill, but it represents a continuation of the powers that the Secretary of State already holds on health authorities, which are the commissioning bodies. PCTs will have that function and if we believe in the Secretary of State having the powers, it is logical to extend them to the new bodies. We believe that, and I am slightly puzzled that the hon. Gentleman does not. His party rightly wants to hold the Secretary of State to account, because that is the job of this House.

Mr. Heald: How can the Minister maintain that this is a devolutionary measure when he keeps on talking about extending the Secretary of State's powers? Why do we not reduce them? What happened to decentralisation and devolution?

Mr. Hutton: I will come to that point in a minute. The hon. Gentleman is falling into the same trap as the hon. Member for Oxford, West and Abingdon. We are devolving power and responsibility to the NHS.

Mr. Heald: No.

Mr. Hutton: We are, and that is the view of the British Medical Association and other organisations in the field. That is not the hon. Gentleman's view; even if we transferred every power—lock, stock and barrel—to the front line of the NHS, he would claim that it was a centralising measure. That is the political position that he and the hon. Member for Oxford, West and Abingdon wish to occupy.

The Secretary of State will take the power that he needs to determine how much to allot each PCT on its performance. He may consider a range of factors and he needs the discretion. It is important also for the Secretary of State to be able to vary an allocation during the course of a year, and I would have thought that the hon. Member for North-East Hertfordshire would have supported that provision. The Secretary of State should also be able to impose conditions, if he feels that they are necessary, on how the money allocated to PCTs is spent. The Secretary of State is accountable to Parliament for the way in which public money is used, and needs the powers to help him discharge the responsibility effectively. I do not agree with the hon. Member for North-East Hertfordshire that we cannot ensure proper parliamentary accountability—which, rightly, preoccupies every Member—and devolve responsibility to the NHS front line.

The hon. Members for North-East Hertfordshire and for Oxford, West and Abingdon both complained about ring fencing. We may want to ring-fence part of the allocation to ensure that funds are spent on the purposes for which they have been allocated. We are doing that, for example, for the development of out-of-hours GP services. It is important to develop those services, and earmarking funds is an effective way of ensuring that priorities are fulfilled. The services are not plucked out of a hat, but represent patients' priorities. The hon. Member for Oxford, West and Abingdon will know about the frustration that some patients and members of the public feel when they cannot access primary care services out of hours. Ring fencing is an important part of ensuring that all the NHS works effectively. We have proper out-of-hours primary care and accident and emergency cover, and they work intricately together. If we do not invest in out-of-hours services in primary care, we will have to soak up problems in accident and emergency departments. We must set our face against that.

In accordance with shifting the balance of power and the philosophy that underpins it, we aim to earmark funds only when necessary. Indeed, we are earmarking less in allocations to health authorities, and will do so to PCTs, than has been the case. This is a classic case of the Opposition trying to have their cake and eat it. They criticise the powers that the Secretary of State needs to have on the basis that they are centralising, but then rail that the Secretary of State is trying to evade his responsibilities and accountability to this House. On this occasion, they cannot have their cake and eat it.

Mr. Baron: The Bill introduces 58 specific instances in which the Secretary of State for Health's powers are enhanced. It introduces micromanagement for targets and performance rewards for individuals in primary care trusts; money can be withdrawn if the targets are not met. Will the Minister explain how it is a decentralising Bill?

11.15 am

Mr. Hutton: We will deal later with the provisions where those regulatory powers are discussed. Under the Bill, some of the Secretary of State's powers are intended to facilitate, for example, the establishment of the new UK council for health care regulators. That professional self-regulation will be a boost to patients' interests, which the hon. Gentleman should support.

In preparing legislation, material in the Bill must be balanced with the regulations. That process is subject to normal scrutiny: the hon. Gentleman may think that it is not sufficiently robust, but that is a separate argument. In drafting primary legislation, subject matter that is appropriate for regulations is distinct from what should be in the Bill. The hon. Gentleman and I may disagree where that balance should be struck. I will have to double check the hon. Gentleman's arithmetic, but it is not right for him to say—based on a crude headcount—that because the Bill contains 58 regulatory powers, it is a centralising measure. It is not as simple as that.

I want to conclude the debate by 11.25 and we have dealt robustly with the hon. Gentleman's arguments—though perhaps not to his satisfaction. His arguments are based on a misunderstanding of the performance fund's nature, purpose and intent. Most depressing of all is the failure of the hon. Gentleman and the hon. Member for North-East Hertfordshire to recognise that the Secretary of State has a role in incentivising and rewarding good performance in the NHS. It is entirely proper for the Secretary of State to have that responsibility, and it is his constitutional role to discharge it. The Bill will equip him with the powers to do so.

Mr. Baron: Will the hon. Gentleman give way?

Mr. Hutton: No.

The clause intends to give the Secretary of State those powers and the amendment would deny them. I cannot accept the amendment.

Dr. Harris: That answer was most unsatisfactory. It is not a case of having one's cake and eating it. Having heard the concept of a cake used in that way, I am sorry that I introduced it. The amendments will not prevent allocation of additional funding during the year, based on weighted capitation in the usual—as the Minister described it—equitable way. I cannot remember the other adjective that he used. It is welcome that the Government want to make allocations in advance, so it is regrettable that more money has to dribble in during the year. No one will complain about extra money, but they certainly would if it was withdrawn, which the Government have the power to do.

We are not debating the principle of additional allocation, but whether it is reasonable for the Government to set performance targets to incentivise staff financially. The Government's remarkable judgment of front-line health care staff is that they do their best only if offered additional money. To the Government, they are not inspired by vocation or by their duty of care to patients; they are inspired to work long, additional hours not on the basis of their wish to do what is best for their patients, in partnership with them, but by the fact that they will get a bit more money next year, either in their pay cheque or for their budgets. That is a remarkable analysis of people's motivation.

The Minister failed to explain the confusion that he caused by stating that there was not a performance fund separate from the general allocation, which is made available differentially to different commissioning groups on the basis of the Government's judgment of performance against Government-imposed targets. They may bear little relation to clinical priorities, or may be counter-productive in that they distort clinical priorities. The Minister did not respond to that allegation, nor did he clarify the issue.

Mr. Hutton: The hon. Gentleman is trying to have his cake and eat it, although it is more of a biscuit in this case. His party's manifesto was full of political commitments on targets for the national health service. What on earth is he talking about?

Dr. Harris: The Minister will have to be more specific. I accept his point that one cannot say that Governments should set maximum waiting time targets and not avoid being hung on them if they do not give health authorities the funding, regardless of clinical or other priorities. That is why our current policy rejects the concept of rigid performance-managed maximum waiting times; we favour using waiting times as a monitor of performance but not as the be-all and end-all, which will distort clinical priorities by making funding depend on them. The more funding there is in the system, the easier it is to drive down overall waiting, but arbitrary, politically driven maximum waiting times will distort clinical priorities. The earmarking of funds, which have to be dealt with on their individual merits, is a separate argument. The Bill may be so badly drafted that it would be impossible to amend it without covering earmarking, and the Government might want to think about that.

Mr. Heald: Does the hon. Gentleman agree that there is a role for incentivising individuals or even primary care trusts? What is wrong about it is the Secretary of State's control at a micro-level, with small clusters of GPs' practices throughout the country being run from Whitehall. Does the hon. Gentleman agree that it is micro-management that is so dreadful?

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Prepared 29 November 2001