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Julia Goldsworthy (Falmouth and Camborne) (LD): I am sure that today's Conservative Opposition day debate will give some flavour of the rapid structural changes that our national health service will go through in the coming years. The restructuring of primary care trusts has followed a very hasty timetable. That timetable was announced during last July's parliamentary recess, and the initial consultation period closed on 15 October. That is neither a long time, nor a particularly appropriate time for such consultation to take place. Let us not forget that this is the third restructuring in 10 years, and that it will reduce the number of PCTs from 300 to 100 by this October.

Initially, the proposed changes were supposed to coincide with trusts shifting toward a commissioning, rather than provider, role. That led to outcry in this place, and to Adjournment debates initiated by Labour Members. There was also outcry from the 200,000 workers directly employed by PCTs, who suddenly did not know how much longer they would have a job, or who their employer would be. They did not know whether it would continue to be the PCT, or whether it would be a private sector charity or the voluntary sector. Following some rapid rowing back, the Secretary of State adopted a new position whereby PCTs would move to a commissioning role only as and when they decided to. However, the chief executive of the NHS has not formally withdrawn his reference, contained in his initial letter, to the 2008 deadline by which PCTs should move over fully to a commissioning role. I should be very grateful if the Minister clarified that contradiction.

There is still a lack of clarity as to the future function of our PCTs. However, the rationale behind the new structure seems clear: it is not a one-size-fits-all approach, but a case of "any size, so long as it's bigger". This approach constitutes a move away from the rationale employed during the previous restructuring of PCTs, which took place only three years ago, whereby greater connection was sought with local communities.
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Only an "any size, so long as it's bigger" rationale can explain why London's PCTs are expected to move from a structure that already provides coterminosity with social services to being even bigger beasts, while Cornwall looks set to have its three PCTs reduced to just one. That is indeed a move towards coterminosity, with local authorities providing social services; then again, the existing structures are under review, so the local authorities may in any event change shape. Their future remains in some doubt.

As if this dog's breakfast were not enough, ambulance trusts are also up for reconfiguration. The intention is not to improve services to the public, but to fit the "any size, so long as it's bigger" mantra by reducing the number of ambulance trusts from 31 to 11.

Ignoring the principle of not fixing things if they are not broken, it seems that even the best-performing ambulance trusts—such as the Staffordshire trust, which has a three-star rating and is the highest performing trust, according to Government targets—are likely to be merged. As the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) said in her earlier intervention, it is not the size of the trust that determines how well it performs—and is there any point in fixing something that is not broken? Surely the emphasis should be on co-operating and sharing best practice with other trusts, rather than on introducing the concept of contestability, which will put trusts in competition with one another.

If the principle is to apply to PCTs and ambulance trusts, SHAs must automatically follow suit, according to the "any size, so long as it's bigger" mantra. They must go through similar upheavals, with the changes to be completed by April 2007.

Mr. Heath: Does my hon. Friend agree, given her experience in her own area, that PCTs had a difficult task in dealing with rural areas in particular, and that some have made a superb job of it? Mendip PCT, in my area, has really got to grips with delivering primary health care in a rural area. It is a great shame if that is now to be put at risk by reorganisation—by putting the PCT into a bigger structure that simply will not have the same feel or be able to cope with the difficulties of scale associated with rural areas.

Julia Goldsworthy: I thank my hon. Friend for that contribution, and that is certainly the feedback that I am getting from my constituents. In the past, there has been a very good relationship between the local PCT and the services offered. There is real concern that a move to a bigger authority will lead to the loss of links that have been built up in the past few years, and that that will have a detrimental impact on the services provided. However, only one proposal—for a single primary care trust—has been put forward for consultation, and the argument is that it will provide a more strategic role. If that is the case, why would we continue to need a strategic health authority?

The changes do not stop at PCTs, ambulance trusts and strategic health authorities. Other significant changes will kick in this year, including payment by results, practice-based commissioning and even the new
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dental contracts, which are all closely interrelated with the changes in the structures. Sir Nigel Crisp was not kidding when he said:

That is possibly the understatement of the year.

When I talked with the chair of an NHS trust in my constituency last week, the point was made—the Minister made it again today—that this is not a time of evolution for the NHS, but a time of rapid and continual revolution. It is unclear what the NHS will look like when we reach the end of this year. A series of potentially destabilising changes will take place simultaneously in an already uncertain climate, in which a quarter of NHS trusts already have to deal with deficits. The impact of many of the changes, even if taken in isolation, is largely unknown because many have not been properly piloted. There has certainly been no piloting of the possible cumulative impact of the changes.

For example, payment by results will start in the next financial year, but concerns are already being raised about the tariff levels for some operations. In Norway, a system of payment by results was introduced at 60 per cent., not for 100 per cent. of care, and it was seen to create perverse incentives, so it was scaled back to 40 per cent. But this Government think that the best approach is to introduce 100 per cent. payment by results straight off, and damn the consequences—even if that may create even greater financial insecurity and instability for many trusts already struggling with deficits, and even if it will lead to incentives to give every headache patient a CT scan to add to their treatment. Such perverse incentives are like the small butterfly wings flapping that create a hurricane further down the line.

Another example of inadequate piloting before rolling out the changes can be seen in the new dental contract. We will not know what the impact of the new contract will be until it rolls out across the country, but I know from surveying dentists in my constituency that about 75 per cent. are thinking of leaving the NHS altogether as a result. That is another unknown factor to be added to an already unstable and high-risk situation. The changes look increasingly like ingredients for a rushed recipe for disaster.

Why the hurry and impatience from the Government? After all, they have had eight years to formulate a solution. Is it the funding time scale of increased investment in the NHS, and the looming end to increased investment in 2008, that is causing the panic? If the changes are not in place and bedded down by then, is their future success even more in doubt? Or is it the hurry to find those pesky efficiency savings demanded by the Gershon review? If so, it would explain the "any size, so long as it's bigger" rationale.

Will the savings be real, or will many of them be lost in setting up and branding the new structures? Given that many PCT mergers will have to take place in mid financial year, has the Department made any assessment of the extra costs of having to file two separate accounts, or any of the other transition costs that will result from the changes?

It is clear that it is not the wishes of the public that are driving the changes. That is evident from the amount of time given to consultation on the changes—and often from what proposals are put forward for consultation.
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As I said, in Cornwall only one proposal for a single primary care trust has been put forward for consultation, so there is no choice of options for the local people.

The Secretary of State's own consultation in Birmingham also showed that the Government's priorities for the NHS were not those of the invited public. The citizens summit in Birmingham last year showed that the public were not interested in improving contestability or even the choice agenda—especially in rural areas, where getting to the local hospital is already enough of a struggle for most people. What they were interested in was increased GP opening hours and out-of-hours provision, which the Government did away with in the most recent contract negotiations. Whatever the priorities of the public—indeed, in spite of their needs and priorities—the changes continue to be pushed apace.

The irony is that at the end of all the changes—three upheavals under this Labour Government—we will be back almost exactly where the NHS was when Labour came to power. Bigger primary care trusts will have become like the health authorities, strategic health authorities will be more like the regional authorities that Labour abolished, and GP fundholders will have become practice-based commissioners. What is even more ironic is that the Conservatives oppose the proposals that will take us back to the last days of their Government.

Greater local democratic accountability could provide better mechanisms to reflect and serve local needs and bring the accountability for underperforming trusts closer to home, rather than centralised up to the Secretary of State. Instead of pursuing and pushing forward contestability at all costs, when the regulatory framework is undeveloped and in some cases gives private providers an unfair advantage, surely trusts would be better served through greater co-operation and sharing best practice.

The Health Committee, in a recent report, described the changes that have been undertaken since Labour came to government as an

This year and future years represent a time of change and an exposure to huge risks for many NHS bodies. That in turn represents great uncertainty for NHS staff and patients alike. It is time for the Department of Health to take greater account of the needs of the public rather than the steamroller of centralised reform, which takes no account of the need for locally accountable bodies to lead locally appropriate reform and locally appropriate provision for our health services. Bigger is certainly not always or automatically better.

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