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29 Jun 2006 : Column 139WH—continued
“nor will we impose any timetable.”—[Official Report, 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.
2.57 pm
Dr. Richard Taylor (Wyre Forest) (Ind): 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:
“I can confirm that there is no duty to consult under section 11... because the SHA, PCT and Ambulance Trust reconfiguration proposals amount to managerial and administrative changes only.”
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 8 December. It said:
“Responsibility for approving PCT consultations, ensuring they reflect the conditionality set out in my 30 November letter and that equal weight is given to all options, rests with the SHA.”
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 the right hon. Member for Rother Valley
(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.
David Taylor: 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, the hon. Member for Loughborough (Mr. Reed) and the former Secretary of State for Health, the right hon. Member for Charnwood (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.
Dr. Richard Taylor: 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.”
Mr. Stephen O'Brien: 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.
Dr. Taylor: 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.
3.15 pm
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