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29 Jun 2006 : Column 144WH—continued
Dr. Howard Stoate (Dartford) (Lab):
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.
Mr. Charles Walker (Broxbourne) (Con): I share many of the hon. Gentleman’s concerns. The Minister came to the House on 16 May and we were told with a great fanfare that we were going to get two PCTs in Hertfordshire. We were very pleased to hear that news, because that was what we had lobbied for. Three weeks later, we received a letter from the chief executive of the strategic health authority saying, “Ah, you’re getting two PCTs, but with one chief executive and one management team.” That is one PCT in all but name.
Dr. Stoate: 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.
3.27 pm
Mr. David Amess (Southend, West) (Con): 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 28 July. I simply say to the House that it was not received particularly well, whatever the reasons for it and whatever the timing of its publication. The last time that the Secretary of State for Health came and gave evidence to our Committee, she was surrounded by people who were acting in their posts. And, of course, Sir Nigel Crisp—the architect of the letter—is no longer with us.
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 the Member for Wyre Forest
(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 28 July 2005, set out the Government’s proposals to reconfigure the current 302 primary care trusts to 152 larger organisations, with—we were told—cost savings of up to £250 million. I hope that the Public Accounts Committee will report in due course on exactly how much money is saved on that little bit of nonsense. The then chief medical officer outlined how the changes would improve and strengthen the commissioning function of PCTs and divest their provider role in areas such as community health service to the non-provider NHS.
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.
Mr. Walker: 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?
Mr. Amess: 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 13 April 1999 I quoted a letter that I had received from the British Medical Association, which said:
“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 1 October to form the south-east Essex PCT, which—if my hon. Friend the Member for Broxbourne (Mr. Walker) will allow me to repeat—will be one of five PCTs that will replace the 13 that currently exist in the county. The new PCT will serve a population of 325,000.
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 27 June. However, will the Minister comment on the success of the programme nationally in reassuring NHS staff about the future of their jobs?
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.
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