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One point that was emphasised throughout the Health Committee inquiry was that PCTs commissioning functions could be strengthened considerably by trusts working with local professionals and engaging with local clinicians.
Clearly, the involvement of general practitioners in practice- based commissioning is essential, and other consultants in a range of specialist areas must not be overlooked.
Clearly, the balance between the provision and the commissioning functions of PCTs needs to be readdressed with a view to whether the divestment of services from the former could lead to the strengthening of the latter. To what extent will those improvements be brought about by the large-scale structural reforms aimed at recentering commissioning skills in the larger PCTs, and by spending £250 million less a year on that function? I would be interested to hear the Ministers response to that. The Government maintain that PCTs commissioning functions will be strengthened, but they have not outlined how that will be achieved at the same time as giving better value for taxpayers.
In his letter to SHAs on 28 July 2005, Sir Nigel Crisp said that PCTs should perform as providers only as a last resort. However, if they are not to act as providers, it should be made clear who will be responsible for that function. For example, will it be GP practices, private providers or secondary providers? As the NHS Confederation argued, divestment of provision should take place only where it offers demonstrable patient benefit and service improvements and therefore should not apply to all services. The Health Committee report asserts that the question whether PCTs should divest themselves of their provider functions is a debate separate from its inquiry, but concerns were raised throughout the evidence sessions about the fragmentation of services if divestment were to take place on a wide scale. I hope that the Government stick to their response to the report:
PCTs are no longer required to stop providing services directly. Instead from 2007 they are required to review the services they commission (including service they provide themselves) to ensure they are delivering value for money, quality and equity.
The concluding recommendation of the Health Committee report was that the Government should allow PCTs to develop organically, sharing best practice and collaborating on their own initiative with other trusts on commissioning and service provision. That recommendation has not been heeded.
Unfortunately, this debate on changes to PCTs comes a little too late to be useful as the decision to reconfigure the organisations has been made and plans have been put in place for the transition. However, having contributed to the 1999 Health Bill that created PCTs and to the report on changes to them now, I know that the underlying message from health professionals then and now is that continual structural change is damaging to service provision and should not be undertaken lightly.
Charlotte Atkins (Staffordshire, Moorlands) (Lab):
The Health Committee report on changes to primary care trusts was extremely timely. It was published on 15 December 2005, a day after the start of a formal consultation. We were thus able to alert Ministers to how badly the pre-consultation phase had gone. The evidence that we took suggested that it was insufficient
and flawed and that the time scale was too short. That was compounded by its inopportune timing at the beginning of the summer holidays.
The Health Committee told Ministers that the consultation had been a top-down process. I feared the worstthat local needs would be overruled after a sham consultation. We called for the rest of the consultation process to be made much more transparent and to offer local people a genuine choice about how local health services could most effectively be restructured.
In my constituency, the Shropshire and Staffordshire strategic health authority was determined to force through its plan for a huge, remote primary care trust, which would gobble up six other PCTs for the whole of Staffordshire. The SHA colluded with Staffordshire county council to ignore the wishes of local people, including a 300-strong public meeting at Leek in my constituency, where a unanimous vote was taken in favour of a more local primary care trust.
I am glad to say that Ministers forced the strategic health authority to consult on a local PCT that would combine just two PCTsthe option that local people really wanted. When the SHA completely ignored the overwhelming local support of clinicians, the voluntary sector, patients and councils for that local option, Ministers again overruled them. Their undemocratic and perverse decision was completely rejected.
That happened not just in Staffordshire but all over the country. When the Minister of State, my hon. Friend the Member for Leigh (Andy Burnham), gave his statement on reconfiguration to the House on 16 May I was surprised to hear so many hon. Members from both sides of the House thank him. He was of course a new Minister but was speaking on behalf of the Secretary of State, who was unavoidably absent. Nearly every hon. Member who spoke congratulated Ministers on listening and acting on what local people had said.
Mr. Stephen O'Brien: The hon. Lady makes an important point. However the ministerial team as it then was dealt with representations that came from all quarters; we had exactly the same problem in Cheshire. What does she think drove the local SHA, and often the county representatives, in a certain direction? Was it to do with envisaging their role or their purpose as an SHA? That had not previously been articulated properly or decided in advance of the reconfiguration proposals. Or was it because of anxiety about the continuation of various jobs and roles that people wanted to preserve?
Charlotte Atkins: As the hon. Gentleman hints, I think that it was complete self-interest. I do not think that it was a matter of reconfiguration only with respect to health matters. It was looking forward to a local government review, which was behind it.
The public consultation, which appeared to be a sham, was transformed into a far more transparent process. I am particularly grateful to Lord Warner, but some credit must also be given to the external panel. When I met him, he said that he viewed the external panel as a good, diverse body that represented a number of stakeholders in the NHS. The panel used its NHS experience to recognise that the approach that local stakeholders and local consultations brought to Ministers was right.
Steve Webb: Does not the hon. Lady think that the process is a nonsense and a farce? The people of Staffordshire must go to Whitehall and beg and borrow and try to get what they want. Some of them do, others do not. Is not the decision for the people of Staffordshire?
Charlotte Atkins: It is, to some extent. In fact, we had the same debate; some people in south Staffordshire wanted Cannock Chase primary care trust to stand on its own. There must be independent decision making; however it is up to the people of Staffordshire to ensure that points are put forward.
I hope that we can build on the new, more transparent process. We must ensure that the appointment of the new chairs and chief executives is seen to be fair and based on independent professional assessment of candidates abilities. All too often in the national health service, it appears that people who are displaced through reorganisation, of whom there have been too many, are slotted into new jobs even when they are not very competent. It is like musical chairs without taking away the chairs.
I want able candidates filling the new jobs. It is crucial, because they will be vital to leading desperately needed NHS reform. The hon. Member for Broxbourne (Mr. Walker) made the point that Ministers must ensure that the appointed people deliver on ministerial decisions, as indicated to local communities, about reconfiguration. Rumours are already circulating, possibly based on the hon. Gentlemans experience, that some people are working to undermine those political decisions by, for instance, forcing new PCTs to share a chief executive or management board. I hope that Ministers are alert to such manoeuvres and that they stamp on them. I hope also that the Minister assures me today that no such back-door mergers will take place.
I am delighted that Staffordshire Moorlands primary care trust in my constituency is already working with Newcastle-under-Lyme primary care trust, with which it will merge, to get things up and running in time for 1 October. They are moving to set up a joint professional executive committee and to fill the gaps that were inevitably and sadly left by staff moving from primary care trusts because of uncertainty over their future roles. Such collaboration, combined with the efforts of the University hospital of North Staffordshire chief executive, Antony Sumara, to mend the previously dysfunctional relationship between the hospital and the PCTs, augurs well for the future.
However, we still need to get the PCTs commissioning function working effectively. In north Staffordshire, the new Stoke-on-Trent and North
Staffordshire primary care trusts must work together more effectively, perhaps on a north Staffordshire commissioning board, to hold the acute sector to account. It is vital that PCTs are not left to sink or swim, and that best practice is shared more widely, through either a central change agency, as the Committee recommended, or a more pro-active role for strategic health authorities. Where necessary, specific support should be provided to the poorest-performing PCTs to get their commissioning role right.
The Committee identified another neglected area: the changes to PCTs vital public health function. It was concerned that there was no consultation with public health professionals prior to the publication of Commissioning a Patient-Led NHS. That is particularly worrying, as public health can be seen as an easy target when finance is tight. That was reinforced by a 2005 survey by the Faculty of Public Health that showed that there were 17 per cent. fewer public health consultants in 2005 than in 2003. It would be fine if those posts were replaced by public health posts in the community. However, having said that, 36 per cent. of PCTs in England believe that they do not have the capacity to deliver their public health programme effectively.
With a new configuration of PCTs and a local engagement of clinicians with the voluntary sector and local authorities, there is a real opportunity for primary care sectors to address public health matters across artificial geographical boundaries by focusing on the problems and finding the best way of delivering public health programmes.
In my own area, it would make sense for that public health remit to stretch right across north Staffordshire and bring directors of public health, consultants and particularly, community health professionals to all work together. However, with PCT deficits, there is a risk that public health will be a casualty of cost-savings.
What are the Government doing to ensure that public health is kept at the forefront of local health priorities? The PCT reconfiguration has been immensely time consuming, distracting and a morale-sapping experience. PCTs have been put in limbo. Now that decisions have been made, it is vital that we focus on best practice and develop the potential of our PCTs working in local partnership.
My Staffordshire PCT has been leading the way. For instance, they have been working with Sure Start, the programme for early-years youngsters. It helps to sustain a project called Special Matters, a unique combination of local parents in a relatively rural area with special needs children. It meets to help steer health professionals to provide a quality and comprehensive service for all those families, not just the ones covered by Sure Start. They all have children with special needs. The project has recently won a national childcare champion award. It is unique and it is parent-led and its activities are targeted towards the whole family. It is fantastic.
However, they are doing other fantastic work using community matrons to manage patients who are at risk of emergency admission. They have reduced the emergency admissions massively. They have introduced
a highly acclaimed falls programme that ensures that those people who are at risk of falls are managed in such a way as to prevent falls and to make sure that they are not admitted to hospital again.
Staffordshire Moorlands PCT has the joint highest uptake of first and second measles, mumps and rubella doses by the childs fifth birthday. It has also set up Physio Direct so that if you have back, neck, joint or muscular problems, you can use a dedicated phone line to contact a qualified physiotherapist straight away for advice or treatment. You do not have to go through a GP.
Mr. Stephen O'Brien: The hon. Lady has been generous in giving way to me for a second time. I congratulate her on a genuinely fine speech. In an important way, she has laid bare the fallacy of seeking to arrange those services from the centre on a geographic basisfor the convenience of Whitehallrather than sectorally focused on local need and demand.
I remember our debates when no one has stood up for her local ambulance service, which was among the first responders. She has just been doing the same thing. I want to put it on record that the example of Staffordshireand her part of Staffordshiredemonstrates how silly it is to approach those on a rather crude geographic basis rather than on a needs and demand basis.
Charlotte Atkins: I agree absolutely with that. That is why it is important that the Government must always listen to local stakeholders, whoever they might be. It is vital, particularly in relation to the Staffordshire ambulance service, which was a fantastic local victory. It will continue to serve me and my family and the whole of Staffordshire rather well. That PCTs work is extremely valuable, and we must ensure that it is not put at risk by lack of staff or inadequate staff training.
The Health Committee received evidence this morning that the primary care work force is somewhat neglected as far as training is concerned. One of our witnesses said that primary care workers desperately need proper career pathways and ring-fenced money to train staff. If we want to expand primary care, we must do so with well-trained and well-prepared staff. That is vital if we are to achieve Government objectives of shifting the balance of health care from the acute sector to the primary sector. I hope that the Minister will give me some assurance today that the Governments priorities for moving care into the community and the primary care sector will be backed up by financial support for staff training and the development of proper career structures.
Mr. Peter Bone (Wellingborough) (Con): It is a great honour to follow the hon. Member for Staffordshire, Moorlands (Charlotte Atkins), who made an excellent and powerful speech. I shall come to the issue of local accountability, which was also raised by the hon. Member for Dartford (Dr. Stoate) when he suggested directly elected PCT members, which seemed to have a lot of merit.
One of the problems that I have had as a new Member of Parliament is getting NHS matters sorted out. I complain to the Minister, who writes me a very nice letter saying that it is the PCTs responsibility, but when I write to the PCT, it tells me that it is the Governments fault, because the PCT is underfunded. The Chairman of the Health Committee mentioned the issue in his powerful opening remarks about independent providers.
My PCT, Northamptonshire Heartlands, had a problem when on 30 November the Prime Minister stood up and announced suddenly that nobody would have to wait more than six months for an NHS operation. The problem was that my hospital could not possibly meet that target, so the PCT had to provide for the independent sector to reduce the numbers on a very short contract. That worked, but the knock-on effect was that the PCT ran out of money this year, which meant ward closures and cutbacks everywhere. Local accountability in the mergers worries me greatly.
The Government are right to try to get the best combination for health care. The only question to be answered is: does this improve health care for patients in my area? In Northamptonshire, we have a slight problem. We were bolted on to the bottom of the East Midlands strategic health authoritya huge, not really geographical area. We are part of the worst funded SHA in the country, and we are at the bottom geographically, so we lose out.
But at least we had a PCT that covered my part of the county. There were three PCTs in Northamptonshire, which divides neatly into two. When the Government considered police forces, they decided that Northamptonshire should have two basic command units. When they considered local development, they decided that it should have two development agencies, given that we are required to build 167,000 new homes during the next few years. It seems strange that we have one PCT for the whole county when everything else has been done on a natural north-and-south basis. That failure in local accountability is at the heart of our problems in Northamptonshire.
As a new Member, I was drawn into a lot of meetings about the proposed PCT mergers. There were lots of cross-party meetings with Labour and Conservative Members. I went to my local hospital, managers came up here and we had lots of briefings. It suddenly dawned on me that it must be costing an absolute fortune, not only because of the actual cost of the meetings but because of the time taken from the PCT managers, who should have been focusing their resources on health care in my area. It then struck me that we have had ongoing problems in Rushton, where there are three local NHS health care units on three sites, when they should have been brought together on one site. For more than five years, efforts have been made to sort that out but, of course, it went by the by. No one wanted to talk about it, only about what would happen when the PCTs merged. My fear is that, when we have one PCT, the Rushton project will disappear for another five years. It will not be of interest to anyone.
In the run-up to the election, one of the matters that I campaigned on and which came out top through our local listening to Wellingborough and Rushton surveys
was the need for a local community hospital. The Government have said rightly that they are in favour of community hospitals. Both my acute hospitals are outside the constituency, so people must travel for half an hour or more to reach them. I have just been successful in getting Heartlands PCT to recognise that that would be a good idea when it is about to be abolished. I now have to go through the whole process again, without local accountability. To a certain extent, I regard matters as change for the sake of change in a quick period. I believe that change should have been made over a period on the basis of what was best for each area. Clearly, we should not have had three PCTs in Northamptonshire, but two. However, there seemed to be an overall plan in the east midlands, at least, that there would be county-wide PCTs. Perhaps the Government had that design in mind before they went into the project.
Many hon. Members have protested, as a result of which their area was altered. Unfortunately, perhaps the new hon. Members who represent parts of Northamptonshirethere was more than onedid not have the clout that some previous hon. Members had or did not know how to get the decision changed. If we are to have a proper consultation, it should not require people afterwards with the biggest stick or the most influence to change things. I know that the Government thought that what they were doing was in the interests of the NHS, but I consider that they failed in Northamptonshire.
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