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29 Jun 2006 : Column 171WH—continued
“the necessary investment from savings in other PCT budgets”.
Cheshire West Primary Care Trust, one of the disasters of the country, has a turnaround team. My local newspaper has reported that it now has £20 million to make up the terrible shortfall, although there was no mention of the MP who has campaigned about it. There are consultants at the trust, while the people who were meant to do the job are still employed—£20,000 a day is being spent on the consultants while the trust still has £20,000 employment costs for those who should have done the job in the first place. It is an absolute basket case. Constituents are now losing front-line patient services, such as the Parkinson’s nurse specialist, who has gone—the job was cut. That is happening with front-line services, not just with the reorganisation as the background. Nevertheless, Cheshire West would say only that it had established a team to develop strategy.
The reduction in the number of child immunisations is another example. It is due to the Government having moved responsibility out to the PCTs under the new GP contract, with cash-strapped PCTs failing to commission immunisation from GPs.
If the Government are moving toward practice-based commissioning for the commissioning side of health care, and are also seeking to divest PCTs of their provider functions, what does the Minister actually see as the future of PCTs? That question was raised a moment ago by the spokesman for the Liberal Democrats. Surely those questions should have been answered before yet another restructuring and morale-sapping reorganisation, as it was described by the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) in her fine speech.
The reorganisation does little to help close the gap between health and social care. Indeed, this restructuring comes soon after the last one, which was off the back of six others, as has been indicated. The price of raising coterminosity to 80 per cent. is that once again relationships painstakingly built up between the two sectors are rendered worthless, and professionals on both sides are forced to return to square one.
We must remember that the Health Committee report says that it will take 18 months for organisations to recover from reorganisation and a further 18 months for any benefits to emerge. That will create uncertainty when, for instance, subtracting the necessary extra investment such as for the important local improvement finance trusts, which rightly want the chance to become the real agents of change and improvement. The Committee report stated:
“There are also well-founded concerns that patient care will suffer as a direct result of the distraction caused by these reforms”.
The national infertility awareness campaign is concerned that the PCTs’ implementation of NICE guidelines on infertility will be further delayed by the restructuring—as it is, that implementation is considerably varied. I hope that the Minister will take this opportunity to give a specific commitment on that.
I dare say that other Members have received a briefing from the campaign group as well.
Mr. Barron: In relation to the hon. Gentleman’s comments, I have had deep concerns since I first raised the question with the Prime Minister in February of last year. As currently arranged, PCTs have not been delivering one third of what NICE said we should have, as far as IVF and infertility treatment is concerned.
Mr. O'Brien: I am grateful to the Chairman of the Health Committee for placing that on the record here, as he has done on the Floor of the House with no less an authority than the Prime Minister. I hope that that will urge the necessary responsiveness, let alone response, required to meet what is unquestionably, in my view, a health right, let alone need.
I shall tackle the public health issue, which I promised to come on to when I intervened on the hon. Member for Staffordshire, Moorlands. I hope that the Minister will explain why, prior to the publication of “Commissioning a Patient-led NHS”, there was no consultation with public health officials on its potential impact on PCTs’ crucial public health functions. The hon. Lady was not the only Member to mention that—I think that it was raised also by my hon. Friend the Member for Wellingborough (Mr. Bone) and others.
According to the BMA, in the next few months, more than 150 directors of public health will lose their jobs. There are now fewer than 1,000 public health doctors. Among other things, the Government have presided over an explosion in sexually transmitted diseases, a crisis of confidence in child immunisations and a failure of readiness to protect the country against pandemic flu. More generally, they have been cavalier in their planning for public health. I believe that the absence of consultation on public health throws up the Government’s ignorance when it comes to supporting closer working relationships between local authorities and health organisations.
The Government have defended the restructuring against the Health Committee’s charge that organic change would be better by denying that it is change for change’s sake. However, this meddling gives the lie to the Government’s claim that they are presiding over a decentralised NHS. Central credit, local blame appears to be the order of the day with constant micro-management from the centre. The NHS should be freed up to change organically and to trust front-line professionals to develop an effective health care system. Change should not be continually imposed from the centre.
Ministers continue to promise an efficiency saving of £250 million a year from 2008, despite the Health Committee’s assertion that it is more likely to be between £160 million and £135 million. That point was raised noticeably in the excellent contribution made by my hon. Friend the Member for Southend, West (Mr. Amess). That promise comes from Ministers who have presided over the largest deficit—two and a half times bigger than the Secretary of State’s estimate as recently as 6 December last year—since the Government came to office.
The Health Committee report deemed it essential that structures to ensure clinical engagement and, most crucially, patient and public involvement were retained at their current levels covering each natural community. Does the Minister agree? If so, why have the Government adopted what I think is a Stalinist approach to public involvement in the NHS? The Government have desperately mismanaged public and patient involvement. They split up the structures of individual patient advocacy, complaints investigation and collective patient representation. Patient and public involvement forums have been the creatures of NHS management. They have lacked independence—which is vital for trust and credibility—have had inadequate specialist staff input and have lacked any influence over the consultations on service configuration throughout the country. The Commission for Patient and Public Involvement in Health had been functioning for only six months when the Government announced its proposed abolition.
After the loss of volunteer expertise and independence with the abolition of community health councils—many will remember that I had quite a hand in the campaign and argument against abolition, and we did achieve a stay of execution for a year—patient forums have had a turnover of 62 per cent. in just three years. Too many good independent people who want to help their local NHS have been turned off by poor training, bureaucratic interference and a lack of real influence.
One reason given for abolishing CHCs was that the volunteers who staffed them were not representative of the general public. On 15 January 2002, the then Under-Secretary of State for Health who is now the Minister without Portfolio stated:
“The commission will go out into communities and hear those different voices and draw in those socially excluded groups and marginalised communities.”—[Official Report, 15 January 2002; Vol. 378, c. 226.]
I hope that this Minister is ready today, given that the issue is part of the Health Committee’s report, to tell us what evidence he can show for the CPPIH having had any success in recruiting and training people from hard-to-reach groups.
The Minister will know that the Conservatives fought tooth and nail against the abolition of CHCs, trying to protect patients and keep the Government accountable. It is important that none of us is afraid of having effective accountability structures in the NHS, and it is doubly important that patients and professionals are trusted, because the alternative—centrally micro-managing everything—is patently causing a diminution in morale and trust. The Health Committee said that the Minister’s view that practice-based commissioning would improve patient and public involvement in health care was not firmly based in any evidence. I hope that the Minister can make such evidence immediately available.
I hope that the Minister will also clarify the impact of PCT mergers on resource allocations. In some areas of the country, PCTs serving more deprived areas have merged with PCTs serving less deprived areas. That is one reason why we managed to resist Cheshire West PCT going into an organisation covering the whole of the rest of Cheshire. Apart from anything else, it would have lost its accountability for the disaster that it had
created. How will the Government ensure that, within the new structure, the more deprived areas continue to receive the funding that they need, without creating large sub-bureaucracies in the new PCTs and masking accountability? My hon. Friend the Member for Wellingborough made that point very effectively, among others, in relation to the Rushton example.
I seek an assurance from the Minister that when the Government say “Separate PCTs”, they mean separate PCTs in every case, with separate boards, chairmen, chief executives and secretariats. As he has today, my hon. Friend the Member for Broxbourne (Mr. Walker) raised that in a point of order on 14 June concerning the two new PCTs in Hertfordshire, but none of us has yet heard an answer from the Department. We hope that an answer will be forthcoming in the next few minutes.
The changes to primary care trusts are the result of a rushed, centralised and, in large part, predetermined consultation and have thrown up a vast number of concerns relating to public health, patient and public involvement, resource allocation and the very future of PCTs. The Government have done little to clarify the grey areas in their policy or to address our concerns or those of the Health Committee over the past six months.
Most tellingly, the Health Committee report recommended that a central change agency be established. Surely the agency responsible for strategic oversight of the NHS is the Department of Health. I dare say that the Committee might not have called for such an agency had it felt that the Department of Health was functioning appropriately. The Department and its Ministers have been too busy micro-managing the NHS and, I fear, chasing headlines to concentrate on a coherent policy that puts patients, the public, in each of their recognised localities, and front-line health care professionals in our NHS first.
5.4 pm
The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis): I congratulate my right hon. Friend the Member for Rother Valley (Mr. Barron) on introducing this important Adjournment debate. I also pay tribute to the work of the Select Committee. Its report was very significant in the influence that it had on the reconfiguration process, and the quality of today’s debate has, on the whole, been very high.
The starting point for considering why the reconfiguration was deemed necessary is how, in the end, we add most value to patient care. I made the point, as soon as I came into this job in the Department of Health, that everything we do is ultimately about supporting the interaction between the people providing the service on the ground and the people receiving that service—whether it be NHS or social care provision.
The Government felt that, based on the ever-changing needs of the health service and the necessary reforms that we have started to put in place, the reorganisation of PCTs was essential to further that reform agenda in a positive way that is consistent with our aspirations for excellent patient care.
I also believe that in the context of my own responsibilities it is crucial that we achieve an integration of health, social and community care in
this country in a way that we have not been able to do previously. That is particularly important in relation to joint commissioning. Therefore, the greater level of coterminosity that has been achieved as a consequence of these change is to be welcomed on the whole. That does not mean that coterminosity has been achieved in every area, but system-wide there is a greater level of coterminosity than has previously been the case.
I understand concerns expressed by those who argue that there is too much restructuring and reorganisation, but one has to look at the specific reconfiguration and make a judgment as to whether at this time, in the development of our NHS reform programme, it was the right thing to do. In time—such matters can be proved only over time—the judgment will be that, on the whole, it was the right thing to do.
I wish to spend most of my contribution responding directly to the many contributions that hon. Members have made. My right hon. Friend raised an important issue about the question of pensions for staff and reassuring staff in that area. I agree entirely that we need to give greater clarity and greater assurances and produce clear guidance for employers and staff in this respect. It is important and we will be doing that as soon as we possibly can. With regard to the question of savings, we expect—I know that there is a difference of opinion on this and that the Select Committee found a different figure from that of the Department—that there will be a recurrent annual saving of £250 million as a consequence of these changes. The important thing about that is the transferral of those resources to front-line services.
The hon. Member for Wyre Forest (Dr. Taylor), who has a tremendous amount of personal knowledge and experience in these areas, asked a number of questions that are worthy of consideration. One of the issues was about publishing the external panel’s response. A number of hon. Members raised this issue. We have published this in the Library only this week in a variety of forms: the external panel advice from Michael O’Higgins to Lord Warner; a table setting out the various decisions that had been made; and the rationale of Ministers’ decisions on PCT configuration. I suggest that the hon. Gentleman consults the Library. He may find that the information is not as complete as he wants it to be and he can come back to me on that point. But, consistent with the commitments that the Minister of State, Department of Health, my hon. Friend the Member for Leigh (Andy Burnham) made when this statement was first made in the House, that information has been placed in the Library this week.
The hon. Gentleman also raised, as did other hon. Members, the question of local focus. Of course, we have made it absolutely clear that in terms of practice-based commissioning there will inevitably be a greater level of local focus than there has been historically. We have also made it clear to each PCT that, post-reconfiguration, we expect them to take account of the different localities that form component parts of the trust. They must be sensitive to the distinct needs of those communities—the health inequalities that may exist and the differences that undoubtedly will. It will be partially about us holding those PCTs to
account in that respect, but it will also be for local hon. Members to hold PCTs to account and to make sure that those commitments are honoured.
The hon. Member for Eddisbury (Mr. O'Brien) raised the question of patient forums and patient involvement in the NHS. Hon. Members are aware that we are due to come forward with some proposals in this area. The hon. Member for Wyre Forest (Dr. Taylor) used the term “well resourced and independent”, and I hope that when we introduce those proposals we can demonstrate that they are properly resourced, with a significant element of independence to reassure hon. Members.
As for the NHS Appointments Commission, as a Minister I would sometimes wonder about its autonomy; however, it has tremendous autonomy. Parliament took that decision for good or for bad. Criteria have been applied for making appointments, and they pay particular regard to ensuring that local appointments reflect local communities. An independent appointments commission, by its very nature, guards fiercely its right to retain its independence.
My hon. Friend the Member for Dartford (Dr. Stoate), who speaks with great knowledge about these issues, raised several important points, such as localism and planning blight. He asked whether the reconfigurations cause a period of blight. We have professional people running the organisations, and most of the agenda, which has been in place for a long time, has not changed as a consequence of the reconfiguration proposals. I do not see why there should be significant planning blight as a consequence of the reorganisation, but the proof of the pudding will be in the eating.
My hon. Friend was also concerned about professional executive committees. We made it clear that we expect high-quality, high-calibre committees to be elected in every PCT area, so perhaps we can discuss at a later stage how we go about that.
My hon. Friend also raised the question about the vital role of community pharmacists in primary care. If I am honest, we have a long way to go towards creating a more central role for them. I suspect that if we looked throughout the country, we would find that there was a patchiness—the new word—in the extent to which PCTs put the role of community pharmacists at the centre of their planning and commissioning. I agree that we should think far more seriously about it.
I am not sure to which international travels my old friend, the hon. Member for Southend, West (Mr. Amess) was referring; he has a better memory than some. He referred to political shenanigans and the meaninglessness of consultation, too, and I must say to him and to other hon. Members who have made that point, that when the first letter was issued there was a case for saying that a number of things could have been done differently. I would be the first to acknowledge that. I guess I can, because I was not part of the team at the time. However, many changes were made as a consequence of listening to the Committee and to Members. They demonstrate that the Government have listened and taken seriously the views of people on the ground, who are democratically accountable and understand the needs of their communities, when health service managers and bureaucrats have not acted in accordance with local needs and preferences.
The Government can be proud of being not too proud—sometimes Governments are—to say where it was appropriate to make changes to the original proposals. I accept that not all hon. Members are satisfied, but in many cases, those changes were made. Based even on today’s debate, there is considerable evidence that those changes were not made on a party political basis, because people of all political persuasions have today been able to point to changes that were made as a consequence of their representations on behalf of their constituents. It is disingenuous of the hon. Gentleman to say that there was no listening process and that somehow there were political shenanigans. I shall leave it to my hon. Friends to determine whether they like the phrase “truly socialist Bill”. I imagine that many of my hon. Friends would be pleased if that title were attributed to a health Bill.
The hon. Gentleman is right when he says that it is very important in the context of reorganisation and restructuring that we reassure front-line staff. It is disingenuous when talking about organisational change to suggest that staff will not be anxious and insecure. They will be. Good management and good leadership are about managing that process on a local level.
Again, the word “patchiness” springs to mind. There are excellent examples of organisations that manage change and deal with the insecurities and anxieties of the people who work there. There are other examples in which the concerns of staff are not taken nearly seriously enough. That has consequences for morale and in other areas. It is about good management.
On the question of the PCT’s continued role as a service provider, we have made it clear that we expect PCTs to continue providing services but that they have the right to consider bringing into the market new providers that may be in a better position to provide those services in a more responsive and high-quality way. There will be no edict or instruction from Government to PCTs to stop providing services, but we need to focus on the best shared outcomes that we can achieve for local populations, and that might sometimes mean bringing in other providers that have not historically been involved.
I spent my entire working life before coming to this place in the voluntary sector. The voluntary sector could do things in terms of responsiveness to user and carer need that statutory services frankly could not and cannot do. It is not a new concept or phenomenon, but it must not be ideologically driven. It must be about shared outcomes and high quality and responsive services.
My hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) felt that despite some of her early frustrations the Government had listened. She also made a point about the centrality of area commissioning, which is one of my responsibilities in a sense. We have not sorted commissioning of health and social care in this country. We need an integrated approach and commissioners who are willing to get their hands dirty by getting close to users and carers as they make decisions about the nature of the services that should be commissioned.
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