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“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.
3.45 pm
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 worst—that 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 PCTs—the 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. Walker: I was one of those hon. Members. Clearly, with hindsight, I did a very stupid thing.
Charlotte Atkins: The hon. Gentleman must be responsible for his own stupidity, but I shall be coming to the point about that.
Mr. 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. Gentleman’s 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 it is 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 child’s 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 straightaway 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 basis—for the convenience of Whitehall—rather 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 on record that the example of Staffordshire—and her part of Staffordshire—demonstrates 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 PCT’s 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 Government’s 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.
4.1 pm
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 PCT’s responsibility, but when I write to the PCT, it tells me that it is the Government’s 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 authority—a 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, they 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 Northamptonshire—there was more than one—did not have the clout that some of 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.
I received an e-mail today. It said:
“I have just returned from my local dentist’s surgery after my 6-monthly checkup. I was absolutely horrified and disgusted to be told that because of the Dept of Health’s changes in the provision of NHS dentists, he would be going private in September. This means that the price for a routine checkup (assuming nothing is wrong) is increasing by almost three times. The quality of service will remain the same so the Dept of Health changes will certainly not improve patient care.”
I read that out in relation to the PCT because the two towns of Wellingborough and Rushton adjoin each other. There is no NHS provision in Wellingborough and the PCT has just managed to obtain some new NHS provision in Rushton. Unfortunately, that dental surgery is already full. Appointments cannot be made before December.
Luckily, a local dentist, Dr. Chan, had a Polish dentist available with experience of the NHS because he has been here for a while. He wanted to work in Rushton for the NHS. That would have solved not only Rushton’s problems, but those of Wellingborough. I had a chance with my partner’s PCT to argue that, in that regard, Wellingborough and Rushton were the same place. If the PCT were based in Northamptonshire, and the strategic health authority covers the whole of the east midlands, it would not even know that Wellingborough and Rushton were joined together, so there would be no chance of more NHS provision in my area.
Unfortunately, I
have just received a letter from the local Heartlands PCT to say that
no funding is available. Can the Minister explain that dilemma to me? I
complained to the Secretary of State for Health, and a meeting was
arranged with the Minister of State, Department of Health, the hon.
Member for Doncaster, Central (Ms Winterton). I complained in
November, but like many people in the NHS, I had to wait, only to have
my appointment cancelled and then cancelled again. It was only six
months later that I actually had the meeting, and the Minister argued
with some clarity that it was for the PCT to decide whether to provide
NHS dental services in my constituency, but the PCT says that the
Government will not fund those services. How, therefore, are Members of
Parliament to get somebody to do something about a situation in which
there is a Polish dentist available to work in the NHS, but there is no
NHS provision in the
constituency?
Let me now move from dentistry to what is, in many ways, a more serious issue and give just one example of the problem that we face locally. Our local hospitals are very efficient—the NHS standard is 100, and they work at 85—but our area is underfunded, even by Government standards. We are underfunded by 4.5 per cent., and it is argued that that is because other areas are overfunded. That might sound very neat, but there is a real and serious problem for the patients.
A five-year-old child in my constituency—with your permission, Miss Begg, I will not identify him—had an operation in February 2005. During the operation, three surgical procedures should have been carried out, but one was not. That has meant that that little boy has had to wait in pain for a considerable time. This month, the consultant agreed that the case should be urgent, but despite the fact the little boy is in urgent need of treatment, the consultant said that he could not be treated for five months because of the PCT’s ruling that it had no funding. The consultant opened his diary and showed all the dates when he could have done the operation, but he cannot do it, because the PCT will not allow it. When that argument is put to the PCT, it says that it is because of Government funding and targets. It has been told that everybody must have an NHS operation within six months, so urgent cases are being put back five months to allow everybody to meet the six-month target.
Such an arrangement cannot be right, and it certainly is not the way to achieve local accountability. Indeed, to conclude, the real issue with which I should like the Minister to deal is the local accountability of PCTs as they are now and as they will be in the future.
4.13 pm
Mr. Paul Truswell (Pudsey) (Lab): I am grateful for the opportunity to intrude on the debate as a non-member of the Select Committee. I appreciate that its report was a snapshot in time and I am sure that my hon. Friend the Minister will tell us just how far we have progressed since. Despite the passage of time and events, however, the report remains extremely topical and relevant to people’s experience in Leeds.
As we know, a tablet of stone
dropped from the lofty heights of Department for Health at the end of
July. It contained two commandments: “Thou shalt reduce the
number of PCTs” and “Thou shalt divest thyself of
services”. To a degree, the second commandment has been
withdrawn, although how far remains the subject of debate. In my area,
for example, the initial requirement for PCTs to divest themselves of
services
has led people to spend considerable time looking at various options,
some of which would have obvious attractions to staff who wanted to
avoid the threat of outsourcing. My fear is that some of those options
might be pursued further out of fear and uncertainty about the future
and about change, rather than primarily on the basis of what is in the
best interests of patients and services.
The proposals that were submitted for reconfiguration in Leeds need to be viewed in the light of the flawed top-down process that the Select Committee report so accurately described, irrespective of the Government’s emollient words in response. They were not carefully considered plans for the improvement and commissioning of services. They were an acquiescent response to the first of the commandments that I referred to a couple of minutes ago. That remains of major concern to us, because in Leeds we have generally found that the PCTs have been a success. They adopted commissioning approaches based on the needs of their communities. They have taken a particularly robust line with the local acute trust. They developed services to meet needs, very much in the way that my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) described in her area. Indeed, community services were transferred from the then community and mental health trust to the PCT as a means of improving them.
In my constituency, for example, the Leeds West PCT developed a whole range of services responding to local needs, including rapid response teams to prevent unnecessary admission of older people to hospital, thereby addressing a major challenge in Leeds, which is that we hospitalise too many people and keep them there for far too long. A respiratory team has been established to advance the care of patients with certain respiratory conditions. Advanced special practitioners, who are basically senior nurses, are working with patients who have had experience of multiple hospital admissions over a year and regularly require the assistance of their GP, again to address the issue of unnecessary admission.
Our profound hope is that with the reconfiguration such innovation and good practice can continue and be disseminated in a much larger PCT area. In Leeds we are talking about moving from five PCTs, the largest of which serves a population of just under 200,000, to a single PCT serving a population of more than 720,000.
Jim Dowd (Lewisham, West) (Lab): I would not expect the hon. Gentleman to know the answer in detail, but can he compare the actions being taken in his native city of Leeds and the bold way that they have gone about merging the PCTs with the absolute lack of commitment and timidity of the Government with the PCTs in London?
Mr. Truswell: My hon. Friend is absolutely correct to anticipate that I cannot answer that question, but I am sure that his intervention will have found its mark.
In fairness, my
Leeds colleagues and I were not opposed in principle to the
changes—we would not take a luddite approach—nor to the
proposal to reduce from five PCTs to one. On the basis, however, of the
sparse information placed before us in the so-called
consultation exercise, we could not support the proposal as it stood.
The picture of how the new PCT would look and function was and, I am
afraid to say, remains far too unclear. We were conscious that the
proposals were not the result of an organic process but were initiated
directly and exclusively as a result of Sir Nigel
Crisp’s letter of 28 July. Neither we nor our constituents have
had any opportunity whatsoever to consider or contribute to a tangible
model of what the new structure would like. We were not looking for
detailed nuts and bolts. That would clearly have been unrealistic,
given the timescale of the process, but we did require a clear
indication of how the key areas of activity—especially the local
focus—might continue to be achieved in Leeds. Certainly, as I
say, we were happy that the five PCTs were achieving
that.
Like the Select Committee, we appreciate that savings released from reducing administrative cost can be reinvested in patient care. We understand the frustrations of the many voluntary organisations in our city that have to deal with five separate commissioners, although there was a degree of lead authority work taking place to address some of those problems. We recognise the problems of working closely with partners such as the local authority and its relevant departments.
In our response to the SHA consultation we stressed that what we wanted to see coming out of the reconfiguration. The points are reflected in a number of the recommendations made in the Select Committee on Health report. I do not intend to take up time reiterating them, because they have been covered by a number of other hon. Members.
It goes without saying that the reconfiguration must maintain and build upon the achievements of our existing PCTs, especially in developing strong local focus and initiatives to meet the needs of our communities. We raised our concerns about whether the move from five PCTs to one could achieve that in a meeting with our right hon. Friend the Secretary of State in the autumn. As a result of our representations, we were pleased that John Bacon’s letter of 30 November to Mike Farrar, the then West Yorkshire SHA chief executive, contained the following sentence:
“Concerns have been expressed about the risk of losing a strong local focus, particularly in Leeds, and it is therefore essential that the consultation document explains how you will sustain this focus within a larger PCT.”
We were therefore hugely disappointed that the consultation document contained just a few glib sentences on that point. In subsequent discussions with Mr. Farrar, he made a number of positive assertions regarding that and other aspects of the issue that we discussed. He asked us to trust him, and we might well have done so. He is an extremely good and effective officer. Unfortunately, and inexcusably for a Yorkshireman, he has now disappeared over the Pennines to become the chief executive in the north west.
We now
have a new chief executive of the SHA and a new chair. They, of course,
have a much larger area to deal with, not only West Yorkshire but the
whole of Yorkshire and Humberside. It seems likely, without wanting to
pre-empt the process, that the new PCT chief executive will come from
outside the area. We also await the appointment of a chair. The Select
Committee’s concerns on the issues of continuity and
responsibility were, I believe, well-founded from the point of view of
our experience in Leeds.
At PCT level, it feels as though there is a centrifugal force pulling the emphasis from localities towards the centre and, at SHA level, pulling it from the west Yorkshire area to a Yorkshire and Humberside level. Whether practice-based commissioning will provide a countervailing centripetal force is totally unclear to us at the moment. There has been precious little in the consultation process, or since, to demonstrate how that would work. The Select Committee’s comments on that point remain entirely valid, from our point of view.
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