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14 May 2009 : Column 308WH—continued

We should bear it in mind that the report was published fairly recently.

The Government response was a little weak and a little defensive about commissioning. It acknowledged that the Government were aware of the problem in 2007, but then went on at great length about world-class commissioning. That part of the response is the most disappointing; it is a fine exercise in NHS management speak and makes much of vision, competencies, assurance and status. I do not doubt the Government’s good intentions on commissioning, but the Minister must accept—particularly when he looks at the review of how PCTs were doing on world-class commissioning—that commissioning is patchy.

Services are often commissioned by people who know little about them. I recall speaking to local commissioners about dentistry. They were new in the job and knew little, at the time, about dentistry. They did not even know how many units of dental activity a dentist could get through. They said, “We are going to commission so many thousand units of dental activity,” and when I asked them how many dentists that meant, they sat scratching their heads for a while. If people with so little understanding of what they are doing are commissioning services, we are clearly not going to commission services of any class—let alone world class. There is also a danger that some of the newer, more innovative services that people are trying to develop will not be commissioned.


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I want to talk about quality and patient-reported outcome measures. I hope that the Minister will update us on that. The four areas that have been outlined were supposed to have been initiated by April. Niall Dixon, of the King’s Fund, described the implementation timetable as “very challenging”. How far has implementation gone, and what is the sample size? Can we have more information about how the data will be used? The Government response gave as much information as was available at the time, but things will have moved on since then. It would also be helpful, as has been mentioned, if the Minister would outline costs. Lord Darzi estimated £6.50 per person, but other witnesses who came before the Committee gave estimates ranging from £2.50 to £10. It would be useful to have a clear idea of the likely reality.

Another aspect of the NSR report—to do with choice, personalisation and access—was also well-intentioned, but it is unclear how it will pan out. In the interim report it was announced that 100 additional GP surgeries would be developed in under-doctored areas. No one could argue that that was a bad thing. I certainly would not; I might ask why there were to be only 100. More controversial, as has been said, was the new GP-led health centre in every PCT—a one-size-fits-all solution. According to my reading, that was supposed to be a matter of improving access, tackling inequalities and fostering team working; so it might be useful to see whether it has worked out. There is a slightly schizoid tension in Government between the top-down imposition of a centre in each PCT and the mantra that enables responsibility to be abdicated: “Ah, but each PCT will decide where it will go locally.” Well, they did not actually want them locally; and there are some PCTs with huge problems—some of the spearhead PCTs—that could probably have done with a couple more of them. There seems to be no overall planning of the matter; it is neither fish nor fowl. If the Government are serious about tackling inequalities it would be better to concentrate more on the under-doctored areas, because the Committee’s report on inequalities highlighted many problems in those areas.

The desire for access and greater team working was not as well thought through as it might have been. I am not sure whether the consequences were thought through. Very little thought was given to the impact of a polyclinic on the local health economy. If existing doctors and pharmacies were to go out of business, would not the public have less choice? Their only choice would be the new GP-led health centre, which might not be as close for people who had to walk or rely on public transport. A significant proportion of the people affected might be disadvantaged.

There are legitimate concerns, but the campaign that the British Medical Association led on the matter was—I am not allowed to say this about hon. Members, but I think I may about the BMA—dishonest, disingenuous and nothing short of disgraceful.

The Minister of State, Department of Health (Mr. Ben Bradshaw): What a shame that the hon. Lady did not say that at the time.

Sandra Gidley: I think I did, actually. I was vociferous with my local doctors. Every hon. Member was contacted by the GPs in their area who were up in arms about
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what they all called polyclinics; they did not seem to know what they were—there is great confusion about polyclinics and GP-led health centres. I went to some surgeries in the south of Hampshire, and said, “I think the clinic is going to be in Basingstoke. No one from the locality is going to go there.” There is a good reason for putting it in Basingstoke, because a lot of housing is planned there. A frenzy was whipped up, with no real thought about whether it was realistic. GPs must be careful before they cry wolf, because there will come a time when we do not believe them. This is such a case. I give credit to the surgery in my locality that did not join in the feeding frenzy, taking the attitude: “We know there is no risk to us; we think we are a good surgery and our patients will not want to go to Basingstoke.” There is nothing wrong with Basingstoke, but it is a long journey from Romsey. That campaign by the BMA was unhelpful.

As to team working, I concede that there are advantages in a variety of health practitioners working together in one location, but that is another approach that ignores the wider health economy. There will be a feeling that there is no mechanism to enable people outside the loop, who could work with the GP health centre and build up links, to do that. The way to get health professionals working together is to start when they are at university. Many schools of nursing at universities are trying, with varying degrees of success, to do that. Students regard aspects of such courses as tokenistic. I took part in a BMA-organised debate in Southampton, which was well attended by medical students. It was good to see that they were interested and engaged enough to come out on a Thursday night. They were quite scathing about the joint working. It was not that they already had an arrogant attitude towards working with other partners. They just felt that it had not been well thought through. When the Committee was in New Zealand we made a visit to someone—I think it was a doctor—who had tried such an approach. I think that a little more thought had gone into what he did. He had not mixed everyone together at the beginning of their training, but had put doctors at the beginning of their training with nurses and pharmacists who had been training for longer, and set exercises that meant that the student doctors had actively to engage with those pharmacists and nurses, and appreciate their expertise. Such approaches should be considered more closely.

The other concern about polyclinics and GP-led health centres is that they are being introduced with no pilots or evaluation. I have never quite understood why some initiatives are introduced with pilot after pilot—and when it is clear that they are doing quite well there is another pilot, so that it takes years to introduce them—whereas other, untried, initiatives are introduced wholesale. It would be helpful if the Minister clarified how the Government decide what will be piloted and what will appear everywhere. The Committee’s report raised concerns that

Obviously, in the current financial climate, we cannot afford to do that.

The Government response in paragraphs 77 to 79 was a little disappointing. Those paragraphs only defended the Government’s position. There was no mention of a review. The Government did not even say, “Well, we’re
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not going to do one, so tough.” It would therefore be helpful if the Minister elaborated on whether there will be any evaluation and, if early health centres are shown not to work, what will be done.

I shall briefly mention personal health budgets. Despite what I have said about piloting, I think that it is absolutely right to pilot those. I have been a great fan of individual budgets in social care, but they are not for everyone. Some people would rather have the responsibility taken off them. For those who like individual budgets, they are brilliant and they have made a huge difference to people’s lives. Hampshire has been at the forefront of piloting them. However, the lessons from social care cannot necessarily be transferred wholesale to health care, for a number of reasons. People live with a range of long-term conditions. We do not all neatly fit into a box, so it is not easy to decide what the budget should be. If someone has three or four conditions, are there economies of scale; can some of them be managed together? Is it the case that someone’s situation is more complex and they need more funding? Also, the budgets could be a back-door route to rationing if there was not careful monitoring.

Despite my criticism of the BMA, I think it only fair to say that it is asking sensible questions about the budgets. What happens if the budget runs out? Who is responsible? Who will have access and how will they have access? Will they be able to access the budget for the next year, in advance? If they spend less, what will happen to the money? Will the patient get a pat on the back and be able to keep it, or will they have to return it to the NHS pot? How will all that be administered? The BMA also raises the point that I have raised. How will the calculations be made? Will there be a consistent methodology between PCTs? We have all seen the differences in the commissioning of various services by PCTs. How can we price health? Not everything can be easily put into a one-size-fits-all tariff. There are realistic and genuine concerns in that regard.

I shall finish with a few words about the NHS constitution. No one could argue with the general idea, but it does seem a bit motherhood and apple pie. It is all very well having a nice document and handbook, but if we are trying to improve the patient experience, we really need to be concentrating even more on clinical leadership, which has been mentioned. Just producing the book will do no good at all if it is not linked with clearly defined ways of inculcating that leadership and ensuring that the thinking behind the constitution, which is well meant, is part of everyday thinking. Otherwise, sadly, we will be sitting here in debates in years to come and the hon. Member for Wyre Forest or his successor will be reading out letters similar to those that he read out today. We would all wish to avoid that.

The nature of these debates is that we often comment on the difficult parts, but I want to end my remarks by saying that, on the whole, the next stage review was a very good thing and I wish all those who have the task of implementing it the best of success. Janet Anderson (in the Chair): As no other hon. Members had previously indicated a wish to speak, I moved on to the winding-up speeches by calling the hon. Member for Romsey (Sandra Gidley) in her capacity as spokesperson for the Liberal Democrats. However, I think that her dual role—she is also a member of the Health
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Committee—has caused some confusion, and the hon. Member for Lewisham, West (Jim Dowd) has now indicated a wish to speak. Therefore, exceptionally, I call Mr. Jim Dowd.

3.34 pm

Jim Dowd (Lewisham, West) (Lab): Your generosity and understanding are legendary, Mrs. Anderson, and I apologise to hon. Members—I was misled. The hon. Member for Wyre Forest (Dr. Taylor) is not only the health spokesman for his party, but the leader of his party. He is with us today, as is the hon. Member for Romsey (Sandra Gidley). I thought that you were just calling members of the Committee and, in my naturally deferential way, I deferred to them before attempting to speak. I will be brief, even though we are not short of time.

To go off on a slight tangent, we have had a next stage review in Lewisham, south-east London, recently. It was principally about the future of acute hospital services. The independent reconfiguration panel reported just last week, and there are difficult choices for some of the hospitals in what was called outer south-east London, although as a native south-east Londoner, I had never heard of such a place before.

Queen Mary’s hospital, Sidcup; the Queen Elizabeth, Woolwich; and the Princess Royal hospital at Farnborough in Kent will have difficulties, but the report was excellent news for Lewisham and for the future of University Hospital Lewisham. The critical services that it provides to my constituents and people across a much larger area have been secured, and I thank the Department and everyone involved for reaching such a conclusion.

Lewisham hospital can now engineer an ever closer collaboration with what will become, I think, the largest academic health sciences centre in the country. It will involve King’s College hospital, King’s college itself, Guy’s and St. Thomas’s hospitals, and the South London and Maudsley NHS Foundation Trust. University Hospital Lewisham looks forward to an increasingly beneficial partnership with them.

As ever, it was a pleasure to serve on the Health Committee and to be part of the preparation of the report. I want to highlight the one area that I mentioned in my intervention on my right hon. Friend the Member for Rother Valley (Mr. Barron). I am referring to the concerns about GP-led health centres, or polyclinics.

I want to echo much of what the hon. Member for Romsey said about the issue. I have to say initially that I notice that the Government response states:

The previous, Conservative Government lost the battle over calling the community charge the community charge, because the rest of the world called it the poll tax, and the current Government are in a similar position over GP-led health centres and polyclinics. The whole world out there believes them to be polyclinics—not that they necessarily understand what a polyclinic is, but even on the title, the Government have lost ground.

I received a delegation at my advice surgery in Forest Hill last Saturday from the Lewisham pensioners forum. It is always a pleasure to meet and discuss issues with them. I think that at the outset of the meeting they did
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not realise that we were discussing this issue today, but they came with a copy of the Select Committee report to say how much they supported it, particularly the less than ringing endorsement that the Committee has given. Perhaps that overstates it, but certainly we have serious reservations about why the Government are proceeding as they are on GP-led health centres. I am referring to the instruction that every PCT has to have one.

The fact that there has to be a private sector bidder is, in particular, causing considerable disquiet among not only the Lewisham pensioners forum, but people far more widely. The fear is that the centres will undermine local GP services and that if they are proved not to work—to have failed, in the absence any evaluation—they might so seriously undermine current provision of GP services that people will have no alternative other than to suffer a degradation in services.

I would contrast that with the Government’s approach on personal budgets, which the hon. Member for Romsey described. There, they are happily, and in my view wisely, proceeding with great caution, because although personal budgets do not necessarily worry people, they are not quite sure what the term means. It may well mean caps on personal budgets, as there are on all other budgets, but what will that mean for the provision of health care needed by the individual?

I believe that the Government are being wisely cautious in preparing for the introduction of personal budgets, if they go ahead, yet that stands in stark contrast to their approach on GP-led health centres—that everyone must have one, and that every PCT should provide one. The Government response suggests that it is up to the PCT to decide what mix of services should be provided. Paragraph 79 states:

That is fair enough, but taking it back one step, it is not up to the PCT to decide whether to have one at all. The Committee found that something of a contradiction, one that at least needs clarification.

The proposals may be beneficial. The PCT in Lewisham is looking to provide a GP-led health centre at the Waldron health centre in New Cross, which is in the constituency next door to mine—that of the Under-Secretary of State for Energy and Climate Change, my hon. Friend the Member for Lewisham, Deptford (Joan Ruddock). There has been little or no enthusiasm for it from the practice already based there and no demand for it from patients in Lewisham; the pressure is coming entirely from the centre, from the Department of Health. The danger is that something will be foisted upon us that we may not need.

I am genuinely optimistic about the programme, but the Government need to show more direction, more clarity and, in particular, more flexibility in introducing it. There is one element that we should never underestimate. The Government have an excellent record with the NHS over the past 12 years, and particularly the last eight. We have made huge, tangible and sustainable progress. I am a great supporter of what the Government have done, but on this matter they need to tread more cautiously and more carefully.


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My right hon. Friend the Member for Rother Valley mentioned the campaign mounted by the British Medical Association. Incidentally, my GP was leading the campaign locally. I have been trying for the past month to get an appointment with him for a medication review; I must say, in all modesty, that he found it a damned sight easier to get hold of me than I found it to get hold of him.

When giving evidence to the Committee, Dr. Hamish Meldrum, chairman of the BMA council, disowned the activities of the GP in the constituency of my right hon. Friend. My right hon. Friend was too modest to mention it, but Dr. Meldrum went on to say that the BMA does not support one-size-fits-all health provision, to which my right hon. Friend rightly pointed out that the BMA supports one-size-fits-all political campaigning when it suits.

Mr. Bradshaw: Is my hon. Friend aware that Dr. Meldrum was successful in his bid to run one of the centres?

Jim Dowd: Of course—if you can’t beat ’em, join ’em!

The Government need to demonstrate more openness and flexibility. The one crucial element to the changes engineered in the health service was taking the public with us. Public confidence can be established, but I am pretty certain that there is none at the moment.

3.43 pm

Mark Simmonds (Boston and Skegness) (Con): May I say how pleased I am to see you in the Chair, Mrs. Anderson?

I congratulate the right hon. Member for Rother Valley (Mr. Barron) and his Committee on putting together a thorough, pithy and succinct report. It clearly sets out the issues raised by the next stage review. I thank him for his comprehensive and detailed introduction to the key points in the report.

The right hon. Gentleman was correct to highlight the concerns of the primary sector. I would go further; it was not only the primary sector and GPs that did not feel that they were involved in the process, but the nursing profession. It would be helpful if the Minister said how many of the 2,000 consulted were GPs and nurses. The right hon. Gentleman also mentioned costs. The primary care sector was supposed to have set out the costs in detail by spring 2009. Will the Minister say how many PCTs met that time scale, and what he and the Department are doing to chase those that have not and to ensure that they do so shortly?

Another issue mentioned by the right hon. Member for Rother Valley and the hon. Members for Lewisham, West (Jim Dowd) and for Romsey (Sandra Gidley) was one that I had intended to refer to without being prompted—the question of pilots. The Minister will not be surprised to hear that I shall return to the subject of polyclinics and GP-led health centres. However, when the right hon. Gentleman was talking about the significance of pilots, I noticed that the Minister was nodding vigorously. If pilots are right in some cases, why were they not right for rolling out GP-led health centres? They were introduced without adequate criteria or clinical evidence and so on. I may go into that in more detail later.


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