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14 May 2009 : Column 320WH—continued
A very strong and robust complaints system is now in place; and it is really important that people use it. We need to change the culture in which the patient feels that
they are a passive recipient of health care and that the doctor, manager or bureaucrat knows best. Everyone in this country needs to get into a mindset where they behave more like a consumer—after all, they are paying for the service, and they need to demand their rights to ensure that the care that they are getting is good. If it is not up to scratch, they should make a heck of a noise.
Another recommendation in the NSR was for a new quality board, which met for the first time at the end of March. It brings together all those with an interest in improving quality across the NHS and will align and agree the NHS’s quality goals, while respecting the independent status of participating organisations. However, we will never attain the high levels of quality that the public demand without strong leadership, which was a point also raised in the Health Select Committee’s report. The National Leadership Council, under the chairmanship of the chief executive of the NHS, David Nicholson, was launched in April and will champion the transformation of leadership across the NHS. It will not only deal with senior management, but develop leaders at all levels of the system—from chief executives to porters. It is about developing and supporting leadership potential wherever it exists.
GP-led health centres were mentioned not only in the Select Committee’s report, but by all hon. Members here today. I hope that we all agree that people want better access to their GP and health care that is more personalised and convenient. According to our annual surveys, the single biggest cause of dissatisfaction among the public is their inability to see a GP at a time and place convenient to them. That was the basis of the programme that we announced. We are investing an additional £250 million every year specifically to improve access to primary care. Every PCT should develop a new GP-led health centre, open from 8am until 8pm, seven days a week, 365 days a year, offering both booked appointments and a walk-in service for any member of the public, who could remain registered with their own GP, but still use this new service.
We will also address the point about under-doctored areas by establishing 112 new GP practices in those areas. Such practices will provide greater access to a wider range of services and offer more choices for patients as to where and when they can see a GP or other health care professional. Moreover, they will help to address inequalities in health care in those areas.
The Select Committee took us to task for our insistence that everyone in England, wherever they live, should have access to one of the new seven-days-a-week, 12-hours-a-day health centres. It argued, and a number of other hon. Members have argued again today, that we should have left it up to PCTs to decide whether or not to have one. The problem that I have with that is that some PCTs are not universally good at standing up to pressure. I am talking here about the pressure that can be exerted by local GPs, who can be an effective and powerful lobby group. As hon. Members have reminded us, there was a massive and—as some hon. Members have belatedly acknowledged—highly misleading campaign against the new centres. I suspect that if we had left the decision up to the PCTs, they would have buckled under the pressure, and said, “This is too much grief.” That would have meant that people in their area would not have been able to enjoy the new service that was available in neighbouring areas.
I am sorry, but I do not believe that there is anywhere in England where people would not appreciate the ability to visit a GP in the evenings, at the weekends or to drop in on spec. I invite the Health Committee to visit some GP-led health centres that are already open and see how incredibly popular they are. In fact, I detect a rewriting of history going on. I remember seeing a Conservative website that encouraged people to support the BMA campaign and sign the petition. The Liberal Democrats were equally critical of the programme of new health centres. However, once the BMA stopped its campaign, so did the Opposition. I have opened a number of centres and I have not been subjected to angry demonstrations, either by local GPs or by local Conservative and Liberal Democrat politicians. On the contrary, I have had local politicians of all political parties coming along to celebrate them and how popular they are.
Sandra Gidley: I admire the Minister’s robust defence, but could he explain how, in a county as large as Hampshire where it can take three hours to travel from one end to the other, sticking one centre in the middle helps the vast majority of the population? It does not. One of the side effects—I do not know whether the two are related—is that the local walk-in centres have now reduced their hours, which is reducing availability. If access is so important, will the Government consider the reduced hours of walk-in centres?
Mr. Bradshaw: The hon. Lady seems to be suggesting that we should force PCTs to open even more GP-led health centres in areas as big as Hampshire. A number of PCTs have, off their own bat, introduced more than one centre. However, we felt that it was reasonable for the public, in whichever PCT area they live, to have at least one such centre. On the one hand we are criticised for doing that, yet on the other, we seem to be criticised for leaving it up to Hampshire PCT to decide where it should go. It may not have been our choice to place it in Basingstoke. Oxfordshire decided to put its centre in Banbury. I had a robust conversation with Oxfordshire PCT in which I said, “Wouldn’t Oxford be better because you have people who commute to Oxford, and a big student population?” We know that access to primary care by students can sometimes be very difficult—incidentally, the centres are incredibly popular with students for that very reason. Therefore, I do not accept the argument.
The parallel development over the last year has been a massive expansion in extended opening hours for GPs. I am not sure how many surgeries in Hampshire are offering such a service, but it is probably around the 80 per cent. mark. Again, that is a result of the Government deliberately ensuring that surgeries open either in the evenings or at the weekends. If any of the hon. Lady’s constituents find it inconvenient to go to Basingstoke, they should be enjoying the benefits of extended hours in GP surgeries.
Mr. Barron:
I was interested to hear what my hon. Friend the Minister said about MPs turning up to the opening of new centres. Presumably they are there to be photographed. Perhaps they could get on a website that has as high a profile as the campaign did. I agree with what my hon. Friend said about local health communities and local GPs lobbying PCTs, but does he not think
that if we had had some good criteria as to why the centres had to be put in areas, such as disease burdens or lack of access, it would have helped? I take what he said about doing other things as well. Rotherham has a new centre and a new GP practice, which is very good. However, if the Government and the professional representative bodies had agreed on a good set of criteria, it would have been a lot easier to put the centres where they should have been, as opposed just to saying, “You shall have one.”
Mr. Bradshaw: To a certain extent, I agree with my right hon. Friend. He is right to highlight the fact that many parts of the country, because they have been either spearhead or under-doctored areas, have received not just a new GP-led health centre, but one, two, three or even four new GP surgeries. The criteria for that have been based on the level of deprivation, disease and the ratio of GPs per head of population. The criteria and the driver for the new GP-led health centres was a real feeling on the part of the Government and the public—it was borne out not just by the annual GP surveys but by MORI and the deliberative events that we did in the context of the next stage review that having tackled waiting times and some of those really big quality and capacity challenges that the NHS used to face in the past what the public most wanted was the ability to see a GP at a time that was more convenient to them.
We had a twin-track approach. Part of that was getting as many GPs as possible to open in the evenings and at weekends, which we have done through the extended hours programme. We had a bit of an argy-bargy with the BMA over that, but in the end it agreed to sign up. I think there is only one PCT in the whole country—it may be in Worcestershire, but do not quote me because I may be wrong—that is not up to 50 per cent. of GP surgeries offering extended hours. The average now is 75 per cent. For those people who live in an area in which they do not have 100 per cent. of GPs offering evening and weekend openings but who want to stay with their own GP, why should they not have the ability to visit a GP in the evenings and at weekends as well? Similarly, a lot of people who commute face difficulties. Hon. Members will be aware from their postbags that a lot of people say, “Why can I not register with a GP where I work rather than where I live?” Of course there is a problem with that because of practice boundaries and the cost of double registration and so on. The new GP-led health centres will provide a useful service for those people who may commute to the nearest local town, be it Banbury, Oxford or wherever, and will be able to visit a GP-led health centre there as well as one at home if that is more convenient.
Jim Dowd: There is a good story to be told about GP-led health centres. I have seen, as I am sure other hon. Members have, that where they have been established, the increase in availability of other GPs has acted almost as a competitive spur. Part of the problem is that the evaluation of the five original centres in London has not even been designed yet. The Government are being a bit tardy. They should insist on an early evaluation, which will then go out to convince all those with reservations that the centres will be an adjunct and an improvement and not a deterioration in services. Will my hon. Friend say why the Government insist on the presence of a private sector bidder because it is causing considerable disquiet?
Mr. Bradshaw: The simple answer to that is we are not. All we insist on is an open and fair procurement process. I invite my hon. Friend, or the Select Committee as a whole, to do a follow-up report. One of the BMA scares was that the centres were the start of the privatisation of the health service, the end of primary care and family doctors. In fact, only a small minority of the contracts are going to the private or independent sector. The vast majority are going to local GPs, local GP consortiums and local GP co-operatives, and those decisions are quite rightly being made by the PCTs on the ground.
Let me deal with my hon. Friend’s other point. There has been a bit of confusion between the new GP-led health centres in every PCT—one in each—and the extra investment going into the more deprived areas to increase the overall capacity in primary care, which has been universally welcomed. There has been particular confusion in London, and outside London, because of this word “polyclinic”. The BMA campaign deliberately tried to conflate the polyclinic model with GP-led health centres. Many people call them Darzi centres. I am sure that my noble friend will leave a significant legacy, but if he does not, there will still be Darzi centres up and down the country.
London is different because it already had a programme to develop a series of polyclinics that was agreed by the London health economy. Those polyclinics are much bigger than the GP-led health centres in other parts of the country and bring in far more GPs and other services. Perhaps my hon. Friend the Member for Lewisham, West (Jim Dowd) is referring to such a polyclinic, rather than to the national programme under which there will be a new GP-led health centre in every PCT area. Confusion over the terminology has sown confusion about the programme up and down the country. People say that they do not want a huge polyclinic, but they are fine about it when they see the kind of little GP-led health centre that they are used to.
Mark Simmonds: I cannot let the Minister rewrite history. The Government backed away from the word polyclinic because of the noise that was created. They changed the terminology to GP-led health centres for those outside London. As the Minister will recall, the reason that so few GP surgeries opened in the evenings, early in the mornings and at weekends was that the Government were outmanoeuvred when negotiating the 2004 GP contracts. The enforcement of extended hours merely replaced what had been taken away in 2004.
Mr. Bradshaw: I do not want to engage in argy-bargy over this. He might not do it now, but I invite the hon. Gentleman to change his party’s official policy of allowing GPs to decide their own opening hours. That would be a massive step backwards. We have achieved a lot in the last 18 months to improve access to primary care. We do not want to go backwards.
Before I leave the issue of London, if he has studied the GP patient survey, my hon. Friend the Member for Lewisham, West will be aware that Lewisham has one of the highest levels in the country of dissatisfaction over access to primary care services. The average level was 18 per cent., but in Lewisham it was 23 per cent. Nearly a quarter of his constituents are not happy. The
survey was carried out before the introduction of the programme of extended hours and GP-led health centres so I hope that the figure will improve next year.
The NSR marks a dramatic development in the relationship between the centre, PCTs and local service providers. It is a move away from the central direction that was needed to successfully tackle historical issues such as waiting lists, to an empowering of local leaders and a devolution of power and decision-making to as close to the patient as possible. The Select Committee report is right to highlight how important effective commissioning is in achieving the goals of the NSR. It is for PCTs to make the decisions that are in the best interests of their patients. However, the system relies on PCTs having the necessary people and skills to use that power effectively. The Select Committee was right to highlight how many PCTs are not as strong as they could be.
The world-class commissioning programme is aimed at raising the standard of commissioning in PCTs across the country. A year in, it has helped PCTs to plot a clear path towards the high standards of commissioning that we all expect. The next two to three years will see better commissioning skills within PCTs and improvements to local health outcomes and to outcomes overall.
The Department is working with strategic health authorities to provide PCTs with a range of world-class commissioning tools, such as improved data, guidance on strategic planning and topic-specific commissioning guidance for areas such as stroke, cancer and primary care. Most PCTs now have a board development programme and each region runs commissioner training programmes. Many PCTs are also working together to improve their analytical and commercial capacity, to better commission services from a single provider or for a particular care pathway.
The hon. Member for Romsey asked how we will evaluate the role of local government. In our surveys of local government and NHS organisations that are involved in the process, 90 per cent. of respondents agreed that world-class commissioning will help them to become better commissioners of services and that it will improve the governance of their systems.
The hon. Member for Boston and Skegness spoke about practice-based commissioning. I accept that that is a vital part of world-class commissioning. As he is aware, in March we published “Clinical commissioning: our vision for practice-based commissioning”, which sets out the role of practice-based commissioning in world-class commissioning. That has been well received by the NHS and by independent commentators. The NHS Alliance commented:
“This confirmation and reinforcement should dispel any doubts about whether PBC is here to stay—it is. This must now mark the end of discussions of the role of PBC, and the start of the real action throughout the English NHS.”
Nick Goodwin, the senior fellow at the King’s Fund, stated:
“The vision outlined by the government...confirms its commitment to PBC”
“its strategic importance within the wider commissioning agenda...The guidance helpfully places PBC as a key tool for PCTs to influence and lead strategic service change through commissioning.”
Practice-based commissioning is a firm and popular foundation from which to build. A recent independent survey of almost 1,900 practices by MORI showed that 64 per cent. supported PBC, with just 16 per cent. opposing it. It showed that clinicians are becoming more involved in commissioning, with 61 per cent. of GP practices commissioning a service through PBC as of February this year, compared to 56 per cent. in the previous quarter.
The PBC development framework and a national PBC improvement team are in place to help PCTs develop practice-based commissioning. We will be holding them to account through the world-class commissioning assurance process, which will ensure that PCTs provide practices with the support and resources they need.
Hon. Members have raised the cost of the NSR, as did the Select Committee report. In our view, the NHS cannot afford not to take the recommendations forward. The national and local visions that were developed as part of the NSR process focused the NHS on prevention, constantly improving quality and innovation. That will enable the NHS to better deliver value for taxpayers’ money. I am sure we all agree that that is necessary to meet the challenges facing the health service and the economy.
Implementing the 10 regional visions of “High Quality Care for All” is now the core business of the NHS. The NHS budget for England will increase to over £100 billion by the end of the year. All the NSR proposals will be funded from within that budget. Prioritising the most effective treatments, reducing errors and waste, and keeping people healthy and independent for as long as possible all contribute to quality care, and to a more efficient and productive health service. High quality and value for money are not competing alternatives; they are often one and the same thing. That is increasingly important in an economic downturn.
There has been discussion about whether high quality always means saving money. I agree with the point the Select Committee Chairman made when he quoted Alan Maynard. He said that high quality is not always cheaper than poor quality. As the hon. Member for Wyre Forest said, although quality sometimes costs more, there are big overall savings to be made through better quality.
Savings can be made if the right treatment is given in the right setting first time round, if the length of stay is reduced by the right support being provided and if the rates of prescribing generic drugs are increased. Care can be organised to ensure it is of a high quality. Simple things can be done such as having protected meal times and freeing up staff time through the productive ward programme. Those are just a few examples of how high-quality productivity, good outcomes and less wastage of resources go together.
The hon. Member for Wyre Forest is right that prioritisation will be critical. We do not just have priorities at local level. Although there are now fewer of them, we still have national targets for waiting times. We also have the annual operating framework, which states what we believe are the top priorities that should guide the service.
Hon. Members mentioned the patient reported outcome measures. That scheme is currently limited to four elective procedures: hip and knee replacements, and groin hernia
and varicose vein surgery. There are no commitments to extend the scheme but the Department is actively exploring the potential for PROMs in other areas such as long-term conditions. Any decision to extend the scheme will be evidence-based.
The cost of implementing PROMs is expected to represent less than 0.5 per cent. of the total spend on the four elective procedures that they cover. The national scheme started in April 2009. Indications are that implementation is going well, and the scheme should be fully embedded by April next year. It will be subject to ongoing review. Incidentally, I forgot to say that GP-led health centres will also be evaluated; a number of hon. Members asked about that. The PROMs scheme will also be evaluated to test and demonstrate its value for money.
Implementation is already under way. All but a handful of providers began collecting PROMs data on schedule in April. The data can be incorporated into quality improvements, such as the commissioning for quality and innovation incentive scheme, in the same way as other quality data.
My right hon. Friend the Chairman of the Select Committee highlighted the importance of leadership in the NHS. We believe that leadership is central to fulfilling the vision of the NSR. I accept that past initiatives to improve the quality of leadership in the NHS have not always succeeded. They have often failed because they have focused on too small a group of people over too short a period. However, I believe that we are better placed than before to drive the leadership agenda forward. We have a clear 10-year plan based on the regional clinical visions and a new emphasis on quality that makes it much more attractive for clinicians to become involved in leadership.
The NSR will ensure that clinicians are fully prepared to take on senior leadership roles within the NHS. It will embed leadership in undergraduate and postgraduate degrees and development programmes at different stages of clinicians’ careers. The NSR is designed to support local health organisations in identifying, developing and recruiting the best leadership talent across their regions. The national leadership council, to which I have referred, will intervene only where it can add value. Its role is to ensure that the system supports high-quality leadership and to challenge it where it does not.
As I said, the NSR supports local health organisations in identifying, developing and recruiting the best leadership talent across their regions. At its core, the guidance is about creating a deep and diverse talent pool from which we will draw our next generation of NHS leaders. All responsibility is devolved to the NHS locally, and managers will face much greater local scrutiny.
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