Localism - Communities and Local Government Committee Contents


Examination of Witnesses (Question Numbers 446 - 480)

PAUL BURSTOW MP

14 FEBRUARY 2011

Q446   Chair: Thank you very much, Minister, for coming to see us this afternoon for the final evidence session on the issue of localism. Perhaps for our records you can introduce yourself.

Paul Burstow: I am Paul Burstow. I am Minister of State at the Department of Health with responsibility for social care and a variety of other policy as well.

Q447   Chair: One of the issues that we have addressed in this inquiry, and indeed in the last Parliament in another inquiry, is the extent to which other Government departments are really signed up to a localist agenda, or whether it is just CLG saying it and other departments perhaps pretending to do so in the background, but not really engaged with it. When you joined up your major policies in the Health and Social Care Bill, to what extent did the Minister for Decentralisation, who is to come and see us later, have any real influence over your proposals, or was it a question of developing them, showing them to him and ticking them off as being okay?

Paul Burstow: As we worked through the proposals and drafted the White Paper, there was certainly extensive consultation at both ministerial and official level on that between CLG and the Department of Health. Given that the proposals represent a significant change in the nature of the relationship between local government and the NHS, CLG had a particular interest in making sure we framed that in a way that was not prescriptive but allowed local government to develop that new opportunity and relationship as they saw fit.

Q448   Chair: Can you tell me one way in which involvement from CLG in the localist agenda changed what you intended to do to what you are now going to do?

Paul Burstow: I think one of the ways in which it changed between White Paper and Command Paper in particular is that in the framing of the White Paper we identified the role of scrutiny as sitting within the proposed statutory health and wellbeing boards. That generated feedback both externally but also, as the proposal at that point was understood, concern from colleagues in CLG. That led us to make the change we made in the Command Paper and the Bill, which means we maintain a separation between the scrutiny role over health for local government and the responsibilities in terms of health and wellbeing boards.

Q449   Chair: Can we possibly be let into any ministerial secrets about changes that were made before the Command Paper, before we had an external influence?

Paul Burstow: I do not think there are any secrets in so far as it was a collaborative process. Eric Pickles and Greg Clark were engaged in that with us at ministerial level during the preparation of the White Paper and obviously during the cross-Government clearance as well.

Q450   Chair: Is that different from that which might normally be expected with simply cross-Government committees looking at issues? Is there a particular role that the Minister for Decentralisation now plays to oversee this?

Paul Burstow: I think there is. One of the things about which we were made very clear when proceeding was the view that CLG rightly had on behalf of local government about not imposing new burdens on local government. That was certainly something of which we were mindful, and they made sure we were very mindful of, as we went through. I think in that sense it was a productive relationship, which led to a clear White Paper and has further informed the policy going forward.

Q451   Bob Blackman: One of the concerns within local government for quite some time is the lack of democratic oversight of the health service. The health and wellbeing board that is to be set up under the Bill only allows for one elected councillor to be a member of it. Did you consider other options to make it much more democratic and accountable to the public?

Paul Burstow: First, it is not a question of only allowing one. What we have set out in the Command Paper and now in the Bill is the de minimis requirement in terms of membership—those who must be members—and we have made clear that there must be at least one elected member appointed by either the leader or mayor of that authority, or indeed those persons themselves, along with a variety of other key actors in the commissioning of health, social care and public health. Some of the early implementer health and wellbeing boards are exploring a variety of options to increase the numbers of elected members involved, so that is perfectly possible. The aim is to make sure that they are led by elected members and are firmly embedded as part of the role of local authorities.

Q452   Bob Blackman: Therefore, is guidance going out from the department in that respect to suggest that the provision that you must have one and no others is not the be-all and end-all, but that expanding that membership might be an option that authorities might pursue?

Paul Burstow: Working with colleagues in local government, LGA, the Local Government Group and others, we already have a number of early implementer authorities that are trialling these ideas. There are 25 at the moment and more are considering taking part. That is forming a learning network. They are all developing proposals and we will make sure that is shared, but the Department of Health will not come up with a preconceived shape and notion of how health and wellbeing boards will and must operate in every locality. That must be something that local authorities shape for themselves.

Q453   Bob Blackman: How do you envisage this working where there is a directly elected mayor?

Paul Burstow: In those circumstances the mayor could, for example, choose to serve in his capacity on the health and wellbeing board for himself, but equally he could choose to appoint someone else to act as his representative in that particular forum. Obviously, the role of an executive elected mayor is somewhat different from the role in an authority where that is not the structure, but we provide for that in the Bill so that it is possible to work.

Q454   Bob Blackman: One other concern that is also expressed is that health and wellbeing boards may go the way of police authorities and will be largely unaccountable and uninteresting to members of the general public. How will you make sure those boards exercise a proper democratic oversight of the health service?

Paul Burstow: In my nine months already as a Health Minister I do not think there is any occasion on which health policy is a source of disinterest to the public, so there will always be that engagement and interest in it. What a health and wellbeing board does is move into a democratic and open forum those very discussions, not just about health policy and priorities but also how they interrelate with social care and public health. I think it creates some new opportunities for the way in which these services can be better planned together, integrated and thus have influence over the commissioning of those services.

Q455   Bob Blackman: How do you see it influencing GP commissioning and also adult social care commissioning?

Paul Burstow: GP commissioning consortia will be required to be members of these boards, as will commissioners of public health and social care. One thing we are trying to achieve—we believe this is the best way to do it—is a change of culture at local level. In the past we have had health flexibilities around partnership arrangements, pooled budgets and so on that have largely gone unused, so it is not just about structure but the behaviours behind it. These structures are intended to try to create a new climate in which the NHS and local authorities effectively pool their sovereignty, working together to deliver better services for their population.

Q456   Heidi Alexander: As a follow-up to Bob's question about the way this would work with directly elected mayors, would your department consider giving a broader remit in health services to directly elected mayors, as opposed to leaders of local authorities?

Paul Burstow: I am not entirely certain I understand the question. A broader remit in what regard?

Q457   Heidi Alexander: Just in relation to health services generally.

Paul Burstow: Oh, I see. I think that at this stage we are not looking to give a broader remit, if you like. Obviously, in London there is an interesting additional dimension that we are working through with both London boroughs and the Mayor for London so there is an opportunity for the Mayor to be able fully to discharge his responsibilities for health improvement alongside the new responsibilities that will come to local authorities in that regard. But at the moment we certainly do not look to exercising differential treatment between authorities that choose to have elected mayors as compared with those who do not.

Q458   Mark Pawsey: One of the key issues in this inquiry is the variation in the level of local services as different communities decide what is right for them in the spirit of localism. What is your view with regard to health? Do you expect more or less variation to develop between different communities as local authorities play a bigger part in the delivery of health services?

Paul Burstow: I think the real test here has to be: does the service actually fit the postcode; in other words, are you delivering services that meet the needs of the people who live in an area, or are you just providing a one-size-fits-all solution? What we are very clear about is that we see a much more enlarged role and significance in joint strategic needs assessments as the way in which health and local government together can assess the needs of their population both to meet their social care and health needs and to drive the wider health agenda in terms of public health. For the first time in the Bill that is going through Parliament at the moment we place statutory requirements on GP commissioning consortia and local authorities to have regard to joint strategic needs assessments. At the moment they are produced in a document of variable quality. Lip-service can be paid to them and there is no obligation to take them into account.

Q459   Mark Pawsey: You drew attention to the postcode lottery. That is an issue that just about every witness has come to sooner or later. There is greater concern, is there not, about postcode lotteries in health than there is about other matters? I think most Members of Parliament are aware that people compare what is available in one community as opposed to another. Is that a matter of concern? At what stage do you as the Minister start to intervene if there is too great a variation?

Paul Burstow: The curious thing is that in a system that is largely command and control we have significant variations between one part of the country and another in terms of the results being achieved and the inputs to the system. We are determined to make sure that the way in which the system is driven is very much anchored on the basis of clinical evidence. NICE will be providing clinical standards that will describe what "good" looks like in a whole range of service and disease areas. That will inform the commissioning activity of the consortia; they will have to take that into account in the work they are doing, and because they will be led by population need, there will be differences between one part of the country and another but those differences will be necessitated by the needs of that local population.

Q460   Mark Pawsey: How about where you have differences in the level of provision between adjacent authorities? Where people are looking over the boundary and seeing what is going on immediately next door, does that bother the department?

Paul Burstow: It requires us to make sure that there is much more transparency and information available so that people can make comparisons to establish whether the difference is a justifiable one based on population need or it is the product of decisions made by commissioners that are not evidenced in that way. Therefore, it is very important that as part of the reforms we are taking forward there is much more transparency and comparability available so people can benchmark and challenge in that way.

Q461   Simon Danczuk: I have a supplementary question about the difference between good and excellent services in different local authority areas. My question is whether you think GPs will be able to cope with the unpopularity and wrath of the public in terms of local decision making. Many of us in the room who have been local government elected members know what that is like. Do you think GPs are ready to feel the wrath of the public in regard to some of the difficult decisions they will decide to make?

Paul Burstow: GPs are certainly keen to take on these responsibilities. At the moment we have about half the population of England covered by pathfinder consortia that over the next two years will develop the skills capabilities and also share in learning, so that process is going on. There is no doubt that in terms of major service reconfigurations, especially when we are trying to deliver what I think many of us would agree would be a better model of healthcare where more is delivered closer to home, that will result in challenging decisions at local level. You are right that elected members of local authorities are only too used to doing that and are very good at it in terms of accounting to their public, explaining those difficulties and taking the consequences of difficult decisions sometimes. I think we will have local government through its health and wellbeing responsibilities bringing that expertise very usefully to the NHS and taking local decisions about how service is provided in the future.

Q462   George Hollingbery: I was intrigued by your use just now of the term "justifiable difference". Mr Pawsey asked you about postcode lottery. I think "postcode difference" is slightly more descriptive. You talked about whether the difference between postcodes was justifiable and so on and so forth. Who is making that judgment about justification? Is it you, the Minister, the ministry or the health and wellbeing board? There are all kinds of tensions here about split accountability. We have the face locally, which is the health and wellbeing board, and you with national policies. Where does accountability sit? What judgments will you, as Minister, not be taking that have characterised previous Ministers in your seat?

Paul Burstow: The Secretary of State's accountability—I think it will be much clearer than it is at present—will be to Parliament just as it is now. The Secretary of State, subject to consultation, will provide a mandate for the NHS that sets the strategic priorities and direction for service improvement. That will be informed by an outcomes framework, the first of which we published just recently, which covers areas of health improvement: areas of mortality more amenable to health intervention; patient experience; long-term conditions; avoidable harm and so on. Each of those is very much oriented towards: how do we get the best possible result out of the system? Therefore, the Secretary of State will set that and it will provide the commissioning board with its set of priorities going forward, if you like, which it then interprets into the commissioning rules and guidance that it gives to consortia. Therefore, there is accountability there.

But perhaps I may answer the question in this way: we are bringing forward a fundamental change with these proposals. That fundamental change is in two parts. First, at the moment we have a system that is top down, command and control, in the way it is organised. We are removing that command and control system and creating much greater autonomy and, in the legislation, considerable clarity about what each organisation in the NHS has to do in future, and its responsibilities thereto. Secondly, we are inverting the current arrangements where managers are primarily in control of the system to one where they are led by clinicians and their clinical decisions, and those are the commissioning consortia. Therefore, in each part of the system there will be clear accountabilities, and also there will be clear accountability by the Secretary of State for the spending of taxpayer's money and accounting for the delivery of a service that continually improves outcomes for patients.

Q463   George Hollingbery: I am still slightly confused. I am not sure I understand how you can have justifiable differences being assessed by somebody, presumably you or your department, and yet local accountability to a board and the GP commissioners.

Paul Burstow: That was the bit I did not answer. At a local level, health and wellbeing boards will be responsible for leading on joint strategic needs assessments. These are looking at population need in terms of health outcomes, social care needs and so on. They will be looking at the demographics and health inequalities of their population, and that will be used as the key document informing the development of joint health and wellbeing strategies, and those strategies will then be used by GP commissioners to inform their commissioning activity. They will have to demonstrate how they have taken those into account to shape the services they are providing and in turn also social services commissioners as well. Therefore, it is justifiable in the sense it is down to each local authority through its health and wellbeing board to account for its JSNA and then each commissioner to account for the service.

Q464   George Hollingbery: But the health and wellbeing board does not control 80% of the health budget; that is being controlled by the GP commissioners, so do they have teeth? Can they make the GP commissioners do it a certain way; and, if so, do they not need to have a majority of local councillors on there so people are properly accountable locally?

Paul Burstow: No. Sometimes the parallel is drawn with the adversarial system that we are used to here, whereas what we are trying to construct is a collaborative, consensual arrangement where health has influence over the shaping of commissioning of social care and public health, and local government has influence over the shaping and commissioning of the NHS. If you like, for the first time local government will not be just a commentator on commissioning activities of health; it will also be an actor, actively shaping those decisions by commissioning consortia.

Q465   George Hollingbery: If a board and GP commissioners argue about how to solve a certain issue, will you as Minister reach down, sort it out and shake them up?

Paul Burstow: No, but the NHS commissioning board, if there was a commissioning consortia in this test-to-destruction scenario, would have certain powers to address that. The GP NHS commissioning board authorises GP commissioning consortia in the first instance and there are reporting mechanisms and accountabilities there as well.

George Hollingbery: That is very useful.

Q466   Chair: To pursue the point in another way, you talked about the influence between the health and wellbeing board and GP commissioners, the involvement of the Secretary of State, the splitting of responsibility on public health, and local professionals and one or two elected members talking to and influencing each other, but in terms of the public and local population—we are talking of localism—it is very difficult, is it not, to see how they would be able to influence any of this process and understand it?

Paul Burstow: Thank you for that because it allows me to say something about HealthWatch and the duties that will apply both to the consortia and to the NHS commissioning board on public and patient involvement and participation in decision making on commissioning and their other functions. First, let me say something about HealthWatch. At a local level HealthWatch is intended to build upon the experience of the work of LINks that have been running for some time, but we are supplementing that with a national body called HealthWatch England, which will provide them with additional support to develop their capacity. HealthWatch England and HealthWatch locally will have the ability to be members of the health and wellbeing boards and they will be engaged with their consortia in the commissioning functions that consortia take forward. They will be involved in joint strategic needs assessments. Therefore, in many ways they are the bodies that look out to the public and have responsibility to provide the opportunities for the public to help shape these services. They will have that voice at the table where these matters are discussed. Therefore, I think that is a very clear way, which does not happen with LINks, in which that body will have a chance to shape what is going on.

Q467   Chair: From the point of view of some people, you might just be confusing the situation even further. Most people may or may not know their local councillor; the chance of their knowing their local member of HealthWatch is probably slightly more remote.

Paul Burstow: That is certainly a criticism that can be levelled at the moment against LINks in some communities, but I do recall two or three iterations ago of public and patient involvement when we had community health councils. In many towns community health councils were popular and well regarded as the entity that was there to champion the voice of patients. That is why we are keen not to replicate but certainly learn lessons from that structure.

Chair: As an ex-member of a community health council, I pass on to James.

Q468   James Morris: One of the most valuable pieces of work done by the previous Government was on Total Place, which shone a light on the amount of public funding that went into local areas. This Government has translated that into community budgets and initial pilots. I think that when the Minister was here he talked about the potential for that to be rolled out into other areas. What contribution is your department intending to make in making community budgets successful?

Paul Burstow: A number of officials in the department are acting as champions in some localities where we are currently piloting community budgets, so their role is very much to act as barrier busters in central Government to make sure that those budgets are—

Q469   James Morris: On that point, do you think there is some institutional resistance within the Department of Health to the concept of developing community-based budgeting?

Paul Burstow: No.

Q470   James Morris: We have heard in evidence that one of the barriers is to do with the fact that there are variable performance regimes across different departments and concerns about protecting funding and fiefdoms within departments to prevent it from happening. Do you see those barriers?

Paul Burstow: No. If community budgets do anything over time, the one thing they will do is cast into sharper relief those kinds of issues and allow us to address them in a more systematic way. The Department of Health is fully engaged with this because we see them as very much part of how we drive an agenda of greater integration and collaboration across public services, which is key to delivering the public health agenda.

Q471   James Morris: Sorry to cut across your answer, but what particular integrated services do you see as the next wave of community-based solutions?

Paul Burstow: Let me start with one area where perhaps there is scope for greater collaboration across health and social care and other aspects of public service. A couple of weeks ago we published our strategy for mental health and identified the need for much earlier interventions to provide support in adolescence that can have a significant impact later on in terms of the burden of mental health in our society. It is very clear that if one is to deliver the appropriate interventions one needs partnership working across not just local public services but also engagement with a number of national public services to be able to put in place the right packages of support for families and individuals in those circumstances. Therefore, that for me would be an area where we could make quite significant inroads.

Q472   David Heyes: You have described your vision of public health—I noted your words—as being "led by elected members and embedded in the work of local authorities". You talked about public health work being based on a local assessment of strategic needs. Why then, exceptionally from other local authority resources, will the public health budget be ring-fenced?

Paul Burstow: This will be the repatriation of public health to local government after an absence of 40 years or so, so this is a new set of responsibilities to the current generation and arrangements of local government. We have taken the view that in order to give local government the confidence that Government is in earnest in transferring this responsibility they should have access to a ring-fenced budget as they take up these new responsibilities.

Q473   David Heyes: It is very nicely presented but to other more cynical people, perhaps me, that would perhaps suggest you just don't trust local government on this.

Paul Burstow: As someone who comes from a local government background and has spent many years regretting the fact that local government was not given a good deal of latitude and freedom to be innovative at local level, that certainly is not the motivation behind the policy. It is to make sure that there is a dedicated resource to deliver some quite important change and enable local authorities to take on their new responsibilities.

Q474   David Heyes: It is a poor start for local authorities in being able to get on and meet what they perceive to be their local strategic needs. It sits alongside other centralising tendencies. Decisions about hiring and firing of directors of public health are to be retained by the Secretary of State. There will need to be consultation with the Secretary of State about those kinds of decisions and about employing what will be local government employees. All of it really indicates a determination to retain central control and not trust local authorities with this important new role.

Paul Burstow: No, no. The joint appointment of directors of public health is to deal with the fact that the Secretary of State will retain accountability for health protection and therefore in extremis needs that line of control to deal with public health emergencies. That is why there is that accountability and a dual appointment. But the responsibility for health improvement sits solely with local authorities and the responsibility for discharging that function through local authorities through directors of public health. Therefore, these two responsibilities as far as we are concerned are very clearly separated. Obviously, as we go through the Public Bill Committee process that will be tested further. On the point about funding, I think the message we have received and understood from colleagues in local government is that they appreciate the certainty of knowing that this resource will be protected to allow them to do the necessary work to start up these new services.

Q475   David Heyes: When can they expect to know whether that resource will be adequate for their new responsibilities and, for example, how the resource will be split between the local authorities and the new quango, HealthWatch England, that is being established?

Paul Burstow: It is not a quango; it will be part of the Department of Health. There will not be a separate legal entity called HealthWatch England; it will be part of the department of state function and will advise the Secretary of State. As to the timetable, we are working at the moment to disaggregate the information from what is currently spent within the NHS budget. We indicated an estimate of £4 billion when we published the White Paper on public health last year, but there is more work to be done and more dialogue and conversation to be had with colleagues in local government before we come to final decisions.

Q476   Stephen Gilbert: Minister, in terms of localism did you give any consideration to allowing local areas to choose whether they wanted to retain the primary care trusts?

Paul Burstow: No, we did not. We took the view that a degree of certainty was needed about the architecture of the new system and that it would be consistently applied with clear accountabilities from one locality to another. What we have not done is prescribe in minute detail the precise way in which these consortia will conduct themselves. Therefore, it will be perfectly possible for consortia to have a very wide membership in their governance arrangements if they see fit.

Q477   Stephen Gilbert: You talked earlier about the cultural change that would be needed to enable councillors and local authorities better to drive the health agenda in their locality. We have had evidence from the Local Government Information Unit that to date at the best of times it has been very difficult to get that relationship between GPs and councillors. How do you see that evolving, and what will be the principal drivers of the change? How will the cultural change, which you mentioned was necessary, take place?

Paul Burstow: It is on a number of levels. Let me just describe it in the context of the legislation and a number of other actions that the department has taken over the past few months: in terms of the legislation, through changes in the remit of NICE we have extended it to social care; through specific duties on the NHS commissioning board to promote the use of the flexibilities around lead commissioning, pooled budgets and so on; and through the requirement that joint strategic needs assessments and joint health and wellbeing strategies are actually documents that have weight in the system and have to be taken notice of and acted upon in commissioning. That signalled a significant number of changes in the system to drive health and local government much closer together.

But also in announcements we have made through the NHS operating framework we have placed requirements on the NHS to agree with their local government partners in areas where previously the NHS was solely responsible for making decisions, for example in terms of carers' breaks, respite and budgets. They now have to agree with their local government partners on how much and how it will be paid out. For example, from 1 April next £648 million will be allocated from NHS PCTs to local authorities to support social care. That itself is engendering a new set of dialogues between those colleagues.

Going forward, GP commissioning consortia will also be distributing that resource to local authorities, so we are trying to do a number of things from the centre to engender what ultimately will have to be down to behaviours and collaborative working at local level. The early implementers and the pathfinder consortia are also ways in which we are experimenting with that to make sure best practice is widely disseminated.

Q478   Bob Blackman: Given everything you have said, why did you not just take the decision to do away with PCTs, merge them into local authorities and let local authorities sort out adult social care and health at local level for the benefit of everyone who lives in that area?

Paul Burstow: The reason we did not do that is that one of the key criticisms levelled at the NHS by successive Select Committees on Health and clinicians has been that clinical engagement in commissioning activity has been patchy and poor in many places and that the way in which we could make a significant change in quality and outcomes was to invert the system so one had clinicians on top supported by managers, not managers on top supported by clinicians. That is fundamentally the change in structure that we are bringing forward.

Q479   Bob Blackman: But, surely, the alternative approach would be local people voting for their local councillors who would then have control over how the money was spent and where the services were provided.

Paul Burstow: It is an alternative and it is one that this Government is not pursuing. I am sure that it is one that would be the subject of an interesting debate for the future.

Q480   James Morris: If I may ask a philosophical question about localism, do you think it will ever be possible for a Secretary of State not to intervene at local level when there is a serious service failure and say, "Actually, it's not to do with me; that's to do with the structures that we have in place"? A lot of the evidence we have had about localism is that culture resistance in the public is one of the barriers to making localism happen. Do you believe it will ever be possible to get to that point?

Paul Burstow: First, I think it is inevitably the case that any honourable Member of this House representing his or her constituents will expect to have the opportunity to raise that matter in a variety of ways here and for Ministers to account at the Dispatch Box. There is nothing we are doing in the reforms that will remove the right of an elected Member here to be able to pursue his or her constituents' interests in the House. Secondly, as long as you have a unitary state, inevitably there will be those kinds of tensions and dichotomies in the system, but as far as I am aware at the moment that is not on the table for debate.

Chair: Minister, thank you very much indeed.


 
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