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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