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Lord Grocott: My Lords, I beg to move that the House do now adjourn during pleasure until 8.35 p.m.
Moved accordingly, and, on Question, Motion agreed to.
[The Sitting was suspended from 8.11 to 8.35 p.m.]
National Health Service Reform and Health Care Professions Bill
Clause 1 [English Health Authorities: change of name]:
Earl Howe moved Amendment No. 14:
- Page 1, line 5, leave out from beginning to "Health" and insert "From 1st April 2003,"
The noble Earl said: In moving this amendment, my principal purpose is to provide the Minister with an opportunity to flesh out in more detail than we currently have the thinking behind the far-reaching
structural changes that the Bill proposes for the NHS. In the process, however, I should like to raise some major question marks over the wisdom of these changes.The restructuring of the NHS that the Government are proposing was foreshadowed in the document Shifting the Balance of Power, published just over 18 months ago. I am the first to acknowledge the significance of these changes for the internal management of the health service. They will entail considerable upheaval for those who administer and run the service—the biggest upheaval for more than 25 years. Their ostensible purpose, if we take our cue from what Ministers have told us, is to devolve power and decision-making downwards from Whitehall, to create shorter chains of command, to introduce greater local responsiveness within the service and to cut bureaucracy. All those objectives are entirely laudable. The question we need to pose as we go through Committee is whether and to what extent the Bill will achieve them.
The Bill places a duty on the Secretary of State to create strategic health authorities for the whole of England. Our understanding is that there will be 28 SHAs, whose function will be to guide and oversee the development of local health services and to performance manage PCTs and NHS trusts under individual performance agreements. At the same time, as we know, the creation of primary care trusts is to be accelerated, and it is PCTs, not strategic health authorities, which will be made responsible for the commissioning of healthcare services. Above the SHAs will remain the regional directors, whose remit will extend over a very much wider area than that of each SHA.
The obvious point to note about this structure is that, far from reducing the tiers of authority within the NHS, it is actually increasing them. Instead of two tiers, we shall have three. Furthermore, because there are going to be a great many more PCTs than there currently are health authorities, the actual number of health service bodies is going to increase as well. I am rather worried about the implications of that structure in terms both of the numbers of managers and administrators that it will require and the associated costs of that management. The costs, of course, are not simply financial; they can also be measured in terms of the time of trained doctors and clinicians that will be taken up in performing non-clinical duties. However, given that we accept that that is a price to be paid for the PCTs, which do have much to recommend them, where does it leave strategic health authorities? We are told that each SHA will be responsible for a population of roughly 1.5 million people, equivalent to perhaps three or four existing health authorities now. What is the rationale for that size of purview?
The BMA, among others, has expressed the worry that all this structural change—which we were promised by Frank Dobson would not happen when the Government first came to office—is going through too rapidly.
There is a strong feeling that, if more time can be taken to agree the planned configuration of strategic health authorities and regions, the end result would be a good deal better. A meeting last October of senior representatives from health, local government, and business in the West Midlands concluded that the planned configuration will be too large and too diffuse to engage effectively with trusts, with PCTs and with local authorities. Why should there be 28 strategic health authorities and not 40 or 50? I suspect that there is no fully coherent answer to that. The answer depends on what SHAs are to do. It would be helpful to hear from the Minister a little more about the role that they will play and what the word "strategic" means?
One of the BMA's concerns, which I share, is that there does not appear to be anyone within the new structure tasked with safeguarding and fostering academic activity. A later amendment deals with this matter in more detail. A debate, last year, introduced by the noble Lord, Lord Walton, most recently brought home to us how vital it is for the good of the health service and for the good of the patients that recruitment and retention in academic medicine should be encouraged. No individual PCT will be capable of performing that function, nor can it be left to Richmond House. If anything is strategic in nature, clinical academic medicine certainly is. What role, if any, is envisaged for strategic health authorities in that regard?
Perhaps the Minister will tell the Committee what mechanisms are to be put in place to ensure that conflict or divergences of opinion between individual strategic health authorities can be resolved. Given that each SHA is to be tasked with brokering solutions across organisational boundaries of PCTs and must, by definition, do the best that it can for the local population that it serves, what degree of latitude can there be for a strategic health authority to compromise on what it sees as an optimum solution, merely because there are objections from the strategic health authority next door? The statutory duty for NHS bodies to co-operate does not appear to be enough in those circumstances because, under the situation that I have described, we would be dealing with two opposing and conflicting views of what is strategically best for an area.
The amendment makes a serious proposal, but it carries with it a great number of questions about the role that strategic health authorities will play in practice. I beg to move.
8.45 p.m.
Lord Hunt of Kings Heath: I am grateful to the noble Earl, Lord Howe, for introducing the debate on strategic health authorities and, more generally, on the new arrangements that we are putting in place. I need to refer back to the speech made by my right honourable friend the Secretary of State for Health, the shifting of the balance of power speech on 25th April 2001, as mentioned by the noble Earl. That set the broad intent of our direction. There is the reduction in the number of health authorities by about
two-thirds by 2002. Some 28 new health authorities are to provide a strategic overview and to take forward some of the functions, including performance management, previously fulfilled by regional offices, with much of the planning and commissioning work previously carried out by health authorities passing to primary care trusts. As we have already commented, by 2004, the intention is that they will be controlling over 75 per cent of NHS funding.There is also the disappearance of NHS regional offices, and the introduction of four directors of health and social care, who together with small groups of staff will work closely with the Government Offices for the Regions, focusing on managing health and social care through regulation, arbitration and resolution. I do not see the four directors of health and social care, alongside the small groups of staff who will work with them, as being an additional tier of management in the health service. Essentially they will be a part of headquarters, part of a central department of health, but, if you like, with a desk responsibility for one part of the country.
On that basis, I argue that we are not, as the noble Earl has suggested, continuing with three tiers. We are reducing to two tiers; the central tier being the strategic health authorities and beneath them the NHS trusts and the primary care trusts. Within that context I believe that strategic health authorities will have an important role to play. They will have responsibility for the strategic framework and the delivery of services across all NHS organisations. They are to ensure strong, coherent, professional leadership and the involvement of all professional groups. I believe that issues concerned with academic medicine in universities fit well within that remit in terms of the relationship between strategic health authorities, professional groups, universities and academic disciplines.
Importantly, strategic health authorities will be responsible for performance, managing NHS trusts and primary care trusts. They will account to the Secretary of State for performance of the NHS in their areas, so they will be the leaders of the NHS within the strategic health authority boundaries. They will deliver agreed progress on the NHS plan through performance agreements with individual trusts and primary care trusts. They will manage performance across organisational boundaries and networks to secure the best possible improvements for patients. They will intervene to broker solutions where problems arise between local NHS bodies.
I believe that that answers the point raised by the noble Earl, Lord Howe. Clearly, in decentralising two primary care trusts, we expect them to take a major leadership role. In some cases they will work on behalf of other primary care trusts. Later we shall debate the commissioning of specialist services. It is likely that within one strategic health authority area, one primary care trust will take on the lead role of commissioning specialist services.
It is possible to envisage that there may be an individual primary care trust that is not prepared to buy-in to the cost and the agreed programme for the commissioning of specialist services. In that case the strategic health authority would have a role to bang heads and ultimately to performance-manage primary care trusts to ensure that everything worked together. There may be many other examples where an individual primary care trust has taken a leadership role. The strategic health authority will be there as a backstop to intervene if matters do not go well or if there is a problem in agreeing an overall solution across the strategic health authority boundary.
There are two other important roles for strategic health authorities. First is the preparation and delivery of strategies for capital investment. The second is workforce development. It is important that the local health economy, covered by the strategic health authority, is exercised about its future workforce requirements and ensures that it plans the right numbers, commissioning the right number of training places. Information management is another area where we shall expect strategic health authorities to take a strong leadership role.
I believe that there is a clear differentiation between the kind of role envisaged for primary care trusts and NHS trusts and strategic health authorities. I have no doubt that the strategic health authority role will be invigorating. We know that we have attracted people of the highest calibre as chief executives designate to lead those strategic health authorities.
Having said that I fully accept that there are those in the service who worry about the pace of change and about the management load that will be placed on the new strategic health authorities and on primary care trusts.
We are setting a challenging programme and timetable. But if one looks at practice in the health service, one of the complaints often raised is that it takes a long time for structural change to take place; certainly much longer than in the private sector.
Once the Government have set out their strategic direction, the best possible course of action is to move as quickly as possible to the new arrangements. I am absolutely confident that the people we have appointed are ready to accept that challenge.
The noble Lord has not as yet raised the issue of primary care trust capacity. I suspect that we shall come on to that. But I repeat—although I know that the noble Earl, Lord Howe, has some concerns about this—that all my experience suggests that the health service will rise to what I believe will be a very invigorating challenge.
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