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Baroness Masham of Ilton: The Minister has just said that it is possible that strategic health authorities will organise specialist services such as supra-regional services. The word "possible" is worrying because it
means that it is not yet organised. Therefore, the amendment of the noble Earl, Lord Howe, to delay the matter for a year may be a good idea.
Lord Hunt of Kings Heath: I will need to read Hansard. But I think that I raised the possibility of a problem with a specialist commissioning of services. If one primary care trust in a health network is not prepared to play ball with the general thrust of the agreement within a locality, the strategic health authority would have the opportunity to intervene and bang heads together.
So far as concerns specialist commissioning, we intend to continue with national specialist commissioning arrangements. The regional commissioning arrangements would be undertaken at local level. It will be a primary care trust responsibility. We would expect them to work together. They would be performance managed by strategic health authorities. I know that we shall come to a later amendment on that issue.
Earl Howe: I thank the Minister for that helpful reply. It has certainly considerably enlarged my understanding of the role of strategic health authorities.
It was good of the Minister to acknowledge that there is concern in some quarters of the health service about the speed of change. That applies in larger measure, perhaps, to the creation of primary care trusts than to strategic health authorities, although I think that it is true there also.
The Minister did not really address my point about the size of the remit that strategic health authorities will have in terms of population and why that particular size had been chosen.
Lord Hunt of Kings Heath: I apologise to the noble Earl for not responding to that question. Clearly, a number of factors must be taken into account in relation to the size of a strategic health authority boundary—for example, geography and population. There is a variation in population size between the largest and the smallest strategic health authority. But one of the most important considerations has been to try to build them as much as possible around care networks.
We recognise that, for example with cancer, for a largish population there is a requirement for an integrated service where primary, secondary and tertiary care elements all have a role to play. It is appropriate that the strategic health authority boundary, by and large, covers the kind of area required for a fully-fledged care network. That means that for a strategic health authority working for a primary care trust one could plan an integrated approach for services. Of course other factors, such as geography, population and size, also come into play.
Earl Howe: Again that was very helpful. I am particularly glad to hear that a flexible approach is being adopted in the department. That is surely right.
My noble friend Lady Noakes will have a number of other questions to ask on the subject of strategic health authorities later on. For now, I thank the Minister once again for what he has said. I beg leave to withdraw my amendment.
Amendment, by leave, withdrawn.
Lord Clement-Jones moved Amendment No. 15:
- Page 1, line 6, leave out "areas" and insert "regions"
The noble Lord said: In moving Amendment No. 15 I shall speak also to Amendments Nos. 16 to 28, 30, 32 and 33, 37 to 40, 44, 46 to 48 and 50.
I was interested to hear what the Minister had to say when speaking to the last amendment, but the key question with regard to Clause 1 still remains: why are strategic health authorities being set up that bear little or no relationship to local government boundaries or the government's own regions for other government departments?
His rather circular argument about care networks was also interesting: the strategic health authorities being set up in an area where it is possible to build a care network. I thought that that was almost a self-fulfilling prophesy: if one decides that that is an area where one can build a care network, one builds one. I do not think that I am being unduly sceptical about that particular choice of words by the Minister, but it would be helpful to have a little more rationale about precisely why 32 strategic health authorities are being chosen.
As we heard earlier in the debate, over the years there have been a massive number of changes to the structure of health services. I do not have the pedigree of the noble Earl, Lord Howe, to go right back to the 1948 era. I start only at 1974. We started with area health authorities. Then there were district health authorities. Then in the early 1990s we moved back into area health authorities. Now, we are going to have strategic health authorities which will cure all known organisational ills. The one constant—that is why I go back to 1974 rather than to an earlier period—has been the NHS region. Although there have been some changing of boundaries and consolidation, there is no doubt—this is something which is very familiar to health professionals—that we need critical mass at regional level, and in particular there is the need for specialist commissioning at regional level.
Many professionals have concluded that the Government's current legislative proposals to devolve NHS commissioning responsibility to PCTs in particular could lead to a deterioration in the national provision of specialised services. Their proposals to create a series of PCT consortiums to commission these services is seriously flawed because of their failure to guarantee that these consortiums will have a sufficient number of local PCT members to provide for viable services. That is part of the reason for the proposals by my noble friends on these Benches for a regional, as opposed to a strategic health authority, basis for re-organisation.
In January 2002, the Department of Health published its revised proposals on specialist commissioning in Shifting the Balance of Power: The Next Steps. The document sets out how PCTs are expected to commission local services, both primary and secondary. Despite being billed as the definitive expression of government policy, it does not contain any mechanism for guaranteeing that local commissioning consortiums will have a sufficiently large membership to be viable. That is another reason for regional commissioning.
The proposed system of PCT consortiums could lead to a substantial disruption in the provision of specialised services, as PCT boards decide that local relatively low cost, high volume services are a greater priority for investment than membership of consortiums with high cost, low volume treatments—precisely those specialised tertiary care areas of commissioning which are so important. That confused picture is of concern because the new system hinges on the good will of the new PCTs. The existing consortiums have had mixed success in attracting health authorities to their membership—even though LHAs have a tradition of strategic planning for specialised services. The problem is likely to be exacerbated by devolution to PCTs, which will undoubtedly have a steep learning curve.
That illustrates the problems of not having a clear regional basis for organisation. Another key benefit of regional organisation is that it would cover enough territory to take a strategic view of regional health services in general. Under the new strategic health authorities, there would be problems with coterminosity that would not exist regionally.
It is important also that public health strategy is dealt with at an appropriate level—such as regionally. In the Act that established the Greater London Authority, health promotion and public health were specifically mentioned—showing that the region is considered an appropriate level.
There will be nine regional directors of public health but they will not be bolted on to any regional structure. They will be without regional health authorities to which they can relate—though they will be better placed in terms of having an individual economic region used by other government departments than the four regional directors of health and social care, who will not bear a relationship with any natural or local government boundary.
Somewhat perversely, the Government have chosen anything but a logical and sensible boundary for the reorganisation of health services. Despite the Minister's comments, if the four regional directors are not another layer of management—the noble Lord mentioned performance management—what are they? If they do not have a function, should they exist in the first place? Either they are a layer of management, have a purpose and a set of objectives or not—in which case, they should not be there. They will each be paid a salary for an inadequate job.
Above all, it is vital to ensure proper accountability for a health strategy that ties in with a known and familiar structure. That could be secured through a regional organisation. In a strategic sense, that accountability is unlikely to be secured any other way. The current scheme of reorganisation, as with so much in the Bill, is half baked. I urge the Government to think again. I beg to move.
9 p.m.
Baroness Finlay of Llandaff: I am unclear where current statutory functions, such as the inspection of nursing homes and duties in relation to the protection children, will lie if there is no coterminosity with local authority boundaries. Who will carry responsibility where the boundaries are blurred?
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