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Lord Hunt of Kings Heath: The Health Development Agency has made a good start. The particular focus of its work is in producing evidence-based research in the area of public health. That will be available for public health professions, NHS authorities, local government and other agencies at local level to inform them as to what is likely to work best in terms of public health intervention. I believe
that that agency has made a good start. We would expect it to work alongside the grain of these new arrangements.I was disappointed that the noble Baroness raised the issue of non-medics performing the role of public health specialists. I would have thought that she, of all people, would have welcomed this move—indeed the Faculty of Public Health Medicine has welcomed it—as she was passionate about nurse-prescribing and about developing the skills of non-medics in the health service. I believe that it will enrich the public health profession.
I accept the implication that the people appointed must have the highest public health skills. My understanding is that the non-medical public health specialists who are likely to be appointed would have either a Masters or a PhD in a public health discipline and would have years of experience behind them in the area of public health. In appointing a non-medic to that post a primary care trust would clearly have to take account of the kind of issues that the noble Baroness has raised. I would not cast aspersions on social scientists, as the noble Baroness did. I am convinced that this will be a way of bringing in new people and giving proper career development to people who have gone into public health but are not medically trained. However, I believe that they will receive support from many in the medical profession.
Lord Clement-Jones: Perhaps I can elicit further information from the Minister. I thank him for his initial statement that set out the broad pattern. However, it is regrettable that he has to set it out in that way, whereas on the face of the Bill it would not have been difficult to set out the strategic health authorities, primary care trusts and—
Lord Hunt of Kings Heath: Earlier I said that I would be happy to meet with noble Lords between the Committee and Report stages. If it is helpful to the Committee, I shall set out in some detail how we see the public health arrangements developing and I shall be happy to send that to the noble Lord and to other noble Lords who have spoken in this debate.
Lord Clement-Jones: That would be helpful. I was going on to ask the Minister whether, in addition to the statements made in Next Steps and what he has said today, there would be a clear statement of accountability. I believe that the accountabilities and the responsibilities at each level will be so important in determining who has the lead role on particular matters. Some will be national; some will be regional; and some will be extremely local with the involvement of the health protection agency as well. I welcome the creation of that agency, but one wants to be sure that that scoops up all the current activities in the effective way in which the PHLS has operated. So I think that that would be helpful.
One matter that the Minister did not touch on is the funding of public health networks. How will they be funded? Will it be a matter of PCTs effectively chipping in to the pot, or will there be another source of funding?
Lord Hunt of Kings Heath: I think that it will be very much a matter of PCTs pooling their budgets together. PCTs are deciding that, in some parts of the public health function, it would be better to work together with a number of other PCTs. It therefore seems eminently appropriate that that should be funded from their own budgets.
Earl Howe: This has been a helpful debate. I thank the Minister for filling in a number of the blank spaces that existed in my mind before we began this discussion. It is not so much a matter of including in the Bill anything relating to public health as of setting out for the National Health Service and those who work in it how these arrangements will work. I am aware that, until very recently, many have been ignorant of how in practice these functions are to be distributed and how accountability will work. However, the Minister has explained, in more detail than we have had to date, how in practice PCTs will take responsibility for their public health function. There has been helpful clarification of the role of public health staff at strategic health authority level and in the regions and the role of the health protection agencies.
The Minister used the word "integrated". Although I am sure that that is what the aim should be, going back to those three headings of the public health—planning, surveillance and delivery of services—I would welcome further clarification of how those functions are to be parcelled out across the tiers of the health service. Perhaps between now and Report the Minister can copy me in on whatever he distributes to Members of the Committee.
Workforce planning is a very difficult exercise in the field of public health, especially in a city such as London. I am aware that the King's Fund report which was referred to by the noble Lord, Lord Clement-Jones, will specifically focus on London. The noble Lord, Lord Turnberg, was absolutely right to draw attention to the wide range of professional expertise to be found in public health, from the very specialised expert to those working in the community. This is certainly not a matter of re-arranging in some simple way the roles and the jobs that are currently being performed. The restructuring will deeply affect the way in which public health is delivered.
I am not clear in my mind what the Chief Medical Officer's role will be in terms of the ultimate accountability for public health. I imagine that, in broad terms, that will remain as it is now. However, if there is any change in substance or in nuance, perhaps the Minister could tell me.
Lord Hunt of Kings Heath: The regional directors of public health will have a performance management responsibility in relation to the strategic health authority public health person, who in turn will performance
manage the primary care trust. The regional public health directors will be managerially accountable for their public health and health protection functions to the Chief Medical Officer as well as to the relevant director of health and social care. So the Chief Medical Officer is at the pinnacle of those levels, and I think that he or she will keep a pivotal role in ensuring that the overall arrangements work effectively.
Earl Howe: I am grateful. I rather deduced that that would be the case from the Minister's earlier remarks. We may see fit to return to this subject at a later stage, but I think that it is now time to move on. I thank all noble Lords who have taken part. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 3 [Directions: distribution of functions]:
[Amendments Nos. 44 to 51 not moved.]
Baroness Noakes moved Amendment No. 53:
- After Clause 3, insert the following new clause—
The noble Baroness said: This amendment inserts a new clause after Clause 3 and is designed to ensure that the Secretary of State does not delegate his functions to primary care trusts unless he has made arrangements for the provision of specialist services. Furthermore, the Secretary of State will be required to consult health professionals who have an interest in those specialist services before making the arrangements.
The roots of this amendment lie in concerns that have been expressed not only by many doctors, but, on Second Reading, by the noble Lords, Lord Turnberg and Lord Walton of Detchant. Those concerns centre on whether PCTs will be effective commissioners of tertiary services and other highly specialised services such as neurosurgery, renal dialysis, transplantation cardiac-thoracic services, and many more. The concerns are on several levels. The first is that the new PCTs will simply not be ready for such complex commissioning. The Committee has already debated the readiness of PCTs. Although I for one am not confident that they will be capable of handling the full range of their responsibilities from October 2002, I shall not labour the point in speaking to this amendment.
Secondly, on Second Reading, concerns were expressed by the noble Lord, Lord Turnberg, that specialist services will be "relatively neglected" by PCTs. It is a question not simply of technical readiness for commissioning, but of attitude and orientation. Indeed, I have heard concerns that the acute sector generally could be neglected by PCTs, which have a natural primary care orientation. If there are fears about the acute sector in general, those fears exist in spades for specialist services.
Thirdly, on the first day of consideration in Committee, concerns surfaced about how commissioning will work in practice. The Minister told us that he expected one PCT to take the lead in commissioning within an area covered by strategic health authorities. However, he also said that it might be possible that a PCT would not buy into what he described as the,
I know that some would have been reassured if responsibility for commissioning specialist services were given to strategic health authorities—much as when, in the good old days, regional health authorities were responsible for funding specialist services within their region. However, the Government seem to have an unbending view that they will place responsibility on the least appropriate tier, and then clear up any messes through intervention—or head banging—by the next tier. It is far from self-evident that those arrangements will work effectively.
The document Shifting the Balance of Power does provide for the continuation during 2002-03 of the existing regional specialised commissioning groups. Will the Minister say what will happen if PCT capacity to take these responsibilities one year hence has not matured sufficiently? Will the Government be prepared to reconsider and keep these regional groups in place?
On our first Committee day last week the Minister said that the Government intended to continue with national specialist commissioning arrangements. Will the Minister say what those arrangements are, and will he say why they could not be extended to provide a more secure commissioning route for a wide range of specialist services?
It would be folly to proceed with the delegation of functions to PCTs if it was not clear beyond peradventure that the commissioning of specialist services would be fully effective. They are vital services and must be protected. I beg to move.
Lord Clement-Jones: The noble Baroness, Lady Noakes, has very succinctly put the case for her amendment, with which I and these Benches wholeheartedly agree.
The Minister will remember that I expressed fears about the current pattern proposed by the Government for specialist commissioning when we debated a regional health authority proposal versus a strategic health authority proposal. I could tell that the Minister's mantra was coming on when the noble Baroness, Lady Noakes, proposed the strategic health authority option, and I am sure that it will come on again when I mention the regional health authority option. The point of devolution, however, is that the service is devolved to the point at which it can be best delivered. There is a considerable fear that these proposed consortia are not the most appropriate way of delivering specialist services.
To remind noble Lords, the Department of Health has recognised 35 treatment areas which are considered as specialist areas, ranging from cancer, to heart disease, to haemophilia, to HIV. They are some of the most serious and important conditions that need to be treated by the health service, and certainly require their own commissioning arrangements. There is no guarantee, however, that the consortia envisaged will have a sufficient number of local PCT members to provide for viable services. This could lead to a new postcode lottery for specialised services—something which the Government dedicated themselves against on coming into office—where the availability of treatment for these serious illnesses is decided not on clinical need but on geographical location.
Shifting the Balance of Power: The Next Steps, which seems to be the Bible for this part of the Bill, sets out how PCTs are expected to commission local services. Despite being billed as the definitive expression of government policy, the document does not contain any mechanism for guaranteeing that local commissioning consortia will have a sufficiently large membership to be viable. This system could lead to 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 consortia for high-cost, low-volume treatments.
The Government's response to these concerns has been to commit themselves,
The Government have committed themselves to a steady state of funding in 2002-03—whatever that means—with PCTs obliged to honour the service
The existing regional specialised commissioning groups will continue for an extra financial year, as the noble Baroness, Lady Noakes, has explained, until April 2003 and,
The regional commissioning groups, however, will have no power to compel PCTs to join consortia. With a large proportion of PCT chief executives still to be appointed, it is not clear how many PCTs are likely to participate actively in their work.
This is rather a confused picture and it is no wonder that there is cause for concern. Local health authorities, who do have the tradition and personnel with experience of commissioning specialised services, will be replaced under the new arrangements with groups led by general practitioners and others, who may well have little experience or indeed familiarity with the priorities for these treatments. Although some personnel will transfer between the two, there is no guarantee that local health authority funding priorities will be shared by their successor PCTs once existing service agreements expire.
Although the existing consortia have had mixed success in attracting health authorities to their membership, even though local health authorities have a tradition of strategic planning for specialised services, this problem is likely to be exacerbated by devolution to PCTs—who will of course have a fairly steep learning curve—for commissioning across the board. It is likely that, under these conditions, the number of opt-outs from consortia will increase and this could undermine the effectiveness of specialised commissioning agreements.
I have painted a fairly bleak picture and I hope that the Minister will be able to dispel some of that bleakness, but those are the fears that many have about the current arrangements and I look forward to his reply.
"PROVISION OF SPECIALIST SERVICES
(1) The Secretary of State may not make directions to a Primary Care Trust as to his functions under section 13 of the 1977 Act unless he has made arrangements for the provision of specialist services.
(2) The Secretary of State must consult health professionals who have an interest in the provision of specialist services before making the arrangements referred to in subsection (1) above.
(3) Specialist services for the purposes of this section are those services which are not provided within the territory covered by the Primary Care Trust."
"agreed programme for the commissioning of specialist services".
He then said that if a PCT was,
"not prepared to play ball ... the strategic health authority would have the opportunity to intervene and bang heads together". [Official Report, 14/03/02; cols. 1024-25.]
It cannot be satisfactory for the commissioning scheme for vital specialist services to depend on the head-banging abilities of strategic health authorities.
7 p.m.
"to maintain service continuity and allow co-ordinated service development",
for specialised services. This policy principle is to be delivered by the proposed system of PCT consortia. Although the health service circular guidance states that PCTs,
"with significant service agreements with the same provider will work together to ensure consistency in the core elements of the service agreements",
and that,
"PCTs will work in consortia to ensure that specialised services continue to be effectively commissioned at StHA and supra StHA levels",
they remain unclear how this will in fact operate on the ground.
"will have a specific role in developing PCT capacity to commission specialised services as part of a planned transition to successor arrangements".
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