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Lord Clement-Jones: My Lords, the Minister is seeking the flexibility to make changes to the boundaries of strategic health authorities and so forth. But are not the Government asking for total flexibility in terms of the arrangements to which I referred earlier; namely, to deliver the NHS Plan by way almost of outsourcing the management and administration of strategic health authorities, which form an absolutely essential part of the NHS—or at least they seem to, as the Minister has described them—through this process of franchising?
Lord Hunt of Kings Heath: My Lords, I think that the noble Lord may have missed the point in relation to franchising. One of the problems encountered over many years by the NHS has been the assumption that every organisation in the NHS is the same and performs to the same extent. We have failed to recognise that, within a national system, it is possible to have very successful organisations, but also some which are not so successful. The emphasis here, as it is in other announcements made by the Government, is to recognise that there are some very successful people in the health service and that in the future we want to be able to extend their ability to manage and lead services.
Through franchising we can, first, enable successful managers to take on a wider range of responsibilities—which is surely a sensible approach—and, secondly, if in the fullness of time there are people from outside the NHS who it is considered could do a good job within the NHS, then again, why not use the franchising facility to enable that?
Lord Clement-Jones: My Lords, I am sure that the Minister is convinced of the case but, in effect, this will sub-contract the mainstream management of the NHS—not a facility of the NHS, an acute trust, a mental health facility or any other area in which sub-contracting, private or independent provision is desirable. This provision will allow for the sub-contracting of performance management of the NHS. What other examples could the Minister cite of successful sub-contracting of performance management in the public services?
Lord Hunt of Kings Heath: My Lords, I am sorry that the noble Lord has taken such an inflexible approach to this matter. Corporate responsibility lies with the board of the strategic health authority, but if such a board were to decide that bringing in external
management would help that authority to achieve its goals, why should it not do so? What could be the objection to that?Are we saying that the current appointment arrangements are exclusively the only arrangements that are desirable with regard to appointing senior people to the NHS? Surely we want to introduce a degree of flexibility so that we see a range of people coming forward to work in the National Health Service. I think that franchising is an excellent idea which will enable us to reach out far more widely than is the case at the moment. If, as a result, better services are provided to the public, then surely that is to be supported.
Lord Filkin: My Lords, perhaps I may remind the House that we are debating this legislation on Report. Rather than opening up a new topic for debate, interventions made after the Minister has begun his response should be limited only to short questions for clarification.
Lord Clement-Jones: My Lords, I fully accept those words, but further clarification is needed on this matter. The words covering the delivery of the NHS Plan were not available when we considered the Bill in Committee. Certain elucidations need to be gained from the Minister.
The franchises appear on the one hand to be a form of outsourcing, while on the other hand they appear to be contracts of employment. Can the Minister clarify that?
Lord Hunt of Kings Heath: My Lords, I think that we are probably moving outside the rules for debate on Report. Perhaps I may conclude my remarks by saying this. In developing and delivering the NHS Plan, it is our intention to provide high quality services to the public. I am sure we all agree that we need high-quality leadership to undertake that. We depend on high-quality management.
If, through franchising, we can—in the first case that I mentioned—ensure that those managers who are outstandingly successful can be given wider responsibilities, then surely that should be supported. If there are people in other areas of either the public or the private sectors who could bring to bear new skills which would be of help to the NHS, then again I believe that it is right for us to be keen to adopt those skills.
However, as we have seen from the appointments that have been made in the first round, the great majority of the people who will be leading the strategic health authorities are those who are currently serving within the NHS. I believe that they are of a high calibre and they understand the balance that needs to be struck between effective accountability to Ministers and Parliament on the one hand, while on the other hand allowing primary care and other trusts as much freedom at the local level as possible. They must ensure that throughout a proper balance is maintained. I am
confident that those who have been appointed will keep to that balance and that the fears expressed by the noble Earl will prove, ultimately, to be groundless.
Earl Howe: My Lords, I thank the Minister for his very full reply. I am also grateful to all noble Lords who have taken part in this debate for their expressions of agreement on a number of the points that I have sought to make.
My message can be summed up quite simply: why not recognise the reality? Strategic health authorities are already showing every sign of being capable of taking the lead in driving through centrally-driven programmes. Let us recognise that they are doing that. In some contexts, that kind of prescriptive line management attitude is regrettable, but in others I would contend that it has something to recommend it. Prescriptiveness is regrettable in the day-to-day operational contexts which ought genuinely to be devolved to PCTs.
The Minister spoke of the prospect of intervention being minimal. I shall cite only one example which perhaps throws doubt on that. Dr Julian Neal, an executive committee member of East Hampshire PCT, was recently quoted in the BMA News Review. He spoke about the way in which strategic health authorities were instructing PCTs on how to allocate their budgets so that centrally-driven initiatives were funded before anything else and money channelled into secondary care. He said:
- "When you hear the rhetoric it is good. They are talking about autonomy and decentralisation. But the reality is getting worse. It has never felt so micromanaged and centralised as it does now . . . We have very little control and that's demoralising for those working in PCTs".
We can see, of course, what is actually happening; it is what I mentioned a little earlier. Steve Gillam, who is director of primary care at the King's Fund and a GP, recently said:
- "The money is being diverted into secondary care. It's going to pay off overspends. Even key areas such as clinical governance are being pushed down the priority lists by all the other must-do's".
The Minister spoke of the SaFF process and tensions. It is more than only tensions. In any structural reform of the health service the first thing that we need is clarity. With that in view, do not let us pretend that there is radical decentralisation and autonomy across the board when there is no such thing. I agree that 75 per cent of the budget being devolved is a significant departure as long as PCTs have real operational freedom, but do not let us use expressions such as "performance-manage" and "setting the structural framework" when what we mean in some important circumstances is "direction from the centre".
I shall not labour the point further. I note the wish of my noble friend Lord Peyton for me to press the amendment. I hope that he will forgive me if I do not. It was wholly and exclusively designed as a probing amendment and it has been extremely useful to that end. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
4 p.m.
Earl Howe moved Amendment No. 3:
- After Clause 1, insert the following new clause—
The noble Earl said: My Lords, we move on now to an issue which, since we debated it in Committee, has caused me and many others a good deal of concern—that is, how the new structures established by the Bill will deliver a coherent public health service. The Minister took the trouble, for which I thank him, to organise a briefing session for Peers on this subject last week. I found it helpful—as I am sure did all those present—but some of the concerns that I had prior to that session persist.
The Government have decided that the delivery of the public health agenda should rest primarily with primary care trusts. Each PCT will have a team dedicated to public health and a director of public health on its board. The Minister said in Committee that:
Sitting above the 300 or so PCTs will be the regional directors of public health based in the offices of the nine government regions. It is the regional directors who will exercise the departmental public health function on behalf of the Chief Medical Officer and to whom the PCTs will be accountable. Their role will be one of planning and co-ordination; they will set up and service the public health networks; they will plan for emergencies; and they will tackle the wider issues associated with health inequalities within the regions.
Set apart from the line of accountability between the regional directors and the PCTs will be the strategic health authorities. The role of the SHAs will be to performance-manage PCTs in their public health functions. Each strategic health authority will have a public health doctor on its top team.
The first thing that strikes you when you look at this tree of accountability is how odd it is. There are two separate and distinct reporting lines: 303 PCTs
While the nine regional directors will have responsibility for maintaining the public health networks, it is far from clear how accountability to, from and within those networks will be defined. Trying to apply the concept of accountability to informal and flexible networks seems fairly impossible. Within a network, accountability acquires an in-built fuzziness. I, for one, find that disturbing.
So odd does the system look that it is as if the Government, having invented a decentralised structure for delivering the bulk of primary and secondary healthcare, suddenly found themselves having to shoehorn public health into that same structure. Having decided that PCTs—and only PCTs—should be the engines of primary care, it is as if Ministers had little alternative but to decide that somehow or other PCTs would need to be responsible for the delivery of public health as well.
I am the first to agree with the Government that effective primary care is integral to improving public health. There is no argument about that. But health protection, health improvement, surveillance and reducing health inequalities—and the specialised skills that go with all of those—are issues that run much wider than an area or population typically served by a single PCT. Of course, the Government recognise this, which is why we have the concept of these so-called networks.
But the obvious question that arises is: why do it this way? Why in particular leave strategic health authorities out of the loop? Instead of these loosely defined networks and instead of vesting responsibilities in PCTs, which they are individually ill-equipped to handle, instead of having two parallel lines of accountability, why not acknowledge that there is a much readier and less complicated route that could be taken? That, as my amendment suggests, is to make strategic health authorities the initiators and drivers of public health programmes across an area and allow SHAs to performance-manage PCTs for the functions devolved to them. Would it not make more sense to allow the strategic direction of public health to rest with the strategic health authorities, each of which would have a dozen or so PCTs underneath it, rather than with the nine regions, each of which would have to direct and co-ordinate between 30 and 40 PCTS?
The extraordinary feature of the Government's model is the proliferation of public health directors and teams in PCTs—more than 300 of them—more people than can possibly exist at the moment with the
A consultant recently told the BMA News that,
The delivery of the public health agenda is about co-ordinating a broad spectrum of discrete but associated activities. It requires firm and clear leadership from people who are capable of identifying what is needed and how to meet that need. Every participant has to be fully aware of how the key public health responsibilities have been allocated and how the services can be accessed. For PCTs to take the lead in this far from simple matrix of function is, I fear, a recipe for fragmentation and dissipation of effort. It is a forced and ill-thought-out answer to a very important set of questions. Those questions, about how exactly the arrangements will work and who will be tasked with doing what, are still being asked throughout the health service.
I am not suggesting that the Government have remained silent or inactive on these issues, but out there—and, indeed, in here—the details are still lacking. Why is that? Why, even now, does the BMA, among others, state that it is practically in the dark about what is intended? The Secretary of State is on record as admitting that the structural changes now under way in the health service present "huge risks". That was a refreshing admission, but if it is true that there are huge risks, why are those risks being magnified by a failure to articulate the strategy for public health in a way that commands the confidence of everyone?
I very much hope that the Minister can be a little more forthcoming and precise on these matters when he replies, because we badly need reassurance. I beg to move.
Lord Clement-Jones: My Lords, I strongly support Amendment No. 3, which was cogently introduced by the noble Earl, Lord Howe. I shall also speak to Amendment No. 4.
There is no doubt about the importance of the debate on the future of public health services. If we are genuinely to switch emphasis towards prevention and make an impact on health inequalities, we need to develop our public health service, not to mention all the issues of health improvement and surveillance mentioned by the noble Earl, Lord Howe.
However, despite the Minister's worthy attempt in Committee to allay worries and the helpful meeting that he arranged to discuss the implications of the new organisation for public health, there are still considerable concerns and many outstanding questions on the issue, as the noble Earl, Lord Howe, has made clear.
Changes have already been made in anticipation of the Bill passing through this House. I understand that public health directors moved from area health authorities to PCTs on 1st April. Those shadow strategic health authorities, which we were debating under the earlier amendment, are already in place.
We have had some reassurance from the Minister on the filling of director of public health roles. That appears by and large to have taken place. However, there are key questions relating to organisational capacity and continuity, how PCTs will deal with public health specialisms, the way in which new management systems will operate and the issue of resources.
As your Lordships have heard from the noble Earl, Lord Howe, despite the need for capacity, the new system is already operating in a bizarre fashion, with consultants having been made redundant and then unmade redundant. It seems extraordinary that public health consultants have been parked at strategic health authorities for the coming year. Many of them have strong specialisms, including epidemiology, health information, statistics, preventive medicine, health promotion, communicable diseases, environmental health, development and evaluation of health services, teaching and research. Those are all valuable areas of specialism that we must not lose to the public health service. It is probable that these public health professionals will be tasked with short projects until their future is determined, but that is hardly a motivational way of dealing with valuable people. What an extraordinary state of affairs, when there is a great need for capacity in the public health service.
There are particular concerns about specialisms being lost. We have heard much in Committee and subsequently about the new public health networks, but there is no obligation on PCTs to ensure that particular specialisms are covered. The relationships will clearly be all about brokering within networks and between agencies to get things done, but there is little obligation on the PCTs as regards particular specialisms.
Furthermore, as the Minister admitted in Committee, if action by a network in a particular area is all about PCTs chipping into the resource pot, we will see a permanent game of NHS budget poker being played between PCTs up and down the NHS structure.
By their nature, networks will require a phenomenal amount of energy and organisation—more than would be present if strategic health authorities had that responsibility. As regards management and accountability, as the noble Earl, Lord Howe, pointed out, the responsibilities for different aspects of public health as between different parts of the health service risk being blurred.
Having heard the Minister and his officials, our concern is that the management structure is over- complicated. It appears that performance management will be carried out by strategic health authorities, but actual management will be carried out by regional public health directors. As the noble Earl, Lord Howe, said, how will those networks be held accountable? In Committee, the Minister talked about headbanging by the strategic health authorities, but what sanctions will they have? Would it not be preferable to give accountability to the strategic health authority, which is then line managed by the regional health director? We seem to have a topsy-turvy set of organisational proposals.
The Minister did not clarify in Committee what resources PCTs will have for public health. Nor do we know whether they will be ring-fenced. Yet here we are with PCTs already taking over public health services. Will they have a ring-fenced budget? Will they have adequate resources to fulfil the Government's agenda? All those difficulties need to be overcome if PCTs are effectively to discharge their public health functions.
The one bright spot relates to the new national agency, explained in Getting Ahead of the Curve. This is along the right lines, even though the way in which it is to be implemented, through the regulatory reform order procedure, is not satisfactory.
We on these Benches are very nervous about the new proposals. The Government risk getting so far ahead of the curve that they will fall off. I hope that the Minister can reassure us.
"STRATEGIC HEALTH AUTHORITIES: PUBLIC HEALTH
(1) Each Strategic Health Authority shall have a duty to—
(a) improve the health of members of the public within its area; and
(b) ensure the delivery of such public health services as may be appropriate by Primary Care Trusts within its area.
(2) Each Strategic Health Authority shall appoint a Director of Public Health who shall be a member of the Authority."
"The new directors of public health . . . will be the engines of public health delivery".—[Official Report, 18/3/02; col. 1156.]
Their focus will be on local neighbourhoods and communities. Specialist expertise in public health will be pooled through the medium of the proposed public health networks, which will be flexible in character and include, among others, NGOs.
"The process has made a mockery of professional qualifications because you don't seem to need them. It has destroyed and demoralised the profession".
Yet, despite that, we are told that all is well. The supreme irony is that individuals who have the relevant specialist qualifications are being given what I can only describe as the elbow. Twelve public health consultants received letters earlier in the year telling them that their jobs were at risk of redundancy, although I believe that the BMA has now intervened on that. I have heard of 20 senior public health consultants who have been parked at strategic health authorities for the coming year. I am told that that number is likely to increase. Of all the daft consequences of this enormous upheaval in the NHS, that has to be the daftest. We cannot afford to lose such people.
4.15 p.m.
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