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Baroness Noakes: My Lords, in moving the amendment, the noble Lord outlined why specialised services are a matter of great concern in the NHS. These Benches support the thrust of the amendment. It ensures that the commissioning of specialised services is done at the right level in the NHS. We believe that that is the correct direction although the amendment may not be in quite the right form.
Highly developed skills for the commissioning of specialised services exist at regional level. I refer to the eight old regions, not the four virtual regions which are being created. The regional specialised commissioning groups ensure that patients have specialised services available to them and the providers of those services have the funding, security and stability which allows them to develop those services.
Pure dogma has driven the Government to propose the break up of those regional groups and to devolve commissioning responsibility to PCTs. PCTs demonstrably do not have the confidence to handle specialised commissioning even if—and it is a big "if"—they have a commitment to specialised commissioning. Only a couple of weeks ago, the Joint Consultants Committee issued a press release saying that it is very worried about specialised commissioning given the lack of readiness of PCTs. This is not a problem that will go away despite the many assurances and expressions of confidence that we have had from the Front Bench opposite.
Has the Minister ever heard of the management maxim, "If it ain't broke don't fix it"? No, the Government's approach is to break it first and then try to fix it. At a stroke the Government will smash the eight regional arrangements into 300 PCT-sized bits which do not work. They will then rearrange them into 28 strategic health authority-sized networks which might work if they are performance managed—but we have no evidence on which to be sure. If noble Lords have ever wondered what nonsense on stilts looks like, this is it.
At Report stage the Minister gave us a glimmer of hope when he referred to the possibility that regional specialised commissioning groups will continue beyond 2002–03. He said that it may well be that they will not be dismantled. We were heartened to hear both that and the review proposed by Mr Hutton. Perhaps I may put a couple of questions to the Minister about Mr Hutton's review? Will he say a little more about it, who will be involved in the review and whether it will seek out the views of the National Specialist Commissioning Advisory Group of specialised service providers throughout the country and, importantly, the view of patients? Will he commit to making public the review and the evidence obtained for it?
Lord Filkin: My Lords, in my naivety I thought that on Report I had made everyone, if not totally content, substantially satisfied, about the queries. Clearly, I was premature on that.
As we know, specialised services are those where patient numbers are small and quality can only be achieved by bringing together a critical mass of patients in each centre. This means that there will be relatively few centres offering treatment and there will not be a specialist centre in every local hospital. Therefore, PCTs acting in isolation could not deliver the quality and cost effectiveness which we all believe is essential for the future.
However, under shifting the balance of power, primary care trusts are responsible for commissioning health services for their local populations. The noble Baroness, Lady Noakes, asked whether I had ever heard of the quotation, "If it ain't broke, don't fix it". Yes, indeed. What is "broke" is the current centralisation of the NHS, on the basis that all of its functions and products can be run on the old command and control model from Whitehall. That is why we believe it is right to establish PCTs, which are
much better and more in touch and have a greater understanding of the needs of the public and patients and can take a wide and long view of how best to meet those needs. That is why we believe it fundamentally right to make sure that one did not half-bake devolution to them, but gave them full budgetary responsibility as far as it is practicable and sensible to do so.We believe that that is a much better approach—although it will require joint working between PCTs to deal with joint commissioning—than to have some rather arbitrary definition, inevitably by central government, about which functions should be dealt with at a different level from PCTs. The thrust of the Government's approach is to devolve, but to set very clear outcomes and standards to be achieved rather than to second guess the mechanisms in detail.
However, I sought to signal in the last debate that we recognise the importance of getting it and the process of development and evolution right rather than suddenly throwing it all up in the air. PCTs both now and in the future will be expected to work together on a consortium basis to secure specialised services. That will certainly be true immediately and it is likely to be true for many functions for the future. In the short term they will be expected to honour existing agreements, financial and otherwise, negotiated by regional specialist commissioning groups. Those groups will continue for at least a further year with PCTs replacing the former health authority members. RSCGs have a specific role in developing PCT capacity to commission specialised services as part of a planned transition to successor arrangements. Ensuring that enough people with the right skills continue in their roles is particularly important in the context of specialised services.
As I believe I indicated last time, there are already encouraging reports of PCTs working together to ensure that specialised services are effectively commissioned. Sometimes these consortia cover populations the size of a strategic health authority and sometime larger populations.
As noble Lords have implied already from the slightly hesitant way in which they signalled that this was a probing amendment, the role of strategic health authorities will be to oversee the consortia arrangements with regional directors of health and social care, ensuring that specialised services are delivered properly across the whole region. Strategic health authorities are not there to commission services, as the amendment suggests.
The amendment also refers to very highly specialised services which are vulnerable for some reason. They will continue to be centrally commissioned under the auspices of the National Specialist Commissioning Advisory Group. But such arrangements are only suitable for those very highly specialised services where there are a handful of providers and perhaps a couple of hundred patients across the whole country. This is not the case for most specialised services.
I also indicated that while there is a clear national list now, that will change over time as technology changes. However, that is not to imply that we see a case for a rapid expansion in any way of the list of functions currently handled by the National Specialist Commissioning Advisory Group.
The Government are adopting the pragmatic approach to commissioning and I believe that has been acknowledged. Current commissioning arrangements will be left alone where they are working well. The experience of PCTs, when they are essentially funding and supporting the new arrangements, will have to make a case both to each other and in practice to the SHA for any significant change to those commissioning arrangements. So it is not a carte blanche situation, being completely free to throw away good practice and common sense.
We have considered further the valid points made by noble Lords during the passage of the Bill. I would like to add emphasis to the review headed by my right honourable friend, John Hutton, into specialised services and the commission arrangements, in particular for the regional-type services covered by several strategic health authorities, with a view to issuing guidance in the autumn on arrangements beyond 2002/3.
The review will canvas views as to how best to integrate the current regional specialised commissioning group arrangements with the new health and social care regional boundaries in order to ensure that highly specialised services covering large geographic areas are properly planned, funded and monitored. It will be a wide review. We shall be interested to hear views from any organisation in the health service which has concerns, interests or issues relevant to the review's terms of reference. I emphasise that those views should be submitted.
The noble Lord, Lord Clement-Jones, gave a specific example of haemophiliacs. He touched on a point which we did not go into in much detail on the last occasion concerning the consortia arrangements. While they are fundamentally concerned to deal with the need to commission over larger-scale populations, they are also a means of sharing risk so that there is no postcode lottery in the future. Therefore, any PCT which might, for example, have a sudden movement into its area of a number of people unfortunate enough to be really high-cost haemophiliacs, would not thereby have its budget skewed, damaged or put at risk other patients. That was a very legitimate concern raised by the noble Lord. That is why joint arrangements will also be put in place, not just for commissioning, but to pool risk.
There is a good example already of a highly successful haemophiliac service commission consortium in south-east England covering over 80 PCTs and a population of 13 million, with financial risk-sharing arrangements. So I am not speaking just from theory, but from practice. Clearly, when one finds such examples one wants to ensure that they are assessed and the good practice is retailed to others, where appropriate.
I hope that I can reassure noble Lords that the National Specialist Commissioning Advisory Group will continue doing its valuable work in relation to the very highly specialist services. But it is right that the primary care trusts should commission other specialist services under the careful scrutiny of strategic health authorities. PCTs will have the best knowledge of the needs of their population and are best placed to provide for their needs, in some cases in isolation, but in many cases working in firm consortia arrangements with others. For these reasons we resist the amendment as we believe that it is not necessary.
4.45 p.m.
Lord Clement-Jones: My Lords, I thank the Minister for that reply. Quite clearly, from the Minister's reply I believe that further torture of him has produced results at Third Reading. I thank him in particular for the point he made about the pooling of risk in the way in which the consortia are constructed. There is a flaw, however. Only time will tell how matters work out in terms of the logic of some of the Government's proposals in this area. I refer to the blanket view that all centralisation is bad and that decentralisation is good for all purposes. That is the initial ground on which one stands.
As a federalist, I have always believed that devolution is best done to the appropriate level. It is not always a question of saying that everything must be pushed down to the lowest possible level. The appropriate level is where the expertise and resources are best deployed. That is the problem that we shall have to address in the future.
I accept the Minister's assurances about the ambit of Mr Hutton's review and in particular about the level of consultation that will be invited from all bodies in terms of the way in which the consultation is conducted. However, there is a lot more water to flow under the bridge. We very much hope—a hope shared by those on other Benches—that the regional groups will be retained as we believe that they fulfil a proper and useful function. We shall be looking at where the expertise properly resides; at the performance management and assessment carried out by the strategic health authorities; and in particular cases at whether or not a specialised piece of commissioning has been carried out at the appropriate level.
For the moment, we are content to examine the Minister's reply and to hold him to account at a future date. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
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