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I should specifically like to know from the Minister what will happen to contracting, although he may not be able to give me an answer right now. The Labour Government made a commitment through the department that, when a social enterprise had been established in the health service, had gone through the right to request and was contracting for services, that enterprise would have a three-year or possibly a five-year contract, which would be guaranteed once it had gone through

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the whole process. Will that continue under the new regime? If the Government are serious about developing social enterprises to deliver primary healthcare and other services within the health service, a contract of three to five years will be vital for those businesses.

The noble Lord, Lord Mawson, talked about the Bromley by Bow Centre, which is a tremendous achievement. I should like to mention the Big Life centres. The Big Life is based in Manchester. It grew out of the Big Issue and works with people completely cut off from health, housing and employment services. There are now eight or 10 centres providing holistic services to the communities in which they are based. The Kath Locke Centre combines the best in conventional NHS healthcare with complementary therapies. It is well built and a good place to relax, and is extremely well used by its local community.

The Big Life Group issued a manifesto for the last general election, which I commend to the Minister. It states:

"We believe, developing a market in the NHS has really only meant opening up to large private sector companies and has largely missed the opportunity to bring in innovation through the social enterprise sector".

I do not agree completely with that: it may be as unfair as some of the comments made by the noble Lord, Lord Mawson. However, the Big Life Group may have a point. We as a Government did not succeed as much as I wish we had. The challenge is now there for the coalition Government. If they are serious about having an innovative marketplace, they must address the issues raised by organisations like the Bromley by Bow Centre and the Big Life Group.

I agree with the noble Lord, Lord Mawson, that the department must encourage more entrepreneurship. Like him, I have been frustrated by slow progress across the piece. As the founding chair of the Social Enterprise Coalition some 10 years ago, I think we should blow our own trumpet. Where there was one Bromley by Bow, there are now many. Social enterprise was mentioned in every party manifesto, and is now part of the coalition Government's programme. We have made great progress. However, there are still huge challenges.

I have some questions for the Minister. It seems that in two years' time, £60 billion of NHS funding might be funded through local commissioning, as the noble Lord, Lord Crisp, mentioned. What will happen to these schemes and programmes if this reconfiguration of the NHS is going to be so profound? How will the Bromley by Bows and the Big Life centres be developed under those circumstances? How will this entrepreneurship be taken into account in the new commissioning scheme? The noble Baroness, Lady Finlay, made a valid and wise point: the rush to change might jeopardise what has already been achieved through partnership and innovation. I agree with the noble Lord, Lord Crisp, that we do not want to lose some wonderful examples of PCT innovation in the forthcoming reorganisation. How will the coalition Government build on the platform that we created-or do they intend to dismantle the platform, with all the risks that go with that?



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4.17 pm

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I begin by expressing my gratitude to the noble Lord, Lord Mawson, for the opportunity to reflect on the changes to primary care over the past decade. Perhaps I should start by confirming the basic principle that the Government will uphold the guiding values of the NHS; that it should be available to all, free at the point of need and based on need and not ability to pay.

For more than 60 years, our system of primary care-the local family doctor-has been the bedrock of the health service. When we are ill, our GP is our first and often only port of call. They are the prescriber, the referrer and the gatekeeper to the vast and often complex labyrinth that is the NHS. Few things are as local as your GP practice. By definition, GPs are of the community and perfectly placed to reflect and respond to the needs of the community. The problem that they face now is that they serve two masters; the patients whom they see every day and the targets imposed from above. However, we believe that, freed from central control, incredible things are possible, as we can see from the rise of the social entrepreneur.

Earlier this month, my right honourable friend the Secretary of State visited the extraordinary Bromley by Bow Centre, of which the noble Lord is the founder and president. Based in one of the most deprived parts of the country, it demonstrates what can be achieved with vision, determination and commitment. It helps people to overcome poor health and unhealthy lifestyles, to learn new skills, to find work and to create an enterprising community. It has been an inspiration to many in Bow and it is an inspiration to this Government.

The noble Lord, Lord Mawson, is right. By responding to local people and by being led by them, the Bromley by Bow Centre and other social enterprises are transforming communities in a way that the state cannot. This is the big society in action. Far from supporting them, however, the state has too often acted as a barrier to social entrepreneurs, limiting what is possible. This needs to change.

A damaging recent development has been the introduction of "preferred provider"; in effect, preferring adequate care delivered directly by NHS organisations over excellent care provided by others. We will encourage "any willing provider" to compete to provide the best outcomes for patients. We will give public-sector workers the right to form employee-owned co-operatives so that they can then bid for and deliver services themselves. We will support the creation and expansion of mutual organisations, co-operatives, charities and social enterprises. These will have a place, above all, in the provision of community services, with the quality of those services driven by innovative approaches to delivery.

Rather than preventing social renewal, government should be a catalyst to encourage and galvanise it; "putting the wind in people's sails", as the noble Lord, Lord Mawson, put it. As he said, there are some excellent examples of where the state already does this without working in silence. In Southend-on-Sea, the St Luke's Healthy Living Centre, in partnership with a local primary school, local residents and a wide range of grassroots representatives, provides counselling services,

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an allotment and food co-operative, advice services and a business support unit. Another social enterprise is Open Door in Grimsby. Open Door works in partnership with local public services, voluntary organisations and Santander bank. Most of all, however, it works with those it supports-the homeless, drug users, refugees-to give them the help they want rather than the help that others assume they need. Both have enjoyed the support of the Department of Health's £100 million Social Enterprise Investment Fund, one practical example of where the state can help. The noble Lord, Lord Crisp, mentioned the work being done by some PCTs under the triple aim barrier. Like him, I commend those initiatives.

The crucial thing is what is delivered-the clinical outcomes and the benefits to patients and residents-not who delivers it. As the noble Lord, Lord Mawson, said, it is about doing, not just talking. This is all part of a massive redistribution of power and control away from the centre to individuals and local communities.

While at the Bromley by Bow Centre, the Secretary of State described our approach to healthcare. These principles are not plucked from thin air but, rather, are garnered from the experience of those parts of the NHS that already deliver truly excellent care. First and foremost, because decisions that include the patient lead to better clinical outcomes, we will place the patient at the heart of everything the NHS does. As the Secretary of State put it, there will be,

Secondly, because what matters most to people is that they receive the very best quality of care, not that their hospital can jump through bureaucratic hoops, the NHS will focus on constantly improving clinical outcomes. We will hold the NHS to account for what it achieves, not how it achieves it.

Thirdly, because there is a limit to the improvements that can be driven from the top down, and we have long ago reached that limit, we will empower professionals. Over the past decade, the NHS has been showered with money, which is marvellous. However, it has also been drowned in red tape and bureaucracy. The Government intend to set the NHS free, not shackle it with centrally imposed process-based targets.

Fourthly, preventing disease will be as important as curing it. What has really improved the nation's health? Is it the National Health Service? Of course it is. Mass immunisation programmes and more recent things, such as the smoking ban, have also saved lives and helped well-being. Beyond a narrow focus on health, improvements in housing and sanitation have been just as important. Health cannot be placed in a silo. That is why public health will play a significantly greater role.

Fifthly, people do not differentiate between healthcare and social care-they just want help. Better social care can often prevent the need for expensive healthcare. For example, fitting a hand rail costing £70 can prevent a fall that would require a hip operation costing £7,000. Therefore, we must properly integrate health and social care, especially if we are to deal with the effects of an ageing population. These are the principles that will underpin our approach to healthcare, but to improve health outcomes we must bring these principles to life.



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The Quality and Outcomes Framework initially helped to raise standards, especially in more deprived areas. However, it did so at significant cost and the improvements have now stalled. I was in considerable sympathy with much of what the noble Lord, Lord Rea, said about this. We will reform the QOF to reward GPs for improving health outcomes. We will also discuss with the profession how patients can help to shape the care they receive. We will also look again at the GP contract. Taxpayers must get value for money in return for the massive investment that they have made in primary care, and the contract must properly reflect and reward what we are asking GPs to do.

Whoever provides health services, high quality commissioning is essential and should be done as closely to the patient as possible. GPs and their primary care colleagues are in the best position to know what services their patients need and will have the power to commission them. In this way, they will also take ownership of the financial implications of their decisions, leading to better value for money. That is not something that they can do in the fullest sense at the moment. This requires leadership. As commissioners, GPs and their colleagues will become the leaders of a more autonomous NHS, supported nationally by a new NHS commissioning board.

Twenty-four-hour urgent care is currently unco-ordinated and of variable quality. We plan to overhaul that system. Nor should we overlook the role of the pharmacists. Every day millions of people visit their local pharmacy. With the right incentives and support, pharmacies can deliver both clinical and public health services. We will also build on the progress that has already been made in recent years.

The noble Lord, Lord Rea, in his excellent speech, pointed to the differential funding of primary care trusts and urged the Government to take account of differing health needs and deprivation. The noble Lord raises an important point. We are committed to ensuring a fair allocation of resources to the new GP commissioning consortium when it is formed. We also want allocations to be made based on the health needs of the registered population for these groups, so that those with the greatest need have their fair share of resources.

The noble Lord referred to the document produced by the Royal College of General Practitioners, which proposes GPs' practices working together in a federation to support each other in the provision of care to serve the local population. These are sensible proposals and we want to build on them, for GPs not only to provide a wider range of care and services to their patients, but to commission wider health and care services for the population. It is right that GPs' practices themselves decide on these federations. We are not prescribing those nationally from the centre.

This very much brings us to the concerns voiced by the noble Lord, Lord Crisp, and the noble Baroness, Lady Finlay, relating to the varying capabilities of GPs and how those who feel less confident and keen about commissioning can be supported. It is very much about GP collaboration. Everything that the

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noble Baroness said about this was absolutely right. The new GP commissioning system that we are proposing will be led by groups of doctors at a local level and overseen nationally by an independent NHS commissioning board. This is not about trying to turn GPs into managers; it is about placing the financial power to change health services in the hands of those NHS professionals whom the public most trust. Giving more responsibility and control over commissioning budgets should help GPs consider the financial consequences of their clinical decisions. This will lead to reducing waste and bureaucracy. Much will depend on the size of GP consortia, but I am confident that the necessary leadership will emerge from those consortia to facilitate the spread of best practice.

The noble Lord, Lord Crisp, sought clarification on the arrangements and the roles of GPs in commissioning services from primary care. We will be bringing forward proposals for change to the roles and responsibilities of GPs before the summer through a White Paper. Shortly after that we intend to publish a consultation document on GP commissioning arrangements. That consultation document will set out in a lot more detail the roles and responsibilities that we are proposing for organisations. We will welcome views and comments from all interested parties.

The noble Baroness, Lady Finlay, referred to the unintended consequences of change, the challenges posed by patients with complex conditions and the requirement to treat those patients in the right settings and along the right care pathway. She is spot on in all that she said. She referred specifically to payment by results acting as a barrier to integrated care. The work that we are doing to underpin our drive to an outcomes-based model of commissioning includes work to refine the tariff to embrace long-term conditions, co-morbidities and complex cases. This is a major undertaking but it is essential that we get there.

My noble friend Lord Alderdice remarked that there is a limit to managerialism. I am right with him on that. The Government are committed to a patient-led NHS, strengthening patient choice and patients' management of their own care. That will involve pro-active, preventive and personalised care planning with a focus on shared decision-making. That will apply especially to the care of people with long-term conditions, a theme pursued very powerfully by the noble Lord, Lord Crisp, and one which brings us back to the wise advice of the noble Baroness, Lady Finlay, on the management of change. We are developing a national support programme aimed at accelerating improved long-term care management. The aim is to realise the benefits of improved quality and productivity more rapidly through a large-scale change management programme that will disseminate good practice.

Front-line staff are, of course, crucial to the delivery of personalised care planning. More needs to be done to support the wider culture change that empowers people with long-term conditions to take more control so we plan to support the workforce with guidance and training resources. There is a clear message here: personalised care planning underpins good management of long-term conditions. The care planning process is about involving people with long-term conditions in

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discussions about their own goals and outcomes for the way they want to live their lives and then agreeing a plan with them on how their care will be managed. It is about addressing their full range of needs: personal, social, economic, educational, mental health and others. That is the way that we will empower people and get them to understand what choice really means.

The noble Baroness, Lady Emerton, in a speech to which I cannot possibly do sufficient justice in the time available, referred to the essential role of community nurses. We are determined to address health inequalities and improve public health. Nurses are key to this, as are health visitors working with families, communities and Sure Start and school nurses working with school populations. They will make skilled and significant contributions to this. We are committed to increasing the number of health visitors in the workforce to provide the best health, well-being and support services for all children and families and to improve services for those who need additional support. The noble Baroness was right in all that she said about the skill set of nurses. Health visitors in particular combine a nursing or midwifery and public health education which gives them the ability to put together a medical and psychosocial knowledge with an understanding of the health system. That is a unique strength.

The noble Baroness, Lady Emerton, referred to the challenges to the nursing workforce and its role in providing community services. She will know that four years ago the Modernising Nursing Careers initiative was launched jointly by the four UK chief nursing officers, with clear priorities. Those priorities were developed to ensure that nursing careers supported health reforms. The programme developed national tools and levers to enable local transformation of the nursing workforce. We will follow that theme.

The noble Baroness, Lady Finlay, referred to a 24/7 service. We are committed to providing universal access to high-quality urgent care, whereby people can have the care that they need whenever they need it. I anticipate that we will shortly make further announcements on that theme.

The noble Baroness, Lady Thornton, asked about the LIFT initiative. I agree with her that much good has emanated from it, and it has the potential to continue delivering. There are a possible 144 new schemes in the pipeline, worth £1.2 billion in total. There are also two new express LIFT companies in procurement that are due to become operational in this financial year. She also asked about social enterprise. I hope that I have said enough to convince her that we are serious about this. A number of initiatives, including using funds from dormant bank accounts to establish a big society bank, will be helpful. This is also about training. We need a new generation of community organisers to support the creation of neighbourhood groups across the UK, especially in the most deprived areas.

My noble friend Lord Colwyn moved us to the subject of dentistry and specifically the regulation of the dental profession. Dental practices will be required to register with the CQC from April next year-the date set by the Health and Social Care Act regulations. I recognise the fear of overregulation that dentists

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may have and I am well aware of the importance of good morale. My clear understanding from the CQC is that it will look at evidence that outcomes are being met, rather than adopting a tick-box approach to compliance. Where possible, the CQC will use existing information held, for example, by the Dental Reference Service, to minimise the demands on dentists. The CQC is agreeing a memorandum of understanding with the General Dental Council. Perhaps I should point out that plans to include in the registration system primary care providers such as dentists were consulted upon in spring 2008, and the majority of respondents supported the decision-including the British Dental Association.

In view of the shortage of time, I will write to my noble friend about the HTM 01-05 guidance, because there is rather a lot to say about that. I have convinced myself in the past fortnight that we are on the right path. I know that there is a lot of concern among dentists about cost, but I believe and have been persuaded that the guidance is the correct way to go.

Primary care is the bedrock of the NHS. It provides some excellent services but is capable of so much more. The balance of power within the NHS will undergo a fundamental shift-away from central control and away from restricted provision. The noble Lord, Lord Mawson, asked: who will lead? It is probably obvious from what I have said that, above all, we want clinicians and professionals rather than the politicians to lead. My noble friend Lord Alderdice spoke powerfully about that. We will give the NHS the freedom to innovate and a mandate to achieve excellence. We need a new can-do and should-do attitude. We need a dramatic improvement in productivity and efficiency. Most important of all, we need to see a significant improvement in the health and well-being of patients.

4.39 pm

Lord Mawson: My Lords, I have found all the contributions to this debate particularly helpful. In many ways, the issues raised provide the raw material on which we all need to work as we move forward to the next stage of the development of primary and community care. I am only sad that there is not more time to debate some of those issues, but I want to make just a couple of points.

I agree with the noble Baroness, Lady Thornton, about the role of LIFT. In the early days, I tried to persuade GPs and others all over the country to get behind LIFT. It has created a very different kind of world. Indeed, my colleagues in east London won the first £35 million contract and began to demonstrate how it might work. My plea to the Government is that they should stay with LIFT, as I think they will. I suspect that, as a structure, it is achieving only 55 per cent of what could be achieved and that it could do a great deal more, as I pointed out earlier.

Some of the points that I made reflected conversations that I have had with colleagues who run the Big Life Company and with others with whom I am very much in touch. We are all aware that we have come a very long way but that we need to go further. That is the key point.



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I thank the noble Earl, Lord Howe, for clarifying some of the issues that I raised. There is a great deal to do, and a lot of practical details that underlie this debate need to be addressed. However, I welcome what I have heard and am certainly willing to play my part in helping some of this thinking to take root.

Finally, if I have any further advice for the Minister, it is the following. First, as I know he is doing, he should decide what his vision for the future of primary and community care is and stick to it. At a time of limited financial resources, I encourage him to embrace the integrated approach to health that I have been describing. It is about more than just the medical profession. Not only does it make good health sense for patients and put flesh on the bones of the concept of the big society at a local level, but it may well enable the Government to get more for less from the limited resources that are now available to them.

Secondly, in deciding their vision, the Government should also take great effort to understand the practical details of how it will work in practice in different

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contexts within the United Kingdom-particularly in some of our more challenging areas. I very much agree with my noble friend Lady Finlay that we should be careful about unintended consequences. For example, the policy to create free schools, which I welcome, may have real benefits in some affluent areas of the country but may well create social havoc in multicultural areas of London, with which I am very familiar.


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