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The Minister of State, Department of Health (Norman Lamb)
It is a pleasure to serve under your chairmanship, Mr Bone. Your arrival has removed the opportunity for me to be accused of sycophancy along with everyone else who has commended your predecessor in the Chair on his knighthood. None the less, I join in congratulating him, even in his absence. It is good to see you this afternoon.
I congratulate my hon. Friend the Member for St Austell and Newquay (Stephen Gilbert) on securing this debate. His speech was impressive and compelling in making his case, and I hope that I can go some way towards reassuring him. However, I am happy to discuss with him further the concerns that he rightly raised, to ensure that commissioning is done in the best possible way.
Various hon. Members said that any change should be based only on improving care, not simply on cutting cost. Of course, everyone needs to be engaged in the debate about how we make the most effective use of money in the NHS, but we should not do things that damage care, simply to cut cost.
Before I go into the detail of my response to my hon. Friend, let me respond to some of the points made by other hon. Members. I will write to all hon. Members who have participated in the debate to deal with all the points of substance that have been made. The hon. Member for Bristol East (Kerry McCarthy), for example, made a number of key points at the end of her contribution. Hon. Members have had a good opportunity to raise concerns about specific conditions and patient groups, and they have done so constructively.
The hon. Member for Blaydon (Mr Anderson) raised important concerns about neuromuscular care and mentioned the Newcastle centre, and I would be happy to see him at one of my Monday evening MP advice sessions to discuss his concerns further. He also raised concerns about the drug Translarna. My colleague, the Under-Secretary of State for Business, Innovation and Skills, the hon. Member for Mid Norfolk (George Freeman), who is responsible for life sciences, has committed to convene further meetings to seek a resolution of the dispute, and I hope that goes some way towards reassuring the hon. Gentleman.
The hon. Member for Congleton (Fiona Bruce) highlighted the brilliant work of the RSA—an organisation based in her constituency. She said that it had raised millions of pounds for treatments and research and that it was important that such groups have a voice and are heard. I completely accept that, and I hope to provide further reassurance in due course.
A number of concerns were raised by the hon. Member for Poplar and Limehouse (Jim Fitzpatrick)—or is he a right hon. Member? [Interruption.] I think that he deserves to be called right honourable. He referred to sickle cell disease—an important condition that was mentioned by the right hon. Member for Wolverhampton South East (Mr McFadden)—or is he an hon. Member? [Interruption.] He certainly deserves to be called right honourable, and he has clearly been rewarded. He highlighted the need to improve the care and treatment of people who suffer from sickle cell disease.
The hon. Member for Poplar and Limehouse also referred to headache disorders. My wife is one of the many people across our country who suffer from headaches and migraines, so I very much understand their impact on well-being. The hon. Gentleman asked specifically about the possibility of a meeting. Again, I would be happy to see him at one of my Monday evening sessions, but I would also be happy to make sure he and his group are put in touch with officials. I am conscious that the Department’s diary up to the end of March is chock-a-block, but I am sure he could meet officials to take the matter further, as well as meeting me on a Monday evening. I hope that is some reassurance.
My hon. Friend the Member for Colchester (Sir Bob Russell) raised the issue of prescription charges. He is right that there are anomalies—there is no point denying that—and they have existed for a long time. The previous Government looked at the issue, but they did not quite get round to doing anything in relation to long-term conditions, and this Government have also not acted. The constant problem is the pressure on resources in the NHS. People on low incomes are, of course, protected, but he made a valid and legitimate point, and the debate is, rightly, bound to continue. The other point that he made, by analogy, is that any move NHS England makes on this front must not do more damage to people with long-term conditions. I hope to reassure him that that will not happen.
Sir Bob Russell
Will the Minister explain what possible justification there can be for somebody with cystic fibrosis having to pay a prescription charge, when they would not have to do so if they had diabetes and cystic fibrosis?
Norman Lamb
My hon. Friend makes a legitimate challenge. These anomalies have not been addressed so far, but they need to be at some point. I do not seek to deny his point.
The hon. Member for Mitcham and Morden (Siobhain McDonagh) highlighted the work of Headway, which provides incredible support for people with brain injuries and their families. She mentioned the helpline and the emergency fund, which will be of enormous help to families in the incredibly difficult circumstances they face.
The hon. Member for Bristol East mentioned the Cystic Fibrosis Trust—another amazing patient organisation that does extraordinarily important work. She talked about the importance of equity of access, and it is incredibly important that that principle is maintained in any changes that take place. We do not want to return to the postcode lottery that existed in the past. Again, I am happy to try to provide responses to the questions she asked at the end of her speech.
The hon. Member for Walsall South (Valerie Vaz) was incredibly generous in her remarks about the shadow Minister, and I feel the same about him—let us be blunt about that. I appreciate her kind remarks about me—indeed, the feeling is entirely mutual. She made some really important points about epilepsy and Epilepsy Action. She highlighted concerns about many CCGs and health and wellbeing boards not yet engaging fully in work on epilepsy. That critical issue goes beyond this debate, but I completely take the point that there needs to be a lot more understanding and recognition of the importance of good epilepsy care that follows good practice and addresses the awful problem of so many people losing their lives unnecessarily to this condition.
Valerie Vaz
The issue is actually within the scope of the debate. We are talking about co-commissioning, but CCGs are not ready.
Norman Lamb
I totally accept the point. Again, I hope to reassure the hon. Lady.
The hon. Member for Luton North (Kelvin Hopkins) referred to robotic assistive surgery. I do not want to give him any particular hope, but it is always possible for new procedures to be added to the list of those that come within specialised commissioning. The prescribed specialist services advisory group keeps the list under review. Just as there are proposals to remove procedures, there is always the possibility, if the case is made and the four conditions that need to be taken into account are met, that additional areas can be included.
Kelvin Hopkins
I should have mentioned that robotics make possible an increase in non-invasive surgery, which is not only better for the patient, but much cheaper for the NHS, because there is less recovery time and so on.
Norman Lamb
I totally take that point. The hon. Gentleman is absolutely right that the NHS must be, as he put it, at the cutting edge of new technologies and new ways to reduce the invasiveness of procedures, although I add that having things in specialised commissioning is not the only way for the NHS to do so.
The hon. Gentleman was at risk of going into too much detail when he started talking about various procedures. Despite being a Health Minister, I am at risk of passing out on such occasions, so I was glad that he stopped when he did.
Norman Lamb
I have hon. Members pleading with me not to give way, but if the hon. Gentleman insists, I will. No—that comes as an enormous relief to everyone.
The hon. Member for Alyn and Deeside (Mark Tami) made some important points about blood cancers and bone marrow transplants. I was interested in his point about the need for more joined-up approaches and services, not only within health, but between health and education. At its best, the proposition being put forward has the potential to achieve that, but I am with him on the ambition for much more integration between public services.
I want now to respond to some key points made by my hon. Friend the Member for St Austell and Newquay. NHS England is responsible for commissioning 147 prescribed medical services on a national basis. Those are specialised services for rare and complex conditions. The services are set out in legislation and commissioned directly by NHS England, through 10 area teams. By commissioning those services nationally, NHS England can commission each service to a single national standard, with single national access criteria, and ensure that patients have the same access to specialised services regardless of where they live in England.
The specialised services that NHS England commissions provide for people with rare or very rare conditions. Therefore, it is necessary to commission those services across a wider population than most CCGs cover—for example, in excess of 1 million people. Specialised services tend to be provided by larger hospitals that are able to recruit and retain clinical and support staff with sufficient specialised knowledge, expertise and leadership. That maximises the provision and co-ordination of care for the relevant patients. The list of prescribed specialised services is kept under review and therefore has the flexibility to change with advances in technology and treatment—such as those that the hon. Member for Luton North referred to.
It is for Ministers to take the final decision on which services should be included on the prescribed specialised services list in legislation and therefore which services are directly commissioned by NHS England. Those decisions are not taken lightly. Expert advice is provided by the prescribed specialised services advisory group—a Department of Health-appointed expert committee established in 2013. NHS England established a specialised commissioning taskforce in April 2014, which my hon. Friend the Member for St Austell and Newquay referred to, to make some immediate improvements to the way in which it commissioned specialised services and to put commissioning arrangements on a stronger footing for the long term. Of course, as I think everyone recognises, such services must be sustainable.
The taskforce aims to improve ways of working and to ensure that the commissioning of specialised services is undertaken in the most efficient and effective way possible. Additional resource from within NHS England has been diverted to the taskforce to ensure that it has the right mix of skills and expertise to enable it to meet its objectives.
Stephen Gilbert
As my right hon. Friend will be aware, the taskforce has just suggested that renal dialysis and morbid obesity should come off the list of prescribed specialised services. The decision has been taken over a short period and is due for implementation before the general election, on 1 April. Will he speak to his officials and NHS England about whether further consultation is needed on the decision and whether it could be delayed?
Norman Lamb
I take the concerns seriously. My hon. Friend discussed the need for more time in his speech. I will put his representations to officials and NHS England. I cannot go further than that, but I recognise the importance of the issues that he raises and I pay tribute to the work of his constituent Nicola Hawkins in collecting many names on her petition.
Following the work of the taskforce and conversations with key stakeholders last year—from individual patients and patient groups to CCG leaders, area teams and providers of services—NHS England has identified opportunities for improvement. That will affect both what is commissioned and how the services are commissioned.
The NHS England taskforce has identified two areas where there is potential for improvement, and that must be what the process is about. First, it has identified commonly-delivered services that it may be appropriate to devolve to CCGs for local commissioning. Formal responsibility for commissioning those services would be transferred to CCGs. Secondly, in line with the vision of the five-year forward view, NHS England proposes a more collaborative approach to commissioning specialised services, whereby it jointly commissions services with CCGs. That is not a transfer to CCGs—it is joint commissioning. While some highly specialised services will continue to be commissioned entirely nationally, CCGs will be invited to have a greater say over the commissioning of the majority of specialised services.
My hon. Friend intervened on the transfer of commissioning responsibility. The PSSAG met and formulated its recommendations on 30 September. Following proposals from NHS England, it concluded that renal dialysis services and morbid obesity bariatric surgery services did not meet the four statutory requirements—debated in Parliament—for commissioning nationally as part of the prescribed specialised services list, and that therefore commissioning responsibility should be devolved to CCGs. Ministers were minded to accept its advice on changes to the list of prescribed specialised services. Given the changes involved, they felt it was important to engage with stakeholders on the practicalities of transferring the commissioning responsibilities.
The Department of Health launched a public consultation on the logistics and timing of the transfer, which ran from November to 9 January. The consultation asked respondents to consider how a transfer of commissioning responsibility from NHS England to local CCGs could take place, and what would need to happen to ensure a smooth transition while service standards and patient safety were maintained.
We are carefully considering all responses to the consultation, and will respond in due course. NHS England has assured me that it is absolutely committed to issuing guidance to ensure the safe transfer of commissioning responsibility from nationally commissioned services to locally commissioned services, where that is recommended by the PSSAG. It is anticipated that a range of products would make up that commissioning guidance, including national service specifications, national standards and contracting information.
Concerns have been raised and views expressed today and through the consultation about the transfer of renal dialysis services, which I think are the subject of the petition that my hon. Friend referred to. I assure hon. Members that NHS England is in dialogue with stakeholders about both the opportunities and the challenges of transferring responsibility for renal services. Indeed, Dr Paul Watson, the specialised services taskforce lead in NHS England, met stakeholders from renal service representative groups on 18 November to hear their concerns. My noble Friend Lord Howe, an Under-Secretary of State, also recently met all-party kidney group. I repeat that I will relay my hon. Friend’s plea for more time and of course respond to him and other hon. Members.
In addition to the proposals for formal transfer of commissioning responsibilities, NHS England is currently exploring collaborative commissioning—which is what most of this afternoon’s speeches have been about—between NHS England and CCGs, for most specialised services. NHS England has identified the fact that some services will always need to be commissioned on a national basis, including, for example, services that were under the previous arrangements commissioned as highly specialised services. However, a number of services on the current list could potentially benefit from being commissioned on a smaller footprint with greater local involvement, to make joined-up services possible across the care pathway, while maintaining national standards.
One faces a danger when separating off some procedures for national commissioning if other parts of the pathway are commissioned at a local level; that is the case with obesity services, because preventive services are commissioned locally whereas bariatric surgery is commissioned nationally. The danger is that one creates false or artificial divides in the patient pathway, which can damage patient care and create perverse incentives. We have to be cognisant of that and see whether there are better ways of doing things.
NHS England is looking to provide an opportunity for CCGs to begin collaboratively commissioning a number of services in the prescribed specialised services list from April. The approach being taken is a deliberative one that does not impose things on the tight time scale that my hon. Friend was concerned about. Collaborative commissioning would likely be carried out through joint NHS England and CCG committees. It would maintain the expertise—the specialism—but there would be the potential to spread that expertise and build capacity at a local level, which could be in the interests of everyone.
NHS England is aware of several CCGs that would welcome the opportunity to become involved in specialised commissioning, but it is equally aware that many CCGs will not be in a position to take on such increased commitments from 2015-16. There is therefore no question of a return to the previous arrangements.
Stephen Gilbert
I remain grateful to my right hon. Friend for giving way, and to other colleagues; this is the last time that I will intervene. I hear what my right hon. Friend is saying. It is reassuring that he is using language about improvements to patient care and the benefits that patients will feel, because there is a danger—I think it is felt by all the patient groups that we have talked about this afternoon—that collaboration becomes buck-passing. I would be reassured if he was giving the undertaking that NHS England will continue to engage with those groups that feel they have not been engaged with already and that improvement to the patient experience is the bottom line in relation to some of these changes.
Norman Lamb
I can reassure my hon. Friend on both those points. Openness, transparency and engagement with patient groups are incredibly important, and I would always argue the case for them.
Collaborative commissioning would be an open offer; it would be an opportunity to keep up momentum for high-performing CCGs that are keen to deliver more for their local communities. NHS England is looking to pilot or trial these innovative arrangements in 2015-16—nothing more than that.
NHS England has established a specialised commissioning co-design group, including members of the NHS commissioning assembly, with advice coming from clinical and patient experts, to develop further the details of the collaborative commissioning approach. NHS England will also support CCGs to ensure that the commissioning system remains stable during the transition to any new arrangements.
NHS England is now embarking on a comprehensive programme of patient and stakeholder engagement to support the implementation of these changes; I think the hon. Member for Mitcham and Morden made a plea for that engagement to happen.
Mark Tami
It all sounds very good; localism is always thrown around as being a positive thing. My concern is that it still creates uncertainty. From the patient’s point of view, the uncertainty must be whether they will be able to access the treatment they need where they live.
Norman Lamb
That is a legitimate concern and fear, but the arrangements have the potential to avoid that risk, so that those concerns and fears are not realised; I will expand on that in a moment.
Guidance will be issued later this month setting out the detail of the proposed changes, alongside the criteria that determines which service is commissioned at which level. The engagement programme will include a number of patient and public engagement events and workshops in February, led by regional and area teams, to help to co-design the process for implementing the changes with CCGs. I encourage involvement with that programme, and as part of it NHS England will seek views on the criteria to decide which service is best commissioned at which level.
NHS England acknowledges that people are concerned about the re-emergence of a “postcode lottery”—the hon. Member for Alyn and Deeside specifically mentioned that point—as a result of a more collaborative approach. In particular, people are concerned that specialised services could once again be commissioned in a variety of ways across the country, resulting in patients experiencing difficulties in accessing services.
I totally understand why people have that anxiety, but let me be clear that NHS England would remain the accountable commissioner for any services commissioned collaboratively with CCGs. My hon. Friend the Member for St Austell and Newquay referred to the Health Committee’s concerns about the previous arrangements. However, because NHS England would remain the accountable commissioner and because commissioning would be done collaboratively, I think that concern has been sufficiently addressed.
Since April 2013, NHS England has achieved significant progress in developing a set of nationally consistent service standards and commissioning policies, which have been widely welcomed. They ensure equity of access to high quality services; the point about access was referred to by a number of hon. Members. These standards and policies will still apply for specialised services that are jointly commissioned by NHS England and CCGs, and NHS England will continue to improve on those in the years to come. I think that the shadow Minister, the hon. Member for Copeland (Mr Reed), also raised concerns about access and I hope that he finds what I have said about it reassuring.
For any services that are fully devolved to CCGs, allocations will be made on the basis of activity. Data from NHS England area teams would be used to trace historical activity levels and CCG funding allocations would be based on those, with adequate adjustments for population increase.
The purpose of the move to collaborative commissioning is to support more effective joint working and to allow discussions about service redesign to take place across the local health economy, engaging both national level and local level to try to build capacity.
In the short term, patients should not notice any difference to the service they receive, and in the medium to long term NHS England is confident that these changes should result in improvements, rather than a deterioration—including improved outcomes for patients, more integrated pathways and a better patient experience. We continue to work closely with NHS England as it develops these proposals and engages with all those involved in the commissioning of specialised services, including CCGs, individual patients and—critically—patient groups, area team commissioners and providers of services.
I thank all hon. Members and the sole right hon. Member here today, the right hon. Member for Wolverhampton South East, for contributing to this debate in a constructive way. The issues that have been discussed are of real concern, and it is right that they should have been raised. However, I think we have the potential to improve the way in which the system operates.
Mr Peter Bone (in the Chair)
I thank all right hon. and hon. Members for this excellent debate.
Question put and agreed to.