NHS: Reorganisation

Baroness Sherlock Excerpts

Thursday 16th December 2010 Lords Chamber

[Baroness Sherlock]

I add my thanks to my noble friend Lord Touhig for securing this debate. Before I start, I declare an interest in that I did some work recently for the Social Care Institute for Excellence on the establishment of a college of social work. The SCIE is interested in the social care elements of this debate.

I spent some time as an adviser in the Treasury, and whenever a new idea came up the kiss of death from Treasury officials was to bill it as “a solution looking for a problem”. When I came up with a pet idea, it was incredibly annoying—I would be pretty clear that it was a great idea—and I would not for a moment suggest to the noble Earl that this was a solution looking for a problem. However, that experience taught me that even when reform is desirable and well implemented, the costs of transition in so many different ways are so huge in terms of a reduction in productivity and all the disruption that it causes that the test has to be set very high to decide that the game is worth the candle. That is something that concerns me now. We have heard a very good defence today from my noble friend Lord Hunt of Kings Heath and the noble Baroness, Lady Williams of Crosby, who remind us that the NHS, with which we are perhaps over-familiar, is a real and rare jewel and something that we should celebrate and defend. It is something that we should take very careful steps to amend only very slowly, if at all, unless the case for change was overwhelming.

Secondly, if there is a case for change, surely if it is on this scale it should happen only when the weather is fair and the wind is at our back. I am afraid that at the moment it does not feel so. We are aware of the constant pressures on the NHS finances of demographics, complex health needs, and the price of drugs and technology. That is why there has been so much investment in the health service in the past decade, which the noble Lord, Lord Alderdice, was kind enough to acknowledge. Now the NHS will face an enormous squeeze; it has to find £20 billion of efficiencies a year, which is a huge challenge. Who will have to find those efficiencies? It will be the PCTs, which will close and their staff face losing their jobs. The PCTs will have to address themselves to the management of change and prepare for the brave new world.

In that circumstance, the only argument for introducing this level of structural change will be if it can be shown that it was necessary in order to achieve those economies. The King’s Fund, for which I have a great deal of respect, as do other Members of this House, has this week disagreed with the idea that structural changes will help to meet the productivity challenge. Indeed, it said that it shared,

“the concerns set out by the Health Select Committee yesterday, that they will still act as a distraction from delivering the enormous productivity improvements required across the system”.

We should take that warning very seriously.

Thirdly, I shall comment on the new governance arrangements. Like many observers, I have been concerned from the first time I heard of these proposals about what would happen to the community aspects of health. We do not live as individuals and we do not experience our health or welfare as individuals; we live in communities. If we move to commissioning by GP practices gathered together in commissioning groups, who will be responsible, and how, for the health of a whole community? I understand from the Government’s response that the local health and well-being boards will be the vehicle for securing collaboration between the NHS, public health, adult social care and other services. Of course, there is also the local government scrutiny, but will not some health and well-being boards have GP consortia that straddle their boundaries, making co-ordination more difficult? How will that be addressed?

There is also the specific role of local authority scrutiny, but this adds up to quite a complex piece of governance machinery. Accountability will run downwards to service users and communities, and sideways through the health and well-being board, the local authority scrutiny group, and perhaps Local Health Watch. It will run upwards to the national commissioning board and perhaps to the CQC, the national health watch Monitor, and the national public health service. That is quite a complex form of governance. What will happen when those different parts of the system pull in different directions? How should a judgment be made by a consortium if one set of pressures comes down from the national commissioning board and another comes locally or sideways for the local variations? How will that work in practice?

I have two specific questions for the noble Earl. Because they are so specific, I would quite understand if he would prefer to write to me. First, much is said about the need for the integration of health and social care. I am very much behind that principle and wish the Government every success in pursuing it, but could the Minister explain how, in practice, social care will be represented on the commissioning boards? How will it have a place in the commissioning structure to ensure that it is delivered in practice as well as thought about in theory?

My second set of concerns relates to the safeguarding of children. I am sure that the Minister is aware of the comments reported in the Telegraph last week by Tim Loughton, the Minister in another place who is responsible for children, who said that it would be more difficult for doctors to spot child abuse as groups of GPs already adopt widely different standards in relation to that. I am sure that the Minister is aware that a number of children’s charities are concerned that aspects of the health service have long been the weak link. That can be a significant concern when one reads serious case reviews. What will happen in this new system? Will the Minister explain how, if the system is to be changed in the way that is described, the Government will ensure consistently high standards of policy, training and practice in safeguarding under the new commissioning arrangements?

Finally, will the Government think of another way of doing this? I was struck by the comments by the noble Baroness, Lady Williams of Crosby, about the expertise in this House. Given that pathfinders will try this in practice—even allowing for the idea of the noble Lord, Lord Rea, that they might do this under canvas—will the Minister consider, when the pathfinders have run their course, pressing the pause button, evaluating carefully what the results tell us and bringing something back for the scrutiny of this House and another place so that we can work out whether people such as me who are worried are wrong? It is very hard for me to admit that I might be wrong, but I concede that on rare occasions this happens—a little less laughter, please. It may even be true of other noble Lords in this House. That would give us an opportunity to take a step back and consider whether our worries have turned out to be right. If they have not, we can carry on with less concern. However, if we are right, we could protect the NHS from damage. The NHS is a jewel in our crown, and we risk public wrath if we do anything that could damage it.