NHS: Standards of Care and Commissioning

Baroness Thornton Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Thornton]

My Lords, I start by thanking my noble friend for initiating this debate and for emphasising the importance of standards of care and of the effect on patients of the proposed changes to the commissioning regime. Indeed, I congratulate all speakers in this debate. On this occasion, the point of my noble friend’s remarks was possibly, “We’re all in this together”, in dealing with the standards of care. However, he also said that we face some major challenges here, which are the challenges that he posed, as did several other noble Lords, including the noble Baronesses, Lady Emerton and Lady Hollins, and my noble friend Lady Sherlock. The question is: will the Bill help or not?

I welcome the noble Lord, Lord Owen, to both this debate and our wider discussions. I look forward to reading his pamphlet, Fatally Flawed, this weekend, and I suggest that the Minister might choose to do the same. However, I will resist the temptation to join the noble Lord in what would be a Second Reading speech.

I start by quoting a young woman who works in healthcare and who spoke last Saturday to between 200,000 and 500,000 people—personally, I think it was nearer the latter. In many ways, her simple eloquence says it all about how thousands of dedicated health workers feel. She said: “I am an NHS physiotherapist and have been for 13 years. My patients are people living with complex disability from conditions such as MS, brain injury, spinal cord injury and stroke. I work with a wonderful team of NHS workers such as occupational therapists, speech therapists, psychologists and rehab assistants, as well as social workers, to support our patients to overcome barriers to their independence, often supporting them back to work and working with their carers to support them to stay in their homes for as long as possible … David Cameron told you all in his election campaign that he would ‘cut the deficit, not the NHS’. Well, if 50,000 frontline NHS posts at risk doesn’t count as a cut, I shudder to think what does … For the sake of my patients, I fear the introduction of ‘any willing provider’. I fear that it will fragment services, will make the postcode lottery of care worse, and the most vulnerable patients, those least able to stick up for themselves—the kind of patients I treat every day—will be hit the hardest. Good quality patient care relies on good communication. How can we guarantee this, when services that currently work together are pitched into direct competition against each other? … In parts of the country, physios are already starting to see the rationing of care to just one or two treatment sessions, regardless of need … This is not the NHS I signed up to work for. I don't believe it is the kind of NHS that people in this country want”.

In this short response to the debate I am going to argue that we would not start here with reform and I will ask some questions about the risks to standards of the proposed commissioning system. I put a plea to the Minister: could we perhaps have some new words in his answers to these debates? I have looked back at the debates and discussions in the House since the White Paper was published last July, and time after time the Minister has stuck admirably to the Andrew Lansley brief, with what is becoming the famous NHS techno-jargon that weaves a web of words but really does not serve to comfort, or even leave one any the wiser. It is very noticeable that when the Minister comes off script and is back to his old, clever self, we prefer it and I, for one, understand things better.

We are nearing the point, after many questions and sustained criticism from professionals, patients and even the Minister’s partners in the coalition, when we need some real answers to real concerns, not least on the commissioning that is the subject of this debate. Notwithstanding the progress of the Health and Social Care Bill, I invite the Minister to agree that there is no doubt that the period 2011-14 is likely to be the most challenging ever faced by the NHS. The NHS is faced with the challenge of producing £20 billion in efficiency savings, putting considerable pressure on the system to maintain current standards of care. Given those constraints, we on this side of the House are still of the view, perhaps even more so now, that this is not the right time to embark on the largest structural reorganisation in NHS history, which includes scrapping those layers of the NHS structure with real experience of commissioning—family care trusts and strategic health authorities—and putting the power in the hands of untested and inexperienced consortia.

I am not saying that PCTs and SHAs have been unfailingly brilliant; in some cases, they have not even been good or average. There was and is significant room for improvement, and I think we would all agree on that. Most notably, clinical leadership and engagement in PCTs has often been weak, local accountability has been lacking and imbalances in status and power that exist between commissioners and providers appear to have limited substantially the former’s ability to influence service provision, to say nothing of the lack of clinical presence in the whole process. However, we believe that it would have been better to tackle this problem rather than to turn the whole NHS upside down.

What of the transition? Responsibility for maintaining and improving the quality of services will fall initially to the new PCT clusters. At a time of major reorganisational transition it will be especially important to have in place adequate performance measures supported by transparent and robust mechanisms, through which the GP consortia and PCT clusters can account to local people for the quality and performance of local health services. I do not see how this can be achieved when PCTs are being decimated either by the efficiency cuts or people jumping ship to work elsewhere. Perhaps the Minister can say how he thinks this will be achieved.

We know that PCTs are responsible for commissioning a range of primary, community, secondary and tertiary health services, often in partnership with local authorities—for instance, in mental health—and, indeed, other PCTs, through networks or consortia for specialised services, and primary care clinicians through practice-based commissioning. That has already been mentioned by the noble Lord, Lord Patel—cancer networks being one of these. This is a complex landscape and it is about to become even more so. It will grow a whole new bureaucracy of its own if the competition which the Government intend to put at the heart of the Bill, whatever one believes about that, is as envisaged.

The majority of concerns with the health Bill in relation to commissioning of services fall into five broad areas: multidisciplinary commissioning; commissioning of long-term conditions; specialist commissioning; a lack of national guidance leading to fragmentation; and communication and co-ordination between providers and commissioners. A theme that runs throughout these areas is concern about the involvement of GPs and the ability of relevant commissioners to secure appropriate clinical input when commissioning services.

The King’s Fund report of the beginning of March highlights the need for strong, strategic commissioning to reconfigure some services such as cancer, cardiac and stroke care across large geographical areas. It argues that this will not be delivered by the Government's health reforms, which will abolish the strategic health authorities currently responsible for leading this work and leave GP consortia to fill the gap, which they are unlikely to be able to fill—to which I add that that will probably be the case for at least 10 years or so.

Briefly, on long-term and specialist conditions, throughout the debates since last July various advocates and campaigning organisations on almost every long-term condition have commented on the proposed reform. The Minster must accept that the Alzheimer’s Society, the cancer campaigns, diabetes organisations and many others are very worried about the commissioning for their conditions becoming fragmented and incoherent, to say nothing of end-of-life care and, for example, treatment for children with very serious conditions.

The Government are asking those who have fought long and hard for recognition of and improvement in the treatment and care of people to take on trust that everything will be okay. The Minister needs to accept that this clamour about commissioning, although we are joining it, is not motivated by Her Majesty’s Opposition being oppositionist; it is about a long list of concerns, questions and anxieties that we have to address without the proposed revolution. I look forward to the Minister’s reply.