NHS: Reorganisation

Lord Beecham Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Beecham]

My Lords, I join previous speakers in congratulating my noble friend Lord Touhig on ensuring that we have had this debate today, and I thank other noble Lords for the thoughtful contributions that we have heard. In particular, I congratulate the noble Lord, Lord Colwyn, on being the only Conservative Back-Bencher to have participated.

I have to begin, somewhat unusually, by declaring a non-interest. The BBC website, in referring to this debate, refers to me as “former president of BUPA”. I have been neither a member nor a president of BUPA. I am, however, a former president of BURA, the British Urban Regeneration Association, in which position I succeeded the noble Lord, Lord Jenkin.

There is a celebrated case in what used to be called “master and servant” law when a workman was denied compensation in a claim against his employer because he had been injured not while going about his employer’s business but when he was on “a frolic of his own”. That phrase might well be applied to the Secretary of State. After all, despite the fact that he has promoted the mantra of “no decision about me without me”, major decisions have been taken without support, or certainly with very little support, from a wide range of consultees including the BMA, the royal colleges, the NHS Confederation, many patient groups and a number of think tanks. Small wonder, then, that he seems to have been supplied with a minder, in the somewhat unlikely shape of Oliver Letwin, to run a rule over what he is apparently doing, and small wonder that apparently today’s Times editorial questions whether No. 10 is continuing to give wholehearted support to these proposals.

Your Lordships have already been reminded of the high level of public satisfaction with the health service by my noble friend Lord Hunt and the noble Baroness, Lady Williams. In addition, as part of the background to this debate, there are of course the pledges that the Government made in their various component parts. There is the issue of top-down reorganisation, to which the noble Baroness referred. That was explicitly excluded in the coalition agreement, but we are now getting not only a top-down reorganisation but a great deal of top-down commissioning as well.

Then of course there is the pledge about the real-terms increase of the health service. Contrary, I am afraid, to the assertion made by the noble Lord, Lord Colwyn, there is to be no real-terms increase for the health service; I refer, as an authority for that, to paragraph 51 of the report of the Health Select Committee, chaired by Stephen Dorrell, the once—and perhaps future—Secretary of State for Health.

Those pledges join a long list of broken pledges across a range of policy areas. There are tuition fees, of course, which we debated in this House this week, real-terms funding increases for schools and, indeed, a range of health issues including a pledge not to close A&E and maternity units, which have in fact closed on the present Secretary of State’s watch. This indeed has become a Government of serial pledge breakers. In fact, there is some danger that they may be becoming addicted to it and need treatment for it.

On the other hand, it is only fair to say that there are changes in the Government's position, seen in this week’s Statement and Command Paper, which are welcome. I certainly welcome the restoration of public health responsibilities to local government and the decision—in this respect, I beg to differ from the noble Lord, Lord Patel—to have maternity commissioned locally rather than nationally. I also welcome the maintenance of the powers of scrutiny of the health service being to local government, which the original White Paper had proposed to take away. Yet there are governance issues that need to be addressed.

The noble Lord, Lord Rodgers, referred to commissioning at a regional and sub-regional level for services which go beyond an immediate locality. There is the accountability of the national commissioning board to the Secretary of State as opposed, perhaps, to Parliament as a whole. There is, if I may say so, something of a degree of naivety in the praise that the document gives this week to the success of the governance of foundation trusts. Whatever their merits, the membership of foundation trusts is very small in relation to their potential membership and the turnout of votes in elections to them is even smaller. There is also the issue, which noble Lords have already referred to, of whether it is sensible to rush forward with the conversion of all trusts into foundation trusts.

Much of this debate has turned on the issue of GP commissioning and it is certainly the case that this is being piloted in a number of pathfinders. I would hesitate before adopting my noble friend Lord Turnberg’s recommendation, which would lead to perhaps only 50 commissioning authorities, but I join him in asking: what number is envisaged and of approximately what average size, when the present range within the pathfinders is enormous? It ranges from 18,000—which is, I suppose, a general practice—to half a million. That is quite extraordinary. What is important is that there should be a strong degree of coterminosity between the GP commissioning consortium and the principal local authority which has responsibility in particular for social care but also for other relevant services.

Moreover, this week’s document says that consortia will be able to contract, to dissolve, to merge and that their boundaries can be flexed. Is that not a recipe for perpetual motion, in a field where we really need stability? Finally, there is the commissioning of GP services, to which many of your Lordships have referred. I return to the proposition of the Local Government Association, and declare an interest as an honorary vice-president of it, to suggest that GP commissioning should be signed off by the local authority in the relevant area. Of course, coterminosity would be needed to do that.

Part of the debate has focused on the issues of choice and personalisation. I said in a previous debate on this matter, as I have said elsewhere and to my own party when in government, that blurring the distinction between choice and personalisation does not help the debate. The two things are not synonymous. Yet if we are to make choice a reality, particularly in providers, to what will it extend? Will it extend to the closures of facilities and will any group of potential patients ever agree to a closure of a facility?

How will the framework proposal for greater choice in mental health services—the framework document was published yesterday—be met under national commissioning? The noble Lord, Lord Alderdice, referred to the problems in urban areas caused by people moving in from outside, very often with acute social problems. Ought not the services for those people to be commissioned locally rather than nationally? Yet that is not what the framework document says. Again, the document makes a rather bold claim for the national commissioning board. It will, it says,

“ensure people who receive services are involved in their planning and development”.

How will a national board do that, as opposed to local organisations?

There has run through this debate and much of the public debate a thread of deep concern about the competitive principle. The BMA is very clear that co-operation, rather than competition, ought to be the watchword. Several noble Lords, including the noble Baroness, Lady Finlay, referred to the issue of willing providers and the need to avoid cherry picking. I ask the Minister whether there will be any safeguards against such practices. Would he care to comment on the OFT investigation into the private healthcare market that has been initiated this week? Five providers apparently deal with 85 per cent of that market, and there has been a suggestion—which is subject to investigation—that that market may have been neutrally managed, not necessarily to the benefit of the consumers. How will that be avoided in the new set-up? To repeat the question of my noble friend Lord Touhig: will the Government ban companies from advising commissioners on the one hand and providing services on the other? It seems fairly obvious that external organisations will do that. Finally, in this rather Darwinian world of competition, what happens to institutions, hospitals and other services that are deemed to be failing? Will they, as we have learnt about schools this week, simply be allowed to fail and close? What happens then to patient choice?

Finally, there is the issue of cost, which the Select Committee looked into in considerable detail this week. It complained that even now there is no robust estimate of the cost of this reorganisation. It has criticised the Government’s figure of a cost of £1.7 billion. Nor does it agree that social care can be sustained without restricting eligibility on the basis of the recent local government finance settlement. I understand from my brief reading of the documents that were published yesterday that a figure for the overall cost of this reorganisation may be given in the impact analysis to be published in January. If it approaches the £3 billion that credible authorities suggest, is that not a complete distortion of spending needs at a time when services will be very much under pressure? Should the Government not reconsider the scale, the timing and, above all, the cost of the reorganisation?