Public Bodies Bill [HL]
Lord Beecham Excerpts(13 years, 6 months ago)
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Lord Taylor of Holbeach
My Lords, I thank the noble Lords, Lord Hunt of Kings Heath and Lord Pannick, for bringing back these issues because it gives me the opportunity to clarify the Government’s position. As they say, Amendments 1 and 6 revisit the issue of consultation and so I shall respond to them together.
Amendment 1, to which the noble Lords, Lord Hunt of Kings Heath and Lord Pannick, have spoken, would require Ministers to publish the proposed reform on their department’s website or to otherwise make it publicly available in the event that a full public consultation was not to be undertaken. This is a helpful amendment and one that speaks to an important principle, so I thank noble Lords for bringing it back at Third Reading.
I said on Report that I thought that this was something that the Government could consider, and I can assure your Lordships’ House that we have done so. Supportive as we are of the objective behind this amendment, on balance, we do not believe that such a requirement is appropriate on the face of the Bill. We are debating ostensibly an issue of guidance and best practice, not imposing a legal requirement. For that reason I am able to support the purpose of the amendment but not its inclusion in the Bill. Given that I believe that this is an issue of guidance, I am happy to give a very specific assurance that the guidance for use by officials on making orders under the Public Bodies Bill, to be published by the Cabinet Office, will include a specific reference that departments ought to consider the most appropriate way of making a proposal publicly available.
The Government are committed to increasing transparency and accountability across the public sector. I do not believe that I can honestly stand here and say that I oppose the purpose of the amendment and still be true to that overall objective. I fear that our only point of divergence is on how to ensure that this purpose is reflected in the best way possible when Ministers are developing proposals and drafting orders. It is the Government’s clear judgment that a more practical and proportionate way of achieving the noble Lord’s objective is to capture this issue in the guidance which will be used by departments when bringing forward orders. On Report, the noble Lord, Lord Hunt, described my pledge to take this back to my colleagues in government as “handsome”. I hope that he will not now consider this an ugly conclusion by the Government. I can assure him that the principle of making proposals publicly available is one on which all sides of the House agree.
I should like to make one further observation on the noble Lord’s amendment. I agree that, in 2011, a website represents a very sensible vehicle for making proposals publicly available; indeed, I should expect departments seriously to consider whether website publication is not appropriate for publicising their proposals. However, my crystal ball will not tell me whether this will be the case for ever. Technology moves on. The statutory framework for consultation on this legislation is set out in Clause 10, and it is intended to be a stable and firm statutory requirement for reforms long into the future. It is guidance, not the statue book, that can be readily updated to reflect whatever is most appropriate at given times. That provides further weight to the argument that, however sensible this amendment might seem, it is not an appropriate addition to the Bill.
I am disappointed that I cannot be more supportive of the noble Lord’s amendment. I know that it is a sincere attempt to improve the Bill and to help the Government deliver a comprehensive and watertight piece of legislation. However, the vote on Report made it clear that consultation must not always be full public consultation and that a Minister must ultimately be responsible and indeed accountable to Parliament for deciding how to undertake proportionate and meaningful consultation. It is therefore not appropriate to seek to alter this legal framework through the noble Lord’s amendment.
I shall now turn to Amendment 6 in the name of the noble Baroness, Lady Royall, and the noble Lord, Lord Hunt of Kings Heath. This proposed amendment to Schedule 1 in practice concerns the issues of consultation and subsequent procedure, set out in Clauses 10 and 11, and how they might apply to the closure of the regional development agencies. I shall start by once again taking the opportunity to pay tribute to the work of the RDAs. I also acknowledge that the noble Lords have a strong regard for the work that the RDAs did and would prefer them to continue.
We have had very thorough debates in the House, in Committee and on Report, on the RDAs. The noble Lord, Lord Hunt, referred to these debates. I have explained that the Government's strong preference is to abolish the RDAs, and I have set out the reasons behind this, including why the current arrangements are no longer sustainable. The coalition agreement, the June 2010 Budget Statement and the local growth White Paper are equally clear about the Government's proposal to abolish the RDAs. The Government continue actively to engage with RDAs and interested parties on how closure is to be achieved. Individual RDAs have been in touch with their stakeholders, for example about their asset plans. The consultation and engagement are taking place irrespective of the requirements in the Bill.
I have listened to the arguments for the reform of public bodies to be an open process. Clauses 10 and 11 underline the Government’s desire for this to be the case. Clause 10 requires a Minister to consult on a proposal to which an order made using the Bill would give effect. The amendment proposes that in the case of RDAs, the explanatory document that accompanies an order should include, first, the question that was asked about the principle of abolishing RDAs and, secondly, a summary of the representations received on that question.
The requirements of Clause 10 on a Minister to consult when making an order covered by the Bill are clear. The requirements applied to the RDAs would oblige the Government to ask about the principle of abolition. Similarly, Clause 11(2)(d) requires that any explanatory document should include a summary of representations received in consultation. Therefore, I do not believe that the amendments in this group would provide any additional information for Parliament. Instead, they would unnecessarily complicate the drafting of the Bill. I hope that, in the light of the clarification that I have given with regard to the existing requirements—
Lord Beecham
My Lords, does the Minister recall that on Report, I asked about the consultation process for RDAs in the light of a letter that the Minister had written to my noble friend Lady Royall, in which he stated that consultation effectively would take place after the passage of the legislation? I asked on that occasion whether in those circumstances the consultation that took place with individual RDAs would be on the basis that each case would be considered on its merits, or whether in effect it was all or nothing in terms of abolition. Will there be an individual consultation in respect of each RDA, with the possibility of a different conclusion in respect of one RDA as opposed to another, or is it to be abolition tout court?
Lord Taylor of Holbeach
The consultation will be based on the statutory instruments that will be tabled in connection with each RDA. Therefore, there will indeed be consultation, and an opportunity for each regional development agency to have input on its future. The regions of the country, if they feel particularly motivated, will be able to discuss the reasons why they believe no change should be made to their status.
Lord Taylor of Holbeach
It is the nature of consultation that the Government are open to persuasion: that is the purpose of a consultative exercise. The policy decision has been made. It is the resolve of the Government to implement the policy. None the less, there will be a consultative process, at which there will be an opportunity to argue the opposite case.
I hope that, in the light of the clarification that I have given on the requirements of Clauses 10 and 11, the noble Baroness and the noble Lord will not press their amendments. I also hope that, given my assurances on guidance and the problems with adding Amendment 1 to the Bill, the noble Lord will withdraw his amendment.
NHS Reform
Lord Beecham Excerpts(13 years, 7 months ago)
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Earl Howe
I can reassure my noble friend Lord Ribeiro instantly on that. He will know, I am sure, that the acronym that was coined by the previous Government, QIPP, which stands for “quality, innovation, prevention and productivity”, is symbolic of a whole series of workstreams not just in the Department of Health but throughout the health service to ensure that quality is maintained and enhanced in the service. Unless we deliver higher quality to patients, the service will not be sustainable. Some people say that higher quality care costs more money but, as my noble friend will know from his own craft speciality, the better the care that you deliver the less costly it often is because care that is delivered in a substandard way often results in unintended consequences, such as patients returning to hospital with complications. We need to drive safe care and right care in the system.
Many of the levers that we have to improve quality are not in the Health and Social Care Bill at all—for example, the need to roll out the information agenda, without which there can be little transparency of quality. Those activities are being pursued with energy and drive in my department.
Baroness Northover
My Lords, I think that we have time for both speakers. It is time to hear from the Labour Party and then the Cross Benches.
Lord Beecham
My Lords, months after the Bill was launched upon an unsuspecting world—including, apparently, the Prime Minister—it seems to have been admitted to the fracture clinic if not to the intensive care ward. A number of questions arise from the Statement itself. For example, the Statement says:
“Some services, like A&E or major trauma, clearly will never be based on competition”.
Is not the implication that other services will be based on competition? Will the Minister comment on the predominant role of Monitor as a promoter of competition, as opposed to being simply an economic regulator?
On the GP commissioning groups or consortia, will the Government look again at the composition of those groups as well as their degree of local accountability? Will he also look at the powers of the health and well-being boards? Does he have any views about those in addition to the question of their composition?
As for the NHS being in a healthy financial position, does the Minister have any comment on tonight’s story in the Evening Standard about people who were made redundant last Friday having to be re-engaged by PCTs and other organisations, at considerable cost to the NHS?
Earl Howe
My Lords, those who have been re-engaged by the health service, having taken redundancy or early retirement, will forfeit their redundancy pay because there is a clawback arrangement in force, as I told the House the other day.
The noble Lord asked a number of questions. I want to be very brief because I am aware that the noble Baroness, Lady Masham, wants to get in before the time is up. Monitor was described as a promoter of competition. Expressed in stark terms like that, it sounds as though its job will be to go around drumming up competition where there is none already. That is not a correct reading of its functions; it is there to bear down on anti-competitive conduct and to ensure fair competition. The composition of consortia is a concern that we have heard about, and we will listen to that concern. It is now up to the pathfinder consortium to think about this kind of question. The early implementers of health and well-being boards are starting to think about those powers and how they can be used and we will listen to whatever they have to tell us.
NHS: Reorganisation
Lord Beecham Excerpts(13 years, 11 months ago)
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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?
Healthcare
Lord Beecham Excerpts(14 years ago)
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Lord Beecham
My Lords, the noble Lord, Lord Hunt, and I last had a brief encounter about 25 years ago when he chaired the inner-city partnership in Newcastle and I was the leader of the city council. I cannot say that that brief encounter leads me to the noble Lord’s Motion in a blithe spirit, but I shall begin as I do not mean to go on by welcoming at least some of the proposals in the White Paper, particularly the return of public health to local government, whence it was removed by Sir Keith Joseph’s reorganisation in 1973, and the conferment on local councils of leadership in health improvement. Both will be good examples of integrating services rather than fragmenting them, which so many of the other proposals in the White Paper will certainly do.
The House will of course welcome the emphasis on patients and clinicians expressed in the mantra that the noble Lord reminded us of: “No decisions about me without me”. It is a pity that that mantra was not applied to the development of the policy that has produced the massive changes that we are debating today.
The White Paper and the Motion seem to imply that, until now, patients and patient care have not been central to policy, as if the record investment in hospitals, clinicians and nurses and the massive reductions in waiting lists were for the benefit of bureaucrats rather than patients. My own personal experience certainly refutes that, unlike the unfortunate experience of the noble Baroness opposite, who told us about her father. Eight weeks ago tomorrow, my wife died, two years after being diagnosed with cancer. She was a health visitor and nurse, but worked with GPs on training. We had nothing but praise and gratitude for the care that she received in a state-of-the-art cancer unit opened just 18 months ago. She was the daughter and sister of doctors and she would want me to say that she entertained grave doubts as to the proposal to go wholesale into GP commissioning, doubts that are shared by the BMA and many others.
It seems extraordinary that GPs are to be conscripted into consortia, whether they like it or not, with no evidence of their capacity to commission and no assurance of coterminosity with the local authority services with which they must surely connect. Perhaps the Minister will indicate how many GP consortia we are to expect—we have heard figures varying from 630 to 80—and how the consortia might be expected to work with appropriate local authorities. In any event, there is a significant shift to nationalising a whole range of commissioning services, including mental health, maternity, dentistry, ophthalmology and pharmacy—so Barnet would not have been able to do its own pharmacy commissioning under these schemes—which will fragment the key relationship with local councils. Commissioning should be local, involve councils and be piloted.
In addition, it is clear that accountability will be weakened as local government scrutiny powers are watered down. A national board will oversee GPs; health and well-being boards with little local government representation will, in effect, scrutinise themselves; an increasing number of hospitals are to be dragooned into foundation status; and, with the concept of “any willing provider”, as the BMA states, there is a significant risk of two-tier services developing, threatening value for money in the NHS.
Much of the White Paper and the debate today is based on a presumed thirsting for choice, which in the BMA’s view—I think that it is shared by many other observers—does not really exist in the form that is imagined. The BMA rightly suggests that, most of all, patients want a high-quality provider close to where they live and to receive timely, competent diagnosis and treatment. The White Paper blurs the distinction between personalisation, which is essential, and choice of provider, which is not. The BMA recognises the need for some proportionate targets.
Support for the Secretary of State seems to be underwhelming from most professional bodies and patient organisations. We are in for a massive and expensive reorganisation, which has been determined with consultation restricted to the detailed application and not the principles. There is no sign here of any clinical trials. The Secretary of State is guilty not merely of a rush to judgment but a rush to misjudgment, with potentially serious consequences to the NHS and the people whom it serves.
Earl Howe
My Lords, under current powers introduced by the noble Baroness’s own Government, GP commissioning can take place within certain limitations, but it is possible for GPs to engage now in the kind of joint working that we envisage and indeed that her Government put in place. I see no inconsistency there, and I think that that will helpfully inform our debates on the Bill.
GP commissioning, as I said, opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to tackle local priorities. For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently, reducing their reliance on the NHS by avoiding things such as hospital admissions.
GPs will lead but they will not be alone. The NHS commissioning board will be there to support and advise GP commissioners and to share and spread their experiences. There will be no need to reinvent the wheel hundreds of times. One thing that the commissioning board will do as little as possible, though, is tell health professionals how to do their job.
We will also give far more power to patients. Research clearly demonstrates that treatment is better and often cheaper when the patient is an active participant in their care, not simply a passive recipient. In the coming years, we will give patients real control over when, where and by whom they are treated. They will be central to all decisions about their aftercare, often—where appropriate—spending their own budget in a way that suits their needs rather than the needs of the system.
Personal choice will not be the only way that people will be able to shape their care; they will also have a say in how local services develop. Strong local democratic accountability will be an essential part of the new system. Patients will have a strong voice in local decision-making through local authorities and HealthWatch, a new patient champion. For the first time, local people will have real powers of scrutiny over local health services.
We are very good at treating ill health in this country but we are less good at preventing it. We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking. As a result, nearly one-quarter of all deaths in England stem at least in part from an unhealthy lifestyle. We have to do far more to stop people from needing treatment in the first place—to keep people healthy. We need a new emphasis on public health. Later this year we will publish a second White Paper on public health. Its aim will be to transform our approach to public health, protecting the public from health emergencies such as swine flu and improving the nation’s overall health and well-being.
I turn to some of the questions that have been asked. As I said earlier, the debate has ranged far and wide, and there have been a great many questions. We are short of time and I apologise to those noble Lords to whom I shall have to write, but I shall endeavour to cover as many topics as I can.
The speech of the noble Lord, Lord Winston, was uncharacteristic of him. I am sorry that he does not buy into the vision that we have set out. I am sorry that he does not think that we published the White Paper in good faith. The noble Lord gave the House to believe that the considerable efficiencies which we have signalled to the NHS it needs to achieve over the next four years were initiated by this Government. He will, I am sure, recall that they were in fact instigated by the previous Government. They are necessary and have nothing whatever to do with the Government’s White Paper. We need to treat more patients for approximately the same money without diminishing quality. That is the challenge.
I could hardly believe what the noble Lord said about the research budget. The announcements that we have made about research, arising out of the spending review, have been widely welcomed by the research community. We were clear that we wanted to protect science and we have done so. In the current economic climate, that is exceedingly good news.
The noble Lord, Lord Turnberg, in particular, should be reassured of our commitment to the promotion and conduct of research as a core NHS role. The White Paper makes that commitment clear. It also commits the department to a culture of evaluation. The reasons are straightforward. Research provides the NHS with the new knowledge needed to improve health outcomes. Research enables the department to know whether our policies are effective, cost effective and acceptable. The Government are committed to maintaining a ring-fence on research funding and will cut the bureaucracy involved in medical research. Work is in hand to achieve that.
The noble Lord, Lord Winston, also expressed scepticism about the whole idea of measuring health outcomes. Again, I was astonished that he, of all people, should pour cold water on our wish to do so. Just because it can sometimes be difficult to measure certain outcomes in a meaningful way does not mean that you should just give up. Great care must, of course, be taken when interpreting outcome indicators. You cannot simply make black-and-white judgments. However, if we focus only on processes, we risk creating a whole system of accountability that has lost sight of the overall purpose: improving the health of patients.
The noble Baroness, Lady Wall, asked me to underline the importance of local decision-making in the NHS. I readily do so. Those in a position to know what services are required to meet the needs of their patients are those closest to those patients—not politicians in Whitehall, but local doctors in general practice, local doctors and managers in hospitals and patient groups with local knowledge. All of this is part of our vision, which we intend to give substance. I was grateful to the noble Lord, Lord Mawson, for all that he said on this.
I welcome the remarks of the noble Lord, Lord Beecham, about health and well-being boards. It is not only they that will be scrutinising their own activities. As part of the public health service, health and well-being boards will be subject to quality and outcome standards set by the Secretary of State, and will be supported in their efforts by the public health service centrally.
The noble Baroness, Lady Masham, spoke in her characteristically impassioned way about patient safety. I agree with her that patient safety is absolutely vital. It is a key domain of our proposed outcomes framework; a key part of the quality agenda. My noble friend Lady Knight will, I am sure, agree that the most important thing that we need to do is bring about an open and transparent safety culture within all NHS organisations, a culture that is open about when mistakes are made and in which the number of serious incidents falls. Most importantly, it must be an NHS that learns from its mistakes.
The noble Baroness, Lady Masham, referred to the case of the tetraplegic man in Wiltshire whose life-support machine was cut off. This is a tragic and deeply distressing case, currently being investigated by the Nursing and Midwifery Council. Under the new registration framework, introduced in April 2010 for NHS trusts, all providers of regulated activities must register with the Care Quality Commission and meet a set of 16 requirements of essential safety and quality. These include a requirement to ensure that all staff have the necessary qualifications, skills and experience, which are necessary for the work to be performed. All agency staff must meet the same professional standards as permanent staff, as set out by the independent regulator, the CQC and each local safeguarding board. The Department of Health expects all NHS trusts to ensure that they employ appropriately qualified and supervised locums and agency staff.
My noble friend Lady Miller set out her view on which outcomes patients want. Her remarks were very helpful. I am pleased that there appears to be much commonality between what she set out and what was included in our proposals for the NHS outcomes framework. At the highest level, the outcomes that we felt mattered were preventing people dying prematurely; enhancing the quality of life of patients with long-term conditions; supporting people to recover from acute episodes of ill health and following injury; ensuring people have a positive experience of care; and, finally, treating people in a safe environment and protecting them from avoidable harm. Those domains get very close to what most of us would regard as a synoptic view of what good outcomes mean.
The noble Lord, Lord Turnberg, spoke about the need to achieve integrated care across primary and secondary sectors. I agree with him. The purchaser and provider split that the White Paper refers to must not be seen as a reason or excuse for GP consortia not to seek the advice, support and collaboration of clinical expertise on the provider side to ensure that the best possible services are commissioned for patients.
The noble Lord, Lord Mawson, asked how we can ensure that GPs will work across the community and public sector generally. Health and well-being boards have a critical role to play in co-ordinating a strategic patient-centred approach at a local level. GPs, local community representatives and democratically elected councillors will be tasked with making sure that they act on behalf of their patients and communities to deliver integrated services. A board will have a formal duty to involve and consult local people.
The noble Lord, Lord Beecham, asked in particular how GP consortia will work with local authorities. We have proposed that local government should have an enhanced responsibility for promoting partnership working and integrated delivery of services across the NHS, social care, public health and other services. It will be important for GP consortia to work in partnership with local authorities—for example, contributing to joint assessments of the health and care needs of local people and neighbourhoods, and ensuring that their commissioning plans reflect these needs.
Lord Beecham
What steps will be taken to ensure coterminosity between consortia and the relevant local authorities?
Earl Howe
This is obviously an issue that is in the minds of those of us in the department as well as those in the health service more widely. It is difficult to give the noble Lord a clear answer at this stage. Coterminosity does help; I agree with him. However, it is too early for me to tell him exactly how consortia will be configured. We can return to that issue.
As part of the consultation exercise, we specifically asked GP practices to begin making stronger links with local authorities and to see how they can best work together. We are currently reviewing the responses that we have received on this.
My noble friends Lord Alderdice and Lady Hussein-Ece spoke well about having informed and engaged patients. This goes back to what I was talking about a moment ago—“no decision about me without me”. That principle is a critical plank of our policy. Shared decision-making means patients jointly working with clinicians to ensure better outcomes and higher satisfaction. As my noble friend Lady Fookes said, the idea is to make the NHS genuinely patient-centred.
My noble friend Lady Hussein-Ece made the vital point that our need to focus on outcomes must reach well beyond simply measuring clinical outcomes. We need to measure patient-reported outcomes as well as patient experiences. Our proposed outcomes framework, as I have just outlined, seeks to do this. However, it is not all about measurement. It is critically important that all parts of the system, whether providers or commissioners, listen to and engage with patients, patient groups and the public more widely about their concerns and ambitions. That is exactly why we have set out proposals to strengthen the patient voice in the new system. The design of HealthWatch draws on the best of previous models of patient and public engagement.
With great respect to the noble Lord, Lord Rea, I fundamentally take issue with his point that all the major health think tanks disagree with our reform proposals. Most, if not all, agree with the vision of a health service judged against outcomes with the patient at the centre of commissioning and provision. The questions they have asked—they are natural ones—are mainly around the implementation. We have consulted on the implementation and will publish our response to these consultations. I look forward to debating the details of our proposals with him and the noble Baroness, Lady Armstrong, when the Health Bill reaches the House. I say to the noble Baroness, Lady Thornton, that that is likely to be in the spring of next year, although I hope that she will not hold me to a precise date.
The noble Lord, Lord Rea, asked us to rethink the whole idea of GP commissioning. I say to him that reform is not an option but a necessity if we are to sustain and improve our NHS. The fundamental problem is that PCT commissioning is remote from patients and does not have sufficient involvement of GPs and clinicians, who are those closest to patients and whose referrals and decisions incur the expenditure of the NHS budget. They are the people who can do much to improve the quality of care, but it needs to be clearly understood that our proposed model does not mean that all GPs have to be actively involved in every aspect of commissioning. A smaller group of primary care practitioners is likely to lead consortia.
I could address many other matters and I am sorry that I do not have time to do so. As I say, I will write to noble Lords. I apologise to them in that the clock is against us. I hope that we can come back to these matters. Suffice to say now that we are living in a financially constrained environment. An extra penny spent on new cancer drugs is excellent. We have the luxury of being able to spend those extra pennies within the confines of a protected budget and of being able to plan on the basis of stable finance over the next three years, unlike colleagues in some other departments. We also have the luxury of being able to plan for higher quality, integrated, patient-centred, outcome-focused health services led by clinicians and patients. I look forward to doing that. Leadership is about making hard choices in difficult times. The choice we have made is to put health first, and the way to do that can be put very briefly—we need to trust the NHS.