NHS: Reorganisation

Lord Patel Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Patel]

My Lords, when you are a tail-end Charlie, most of the things that you wanted to say may already have been said. However, the breadth and depth of the proposed reforms are such that there is plenty left for me to say. First, I declare an interest. Like many other noble Lords, I have been a lifelong clinician—in my case for 39 years, in different forms. I have also chaired NHS regulators, standard-setting organisations in quality and safety, and facilitative organisations.

Like other noble Lords, I feel that we need much clarification of the proposed reforms. Apart from the White Paper and the myriad different documents, I have read all the speeches that the Minister has given recently. While his message has been consistent, explanation of how it will all work is not clear. No doubt when we get the legislation in your Lordships’ House we will spend many happy days scrutinising it—and, on my part, helping to improve it.

Today I have some general comments and one or two specific ones. As others have mentioned, the main conclusion of much of the coverage concerns the bringing in of major institutional reforms that attract major costs, coupled with the drive to realise greater efficiency savings in both the health and social care budgets. Small organisations such as consortia may well drive up costs or reduce clinical delivery times. GPs have said that they will need time and resources to develop and deliver a professional-led service. Will the Minister say how this will be possible?

One component of the White Paper is the introduction of an outcomes framework for holding the NHS commissioning board to account. One problem with PCTs was that they contracted with organisations rather than contracting for services and outcomes. The outcomes framework maintains the three domains of quality identified by the noble Lord, Lord Darzi—those of effectiveness, patient experience and safety—and has developed five domains, which on the face of it is all good. However, if the outcomes framework is the means by which the Secretary of State can hold the national commissioning board to account for the performance of the whole NHS, it needs to be much broader. Currently it is focused too narrowly on clinical outcomes. It should be broad and high level. Furthermore, the relationship between the outcomes framework and the commissioning framework needs careful consideration. National goals often become targets that are used for the assessment and management of performance. Does the Minister agree that the commissioning framework for assessing the performance of GP consortia needs to go beyond the outcomes framework to include the commissioning skills and performance of GP consortia?

I turn now to international comparability. Why are we not going to use an internationally recognised framework for assessing healthcare performance, such as the one developed by the OECD, especially as this not only has parallels with the proposed outcomes framework but includes health improvement and risk factors, as well as the three themes of effectiveness, safety and patient experience, with equity as an overarching dimension? The framework also needs to measure integrated care, care pathways and the quality of care, including social care. How will improvement be assessed? What will constitute acceptable and unacceptable performance and how will it be measured?

My next point relates to process measures. The framework accepts that these are important and are needed locally. Why are these not considered appropriate for the outcomes framework? The relationship between GP consortia, health and well-being boards and local authorities seems unclear. GP consortia will have to commission and deliver high-quality care. How will their accountability to the board work, in particular when contracts are held by boards and not by local authorities or consortia?

I turn to regulation. The Care Quality Commission will be the quality inspectorate. In an environment where there will be willing providers and patient choice, how will the CQC ensure the equity or safety of quality for all providers and who will monitor that? The second regulator will be Monitor—the new, stronger economic regulator—with functions to ensure access to key and essential services. What are key and essential services? What is the definition? Will they be available in each geographical area? That needs to be clarified, as does the question of who will ensure that it happens. The other function of Monitor will be to set prices. While sufficient pricing is a worthwhile ambition, the challenge is to set prices at a level that does not compromise quality. In health, as in everyday life, you get what you pay for.

The Government seem to have changed their mind about how maternity services will be commissioned. Initially, they said that they would be commissioned by the national commissioning board. Now it seems that the consortia will do that. The Minister may well be aware, however, that all the professional organisations have accepted that it would be better for the maternity services to be commissioned by the commissioning board and for the maternity networks to be developed to be able to do this.

While we await the Government’s new cancer strategy, I hope that the framework that is produced will recognise that not all cancer services will be appropriate to be commissioned by GP consortia and that commissioning groups should include clinicians with expertise in cancer. Appropriate data related to cancer diagnosis and survival will need to be included and are important as part of the outcomes framework. How information on outcomes is provided to patients so that they can make a choice will also be crucial.

On the question of competition, what evidence exists that increasing marketisation will benefit patients? Is there an example of a country that has had a defined and conscious change to a market-based approach that has led to improved patient outcomes?