NHS: Standards of Care and Commissioning

Lord Warner Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Warner]

My Lords, I am grateful to my noble friend for securing this warm-up debate before the Government’s legislative juggernaut reaches this House. In the time available, I want to confine myself to talking about commissioning because good commissioning has a significant impact on achieving good service standards. For 20 years, we have been trying to establish an effective NHS commissioning system. Ken Clarke’s GP fundholding and partial purchaser/provider split was followed by Labour’s PCT commissioner model, again without a full purchaser/provider split. Just for good measure, I added on a practice-based commissioning dimension in 2006 which many PCTs were pretty effective at thwarting. Now we are to have another legislative go. That is a summary of the history of commissioning.

All too often, PCT commissioners have lacked the know-how, competence and muscle to commission effectively. Too often, they have been unable to manage demand, keep in check acute hospital expenditure and hold hospitals to account. We know from the Care Quality Commission data that there are too many PCTs with poor track records on quality and financial management. The House of Commons Health Select Committee’s excellent reports on PCT commissioning make for depressing reading. It is not, in my view, unreasonable to decide that PCTs have had their chance and failed overall, so we should try a more clinically driven model of commissioning, as the Government wish to do. In many ways, this is a logical development from practice-based commissioning. However, the Government must learn the lessons of past mistakes in designing a new commissioning model if they are not simply to repeat those mistakes.

The population size of many commissioning bodies has been too small for effective health-risk pooling. When I hear the BMA say that there is a new commissioning consortium with a population of 18,000 people, I despair. I managed to reduce the number of PCTs from 302 to 150, but could not secure agreement politically to go down to 50. That would have given us commissioning bodies with populations of about half a million to 1.5 million people. I believe that is the kind of population we should be looking for in commissioning the full range of services that the Government wish to give to those kinds of consortia. The amount of high-quality commissioning capability in the NHS that we had in 2005 was insufficient to service the number of bodies involved. That remains the case today and the added trouble is that the amount of money available to pay for them has become even smaller in size.

When the Bill comes to this House, we are going to have to probe the area of commissioning forensically. We will need to ensure that there is a proper system of licensing or accrediting commissioners, however the function is organised. We need to ensure that commissioning bodies have the data collection and the analytical, financial, contracting and clinical expertise to commission safely and cost-effectively the range of services that they will be legally required to commission with about £60 billion of public money a year, on present estimates. The National Commissioning Board must have the authority and capacity to prevent people without the competence to commission getting their hands on big slugs of public money. The board has to be able to remove and replace inefficient, incompetent or overspending commissioners in a timely way. Those are the kind of issues we should be considering when we come to that Bill.

In conclusion, as a former commissioner of social care I found it jolly useful to have a diversity of service providers so, unlike a number of people, I congratulate the Government on going for a bit more competition and extending the market for providers—not just from the private sector but with good providers from within the NHS and good mutuals, of which I suspect we will see a lot more in future. We will have a lot of time to discover what the Government’s thinking is on some of these issues as we take the Bill forward in this House.