NHS Future Forum

Lord Warner Excerpts

Thursday 15th September 2011 Lords Chamber

[Lord Warner]

My Lords, I, too, welcome my noble friend’s ability to secure this debate today because it gives us a chance to limber up for the marathon that now approaches in a few weeks’ time. I also endorse her view and that expressed by my noble friend Lady Pitkeathley with their timely reminder that this is a health and social care Bill. I should declare my interest as a member of the Dilnot commission on the funding of social care. It is important that we do not shut the door on changes in social care in this Bill that would help the NHS to face some of its challenges for the future. I have in mind particularly some of the non-financial aspects raised in the Dilnot report, such as assessment and integrating better the assessment of people for adult social care and NHS continuing care. That is one of the great and difficult boundary issues in our modern world.

Let me be clear at the outset that I fully support the need for continuing reform of the NHS. I certainly do not view the proposed changes with the same level of horror as many of the Government’s critics do. As a former Minister responsible for NHS reform, I remain a strong supporter of more patient choice and competition among a greater diversity of providers of NHS services, with an economic regulator holding the ring. We need to finish the job of separating the commissioning function from service provision. We need to give clinicians a larger role in commissioning services and to accelerate the transfer of more care and treatment to community settings across the health and adult social care divide.

However, as I have set out in a book about my own experience of trying to reform the NHS, the forces of opposition to reforming this icon are formidable. I notice the noble Lord, Lord Fowler, in his place. He has, I suspect, had a very similar experience. The Government launched this blockbuster of legislative change on an unsuspecting NHS. If you do that, it is hardly surprising, if you have such a poor narrative of why this change was necessary, if you get a rather considerable adverse response. Rebellion from the usual suspects—many of whom were my old sparring partners—was totally predictable.

The NHS is a provider-dominated service with a huge element of public monopoly provision. That is the reality of today’s NHS. It is the reality of the NHS over a long period. If you attempt to change that, you must expect vociferous opposition. It should have come as no surprise that with such a poor narrative the Prime Minister felt the need to call time out and attempt to regroup. Today, we are having a peep at the regrouping, or at least at the bits we know about because the Future Forum is still at work. I hope that the Minister can lift the veil a bit more on this and explain to us what further homework the forum has been set and how long it has been allowed to complete it.

What are we to make of the changes that the forum has proposed so far? Do they improve the coherence of the reforms and the likelihood of their success? Do they improve the prospects of the NHS meeting the formidable financial, productivity and service reconfiguration challenges that it faces over the coming years? My good friend, Professor Paul Corrigan, has today produced a new pamphlet that identifies some of these problems, and I hope that all noble Lords will avail themselves of the chance to read it. Let me make it clear that I am not paid anything by Professor Corrigan for giving his work that small plug.

The proposed changes by the Future Forum seem to have pleased the leader of the Liberal Democrats, although, from my observations, many of his foot soldiers still seem to be pretty disgruntled. Although the coalition agreement advocated making Monitor an economic regulator, the reality seems to put the wind up a number of Liberal Democrats. I have not seen many NHS interest groups putting out a lot of celebratory flags as a result of the forum’s report. The disgruntlement of the BMA and other public sector unions seems little abated. Perhaps more significantly the NHS Confederation, for which I have very high regard, hardly seems to be bowled over.

If I was still a Minister, I would also be a bit more anxious about the continuing concerns of more objective and analytical observers such as the King’s Fund and the Nuffield Trust. They have drawn attention, rightly in my view, to the additional complexity and cumbersomeness that the forum’s proposals have introduced. The original enthusiasm for GPs running more of the commissioning show seems to be evaporating as the hospital specialists fight back to retrieve more ground through the modification of consortia membership and the rather ghost-like senates that will lurk there. We certainly seem to have a lot of fingers in the needs assessment and service commissioning pie—the National Commissioning Board, a rump of SHA and PCT clusters posing as outposts of the board, clinical commissioning groups and health and well-being boards.

The forum seems to have helped the Government further along a path of public confusion over who is really in charge of NHS commissioning and who is accountable when things go wrong. There is now plenty of scope for dodging accountability and laying off the blame for failure. This is particularly the case in the area of service reconfiguration which the NHS needs so badly. It is perhaps appropriate that we have just seen a Health Secretary finally take a decision on service changes in Chase Farm Hospital the best part of a decade after it should have been taken. Let me congratulate the Health Secretary on showing the courage to do this eventually.

In my view, the forum’s proposals make worse the already unsatisfactory accountability for service needs assessment and the commissioning of services, and will make the much needed reconfiguration of services even more difficult. We have to concentrate more hospital specialist services on fewer sites and provide much more care and treatment in the community on an ambulatory basis if the NHS is to live within its means. This requires us to reduce expensive, unsustainable, low-quality and unnecessary acute hospital services and to transfer service resources to new service configurations with different providers from the public and, yes, the private and, yes, the not-for-profit sectors. We have to face up to moving away from the outdated business model of the all-purpose district general hospital of the 1960s.

Modifying reform in ways that make these changes more difficult to achieve is bad news for those of us who believe in a tax-funded NHS that is free at the point of clinical need, especially given the £20 billion of efficiency improvements that the NHS has to make over the next four years. These are issues to which some of us will want to return in a lot more detail during the passage of the Bill. I very much commend the remarks of the noble Lord, Lord Ribeiro, about some of these issues.

I conclude by saying a few words about integration and competition, which seem to have produced rather more heat than light in the recent public discourse. We are all in favour of integration, but we need to understand what we are talking about. From my point of view, I think that patients benefit from integration if it is related to the delivery of services to individual patients, but they may not benefit from the horizontal integration of service providers if it simply produces mergers that create far more monopoly provision and little improvement for patients.

It is also nonsense to suggest, as some have done, that competition inevitably means the fragmentation of service delivery and is inimical to integrated delivery. It is perfectly possible to have competition for the provision of integrated services; it just depends on the commissioner’s service specification and the payment mechanisms. In the US, Kaiser Permanente and others have shown that the integration of patients’ service delivery can flourish in a competitive healthcare market. Again, these are issues that we will need to come back to in the Bill.

Let me end by wishing the Minister well as he faces the Herculean task of taking the Bill through the House, but I cannot guarantee that it will be a totally pain-free experience.

NHS: Medical Records

Lord Warner Excerpts

Wednesday 7th September 2011 Lords Chamber

[Earl Howe]

My Lords, I can well understand my noble friend’s acute disquiet over this matter, particularly in light of the recent report from the Public Accounts Committee. The view we have taken is that some very good things have been achieved so far, particularly from the national elements of the programme, but it is equally clear that the top-down policy approach taken to the computerisation of the NHS has not delivered the benefits at local level that everybody was hoping for and has failed to engage the NHS sufficiently. Those are the things we are now concentrating on: making sure that the governance of the programme is sound; learning lessons from what has happened; and achieving value for money.

[Lord Warner]

My Lords, I declare an interest as the former Minister responsible for this programme—one does have to own up to one’s past from time to time. Could the Minister assure the House that the Government are fully committed to the idea of an electronic patient record system as the way forward for the NHS, given its benefits for patient care, research and NHS efficiency? Could he tell the House what proportion of the population has now been able to avail itself of an electronic summary record?

[Earl Howe]

I pay tribute to the work that the noble Lord did when he was a Minister. Yes, the Government are committed to a summary care record, which, for the benefit of noble Lords, is a record that includes a defined set of key patient data, other than for patients who choose to opt out—that is an important rider. Clinicians can then access essential medical information that they need to support safe treatment and to reduce the risk of inadvertent harm, especially during emergency care. To answer the second question that the noble Lord asked, over six million patients now have a summary care record, which is a considerable increase over a few months ago.

NHS Reform

Lord Warner Excerpts

Monday 4th April 2011 Lords Chamber

[Earl Howe]

The economic regulator will do two things. It will fix prices for the purposes of the tariff and it will preside over the marketplace—such as it exists—in healthcare so that anti-competitive conduct will be prohibited. It will bear down upon conflicts of interest and anti-competitive practices of all kinds and, in conjunction with the NHS commissioning board, it will ensure that the pricing system in the NHS incentivises quality. There are, as the noble Lord knows, a number of levers that we can use to do that through the tariff.

[Lord Warner]

Is the Minister aware that many people are concerned about whether the Government will listen excessively to those who make the greatest noise among some of the vested interests that the Bill tries to tackle? Is he aware that many people wish to look at the Bill forensically to make sure that changes in commissioning lead to more competent commissioners, something we have not achieved in the past: that we start to dismantle some of the barriers to entry in order to create more diverse providers; and that we look very seriously at the pricing system to make sure that it does not just put money into the pockets of acute hospitals, but brings more care closer to home?

[Earl Howe]

I am grateful to the noble Lord, Lord Warner, whose book, I may say—without indicating that I am in receipt of a commission for saying so—deserves reading by every thinking healthcare commentator. He is right, of course; we need to ensure that the vision that I think is shared by many in this House, regardless of party, can be successfully implemented. I recognise the implication of his question, which is that this House is eminently capable of examining the Bill forensically. When it comes to us I have no doubt that we will do that however long it takes, and I look forward to that. However, it would be a rather cloth-eared Government who were insensitive to the voices that have been heard in recent days outside this Chamber and another place. We need to dispel many of the misunderstandings that exist as well as address some of the genuine misgivings that people have. It is right that, without losing too much momentum in the process, we take these few weeks to do just that.

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.

Public Bodies Bill [HL]

Lord Warner Excerpts

Monday 28th March 2011 Lords Chamber

I believe that the fear of many professional bodies and patient groups is that by disassembling the HFEA, we could end up with something much worse. It would seem prudent to do the review and the consultations before we determine the outcome. There is no hurry; one can wait until the new, all-purpose medical regulatory authority is established, and then decide what to do. If not, there is great risk so I hope that the Government will accept this amendment and believe that they would be greatly relieved if they did.

[Lord Warner]

My Lords, I support this amendment. I am conscious that I must guard against triumphalism after the Youth Justice Board amendment earlier, but I raise that because there are some similarities, in that the Government could walk into the same situation. With the Youth Justice Board, we had a situation where a body was functioning perfectly well and the Government tried to change it before they knew or could explain what to put in its place to safeguard the development of youth justice and the future delivery of services. The Government are in danger of falling into exactly the same position with the HFEA and the HTA: two bodies functioning perfectly well, which have international reputations and which, certainly in the HTA’s case, are of relatively recent origin in their passage through Parliament. It is far from clear what the Government will do for a new set of arrangements that go wider than those two bodies and embrace a new agency of health research.

I am grateful to the Minister for his letter of 22 March about the Government’s ideas for taking forward the transfer of functions of the HFEA and the HTA using this Bill’s powers. However, I am not at all sure that I am much clearer about how things will work out in practice because the Government seem to be saying in that letter that they have a lot of options for changing things but seem rather uncertain about which option to pursue. On the Minister’s own admission the Government cannot say at this stage what approach they prefer to take on transferring functions. That is a fairly big lacuna in the Government’s thinking. If they cannot say how they want to change these functions with some degree of clarity and when this new agency will be set up, it is asking quite a lot of Parliament to take it on trust that we should plonk a couple of organisations of some standing and good functioning in Schedule 5 of the Bill and hope it will all turn out okay eventually. That seems to be the situation—with the greatest respect to the Minister—that we are placed in at this moment.

Part of the problem, it seems to me, is that the Government are very unclear on when they will actually set up the new research agency. The proposed agency commands a huge amount of support across this House and indeed in the world outside. Many of us have long wanted to see that kind of comprehensive, coherent health research agency in place, but it is not an easy job to do. It will be quite a complicated business setting that up. I do not know, and I am not sure that the Government know, when they will have this body up and working and where they will get the funding from. They will need to carry on running existing agencies at a time of some degree of financial restraint and set up a new body to take over those functions in an orderly way. In my time in the public sector I have rarely seen changes of that kind implemented without some extra costs. I have read the Chancellor’s statement, in which we all live happily ever after on this particular issue. I would really like to know from the Minister whether the Department of Health has actually got the funding. Has it got a game plan for implementing this agency? When will it come on stream? We need to know that to make any sensible judgments about the transferring of functions.

The noble Lord, Lord Willis, has drawn attention to the complications around licensing in relation to clinical research and clinical practice in these areas. These are complex issues. If we do not know in detail when the agency will be operational and what functions it will have transferred to it, it seems a great leap of faith to put these two bodies in Schedule 5 with a strong commitment from the Government that they are going to act on Schedule 5 and make changes in the functioning of these bodies but without knowing precisely what those changes will actually mean.

I found the penultimate paragraph of the Minister’s letter to me of 22 March particularly puzzling. He claims that the mechanism in this Bill reduces the risk of opening up the whole HFEA primary legislation for debate. Like other noble Lords, I view that with deep, deep scepticism. The idea that we can open up a debate about the functions of the HFEA being transferred from it to another body without opening up many of the public concerns around that body and similarly with the HTA seems to me, if I may put it as brutally as this, extremely naive. It is not going to happen. Once you start tinkering with these two bodies of great sensitivity, as I am well aware of from taking the HTA legislation through this House, you are actually opening Pandora’s box. You cannot be sure what the outcome will be in terms of public concerns.

I think that we have to go a long way further down the track in understanding the Government’s thinking and how this will all work with the establishment of the new health research agency. I do not believe that it is either smart politically or sensible managerially to be heading off in this direction without knowing where the finishing post is.

Public Bodies Bill [HL]

Lord Warner Excerpts

Wednesday 9th March 2011 Lords Chamber

[Baroness Thornton]

My Lords, I shall speak also to Amendments 93, 150 and 151. On Second Reading, many noble Lords expressed their disquiet at the inclusion in the Bill of the HFEA and the HTA. At the time, I wondered if they were included because the Minister’s department insisted that the Department of Health had to offer something up to the Bill, so the poor old HFEA and HTA were the sacrificial lambs. Indeed, in its own review of the arm’s-length bodies, the Department of Health gives a much more measured suggestion of the deliberation and consultation before decisions were taken about the HFEA and HTA over a timescale that is the life of this Parliament. Unless something has changed about the expected length of this Parliament, it seems precipitate and unnecessary to include these bodies in the Bill.

In a meeting convened by the Minister—the noble Earl, Lord Howe—to discuss this important matter with interested parties, which I was pleased to attend, he was concerned to reassure us about the consultation and discussion to take place before decisions were reached. We can add to those reassurances the proposal, as I understand it, that in the next Session—in other words, after May 2012—primary legislation will be introduced to establish a new science regulator in the department. If that is the case, the passage of that legislation would allow proper consultation and scrutiny across the field including the work of the HFEA and the HTA, which is the way in which such reforms should be carried out. So I ask again: why is it necessary for these bodies to be included in the Bill?

The HFEA and the HTA almost symbolise the concerns that noble Lords have expressed in relation to the constitutional propriety of the Bill in giving Ministers powers to amend primary legislation. Both organisations would have their work and their regulation fragmented unnecessarily when they need to be left alone to get on with the jobs that they do very well—although there is always room for improvement—until a proper period of consultation and pre-legislative scrutiny, which I am sure the noble Earl would wish to have, can precede the introduction of the science regulator Bill or whatever it will be called. That is the way to proceed.

What do these bodies do? The HTA licenses and inspects organisations that store and use human tissue for purposes such as research, patient treatment and post-mortem examination, teaching and public exhibitions. It also gives approval for organ and bone marrow donations from living people, including anatomy and stem cells and cord blood; public display—that is, the public display of any human body parts in various forms—post mortems; coroners; and transplants.

The advances made by science throw up new and sometimes complex ethical issues for the HTA to address. The cavalier use of body parts for research without the knowledge or consent of patients and their families was a huge scandal, leading to public indignation. Many in your Lordships’ House will recall the time and the thought given to the creation of a regulatory framework that would command public confidence. I fail to see what has changed that can allow any slackening off of the responsibility that the HTA bears for the use of human tissue.

The HFEA is the UK’s independent regulator of treatment using eggs and sperm and of treatment and research involving human embryos. It sets standards for and issues licences to centres and provides authoritative information for the public, particularly for people seeking treatment, donor-conceived people and donors. Very importantly, it also determined a policy framework for fertility issues which are sometimes ethically and clinically complex. The HFEA Act 2008 includes provisions for research on different types of embryos and changes the definition of legal parenthood for cases involving assisted reproduction. Therefore, the work of both bodies is of enormous scientific importance apart from anything else.

The arm’s-length body review in July 2010 concluded that the HFEA carries out essential functions which satisfy,

“the criteria for being undertaken by an arm’s-length body”.

The review states that the HFEA,

“deals with issues that are judicially and ethically complex and contentious”.

The HFEA is a world-respected model which has been used by other jurisdictions to deal with extremely technical and legally complex areas of practice. We have to ask what will happen to the high level of expertise and experience in both organisations and whether it will be in the public interest to transfer regulatory functions to other organisations where this knowledge may be lost to the detriment of patient safety.

I know that some noble Lords, particularly some of our very respected medics, for sometimes differing reasons have expressed the view that time has moved on since the original reason was established for setting up these bodies, human fertilisation is not the novelty that it once was, these medical procedures no longer need the attention of their own regulator and therefore change is necessary. That is a powerful argument but I disagree with it, or at least I have yet to be convinced. It seems to me that the powerful reasons that brought these two bodies into existence, and the reason we in Parliament paid such close attention to establishing their duties, responsibilities and independence, are still as potent today as they were when they were founded. These are not primarily medical or scientific reasons but concern the need to maintain public confidence in the uses to which human tissue is put, and sometimes in the very controversial issues arising out of human fertility and procreation.

Time and consideration need to be given to the contribution to scientific research made by the HTA and the HFEA, and, of course, they should carry out their respective functions in a cost-effective and efficient manner with appropriate public accountability. We may wish to see change in the way that the HTA and the HFEA functions are carried out but I believe many of the changes needed could be achieved without their inclusion in the Bill. Change should be helpful in achieving the broader stated aims of reducing bureaucracy and saving money rather than simply focusing on a reduction in the number of arm’s-length bodies. By and large, by the way, I believe that both bodies have sought to make and have succeeded in making improvements in their work and functions in recent times. I believe that more now even than at Second Reading, given the Government’s proposals on research. As the proposals for the reorganisation of the NHS are discussed it seems to me that the future of the HTA and the HFEA need more time and much more consideration. Apart from anything else, the CQC, which it is proposed should become the healthcare regulator for the HTA and fertility treatment, will have neither the time nor the expertise to carry out this function until it has swallowed the regulation of the whole of the rest of medical and social care. One might imagine that if a scandal arises in four or five years’ time regarding either fertility regulation or the use of human tissues, the excuse will be given that the CQC was too preoccupied with the rest of its enormous brief to give these matters the important attention that they warrant. I beg to move.

[Lord Warner]

My Lords, I have added my name to Amendments 92 and 93 in part in a spirit of helpfulness—I hope that is the case—to the Minister as I have traversed the same ground as him on Department of Health arm’s-length bodies. In 2003-04, I was the Minister who reviewed DH arm’s-length bodies and halved their number. Therefore, I cannot claim to be against reducing the number of Department of Health arm’s-length bodies. Indeed, my sins are fully catalogued by this Government in annexe B of their document on the arm’s-length body review, which was published last year. Therefore, I own up fully to these past misdemeanours. However, as I have previously said about the Government’s own arm’s-length body review, although I do not necessarily agree with every aspect of it, it comprises a serious, comprehensive, clear and coherent set of proposals, unlike some of the things which emerged from other departments under this Bill. Therefore, I do not in any way wish to argue that it was not a thorough piece of work.

--- Later in debate ---

[Lord Warner]

I am sorry to interrupt the Minister. I have been listening intently to what he has said. I am extremely confused about the order in which things are going to be done. As I understood what he was saying, we are going to get a series of orders that transfer functions through a process of consultation, which I welcome, but we may or may not know at that point what the Government are going to do about setting up a health research agency, either by statute or otherwise. As I understood him, we could be in the position of being asked to agree those orders before we know what the final endgame is. It would be helpful if, before the next stage of the Bill, the Minister could set this out more clearly for us in writing so that we can understand the sequence. I found it rather difficult to understand.

[Earl Howe]

I must apologise to the Committee if I was not sufficiently clear and I will be happy to write to those who have participated in this debate to make the position clearer. I was seeking to say that we do not wish to take a disjointed, piecemeal approach. There is a natural flow of process that, if Parliament agrees, can lead us to a position where we are able in one move, so to speak, to transfer the various functions more or less simultaneously—although I would not wish to undertake that the whole thing would be done on the same day—so as to arrive at that point.

In our view it is desirable to consult during the late summer of this year. We will then set about the process of designing statutory instruments based on that consultation and go out to consultation on them. All being well, we will then introduce a second-Session health Bill that will have within it the provisions to establish a single research regulator, assuming that that is what we decide to do. Therefore, the whole process should work in a seamless way. However, I shall be very happy to write to noble Lords setting that out.

I return to the point at which I left off, which is to express the hope that the noble Baroness will not press her amendment this evening. I hope that she will accept our assurance that we have a clear intention to consult on the proposed transfers of functions and that she will be willing to withdraw the amendment.

NHS: White Paper

Lord Warner Excerpts

Monday 12th July 2010 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness identifies two particularly important issues. How will GPs be held to account for the clinical care that they provide? The data emanating from their performance will be transparent and published. The consortia will monitor the performance of each practice. They will identify outliers, whether good or bad, and act accordingly. We do not have those information systems sufficiently in place—I hope that, over the next 18 months or so, there will be time to develop the systems needed for consortia to do this—but it is vital that GPs are held to account for their performance and they will be incentivised in their remuneration to provide high quality.

The noble Baroness made an important point about loss leaders among providers. The NHS commissioning board will license a provider only if it is satisfied that the quality of care delivered by that body is of an adequate standard. I think that the board will look with great care at the practice of introducing loss-leader services and rule out, if there is any doubt at all, quality being compromised in the process.

[Lord Warner]

My Lords, I warmly welcome some of those ideas in the White Paper that build on the previous Government’s reforms such as choice and competition. However, is the Minister aware—as am I from my own experience as a Minister—that many in the NHS do not wish to be liberated? What will be his approach to those areas where GPs’ consortia do not live up to the standards required of the commissioning board? What will he do to ensure that we do not lose the benefits of regional specialised commissioning, which it has taken many years to bring to the level of quality that exists today?

[Earl Howe]

My Lords, I shall be brief because time is against us. I agree with the noble Lord that we must not lose the gains that we have made in specialised commissioning following the Carter reforms. He will see that the national commissioning board will retain responsibility not only for national specialised commissioning but for regional specialised commissioning. That will safeguard the quality of those services.

The noble Lord referred to GPs who do not wish to commission or who are in some way found wanting in their performance. Our experience to date—a number of consortia have been formed around the country, all of which are working encouragingly well—suggests that those GPs within the consortium who are in the lead and are the most go-ahead are best placed to bring up to standard their colleagues who are perhaps struggling. We have witnessed that in a number of instances. Those GPs who are incapable of being brought up to an adequate standard may be subject to a question over their future. In certain consortia, we have seen GPs retiring from NHS service.

NHS: Budget

Lord Warner Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Earl Howe]

My noble friend makes an extremely good point. Much of the thrust of what we are trying to do is to achieve much greater local ownership by clinicians, staff and managers of the problems that we can all identify. The ideas that my noble friend has put forward already operate in many trusts, but they should be imposed more widely.

[Lord Warner]

My Lords, in his review will the Minister encourage his ministerial colleagues to enhance the coalition Government’s reputation for taking tough decisions by looking seriously at the number of acute hospitals that are failing financially and are unsustainable, especially in London? Is he willing to market-test the provider side of PCTs, which the Department of Health has identified as inefficient?

[Earl Howe]

My Lords, the noble Lord, with his knowledge of London, speaks with great authority and he will know that reconfiguration is high on the agenda in London. Efficiencies can be created, but we want to see local buy-in to those changes rather than any top-down prescription. On his second point, we are keen on the split between the commissioning and the provision of community services, so that we can get greater plurality of provision in community services.

Health: Government Spending

Lord Warner Excerpts

Monday 14th June 2010 Lords Chamber

[Earl Howe]

My Lords, there are several principles. A reduction in the number of arm’s-length bodies is only one of the possible outcomes. As I have said, we are not looking necessarily for a large-scale reduction in numbers, but we want to see both efficiency and the delivery of quality. With those two ends in view, the bodies that we end up with have to make sense in terms of what matters in our wider system reform, which is, as I have said, to deliver quality.

[Lord Warner]

My Lords, the Minister has said that he will be looking at functions in the review of bodies and that he will be looking to save one-third of running costs. In carrying out this review, will PCTs be examined carefully in terms of divesting themselves of their provider-arm functions so that they can concentrate on their commissioning functions?

[Earl Howe]

My Lords, strictly speaking, primary care trusts are not considered to be arm’s-length bodies, but the coalition agreement, which I am sure the noble Lord has read from cover to cover, indicates the new role and the functions envisaged for PCTs. Further details of our plans will be announced very soon.

Mid Staffordshire NHS Foundation Trust

Lord Warner Excerpts

Wednesday 9th June 2010 Lords Chamber

[Baroness Knight of Collingtree]

My Lords—

[Lord Warner]

My Lords, I think that it is this side’s turn—

[Noble Lords]

Order.

--- Later in debate ---

[Earl Howe]

I am grateful to my noble friend for her kind comments. The House will know what a champion she is of patient care and compassion in the health service. On her last point, it is of course for Robert Francis, who is in charge of the inquiry, to decide whom he calls as witnesses, but he has a completely free hand and I am sure that he will take note of my noble friend’s suggestion.

[Lord Warner]

My Lords, before I ask my question, I suggest that we register that the usual channels might discuss the sequencing of speakers from the government Benches and these Benches, because I am not sure that there is a correct interpretation.

I have no objections whatsoever to this wider inquiry. I hope that it will look carefully at the extent to which doctors, nurses and managers failed in their professional responsibilities. What the regulators and other bodies did might also be usefully looked at. However, does the Minister accept that it is easy in such circumstances to reach for something that cannot answer back, such as a target, to explain away what is essentially appalling clinical and managerial behaviour? That is clear from many other inquiries into what happened in Mid Staffordshire.

If the Minister wants seriously to consider targets, he might read some of the speeches made by previous Ministers, who made it crystal clear to the NHS that its overriding responsibility was to the care and safety of patients, not obsessively to implement targets. I know that there are conventions about looking at papers from previous Administrations, but I would certainly be prepared to waive that consideration. Will he also look at the extent to which John Reid, when he was Health Secretary, amended the way in which the four-hour target was implemented in response to concerns expressed by doctors? He might like to see the minutes of a meeting that I had with the College of Emergency Medicine. Members of the college came to see me as a Health Minister to ask me—beg me, almost—not to amend the four-hour target because of the improvements that it had produced for its members, for patients and for the way in which hospitals were run. Will he also look at the Nuffield Trust’s independent inquiry into targets, which also shows the benefits that they have brought to patients in terms of better access and shorter waiting times and which compares the experience in England, where there were targets, very favourably with that in the Celtic fringes, which did not have them?

[Earl Howe]

My Lords, we are not targeting the targets with this inquiry. They are not the main point at issue. The noble Lord is right that the main point at issue is the failure of care, but that is also, as we hope this inquiry will show, a systemic failure. That is the point of the inquiry. I do not doubt anything that he said about the commitment of previous Ministers to putting care above any rigid adherence to targets; I fully accept the good faith of Ministers in the previous Administration in that regard. However, the noble Lord will know that what Ministers say is very often not interpreted in the same way on the ground in the NHS. When people in the NHS hear things coming out of Whitehall, they are inclined to adhere rigidly to what they are told to do. That is part of the problem, but it is not the problem that I want to emphasise in this context. We need to understand how the wider performance management and regulatory system failed to spot the problems earlier and deal with them and why so few professionals felt that they could challenge what they saw. Understanding the lessons from that and the culture in which the events at Mid Staffs were allowed to happen will be key to informing and shaping our plans for the future.