NHS: White Paper

Earl Howe Excerpts

Monday 12th July 2010 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, with the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health.

“With permission, Mr Speaker, I would like to make a Statement on the future of the National Health Service. The NHS is one of our great institutions and a symbol of our society’s solidarity and compassion. It is admired around the world for the comprehensive care it provides and for the quality, skill and dedication of its staff. I begin today by paying tribute to the staff of the NHS and the commitment they show to patients.

This Government will always adhere to the core principles of the NHS; a comprehensive service for all, free at the point of use, based on need not ability to pay. This principle of equity will be maintained, but we need the NHS also consistently to provide excellent care. The NHS today faces great challenges: it must respond to the demands of an increasing and ageing population, advances in medical technology and rising expectations; it remains stifled by a culture of top-down bureaucracy, which blocks the creativity and innovation of its staff; and it does not deliver outcomes in line with the best health services internationally—many of our survival rates for disease are worse than those of our neighbours. The NHS must be equipped to meet these challenges—we believe it can do much better for patients—so today I am publishing this White Paper, Equity and Excellence: Liberating the NHS, so that we can put patients right at the heart of decisions made about their care; put clinicians in the driving seat on decisions about services; and focus the NHS on delivering health outcomes that are comparable with, or even better than, those of our international neighbours.

For too long, processes have come before outcomes as NHS staff have had to contend with 100 targets and more than 260,000 separate data returns to the department each year. We will remove unjustified targets and the bureaucracy which sustains them. In their place, we will introduce an outcomes framework to set out what the service should achieve, leaving the professionals to develop how. We should have clear ambitions, and our approach to this will be set out shortly in a consultation document. For example, our aims could be: to achieve one and five-year cancer survival rates above the European average; to minimise avoidable hospital-acquired infections; to increase the proportion of stroke victims who are able to go home and live independently—in short, care that is effective, safe and meets patients’ expectations. The outcomes framework will be supported by clinically established quality standards, and the NHS will be geared across the board towards meeting them. We will do this by rewarding commissioners for delivering care in line with quality standards; strengthening the regulatory regime, so that patients can be assured that services are safe; and reforming the payment system in the NHS, so that it is not just a driver for activity, but also for quality, efficiency and integrated care.

Patients will be at the heart of the new NHS. Our guiding principle will be, “no decision about me, without me”. We will bring NHS resources and NHS decision-making as close to the patient as possible. We will extend personal budgets, giving patients with long-term conditions real choices about their care. We will introduce real, local democratic accountability to healthcare for the first time in almost 40 years by giving local authorities the power to agree local strategies to bring the NHS, public health and social care together. Local authorities will also be given control over local health-improvement budgets. This will give an unprecedented opportunity to link health and social care services for patients.

We will give general practices, working together in local consortia, the responsibility for commissioning NHS services, so that they are able to respond to the wishes and needs of their patients. This principle is vital, bringing together the management of care with the management of resources. With commissioning support, GPs collectively will lead a bottom-up design of services.

In addition, we will introduce more say for patients at every stage of their care, extending the right to choose far beyond a choice of hospital. Patients will have choice over treatment options, where clinically appropriate, and the consultant-led team by whom they are treated. They will have the right to choose their GP practice. And they will have much greater access to information, including the power to control their patient record.

We must ensure that patients’ voices are heard, so we will establish HealthWatch nationally and locally, based on local involvement networks, to champion the needs of patients and the public at every level of the system.

To achieve these improvements in outcomes, we need to liberate the NHS from the old command-and-control regime. So all NHS trusts will become foundation trusts—freed from the constraints of top-down control, with power increasingly placed in the hands of their employees; and we will allow any willing provider to deliver services to NHS patients, provided that they deliver the high-quality standards of care we expect from them.

Our aim is to create the largest social enterprise sector in the world. But it is not a free-for-all. Monitor will become a stronger economic regulator to ensure that the services being provided are efficient and effective, and that every area of the country has the NHS services it needs to provide a comprehensive service to all. The Care Quality Commission will safeguard standards of safety and quality.

An independent and accountable NHS commissioning board will be established to drive quality improvements through national guidance and standards to inform GP-led commissioning. The board will allocate resources according to the needs of local areas, and lead specialised commissioning.

In the coming weeks, detailed consultation documents will enable people to comment on the implementation of this strategy, leading to the publication of a Health Bill later this year.

I recognise that the scale of today’s reforms is challenging, but they are designed to build on the best of what the NHS is already doing. Clinicians are already working to facilitate patient choice—giving patients the information they need to make an effective decision. GP consortia are already established in some areas of the country, and ready to go. Local authorities in some areas are already working closely with local clinicians to co-ordinate health and social care, and improve public health. Payment by Results already gives us a starting framework for building a payment system that really drives performance. Foundation trusts are already using the freedoms that they have to innovate.

We will build on this progress, not dismantle it. With this White Paper, we are shifting power decisively towards patients and clinicians. We will seek out and support clinical leadership. That means simplifying the NHS landscape and taking a further, radical look at the whole range of public bodies. We will reduce the Department of Health’s NHS functions, delivering efficiency savings in administration costs. We will rebalance the NHS, reducing management costs by 45 per cent over the next four years, and abolishing quangos that do not need to exist, in particular if they do not meet the Government’s three tests for public bodies—shifting more than £1 billion from the back office to the front line.

Form will follow function. As we empower the front line, so we must disempower the bureaucracy. After a transitional period, we will phase out the top-down management hierarchy, including both strategic health authorities and primary care trusts. Later in the summer, we will be publishing a report setting out how we see the future of NHS-related quangos. I can say now that this will mean a reduction of at least a third in the number of such bodies. This is part of the wider drive, across government, to increase the accountability of public bodies and reduce their number and cost. The dismantling of this bureaucracy will help the NHS realise up to £20 billion of efficiency savings by 2014—all of which will be reinvested in patient care.

Today’s reforms set out a long-term vision for an NHS which is led by patients and professionals, not by politicians. It sets out a vision for an NHS empowered to deliver health outcomes as good as any in the world. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I am sure that the House will be grateful for the noble Baroness’s questions, although I have to express considerable disappointment that she finds so little to commend in the White Paper, which to me is a very exciting document, and one which builds in many important respects on the structures which her Government put in place. Lest it be thought otherwise, I am the first to knowledge the improvements in the health service which the previous Administration effected. They did so with the benefit of a great deal of extra public funding and no doubt we should be grateful for that. The problem that we perceive is that despite the progress that was undoubtedly made during the 13 years of the Labour Government, one thing did not keep up with funding: the outcomes that we saw emerging from that increased investment. The fact is that we are not matching the performance of our counterparts in Europe in a number of respects: in cancer survival rates and an array of other conditions. That has to change. We have asked ourselves how we can best deliver those outcomes and the quality of care that the noble Lord, Lord Darzi, envisioned in his strategy when he became a Minister. We want to build on the work of the noble Lord, Lord Darzi, and we believe that this programme of action will do that.

Our plans for GP consortia are very much based on practice-based commissioning arrangements and clusters. Our plans for economic regulation build on the work of Monitor. Currently, many of the functions of the NHS commissioning board already exist within the Department of Health. We are carving them out and slimming them down by stripping out avoidable layers of management. We have always been clear that we want to have GP commissioning, and our plans are the logical extension of that.

I must comment on the noble Baroness’s first remarks about the leaks to the press. I very much regret them. We do not know where they came from and are making the kind of investigations that she would expect. Our policy and our aim are always to make announcements of this kind to Parliament in the first instance. I am sorry that that has not happened in some cases. The press coverage has not been accurate in all respects.

I hope that when the noble Baroness digests this White Paper, she will come to view it rather more favourably than she has indicated. She suggested that our proposals are ideologically driven. There are only two pieces of ideology here: the desire to continue the quality agenda that the noble Lord, Lord Darzi, started and a desire to bring health and social care much closer together. The proposals for the role of local authorities will achieve that and, at the same time, they will introduce a greater degree of democratic accountability. Accountability will operate on several levels, and the noble Baroness asked me about it. There will be accountability to Parliament through the Secretary of State via the NHS commissioning board, which will hold GP consortia to account for the money they receive. At a local level, there will be accountability through HealthWatch and local authorities. That dimension of local authorities’ remit to enable them to have a say in the planning and configuration of services at a local level is a very important development because it will enable public health, social care and the NHS to be looked at in the round.

The noble Baroness asked whether we envisage any limit on the use of the private sector by GP consortia. The principle that we will adopt is that GP consortia should take on as much responsibility as they wish. The national commissioning board will support them in developing the necessary expertise but, if they want to, we are proposing that they should be able to seek support from elsewhere, including the private sector, within their budgets. In no sense are we proposing a privatisation of the NHS. In particular, lest anyone should think otherwise, our proposals for foundation trusts do not do this. I refer noble Lords to paragraph 4.21 of the White Paper, which makes this unequivocally clear.

There are certainly risks in managing the transition. Indeed, managing risk is not a new problem in the health service—it has happened since time immemorial—but the NHS chief executive and Ministers are extremely mindful of the need to control and manage risks, particularly during the transition. David Nicholson has set out the framework for implementation, with clear plans to minimise risk such as shadow-running bodies for a period of time.

It will take time for these changes to become fully embedded. That is a good thing. We recognise that not all GPs will be able to go at the pace of the fastest, and those who are not in the vanguard will be supported appropriately, but we are clear that GP commissioning is the way forward. It will align decision-making for clinical care with decision-making for financial flows. These are segregated at the moment. If you bring them together, commissioning is much more likely to be cost-effective and in the better interests of patients. While I recognise that the noble Baroness has anxieties, I hope that my colleagues and I can reassure her over the weeks and months ahead that this is a programme to be excited about, rather than the reverse.

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[Lord Walton of Detchant]

Will the Minister say whether he believes that abolishing all regional planning is absolutely right? I believe that it could be dangerous.

[Earl Howe]

My Lords, I am grateful to the noble Lord for his questions. He will know that our plans do not constitute reorganisation for its own sake. The only purpose of the reorganisations that we are proposing is to embed higher-quality practice and better outcomes for patients, and for no other reason.

The noble Lord asked several questions about GP commissioning. As he will know, the previous Administration introduced practice-based commissioning more than five years ago. Some consortia are doing an excellent job, but many GPs have been frustrated by not having clear responsibility and control. They find very often that PCTs get in their way rather than help them. I think that it will be music to their ears that they will be able to create structures and management systems for themselves that will help them rather than get in their way. We are going to enable them to learn from the past. We are engaged in talks with the profession about how we implement the change, which will, I emphasise, be bottom up.

The noble Lord also referred to GP fund-holding, which as the House will know was a policy introduced by the Conservative Government. There were good points and bad points about fund-holding. The good points were that it empowered GPs and, in many cases, delivered good quality care. But the criticisms revolved around high transaction costs, bureaucracy and, in many ways, inequalities that resulted. We want to avoid those pitfalls. The support that GPs will get will not be prescribed from the centre. A range of support is already available for commissioning, including PCT teams, local authorities and independent commissioning support organisations. There will be no shortage of help out there.

[Baroness Northover]

My Lords, perhaps I may remind the House, as invited, that this is a brief Statement. We have 20 minutes all together and we are already five minutes in. Many people want to intervene on this extremely important Statement, so if people can be brief we will be able to cover as much as possible.

[Baroness Morgan of Drefelin]

My Lords, the Minister talked about an NHS that was stifled by top-down bureaucracy. Given the impressive outcomes that we have seen with improvements in cancer treatment, I do not think that many people would recognise that story. Does the Minister accept that medicine is a fast-changing field where innovation needs to be translated into practice on the front line as quickly as possible? Does he further accept that there needs to be leadership in a complex system like this if patients are to have access to the improvements in innovation and care? How does he see that leadership working?

How will patients be represented throughout the system? For example, how will they be represented at the NHS board? How will GPs ensure that they can access fairly and without bias the views of all their patients, not just those they see regularly? How will GPs translate those patient perspectives into commissioning in line with this new strategy that the local authorities will be responsible for developing? I want to hear the Minister answer that important question in some detail.

[Earl Howe]

My Lords, the noble Baroness makes an important point about innovation. We are clear, as is the White Paper, that driving innovation through the system will remain an extremely important part of what we mean by quality. The QIPP agenda is alive and kicking. For those noble Lords who are not familiar with the acronym, QIPP stands for quality, innovation, productivity and prevention. The innovation part of that will be driven in several ways, not least by the NHS commissioning board, which will have access to sources of advice from NICE, the NHS quality board and many other sources. But we also plan to put in place incentives in the tariff, which will drive innovation and high-quality care. Our proposals for those will be forthcoming.

The noble Baroness asked about patient representation. She was absolutely right about clinical leadership, but she was also correct to say that we need to ensure that the patient’s voice is heard at every level of the health service. At the local authority level, there is no doubt that Health Watch will have a presence as the voice of local patients. We are also creating a national Health Watch, which will act as the national voice for patients, feeding directly into the Care Quality Commission so that assessments of quality can be informed by patient experience on the ground. We are not planning in any way to dilute the duty under Section 242 of the 2006 Act to involve patients in the configuration of services. It is important that local people feel that they have a say in the way that services are developed. Our proposals for this will be laid out in an engagement document that is to be published in a short while.

[Baroness Barker]

My Lords, I welcome the Statement repeated by the noble Earl, and in particular the fact that it builds on many of the best innovations developed by the previous Government such as the commitment by the noble Lord, Lord Darzi, to clinical excellence as the lead factor in the development of services. What I also welcome is that, unlike under the previous Government, the default position is that power will be vested in local communities rather than with the Secretary of State, particularly the commitment to ring-fenced funding for public health and, even more so, having a public health strategy that includes mental health.

I have two questions for the Minister. The first concerns the choice of provider. A large section of the paper emphasises the right of patients to choose a provider. Is it not the case that, in order for there to be a choice of provider, there has to be overcapacity in the system? Can the noble Earl tell us what estimate the department has made of that, given that the White Paper also talks about the challenging financial position in which these plans will go forward? The second question concerns a statement in the papers that the Government intend to create the biggest social enterprise sector, which no doubt will be welcomed by the noble Baroness, Lady Thornton, as doing such a thing was also a policy of her Government. Can the noble Earl explain whether that means that many, if not most, of the existing providers of health services will cease to be providers of those services in the future?

[Earl Howe]

My Lords, I am grateful to the noble Baroness for her positive comments. On public health, she will see in the White Paper that we will be publishing a further White Paper later in the year specifically about public health. Quite deliberately, there is only limited information on that subject in this White Paper. As regards choice of provider, she will see in the White Paper that our policy is clear: it is a policy of “any willing provider”. That means that any provider who is able to provide services to the NHS at the right level of quality and at or below the tariff will be allowed to do so. However, as I said in the Statement, this will not be a free-for-all because providers, if they provide services to the NHS, will be subject to the scrutiny of Monitor, and there will be a joint licensing system between Monitor and the CQC in respect of financial systems and quality, so that those providers who offer their services to the NHS will be regulated on a level playing field. I shall take away the concern she raised at the end of her question, and if I have not covered it adequately in my answer, I will write to her.

[Lord Snape]

Does the Minister accept that this is not a reorganisation of the National Health Service being proposed by the Government, but a balkanisation of that service? Did he not notice the lack of enthusiasm for these proposals of those on the Benches behind him, particularly his junior partners in this alliance? Where is the sense in taking away powers from primary care trusts and strategic health authorities and giving them to individual GPs—ironically, to those in the one group who are not employees of the National Health Service? How will it be possible to continue with a unified National Health Service throughout the United Kingdom if hundreds, if not thousands, of GP practices all promote their own ideas in their own specific areas? These proposals will kill the National Health Service, as the Government well know. Why their allies are supporting them, only they will know.

[Earl Howe]

My Lords, I am not sure what the noble Lord’s question was but I profoundly disagree with his analysis of the proposals before the House. Far from killing off the National Health Service they will give it added life. What is the National Health Service about? It is there to serve patients. If we take as our guiding principle that patients matter more than anyone else—more than the system and more than PCTs—and that we want to take care of patients in the best possible way, we need to enable doctors and patients, working together, to take ownership of the patients’ state of health and to take decisions together. If you arrive at that conclusion, the structures that we are proposing are the logical outcome. The noble Lord’s concerns are for the system, which has often got in the way of patient care. The whole point of these proposals is to remove those obstacles. I hope he will have cause to change his mind as he reads the White Paper.

[Lord Newton of Braintree]

My Lords, I preface my three questions by declaring that I am the chair of an NHS trust. First, does the Minister think there is scope for organisational reconfiguration, to use an awful phrase, to contribute to the achievement of the Government’s objective of higher quality in a cost-effective way? Secondly, if he does, does he think—as I do—that such experience as there is suggests that the road to such reconfiguration is strewn with bureaucratic obstacles, delays and unnecessary costs? Thirdly, if he agrees with that, will he do something about it?

[Earl Howe]

My Lords, I agree with my noble friend. There is no doubt scope for reconfiguration but we are not going to prescribe it from Whitehall. The structures that we propose in the White Paper will facilitate reconfiguration in a much more coherent and structured way on a local level because, with the buy-in of patients, local authorities will have a major say in the way in which services are configured, as will GPs, acting in consortia, jointly. The key issue is whether reconfiguration makes sense from a clinical perspective. Politicians are not in the best position to decide that. Having said that, there will be occasions when people will be unable to agree at a local level and we have plans to cater for that situation: ultimately, the Secretary of State will stand as arbiter in such difficult cases. However, in the majority of cases, we see decisions as properly lying at a local level.

[Baroness Finlay of Llandaff]

I have two brief questions. First, in the Statement the Minister referred to outcomes. Given that secondary care sometimes has patients—sadly too often—referred late because of delayed diagnosis in primary care, how is the clinical care of the general practitioner going to be held to account in this system? My second question relates to the Minister’s mention of “any willing provider”. What security will there be to ensure that a provider cannot introduce a loss-leader service with clearly defined boundaries in order to gain a market share, and to prevent complex and difficult cases not covered by that provider being dumped on the NHS? This has been the experience with some private practices where patients are in private hospitals but, when things become too complicated, they are shipped down the road to the local NHS intensive care unit.

[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.

[Baroness Wall of New Barnet]

My Lords—