NHS: Future Forum

Earl Howe Excerpts

Tuesday 14th June 2011 Lords Chamber

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

My Lords, I shall now repeat a Statement that has been made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

“With permission, Mr Speaker, and further to the Written Ministerial Statement I laid in the House earlier today, I wish to make a statement on the Government’s response to the NHS Future Forum.

We established the independent Future Forum on 6 April, under the chairmanship of Professor Steve Field, to look again at our proposals on the modernisation of the NHS. Yesterday it published its report and recommendations. I would like to thank Professor Field and his 44 senior colleagues from across health and social care who have worked so hard these past eight weeks. I would also like to thank the more than 8,000 members of the public, health professionals, and representatives from over 250 stakeholder organisations who attended some 250 events across the country; also the tens of thousands who wrote to us with their views. I want also to thank the many officials in my department who supported this unprecedented engagement across the country.

I said two months ago that we would pause, listen, reflect and improve our plans. Our commitment to engage and improve the Bill has been genuine and has been rewarded with an independent, expert and immensely valuable report and recommendations from the NHS Future Forum. I can tell the House that we will ask the forum to continue its work, including looking at the implementation of proposals in areas including education and training and public health.

In his report, Professor Field set out clearly that the NHS must change if it is to respond to challenges and realise the opportunities of more preventative, personalised, integrated and effective care. It said that the principles of NHS modernisation were supported: to put patients at the heart of care; to focus on quality and outcomes for patients; and to give clinicians a central role in commissioning health services.

In the forum’s work, it set out to make proposals for improving the Bill, and its implementation; to provide reassurance and safeguards; and to recommend changes where needed. As Professor Field put it, the forum did this not to resist change, but to embrace it, guided by the values of the NHS and a relentless focus on the provision of high quality care and improved outcomes for patients.

We accept the NHS Future Forum’s core recommendations. We will make significant changes to implement those recommendations and, in some cases, offer further specific assurances which we know have been sought. There are many proposed changes and we will publish our more detailed response shortly. But I would now like to tell the House some of the main changes we will make.

The Bill will make clear that the Secretary of State will have a duty to promote a comprehensive health service, as in the 1946 Act, and be accountable for securing its provision and for the oversight of the national bodies charged with doing so. We will also place duties on the Secretary of State to maintain a system for professional education and training within the health service, and a duty to promote research.

One of the most vital areas of modernisation to get right is the commissioning of local services. For commissioning to be effective, it must draw upon a wide range of people when designing local services, including clinicians, patients and patient groups, carers and charities. We will amend the Bill so that the governing body of every clinical commissioning group will have at least two lay members—one focusing on public and patient involvement, the other overseeing key elements of governance, such as audit, remuneration and managing conflicts of interest.

While we should not centrally prescribe the make-up of the governing body, it will also need to include at least one registered nurse and one secondary care specialist doctor. To avoid any potential conflict of interest, neither should be employed by a local health provider. These governing bodies will meet in public and publish their minutes. The clinical commissioning groups will also need to publish details of all contracts they have with health service providers.

To support commissioning, the independent NHS commissioning board will host ‘clinical senates’, providing expert advice on the shape and fit of healthcare across a wider area of the country, and it will develop existing clinical networks, which will advise on how specific services, such as cancer, stroke or mental health, can be better designed to provide integrated, effective care. Building on this multi-professional involvement, clinical commissioning groups will have a duty to promote integrated health and social care around the needs of their users.

To encourage greater integration with social care and public health, the boundaries of clinical commissioning groups should not normally cross those of local authorities. If they do, clinical commissioning groups will need to demonstrate to the NHS commissioning board a clear rationale for doing so in terms of benefit to patients.

I have always said that I want there to be ‘no decision about me, without me’ for patients when it comes to their own care. The same goes for the design of local services, so we will further clarify the duties on the NHS commissioning board and clinical commissioning groups to involve patients, carers and the public. Commissioning groups will have to consult the public on their annual commissioning plans and involve them in any changes that would affect patient services.

One of the main ways that patients will influence the NHS will be through the exercise of informed choice. We will amend the Bill to strengthen and emphasise commissioners’ duty to promote patient choice. Choice of any qualified provider will be limited to those areas where there is a national or local tariff, ensuring that competition is based solely on quality. This tariff development, alongside a best-value approach to tendered services, will safeguard against cherry-picking.

Monitor’s core duty will be to protect and promote the interests of patients. We will remove its duty to promote competition as though that were an end in itself. Instead, it will be under a duty to support services integrated around the needs of patients and the continuous improvement of quality. It will have a power to tackle specific abuses and restrictions of competition that act against patients’ interests. Competition will be a means by which NHS commissioners are able to improve the quality of services for patients.

We will keep the existing competition rules introduced by the last Government—the Principles and Rules for Co-operation and Competition—and give them a firmer statutory underpinning. The Co-operation and Competition Panel, which oversees the rules, will transfer to Monitor and retain its distinct identity. And we will amend the Bill to make it illegal for the Secretary of State or regulator to encourage the growth of one type of provider over another. There must be a level playing field.

We will strengthen the role of health and well-being boards in local councils, making sure that they are involved throughout the commissioning process and that local health service plans are aligned with local health and well-being strategies.

In a number of areas, we will make the timetable for change more flexible to ensure that no one is forced to take on new responsibilities before they are ready, while enabling those who are ready to make faster progress.

If any of the remaining NHS trusts cannot meet foundation trust criteria by 2014, we will support them to achieve it subsequently. But all NHS trusts will be required to become foundation trusts as soon as clinically feasible, with an agreed deadline for each trust.

We will ensure a safe and robust transition for the education and training system. It is vital that change is introduced carefully and without creating instability, and we will take the time to get it right, as the Future Forum has recommended. During the transition, we will retain postgraduate deaneries and give them a clear home within the NHS family. On any qualified provider, its extension will be phased carefully to reflect and support the availability of choice for patients.

Strategic health authorities and primary care trusts will cease to exist in April 2013. By April 2013, all GP practices will be members of either a fully or partly authorised clinical commissioning group or one in shadow form. There will be no two-tier NHS. However, individual clinical commissioning groups will not be authorised to take over any part of the commissioning budget until they are ready to do so. GPs need not take managerial responsibility in a commissioning group if they do not want to. April 2013 will not be a ‘drop dead’ date for the new commissioners. Where a clinical commissioning group is not able to take on some or all aspects of commissioning, the local arms of the NHS commissioning board will commission on its behalf. Those groups keen to press on will not in any way be prevented from becoming fully authorised as soon as they are ready.

I also told the House on 4 April that we would secure proper scrutiny for any changes we made to the Bill. In order to do this, without trespassing on the House’s time to review the Bill as a whole at Report, we will ask the House to recommit the relevant parts of the Bill to a Public Bill Committee shortly.

Through the recommendations of the NHS Future Forum and our response we have demonstrated our willingness to listen and to improve our plans, to make big changes—not to abandon the principles of reform, which the Future Forum itself said were supported across the service, but to be clear that the NHS is too important and modernisation too vital for us not to be sure of getting the legislation right.

The service can adapt and improve as we modernise and change. But the legislation cannot be continuously changed. On the contrary, it must be an enduring structure and statement. So it must reflect our commitment to the NHS constitution and values. It must incorporate the safeguards and accountabilities which we require. It must protect and enhance patients’ rights and services, and it must be crystal clear about the duties and priorities which we will expect of all NHS bodies and in local government for the future.

Professor Field’s report says that it is time for the pause to end. Strengthened by the forum’s report and recommendations, we will now ask the House to re-engage with delivering the changes and the modernisation that the NHS needs. I commend this Statement to the House”.

My Lords, that concludes the Statement.

[Baroness Thornton]

My Lords, I thank the Minister for repeating the Statement. I start by paying tribute to him for the way in which he has facilitated the debate about the future of the NHS thus far across the House. The all-Peer seminars benefited hugely from the fact that his office ensured the input from senior department officials. I have to add that his noble friend Lady Northover attended every one of those seminars. They have continued and, I believe, have ensured a greater understanding of the Bill from which it can only benefit. Notwithstanding Nick Clegg waving about his list of changes and claiming all, I think we might find out as we move on how influential the Minister has been in bringing about changes to the Bill. However,

“there is more joy in heaven when one sinner repents”.

About a year ago the Minister gently chided me, when he launched the health White Paper, by saying:

“I hope that when the noble Baroness digests this White Paper, she will come to view it rather more favourably than she has indicated”.—[Official Report, 12/7/10; col. 535.]

On this occasion, lest the noble Earl misunderstands me, I will say that I welcome the findings of the Future Forum, although I think that we would both agree that it cannot possibly have covered all the important issues in the NHS in eight weeks. In the detailed response that accompanies the Statement, the Government have gone further than the Future Forum in their proposed changes to the Bill; they are very significant. I particularly welcome issues such as the commitment to the NHS constitution. However, it begs the question of whether we might need a whole new Bill, or no Bill at all, if we all now agree that evolution is better than revolution.

I will mention the process. In this House we are more familiar with the parliamentary process whereby you consult, legislate and implement—not the other way around, which is what seems to have happened here. However, the Future Forum was a device that I think everyone understood. There was a pressing political need to get the coalition Government—Nick Clegg, David Cameron and in particular Andrew Lansley—off the hook. I will say this only once, despite severe temptation; the uniformly fulsome and enthusiastic welcome from Nick Clegg and David Cameron for the White Paper and the Bill ring rather hollow today. However unworthy the motivation, the end of the pause means one very good outcome for which we should all be grateful—probably none more so than patients and staff—namely, that the Prime Minister, Deputy Prime Minister and Secretary of State will cease their endless visits to hospitals to prove how much they love the NHS.

The chairman of the Future Forum said that opposition to the Bill stemmed from “genuine fear and anxiety”. He went on to say that NHS staff feared for their jobs, and feared that their NHS was about to be broken up and—their word—“privatised”. Thank goodness the Future Forum had the wisdom to listen to what so many people have been saying for a year to the Prime Minister and the Secretary of State: during the consultation period, after the Bill was published, with increasing volume during its passage in the Commons, and despite two very sensible Health Select Committee reports. Does the Minister think that the terrible mess that the Government have found themselves in could have been avoided, and have they learnt their lessons?

Since we are now promised significant changes, will the Minister confirm that there will be a new and proper impact assessment and a new set of Explanatory Notes, and that there will be consultation on the changes proposed through amendments before recommittal? Will there be a formal response to the well argued report of the Health Select Committee and its recommendations, not all of which agree with the Future Forum report? Most importantly in many ways, if there is to be a long period of enactment when the Bill is passed—and, as the Minister explained, no drop -dead moments—a very strong recommendation of the Future Forum report must be acted on; namely, the production of a timetabling and transition plan. This must be in place as soon as possible and must be robust. When does the Minister envisage that it will be published?

As the House would expect, since Part 3 is still in the Bill we will seek reassurances on competition, the composition of consortia, NICE, the minimum references to social care that are there, and, for example, the lack of references to mental health. We will pursue all these issues in due course. Will it be possible for the Minister to use his good offices to ask the Government to make time available for a longer debate in the House about these issues before we receive the Bill? When does the noble Earl think that we might start consideration of the Bill?

While the uncertainty continues, the NHS is going backwards. The Future Forum suggested—and we all know—that there is widespread demoralisation and even fear in the NHS. Good managers are being denigrated and made redundant, front-line staff are facing the sack and major projects and initiatives have been put on hold, as nobody knows what structures will be in place in the next few weeks, let alone the coming months. That is the result of the earlier rush, which can now be remedied by a robust transition plan.

It is to the credit of all the organisations—patient groups, carers, long-term conditions, medical and others—that have persisted in making their views known and whose views the Future Forum heard. During this period, my colleagues and I concentrated on asking people to look at and understand the Bill because we were confident that the more people understood this legislation, the less happy they would be about the threat to our NHS and to patients. We will be doing the same with the new Bill. We will look at it carefully in detail, and I will again be asking whether it meets the concerns that they and their organisations have raised. I say that because almost every single suggestion in the Future Forum report was put down as an amendment by my colleagues in the Commons in Standing Committee. I suggest to the Government that they might save a lot of time and trouble if they adopted all the other amendments that we put down that were not in the Future Forum. Honestly, what a way to conduct the reform of our most precious national asset. The lesson I take from the past year is this: it is very important not to suspend our critical faculties, even in the face of what seems a huge and, at the moment, welcome change. I am sure that this House will not do that. We have a very important job to do in making sense of this Bill and in ensuring that whatever the Government say today, their rhetoric is matched by the reality. We need to consider these suggested changes in this light. We have much work to do, and the sooner we start, the better.

[Earl Howe]

My Lords, I am grateful for the constructive and positive tone that the noble Baroness adopted in her response. I am grateful to her for her welcome of the Future Forum report, and I thank her for expressing appreciation for the seminars which my department is continuing to run. I can return the compliment in expressing my gratitude for the seminars that she has organised to inform Peers.

There is no disguising the fact that this is an extremely wide and detailed programme of modernisation. There is a great deal to absorb. It is important for noble Lords to understand as fully as possible what the proposals amount to before the Bill reaches your Lordships' House. She is right: they are significant changes. However, I would disagree with her about there being no need for a Bill. Since these changes are so extensive, it is appropriate that Parliament should have the opportunity of approving what is proposed for the National Health Service which, as the Statement said, is designed to be an enduring structure that successive Governments can back. Certainly, lessons have been learnt. I think that when we consulted on the White Paper last year, it was clear that there was general acceptance of the key principles that we set out in it, but when the Bill, which set out how we proposed to implement those principles, was published, the concerns bubbled to the surface, which was why we thought it right, and I still think it right, to have the listening exercise.

The noble Baroness asked me whether we would publish a new impact assessment and Explanatory Notes. We will be updating the impact assessment and Explanatory Notes to reflect the changes to the Bill. They will be published when the Bill is introduced in this House in accordance with normal protocol. She also asked me about timetabling. We want to ensure that the Bill is given sufficient scrutiny in both Houses. We hope that the stronger consensus for change that has been built as a result of the listening exercise will be reflected when both Houses consider timing issues and that the Bill will come to this House at the earliest appropriate moment. Currently, I cannot tell the noble Baroness when that will be. It is, of course, not for us to dictate to another place how it should manage its business. She also asked about the possibility of time being available for a health-related debate. The Leader of the House is sitting beside me, and I am sure he heard that request and that it will be discussed in the usual channels.

The noble Baroness rightly insisted on a robust transition plan, which I believe we have. She will have noticed from the Statement that we have adjusted quite significantly the pace at which these changes will be rolled out. I believe that those working in the health service will be reassured by that because in some quarters there was anxiety that we were going too fast for some to be sure that they would be ready in time.

The noble Baroness asked a number of questions, many of which will be the subject of a paper we plan to publish during the next week or so. The paper will set out more precisely how we plan to implement the changes proposed by the NHS Future Forum. I am not in a position to provide all the answers today but it is clear that, above all, the NHS needs certainty, which we can now give to those who work in it. However, I can say today that there is hardly anything in our proposals that does not represent a natural evolution from the policies and programmes pursued by the previous Government: that is, the development of the quality agenda initiated by the noble Lord, Lord Darzi; extending patient choice; developing the tariff; clinically led commissioning at primary care level, which is a natural extension of practice-based commissioning; completing the foundation trust programme; the continuation of the co-operation and competition panel established by the previous Government but now within the framework of a bespoke healthcare regulator; strengthening the patient voice by the evolution of links to HealthWatch; and augmenting the role of the CQC. None of that is wholly new: the difference is that for the first time we are setting all these things out in one coherent programme and not, as did the previous Government, in a piecemeal fashion.

I believe, and I hope, that we have the basis for broad consensus. We will see when the Bill reaches this House whether that belief is borne out. Not for a minute would I wish the noble Baroness to suspend her critical faculties, or for any other noble Lord to do that. I look forward to those debates in due course.

[Lord Alderdice]

My Lords, I am grateful to my noble friend for repeating this important and welcome Statement. It reaffirms the coalition’s commitment to a reformed NHS, which is patient-centred, clinician-led and outcome-focused. Does he accept that the concerns, which are fully addressed in this Statement, were shared not alone on these Benches but by many Conservative colleagues, as well as patients, professionals and other stakeholders, and others in your Lordships’ House, as exemplified in the national debate instituted by the Government? Will he now confirm that, despite the anxieties that there have been, the duties and responsibilities of the Secretary of State will be reaffirmed in the Bill in the language used when our beloved NHS was established? Will he confirm that there will now be a level playing field and that private providers will not be advantaged against public providers, as was the case under the previous Labour Government? Will he further confirm that Monitor will be redesigned to be more than a mere economic utility regulator but will facilitate co-operation and integration, as well as competition on quality rather than on price?

[Earl Howe]

I am most grateful to my noble friend. He is right that the concerns that arose in relation to the Bill stemmed from many quarters—certainly from my own Benches and his but also from the wider public. I think we took on board those concerns almost as soon as the Bill was published. They were reflected in a large volume of correspondence, a high proportion of which I dealt with. I was keenly aware of the issues occupying people’s minds. I believe and hope that in the Future Forum’s report, and in our acceptance of that report, we have the basis for allaying most of those concerns.

My noble friend asked three questions. The first was around the duties of the Secretary of State. The Statement made clear that, as now, the Secretary of State will remain responsible for promoting a comprehensive health service. It has never been our intention to do anything else. Indeed, the Bill did not specify anything else. That will be underpinned by the new duties that the Bill already places on the Secretary of State around promoting quality improvement and reducing inequalities. We shall be setting out other duties on the Secretary of State to strengthen his accountability.

On private providers, the noble Lord is right. We are clear that private providers should not be advantaged over the NHS. Indeed, the amendments that we will make to the Bill will put that concern to rest, I hope, once and for all.

Monitor will have its duties rephrased. As the Statement also made clear, the duty to promote competition, which is now in the Bill, will be replaced by a different set of duties around patients, integration and the promotion of quality. There will be quite a different flavour to Monitor's duties.

[Lord Walton of Detchant]

My Lords, I, too, congratulate the noble Earl, who is so widely respected on all sides the House, on the statesmanlike way in which he and the noble Baroness, Lady Northover, have led discussions on the Bill in the past few weeks. I pay tribute also to the contribution of the Opposition. In all, we have had something like 25 seminars looking at the detail of the Bill. The developments that have been discussed and which Steve Field and his colleagues have put forward look as though they will produce major amendments to the Bill, which will be welcome on all sides of the House.

I have three specific questions. The one of greatest importance relates not only to the local clinical commissioning groups, but the clinical senates. We need to know a good deal more about them. Will they take on board some of the people who were previously employed by regional strategic authorities who are involved in the specialist commissioning of highly specialised services? That needs to be looked at carefully because of the unevenness in standards of specialised care throughout the country.

In relation to those clinical senates, will the role of universities be taken on board; not only those with medical schools but the ones that have responsibility for training other healthcare professionals? They should be thought of as having some kind of formal role in relation to those senates. I also suggest to the noble Earl in relation to clinical networks that, with the development of genomic medicine, rare diseases are becoming so important that we may need to have a clinical network for them because of the very expensive and rare orphan drugs that are being rapidly introduced for the treatment of these conditions.

Finally, the Bill as originally constructed did not deal in any depth with research or clinical education and training. The developments in this particular report on those two fields are very welcome. We look forward to having further details.

[Earl Howe]

I am most grateful to the noble Lord, Lord Walton, as I always am, particularly for his welcome for the idea of clinical senates. They will provide the kind of multiprofessional advice on local commissioning plans that everybody has been calling for. The senates will be hosted by the NHS Commissioning Board. The detail is still to be worked out, but it is likely that they will be located regionally. They will be in prime position to do the very thing that the noble Lord seeks: to provide expert advice on good commissioning, not just for the treatment of everyday conditions, but for specialised services, which I know is of particular concern to noble Lords.

The noble Lord suggested that there should be a role for the universities, and that is a constructive idea that I will take away. As regards clinical networks, we are certainly of the view that they have proved their worth over the past few years and we are keen to see more of them created. I hope that that will be facilitated by the structures we are putting in place.

[Lord Darzi of Denham]

My Lords, I welcome the Statement from the noble Earl and also congratulate him on his leadership in getting us back on track. One of the commonest sayings about a good clinician, whether a doctor or nurse, is that they listen to a patient but also seek the opinion of others if dealing with a complicated case. In this instance, the noble Earl has done both.

I am very reassured that the language has changed. As the noble Earl said, quality will remain the organising principle of the NHS. I know and he knows that quality is what unites those who deliver healthcare. Quality is what the public and patients expect. I am also reassured by the concept of using competition when necessary. I strongly support competition, have always done so and work in an organisation that competes not only in the NHS in England but also globally. I acknowledge, too, that integration should also be used as a tool where possible. The listening exercise is not at the end. It should start from now. Where will the engagement exercise lead?

Finally, and more importantly, there is the management and leadership now required to drive these important sets of reforms at a time of austerity. We have heard a lot about management. It is an easy political target but the NHS needs better management rather than less. I am pleased to see that the Government are committing to retaining the best managers and to develop managerial skills. However, this commitment is distinctly lacking in specifics. More detail and action are required before I could confidently say that the importance of management has been grasped. I say this within the context of the age of austerity. We need leadership and management to drive this set of reforms. I strongly agree that we need reforms and they need to be continual reforms rather than destructive ones. On that note, I look forward to Second Reading.

--- Later in debate ---

[Earl Howe]

My Lords, I am extremely grateful to the noble Lord, Lord Darzi, and would reassure him—I am sure that I do not need to—that our ambition is to carry through the agenda that he began when he was Minister of raising the quality of care throughout the NHS. He will see that we have defined quality in the Bill. It is the one part of the Bill that I do not think anybody has quibbled with. We have used his definition and I hope that no amendments will be tabled to change that.

The noble Lord said “competition when necessary” and I thoroughly agree with that. What we do not want to see is competition as an end in itself. It is never that. It can be there only to support better care of patients and buttress patient choice. If we believe in patient choice then we must inevitably believe in an element of competition. The key is making that competition work for patients properly, as we all would wish. Over the past few years we have seen how it can do that.

The listening exercise will not come to an end. We have asked the Future Forum to remain in being and to continue its work in a number of other areas. I am pleased to say that it has agreed to do so. Education and training will be one such area, public health another.

Finally, the noble Lord is absolutely right to direct our attention to the importance of good management. I think I read the other day in an article that he published that, if anything, the NHS has been over-administered and under-managed. I would agree with that analysis. We need good quality managers. I have never been one to denigrate managers. They are of the highest importance if we are to have a first-rate NHS. I hope to have further news on that front before long.

[Lord Blackwell]

My Lords, I add my congratulations to my noble friend on his Statement which has certainly reassured me that the principles in the White Paper have been maintained. Can he elaborate a little more on the development of competition and choice to which he referred? The Statement says that Monitor’s core duty will be to protect and promote the interests of patients, not to promote competition as if it were an end in itself. Can I take it from what my noble friend has said that the Government continue to believe that competition and choice are key drivers of improving the interests of patients and quality in the health service?

Following on from that, on the Government’s commitment to extending patients’ choice of any qualified provider, which is reasserted in the Statement, how will the phasing of the introduction or further expansion of alternative providers evolve in a way that will give those alternative providers the confidence to make the investments necessary so that they can play their full part in providing quality services under the NHS?

[Earl Howe]

I thank my noble friend for raising this important topic. I cannot provide him with the kind of detailed replies that he seeks. Those should emerge over the next few days as we work through our response fully. But I can tell him that we will amend the Bill to strengthen and emphasise the commissioner’s duty to promote choice in line with the right in the NHS constitution for patients to make choices about their NHS care and to receive information to support those choices. We believe in patients’ choice and in competition, as I have already indicated, where that is appropriate. As recommended by the Future Forum, the Secretary of State’s mandate to the board will set clear expectations about offering patients choice.

We will maintain our commitment to extending patients’ choice of any qualified provider, but we will do this in a much more phased way. We will delay starting until April 2012, and the choice of any qualified provider will be limited to services covered by national or local tariff pricing to ensure that competition, where it occurs, is based on quality. We will focus on the services where patients say they want more choice—for example, starting with selected community services—rather than seeking blanket coverage. Of course, with some services such as A&E and critical care, any qualified provider will never be practicable or in patients’ interests.

I have already referred to the changes in the duties of Monitor, in its competition functions. The NHS Commissioning Board, in consultation with Monitor, will set out guidance on how choice and competition should be applied to particular services, guided by the mandate set by Ministers. That includes guidance on how services should be bundled or integrated.

[Lord Hunt of Kings Heath]

My Lords, I declare an interest as chair of the Heart of England NHS foundation trust and as a consultant trainer in the NHS. Like other noble Lords, I am very grateful to the noble Earl for his stewardship of this matter in your Lordships' House. It is noticeable that the Government are continuing with their policy of placing £60 billion in the hands of commissioning consortia, which would be largely led by general practitioners. What I thought was missing from both the listening exercise and the Government’s general approach was any indication of how the standards in general practice are to be improved. A huge amount of power is to be given to general practice, yet we know that the general quality of GPs is very variable. In some parts of the country, it is very difficult to get access to GPs out of nine to five hours; in some parts, GPs have shown themselves completely unable to engage in demand management. Will these commissioning consortia be able to get to grips with poor quality GP performance?

[Earl Howe]

The noble Lord, Lord Hunt, raises an important issue. I agree with him that the quality of general practice has been extremely variable. We saw a report the other day, published by one of the think tanks, which said exactly that. We have some very good GPs, but we have some who, frankly, are less than the standard that we would want and expect in primary care.

We are doing a lot of work to roll out leadership programmes for general practitioners. The National Leadership Council is working with GPs to agree the skills required for commissioning and will assist GPs in developing these skills as appropriate. The NHS institute is also doing some good work in this area and we will shortly be able to provide a bit more detail on how we can develop leadership, regionally and nationwide.

The noble Lord’s question runs rather wider than that, being about the quality of care delivered by GPs. In rolling out the outcomes framework and the commissioning outcomes framework, and the transparency that goes with that, it will become rapidly apparent which GPs require more support. I have no doubt that the consortia or, as we are now calling them, clinical commissioning groups will see it as being in their interests to ensure that the poorer performers are brought up to the standard of the best.

[Baroness Hollins]

My Lords, I commend the Government on the depth and breadth of the consultation that has taken place. I particularly welcome the new focus for Monitor on integration and the proposed coterminosity of the clinical commissioning groups with local authorities, which is particularly important in the case of commissioning integrated mental health and learning disability services. Does the Minister agree that the changes now proposed can be expected to meet better the needs of people with serious mental illness, learning disabilities and other complex needs than the Bill as originally published, and that the focus on health inequalities will allow the Secretary of State to monitor reductions in them for those vulnerable groups?

[Earl Howe]

I am very glad that the noble Baroness, with her considerable expertise, raised the important subject of serious mental illness and the needs of those who are particularly disadvantaged. She is right: we now have a much better way forward in commissioning services for those particularly difficult-to-care-for groups, if I may put it that way. How services will be commissioned for those with special needs and serious mental illness will, I think, emerge as we go forward. However, in my own mind I can see that local authorities and consortia may well decide to commission services jointly. There will be the means to do that through pooled budgets and shared arrangements. We will ensure that the quality premium, the details of which are still being worked through, genuinely rewards the ironing-out of health inequalities. We are absolutely clear that one of our goals is to address health inequalities at every level, and that includes in mental health.