Health (CSR)

Kevin Barron Excerpts

Thursday 11th November 2010 Westminster Hall

[Mr Kevin Barron (Rother Valley) (Lab)]

It is good to be here this afternoon under your chairmanship, Mr Gale.

First, let me congratulate my hon. Friend the Member for Easington (Grahame M. Morris) on having the foresight to table this subject for debate. The Minister and the rest of those present will be pleased to know that I shall not be quoting from the King’s Fund during this debate—yes, I see that he is quite pleased about that. Instead, I have a brief from the Nuffield Trust about the likely effect of the comprehensive spending review on health, on top of what we have just been discussing. My hon. Friend talked about a 0.5% increase over four years, or something like that, but the Nuffield Trust argues at one level that there might be a bit more to it. Let me go into the brief it published last month, although it is not related to this particular debate:

“The 2010 Spending Review announced that the NHS will receive 0.4 per cent… growth over the next four years—0.1 per cent a year. This compares to an average real-terms increase of 5.7 per cent per year from 1997/98 to 2009/10. This is the lowest four years’ increase for the NHS since 1951-56. The Spending Review also allocates £1 billion a year from NHS funding to social care. The real-terms change in NHS funding, net of the social care support, is therefore a reduction of 0.5 per cent over the next four years.”

[Interruption.] The Minister says that that is rubbish. Perhaps he can stand up and tell us whether he disagrees with it. I want to continue with this brief and ask him about something that is directly related to this. The next paragraph states:

“The Spending Review also announced important changes to the treatment of past underspends.”

Many of us will know from talking to the NHS locally over the past few years that, because of the generous funding over the past decade, there are such things as underspends. The brief continues:

“Health has accumulated underspends of £5.5 billion, of which £3.7 billion is classified as ‘resource’ (ongoing expenditure on staff, medicines, equipment and the like) and £1.8 billion as capital. There is also a planned underspend for 2010/11 of £1 billion. According to the Spending Review, these accumulated stocks—known as end-year flexibility (EYF)—have been abolished. This means that any previous underspend that is honoured by the Department of Health will have to be made within the settlement outlined in the Spending Review.”

Will the Minister tell us whether the current underspends that our primary care trusts, or perhaps hospitals, hold at the moment—I hope they will be spent on expanding services, as they have been over the past decade—will be clawed out?

The other issue that I would like to raise relates to the changes in commissioning. I am in a peculiar position on this. Some Members will know that I chaired the Health Committee in the previous Parliament. In March, we brought out a report on commissioning. The Government responded some time in July. When the Secretary of State was on the Floor of the House making his statement on the White Paper, he talked about the Health Committee and said:

“Before the election, when it had a majority of Labour Members, the Select Committee on Health said that PCT commissioning was weak and that it was not delivering what was intended. He set up a programme called world class commissioning—it never worked.”

He was replying to the then shadow Secretary of State for Health. The Secretary of State went on:

“Central to delivering better commissioning in the health service is ensuring that those people who incur the expenditure—the general practitioners, on behalf of their patients—and who decide about the referral of patients are the same people who”

blah, blah, blah, blah. In reply to a comment from the current Chair of the Health Committee, the right hon. Member for Charnwood (Mr Dorrell), the Secretary of State said:

“In his capacity as Chair of the Select Committee on Health, we will be responding to him very shortly regarding the Select Committee’s report from before the election on commissioning... What he has just said is absolutely right; we have been able—this is a central task in commissioning—to bring together the responsibility for management of patient care with the responsibility for the commissioning of services.”—[Official Report, 12 July 2010; Vol. 513, c. 665-66.]

I have mentioned that because he has used my name on at least two occasions on the Floor of the House, basically to say that the report on commissioning that we published supports GP commissioning. I want to put it on record that, in my view—it was obviously my draft report and it was not challenged at the time—it does not support GP commissioning in the way that the Government are bringing forward the changes in commissioning.

We looked at four areas in that report, in relation to commissioning: whether to abolish PCTs and reintroduce health authorities; retain PCTs but introduce more integrated care; retain PCTs but introduce local clinical partnerships, under which GPs would directly control commissioning; and retain PCTs but commission services from hospitals. There was also the option to retain and strengthen PCTs. We did not come to a hard conclusion on any of that. I will not bore this gathering with the conclusions we did come to, but it is a gross misrepresentation to say that we were arguing for GP commissioning.

Maybe the nearest scenario that we looked at was the one in relation to local clinical partnerships. The Nuffield Trust informed us:

“There are key changes to the policy environment that are required if commissioning is to stand a chance of becoming effective.”

That was one option, but local clinical partnerships, as we quoted in the report, look very much like the system of GP fund-holding, which had failed to improve commissioning, in our view and that of many other people. We also said that it might be expected to have the advantages and disadvantages of that system.

[Mr Virendra Sharma (Ealing, Southall) (Lab)]

My right hon. Friend is talking about the GP’s role. Does he agree that GPs are not trained for many of the roles asked of them, and not qualified to play those roles? There are no extra resources made available in order to gain the skills.

[Mr Barron]

That is absolutely true. There are fewer resources, because more is being taken out of administration than was planned before the spending review came along.

I am intrigued by the idea of giving clinicians power or giving GPs power. The British Medical Association is not saying no to the idea of GP commissioning. That is good—I have some quotations from it in front of me—but it would want to look at having a real local clinical partnership that included clinicians who worked in the local provider—the local hospitals. It believes that if we are going to do this, that ought to be looked at. I am interested to see whether the Minister agrees. One reason I say that is because, when we took evidence from his favourite organisation, the King’s Fund, the Royal College of Physicians and others thought that PCTs should be retained, but that hospital clinicians and GPs should work more closely together. Professor Ham, who is obviously one of the Minister’s favourite authors in these matters, said:

“There should be progressive migration towards clinically integrated systems, building on the most promising aspects of current reforms and drawing on evidence that shows the benefits of integration and the challenges of making a commissioner/provider split system function effectively.”

He was arguing for real integrated care, but my understanding is that that is not what the White Paper is proposing. It is proposing that only GPs will have the power to spend 70 or 80% of the NHS budget, not other local clinicians as well. I would like the Minister to reply on that specific point.

[Grahame M. Morris]

I thank my right hon. Friend for giving way on the point about GP commissioning. That is an issue that the Minister might address. If streamlining in commissioning bodies saves money—I think the previous Labour Government demonstrated that by reducing the number of PCTs from 350 to 150, which was acknowledged by Sir David Nicholson—how can it save money to be creating a plethora of GP consortiums that will be responsible for commissioning? Creating such a plethora of bodies must add to administrative costs.

[Mr Barron]

I am grateful to my hon. Friend for his intervention. I have to say to the Minister that at no time when members of the Health Committee in the previous Parliament were looking at commissioning did we ever think that the Government would hand it over to GPs in the way being proposed in the White Paper. It has huge implications, not just for the NHS, but for GPs themselves. The only evidence we saw was that GP fund-holding has struggled for nearly 20 years to be a good, proper and efficient way to commission services. Frankly, nobody submitted any evidence to my knowledge for the leap into the dark of handing commissioning to GPs in such a quick period of time. Nobody gave that evidence whatever. There were some arguments about keeping the PCT and adding GPs to it, so that they could get the experience. Frankly, there should be more medical leadership in our national health service; I have no doubts about that. This leap in the dark with GP commissioning is something that, I fear, is unlikely to work. The professionals who work in the health service appear to have that same fear.

[Ian Lavery]

The coalition agreement states quite clearly:

“We will stop the top-down re-organisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.”

Now we are seeing the largest ever reorganisation in the NHS. We are seeing the PCTs abolished and GP consortiums looking to take their place, which will inevitably create duplication and require more finance and more resources to be spent on administration. What does my right hon. Friend think about that?

--- Later in debate ---

[Mr Barron]

I had nothing to do with the interventions, Mr Gale, apart from giving way. There is no plan or plot. I thought I would seize the opportunity to talk about the commissioning report, because the current Health Committee is looking again at commissioning and the House has not had the opportunity to debate the report and the Government’s response, which came in July.

In relation to the latest intervention, at the last Health Question Time the Minister attempted to reply to what I said about major reorganisations in the health service. It is well known now that they take years to embed, are normally very expensive and usually have a negative effect on performance while they happen. That has happened under every major NHS reorganisation in the last 20 or 30 years. That is the truth of the matter. If the estimate of the increase in costs arising from the reorganisation is right, the CSR will have a significant impact on the NHS in the future.

[Frank Dobson (Holborn and St Pancras) (Lab)]

Beside the financial impact of reorganisation, even more important is the fact that large numbers of clinicians and others working in the NHS are distracted from their day job of looking after patients to go to innumerable meetings and discussions. In some cases, they even have to reapply for their current jobs. That is all to do with the reorganisation, so it wastes staff time, as well as wasting money.

[Mr Barron]

I think that there is some evidence in relation to that. Having said that, the evidence that we should be concerned about is the evidence that has come out in surveys recently about what GPs think about the proposed reorganisation.

I have in front of me a press release from what is probably the strongest trade union that we have in the United Kingdom, which is the BMA. The BMA does not like to be called a trade union, but, indeed, that is what it is. Along with the Minister’s favourite organisation, the King’s Fund, the BMA conducted a survey of doctors. I will quote from the results of that survey:

“Asked if the reforms would improve patient care, 38 per cent of doctors who responded either said they did not know, or said they neither agreed nor disagreed. Less than a quarter believed patient care would be improved.”

Obviously surveys are surveys—we do not know what question was asked. In addition, I think that the number of doctors who responded to that survey was quite low. I would not lay great store in it, and the Minister probably has the figures from the survey in front of him. However, I want to point out what Dr Hamish Meldrum of the BMA said about the White Paper. He said that it had “many positive aspects” but added:

“Giving more power to clinicians has the potential to improve the quality and cost-effectiveness of patient care, but as this survey reflects, doctors believe that many of the proposals in the white paper would make joint working much harder.”

He continued:

“GP-led commissioning will only be successful if there is effective integration between different parts of the NHS, but some of the proposals in the white paper will accelerate competition and fragmentation.”

That comment takes me back to the question that I posed to the Minister about whether those local GP consortiums can include other people who work in the NHS, such as consultants, other people from the local hospital or providers of primary care services. Can such people sit on those consortiums or is it exclusively GPs who will do the commissioning?

I will not go into much detail, but I want to refer briefly to the comment that the coalition said that these proposed changes are not “top down”. I appreciate that this debate might not be the right forum in which to debate that issue much further, Mr Gale, but what is the national commissioning board going to do if not act in a “top-down” manner?

There is good evidence—I do not think it has been denied by the Department of Health—that if a local GP consortium were to fail, the national commissioning board would intervene. I want to know what is the difference in concept between the national commissioning board and Richmond house. We have had about 40 years of battles between the NHS at local level and central Government, over central Government trying to give direction to the NHS at local level. How will that change?

Before I sit down I have a nice easy question for the Minister. I have here a press release that went out on 21 October, and the heading reads:

“New support for GPs will cut the costs of commissioning”.

The press release continues:

“A new series of resources to support GP Consortia to design and commission services for patients was announced today by Health Secretary Andrew Lansley”.

It says that those resources

“will provide… a set of tools and templates to use when designing and buying services for their patients. The first of these support packs published today is for cardiac rehabilitation services”.

We are apparently saving money with GP commissioning, so I want the Minister to tell us what evidence he has that this new system will save money and cut the costs of commissioning? I ask that question because such evidence—evidence of how commissioning had cut costs—was one of the holy grails that the Health Committee could never find. It has been said in the debate, and it is well evidenced, that the changes in commissioning that we have had during the past few decades have done anything but cut costs. In fact, they have increased them.

I will finish by saying that the Health Committee’s report on commissioning that was published in March said that we need to look wholesale at the past 20 years of payment by results, because payment by results is not working no matter what shape it comes in. We said that quite clearly in the report.

I do not necessarily want to make radical changes to commissioning, but I do want things to be better for patients and the public, and I am not convinced that the outcome of the White Paper will be better treatment for patients and the public, nor am I convinced about the evidence that the CSR’s effect on health will be a better outcome for patients and the public. As I said, organisations such as the Nuffield Trust, which have great experience of our national health care system, are talking about a reduction of 0.5% in NHS spending. I fear that that will happen, and it is not what was in people’s manifestos before the general election. I want the Minister to tell us what he thinks about that.

--- Later in debate ---

[Mr Burns]

I am grateful to the hon. Gentleman for that intervention, and I am sure that his reputation will survive my praise of him. I shall, in my own way, come to the point that he raises.

Before I begin to explain why we have not broken our election pledge, let me congratulate the hon. Member for Halton (Derek Twigg). He is a dedicated and decent man who was always an exemplary Minister when he was in government. I am delighted to see him back on his party’s Front Bench, albeit in a shadow ministerial post, and I wish him well in his endeavours. I trust that he will be doing the job for many years to come and that the same fate will not befall him as sadly befell him when he left the previous Government: ironically—I grieve as much as he does about this—his place was taken by someone who was ostensibly a Tory, who was, for some bizarre reason, embraced with both arms by previous Prime Minister. It is great to see the hon. Gentleman back, and I look forward to many debates over the coming years as our careers continue.

This debate goes to the heart of two of the coalition Government’s main priorities: bringing the public finances back on to a sustainable footing and ensuring the future health of the nation. Our manifesto commitment, reiterated in the coalition agreement, was to increase spending on the NHS in real terms for every year of this Parliament. Notwithstanding the comments of some hon. Members, I am tremendously proud of the fact that we have kept the faith and honoured that pledge. Before anybody jumps up to try to intervene, let me remind them that I am proud of keeping that pledge.

The right hon. Member for Leigh, the former Secretary of State in the outgoing Labour Government, has criticised my party for keeping that pledge because he thought it was wrong. It would be difficult for any Labour Member to claim that we have broken the pledge, because, by definition, if we have broken the pledge, the right hon. Gentleman is factually incorrect in his criticism of us. It is a bit of a dilemma for Labour Members.

[Mr Barron]

rose—

[Mr Burns]

I give way to the former Chair of the Health Committee.

[Mr Barron]

What does the Minister say when the Nuffield Trust states that the Government have broken the pledge by reducing spending by 0.5%?

[Mr Burns]

We will come to that point. Whenever there is a parliamentary briefing or statement for a debate that fits the prejudices that Labour Members want to project—their straitjacket—that is fine, but anything that does not conform to their prejudices or prejudged views, or to the facts, such as the comments from the King’s Fund on which I kept pressing the hon. Member for Easington, which confirmed its view that we had honoured our pledge and made a real-terms increase, they dismiss as fiction. I am afraid that I do not share the support offered by the right hon. Member for Rother Valley (Mr Barron) for the views in the Nuffield Trust document.

I will come on to social care spending, because I know that the shadow Minister, the hon. Member for Halton, made quite a lot of that. I will try, in a longer period than I would have in an intervention, to show that he is wrong and the Government are right.