NHS Commissioning Board: Mandate

Lord Hunt of Kings Heath Excerpts

Tuesday 13th November 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, first, I thank the Minister for repeating the Statement and for the briefing that he gave me earlier today. I also refer noble Lords to my interest in health, contained in the register.

This morning I had the great privilege of hosting a ministerial visit to Birmingham Heartlands Hospital by the Minister’s honourable friend, Mr Norman Lamb. He came to see the Birmingham and Solihull Rapid Assessment, Interface and Discharge service—RAID—which essentially is a partnership that has placed mental health professionals inside the emergency department of my local hospital to give people a holistic physical and mental health response. In that context, I very much welcome the emphasis in the mandate on mental health priority and the promise to implement the amendment that we tabled in your Lordships’ House in relation to parity of esteem between physical and mental health.

But—and there is a but—the problem at the moment in the National Health Service is that mental health has been first in line for reductions in expenditure. Is the Minister in a position to confirm that mental health spending was cut in real terms last year, and to say what the Government intend to do to reverse that? Will he also confirm, in relation to mental health, that he is determined to see that primary care plays its role and that we will see more mental health specialists working in teams with GPs, nurses and carers? Will personal health budgets be extended to enable patients with mental health issues to select the best combination of services and treatments for themselves? Furthermore, does the Minister agree that good mental health does not start in the hospital or treatment room but in our workplaces, schools and communities? For example, poor mental health in the workplace costs the UK an estimated £26 billion a year. Does the Minister accept that this requires a cross-government approach, and is he as disappointed as I am at the news of the apparent demise of the Cabinet Sub-Committee on Public Health—due, it is said, to a lack of interest from other government departments?

The mandate contains a number of welcome references to helping to improve people’s health. I would be grateful if the Minister could tell me what the Government are doing to reawaken interest across Whitehall. The whole architecture of the NHS that the Minister brought to your Lordships’ House in the Health and Social Care Act was about the Department of Health passing over day-to-day concerns about the NHS to the national Commissioning Board, giving itself time to work on wider public health issues—and, I have always assumed, to seek to influence the rest of Whitehall. Would he accept that the demise of this Cabinet sub-committee is a very disappointing signal?

I have three fundamental questions concerning the mandate, which relate to funding, the measurement of performance and the role of Ministers. As the Minister has intimated, this is a multiyear document, setting objectives for the period April 2013 to March 2015 but subject to revision at the end of each year—or, in other special circumstances, including a general election. We can only hope that we might be coming back to this mandate sooner than the Government perhaps would wish. I have noted that the mandate has been restructured around the outcomes framework, which is to be welcomed, and that some of the specific levels of ambition that were placed in the consultation on the mandate have now been replaced by what the Minister described as stretched levels of ambition. Has the mandate been costed out? I could not help but contrast the optimistic claims of Ministers with the everyday financial realities of life in the NHS. Is the mandate a realistic document about what the public can expect to happen or is it little more than a Christmas shopping list which is unlikely to be realised in full?

The noble Earl will have seen the RCN’s warning today of thousands of job losses among clinical staff. That appears to be the reality of life in the NHS. Emergency services are under pressure and a toxic mix of reorganisation and real-terms cuts risks plunging the NHS into a very difficult situation. There has been a great deal of publicity and concern about the decision of the BBC in relation to the retirement package, as it were, of the former director-general. However, the Government stand accused of wasting a full £1 billion on redundancy packages for health service managers as a result of the recent reforms. That money could have been spent on patient care.

I note that most of the time the Statement seeks to create a consensus but every so often it descends into political rhetoric, which I regret. I was pained to hear the noble Earl say that the previous Government sent endless instructions to the health service and constantly bombarded it with new targets. However, those targets, which focused on reducing waiting times and improving clinical performance, were absolutely pivotal to improving the performance of the National Health Service. We will, of course, always find ways to make further improvements, but there is no doubt whatever that between 1997 and 2010 the NHS was vastly improved.

The new architecture which the Government have set in place feels very bureaucratic to those working in the National Health Service. Instead of clear departmental direction, three major agencies have been created, which often row in different directions. Monitor, the economic regulator, has conflicting roles. It is unsure about how to incentivise integration but is stuck with the mantra of the market and enforced competition. The CQC lacks confidence and credibility and awaits the Francis verdict, although the appointment of the new chief executive, David Behan, is a very good step forward. The national Commissioning Board is all-powerful and talks the talk of devolution but I am afraid to report that it displays some centralist tendencies. Indeed, I have heard that “aggressive commissioning” is the buzzword around the national Commissioning Board. I certainly hope that it can do better than that. I do not think that the frail elderly, who comprise the patient group that makes the most demands on the health service, need aggressive commissioning. They need an integrationist approach whereby the architecture and the key national players—the department, Monitor, the CQC and the NCB—work together to get the conditions right for an integrationist approach.

I urge the national Commissioning Board to focus its attention on primary care, community care and adult social care. Does the noble Earl agree with that? We are seeing in the health service the development of seven-day working in acute hospitals. I welcome the mandate’s emphasis on mental health playing its full part, but it requires the same commitment from GPs, community services and adult social services. The contrast between what is happening in some parts of the NHS with the desperate struggle that local authorities are facing to keep council social care services for adults going could not be wider. Indeed, millions of people face higher care charges as councils are forced to put up the cost of meals on wheels and other services. The response from local government to the need for a seven-day service is extremely patchy and very worrying.

I would like also to refer to the comment made in the Statement about the performance of the NHS in relation to certain clinical services. If the Government are so concerned, why on earth are they proceeding with cuts to the cancer, heart and stroke networks? Surely that needs to be reconsidered.

Turning to the performance of the national Commissioning Board and how it is to be measured, the mandate contains a long list of improvement areas —as they are called—and says that it is the Government’s ambition,

“for England to become one of the most successful countries in Europe at preventing premature deaths, and our objective for the NHS Commissioning Board is to make measurable progress towards this outcome by 2016”.

What do the Government mean by “measurable progress”? Are there going to be some numbers or is this going to be a vague promise by the national Commissioning Board? What will happen if the national Commissioning Board does not meet those objectives and ambitions? Will there be any sanction placed on it?

The noble Earl repeated the mantra that the NHS is being liberated from day-to-day, top-down interference in its operational management. The mandate seems to have issued an uncosted wish list and is hoping to contract out responsibility to the national Commissioning Board, but it does not absolve Ministers of their accountability for giving Parliament as much information as possible and, ultimately, accepting their responsibility to Parliament for the performance of this great public service.

--- Later in debate ---

[Baroness Northover]

My Lords, it is the turn of the Conservatives.

[Lord Hunt of Kings Heath]

My Lords, there was an agreement between the usual channels that it is the Government Benches, then the Opposition and then the Cross Benches. The noble Baroness is seeking to reinterpret what has already been agreed.

[Baroness Northover]

It is the turn of the Conservatives.