Health and Social Care Bill

My Lords, I have one amendment in this group and have added my name in opposition to Clause 31 standing part of the Bill. At face value, these are very different but they are grouped because of the radical changes that are occurring. In relation to Clause 31, I want to address where clinical commissioning groups are different from PCTs and what might be lost in the process, and that is why I have put my name to opposing the clause. These organisations appear to be emerging with a hybrid responsibility. On 2 November, in response to a question about whether clinical commissioning groups are just like PCTs and asked for a yes or no answer, the Minister replied: "““In terms of population responsibility, the responsibilities are very similar. CCGs are responsible for patients on the registered lists of their constituent practices as well as having specific area-based responsibilities … linked to their unique geographic coverage””." Of course, the difficulty here is that clinical commissioning group areas are indeterminate and their responsibilities are not comprehensive, whereas at the moment PCTs, however much they appear to be failing, as they are in some areas, have in statute a range of clear responsibilities. Clinical commissioning groups will not be formed on the basis of responsibility for all residents within a contiguous geographical area. As was pointed out on 2 November, it will be possible, "““for individuals within that area to be registered with a GP practice which is a member of a different CCG. It would therefore be the responsibility of that other CCG””.—[Official Report, 2/11/11; cols. 1270-71.]" We have debated the problem for people with difficult conditions. I know that the clinical commissioning groups’ responsibilities will be for emergency care for people within their area; that seems to be one of their limits, but they do not go much further than that. David Nicholson confirmed the Government’s position when he spoke on the ““Today”” programme on 31 October. He said: "““We will publish information about general practices so you will be able to see what your general practice provides, as compared with other GPs in the area and nationally… If you’ve got a long-term condition, you might want to think in future about different GPs and whether they are providing a full range of services for particular people with long-term conditions””." Of course it would be fantastic if patients could move between one general practitioner and another, but I fear that the financial restraints on all of the system will mean that that ideal will just not be met. In the document Developing Commissioning Support: Towards Service Excellence, it is clear that the commissioning support is viewed to come from a commercial source. In the summary document to that, the running cost estimated for the arrangements will be £25 to £35 per head of population, which will be there to optimise arrangements to suit the scale of the problem facing the group. The commissioning support will come from commercial providers. However, as we have already heard, many of those are actually ex-PCT employees who have gone across into other organisations. From 2013 to 2016, the Commissioning Board will host some of the commissioning support via an arm’s-length senior accountable individual. That commissioning support will be assessed against a focus on the consumer, as defined by their consumer base and working relationships; on leadership, particularly to bring about change; on delivery, with a technical capability; on governance, to provide the services needed; and on the business case. All of that sounds eminently sensible. I do question, however, whether this enormous upheaval was actually necessary or whether a revision of the PCTs, an increased input from clinicians and a tightening up of the commissioning focus within PCTs, with the courage to weed out those who were not performing well, would have been a more cost-effective way to deliver what we will have in the long term anyway. It seems that when people are reapplying for jobs in other organisations, the stronger ones will come through and the weaker ones will not. Although we have heard a lot about local accountability and the clinical commissioning group having a very local focus, I would like to quote from page 27 of the larger document: "““It is clear from discussions with Pathfinder clinical commissioning groups that the principles and rationale for delivering some services at significant scale is well understood and accepted: it will allow them to influence and concentrate on the aspects of commissioning where they can add most value … However, there is also a clear message that the focus should be delivering customer focused services and maintaining responsiveness, even where services are delivered at scale””." The clusters are, of course, providing a degree of scale, but there seems to be a hybrid spectrum between the very small going right up to the larger cluster, and items which need to be commissioned at what used to be almost SHA level. I therefore question the rationale for this whole process and that is why I added my name to the amendment. I now turn to Amendment 236AA, concerning medical and dental postgraduate deans. I have discussed this with the General Medical Council and with postgraduate deans, with the lead dean from COPMeD. The reason they want to be funded by HEE is quite specifically so that they can maintain their independence and have the leverage to bring about change. The postgraduate deans’ budget overall is somewhere in the region of £2 billion: it is not insignificant; 90 per cent of the training posts across the UK are funded through them. Many posts, such as first-year foundation posts and most specialty training posts are 100 per cent core-funded through the deans’ budgets. The remainder of the posts are mostly 50 per cent core funded. Their ring-fencing allows money to be moved to change the distribution of posts. At the moment, for example, they are driving down surgical training posts and increasing general practice training posts. There is always a pressure from within the service to maintain the status quo because services are often trainee-dependent. The postgraduate deans themselves have rationalised their costs greatly, so their on costs are only 4 per cent, compared to universities which run at about 15 per cent. Previously they had been placed in universities, but that did not work well because of conflicting research assessment pressures. They are concerned if that if they are part of the service, service pressures will dominate. Their independence allows them two key functions: one to maintain quality assurance and the second is to drive up and improve quality. They are handling public money to train the doctors of the future, not only to provide the service needs of today—but within the training context, to meet the needs of today. They need to be local education and training board members because very often they are the only people on such a board who will bring educational literacy. They are all fellows of the Academy of Medical Educators or hold an MSc in medical education. They have an ability to assess both the provision of education and the assessment methods used in education. There is an awful lot of provision of education which is, frankly, inefficient and there is an awful lot of assessment that does not actually assess what it claims to be assessing. At the moment, there is only one workforce director who has any education training at all; so without this high level of educational literacy, the local education and training boards are going to be severely disadvantaged. The NHS itself has to provide care today and high-quality care into the future. It is easy to focus on the present, but however good a medical school is, when its graduates move out, being employed is different. Training is dramatically different from 10 years ago. The postgraduate deans have really proven how they have driven up—despite the constraints of the European Working Time Directive—the ability of the juniors to be trained well and to cope with the changing pressures in the NHS. For example, the medical take now in many centres averages 120 to 140 admissions a day. That is dramatically different from how it was 10 years ago. The trainees are better supervised; they are trained to avoid mistakes, not repeat ones they or those who have gone before them have made. The curricula are better focused across all the needs of the service, not only the technical needs. The postgraduate deans weed out about 3 to 6 per cent of all trainees: they are either moved sideways, have to repeat some training time or—in the case of a few—are weeded out completely. So they are exercising their independence and discretion to train for the future. I know that the Minister has undertaken to look in detail at all aspects of education and training, but I want to have on the record the postgraduate deans’ need to be independent. That is supported both by the deans themselves and the General Medical Council, because in considering the future, it is very important that we do not lose the educational expertise from the current set of deans.