Health and Social Care Bill

I suggest that this group of amendments has been provoked by the extremely unconvincing nature of the Government’s organisational structure for delivering the reforms they consider necessary to the NHS; they would in themselves, I suspect, attract a wide range of support. I want to address my remarks to Clauses 30 and 31 on the abolition of SHAs and PCTs. I think the concerns many of us have were well put by my noble friend Lord Hunt. I want to divert a little from my remarks to congratulate the noble Lord, Lord Mawhinney, on his detective work. If he wants to continue in that vein, I suspect that he could find some examples in other parts of the country that go wider than that in Peterborough. He might want to entertain us with more of those examples at a later stage in the Bill because I suspect there are plenty of them. In a spirit of helpfulness, I say to him and to the Minister that among the department’s papers of around 2005 are quite a lot showing how you go about consulting local people about the removal of PCTs and how you use a proper legislative basis for abolishing them and replacing them with new, properly authorised and properly appointed PCTs. I would be very happy to give my approval to the opening up of those papers so that the Minister can help the noble Lord, Lord Mawhinney, see how you can go about this. It is often controversial, but there is a process for doing it, which is well documented, and you do not have to go along the path of clusters. It is perfectly possible to engage with people—sometimes they do not like it—and go through a proper process for replacing a number of them. It can be done, and it can be done in a proper way, but it takes a bit longer. I would be very happy for those papers to be made available to the noble Lord, Lord Mawhinney, and the Minister so that if they are struggling a bit in seeing how it can be done, they can draw on that example. Some of us on these Benches have acknowledged that the 2002 NHS reorganisation rather overdosed on the number of SHAs and PCTs and, as I have just said, we tried to put that right in 2005 and 2006 with a reduction to 10 SHAs and 152 PCTs. Some of us would have liked to have gone a bit further and reduced PCTs further, but that’s life. You do not always get what you would want. In practice, that further reduction could have led, as I think the noble Baroness, Lady Finlay, said, to a much more straightforward way of making the changes that needed to be made and could have included a very large increase in the number of clinicians involved in the process of commissioning. I do not think anybody in this Chamber is opposed to the Government’s idea of increasing substantially the amount of clinical and, in particular, GP involvement in the commissioning of services. However, it could have been done without this process, and it could have built on the lessons of GP fundholding, on which I have always been a supporter of the Government’s approach. I thought it was a bold experiment, and I do not say that with any sarcasm at all. It was a bold experiment that was well worth trying and which we built on further with practice-based commissioning, so I do not think there is a lot of political dispute about more clinical involvement in commissioning. The Government could have done that without clusters by simply reshaping PCTs, changing their membership, probably reducing their number and possibly increasing—dare I say this to some of my colleagues on these Benches?—the involvement of private sector skills in the commissioning function with the data analysis and information gathering. They could even have done it with a little more democracy in the membership of PCTs on which, as I recall, the Liberal Democrats were rather keen at one point. The coalition partners could have been brought onboard with a bit more democracy in PCTs as well. That might have been a good mix to go forward. As I said, the Government have managed to go along a totally different path and on many occasions they have stuck to their guns when there has been the opportunity to change course. I want to remind them and the House of something I have said on a number of occasions. It is that no Government since the beginning of the NHS have managed to run it without an intermediate tier. There is a good reason why different parties have found it necessary to have an intermediate tier. It is because there are a lot of functions that do not easily sit at the local or the national level. Those of us who have been Ministers know that only too well. A bridge is often needed to the local areas through a regional presence, and it does not matter whether you call them regional health authorities or strategic health authorities. If you want, you could even call them sub-national board entities. I do not mind, but that intermediate tier is essential. It is even more essential if you have a financial crisis because it is the way to try to make budgets stick at the local level. That is not just because we like to have some heavy-handed financial thugs—although occasionally they are quite useful—to do this. It is because it is a way of persuading people locally to face up to their responsibilities and to get a collective agreement on the changes that need to take place in order to make the NHS function reasonably well with the money available. There are always going to be overspenders at the local level. We have never had a period in the NHS’s history when everybody at the local level has managed their budgets perfectly. There have always been hospitals or commissioners that have overspent, and you need that intermediate tier to keep things under control. The beauty of the previous arrangements, whether they were strategic health authorities, regional health authorities or regional hospital boards, was that, first, it was transparent that they were there; secondly, they were properly appointed; and, thirdly, they often had people who had some knowledge about the areas for which they were responsible. That function will not go away. What we are doing now is burying that function somewhere in the national Commissioning Board and, as my noble friend Lord Hunt made very clear, we are not at all clear how it is going to be discharged. To make life even more complicated, the Government have thrown in senates for good measure. It is not terribly clear how they are going to function or whether, in practice, they will be a block on the process of changing the configuration of services. It is not just me saying that; groups such as the NHS Confederation are very concerned that what we will have created is a kind of paralysis in decision-making at local level and in between the local level and the centre. I will put it no clearer than that because I do not think it is any clearer than that. Something is floating around in the ether: presences between the local level and the national Commissioning Board. That is where we have ended up. Clusters were invented, I think, to try to recognise that we need to reduce the number of PCTs, but there was no appetite for going through the process to do that in a proper and considered way. Just to make things really interesting, the Government have also introduced an interesting new geographical concept for commissioning services based on GP practice areas. They have not just stuck with GP practice areas. They have invented—actually, we are seeing the invention as we sit here—new arrangements for new kinds of areas in which someone is forced to take some responsibility for the commissioning of services. Instead of having areas that are clear and publicly known, which is what we have got with PCTs, and which often had a pretty good relationship with the boundaries of local authorities, we have got we know not what. We have seen some maps from the Minister, who kindly circulated them, but they show, particularly in the West Midlands, the neck of the woods of my noble friend Lord Hunt, a rather confusing picture about practice areas and how they relate to the old PCTs areas. Whether there are going to be very many people in the West Midlands who understand who is responsible for some of these areas must remain open to doubt. I certainly found the maps revealing but quite difficult to understand. It is not surprising, in that set of circumstances, that people are anxious about what is going to happen in a period when the NHS is trying to deliver the Nicholson challenge of £20 billion of productivity improvements or savings—call it what you will—over four years. People are worried because the NHS has never introduced the kind of productivity improvements that are needed to deliver the Nicholson challenge. Put cautiously, this is 5 per cent a year in real terms. The NHS has never delivered that annual saving in one year, let alone four years on the trot. Here we are throwing all the organisational cards up in the air—if I may put it like that, as that is what it feels like to many people in the NHS—and saying we are going to get rid of strategic health authorities in April 2013. That is the Government’s plan. The very organisations which might have kept some kind of grip on the finances and the way the NHS is being managed have been put on notice that they are going to disappear. Some of them will reappear in some guise, although not as a public body, somewhere in the middle of the national Commissioning Board. Others will appear as local offices. They may not be called that, as we are not yet quite sure what they are going to be called, but they will reappear as a local presence of the national Commissioning Board. We are relying on a huge amount of faith in the Government knowing what they are doing. We are relying on that in regard to about £120 billion, give or take, of public money every year. Not surprisingly, coming to the amendments in this group we see that people think there should be some checks. We need to have some safeguards in here, so that if it does go a bit wrong there is some way of salvaging the situation, instead of people assuming that we will keep all the expertise that we currently have in PCTs and SHAs. I know that PCTs and some SHAs have had their problems, but there is also a lot of expertise there. The bits of that expertise which disappear and the bits which remain will, I suggest, be slightly random; it will revolve around a lot of personal choices as much as anything. So we need some checks in this. It is not too late for the Government to be mature and recognise that we need better safeguards. That is why I am very sympathetic to changes which preserve the SHAs, in particular, for a longer period until we have actually got through the financial challenges that the NHS faces.