Health and Social Care Bill
Public Bill Committee, 8 February 2011.
Jimmy Hood (Labour, Lanark and Hamilton East)
Before we begin, I have a few preliminary announcements. Members may, if they wish, remove their jackets during Committee meetings—that is a huge concession on my part, but I am sure that it will be appreciated. Would all Members please ensure that their mobile phones and so on are turned off or switched to silent mode during Committee meetings? As a general rule, I and my fellow Chair, Mr Hancock, do not intend to call starred amendments that have not been tabled with adequate notice. There is a money resolution and a ways and means resolution in connection with the Bill. Copies are available.
Not everyone is familiar with the process of taking oral evidence in Public Bill Committees, so it might be helpful if I briefly explain how we will proceed. The Committee will first be asked to consider the programme motion on the amendment paper, for which debate is limited to half an hour. We will then proceed to motions, which I hope we can take formally, to report written evidence and to permit the Committee to deliberate in private in advance of the oral evidence sessions. If the third motion is agreed to, the Committee will move into private session. Once the Committee has deliberated, witnesses and members of the public will be invited back into the room and the oral evidence session will begin.
If the Committee agrees to the programme motion, it will hear oral evidence this morning and this afternoon, as well as Thursday morning and afternoon.
Jimmy Hood (Labour, Lanark and Hamilton East)
Sir David, welcome to this evidence session. We are looking forward to asking you some short questions and I would invite brief replies so that we can ask you as many questions in this evidence session as possible. To kick off the evidence session, I call Emily Thornberry.
Emily Thornberry (Labour, Islington South and Finsbury)
With the Chair’s indulgence, I have three questions for you. First, in your evidence to the Health Committee on 12 October you spoke of the need to make £15 billion to £20 billion of efficiency savings in the next three years, which has been dubbed the Nicholson challenge. You said that half of that change was in better community services. You said that a quarter of hospital beds were full of people with four or more long-term conditions, and they would be better managed in the community. In what way does the Bill help with better integration of health and social care?
Emily Thornberry (Labour, Islington South and Finsbury)
But my question was about the integration of social and health care.
Emily Thornberry (Labour, Islington South and Finsbury)
I want to ask you about strategic planning. Again, your evidence to the Health Select Committee seemed to suggest that you accepted that the strategic health authorities played a key role in driving productivity and maintaining improvements in the service. In London, of course, we have a great example of that in stroke services. If you have a stroke, you go to certain hospitals and not to others, and many lives have been saved. In the future, under these reforms, how will we get that strategic planning? Do you think there is a role for the NHS commissioning board to have regional boards?
Emily Thornberry (Labour, Islington South and Finsbury)
Can I move on to what will happen to QIPP—the quality, innovation, productivity and prevention plan? If the Bill goes through, GPs may well focus their attention and energy on governance, how they will organise themselves and so on. Should they focus primarily on that or on QIPP? Can they do both at the same time?
Emily Thornberry (Labour, Islington South and Finsbury)
But do you think that all GP consortiums will be able to behave in the proper way? How will you stop them playing in what you have called the sandpit of redesign?
Nick de Bois (Conservative, Enfield North)
Sir David, I believe you originally said these reforms were so large you could actually see them from space. In fact, on further examination, and now that the Bill has been presented to Parliament, where there is clearly evidence of its being more evolutionary—building on other pre-existing services, practice-based commissioning and so forth—do you still hold to that view, or do you accept that there is more evolution than revolution?
Liz Kendall (Labour, Leicester West)
Thanks for coming. You are giving an awful lot of evidence, Sir David, and I have three brief questions. The first is about the role of Monitor, which, as you know, will stop being the regulator of foundation trusts and start being the economic regulator. At the Public Accounts Committee evidence session on 18 January 2011 you said that ultimately, if a foundation trust is failing,
“The buck stops in the foundation trust.”
Under the new system, how does anyone step in to prevent a hospital from failing?
Liz Kendall (Labour, Leicester West)
With respect, my question was about who prevents them from getting to the position where they fail.
Liz Kendall (Labour, Leicester West)
My second question is about Monitor’s role in setting price under the new system. You were very clear in your evidence to the PAC that you thought that services should be allowed to go below the maximum price only if you were able to measure quality but that you had
“yet to come across any services that have done that”.
I am confused here. You are clear from your position as the chief executive of the national commissioning board that you do not want any services to go below the maximum price if we cannot measure quality, but is it not Monitor that sets price under the new system, not the national commissioning board?
Liz Kendall (Labour, Leicester West)
So you have to jointly agree the price?
Liz Kendall (Labour, Leicester West)
Finally, I would like you to confirm something that you said in the Public Accounts Committee, which is that although your aim is to ensure that no PCT debts are passed on to consortia, you could not guarantee that GPs would not have to take on PCT debts. Is that correct?
John Pugh (Liberal Democrat, Southport)
Sir David, we have met often in the past in the Public Accounts Committee, when you have been explaining some NHS financial problem—and doing it rather well, I have to say. I think that it would be accepted if you brought NHS accounts under control in a way that they have not been hitherto, so you will excuse me if all my questions are on just the financial side of things.
If this legislation had not existed, I think that PCTs would have been under a remit to reduce their administrative costs by 30%—obviously some PCTs will continue to exist for a little while anyway. Would they have met that target, and will they continue to meet the target, given that the legislation is in the offing?
John Pugh (Liberal Democrat, Southport)
Are you saying that you probably would have met that 30% target, but in current circumstances there is an uncertainty there?
John Pugh (Liberal Democrat, Southport)
There are obviously different elements to assessing the administrative costs of PCTs. There is the commissioning, which is being transferred, and there is the administration of various producer organisations—the producer or provider arm of the PCT—which presumably will continue to exist. Are you able to give an average administrative cost of commissioning in a PCT currently, separate from the cost of general administration?
John Pugh (Liberal Democrat, Southport)
Okay. During most previous reorganisations, there has been a drop in productivity in the NHS, or in whatever organisation was being reorganised. What are you going to do to measure productivity over the next two to three years?
John Pugh (Liberal Democrat, Southport)
A last question about the one-off costs of reorganisation, which I think are £1.4 billion in the impact assessment: can I tease out of you the distinction between the impact assessment as provided by the Department of Health and the impact assessment as offered by the National Audit Office? As I understand it, the NAO gives a figure of £15 million per reorganisation of an organisation. Presumably it is thinking of SHAs, PCTs and so on. The Department has scaled it down by taking out the estimated costs of redundancies and then suggests that the cost of reorganising a large organisation differs from the NAO’s understanding of the costs of reorganisation. The letter I have from the Comptroller and Auditor General says:
“The NAO has not validated the Department’s figures.”
Given that you will eventually appear before the Public Accounts Committee in a few years’ time, are you happy with that? Would you like the validation or are you prepared to stand very robustly by the figure in the impact assessment?
Grahame Morris (Labour, Easington)
Sir David, in evidence to the Health Select Committee on 19 October, which is only three months ago, you said:
“If you look at what commissioning is, it is often kind of caricatured as some kind of transaction arrangement, but of course it isn’t that at all. It has a major strategic context in relation to whole population planning”.
If we have a completely open market you can never plan strategically. If Monitor’s job is to enforce competition rules, would not any sort of strategic planning contravene those rules?
Grahame Morris (Labour, Easington)
May I ask a quick supplementary on that? In relation to the risks to destabilising the system and Monitor’s role as an economic regulator looking at price competition, could you comment on what is happening at the moment with the reduction in the tariff of 1.5% that is being passported through to foundation trusts and the impact that has had in terms of job losses?
Steve Brine (Conservative, Winchester)
Hello, Sir David. Thank you for coming. May I press you a little with regard to the commissioning board, of which you are, obviously, the head? I appreciate that you are chief executive designate at the moment. You mentioned that there would not be a regional structure, which I completely endorse. There is no point in taking one apart to recreate one, if we are looking for savings and to eliminate bureaucracy. However, dental services commissioning, for instance, will sit with the board. Can you take us in more detail through how that will work? How will you commission dental services in Winchester and in the north-east of England, for instance?
Steve Brine (Conservative, Winchester)
May I ask you one more general question in your role as chief executive of the NHS? I think that what health care professionals—I am married to one—and front-line staff would say to Governments over the years, because this certainly did not begin in 1997, is that when something goes right in the NHS, it is a triumph of Government policy and the Health Secretary wants to tell everybody about it, but when something goes wrong in the NHS, it is the fault of NHS trusts and front-line professionals. How do you see that changing under the proposals?
Steve Brine (Conservative, Winchester)
I hope so. Thank you.
Phil Wilson (Labour, Sedgefield)
One of the main tenets of the Bill is ultimately to hand over to GPs a budget equivalent to the GDP of Hungary. Is that evolutionary or revolutionary?
Phil Wilson (Labour, Sedgefield)
So is it revolutionary or evolutionary?
Phil Wilson (Labour, Sedgefield)
Bold and imaginative; a very nice way of putting it. So we are essentially going from first gear to fifth gear, missing out second, third and fourth, really. You have said yourself it is the largest reorganisation ever—you can see it from space.
Phil Wilson (Labour, Sedgefield)
The perception that is given with the Bill and what we read about in the press and hear in speeches is that it is like devolving the NHS to GPs and making it more globalised, essentially. Obviously the GPs know what is going on in their area—but you have a national commissioning board at the same time. You have said yourself in answer to a previous question that you will end up employing local people to administer all this. Does that mean you will end up re-employing people who have been made redundant from PCTs?
Phil Wilson (Labour, Sedgefield)
So what you are saying is that it is the PCT structure by another name.
Jeremy Lefroy (Conservative, Stafford)
Good Morning, Sir David. I would like to raise three questions that come out of the evidence being given at the Mid Staffordshire inquiry at the moment. The first is on local government and the health and well-being boards being critical, which you mentioned earlier. One thing that has come out is that the expertise available to, for instance, the oversight and scrutiny committees, or even the health and well-being boards, might not be sufficient to enable them to do their very important job. How do you envisage that being addressed?
Jeremy Lefroy (Conservative, Stafford)
My second question is on the approval of foundation trusts. It was clearly a problem with Mid Staffordshire that it was approved at a time when it should not have been. My concern is that, according to the legislation, all trusts have to become foundation trusts by 2014. How would you ensure that there is no repeat because of a trust being rushed into foundation trust status? As a supplement to that, we are aware that some of the private finance initiative contracts that are going through at the moment mean that some of those trusts will not be able to meet their financial return of 8%, or whatever it is, because of the payments.
Jeremy Lefroy (Conservative, Stafford)
Thank you very much for that. You referred to the issue of accountability briefly in your answer. However, judging from the Mid Staffordshire experience it still seems to me that we are not quite sure who will pick these things up in future and who will aggregate the evidence that is out there that a trust is failing. Where does accountability for blowing the whistle on that lie, because it really has to lie in one place?
Owen Smith (Labour, Pontypridd)
It is very interesting to hear about the local strata that you are now talking about for the commissioning board, which I do not think are included in the Bill in any form. How many of these sorts of local people do you anticipate you will need, how local will they be and what sort of costs are associated with them?
Owen Smith (Labour, Pontypridd)
Continuing on that theme of regional variation, do you think it is inevitable that at the end of this process we will have a less homogenous and perhaps less equitable NHS across England?
Owen Smith (Labour, Pontypridd)
My final question goes back to strategic planning. Under the new dispensation, who at local level will make the key decisions about reconfiguration of, for example, secondary care services? Who will decide whether a maternity ward needs to close due to population changes, or even whether a district general hospital needs to shut?
Jimmy Hood (Labour, Lanark and Hamilton East)
Five Members still want to ask questions and the clock is ticking.
Kevin Barron (Labour, Rother Valley)
Can I go back to the issue of the national commissioning board’s role in direct commissioning locally? You said earlier that you simply had not done the work in relation to dentistry. We have a brief from the British Dental Association that says that, while it supports the NHS commissioning board, it is
“anxious to ensure that mechanisms are in place to strengthen the ability of commissioners and providers to develop services that are responsive to local needs, and to ensure that they are fully integrated with other NHS services.”
Given the history of NHS dental services in the past 10 years, are you sure that a national commissioning board is the right and proper way to do this?
Kevin Barron (Labour, Rother Valley)
Would not some people just say it would be better if the GP consortia had responsibility for commissioning dental care?
Kevin Barron (Labour, Rother Valley)
I have just one more question, on a related matter. I ought to declare that I chair the all-party group on pharmacy. My local PCT has a number of contacts with local pharmacies. In some pharmacies, it delivers smoking cessation measures; in others, it delivers daily doses of methadone. A minor ailments treatment scheme runs throughout the PCT, which means that the pharmacists can do it and there is no need to clutter the doctors’ surgeries. Are we saying that the way forward is for national commissioning of those things? The PCT commissions those things effectively on a pharmacy-by-pharmacy basis at the moment. What are we going to end up with if it is commissioned at a national level?
Kevin Barron (Labour, Rother Valley)
Of what?
Kevin Barron (Labour, Rother Valley)
So why do the GP consortia not do it?
Dan Byles (Conservative, North Warwickshire)
I am conscious of the time, so I will stick to one quick question.
Many GP practices are providers through practice-based commissioning and non-general medical services work. Do you see a potential conflict of interests there, and how can that be managed?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Good morning, Sir David. My question relates to health inequalities and follows on from one of my colleague’s earlier remarks about how the proposals might contribute to less equitable access to care. Can you tell me what evidence there is to support what you were saying about this actually increasing access to care? An inverse care law exists at the moment. Those who need care are less likely to get it, and I want to know what these proposals are going to do to address that.
Debbie Abrahams (Labour, Oldham East and Saddleworth)
So you are saying that there is no tangible evidence at the moment, but you estimate that that might happen.
Within the existing primary care trust boundaries, there may be several GP consortia, and there is no requirement for them to communicate together. How might that pan out if they come to different decisions on the services that they want to provide?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. I am afraid that that brings us to the end of the time allotted for the Committee to ask questions of this witness. I thank Sir David on behalf of the Committee for his attendance.
Jimmy Hood (Labour, Lanark and Hamilton East)
We will now hear evidence from the Health Foundation, the Nuffield Trust and Professor Julian Le Grand.Welcome to the Committee. I am sure that you will be well received. We have a number of questions. I suspect that, as in the last evidence session, the questions will need more time than is allotted to the Committee.
Emily Thornberry (Labour, Islington South and Finsbury)
May I begin with a question for the whole panel? What risks do the witnesses feel may be associated with the changes that will be introduced by the Bill, if it is passed?
Emily Thornberry (Labour, Islington South and Finsbury)
The Health Foundation did a review of evidence in 2004 about the effectiveness of primary care-led commissioning. I believe you came to the conclusion that such commissioning struggled to engage patients and the public in a significant way. Do you still stand by that, and do you feel that changes ought to be made in the Bill to address the tendency of primary care to struggle with engagement?
Emily Thornberry (Labour, Islington South and Finsbury)
Do you agree that the promotion of competition, which, in my view, is at the heart of the Bill, threatens the integration between primary and secondary care and the integration of social and health care?
Emily Thornberry (Labour, Islington South and Finsbury)
Will it be within the Bill’s parameters to allow GP consortia to give efficiency bonuses to GPs?
Jimmy Hood (Labour, Lanark and Hamilton East)
Margot James?
Emily Thornberry (Labour, Islington South and Finsbury)
Sorry, may I just ask Professor Le Grand what he thinks the dangers are, if there are any?
Emily Thornberry (Labour, Islington South and Finsbury)
Are GPs able to make strategic decisions on a regional basis?
Margot James (Conservative, Stourbridge)
I would like to move the discussion to clinical practice. There has been so much discussion about the Bill’s proposed changes to structures, but one of the main drivers in relation to differences in both cost overruns and quality variance is the different standards of clinical practice throughout the country, even within the same hospital. In general, what do you think the Bill’s reforms will do to iron some of those changes out in a positive direction? Specifically, what are your thoughts about the changes to NICE, which is going to be renamed the National Institute for Health and Care Excellence, and the new pathways with which it will be charged in addition to those of its prior role? How do you think those care pathways will impact on the variance of clinical standards in practice?
Jimmy Hood (Labour, Lanark and Hamilton East)
I call Kevin Barron. Sorry. You have to jump in there. [ Laughter. ]
Jimmy Hood (Labour, Lanark and Hamilton East)
My list is increasing, as usual. I invite hon. Members to ask one question, if possible, without too many supplementaries to it.
Kevin Barron (Labour, Rother Valley)
This is in relation to quality. Outside the pilot schemes that have been run by North West strategic health authority, which has been looking at quality, what evidence do we have from the NHS in the past six years that quality is something that can be measured, something we can put faith in, as opposed to a target, and something that is going to improve services? I do not know who would like to start. Stephen, you are on the National Quality Board.
Nick de Bois (Conservative, Enfield North)
Dr Dixon, I noticed the Nuffield Trust made a suggestion to de-risk the legislation in one area—that, in the event of service reconfiguration, ward downgrading or whatever, it would be better left to SHAs and PCTs by effectively allowing them to run longer, because, you argue, GP consortia are not well placed or are too overburdened to do this. My concern is that that runs against something else I think you believe in, in terms of local accountability, transparency and engagement, which have all been lacking in just about every service reconfiguration that has taken place under PCTs and SHAs. I am not sure that is a price worth paying. Is not the assumption that GP consortia cannot do this really just speculation or worry?
Nick de Bois (Conservative, Enfield North)
On that basis, I think you are saying that some would be fit to do it and some would not. Are you recommending that we differentiate between the two? Is it reasonable to think that that could be done, or would we end up with a one size fits all?
Liz Kendall (Labour, Leicester West)
Some 90% of patient contact with the NHS, as you know, is in primary care. We know that if we want to provide better care for patients with long-term chronic conditions, developing primary and community services to keep people out of hospital is vital. In my area, poor provision of GP services in the past is one reason why we have some very high emergency admission rates in Leicester’s hospitals. What does the Bill do to improve primary care? I would like to ask Dr Dixon first, if that is okay.
Liz Kendall (Labour, Leicester West)
Does that mean that GPs will manage their fellow GPs?
Liz Kendall (Labour, Leicester West)
May I come back to that point, as you have raised it several times? If GP consortia are very small, if they get a couple of expensive patients—perhaps two, three, four or five—they could run out of money. David Nicholson, in his response to the Public Accounts Committee last week, said that, in the end, it is the GPs’ responsibility, so they could end up going into debt.
John Pugh (Liberal Democrat, Southport)
The one thing that you can say about the proposals is that they create plenty of work to do. I am losing track of the number of occasions on which I have heard some of you speak on this topic. Normally, Dr Dixon celebrates the virtues of co-operation and Professor Le Grand the virtues of competition. I would like you to comment on how the legislation gets that balance right.
More specifically, following Nick’s question earlier, one of the things that does not endear PCTs to Members of Parliament is the fact that they are incredibly unsupportive when a difficult reconfiguration issue occurs. Perhaps the expectation of the new GP consortia is that they might do the job better or be more accountable in some ways. Given the reduction in the acute tariff, which apparently is going to happen anyway, is it your view that such difficult decisions will be more likely to occur in the future, notwithstanding all this; and if they do occur, will they be more manageable? Often they can lead to extreme political volatility.
John Pugh (Liberal Democrat, Southport)
I wonder if Professor Le Grand could comment on the London situation, because, obviously, there the reconfiguration problems are at their most acute. Will they go away, remain the same or be adequately addressed through the legislation?
Owen Smith (Labour, Pontypridd)
We heard from Sir David about what might be thought of as a counter-intuitive suggestion that this more market-driven, less planned world that we are moving into will provide a more homogenous, just as equitable provision of health care across the UK. Do you agree with him about that conclusion?
Grahame Morris (Labour, Easington)
May I ask Dr Dixon a question in relation to the work that the Nuffield Trust has carried out, which looks at evidence from the United States? In response to an earlier question, you mentioned that you felt the failing of the Bill was a separation of primary and secondary clinical expertise in terms of commissioning. Will you say a little more about that and what the evidence base is for the system that we are considering at the moment? Will you also say something about the capacity of GPs in the United Kingdom based on your experience? In the evidence you submitted, you say:
“many English GP consortia will really struggle unless there is a relentless focus on securing and sustaining high-quality leadership and substantial investment in management”.
Given that the Government’s principal driver for reform is drastically to cut management and admin costs, is there a tension there?
Grahame Morris (Labour, Easington)
What were the numbers? What was the percentage of failures in the study?
Kevin Barron (Labour, Rother Valley)
Not that many years ago now, we saw the reorganisation that brought in primary care trusts, followed three years later by the reorganisation that made PCTs bigger. That seems to be contrary to what you have just said about size, Professor Le Grand. Would smaller bodies not have a major problem with administration?
Kevin Barron (Labour, Rother Valley)
Do you think the GP consortia that are not that good will take kindly to being told by the national commissioning board that they have to improve in certain areas?
Kevin Barron (Labour, Rother Valley)
We have had 60 years of this now. I just wondered whether you think things will change in the next few years.
Dan Byles (Conservative, North Warwickshire)
That is really interesting, but what about the idea that smaller consortia can still band together with neighbouring consortia to commission some of these services? It is not automatically the case that the size of the minimum consortium will be a constraint on commissioning some services, because my understanding of the Bill is that we are expecting strategic partnerships, possibly different strategic partnerships with—
Jimmy Hood (Labour, Lanark and Hamilton East)
Order.
Dan Byles (Conservative, North Warwickshire)
It would have been a fantastic question.
Jimmy Hood (Labour, Lanark and Hamilton East)
I thank the witnesses on behalf of the Committee.
Jimmy Hood (Labour, Lanark and Hamilton East)
We will now hear evidence from the Centre for Public Scrutiny, the King’s Fund and the British Medical Association. Welcome gentlemen. The first question is from Emily Thornberry.
Emily Thornberry (Labour, Islington South and Finsbury)
I am tempted to ask the same question of the three of you that I asked the previous three witnesses, and perhaps I may begin with that. Looking at this legislation and the changes attached to it, what do you think might be the biggest risk attached to that new legislation, if you see any at all?
Emily Thornberry (Labour, Islington South and Finsbury)
I think my hon. Friend the Member for Leicester West will ask you more questions about that. Doctor Meldrum?
Emily Thornberry (Labour, Islington South and Finsbury)
May I just ask a couple of questions of Tim Gilling, if that is alright? But first of all I will give you an opportunity to answer the first question, then I have a couple more questions for you.
Emily Thornberry (Labour, Islington South and Finsbury)
I want to ask some questions about public accountability and to use a fairly graphic example. I could use my local hospital, but I will use Chase Farm instead. If a decision was made to close Chase Farm, or, indeed, the A and E at the Whittington, who would be making that decision, how would they be accountable and how would the public and patients have a voice in order to try to stop that? Could you help us with the different levels and how someone living in north-east London could try to stop a reconfiguration?
Emily Thornberry (Labour, Islington South and Finsbury)
If you would explain how it works now, you are very welcome to say then how you think it should change. We need to understand how the Bill stands at the moment to begin with.
Emily Thornberry (Labour, Islington South and Finsbury)
Perhaps I am not making my question clear enough. What I would like to know is who will be making the decision, at what level, when it comes to reconfiguration of services? Where are the pressure points that the public could take advantage of in order to make sure that their voice is heard, as the Bill stands? Where is the “no decision about me without me” in the Bill?
Emily Thornberry (Labour, Islington South and Finsbury)
Does it have legitimacy at the moment, as the Bill is currently drafted?
Emily Thornberry (Labour, Islington South and Finsbury)
Could the health and well-being board stop a reconfiguration?
Emily Thornberry (Labour, Islington South and Finsbury)
Could anybody else stop a reconfiguration, where the patients might have a voice?
Emily Thornberry (Labour, Islington South and Finsbury)
Is it right that the public cannot require GP consortia to do anything and do you agree, if you have seen it, with the letter that is in The T imes today, signed by eight major charities, in which they say that there is a gap between the rhetoric and reality in relation to patient involvement and democratic accountability?
Jeremy Lefroy (Conservative, Stafford)
I have three questions. The first relates specifically to public scrutiny, and is addressed mainly to Mr Gilling. I am talking about the matter in the context of Mid Staffordshire NHS Foundation Trust in my constituency. What provisions of the Bill do you think would make public scrutiny more effective than it was in the case of mid-Staffordshire?
Jeremy Lefroy (Conservative, Stafford)
Do you think that the Bill does that? Does it provide for a closer relationship or does it just leave it up to individual organisations to make that relationship for themselves?
Liz Kendall (Labour, Leicester West)
I am sorry but I could not hear the answer to that question. Could you say that again?
Liz Kendall (Labour, Leicester West)
So it does not clarify that?
Jeremy Lefroy (Conservative, Stafford)
My second question is directed to all three gentlemen. Do you think that there would be a case for, for instance, Monitor having a responsibility to consider the stability of the provision of acute services in a particular area when deciding which providers to authorise in that area?
Liz Kendall (Labour, Leicester West)
This is a question for Dr Meldrum. In the evidence that you provided for this session, there is quite a lot about your concerns about introducing competition, including on price. There are two quotes in particular that I want to ask you to expand on. In the first, you say that it could make it impossible for commissioners and providers to operate in the best interests of their patient population and in the confidence that they will not be exposed to frequent and potentially costly challenge. The second point that you raise is that FTs will become private entities rather than NHS entities, and as such will be subject to the same rules and regulations that apply to other private companies, including UK and EU competition law. Have you received any legal advice about how the Bill subjects the NHS to the competition law of this country and of the EU?
Liz Kendall (Labour, Leicester West)
May I confirm this? You think that the Bill raises at least the possibility that foundation trusts could be treated as private companies under EU competition law?
Nick de Bois (Conservative, Enfield North)
Mr Gilling, I will take you back, if I may, to an earlier conversation. Can you confirm whether, in your opinion, the Bill gives more public and democratic accountability than before?
Nick de Bois (Conservative, Enfield North)
Thank you. May I pick up the point made by the hon. Member for Islington South? If there is a scenario of potential reconfiguration, and the GP consortium that would be principally affected by that made it clear that if reconfiguration was to happen, it would not be inclined to procure those services, is it not realistic to assume that that would significantly influence the decision about reconfiguration?
Nick de Bois (Conservative, Enfield North)
One final question, if I may. It is brief. Dr Meldrum, in respect of the BMA, I am slightly confused about something. The BMA wants hospital specialists to be involved in GP consortia. I understand that; you want that written into the Bill. What I do not understand is why you want it written into the Bill when the Bill allows it in the first place.
Nick de Bois (Conservative, Enfield North)
Okay. Thank you.
Kevin Barron (Labour, Rother Valley)
What evidence is there that GPs want to take on responsibility for commissioning, and are they actually capable of doing so?
Kevin Barron (Labour, Rother Valley)
How reasonable are the fears of some GPs that their relationship with their patients will be damaged by suspicions that they are making, referring and prescribing decisions for financial rather than clinical reasons?
Kevin Barron (Labour, Rother Valley)
Finally, funds for commissioning will be calculated at practice-budget level, and allocated directly to consortia. The Government say that practice-level budgets must reflect the needs of both registered and unregistered patients. How can that be achieved, given that the practice boundaries will be abolished and practices will no longer relate to defined catchment populations?
John Pugh (Liberal Democrat, Southport)
I am sure you could help me with this, Chris Ham. One of the arguments sometimes given for this legislation is that there is a differential between the survival rates for diseases such as cancer and heart attacks in the UK and other countries. Clearly, the causal connection between those sorts of health outcomes and the management and commissioning structures is slightly opaque, but can you clarify your view? Do you think that structural reorganisation is possibly a necessary, if not a sufficient, condition for improvement? If not, what is?
John Pugh (Liberal Democrat, Southport)
Yes.
John Pugh (Liberal Democrat, Southport)
On that point, do you think that the GP consortia are perhaps better set up to deliver best practice than the PCTs were to spread best practice?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
May I follow up on the questions we have had about scrutiny? The Bill says that there must be a duty to consult the public on significant changes in provision. What is “significant”?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Exactly what is that?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
So is it closing a ward or a full reconfiguration of a sub-region? We do not have a definition.
Debbie Abrahams (Labour, Oldham East and Saddleworth)
May I follow that briefly with a question I have asked before about inequitable access to care? There seem to be different views in the evidence we have had so far about the Bill’s impact on equitable access to care. What do you think? That is to the whole panel.
Debbie Abrahams (Labour, Oldham East and Saddleworth)
For example, there may be a differential in terms of people who need care actually being able to access it. A different level of service may be provided in different areas. If there is an increase in private providers, how might they define the type of patient who may be able to access their care? What do you think the impact will be?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Okay. So do you think it will improve equitable access to care?
Nicky Morgan (Conservative, Loughborough)
I want to ask Dr Meldrum a question. You have received a summary of the amendment that you are seeking. There are two points that seem to be slightly conflicting. It goes back to the point that Liz Kendall raised about tariff pricing in competition. It says that
“Maximum national tariff pricing is rejected as it opens the way for price competition, with the associated risk of a decline in quality.”
Later, it mentions
“commissioning decisions driven by clinical need, quality, sustainability and local priorities, as well as best value”.
That seems to suggest that you accept that GP commissioning will have interest in terms of its value. I assume from conversations that I have had with GPs that they are driven by clinical need and quality of service, but there is rightly an emphasis on value for money for their patients. I wonder why price competition automatically assumes the associated risk of decline in quality; I do not see how one follows the other.
Nicky Morgan (Conservative, Loughborough)
But purely on terms of price, do you accept that those commissioning services—it is the PCTs at the moment—will be looking to get best value for the NHS budget, for the taxpayer, as well as the right level of quality?
Nicky Morgan (Conservative, Loughborough)
Can I move on to GPs and commissioning? One of the issues that has come up a lot with specialist commissioning, in particular for mental health—the panel might have views on this as well—is whether GPs need additional advice and assistance. Do you have any thoughts on that?
Nicky Morgan (Conservative, Loughborough)
You feel you would know where to turn to get that advice. It is not a barrier to providing good patient care.
Grahame Morris (Labour, Easington)
The BMA is on record and has submitted evidence that it is against the increasing commercialisation of patient care, and that it wants to see the NHS restored as a public service, working co-operatively for patients. A recent big BMA campaign, “Look After Our NHS”, publicly funded and provided, focused on money lost to the NHS when it is spent in the private sector.
What do you think the impact of more and more public money going into the private sector will be over the longer term? I would like to draw your attention to the impact assessment, page 42, paragraph B55, where it identifies that the private sector health care companies are 14% higher in cost terms than the in-house NHS provider.
Jimmy Hood (Labour, Lanark and Hamilton East)
I am afraid that brings us to the end of the questions.
Jimmy Hood (Labour, Lanark and Hamilton East)
We will now hear oral evidence from the NHS Alliance, the National Association of Primary Care and the Royal College of General Practitioners. I welcome our guests to the Committee. So that we can get on with the evidence session, I advise them to introduce themselves when they answer their first question, if that is acceptable.
Emily Thornberry (Labour, Islington South and Finsbury)
A large number of people want to ask questions, so to be fair I will ask everyone one general question, and then I will back off and let my colleagues put their questions. The Bill has been criticised by many as risky. Do you think there are risks associated with it and with the reorganisation that it attempts to marshal? If so, what do you see as the main risks? If possible, perhaps you could each answer that question in turn.
Emily Thornberry (Labour, Islington South and Finsbury)
You are confident that you speak in a representative capacity having involved your members?
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you. Dr Kingsland?
Emily Thornberry (Labour, Islington South and Finsbury)
When you refer to clinicians, do you just mean general practitioners or do you mean doctors in secondary care as well?
Emily Thornberry (Labour, Islington South and Finsbury)
Before I pass on the baton, you said that there was a risk associated with public accountability to the GP consortia. We heard a little bit about that before lunch. Would you mind just giving us a few more details of your concerns in relation to that and then I shall move on to the others?
Jeremy Lefroy (Conservative, Stafford)
First, I declare an interest in that my wife is a member of the Royal College of General Practitioners.
I would like to ask a specific question about GP boundaries and list sizes, with particular reference to clause 21. What are your views on whether the abolition of practice boundaries, presumably within the area of a consortium, is a good thing; and whether, at the same time and in order to protect small practices, which often seem to rate highest in public esteem, should there be some provision for practices to cap list size or at least say, “I want to remain a small practice and not take any more patients on to my list.”?
Kevin Barron (Labour, Rother Valley)
I have just two quick questions. One is directed at Michael, but I would like other witnesses’ views as well. Michael, in your evidence you said that the Bill will be successful only if it can bring about major behavioural and cultural changes inside the NHS, and the risk is that we might simply see changes to the structure and little else, and that if that were to be the case, it would mirror many NHS changes of the past. What evidence can we see that this change is not going to be a change similar to those of the past?
Kevin Barron (Labour, Rother Valley)
Do you think GP fundholding changed the culture in those that were fundholders?
Kevin Barron (Labour, Rother Valley)
You mentioned population health. My understanding is that this change will mean that health improvement and illness prevention will be the responsibility of the local authority as opposed to the local NHS. It will be the local authority and the public health service, which we have not seen much of, that will be responsible for this. If my interpretation is right, do you think that it is a good idea to take responsibility for population health away from the local NHS? Is that a good or a bad thing?
Margot James (Conservative, Stourbridge)
Dr Gerada, I was comforted by what you had to say about the public health moving to local authority, and also that the royal college is developing training for GPs who want to take the commissioning role. Hearing your earlier evidence, I was beginning to think that your college was against all the proposals in the Bill, but it seems not. You expressed concern earlier, though, about the competition and greater choice aspects. Do you not agree that the Bill does not rule out collaboration and partnership working? In fact, it sets out to encourage that and greater integration of care. Are those not all good developments? Why would competition, added to those other good things, not achieve what it does in so many other areas, which is to drive up performance standards, both in quality and savings?
Margot James (Conservative, Stourbridge)
On the costs side, you mentioned a possible race to the bottom in terms of price. Effective procurement is based on a combination of value, price and quality. Why would GP commissioning groups not want to see it in those terms, bearing it in mind also that they will be inspected by the Care Quality Commission, which will be more focused on quality?
Liz Kendall (Labour, Leicester West)
Coming back to that specific point about whether it is clear in the Bill about any willing provider competitive tendering, clause 63 says:
“Regulations may impose requirements on the National Health Service Commissioning Board and commissioning consortia”.
Those regulations may impose requirements relating to the
“competitive tendering for the provision of services.”
If it were the case that regulations issued by the Secretary of State, which of course would not be discussed by Parliament, could impose a requirement on the national board and commissioning consortia to put services out to tender, what would your view be of that?
Liz Kendall (Labour, Leicester West)
Yes. If a requirement is imposed by Monitor on the national board and on consortia, what would your view be about that?
Liz Kendall (Labour, Leicester West)
But that would be if that were what the Bill said. I am sure there will be different interpretations of it, but do you think you would have a problem with that?
Liz Kendall (Labour, Leicester West)
There has been a lot of discussion about the fact that the national commissioning board will commission primary care services. I wondered what your opinion of that is.
Steve Brine (Conservative, Winchester)
This question is for Dr Gerada, I guess. I just want to probe you a little more on the level of enthusiasm among GPs for this shift to GP-led commissioning consortia. We had somebody here from the British Medical Association this morning, and the gist of what he said to us was that a lot of GPs have seen a lot of changes during the years and frankly they will jump on this one and go along with it, for fear of being left behind. The GPs that I know are certainly not passive sheep who just follow on aimlessly. Given that 55% of the population in England are covered by the GP pathfinder consortia, what do you think that says about your members’ enthusiasm for these changes?
Steve Brine (Conservative, Winchester)
But you think that a lot of GPs are being dragged to this?
Steve Brine (Conservative, Winchester)
Your eyes lit up when you talked about the public health opportunities.
Steve Brine (Conservative, Winchester)
And I saw enthusiasm in you then for that. I thought, “Well, don’t things turn out best for those who make the best of the way things turn out”.
Steve Brine (Conservative, Winchester)
It is not what my GPs say, but thank you very much.
Jimmy Hood (Labour, Lanark and Hamilton East)
We have one minute left. Owen Smith.
Owen Smith (Labour, Pontypridd)
You mentioned privatisation earlier on, Dr Gerada.
Owen Smith (Labour, Pontypridd)
It did slip out. Was it a slip, or is that what most of your members actually see here?
Jimmy Hood (Labour, Lanark and Hamilton East)
Dr Gerada, I am sorry, but I have to bring this to a close as we have run out of time. That brings us to the end of our allotted time.
I thank you all on behalf of the Committee. Thank you.
Jimmy Hood (Labour, Lanark and Hamilton East)
We will now hear evidence from the Local Government Association. Welcome, gentlemen. As with our previous guests, would you introduce yourselves when you answer your first question, so that we can get more into our evidence session? Thank you very much for coming.
Emily Thornberry (Labour, Islington South and Finsbury)
I shall ask a couple of questions about two main things. The first is about integration, particularly of health and social care, and about whether the Bill will be of any assistance in that. The second will focus on the power of health and well-being boards—if, indeed, there is any. Perhaps I could ask Councillor Roberts the questions about the health and well-being boards. Would that be appropriate?
Emily Thornberry (Labour, Islington South and Finsbury)
Will the health and well-being boards have any teeth? Will you have sign-off on GP consortia’s plans, as has been claimed? Can you ensure that GP consortia or any health provider will do anything that they do not want to do?
Emily Thornberry (Labour, Islington South and Finsbury)
May I pause you there? The area that you may get under a health and well-being board will not necessarily be the same area covered by a GP consortium. Is that right?
Emily Thornberry (Labour, Islington South and Finsbury)
But you could have one GP consortium covering one bit, and another covering another—or, indeed, one GP consortium straddling two local authority areas. You are aware of that.
Emily Thornberry (Labour, Islington South and Finsbury)
I shall stick to the executive function and the health and well-being boards. According to your understanding of the Bill, do you think that those boards will have enough power over GP consortia or any other health providers to get them to do anything? Do you believe that health and well-being boards, under the Bill as drafted, will give you sign-off on the plans of GP consortia?
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you very much. Mr Hood, may I also ask a couple of questions about social care and health care?
I am sure that Mr Cozens is aware that Richard Jones, the chair of the Association of Directors of Adult Social Services, says that between 35% and 40% of hospital admissions into acute beds are avoidable, and that, of that group, 70% stay longer than they need to. It is, therefore, to the advantage of those who go into hospital but need not, and to all of us as taxpayers, that there should be more working together at social care and health care. Do you feel that there is anything in particular in the Bill that may help the integration of social and health care? If not, what else ought to be in it?
Emily Thornberry (Labour, Islington South and Finsbury)
Could you tell us a little more about the safeguarding? Clearly, that ought to be a priority for us all.
Simon Burns (Conservative, Chelmsford)
Thank you for your evidence so far. So that my colleagues and the rest of the Committee can fully consider the views that you have given, would you be kind enough to tell the Committee, given your long and illustrious career in local government, which political party you represent?
Simon Burns (Conservative, Chelmsford)
Thank you.
Simon Burns (Conservative, Chelmsford)
I fully accept that. I just thought it would be useful for the Committee to know the whole story.
Liz Kendall (Labour, Leicester West)
I want to come back to the relationship between the health and well-being boards and GP consortia. We are trying to get to the bottom of whether the health and well-being boards can require a GP consortium to do anything, and whether if a GP consortium proposes to change a hospital service, the power of the local health and well-being board will trump that. I ask that question to Mr Cozens.
Liz Kendall (Labour, Leicester West)
So in the end, in your view the national commissioning board, not local health and well-being boards, will have the ultimate say over the consortia.
Liz Kendall (Labour, Leicester West)
You mentioned concerns about where the responsibility for safeguarding lies. I think that is a real issue. The other area where there has long been a challenging relationship between the NHS and local authorities, as you say, relates to free nursing care and continuing care. Will it be the responsibility of GP consortia or the national board to pay for those services?
Julian Sturdy (Conservative, York Outer)
The importance of public health and the role it plays in bringing about key health outcomes was touched on in the previous session. I would just like to know your thoughts on whether you believe the transfer of the public health functions in the Bill are an important step forward in tackling the key issues of poor health.
Grahame Morris (Labour, Easington)
In relation to strengthening the role of local government, do you feel that the Bill goes far enough in its representation on local commissioning boards, or would you prefer to see that aspect of the Bill tightened up?
Grahame Morris (Labour, Easington)
Would it assist closer working between health and social care, particularly in addressing issues on health inequalities, if there was a greater input—perhaps even with the director of public health being part of that arrangement?
Grahame Morris (Labour, Easington)
I was thinking more about the local commissioning consortia.
Nick de Bois (Conservative, Enfield North)
I would like to explore a little bit about democratic accountability with you two, as I am getting slightly mixed signals. If you could bear with me, I shall pick up on some of the comments made by my Opposition colleagues.
Suppose, for example, we were facing a reconfiguration of services; I do not know whether you have had that in your patch. At present, the process is pretty much driven by the NHS—in London, by NHS London—down to PCTs, very much with a tick-box approach, and it gets done. If that was to happen under the Bill, would you agree that, to begin with, you would need the support of the GP consortia that ultimately would be buying services, say, from a reconfigured hospital? Would you both agree that that is something that would have to happen as part of this process?
Equally, it would have to have the support of the health and well-being board. Do you agree that if reconfiguration is to happen with confidence, it would fly in the face of logic, for example, if it did not have the support of those two organisations, Mr Cozens?
Nick de Bois (Conservative, Enfield North)
I do not doubt that tension. Councillor Roberts, do you share the view in Mr Cozens’s summary?
Nick de Bois (Conservative, Enfield North)
If I may interrupt you there, I think we are going off the subject slightly. I think you are almost supporting the point that there is greater involvement through the two processes and through the GP commissioners, which are not local authorities. I think that you are agreeing that you would like to be engaged in that democratic process involving the health and well-being board, be it one or multiple, should the process come up, and that that might be a vehicle for doing so.
Nick de Bois (Conservative, Enfield North)
So would it be fair for me to conclude, then, that on balance, the Local Government Group thinks that the Bill will tip the balance of health care decision making in favour of communities, which has not been the case to date?
Nick de Bois (Conservative, Enfield North)
You do not see any progress at all?
Nick de Bois (Conservative, Enfield North)
Equally—if I can conclude and move away from reconfiguration—do you agree that the joint strategy needs for health care process engages with the local authority as much as anyone else? I do not think you have really had that before.
Kevin Barron (Labour, Rother Valley)
Councillor Roberts said earlier that there is not much detail about public health functions. What we do know is that, as of next year, local authorities will be responsible for local health improvement and illness prevention, including health promotion. If my memory serves me well, you said—and rightly so—that public health was a matter for local authorities prior to 1974. Sanitation, clean water supplies and environmental health are big issues and housing is still an issue in terms of public health, I am sure. But one of the major issues that threatens the public health of the 21st century is lifestyle—what you eat, what you drink, whether you take exercise, whether you drink too much alcohol or you smoke. Do you think that local authorities are going to be comfortable telling their population that they have got to take action around those areas of lifestyle?
Kevin Barron (Labour, Rother Valley)
You are not an elected councillor.
Kevin Barron (Labour, Rother Valley)
Do you not think that elected councillors are going to be nervous about being seen to be, in some instances, preaching about individuals’ lifestyles?
Paul Burstow (Liberal Democrat, Sutton and Cheam)
I wanted to explore a bit further the duties that the Bill will place on both GP commissioning consortia and local authorities to facilitate collaborative working and integration. Could you say from your experience, looking back over past legislation, to what extent the duties being imposed here are novel?
Jeremy Lefroy (Conservative, Stafford)
I want to explore the consequences of the Mid-Staffordshire inquiry in my constituency. The Government have rightly said that lessons will be learnt from the inquiry and included in the Bill, and in the way that they approach scrutiny of the health service. Do you believe that the way in which the oversight and scrutiny committee is presented in this Bill, together with health and well-being boards and other methods of oversight—for instance, HealthWatch England—would be adequate to prevent an occurrence such as the Mid-Staffordshire problem from reoccurring?
Jeremy Lefroy (Conservative, Stafford)
To conclude, one of the things being brought out by the Francis inquiry at the moment is that the overview and scrutiny committee felt that it often did not have the power to summon people to give evidence and, at the same time, that it perhaps did not have the expertise available with which to question. Do you feel that the Bill could help to address that?
Jimmy Hood (Labour, Lanark and Hamilton East)
I think that this will be the last question.
Kevin Barron (Labour, Rother Valley)
Again, Councillor Roberts, my experience of local scrutiny committees is quite positive in terms of how I have seen them operating. The difference with the health and well-being boards is that they will be overseeing the commissioning, but they will have commissioners sat on them. Do you think that that would in any way hinder good scrutiny?
Jimmy Hood (Labour, Lanark and Hamilton East)
If there are no further questions, I thank our witnesses for coming along today, and thank you very much for useful evidence. I am sure that it will be very useful to the Committee as we go through the Committee stage.
Jimmy Hood (Labour, Lanark and Hamilton East)
We will now hear evidence from the NHS Confederation. Welcome, Mr Edwards.
Owen Smith (Labour, Pontypridd)
Mr Edwards, thank you for coming to see us. In your evidence, you highlighted an area of the Bill that lots of people have grave concerns about, and that is particularly the reconcilability of greater competition and price competition, as well as integrated care, and integrated pathways.
You highlighted two aspects of our concerns, and I wonder if you could elucidate on those. The first is about where pieces of care pathways are being commissioned under the new provisions by both the national board and local GP consortia. Where might you see problems there? The second is, essentially, about competition being kept out of the system, because you think it will inhibit integration and cause problems in respect of health care.
Owen Smith (Labour, Pontypridd)
I have a supplementary question, which is about the time frame, or choreography, of all these very complicated changes. In your evidence, you seemed to suggest that perhaps there ought to be pilots or some consideration of how these things will bed down, and particularly, how the maximum price tariff might play out on the ground. Do you think the Government are being hasty and that the Bill’s timetable is just too rapid?
John Pugh (Liberal Democrat, Southport)
You reflect the views of the chief executives of the ambulance services, as well as the hospitals. Is that right?
John Pugh (Liberal Democrat, Southport)
At the moment the ambulance service is basically a regional service. It is a regional monopoly provider commissioned by PCTs, normally with one lead commissioner. How do you see that system changing under the new order?
John Pugh (Liberal Democrat, Southport)
What do you mean when you say “a more competitive approach”?
John Pugh (Liberal Democrat, Southport)
So you do not visualise it being possible for different commissioning consortia to demand different levels of blue light cover?
John Pugh (Liberal Democrat, Southport)
If the block contract arrangements continue to exist for blue light services and the like, which we assume they must, one runs into the difficulty that, at the moment, the ambulance services bill people on historic business, as it were—I hate to use that word. There will be no historic business for GP consortia, because they will exist in different frames and different time scales. The ambulance services currently bill by postcode, rather than by doctor, do they not?
Emily Thornberry (Labour, Islington South and Finsbury)
I would like to ask you some questions about the patient voice. Where under the new system do you think that patient voice is likely to be loudest and most effectively heard? How would a hospital configuration work? Who would make the decisions and where, if anywhere, would the patient voice be heard in relation to that?
Emily Thornberry (Labour, Islington South and Finsbury)
Could you give us some particular areas where you think more power should be put in? You do not have to cover them all, but just give us your top three.
Liz Kendall (Labour, Leicester West)
I should declare an interest here. I ran the ambulance service network of the NHS Confederation for a couple of years before I became a Member of Parliament. You have already said that you think some of the accountability on the commissioning side is very weak, because the consortia only have to produce an annual report, they are not required to meet in public and they do not have to have members of the public or patients on their boards. I wanted to talk about the accountability on the provider side, as it is something that we discussed with David Nicholson this morning, and it is an issue that I know the hon. Member for Stafford is very interested in.
As Monitor stops being responsible for foundation trusts and moves to being an economic regulator, it loses the power to appoint to the board, or remove people from the board, or to bring people in to improve an FT that has been failing. Under the Bill, there is an idea that governors will have more duties and be better trained, but what will prevent an FT from failing under the new reforms?
Liz Kendall (Labour, Leicester West)
Can I come back on a supplementary question because we have a few minutes? The analogy of the tightrope and no net speaks volumes. The directors of FTs will take on the responsibility of directors under company law, which means it is not just the interests of patients and the public they will have to bear in mind, but the interests of that entity. What do you think that will mean, if directors and governors have to think about the financial success of that organisation as much as what patients and the public want?
Liz Kendall (Labour, Leicester West)
But they will be made company directors with similar powers under the Bill.
Liz Kendall (Labour, Leicester West)
That is what the Foundation Trust Network, which is part of the NHS Confederation, said to the Committee.
Liz Kendall (Labour, Leicester West)
Thank you.
Jimmy Hood (Labour, Lanark and Hamilton East)
If there are no further questions, that is the end of the evidence session. I thank you very much for coming.
Jimmy Hood (Labour, Lanark and Hamilton East)
We now take evidence from Unison, Unite and GMB.
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you very much for coming. I will kick off. If you don’t mind, may I start with a standard question that I have asked many of the witnesses? Do you think that there are any risks associated with the legislation and the changes that it hopes to bring about, and if you do, what are they?
Jimmy Hood (Labour, Lanark and Hamilton East)
May I ask you to identify yourselves to the Committee when you answer your first question?
Jimmy Hood (Labour, Lanark and Hamilton East)
Welcome Karen.
Emily Thornberry (Labour, Islington South and Finsbury)
Karen, what we have done in the past—I do not know if this is all right—is that as each person answers they tell us who they are. So, since you have introduced yourself first, would it be all right if you explained to us what, if any, risks you see might coming if the proposed changes to the NHS are brought about?
Emily Thornberry (Labour, Islington South and Finsbury)
Just for the record, how many Unison members work for the NHS?
Emily Thornberry (Labour, Islington South and Finsbury)
We have heard evidence about public accountability and the different layers in which there may be a patient voice. Before I hand on to other Members, would you mind outlining briefly whether you have any concerns about whether there will be additional democracy in the NHS as a result of the legislation?
Nick de Bois (Conservative, Enfield North)
I am not quite sure where to begin. Perhaps I could just ask you, Miss Jennings, whether you think that any cuts in management need to be made in the NHS.
Nick de Bois (Conservative, Enfield North)
I am not quite clear. You think you have to have cuts, but Unison does not believe that there should be cuts in management—in the NHS bureaucracy. Is that your position?
Nick de Bois (Conservative, Enfield North)
I am sorry to stop you, but I understand that.
Nick de Bois (Conservative, Enfield North)
Okay, let us look at it another way, shall we? You are now in the position of defending a massive increase in bureaucracy in the primary care trusts, for example, yet you do not think that there is room to make cuts there, or that you should actually welcome the cuts, however painful they may be, as a way of reducing the imbalance and over-management. Is that correct? You are defending the status quo.
Nick de Bois (Conservative, Enfield North)
You might be interested in what the clinical director of the BMJ Evidence Centre, Dr Rubin Minhas, has said. Only last week, he wrote:
“More is wasted on obsolete drug stocks and variations in care”.
He went on to say that
“the time and energy spent navigating a path for our patients through the NHS’s bureaucratic maze”
is a waste of clinical time and management. Let me rephrase; I would like to press you on this, if I may.
Nick de Bois (Conservative, Enfield North)
In 2009, the ratio of recruitment from clinical to management was 5:1. Are you still asking this Committee to accept that we should not welcome and embrace change that reduces that growth of bureaucracy and administration?