Health and Social Care Bill
Public Bill Committee, 10 February 2011.
Mike Hancock (Liberal Democrat, Portsmouth South)
Good morning and welcome. We are very pushed for time, so I will not invite you to introduce yourselves and tell us all about where you have been for the last 20 years. However, I do want us to get as much out of the session as we can, so if you want to make some comments about your own situations, I suggest that you do that in response to the first question that you are asked.
I am grateful to you all for giving up your time to give evidence, which will enable the Committee to function far better than it could have expected to without your assistance. I am sure that you will give the advice that the Committee needs to take it through the next six or seven weeks.
Emily Thornberry (Labour, Islington South and Finsbury)
I thought that I would kick off the proceedings with a fairly general question, which I have been asking many witnesses. Do you think that there are any risks associated with the Bill? Could each witness answer in turn?
Emily Thornberry (Labour, Islington South and Finsbury)
Have you any comments about price?
Mike Hancock (Liberal Democrat, Portsmouth South)
Does anyone want to add anything to that?
John Pugh (Liberal Democrat, Southport)
Sir Stephen, you have just mentioned the third sector. The third sector is a very wide category, and you are down on the list as voluntary organisations. Are we assuming that the third sector includes other things that are not voluntary organisations?
John Pugh (Liberal Democrat, Southport)
There are some quite big players in the third sector, are there not?
John Pugh (Liberal Democrat, Southport)
May I ask David Bennett a question, given his position in Monitor? You have two roles, do you not? One involves price competition and the other is sustaining core services or designated services. Do you think that you will do the designation or will that be left to local organisations? How will you be able to balance the two drivers of your job, which is basically to sustain core services and encourage competition?
John Pugh (Liberal Democrat, Southport)
Three?
John Pugh (Liberal Democrat, Southport)
Just on that precise point, it could be that in one area a maternity service is designated within the guidelines and in another area, abiding by the guidelines, a maternity service is not.
John Pugh (Liberal Democrat, Southport)
In terms of the balance between the two roles—competition versus protecting core services—how do you get that balance right?
Liz Kendall (Labour, Leicester West)
I have one question for David and one for the Foundation Trust Network. Apologies to Sir Stephen.
Under the Bill, Monitor gets the powers that the OFT has in relation to the Competition Act 1998 and the Enterprise Act 2002. The explanatory notes say that it is based on the model of regulated industries,
“such as telecommunications, gas, electricity, water and sewerage and railway”.
Could you explain to the Committee what that means, and what the similarities are between health and gas, for example?
Liz Kendall (Labour, Leicester West)
Can I come back? This is the first time it has been put in primary legislation.
Liz Kendall (Labour, Leicester West)
That means that if a hospital merges, that will go to the OFT.
Liz Kendall (Labour, Leicester West)
So it will be responsible for deciding whether a hospital could merge.
Liz Kendall (Labour, Leicester West)
I want to follow up on some of your comments. What do you think is anti-competitive behaviour in the NHS? Could you give me an example of what that might mean?
Liz Kendall (Labour, Leicester West)
GP commissioners?
Liz Kendall (Labour, Leicester West)
Such as what? Just to make it real. What in practice might that be?
Liz Kendall (Labour, Leicester West)
So if there was only a local hospital and those commissioners only asked that hospital to provide a service, and nobody else, they could be referred to the OFT.
Liz Kendall (Labour, Leicester West)
Are those the EU procurement guidelines?
Liz Kendall (Labour, Leicester West)
So, for example, if a GP wanted to refer patients for hip operations to the local hospital and did not put that out for tender, would that be considered anti-competitive?
Liz Kendall (Labour, Leicester West)
May I ask a question now of Sue Slipman? You said you had concerns about who drives quality, and you mentioned GPs, who will be responsible for that under this Bill. What are your concerns—could you explain them some more?
Liz Kendall (Labour, Leicester West)
So not the OFT and not GP commissioners? Sue Slipman: No, it will be approved by the governors.
Liz Kendall (Labour, Leicester West)
And not local government?
Liz Kendall (Labour, Leicester West)
Is that a difference of opinion between you and Mr Bennett?
Liz Kendall (Labour, Leicester West)
He just said that it would be the OFT that would decide—
Jeremy Lefroy (Conservative, Stafford)
I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire?
Jeremy Lefroy (Conservative, Stafford)
Sorry, are we saying that there was not a clear quality bar for approval of foundation trusts up till now?
Jeremy Lefroy (Conservative, Stafford)
When was that introduced?
Jeremy Lefroy (Conservative, Stafford)
Just to follow up on that, the Bill makes it clear that all trusts should become foundation trusts by 2014, so there is a time limit. If you feel that trusts are not able to become foundation trusts, are you prepared to stand up and say that they are not ready, irrespective of the deadline?
Kevin Barron (Labour, Rother Valley)
A question for Mr Bennett. The impact assessment for the Bill refers to “fair playing field distortions” and says:
“The majority of the quantifiable distortions work in favour of NHS organisations; tax, capital and pensions distortions result in a private sector acute provider facing costs about £14 higher for every £100 of cost relative to an NHS acute provider.”
My understanding is that you would be responsible for addressing that system. What is your view of those fair playing field distortions?
Kevin Barron (Labour, Rother Valley)
This says that it is the other way around, actually. The public sector costs are higher than private. Do you agree with that?
Kevin Barron (Labour, Rother Valley)
If this is the case, what are the implications for public sector workers?
Kevin Barron (Labour, Rother Valley)
My first point is that our starting point must be to do the analysis more extensively, looking at a broader set of issues. I cannot say that those figures are the ones that we would come up with.
Kevin Barron (Labour, Rother Valley)
I was on the Health Committee during the previous Parliament, when it looked into the independent sector treatment centre programme. I had conversations with more than one company running the programme that said they felt threatened by the pensions implications, with the work force working in the independent sector while keeping the NHS rewards such as pensions. I call them distortions, but most of us have one. By implication, what does that mean?
Kevin Barron (Labour, Rother Valley)
I accept that. ISTCs were contracted for cases that were not likely to go wrong in surgery, because there was no back-up in the hospitals or institutions if someone needed to go into ITU, and so on. I understand that exactly.
I am not talking about that, but about the implications of the work force transferring when we have these comments in the impact assessment about what is likely to happen. Surely, the implication is that if you have to address these so-called distortions, people are likely to be working for less than they are now.
Kevin Barron (Labour, Rother Valley)
So you do not agree with that analysis in the assessment?
Kevin Barron (Labour, Rother Valley)
And obviously you will do those assessments? That will be part of Monitor’s new role, will it?
Kevin Barron (Labour, Rother Valley)
And you will publish those assessments?
Mike Hancock (Liberal Democrat, Portsmouth South)
This is a very important point. I know that Emily wants to come back, but does anyone else want to ask a follow-up question, or do any of the other people at the top, such as Sue or Sir Stephen, want to add anything?
Mike Hancock (Liberal Democrat, Portsmouth South)
I think that they accept that.
Emily Thornberry (Labour, Islington South and Finsbury)
I am tempted to press you further, David, given the profound implications of what you said in relation to work force pensions. We are about to pass this legislation and you are saying, “Take it on trust, as it will all be sorted out.” But we are talking about millions of people’s pensions here, and it is difficult not to push you at this stage.
Worse than that, you said in an incomplete answer earlier that there were other obvious distortions and advantages that the NHS had over the private sector. I wonder whether you could list anything else, on top of pensions, that you might think might of?
Emily Thornberry (Labour, Islington South and Finsbury)
Do you have any others?
Emily Thornberry (Labour, Islington South and Finsbury)
But we have to take you on trust when it comes to passing this Bill?
Mike Hancock (Liberal Democrat, Portsmouth South)
I am sorry to interrupt, but four other Committee members want to come in on this issue. So to be fair to them, I shall let them do so. Mr Lefroy first.
Jeremy Lefroy (Conservative, Stafford)
Would you consider that another of the things that the NHS have to take on board, which the private sector would not necessarily be interested in, is emergency—particularly acute—care and the block of services around that? There is perhaps a risk that, unless you have a duty to ensure some kind of stability of that kind of provision, the services surrounding acute and emergency care will be cherry-picked, leaving it unviable.
Mike Hancock (Liberal Democrat, Portsmouth South)
Before you come in, Sue, I invite Grahame Morris to make his point on this issue.
Grahame Morris (Labour, Easington)
We have moved on a touch, but I will bring it back if that is in order. I refer to an article that David Bennett published in the Financial Times on 6 January, where he queried the independence and stability of the Government’s flagship NHS proposals, which he said could be
“compromised by the coalition's refusal to create an independent body to oversee them,”
My interpretation was that you were raising concerns about what you referred to as
“the operationally independent banking function”.
Presumably, that is the £24 billion, aside from the £80 billion that has gone into GP commissioning, that you are raising concerns about and that would be retained by the Department of Health and would oversee loans to hospitals at commercial rates. Sue Slipman said that if the responsibility is left to the Department of Health, it could be used as a policy transmission belt that would affect independence.
So is it correct that Monitor would lose direct oversight over this budget and would that leave a possibility that there would be some political influence in what we are being told in the Bill is a wholly free-market and independent system, particularly in relation to reconfigurations and withholding capital for a particular purpose?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
A lot has been said this morning about the appropriateness of services. Although there is no definition of fairness, clause 54 says that
“the provision of access to the services for those purposes operates fairly.”
How will you achieve that as the regulator? We have talked about the fact that certain providers exclude people with complex conditions. How will you ensure that there is fair access to services?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Is that not fudging it? How then will we ensure that there is equitable access?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
May I just follow that up?
Mike Hancock (Liberal Democrat, Portsmouth South)
We must be fair to everyone. Can we keep our questions short and our answers shorter?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
If we find, as we strongly suspect that we will, that fairness in access to services does not happen, what will you be able to do about it? Will you be able to withdraw the licence of certain providers?
Liz Kendall (Labour, Leicester West)
I am sure many of you will remember the controversy the last time a foundation trust Bill went through Parliament. There are two key things I am completely confused about. One is that there does not appear to be any clarity about which body will be responsible for the £24 billion of FT assets; it is just a vehicle with operational independence. Secondly, I am not clear whether it is a GP, a local authority or Monitor who designates which services are saved.
Mike Hancock (Liberal Democrat, Portsmouth South)
Who wants to take that?
Liz Kendall (Labour, Leicester West)
But just a vehicle.
Liz Kendall (Labour, Leicester West)
And who designates?
Liz Kendall (Labour, Leicester West)
We do not have the detail yet of how we say which services will be guaranteed.
Dan Byles (Conservative, North Warwickshire)
A number of people have been expressing concerns about the issue of competition—particularly focusing in on competition on price. A view has been expressed on some sides that that inevitably would push down quality. Obviously, that would be a concern, if it was the case. Given that competition is a core part of Monitor’s function, I would quite like your view on that.
Dan Byles (Conservative, North Warwickshire)
So you believe that the competition element of Monitor is not purely about price; it is also about quality—
Mike Hancock (Liberal Democrat, Portsmouth South)
We have five on this point.
Owen Smith (Labour, Pontypridd)
It is interesting that there is obviously clear agreement among the panel that the evidence shows that price competition in health care drives down quality, or tends to. Sue, you said earlier that therefore you thought there ought to be some sort of stabilisation period. What does that mean? Does it mean that you do not think that the maximum tariff that effectively drives the price competition should come in at the onset of the new regime?
Owen Smith (Labour, Pontypridd)
Can you bring that alive for us? Can you give me two examples—one area where you think price competition would be safe on current evidence, and one where you cannot imagine price competition would ever be safe?
Margot James (Conservative, Stourbridge)
I would like to bring Sir Stephen in on the discussion. Most of us have hospices in our constituencies and end-of-life care is dominated by the hospice movement. From my observations, the service has been provided on a very price-competitive basis and is of high quality. Do you have any comments about the role of the third sector in competing on both price and quality?
Mike Hancock (Liberal Democrat, Portsmouth South)
It was a very good and interesting answer, but we have to move on.
Margot James (Conservative, Stourbridge)
Can I just ask one supplementary?
Mike Hancock (Liberal Democrat, Portsmouth South)
I am coming back to you. I think that Tom Blenkinsop wanted to ask a question on this issue.
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
Sir Stephen, under the new provisions, competition on price will be a key factor, and where big private companies believe that one of your members has been picked on the basis of organisational structure and not on the basis of price, they will be able to call for the regulator to look into that decision. Do you not think that those companies will be able to throw money into litigation to back up their argument?
Margot James (Conservative, Stourbridge)
I want to follow that up. Do you think, Sir Stephen, that the Bill provides enough scope to allow the third sector to develop into new areas, where it might be able to drive innovation?
Phil Wilson (Labour, Sedgefield)
On the face of it, patients at a GP practice, for example, have a choice of where they go for a hip replacement, but generally they end up going to their local hospital. Could that be challenged on the ground of anti-competitive practices by another hospital?
Phil Wilson (Labour, Sedgefield)
But could not another hospital challenge that?
Nick de Bois (Conservative, Enfield North)
Mr Bennett, I just want to seek a bit of clarity on the competition point. Given what you have said, and your role in Monitor on this, are you saying that over the medium term, the advantages of introducing competition outweigh any of the disadvantages that have been discussed?
Nick de Bois (Conservative, Enfield North)
And Monitor will do that?
Paul Burstow (Liberal Democrat, Sutton and Cheam)
I want to follow up that point. Am I correct in understanding you to have said that the majority of—most of—the competition activity that would take place as a result of this Bill would be on quality, not price?
Grahame Morris (Labour, Easington)
I want to return to the point that Nick made a little earlier about competition on price. I want to be clear in my own mind about this cost-based argument. It strikes me, as was mentioned earlier, that it is a real barrier that, in general, NHS providers are 14% cheaper than private sector providers, given the Government’s intention to introduce competition and private sector providers into the system. What remedies could be applied? Could you give an example? Could it be a tax break given to a private sector company as an incentive to enter the market, in order to overcome that market distortion?
Grahame Morris (Labour, Easington)
But it is in the Department’s own impact assessment.
Grahame Morris (Labour, Easington)
Even if that is not correct, as a bit of supposition, how would such a distortion be corrected? How would you create a level playing field to bring in the private sector as the Government clearly wish to, to introduce competition?
Grahame Morris (Labour, Easington)
In layman’s terms, does that mean that a private sector provider would be paid a supplement above the normal tariff? Is that what you are alluding to?
John Pugh (Liberal Democrat, Southport)
To précis what you have told us—you can tell me where I have gone wrong—when I asked my first question, about competition, you seemed to be saying that there were designated services and outside that, it was just crude financial competition of one kind. You are clearly not saying that, though. You are clearly saying it is not like competitive tendering in local authorities; it is more like best value, although we are not quite clear about how it is going to go. What we are not clear about yet is what you will do to prevent yourself from ending up like another Postcomm. You are aware that competition in the Royal Mail system, in the mail delivery system, has led to one major supplier—the state supplier, in that case—bearing the costs of the last mile for all its competitors. In pure competition terms, that does not happen normally. Tesco and Sainsbury compete, but Sainsbury does not ask Tesco to deliver its stuff. Given that clinical processes are fairly complex and often involve long-term treatment of a variety of kinds, how will you avoid ending up like another Postcomm?
Mike Hancock (Liberal Democrat, Portsmouth South)
You will have to be fairly sharp here.
John Pugh (Liberal Democrat, Southport)
Sorry, but not necessarily. You might have a clinical process such as a hip replacement—that is quite a good example—which might involve a range of different sections of treatment, only one of which is the operation side; the others will be physiotherapy and so on. If the private supplier or third sector supplier works from the assumption that the NHS will, as it were, pick up the pieces, you are into the Postcomm situation, are you not?
Mike Hancock (Liberal Democrat, Portsmouth South)
I am sorry, Mr Bennett, but we have one last question and then we have to call a halt, I am afraid. It is from Mr Smith.
Owen Smith (Labour, Pontypridd)
It is a question of where the buck stops where there are service reconfigurations. Let us take the example of a merger. You said earlier that the OFT and the Competition Commission have a potential role here. In the event that the OFT or the Competition Commission deems that there is a competition issue, who has the power to stop the merger occurring? In the event that there is not deemed to be a competition issue, but there is some other reason for not wanting a merger to happen, who has the power to prohibit the merger?
Mike Hancock (Liberal Democrat, Portsmouth South)
Can I intervene? Not for the first time, and probably not for the last time, I will give the last word to Sue Slipman. Then we have to finish. We are committed to end this part of our session at 10 o’clock, and we have other guests who are coming to give evidence.
Mike Hancock (Liberal Democrat, Portsmouth South)
On behalf of the Committee, I thank all four of you for your answers to the questions. I am sure that a lot of what you have said will come back in this Committee over the next few weeks, and I am sure that you will wait with interest to hear what is said about what you have had to say. Thank you all for coming, and for the precise way that you have answered the questions.
Mike Hancock (Liberal Democrat, Portsmouth South)
Good morning, gentlemen. Thank you very much for coming to give evidence to the Committee and answer our questions. I will not ask you to introduce yourselves or tell us too much about why you are here, as I think everyone in the room knows why you are here. We have a series of questions for you, and I invite Emily Thornberry to ask the first.
Emily Thornberry (Labour, Islington South and Finsbury)
As an opener, I will ask the question that I have been asking most of the witnesses. Do you think that there are any risks associated with this legislation? If so, can you explain what they might be?
Emily Thornberry (Labour, Islington South and Finsbury)
But you do not think that there are any other specific risks associated with this legislation and these changes—it is simply the risks associated with change?
Kevin Barron (Labour, Rother Valley)
On the issue of transitional risks, I have a question about costs. Most people think that the costs of transitions and reorganisation in the NHS adds to what is currently around. I wanted to ask Richard Douglas, given the position that you hold in the Department, about the issue of costs running alongside the efficiency savings outlined last year for the national health service. What do you think is likely to happen?
Kevin Barron (Labour, Rother Valley)
Do you think it just makes the £15 billion to £20 billion savings more difficult to reach?
Kevin Barron (Labour, Rother Valley)
Do you have good evidence of that in terms of NHS? Do you think they have? You did not say yes.
Kevin Barron (Labour, Rother Valley)
I have question for Andrew Dillon. NICE will no longer make a judgment on the cost of new drugs and whether the NHS can afford them. Instead, the Government want to move to a value-based pricing system where they take a central role in deciding on price and, GP commissioning aside, if the local NHS can afford it. Given your organisation’s involvement in new drugs particularly over the past few years, will you retain responsibility to advise Government? What change will it have on the provision of drugs to patients? Do you think it will result in major changes?
Kevin Barron (Labour, Rother Valley)
This is really a question for both of you, though you may not have direct responsibility for it at the moment. For many years now, there has been an argument that the pharmaceutical price regulation scheme has helped to sustain a large part of manufacturing in this country—drugs manufacturing exports total about £9 billion a year. Do you think that changing the way the NHS purchases from the pharmaceutical companies will change that? Do you think it will have an effect on our potential to keep a healthy part of the economy running?
Margot James (Conservative, Stourbridge)
Sir Andrew, leading nicely on from the clinical and cost-effectiveness guidance that you are already producing in your organisation, can I ask how you envisage care pathways, which are going to be the next big thing, being taken up by GP commissioners? Do you see it as being almost as ubiquitous as the clinical and cost-effectiveness guidance has been in the past? What are you expecting from Monitor and the commissioning board by way of enforcement?
Mike Hancock (Liberal Democrat, Portsmouth South)
Many Members want to ask questions. Have you got a supplementary, Margot?
Margot James (Conservative, Stourbridge)
No.
Mike Hancock (Liberal Democrat, Portsmouth South)
Grahame, is it on this point?
Grahame Morris (Labour, Easington)
No, I wanted to ask Richard a question.
Mike Hancock (Liberal Democrat, Portsmouth South)
I will come back to you. Owen, is it on this point?
Owen Smith (Labour, Pontypridd)
On a previous point about value-based pricing.
My question is for Sir Andrew. Given the complexity of introducing value-based pricing, and the extent to which it is very much understood to be a very difficult issue, are you confident that you will be able to get that resolved and agreed with the industry in time for your divesting your responsibility to provide cost-effectiveness advice to the NHS?
Owen Smith (Labour, Pontypridd)
This is a very big change in your role, potentially giving you much more influence over pricing at the outset—at the beginning of the food chain, if you like—but giving you much less influence over prescribing practices. In some respects, NICE was set up to deal with irrationality in GP prescribing practices, but GPs will now be holding the ring and holding the money. Are you worried that you will see less rational prescribing when you have less influence over their activities?
Owen Smith (Labour, Pontypridd)
But there will not be the same obligation to follow your guidance in respect of prescription of medicines as there was hitherto.
Mike Hancock (Liberal Democrat, Portsmouth South)
We have nine minutes and nine questions still to be answered. Dan, you had something on this point.
Dan Byles (Conservative, North Warwickshire)
It has been covered.
Mike Hancock (Liberal Democrat, Portsmouth South)
Fine. Liz?
Liz Kendall (Labour, Leicester West)
Hello, Mr Douglas. I have a money question and a NICE question. David Nicholson made it clear in his evidence to the Public Accounts Committee that, in terms of finances, in the new world the buck stops with foundation trusts. Does that mean that in the new world, when Monitor is an economic regulator and is not looking after the finances of FTs, it is up to the board, full stop, and there is no one else who can check? That is what I am worried about. I do not understand who will check that stuff is okay in terms of the budgets of the FTs.
Liz Kendall (Labour, Leicester West)
Thank you. This is a question to Sir Andrew. The long-term problem is how we get the best health and other value out of the NHS budget. You did the guidelines and PCTs often implemented them, but sometimes did not because, they said, they did not have enough money. What will be the difference now with GPs being responsible? They still have to decide whether to implement your guidelines, so in that way it is no different—it is just up to GPs now. Is that right?
Liz Kendall (Labour, Leicester West)
So it will now just be up to GPs?
Liz Kendall (Labour, Leicester West)
Just as you did with PCTs?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
Sir Andrew, you mentioned having an effective dialogue between primary and secondary care providers. How effective do you think that dialogue is currently? Could it be better, and how would the Bill help to improve it, in your view?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
I would like to ask a finance question as well. We know that not all treatments and medicines have NICE guidance currently and that some, but not all, areas have effective use of resources groups, for example. How do you think that that will change with the Bill?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
That relates to what Ms Kendall said about there being more opportunities for GP consortia to decide whether to apply NICE guidance, and to make their own decisions in the absence of NICE guidance.
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Assuming that they want the evidence. What percentage of the NHS budget do you think will be spent on private health care providers by 2014?
Debbie Abrahams (Labour, Oldham East and Saddleworth)
Okay, I will accept that at face value.
Mike Hancock (Liberal Democrat, Portsmouth South)
I do not think that we can pursue that much further today. Daniel, I apologise, did you have a follow-up question?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
No, I have another question on setting national care pathways. What role do you envisage the royal colleges playing in that?
Nick de Bois (Conservative, Enfield North)
Mr Douglas, are you confident that the GP commissioners will be able to keep their management costs strictly under control, so that we do not get any threat of overspend? I am talking about the management portion of their budget.
Mike Hancock (Liberal Democrat, Portsmouth South)
We have one minute. John Pugh.
John Pugh (Liberal Democrat, Southport)
Had we not had this piece of legislation, administrative costs of PCTs were going to be managed down by 30%. Is that right?
John Pugh (Liberal Democrat, Southport)
What was going to be the next saving after that and what were going to be the redundancy costs attached to that?
John Pugh (Liberal Democrat, Southport)
Is that a net saving or a gross saving?
Mike Hancock (Liberal Democrat, Portsmouth South)
Thank you very much indeed. Apologies to Jeremy and Grahame for not getting to your questions. Thank you, Richard and Sir Andrew, for your precise answers and for the way in which the meeting was conducted.
Mike Hancock (Liberal Democrat, Portsmouth South)
Good afternoon and welcome to our first witness. Thank you for coming to give evidence. It is a pleasure to have you with us. As we are very short of time, we will not have lengthy introductions. I hope that if you have anything to say about your own position on anything, you will engage us with that in the answer to your first question, which will be asked by Emily Thornberry.
Emily Thornberry (Labour, Islington South and Finsbury)
Having read your submissions, which have been very helpful, thank you, it is clear that you have concerns about the extent of public and patient involvement in the new structures as developed by the Bill. Could I give you a general opener and ask you explain in your own words why you are so concerned?
Emily Thornberry (Labour, Islington South and Finsbury)
Enjoyable and colourful though this is, what do you want?
Emily Thornberry (Labour, Islington South and Finsbury)
So can you give us a summary in relation to healthwatch, for example?
Emily Thornberry (Labour, Islington South and Finsbury)
Do you have any concerns about whether the patients’ voice will by heard by a body we heard from before lunch, Monitor, which, speaking personally, sounded like a fairly scary body? Are you concerned about whether there should be any patient voice in relation to Monitor, or, indeed, the national commissioning board?
Emily Thornberry (Labour, Islington South and Finsbury)
Mr Hancock, I am happy to ask more questions, but in deference to other Members I hope that that is sufficient to get things going.
Jeremy Lefroy (Conservative, Stafford)
I am speaking really as the Member of Parliament for Stafford in relation to the Mid Staffordshire inquiry. I wondered whether you thought that the new arrangements for healthwatch were an improvement over local involvement networks, community health councils and patients forums, and that they would ensure that cases like Mid Staffordshire would be flagged up at a much earlier stage than that one was.
Jeremy Lefroy (Conservative, Stafford)
Thank you for that. Are you saying that the legislative framework is adequate—that it is just a question of how it is implemented, rather than there being any need for the proposed legislative framework to be amended?
Kevin Barron (Labour, Rother Valley)
In your written submission you said that the public will want, and I quote,
“all NHS (and NHS-funded) bodies to meet in public and be fully transparent”.
Their decisions and operations must not be hidden behind commercial confidentiality. Given that National Voices has been in operation now for more than two years, and we have had the independent sector treatment centres and NHS patients in BUPA hospitals and many others, have you had any experience in terms of talking to other operators within the NHS?
Kevin Barron (Labour, Rother Valley)
Have you attempted to?
Kevin Barron (Labour, Rother Valley)
I just wonder what is behind “commercial confidentiality”? It sounds as though you have been blocked off from talking about that.
Owen Smith (Labour, Pontypridd)
On the same theme, I wonder what experience you can share with us about the extent to which you have been able to engage with existing foundation trusts? How have you found them in respect of transparency and willingness to engage with patients and patient voices?
Emily Thornberry (Labour, Islington South and Finsbury)
Although you have not given oral evidence about it today, I think you have views about lay representation on commissioning consortia as well. Could you use the time you have to explain to us why that is so important, and the relationship between that and the health and well-being boards?
Emily Thornberry (Labour, Islington South and Finsbury)
Could you briefly give us your critique of health and well-being boards? A lot seems to have been put on them as being pivotal within local communities. As they stand, are you happy with their status?
Emily Thornberry (Labour, Islington South and Finsbury)
Presumably, the health and well-being board will have a key role in integrating social care and health care services, if it works properly.
Mike Hancock (Liberal Democrat, Portsmouth South)
I have to interrupt you there, Mr Redding, because we have one more question. Sorry, Emily.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
I want to tease out one thing a little more. You gave us an example comparing the role with that of school governors. There is perhaps a distinction, because one of the criticisms of LINk organisations has been that the people who get involved often have their own agenda and do not represent the general issues of concern to that part of the country or locality—the more general health care issues in an area. Often the people who get involved have their own specific medical agenda—
Mike Hancock (Liberal Democrat, Portsmouth South)
Daniel, we have less than a minute.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
I was just coming to the question, Mr Hancock. You were saying that you want to have people on the health and well-being boards. If that were the case, how would you avoid people taking a specific medical agenda and hijacking the board?
Mike Hancock (Liberal Democrat, Portsmouth South)
Don, I am sorry to have to say it, but thank you very much for giving your time up today to give evidence. I am sorry that we impose these very strict roles on ourselves—self-inflicted wounds, I am afraid, because we agreed to this very tight time schedule. Thank you again, and I am sorry if you feel that you have not had enough time.
Mike Hancock (Liberal Democrat, Portsmouth South)
I am very grateful that you came. I invite our next witnesses to come forward.
Mike Hancock (Liberal Democrat, Portsmouth South)
Good afternoon and welcome. Thank you for giving up your time to come and give evidence this afternoon. As I have said all through today, we are working to a very tight schedule, so there will not be time for lengthy introductions or anything of that nature. Rather than invite each of you to make contributions at the beginning, if you have something specific to say, I would be grateful if you say it quickly when you are answering your first question.
Nicky Morgan (Conservative, Loughborough)
Good afternoon. I particularly want to direct my questions to Mind and Rethink, although I am sure that the others will have views. You probably came in at the end of the last witness session, when we were discussing multidisciplinary commissioning. I know that there is concern, which all of you probably share, that GPs are generalists—we heard that from Hamish Meldrum on Tuesday. GP may not have specific experience of certain conditions, particularly long-term conditions. What are your views on GPs being able to get expert advice when they are commissioning and how the Bill helps that? Also, what is the role of the third sector in providing those services, taking in multidisciplinary commissioning and “any willing provider”? I would be grateful for your thoughts on the involvement of the voluntary or third sector, particularly in relation to the conditions that you represent.
Nicky Morgan (Conservative, Loughborough)
Jenny, that is very interesting, but on Steve’s point: after 18 months, or whenever you feel ready, perhaps in a few years’ time, given your involvement and understanding of the system—I am sure you would rather not have that understanding but you do—do you feel that your knowledge could help your GP to commission services, or that you could offer advice to other patients? That builds on what Steve was saying about how patients do want to be involved. There is a certain cynicism surrounding the Bill sometimes, and localism generally, that people do not want to be involved in their lives or their care. Actually, from what you were saying Steve, that is not the case with many patients, who would want to be involved, perhaps once their treatment has concluded.
Mike Hancock (Liberal Democrat, Portsmouth South)
Jenny, I think I speak on behalf of the whole Committee in saying that we all wish you the very best for your treatment coming up. We look forward to hearing of your speedy recovery from the illness that has tragically beset you. I say that on behalf of everyone in the room. We wish you well.
Mike Hancock (Liberal Democrat, Portsmouth South)
Thank you. We will now move on to another round of questioning.
Emily Thornberry (Labour, Islington South and Finsbury)
Having listened to the various pieces of evidence from people with different experiences, I would be interested to hear what you have to say about this. We heard this morning that you can get NICE guidelines that will give assistance on best practice in relation to commissioning care, but that you cannot force GPs to stick to them. There may be lots of other ideas for advice that can be given to GPs or to patients in terms of information, or to groups or anything else, but, as the Bill stands, there is nothing to force GPs or anyone else to listen to any of that good advice. Are we not simply handing over this power in good faith that GPs will do the right thing? Are you not concerned that we will end up with very patchy GP services and health services throughout the country as a result?
Emily Thornberry (Labour, Islington South and Finsbury)
You have referred to cancer networks, but some people might not be entirely sure what they are—many of us know, but not everybody. I think it is important for that to be understood. It is also important to understand what the future of cancer networks might be in the light of what might happen under the Bill.
Emily Thornberry (Labour, Islington South and Finsbury)
May I ask a further question?
Mike Hancock (Liberal Democrat, Portsmouth South)
I want to be fair to everyone. It must be quick.
Emily Thornberry (Labour, Islington South and Finsbury)
Given that you are the layperson here, Jenny, I wondered whether we had fairly given you an opportunity to say everything. Is there anything else you would like to say?
Mike Hancock (Liberal Democrat, Portsmouth South)
Jenny, I think that point is not lost on the two Ministers sitting here. I am sure they will take that back.
Steve Brine (Conservative, Winchester)
Jenny, I wish you well. You also gave evidence very well to the all-party group on ovarian cancer recently. Thank you for coming today. I was going to ask about cancer networks, but Emily has covered it so well. I spoke about them on Second Reading.
Sarah, you have two Ministers here and the Secretary of State will be here later. What would be your advice to Government to secure the safe transition of the cancer networks to consortia? I think that that is the nub of good cancer commissioning. There are, as we know, more than 200 cancers.
That was part one. The other part is really for Steve Ford. Nice to see you, Steve. We met before when you launched your Fair Care for Parkinson’s campaign. I pay great tribute to the work that you have done through the Neurological Alliance. You have taken a really positive approach to embrace what the Bill is about. If you were launching Fair Care for Parkinson’s now, as opposed to when I first met you 18 months ago, what opportunity would there be for an organisation such as yours to work with consortia and see that the request that you made in that very good campaign had even more impact?
Liz Kendall (Labour, Leicester West)
This links well to evidence that we heard this morning from NICE that its guidelines are not always implemented by PCTs now and that is going to be the responsibility of GP consortia. How will we make those national standards? You talk about mandated services—it is actually a planned service. We have discussed accountability and how we can create pressure from the bottom up. Some of you sent a letter to The Times this week, in which you stated that you were concerned that plans to make GP consortia accountable to the public were “far too weak”; that the reforms would
“allow local authorities to replace existing democratically elected overview and scrutiny committees with their own systems”;
that you wanted the Bill to have a stronger
“independent scrutiny function led by democratically elected representatives”;
and that healthwatch bodies would not have the “powers or resources” to ensure that patients’ voices were heard. It seems that you are saying that to get high quality for everyone, there must be much more accountability. Will each of you say one thing that you would like to see in the Bill to make such accountability real?
Steve Brine (Conservative, Winchester)
I do a lot of work within the field of breast cancer. The screening programme has been phenomenally successful, but with 12,000 women a year dying of the disease, boy, do we have work to do. That is a classic role in which consortia and local authorities could work together—we need to do much better on our screening.
John Pugh (Liberal Democrat, Southport)
One of you—I forget who—said earlier that there was a certain nervousness on GPs’ part about commissioning mental health services. Can you say anything about the evidence for that and whether it applies to all mental health commissioning or only to severe mental health conditions? Do you think the remedy is to put somebody with psychiatric training—maybe a GP for whom that is a specialism, or a psychiatrist—on the GP commissioning board, given that mental health issues are very common?
John Pugh (Liberal Democrat, Southport)
On a second, related question, the PCTs have various statutory functions under the Mental Health Act to place individuals in time. That is obviously a highly mission-critical role. Are you clear about who takes over that role in the legislation, given that those people are potentially very difficult individuals?
John Pugh (Liberal Democrat, Southport)
Do you anticipate GPs taking on that task?
John Pugh (Liberal Democrat, Southport)
Would there not be a concern that a small GP commissioning body would not have the legal expertise or background to discharge that duty?
Mike Hancock (Liberal Democrat, Portsmouth South)
Steve, I apologise. I missed it when you indicated that you wanted to comment on a previous question from Liz Kendall.
Kevin Barron (Labour, Rother Valley)
I have a very short question for Paul Jenkins. On the issue of quality, you talked earlier about local authority scrutiny. It seems that the idea that they will be able to understand NICE quality standards is a bit difficult. Do you not think that the national commissioning board has a role to play to ensure that commissioning streams are done within these types of guidelines?
Owen Smith (Labour, Pontypridd)
Sarah, research and development has been one of the focuses of Government policy recently. They have tried to get the NHS to concentrate on research and, hitherto, PCTs have held the funding budgets. What will happen to that research and who will pay for it? If it is GP consortia that will henceforth be involved with that, will they have either the requisite expertise or the interest to engage in R and D?
Owen Smith (Labour, Pontypridd)
So to bring it alive, the risk is that a patient will turn up at a GP’s surgery with a cancer and the GP may not have—as would happen under current circumstances—sufficient insight into where the clinical trials that might be of relevance are going on. They also might not understand how to navigate the patient to those trials.
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
How would you define “meaningful consultation by a commissioning consortium”? How would you define that consultation with the public, especially in relation to lay representatives?
John Pugh (Liberal Democrat, Southport)
Would I be wrong in saying that research is being conducted which shows that very few of the pathfinders we have got so far actually have patient engagement plans, or have been asked about those plans?
Margot James (Conservative, Stourbridge)
What do you consider the opportunities for patient organisations inputting into the system via healthwatch, and also the well-being boards at the local level? Those seem to me to be a very valuable channel for patient groups to engage with the commissioning process.
Grahame Morris (Labour, Easington)
I would like to ask a question about the elephant in the room, the price competition issue in relation to both cancer and mental health illnesses. As with many other types of care and treatment, we are all agreed it is essential that we have a co-operative and co-ordinated environment where patients get the most clinically, appropriate care. I wonder about your views on the introduction of price competition and an open market. Do you think that that would be the best way to achieve a co-operative and co-ordinated approach?
Emily Thornberry (Labour, Islington South and Finsbury)
That takes me to exactly the question I wanted to ask. If GPs are, essentially, generalists who hold the gate for people going to see the specialists, are you concerned about the possibility that, instead of a patient going off to the hospital and specialists there saying, “Right, the treatment you need for cancer is surgery here, chemo here, radio here, and in this order, let’s get it done—chop, chop, chop,” you have a generalist who has to commission all of that? Is that not problem No. 1? Problem No. 2: as gatekeepers with a budget, is there not a concern that GPs might feel there are times when they need to lock the gate?
Emily Thornberry (Labour, Islington South and Finsbury)
So if we get it wrong, people could be dying and we would not know fast enough?
Emily Thornberry (Labour, Islington South and Finsbury)
Who will do that monitoring under the Bill?
Mike Hancock (Liberal Democrat, Portsmouth South)
We have to be very quick on this.
Mike Hancock (Liberal Democrat, Portsmouth South)
Unfortunately, the time has come when we have to say thank you very much for your help this afternoon and for giving up your time. It was a pleasure to have you here and I hope that your information will be useful in the Committee’s deliberations over the next seven weeks.
I reiterate what I said earlier, Jenny: on behalf of us all, I wish you all the very best. We hope to hear some good news from you.
Mike Hancock (Liberal Democrat, Portsmouth South)
Good afternoon, ladies. It is nice to have you with us. Thank you for coming along to help us with our deliberations on this very, very big piece of legislation. We have not had introductions and we will forgo those, but if you have anything specific you want to say generally, perhaps you could wrap that into your first answer, as we have asked others to do.
Emily Thornberry (Labour, Islington South and Finsbury)
The Care Quality Commission has, I understand, a large—seemingly increasingly large—and pivotal role within the health service. We have heard this morning that there will be competition, but it is hoped that it will be largely on the basis of quality as opposed to price. Who will monitor quality? Will it be you?
Emily Thornberry (Labour, Islington South and Finsbury)
That is what I wanted to highlight. Is it correct that your role is to be the safety net—to ensure that standards do not fall below a certain level? You are responsible for safeguarding. We are talking about driving standards up and there being competition on the basis of quality. Will you be able to monitor that? Where will people go to know and to understand?
Emily Thornberry (Labour, Islington South and Finsbury)
So it will be the commissioners making decisions on where they think the best quality is. Otherwise, is there anyone who will be monitoring or giving five stars to this or that health provider, so that we understand where the quality is?
Jeremy Lefroy (Conservative, Stafford)
I would like to ask about clauses 264 and 265 specifically, which impose a reciprocal duty on Monitor and the CQC to co-operate with each other. How do you envisage that happening? I am talking specifically in the context of the Mid Staffordshire trust in my constituency, where there was a failure of Monitor and the then Healthcare Commission to co-operate with each other, or at least perhaps they relied too much on each other’s assurances. How do you think the duty to co-operate might prevent that from happening in future?
Jeremy Lefroy (Conservative, Stafford)
If I may, I will just follow up on that. One witness this morning talked about the importance of so-called soft intelligence, which comes not necessarily from official organisations, but through patient groups or even MPs. How do you see that feeding into the work of the Care Quality Commission, both in your normal work of reviewing quality standards in trusts and elsewhere and in approving foundation trusts?
Jeremy Lefroy (Conservative, Stafford)
To follow up on that, since MPs are often at the forefront of getting information from constituents, would it not be a good idea for MPs to be included in those quality and risk profiles, or at least feed into them?
Jeremy Lefroy (Conservative, Stafford)
Does it happen now?
Kevin Barron (Labour, Rother Valley)
Your organisation and Monitor will also be responsible for operating a joint licensing and registration scheme. Are the roles of the two organisations accurately defined in terms of what they have to do? Will you be equal partners, or will one organisation have greater authority than the other?
Kevin Barron (Labour, Rother Valley)
It is Monitor’s licensing process, so do you assume that it will have the upper hand in this?
Kevin Barron (Labour, Rother Valley)
We understand that the licensing and registration scheme will have a single application form. Is that correct?
Kevin Barron (Labour, Rother Valley)
Who is working on it—both organisations or just you?
Kevin Barron (Labour, Rother Valley)
So effectively you have a joint operation?
Owen Smith (Labour, Pontypridd)
We heard this morning a surprising amount of agreement that price competition tends to drive down quality in health care. What is your view of that evidence?
Owen Smith (Labour, Pontypridd)
With respect, can you afford to remain indifferent to the impact of price competition, given that it is being introduced for the first time and that all the evidence seems to show that it drives down quality? Even the economic regulator seemed very wary of accepting that it has a role to play.
Owen Smith (Labour, Pontypridd)
What would happen in the event of your discerning that price competition was impacting upon quality? To whom would you articulate your concerns?
Nick de Bois (Conservative, Enfield North)
Can I clarify this point? Your concern is the quality of care. Whether it is done for less or for more is not really in your remit, because you are only going to draw attention to where you think care is either failing or succeeding. Do I understand correctly?
Nick de Bois (Conservative, Enfield North)
So, with you, we should focus on that. If you are satisfied that care quality is at a high enough level, we will be succeeding in improving the quality of care and hopefully outcomes. Is that a fair summary?
Grahame Morris (Labour, Easington)
Could you clarify a point that has been raised by my colleague, Tom Blenkinsop in relation to your role in assessing the standards of providers? Is it not true that providers can be commissioners as well? For example, from responses to parliamentary questions, it is clear to me that applications may not be only from GPs in consortia but from private companies. I have not seen anything to contradict that. Is there a conflict of interest there? It could be that a private health care company is a provider and also a commissioner. How will you deal with that?
Liz Kendall (Labour, Leicester West)
Throughout your experience of trying to determine whether a minimum standard of quality has been provided, can you reach any conclusions about the kinds of organisations that have failed to do that and their problems are? I know it is a massive question, but are there any two or three key problems that you found in providers that have not met standards?
Liz Kendall (Labour, Leicester West)
It is clear from previous evidence that under the old system, Monitor, strategic health authorities sometimes and others were able to intervene on poor management in hospitals. Now that Monitor will become an economic regulator, FTs will be stand-alone entities. David Nicholson said that the buck stops with the board; Sue Slipman from the Foundation Trust Network said it is up to the board of governors. What checks and balances are there on the people you know are crucial to ensuring quality?
Liz Kendall (Labour, Leicester West)
Let me clarify. Normal routes for intervening on boards—the performance unit in the Department of Health and SHAs—are going; under the new system, it will be down in the end to GPs and local authorities. Following from that, do you often receive formal or informal complaints—soft intelligence—from GPs about poor-quality hospitals?
Nicky Morgan (Conservative, Loughborough)
From whom do you receive information? We talked about patients. Your predecessor was the CSCI, and CQC has been around for a couple of years. Are there any lessons you have learned, either from Mid Staffordshire or elsewhere, for the way you handle risk and information gathering that you would like to share with the Committee? Perhaps you could explain your inspection regime. How often do you check providers? Do you wait until you are prompted by a series of complaints, or do you have a regular monitoring schedule—a bit like Ofsted with schools?
Nicky Morgan (Conservative, Loughborough)
The whistleblowing calls are presumably from health professionals within the service.
Nicky Morgan (Conservative, Loughborough)
Are they anonymous?
Nicky Morgan (Conservative, Loughborough)
So there is no schedule. Do you wait for something to become a problem?
Mike Hancock (Liberal Democrat, Portsmouth South)
We have two more people who want to ask questions, and we have roughly three minutes, so short questions and short answers please.