Health and Social Care(Re-Committed) Bill
Public Bill Committee, 28 June 2011.
Jimmy Hood (Labour, Lanark and Hamilton East)
Good morning. Before we begin, I have a few preliminary announcements. Members may, if they wish, remove their jackets during Committee meetings. It is pretty warm today, so that is a kind gesture on my part. Would all Members please ensure that their mobile phones, pagers and so on are turned off or switched to silent during Committee meetings? As a general rule, my fellow Chair and I do not intend to call starred amendments that have not been tabled with adequate notice; the required notice period in Public Bill Committees is three working days.
I shall 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 the motion to report written evidence and the motion to permit the Committee to deliberate in private in advance of the oral evidence sessions. Assuming that those three motions are 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, we will hear oral evidence this morning—the session with the first set of witnesses must finish at 11.30 am.
Simon Burns (Conservative, Chelmsford)
On a point of order, Mr Hood. Will you confirm that, if we debate the programme motion, up to half an hour will come out of the time available to question the first witnesses?
Jimmy Hood (Labour, Lanark and Hamilton East)
I am afraid so, yes.
Fiona O'Donnell (Labour, East Lothian)
It is difficult to hear the Minister because he is not speaking into his microphone.
Jimmy Hood (Labour, Lanark and Hamilton East)
I was asked, “If we debate the programme motion for half an hour, does the half hour come out of the time allotted for the first set of witnesses?” The answer to that question, unfortunately, is yes.
Jimmy Hood (Labour, Lanark and Hamilton East)
I have notice of three amendments to the programme motion.
Emily Thornberry (Labour, Islington South and Finsbury)
I beg to move manuscript amendment 1, in paragraph (1), leave out subparagraphs (d), (e) and (f) and insert—
‘(d) at 9.30 am and 2.00 pm on Wednesday 6 July;
(e) at 9.00 am and 1.00 pm on Thursday 7 July;
(f) at 9.00 am and 1.00 pm on Friday 8 July;
(g) at 10.30 am and 4.00 pm on Monday 11 July;
(h) at 10.30 am and 4.00 pm on Tuesday 12 July;
(i) at 9.30 am and 2.00 pm on Wednesday 13 July;
(j) at 9.00 am and 1.00 pm on Thursday 14 July’.
Jimmy Hood (Labour, Lanark and Hamilton East)
With this it will be convenient to take the following:
Manuscript amendment 2, in the Table in paragraph (2), leave out the second, third, fourth, fifth, sixth, seventh and eighth entries (relating to Tuesday 28 June), and insert
‘Tuesday 28 June
Until no later than 12.15 pm
NHS Confederation
Tuesday 28 June
Until no later than 1.00 pm
Independent Regulator of NHS Foundation Trusts (Monitor)
Tuesday 28 June
Until no later than 5.30 pm
Dr Michael Lloyd and Peter Roderick
Thursday 30 June
Until no later than 10.25 am
The King’s Fund; the Nuffield Trust
Thursday 30 June
Until no later than 1.45 pm
Foundation Trust Network; LGA
Thursday 30 June
Until no later than 2.30 pm
British Medical Association; RCN; Royal College of Physicians; Academy of Medical Royal Colleges
Thursday 30 June
Until no later than 3.30 pm
Royal College of General Practitioners; NHS Alliance
Tuesday 5 July
Until no later than 1.00 pm
National Voices; Rethink; MacMillan Cancer Support; Asthma UK; Diabetes UK; Stroke Association
Tuesday 5 July
Until no later than 5.00 pm
Unite; Unison
Tuesday 5 July
Until no later than 7.00 pm
Department of Health’.
Manuscript amendment 3, leave out paragraph (3) and insert:
‘(3) proceedings on consideration of the Bill shall be taken in the following order: Clauses 1 to 5; Schedule 1; Clause 6; Clauses 9 to 11; Clauses 19 to 21; Schedule 2; Clauses 22 to 24; Clauses 28 and 29; Schedule 3; Clause 55; Schedule 8; Clause 56; Clauses 58 and 59; Clauses 63 to 69; Schedule 9; Clauses 70 to 75; Clauses 100 and 101; Clauses 112 to 117; Clause 147; Clause 149; Clause 156; Clauses 165 and 166; Clause 176; Clauses 178 to 179; Schedule 15; Clause 180; Clauses 189 to 193; Clause 242; Clause 265; Clauses 285 and 286; Clause 295; Clauses 297 and 298; new Clauses; new Schedules; remaining proceedings on the Bill.
(4) the proceedings shall (so far as not previously concluded) be brought to a conclusion at 11.55 pm on Thursday 14 July.’
Emily Thornberry (Labour, Islington South and Finsbury)
The Government’s amendments have been tabled at extremely short notice. Such short notice is unprecedented, and it is unfair, unnecessary, impractical and undemocratic for the Government to behave as they are.
The Government’s tabling of 180 amendments at 5 o’clock on Thursday evening, allowing two full working days before the Committee’s first sitting, means that there is insufficient time for those amendments to be properly read through and for proper work to be done so that we can scrutinise the Bill in the way that the Bill and the national health service deserve. We should, therefore, amend the programme motion to allow more time for witnesses to read through the amendments, to consult their members and to give proper evidence to this Committee. Our amendments would allocate today, Thursday and next Tuesday for the Committee to hear from witnesses.
In passing, I should say that it is completely inappropriate for there to be only one hour to hear from patient groups. If the national health service is about patients, it is unfair to allow patients one hour to give evidence with two days’ notice of 180 amendments. In reality, patient groups do not have the same resources as, for example, the Government, so it is not possible for them to consult. The Committee may know that the British Medical Association is beginning a conference, and we think that it is important for it to be able to consult its members before giving evidence to the Committee. If we want to scrutinise the Bill properly, we suggest that that should happen.
We agreed with the Prime Minister when he said that it would take about 10 days to scrutinise the amendments, but 10 days have not been granted under the programme motion that the Government tabled. Our solution is to spend three days listening to witnesses, to give them more time to look at the amendments and talk to their members, and then to have many more days of scrutiny with longer hours and without knives at the end, so that we can look at this properly. We also fundamentally disagree with the fact that only part of the Bill is being re-examined in Committee; it is not only a matter of looking at the 180 amendments, but of looking at them in the context of the entire Bill.
We know that we are short of time and we do not want to cut into the time available to witnesses, but we work with the programme that the Government suggest unless we can amend it today. In summary, the kernel of our objections is that the proposed programme is undemocratic, is not in the interests of the NHS and does not allow for proper scrutiny. I urge Members to consider carefully the amendments that I have tabled to the programme motion.
Simon Burns (Conservative, Chelmsford)
I, too, will be brief, because I do not want to eat into the time for witnesses, which is probably more beneficial to the Committee.
I urge my hon. Friends and other hon. Members to oppose amending the programme motion. As the Committee is aware, the Government have been extremely anxious from the start to give full scrutiny to the legislation. At the end of the original Bill Committee, the hon. Member for Halton (Derek Twigg), who led for the Opposition, said in his concluding remarks that “every inch of the Bill” had been examined.
As we all know, the Government accepted the core recommendations of the independent NHS Future Forum following its review. To fulfil the changes recommended to strengthen and improve the legislation, it is right to recommit the parts of the Bill that we seek to amend. I will not rehearse the debate on recommittal, but I believe that the timetable we are offering the Committee is more than generous. In fact, it is double the time of the Committee stage of the last Government’s Health Act 2009, in that we are offering 12 sessions; for that Act, the Committee was offered six sessions.
Similarly, I believe that the attempt to amend the programme motion is a red herring and part of a delaying process, because the Opposition have made it clear from the outset that they want to delay—their original motion was to stay in Committee until 18 October. We had a full discussion in the Programming Sub-Committee yesterday, where we thrashed out and voted on the issues. The Opposition are seeking to live up to their original line, conveyed at the outset of the proceedings to discuss recommittal through the usual channels, that they would oppose everything.
As the hon. Member for Islington South and Finsbury has said, the Government amendments were tabled on Thursday, but she did not tell the Committee that the Labour party tabled a host of amendments yesterday, three days after the Government. If she does not think that there is enough time to consider the Government’s amendments—I do not share that view—she must think that there is even less time to consider the Opposition amendments. On those grounds, I regard the argument as bogus, and if the hon. Lady decides to divide the Committee on amending the programme motion, I urge my hon. Friends and any other reasonable hon. Member to join us in voting it down.
Emily Thornberry (Labour, Islington South and Finsbury)
This Bill is of a completely different nature to the 2009 Act; I challenge Members to list the five most controversial clauses in that legislation. This Bill has had the national health service up in arms. The Government say that they have listened and that they want to put into law the challenges and concerns that have been well expressed by the NHS, but if the Government believe that they are doing that, what are they afraid of? Why will they not give us all sufficient time to scrutinise the Bill properly? I appreciate that the Government might find it inconvenient if the Opposition wish to look at such things, but that is democracy. We are doing our job properly, and we, the national health service and all the groups involved need to be able to scrutinise the Bill.
It is a red herring—again, we are talking about red herrings—to draw any parallels between this Bill and the 2009 Act. In some written evidence that has been submitted—of course, not all organisations have had the opportunity or sufficient time to write evidence—it is clear that various groups, and I pray in aid the Royal College of Nursing and the BMA, have not had enough time to discuss the changes in anything other than generalities. That is wrong.
There would have been nothing wrong with putting this matter back to 18 October. Unfortunately, we have lost that opportunity, and we are now working within the constraints of the decision that was made. We are prepared, however, to work all hours to get this out of Committee within the time frame that has now been set. To do that, we need more time to hear from the NHS and its representatives, and we then need sufficient time to scrutinise the Bill properly and still get it to Report by Thursday 14 July. It will take a lot of time and a lot of work, but the national health service is worth it.
Phil Wilson (Labour, Sedgefield)
Very quickly, there were no internal knives in the Committee stage of the 2009 Act, so the debate could go on, whereas this has been time-limited. If the Government thought that the time allocated was adequate, why did they include knives? There were none in the previous Committee stage on this Bill, which had 28 sittings. The knives have been included, because the Government want proceedings to end when they say, and because they know that there is insufficient time to discuss all the proposals.
There is no way that this Bill can be compared with the 2009 Act, because it is highly contentious. My hon. Friend the Member for Halton (Derek Twigg), who is not on the Committee today because of ill health, would say that we thoroughly scrutinised this Bill, as it was at the time. However, if he were here, he would also say that this is a completely different Bill, and that we need to go through it all again.
Simon Burns (Conservative, Chelmsford)
It is not.
Phil Wilson (Labour, Sedgefield)
The Minister says that it is not, but why are we debating it if it is exactly the same? Is he saying that there are no real changes?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. We are not having a conversation here.
Phil Wilson (Labour, Sedgefield)
The key thing is that adequate time needs to be provided for people to give evidence on proposals that they have had sight of for only two or three days. Secondly, the knives should be removed, so that we can discuss this adequately.
Simon Burns (Conservative, Chelmsford)
May I very briefly respond to that point? This is not a completely different Bill. Substantial changes have been made to strengthen and improve the Bill, as a result of the recommendations from the NHS Future Forum. As a Government, we believe that the Committee should have significant and ample time to consider the changes. That is why we have re-committed the relevant clauses and some others to give context, so that the Committee can do its work and fully scrutinise the new parts that are a result of the Government’s amendments. It is palpably absurd to suggest that we are not giving hon. Members enough time to consider those points.
Examination of Witnesses
Jimmy Hood (Labour, Lanark and Hamilton East)
Professor Field and Dr McLean, welcome. We are finally getting down to our evidence session; I am sorry for the delay. I will ask Emily Thornberry to ask the first question.
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you very much, Professor Field, for the work that you have done. During the two working days that you were given, do you think that you had sufficient time to compare your recommendations with the Government’s oral and written responses to those recommendations and, perhaps most importantly, to see whether they have been implemented in the 180 amendments that the Government have tabled?
Emily Thornberry (Labour, Islington South and Finsbury)
Do you believe that any parts of your recommendations have not been put into amendments to the Bill?
Emily Thornberry (Labour, Islington South and Finsbury)
On my question about which of your recommendations had been left out of the amendments, are you able to particularise perhaps the top three that have not been included?
Emily Thornberry (Labour, Islington South and Finsbury)
That is just two.
Liz Kendall (Labour, Leicester West)
Hello and thank you very much for coming. I am sorry that you had to go in and out of the room.
I want to ask Professor Field a question and then Dr McLean. In your report, Professor Field, you recommend the establishment of clinical senates and a stronger role for clinical networks, and the Government have said that they will be run by the NHS commissioning board. Is that a good idea?
Liz Kendall (Labour, Leicester West)
I do not really understand the difference between those two things. What would that mean?
Liz Kendall (Labour, Leicester West)
So there would have to be staff within the NHS board to run them.
Liz Kendall (Labour, Leicester West)
What is the difference between a senate and a network?
Liz Kendall (Labour, Leicester West)
Who would have the final say about a decision on services?
Liz Kendall (Labour, Leicester West)
But as you understand it—Professor Field said that he was pleased that the Government had done everything that you said—who has the final say about how services change?
Liz Kendall (Labour, Leicester West)
We have argued that there should be lots of other clinical advice put in, and quite a lot of people are confused about how the bodies will run. I wanted to ask you, Dr McLean, about one of the big recommendations in your specific report—something I am very interested in—which is a concern about leads for safeguarding children. As far as I can see, nothing in any of the amendments specifies where that responsibility will lie. Where do you think it should lie? Where should the safeguarding lead be?
Liz Kendall (Labour, Leicester West)
Which area?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. A lot of Members are putting their hands up to ask questions, and that has been four or five already.
Dan Byles (Conservative, North Warwickshire)
I will ask two very brief questions, if I may, because I know that time is pressing. They are directed more to Professor Field. First, I want to summarise what I think you said in your opening remarks. Is it fair to say that following the very impressive listening exercise that you and the Future Forum did, you feel that the recommendations that you put forward, which have been predominantly accepted by the Government, address what you consider the legitimate concerns expressed to you during the listening exercise?
Dan Byles (Conservative, North Warwickshire)
Marvellous. Thank you for that very concise answer. Secondly, I would like briefly to quote one line—I do not know whether they are your words or the forum’s words—from the summary of your document:
“It was right to pause and reflect. It has, however, been a destabilising period for the NHS and an unsettling time for staff and for patients. It is time for the pause to end.”
Do you consider that it is quite important that we do not spend too long now chasing our tail over what to do next, and that we get on, get behind these reforms and get moving?
Dan Byles (Conservative, North Warwickshire)
Wonderful. Thank you, Professor Field.
Owen Smith (Labour, Pontypridd)
Professor Field, in the report you referred to the fact that you no longer wanted Monitor to be an economic regulator, and that you wanted choice to be emphasised and competition to be played down. Are you not disappointed, therefore, that part 3 of the Bill, which relates to competition, is still called “Economic regulation of health and adult social care services”? Are you not also slightly concerned that the shift of emphasis in the wording of the amendments from promoting competition to preventing anti-competition, which I contend is pretty much the same duty, is a very minimal change?
Owen Smith (Labour, Pontypridd)
So perhaps you can help me. What is the difference in your interpretation between promoting competition and preventing anti-competition?
Kevin Barron (Labour, Rother Valley)
May I question you further on that? My understanding was that you recommended that Monitor should be stripped of the competition issue altogether and also be stripped of its economic regulator role. Correct me if I am wrong, but it will still remain an economic regulator. Really the question I should be posing to you is this: what is the difference, if any, between a sector regulator and an economic regulator? What does this mean?
Kevin Barron (Labour, Rother Valley)
So the Office of Fair Trading and the Competition Commission should have no role to play in terms of the merger of NHS trusts?
Kevin Barron (Labour, Rother Valley)
I have asked it before in this Committee in a previous life and I still have not had an answer as to whether they should or should not.
Kevin Barron (Labour, Rother Valley)
So should the OFT have a role in NHS trust mergers?
Jimmy Hood (Labour, Lanark and Hamilton East)
Before I call the next question, I remind Members to keep their mobile phones away from the microphones as they are causing interference—a bit of IT advice.
Grahame Morris (Labour, Easington)
I would like to follow along on the same theme. The concern on the Opposition side of the Committee has been about Monitor as a potential Trojan horse for introducing competition into the heart of the NHS. One of the NHS Future Forum’s recommendations was about raising concerns about promoting competition as an end in itself, which was set out in the original Bill. You recommended that Monitor be stripped of the competition duties and no longer be an economic regulator. I am surprised that you said that looking at the Government amendments you were not concerned that there is no provision to remove the role of Monitor as the economic regulator.
I want to consider the costs of Monitor because the Minister of State, the right hon. Member for Chelmsford, indicated in evidence to the original Bill Committee that the costs of Monitor would be between £40 million and £130 million a year. It is a huge bureaucratic machine. Given that its powers are being diluted, is there an argument for asking why we need it? Could its powers not be transferred to the Care Quality Commission, HealthWatch England or another organisation in the new architecture that the Bill establishes?
Grahame Morris (Labour, Easington)
The costs, Mr Hood, are not incidental. Over the lifetime of a Parliament, they equate to the cuts in social care for elderly people, highlighted only yesterday in a report published by Age Concern—it is around £600 million in total.
Could you comment on another recommendation of the NHS Future Forum, which is the system for designation that allows services to close without consultation? My understanding is that the NHS Future Forum indicated that it would like that changed, but as yet that change does not seem to be among the 180 amendments the Government have tabled.
Grahame Morris (Labour, Easington)
Is that a matter of concern, given that 20 units have been identified in the press as at risk of closure?
Fiona O'Donnell (Labour, East Lothian)
Professor Field, I welcomed your remarks at the beginning when you said that it was worth giving all of our waking time to consideration of the Government’s amendments, and I want to reassure you that at least some of us feel the same way.
Can I ask about the cap on private patients in foundation trust hospitals? What representations and submissions did you receive about that?
Fiona O'Donnell (Labour, East Lothian)
Can I ask a quick question about Monitor? I am new to this Bill Committee—I was not part of the previous one—and I am thinking about patients being at the centre of this and about explaining to them the difference in the wording between a positive statement about competition and a double negative one. What could have happened under the previous Bill that cannot now happen under the recommitted Bill? Is there an example that you could give patients today?
Fiona O'Donnell (Labour, East Lothian)
Is there an example that you could give patients? I am just concerned that it sounds like we do not know what the Government’s amendments will actually do.
Fiona O'Donnell (Labour, East Lothian)
Just to press you a third time, can you give us an example for patients of how their experience will be different?
Fiona O'Donnell (Labour, East Lothian)
So the amendment makes no difference.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
The key issue that we have picked up on is about the integration of services, competition and patient choice. We have talked also about reconfiguring services, which you mentioned briefly. Do you now feel that the Bill is well suited to doing that? Obviously, there are different challenges in different parts of the country; perhaps better integrating adult social care with NHS care is a challenge where there are more elderly populations with health and services issues. In the Bill as it now stands, how do you see Monitor’s role in promoting that sort of integrated working?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
Do you see the Bill as promoting a greater community focus with services being provided more around the patient in the community? Do you feel that the Bill supports a move in that direction in health care?
Karl Turner (Labour, Kingston upon Hull East)
Professor, Monitor remains an economic regulator with wide pro-competition powers, does it not?
Karl Turner (Labour, Kingston upon Hull East)
But it still has wide powers to promote competition, does it not?
Karl Turner (Labour, Kingston upon Hull East)
Professor, with respect, it is a fairly simple question. Does Monitor remain an economic regulator with wide pro-competition powers: yes or no?
Karl Turner (Labour, Kingston upon Hull East)
Yes, professor; the answer is yes, is it not?
Karl Turner (Labour, Kingston upon Hull East)
The answer, professor, is yes, is it not?
Karl Turner (Labour, Kingston upon Hull East)
Professor, did you not recommend that Monitor be stripped of its competition duties? Is that what you recommended?
Karl Turner (Labour, Kingston upon Hull East)
I have the wording, I think. You said that the Bill should
“clarify that Monitor’s role should support choice, competition and integrated care”.
Karl Turner (Labour, Kingston upon Hull East)
Finally, would you accept that Monitor remains an economic regulator with wide pro-competition powers? That is the truth, is it not?
John Pugh (Liberal Democrat, Southport)
Can I take you back to a remark that you made earlier? One thing that you thought had not quite been embodied in the legislation and that was demanded by some contributors to the listening exercise was a demand for greater transparency with regard to private sector providers. The Government have the laudable intention of trying to secure a level playing field, but clearly, without financial transparency, you could get a private provider behaving in a predatory way—trade at a tariff but at a loss for a period of time to remove a hospital unit that is thought to be fragile, or whatever. Is that a problem that people wanted TO be addressed? Were there any obvious solutions coming from the Future Forum, or that have been, as you can see, embodied in the legislation to deal with that issue? It is obviously a tricky problem, because private firms are not very good at letting people know precisely how their finances stack up.
Jimmy Hood (Labour, Lanark and Hamilton East)
I am afraid that this will probably have to be the last question.
Steve Brine (Conservative, Winchester)
I am trying to get to the spirit of the input that the Future Forum received, so this is a general question to finish. Many representations that have been made to me in the past few months regretted the unsightly political football match that had taken place. In the summary to your report, you said that things became polarised; on one hand, the Bill was about all-out privatisation of the NHS—we will call that option A—and on the other, reform was the only way to safeguard the principles of the NHS that we all hold dear. We will call that option B. Were most of the tens of thousands of people who contacted you coming from position A, position B, or somewhere more moderate in between?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. I am afraid it is 11.30, so the session is over. Thank you.
John Pugh (Liberal Democrat, Southport)
May I put a simple question, to which I might know the answer, to Mike Farrar? You represent the people who administer the NHS and most health providers across the UK. What is the feeling apropos the situation we are in? Would you welcome a prolonged legislative bout going into December, or would you like Parliament to make up its mind one way or the other on what it wants to do with this legislation?
Emily Thornberry (Labour, Islington South and Finsbury)
Listening to the evidence, is another way of putting it that the NHS has been directionless for the past year and has been unable to address the fundamental issues? Amended or not, does the Bill address those fundamental issues?
Emily Thornberry (Labour, Islington South and Finsbury)
I think you have been able to give us written submissions. Do they include an analysis of the amendments?
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you. May I put a similar question to Professor Ham and Dr Dixon?
Emily Thornberry (Labour, Islington South and Finsbury)
Could you give some examples?
Emily Thornberry (Labour, Islington South and Finsbury)
Doctors paying themselves bonuses.
Kevin Barron (Labour, Rother Valley)
I have a question to Mike Farrar. You said that you members feel that they are in a better place. Clause 65 of the original Bill said that any merger between NHS trusts or a merger between NHS trusts and another business could be referred to the OFT or the Competition Commission. That provision remains unaltered by the amendments tabled. Do you think your members would be happy with that?
Kevin Barron (Labour, Rother Valley)
Does the OFT have a role to play in that?
Kevin Barron (Labour, Rother Valley)
Could I put this to the other two witnesses? Your written evidence states that competition has changed in the last few weeks, but this Act remains—clause 65 refers to part 4 of the Enterprise Act 2002. Are you comfortable that this and other clauses related to competition remain in the Bill, or do you think there has been a fundamental change in terms of using competition law in NHS reconfigurations and services?
Margot James (Conservative, Stourbridge)
I should like to ask Professor Ham about reconfigurations of hospital services. In the previous session, we heard from Professor Field that the whole Bill is focused on a move from a hospital-based system to a more community-centred, preventive role of delivering health care. He felt that the Bill in its previous incarnation went some way towards achieving that goal and that the Government’s amendments had moved that means to that end forward. In its written evidence the King’s Fund states that it remains
“concerned about the lack of clear responsibility for driving forward major reconfigurations of hospital services.”
Could you expand on that? It will clearly be a fundamental issue in the coming years.
Fiona O'Donnell (Labour, East Lothian)
I have a general question for all three of you. Is the recommitted Bill more complex? Does it involve more reorganisation and bureaucracy than its predecessor?
Fiona O'Donnell (Labour, East Lothian)
Is that a more or a less, then?
Fiona O'Donnell (Labour, East Lothian)
Professor Ham, you talked about a slowing-down of the process. Focusing on patients and given the efficiency savings that the NHS is being asked to make, what might be the effect on the delivery of services for patients?
Dan Byles (Conservative, North Warwickshire)
Mr Farrar, in your opening statement you referred to the fact that people are trying to make decisions in a period of uncertainty. I know that is difficult, and it is a concern that we all share. It is probably inevitable in any large period of managing structural and organisational change. Would you agree that, if anything, that is an argument for not spending too long navel gazing about what we are going to do and for actually saying, “Once you make the decision, the impetus is then to get on and implement the changes quickly to reduce that period of uncertainty”?
Dan Byles (Conservative, North Warwickshire)
Do the other witnesses have anything to say on that?
Grahame Morris (Labour, Easington)
In their response, which the Committee only received yesterday tea time as well, the Government identify how they would assuage concerns about cherry-picking of particular services. One of the ways in which they suggest that that might be done is through a more complex tariff system. Both Mr Farrar and Professor Ham have raised concerns about the new bureaucracy and the complexities that that will bring into the system. Have you given any thought to how commissioners will cope with that, given that their admin costs are capped elsewhere?
Grahame Morris (Labour, Easington)
The dilemma with that, which you have highlighted previously, Dr Dixon, regarding Professor Ham’s question about why we should cap admin costs, is that presumably that money might otherwise go into patient care. You have identified in the north American study, however, that the failure rate was because not enough investment went into that area.
Owen Smith (Labour, Pontypridd)
May I pursue the point about tariff with Dr Dixon? In the amendments, the Government are clearly seeking to create a more sophisticated national tariff. In so doing, they are trying to do what they say they want to do, which is to prevent price competition. In a new NHS, where we have this more labyrinthine set of rules about setting tariff, is there anything in the amendments that you have seen that would stop price competition? Is it not actually more likely?
The substantive change on the face of the amendments is that commissioners have to publish information when there is a variance from tariff, so is having that new information in the system and in the public domain not more likely to mean that there will be price competition in the NHS, once a whole variety of different prices is out there in the public domain?
Owen Smith (Labour, Pontypridd)
What is the difference?
Owen Smith (Labour, Pontypridd)
But at the moment, they are not obligated to publish the prices that they have struck with the provider. The Bill envisages a world in which they will have to publish what that varied price is and why it is a different price. Is that not more likely to lead to price competition across the NHS, as people chase the lower price?
Liz Kendall (Labour, Leicester West)
We know that long-term conditions are obviously the biggest challenge that the NHS faces, and that about 80% of patient contact is in primary care. I want to ask each of the witnesses what the Bill does to improve primary care. Dr Dixon, perhaps you could go first.
Liz Kendall (Labour, Leicester West)
As a quick follow-up, going back to the point that you all made earlier about the need to take difficult decisions about hospital services, do you think the Bill makes that harder or easier?
Liz Kendall (Labour, Leicester West)
Yes.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
To follow up on that, the King’s Fund put out a good report recently on incentives in the NHS. It found that the current system of incentives does not really incentivise dealing with health care inequalities, as set up around the QOF payment, or with the big challenge of supporting people living longer with many medical co-morbidities. The focus is now on commissioning boards, so, to start with Professor Ham, do you think that it is a good way to tackle some of the key issues around health care inequalities and to deal better with looking after people in the community and preventing unnecessary acute hospital admissions?
Jimmy Hood (Labour, Lanark and Hamilton East)
We are coming to the end of our evidence session. This will probably be the last question.
Fiona O'Donnell (Labour, East Lothian)
I want to ask about the voluntary sector, following the questions Mr Smith asked about price competition. With the Government’s Work programme, the voluntary sector has had problems getting its services commissioned. Obviously, it plays a vital role in the provision of high quality social care services, so are you concerned that it could face similar challenges in bidding to provide services from this Bill?
Jimmy Hood (Labour, Lanark and Hamilton East)
That brings us to the end of our allotted time for the Committee to ask questions to these witnesses. I thank them very much for giving their evidence this morning. We now move on to hear evidence from Monitor, the Foundation Trust Network and the Local Government Association.
Jimmy Hood (Labour, Lanark and Hamilton East)
Welcome to our meeting. We will move straight into questions, if that is okay. When you answer your first question, you can give us a brief description of who you are—it saves time if we let you do that when you answer your first question.
Emily Thornberry (Labour, Islington South and Finsbury)
I do not think, looking through the paperwork, that any of you have yet had an opportunity to submit any written evidence. I shall ask the obvious question: presumably that is because you have not had sufficient time? Do you all intend to submit written evidence at a later stage and have you, before giving evidence today, had sufficient time to closely examine the 180 amendments, compare them with the Bill and cross-reference them with the Future Forum report and the Government’s response?
Emily Thornberry (Labour, Islington South and Finsbury)
I wonder, then, whether you feel confident that you will be able to answer questions fully. If there were one further amendment—perhaps with reference to the Future Forum or to your own particular interest—that you think the Bill should have that it may have missed out, what might that be?
Owen Smith (Labour, Pontypridd)
I have a specific question for Dr Bennett. In your understanding, was it ever a primary duty of Monitor to promote competition as an end in itself?
Owen Smith (Labour, Pontypridd)
Which is obviously the way in which the Government have chosen to characterise repeatedly—notably in the notes that came out yesterday—what they have changed about you, because they are talking about you having hitherto had this duty to promote competition as an end in itself. You never thought that was the case, and I didn’t either. Given that we agree that it was never your job, could you explain to us what exactly has changed in respect of your duty with regard to competition? What is the difference between promoting competition and preventing anti-competitive behaviours, which the notes describe as preventing anti-competition?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. There is a bit of chuntering going on to my right hand side. Please give the witness some order.
Owen Smith (Labour, Pontypridd)
Can you point to anywhere else in the Bill where your fundamental core powers are altered by the amendments that were tabled last weekend?
Owen Smith (Labour, Pontypridd)
Do you have a specific power in relation to integrating care or encouraging the integration of care in the same way as you obviously have powers to promote competition?
Owen Smith (Labour, Pontypridd)
You mentioned pricing. One of the substantive changes that I can see in the amendments is that commissioners will now be obligated to publish prices when they vary from tariff. This will be the first time we have seen that applied across the board in the NHS. Is that not likely to make price competition more prevalent, as there will be more prices and more information in the market?
Owen Smith (Labour, Pontypridd)
Among prices that are off-tariff, are you suggesting that there might be more price competition?
Fiona O'Donnell (Labour, East Lothian)
Although it did not form part of the Future Forum report, Professor Field said in his evidence that he favoured retaining a cap on the number of private patients treated in foundation trust hospitals. This is possibly one for Sue Slipman, but I am happy to hear from others. Do you support Professor Field’s view?
Fiona O'Donnell (Labour, East Lothian)
They want to be able to treat more private patients to fill funding gaps, but how can you increase capacity for private patients without lessening the service you give NHS patients?
Emily Thornberry (Labour, Islington South and Finsbury)
I am sorry, but I do not understand that answer. Are you in favour of raising the cap on the number of private patients that we can have in national health service hospitals? If you are, does that not mean that there will be fewer NHS patients in NHS hospitals?
Emily Thornberry (Labour, Islington South and Finsbury)
So you support the Bill, which allows the cap to be lifted.
Grahame Morris (Labour, Easington)
I want to move on, in particular to the issue of European competition rules. I am afraid that I have not seen the most recent evidence from Monitor, but I refer to an article in the Health Service Journal, which is an interview that Dr Bennett gave in response to the Government’s accepting the Future Forum’s recommendations on diluting the role of Monitor as an economic regulator driving forward competition. Your response, Dr Bennett, was:
“The policy statement makes clear Monitor will still be given enforcement powers concurrent with the Office of Fair Trading and the Commissioning Board will have to consult with Monitor on its competition guidance.”
I am not sure how the powers have been watered down, but can you comment on that in relation to European competition law? A spokesman for the private sector, a gentleman called David Worskett from the NHS Partners Network, suggested that the NHS market would now be opened up through legal challenges and case law, and he predicted that it would still happen but over a longer time frame. How do you respond to that?
Grahame Morris (Labour, Easington)
I note what you said, but the implication is that there is no change. Is not the change that the architecture envisaged by the Bill itself exposes the NHS to greater competition, particularly using EU competition laws?
Grahame Morris (Labour, Easington)
Is it not the case that the private sector sees European competition law as a mechanism that would allow it entry to the market?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
I have two questions, the first to Dr Bennett and Sonia Brown. You said that the focus was going to be on achieving value for the NHS and promoting integrated care. There are, obviously, considerable health care economic arguments as well as patient arguments for supporting integrated care and preventing unnecessary hospital admissions, as we heard earlier on. In Monitor’s role as part of integrated care, would you be looking specifically at community-focused care and providing more joined-up thinking in that part of health care?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
You are saying that value for money for the NHS is the same as value for money for the patient, in terms of providing good care and joined-up care.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
My second question is to our colleagues from local government. On the idea of integrated care, in my experience there is often a lot of silo working between social services and the NHS. At the moment, we do not always see enough integrated care, in my view. For example, someone may have an acute event—a stroke—that will require NHS care for some of the time and social services care later on. One of the key challenges is for funding and support to follow the patient rather than the institution. How do you see this Bill supporting that objective?
Emily Thornberry (Labour, Islington South and Finsbury)
During the first appearance of this Committee, the Local Government Group gave us some evidence about care trusts in which the chief executive from the primary care trust and the chief executive of the local authority had merged. Local authorities and the primary care trusts were trying to work closely together to provide health and social care at local level and there was great concern that the Bill was driving a coach and horses through that. Will you give us an update on what has happened to the care trusts?
Kevin Barron (Labour, Rother Valley)
First, a question for David Bennett. You have said—please tell me if this is a misinterpretation—that competition law in the national health service is covered at the moment. We have more than 80 clauses in this Bill bringing in competition law. One of those clauses, which remains unamended at the moment, gives you the power under part 4 of the Enterprise Act 2002 to refer any mergers between NHS trusts or mergers between NHS trusts and other businesses to the Office of Fair Trading or the Competition Commission. Under what circumstances do you think that you would use those powers? Could you give us an example of how you think that they will be used by Monitor in future?
Jimmy Hood (Labour, Lanark and Hamilton East)
Liz Kendall.
Kevin Barron (Labour, Rother Valley)
Can I just finish, Mr Hood?
Jimmy Hood (Labour, Lanark and Hamilton East)
If it’s just one more.
Kevin Barron (Labour, Rother Valley)
If it is just one more, I’ll leave the need of clauses alone. I wanted to ask Dr Barnard just one question, but did you have a view on that first question?
Kevin Barron (Labour, Rother Valley)
And that remains?
Kevin Barron (Labour, Rother Valley)
Just one quick question, Dr Barnard. The changes proposed in the amendments, we are told, give more power to health and well-being boards, inasmuch as you have to be consulted about commissioning plans. It says that on an ongoing basis, not just that this is the commissioning plan—and then go away for the next 12 months. Commissioning bodies will have limited money. One of the matters raised is, do you think that health and well-being boards, given that they are looking at the wider strategy of health and well-being in communities, should have the power to veto commissioning groups’ plans?
Liz Kendall (Labour, Leicester West)
That you all for coming. Dr Bennett and Sue Slipman said that the biggest gap in the Bill was now a lack of a failure regime. I would like to ask you both, approximately how many NHS trusts will currently find it impossible to become a foundation trust because of their financial problems?
Liz Kendall (Labour, Leicester West)
We will certainly ask the Ministers the question again later. What does a lack of a failure regime—that is a very technical term for some people—mean for patients? Again, I would like to ask Dr Bennett and Sue Slipman.
Liz Kendall (Labour, Leicester West)
Does that mean that someone has to bail them out?
Liz Kendall (Labour, Leicester West)
It is used in the Government’s response to the Future Forum; those are not my words.
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
Dr Bennett, do you believe that the statement that the Minister, Paul Burstow, gave—that competition has been put back in its box—is correct when we have no substantive amendments to clauses 60, 64 and 65, which hold the real power in terms of competition law and the implications for the health service, and Monitor’s core function and role in the original Bill?
Fiona O'Donnell (Labour, East Lothian)
You are saying that those safeguards are in place. I do not buy the idea that all this income will be generated to treat NHS patients simply through intellectual property, so you will have to develop new capacity to treat more private patients. Where does the capital come from to do that?
Fiona O'Donnell (Labour, East Lothian)
Where does the capital come from?
Fiona O'Donnell (Labour, East Lothian)
Surpluses earned? So existing public funds would be diverted?
Fiona O'Donnell (Labour, East Lothian)
Sorry, it is really important. Can I just clarify that the capital may come from public funds?
Jimmy Hood (Labour, Lanark and Hamilton East)
We have two more minutes. Are there any other questions for our witnesses?
Owen Smith (Labour, Pontypridd)
Dr Bennett, you have referred several times to the higher burden of proof that you are going to have to meet when you determine whether you will apply measures to increase competition. I presume that that is in the changes to clause 56, which are about your needing to be mindful of making sure that the competition floor would only improve patient outcomes and standards—clinical judgments, basically. Are you confident that Monitor has the expertise to exercise what are going to be clinical judgments, given that you are economists?
Emily Thornberry (Labour, Islington South and Finsbury)
At the beginning of your evidence, Mr Cozens, you told us you had three concerns. Have you told us what the other two are?
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 the witnesses.
Jimmy Hood (Labour, Lanark and Hamilton East)
Good afternoon, gentlemen. I welcome Dr Hamish Meldrum who is video-linked to us from Cardiff; Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing; Sir Richard Thompson, president of the Royal College of Physicians; and Professor Sir Neil Douglas, chairman of the Academy of Medical Royal Colleges. We have a video link, but we will run the evidence session as though Dr Meldrum was sitting in his chair, and for all intents and purposes that is exactly where he is sitting.
Emily Thornberry (Labour, Islington South and Finsbury)
It is nice to speak to you, Dr Meldrum. Can you see us?
Emily Thornberry (Labour, Islington South and Finsbury)
I shall begin with a question to all four witnesses that is similar to the one I asked first thing this morning. Although there might be pressure to get on with the changes and it might be regarded as important for the national health service to be able to move on, do you believe that the timetable that has been set out for all of us, and particularly for you, has been sufficient to enable you to go through the 180 amendments, compare the new document with the original Bill, consider the suggestions from the Future Forum and the Government’s response, and then look at whether the clauses reflect the promised changes? Do you think that you are in a position to represent fully your views and the views of your members in the time you have been given?
Emily Thornberry (Labour, Islington South and Finsbury)
Dr Meldrum, I think some of us may have received by e-mail about 10 minutes ago some form of response from the BMA, but you will forgive us if not all of us have been able to read it in some detail. We promise that we will. Could you give us a response to whether you feel that you have had a sufficient timetable?
Emily Thornberry (Labour, Islington South and Finsbury)
Thank you very much.
John Pugh (Liberal Democrat, Southport)
Can I direct both of my questions to Hamish? I, too, received some communication during the lunch hour on a resolution passed by the BMA, and it would be helpful, Dr Meldrum, if you were able to amplify a little bit on it. Can I just take the resolution in reverse order? I understand that the BMA wants the Bill withdrawn, and three or four reasons are given there. One reason is that it imposes a duty on commissioners to promote choice as a higher priority than tackling fair access and health inequalities. An awful lot of the amendments are about tackling fair access and health equalities and, indeed, some are about promoting choice. Is your reading of the Bill that it promotes choice as a higher priority than tackling fair access and health inequalities?
John Pugh (Liberal Democrat, Southport)
I can entirely understand your difficulty in getting clear about what all the legislation means in the round. What I am trying to do is clarify the BMA’s present position. The second reason is that you believe that Monitor, the CQC and the NHS commissioning board should have a legal duty to act and to avoid the undermining of existing NHS services. That is something that you would hope that everybody in the NHS would seek to do—avoid undermining services. According to the BMA, what would it involve any of those bodies doing that they do not currently do and are not mandated to do by legislation?
John Pugh (Liberal Democrat, Southport)
It is about getting the balance right between integration and choice. I will not go into the issue about the duty of the Secretary of State for Health because we will have him here quite soon. The other reason given is in regard to the function of Monitor to promote competition in the provision of health services. We had an interesting debate this morning as to whether preventing anti-competitive behaviour, which is what the actual amendment states, is the same as promoting competition. Your members are presumably aware that that particular phrase does not occur?
John Pugh (Liberal Democrat, Southport)
I do not think passion helps here. Clarity helps.
Owen Smith (Labour, Pontypridd)
I will put my question to the people in the room, starting with Sir Richard. When you gave evidence to us previously, you were not sanguine at all about the changes that the Bill was going to introduce into the health service. Are you reassured by the amendments that we have seen, albeit at very late notice?
Owen Smith (Labour, Pontypridd)
One of the issues that we discussed this morning was the extent to which Monitor’s powers remain effectively the same. It has powers to promote competition; it has words relating to integration but no powers to compel or to encourage integration. Are you still concerned that we will see more competition and that that will play against further integration in the NHS?
Owen Smith (Labour, Pontypridd)
Dr Carter, do you feel that the balance between integration and competition is better struck?
Steve Brine (Conservative, Winchester)
This is a question for any of you, but let us start with Cardiff. Dr Meldrum, thank you very much for joining us. I know that the BMA union has had its run-ins with Government over the years—some would say right from the start—and that has certainly been the case recently. Can I ask you two questions? First, I know that the BMA has made its position clear today, as is being reported, but what do you personally like in the new Health and Social Care Bill?
Secondly—the other gentlemen may be able to answer this as well—I am interested in probing the representative voice a bit. Obviously, the views of your organisations about this Bill have been well reported in recent months, but I am wondering what ongoing surveying of membership takes place. How many members do you have, and how many have answered your calls for responses about the Bill?
Steve Brine (Conservative, Winchester)
Sorry to interrupt you, but let us just be clear. You asked your members not to support the withdrawal of Bill motion today, so presumably you were arguing a slightly different case from them. I tend to be a rather positive person, so I am asking you what you like in the Bill.
Liz Kendall (Labour, Leicester West)
Thanks to everyone for joining us, here and from afar. I want to come back to a point made right at the beginning about what is happening now out in the services. The NHS Confederation managed to get us a briefing on the amendments to the Bill. It says:
“The new system could make it more difficult to make urgent decisions about reconfiguring local services when this will improve the quality of care for patients”.
It also stated that
“the reforms do not sufficiently focus on the big challenges facing the NHS: making £20 billion of efficiencies over four years”.
I want to ask each of the four witnesses whether, from what you understand that the Government are now saying, you think that those difficult decisions are going to be easier or harder.
Liz Kendall (Labour, Leicester West)
You do not think that any of these changes help to deal with the problems that we face?
Liz Kendall (Labour, Leicester West)
Neither the need to make current savings nor the need to reconfigure services is affected by the reforms?
Liz Kendall (Labour, Leicester West)
Thank you. Dr Carter?
Dan Byles (Conservative, North Warwickshire)
I have two questions, one of the entire panel and one of Dr Meldrum. First, you stated that you have perhaps not had as much time as you might have liked to look at the amendments. However, I would suggest that you have had plenty of time to look at the NHS Future Forum report, which this morning Professor Field said he was extremely pleased about, and that it was remarkable how the Government had responded to it in such a positive way. He felt that the vast majority of what had been recommended is reflected in the amendments. [ Interruption. ] You can read it in Hansard tomorrow. I think you will find that he did. Based on the NHS Future Forum report, which you have had time to read, I am curious to know whether you are satisfied that, if the Government amendments are to reflect accurately the Future Forum recommendations, it is the right move and will take us forward in the right direction.
Dan Byles (Conservative, North Warwickshire)
Dr Meldrum, picking up on my colleague Mr Brine’s question, I am very interested that the BMA has voted the way it has today, because it seems to be at odds with the way quite a lot of doctors in my constituency whom I speak with say that they feel. Can you tell me what the total membership of the BMA is and how many people are present at the conference and voted today?
Kevin Barron (Labour, Rother Valley)
I declare my interest again as an honorary fellow of the Royal College of Physicians. I have just two questions. One is to Dr Hamish Meldrum. Dr Meldrum, I will quote from your speech yesterday:
“There is a huge difference between adapt and change and slash and burn, between carefully planned reorganisations and knee-jerk closures and redundancies, between partnership working amongst health professionals, managers and patients and imposed, top-down, politically motivated diktat.”
Clearly, you are shy with words, Dr Meldrum, but could you put that quote in some context for the Committee this afternoon?
Kevin Barron (Labour, Rother Valley)
One further question to the panel. We had it confirmed from Monitor this morning that mergers between national health service trusts and between NHS trusts and other bodies could become a matter for the Office of Fair Trading and the Competition Commission. I wanted to ask all four of you whether you as individuals are happy with that. Do you think your members would be happy with that?
Kevin Barron (Labour, Rother Valley)
I am talking specifically about clause 65, which remains unamended. Professor Douglas?
Kevin Barron (Labour, Rother Valley)
Dr Meldrum?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
There has rightly been a focus on integration of services. I know, Dr Thompson, that when you were here last time that was one of your concerns, particularly given our ageing population and the fact that many people now are living with multiple medical co-morbidities. It is obviously a key challenge. This morning we heard from Sonia Brown and David Bennett of Monitor that the key focus of Monitor now would be on promoting integrated care. I want to get your views on that. Monitor would be looking to achieve value for the NHS, and value for the NHS is also value for patients; which meant, from further questions, that it would be better looking after patients in the community to prevent inappropriate hospital admissions, which is good for patients and good financially. Would you welcome that sort of thing in our focus from Monitor?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
So you very much welcome that Monitor said this morning that it was taking that into account in its involvement in securing provision?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
I do not think it was saying it was the driver, but that it saw that its role was to help to promote integration, and we heard that very clearly this morning.
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
Indeed. Very good. Do you think that it is none the less a welcome direction of travel for Monitor?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
Fantastic.
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
I address this question directly to Dr Meldrum. You said today that the BMA discussed the Future Forum document and the Government’s proposed amendments, and you said to the BMA conference that the Government response on the issue of competition largely addressed the BMA’s concerns, but members today clearly rejected your view and advice, and the Bill. Why do you think they did that?
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
Dr Meldrum, I would imagine that your members are of average and above-average intelligence.
Tom Blenkinsop (Labour, Middlesbrough South and East Cleveland)
Given that there are no amendments to clauses 60, 64 and 65, which are a substantial part of the Bill with regards to competition law, would you not say that that might be one of a few reasons why your members voted against the Bill?
Liz Kendall (Labour, Leicester West)
I think everyone supports the idea that commissioning should engage the full range of clinicians, but what do you think of the fact that clinical senates and clinical networks will be run by the national commissioning board and that the legislation gives the board the power to tell commissioning groups how they get their guidance?
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. We had time for the question, but unfortunately we do not have time for the answer. I would like to thank our guests for coming along. It was an interesting video link. [ Interruption. ] I think it is a first for a Public Bill Committee, but Select Committees may have tried it before.
Jimmy Hood (Labour, Lanark and Hamilton East)
I welcome our guests to this evidence session.
Emily Thornberry (Labour, Islington South and Finsbury)
I wonder whether you feel that you have been given sufficient time to read the Future Forum’s report and the Government’s response, to listen to what various people have said, to read 180 amendments and to consult your members in the two working days that have been made available to you. Will you comment on that before giving any further evidence?
Emily Thornberry (Labour, Islington South and Finsbury)
I do not believe that any of your organisations have been able to put in a written submission, so, when answering the question, will you confirm whether you will be in a position to give us anything in writing in furtherance of the evidence that you give today when you have had an opportunity to read through everything?
John Pugh (Liberal Democrat, Southport)
I suggest to you all that it is probably rather hard to consult on something that you understand only imperfectly in a fair or objective way, so it may be a few days or even weeks before you are able to get the full flavour. However, I ask Dr Gerada to tell us about the different nuances of response to the Future Forum, rather than what people have heard about the legislation. Given that everybody agrees that greater integration is the way forward—it is the bottom line for everyone—what are the obstacles, if any, or opportunities, if any, in doing that under the Bill?
John Pugh (Liberal Democrat, Southport)
I did ask what obstacles remain in the Bill that would hinder that.
John Pugh (Liberal Democrat, Southport)
These are not in the Bill. They have been in the NHS for quite some time.
John Pugh (Liberal Democrat, Southport)
May I press you a little on that, because it was a point made about the initial legislation? Clearly, the initial legislation has been changed—and changed in the direction of making that less rather than more possible, would you agree? Without actually abolishing competition altogether, what further changes to the legislation are you looking for that would do the trick?
John Pugh (Liberal Democrat, Southport)
Assurance, not legislation?
John Pugh (Liberal Democrat, Southport)
The role of the Secretary of State and how it is defined in the Bill has been mentioned. I have seen various wordings, some of which has been rather confusing. What operational difference do you see, as far as the NHS is concerned, with one wording rather than another? Do all of you see a big operational difference or is it just an issue for Dr Gerada?
Liz Kendall (Labour, Leicester West)
Thank you all very much for coming today. I did not manage to ask a question at the end of the previous witness session, so I will ask it of you now. The briefing that the NHS Confederation has provided says:
“The role of the NHS Commissioning Board has been extended, which means decision-making and financial control are more centralised than previously anticipated and far more than is the case in our current health system”.
It also says that the NHS commissioning board will commission services on behalf of any clinical groups that are not ready to do so and will run the clinical senates and clinical networks, and have powers to determine how else commissioning groups get their advice, how frequently your governing bodies meet and so on. What do each of you think about those extra powers being given to the commissioning board? Perhaps we can start with Dr Dixon.
Fiona O'Donnell (Labour, East Lothian)
The message we have heard so far today is that the biggest challenge facing the NHS, as you have also all said, is an ageing population and the need to meet their care needs through integrated services. Dr Gerada, we had a very clear example of your view of integrated services. My question to each of the panel is whether we need legislation for you to be able to deliver that.
Fiona O'Donnell (Labour, East Lothian)
You are both agreeing that the doctor-patient relationship is so important. What do you think—first in terms of that relationship, but also in terms of the efficiency drive in the NHS—of the power for the national commissioning board to make bonus payments to clinical commissioning groups? How do you think that impacts?
Fiona O'Donnell (Labour, East Lothian)
But Dr Dixon, what you and David said was that you were not just thinking about me; you are thinking about the next person to walk through the door. I am alarmed, because I have never sat in front of my GP thinking for one minute that they were not absolutely focused on my needs, but were thinking about the next person to walk through the door. I am living in a different health system.
Fiona O'Donnell (Labour, East Lothian)
I could not possibly comment on that.
Owen Smith (Labour, Pontypridd)
Dr Gerada, I have a question about new clause 4. I will read a bit of it to you, because I heard you say earlier about not having enough time to do so. It is a clause in which the Government are trying to alleviate fears that there is a danger that we will see the NHS privatised. They have highlighted this as ruling out privatisation. It says, in effect, that the Secretary of State will no longer in future be able to promote the interests of any one group. He will not be able to promote the interests of a private provider over another group.
It also says, equally, that the new clauses would prevent the Secretary of State from deliberately promoting the growth of state providers over voluntary sector or private ones. Is it your view that that is another perverse consequence in the Bill? In a tax-funded and still overwhelmingly publicly owned NHS, the Secretary of State would be so hidebound by competition law as to stop him protecting publicly owned bits of the NHS.
Jimmy Hood (Labour, Lanark and Hamilton East)
Order. I am afraid I must announce that that brings us to the end of the time allocated to the Committee to ask questions of our witnesses. I thank you on behalf of the Committee.
Jimmy Hood (Labour, Lanark and Hamilton East)
Welcome, lady and gentlemen. Can I have a bid for questions? Emily Thornberry?
Emily Thornberry (Labour, Islington South and Finsbury)
I want to begin with a general question to put your evidence in context. Do you feel that you have had sufficient time to look at the 180 Government amendments, the Future Forum report and the Government’s response, and to consult your members before coming before us to give evidence? I know that not many of you have been able to do written evidence for us, and I wondered whether you were hoping that you may be able to in future.
Emily Thornberry (Labour, Islington South and Finsbury)
Do any of you have any particular anxieties about the process?
Emily Thornberry (Labour, Islington South and Finsbury)
A fair summary: for those who have not spoken, you have been spoken for. Thank you.
Kevin Barron (Labour, Rother Valley)
I have a question for all of you. There has been much talk in the past seven days about how the changes will open up decision making, commissioning and such things to patients. Given the organisations that you represent, do you feel that the concerns of the different charities will get more of a hearing in what happens now than in what was going to happen three weeks ago?
Daniel Poulter (Conservative, Central Suffolk and North Ipswich)
There is obviously an issue here about how we have and how we put into legislation effective discussion and engagement with patients. Often, the people with whom we want to engage do not engage. Patients are incredibly accepting, but unfortunately there are sometimes things that are unacceptable: for example, being treated with chemotherapy in a hospital corridor or on mixed sex wards, which, thankfully, are almost a thing of the past now, but they have been going on, and still go on in some cases, and are not very good practice. Nevertheless, the point is that we often see in local LINk organisations, for example, the agenda is hijacked by one or two articulate individuals who have their own agenda, which is not necessarily representative of a wider body of patient opinion and does not necessarily capture the key challenges for patient care either at the local hospital or in local community services and community care. How do you see the Bill improving engagement with patients to make it more effective, as that is a key challenge?
Liz Kendall (Labour, Leicester West)
Thank you all for coming today. I want to ask you about your views on HealthWatch and whether you think it is strong enough. Do you think that it will be as powerful a voice for driving change in the system as the Care Quality Commission, Monitor and the national NHS commissioning board, when we now know from the Government’s response to the Future Forum that it remains a sub-committee of the CQC?
John Pugh (Liberal Democrat, Southport)
I wonder whether the Government can keep all you guys and girls happy. Clearly, some of you want to provide services for the NHS, and some want to monitor what services the NHS provides.
I was struck by the report “Choice and Competition: Delivering Real Choice” by the Future Forum group, whose members included people from Mind, Marie Curie, Turning Point and so on. As part of the framework on choice and competition, it recommended that
“Consortia would apply the policy on choice and the competition model to their local commissioning decisions to ensure they are delivering real choice”—
although I am not sure how real choice differs from ordinary choice. There seems to be a paradox here, in that some of you are unhappy with too much choice because it prevents integration, and others want a piece of the action. I am not clear whether the Government can write legislation that would satisfy you all, other than by including a clause saying, “Give only so much choice as would please the charitable sector.” How can they do that?
John Pugh (Liberal Democrat, Southport)
If you offer choice, to use the BMA’s words, you are not going at any stage to undermine existing NHS facilities?
John Pugh (Liberal Democrat, Southport)
Bearing in mind that the choice and competition section was chaired by the Association of Chief Executives of Voluntary Organisations. He may be off on one and not representative of you as a whole—
John Pugh (Liberal Democrat, Southport)
Do you not think that commissioners will be properly mindful of that, given their knowledge of their patients?
Jimmy Hood (Labour, Lanark and Hamilton East)
Our witnesses are inspiring or inciting Members to think of questions, and Members are indicating to me that they want to come in to ask questions. I have my own waiting list, and I can only call people in order. If Members are able to come in later, they may refer back to the point that inspired or incited them.
Emily Thornberry (Labour, Islington South and Finsbury)
I want briefly to go back to the CQC and HealthWatch, and then I want to ask about choice. If HealthWatch had been up and running during the scandal at Winterbourne View, one of the things we would expect it to do would be to investigate the CQC’s failure properly to watch what was going on. HealthWatch might have decided that we should be looking not only at Winterbourne View but at large locked institutions for people with learning disabilities and that it is important that the CQC does a study of many organisations. That is a real-life situation happening at the moment. Let us think about the impact of that. With HealthWatch being a sub-department or committee of the CQC, would it not be subject to, for example, pressures from the CQC saying, “We’re 300 people short; we simply can’t do that.”? Do we not need the two organisations to be a little more separate, so that the CQC at the very least can be watched by HealthWatch?
Emily Thornberry (Labour, Islington South and Finsbury)
May I move on to choice? In a way, perhaps that has been investigated sufficiently, but I want to take this opportunity to underline it. For most patients, choice is not, “I’m going to this hospital instead of that hospital.” As you explained, it is about sitting down with your doctor and saying, “My daughter comes to me three days a week. I have diabetes. I also have this condition and that condition. What are the different ways in which we can work together to give me the support that I need to keep me out of hospital?” That is choice in the modern context, isn’t it?
Margot James (Conservative, Stourbridge)
I would like to keep the focus on clinical pathways, because there are various roles for the patient voice in the health service, but one of the most important is in the devising of the clinical pathway. Do you not feel that under the amended legislation, there is even more scope for patient organisations to have an input into commissioning plans, not from the general LINks-type approach, but more from the specialist patient organisations such as yours, whereby you have input into the commissioning of diabetes or asthma services at local level. We heard this morning that the push to more community involvement and greater input into commissioning plans would be extended. Do you not see that as an opportunity?
Margot James (Conservative, Stourbridge)
Can I add a rider to that? The challenge to you is to operate at the local level, which the Bill gives you the opportunity to do, but also to operate at the national level on the evidence base through your channels into NICE, so that the evidence on which clinical pathways should be based has your input at that level as well, and that that is also facilitated. Do you agree?
Owen Smith (Labour, Pontypridd)
My question is specifically for Mr Korner and Mr Devane. It is about the level at which services might be commissioned. I am asking you specifically because of the interest groups that you represent. There has obviously been a concern that, with the national commissioning board commissioning some things nationally, specialist services, and with consortia commissioning things locally, will consortia at the local level have the requisite expertise, and will the national commissioning board have the insight into local conditions to be able adequately to commission across the country? Do you think those concerns have been addressed by the changes in the Bill, notably the creation of senates and networks?
Paul Burstow (Liberal Democrat, Sutton and Cheam)
I want to pick up on Mr Korner’s comment. He posited the notion that the Bill does not provide the changes that will deliver the stroke care that he and every member of the Committee want to see. If we maintained the status quo, would the current system do that?
Paul Burstow (Liberal Democrat, Sutton and Cheam)
Manchester and London?