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Editor’s blog Tuesday 20 July 2010: Notes from Health Secretary Andrew Lansley's first Health Select Committee appearance

This is summary, notes, emerging. Uncorrected and then some. There are going to be a lot of typos. UPDATE: It seems to be on a loop here - don't know how long it stays live.

There is jacket-off 'mirroring' between HSC chair Stephen Dorrell and Andrew Lansley – like the Cameron-Clegg arm-touching on the steps of Downing Street.

Dorrell: “The session was actually envisaged before we knew the White Paper was going to be published.”

Stephen Dorrell kicks off with the un-promised “major reorganisation – why it was necessary and how different it is from the primary care group-led reorganisation 13 years ago”.

Andrew Lansley: White Paper not about organisation, it’s about control, giving patients opportunity and choice and information. Focus on outcomes – if we are serious about purpose of NHS – patients have acces to treatments and services as good as any in world, let’s measure results and not processes. Third, how we achieve this. Evidence theat professional empowerment is key ingredient of public service reform.

AL: White Paper (WP) was essentially about those. Form follows function. Was not intention should abolish PCTs, but conclusion reached, looking in addition for not only professional empowerment but genuine accountability, lacking in the past.

AL: Was no genuine accountability before – want to hold bodies to account but not prescribe how it is to be done. Up to professionals and local democratic accountability.

AL: Having done that, organisatin changes flow from that. I have talked to thousands of clinicians saying no more big upheaval. Wont; change things if you work in GP surgery or hospital or community service. Doesn’t change the character of work. It was always intended NHS trusts should become FTs. For great majority of NHS staff, not reorganisation but liberation.

AL: Looking for substatial reductions in management cost across services, accumulating to 45% of management costs across service. Hard to see residual role of PCTs. Enables us to delayer management wile reducing costs.

AL: Locality commissioning highly bureaucratic, conflicts of interest with provision, two-tier, so broader responsibility for commissioning on locality basis had to be geographical. But PCGs ceased to be owned by clinicians but by DH. If what I propose owned by DH, will have failed. Not subject to constant top-down prescription. Not saying wholly different to locality commissionin in past. Very clear it will not be top-down.

Questioner: You’ve been frank that contradicting Coalition Agreement, this is top-down reorganisation. Where is the local democratic accountability? Not in PCT. What can local communities do?

AL: Coalition programme clear would have independent board, followed through logic of issues, Conservative manifesto of patient empowerment and Lib Deb local democratic accountability. When think through functions of residual PCT when public healthy responsibility goes to local authority, day-to-day responsibility in GP consortia and independent NHS board specialised commissioning, PCT little left, and why elect to that?

AL: have democratic body of local authorities which have statutory powers for health and wellbeing. We concluded make stronger strategic relationship[ general practice-local authority. People have probably not recognised most significant statement of linking GP commisisonig to strategic role for local authorities, not just about integrating, LAs have an explicit responsibility to agree with consortium on strategy.

AL: Local authorities (LAs) already have statutory powers in relation to health and wellbeing in their area, which we will strengthen. We concluded they could achieve democratic accountability more effectively by creating a stronger strategic relationship between consortia and local authorities. People have not recognised that the probably most significant new statement in the White Paper is not having GP-led commissioning but allying it to a strategic role for local authorities – not just about meshing together and integrating health, public health and social care services; it is about the LA explicitly having a responsibility together with consortia to agree on what the health service commissioning strategy looks like. And if the LA don’t agree, can refer to Independent Reconfiguration Panel and to the Secretary Of State.

Questioner: What if referrals undermine loved easy-to-visit local NHS organisations?

AL: The implication of what you’re saying is that commissioning equals the transfer of patients to different places, which it doesn’t. Commissioning means establishing a conceptual framework, the purpose of which is to give patients choice. It’s perfectly reasonable to establish contracts that allow patients to access servcies in a number of places. The question of where patients then choose to go result of individual choice and individual GP referral. PCTs do look at commissioning as doing their calculations, and try to decide where they should go like moving people about on a ‘Battle Of Britain’ board, deciding who providers services, who’s viable and who isn’t.

AL: Patient choice and commissioner decision will guide referrals. Things can change, and some services may not be good enoough and so not supported. But protection of local authorities calling services essential for area. And Monitor will have responsibility to determine essential services, which cannot be closed down without express Monitor approval

Questioner; NHS HQ will be in consulting room and clinic - to what degree will central management or guidence create framework for that to work within?

AL: WP aimed to set out central framework. NHS is what SoS thinks it is, currently

Q: Has a constitution

AL: But not one defining the SoS's job. I intend to be first SoS ending their tenure of office having genuinely transfrerred responsibility from SoS to clinicians. Not 100% decenrtralisation - which would put all budgets to practices. This is a national service, natioally funded through taxation with national responsibility for outcomes and NHS independent commisisoning board to provide evidence-based standards to inform commissioning, so publishing the new standards.

AL: Public want NHS clearly intending to meet national standards with equal access but want decisions about their care personal to them and locally repsonsivel

AL: There's a balance that has to be struck. Allocate resources natioanaly on fair basis to provide quality standards and commisisoning guidelines to enable people to make good deceiosnis. Make peple responsible to Parliament for tax. Day-to-day priotrities should be decided by clinicians we trust locally.

Questioner: There will be circumstances where this doesn't work well. Not sure I can see through forest of structures, are we going to see the kind of corruption that happened years ago between pharma companies and GPs (which has ended) - individual patient is not effective at dealing with that kind of situation.

AL: There will be fewer structures as a result of this. Ask people what PCTs and SHAs do?

Questioner: Not point. Do you get safe care?

AL: Patient expect broadly to have relatioonship with local general practice, through whom can access servcies. Most structures beyuond that opaque. Public expect people tio take collective responsibility for their healthcare - GPs. GP accountability - and this will help strengthen GP accountability. Peer review strengthens by holding practices to account. Small GP practices do a good job, but are often lacking on support and clinical goverenance framework to alow peer review.

AL: Failure in current system Mid-Staffs - Maidstone and Tunbridge Wells, Stoke Mandeville. Who was accountable? Were SHA, PCT, GPs, Healthcare Commission and then CQC, Monitor, DH. Nobody was taking actual responsibility. This will simplify that and be clearers, and commissioners will have responsibility. Where there's clinical failure, CQC will act. Where there's financial failure, Monitor will step in.

Questioner: This is a major change - Chris Ham called it that, others call privatisation. In relation to new structures within 2 years, not prudent to move more slowly based on evidence? Will be problems moving to service fragmentation, over 500 consortia?

AL: 500 consortia is not a figure I've offered,. Number will relate to proposals from GPs. Average PBC consrtia now is 80,000 but largest 530,000. Early adopters like Cumbria and Northampton are larger. I am not going to specify size of consortia.

AL: We're not starting evidence-free. Research has shown some showing clear benefits. Evidence from physician led organisations here and abroad; total purchasing and locality commissioning here. There's a body of evidence of benefits. PBC consortia have existing structures and people and relationships. There's a balance to be struck between sufficient pace to make worth while making relationships now so see sense of progress and evolution, and opportunity to be properly piloted. 2011-12 early adopters will show how this work in practice. 2012-13, can pilot without legal responsibility, and in 2013-14, will be able to take responsibility. PBC consortia tell me they regard 2 years as adequate. We have to achieve substantial management cost reductions over this time anyway. I think it's better to have simpler delayered system quickly.

AL: privatisation completely misleading terminology. This is public money, commissioners will not be able to transfer that money to themselves.

Questioner: You are raising bar for GPs operating within consortia. Plan to licence, accredit GPs in consortia?

AL: 2 aspects - RCGPs putting in quality framework for general practice, and CQC starting to register general practice, so we anticipate quality assurance via those. I don’t want either to be deeply prescriptive or intrusive, but I think these will strengthen local governance. Response I get from most GPs is that they felt they're now well-paid professionals, but are not treated as such; indeed, treated more as people to be told what to do especially by PCTs. They understand they make most important decisions about treatment and referral, not big steep to decide with commissioning.

Q: How will the interface work between commissioning board and GPs - via LA?

AL: The statutory relationship will be between independent board and GP practice. Locally, LA and consortia should inter-relate

Q: Resource allocation – what is role of independent board. Clear now Advisory Committee on Resource Allocation (ACRA) RAWP, and transparent

AL: up to a point!

Q: ish – know 152 barriers, target for funding and distance form target. Replaced with uncertain number of GP consortia – how allocated on basis of need. Do ACRA have role and how can consortia know getting fair share of privately negotiated contract –board to practice?

AL: I don’t think current system's clear. Resources provided for patient treatments, and also for improving health outcomes. Advisory Committee on Resource Allocations told the last government could pretty much work out formula for reducing burden of disease, but public don’t know how much to fund public health. Could allocate 10, 15 or 20%. Not start on how much now spent (probably c. 4%). Ministers chose 15%. Changed nothing much. And just distorted things.

AL: I intend to use ACRA, but to ensure the two resource allocations very distinct – allocate great majority of resources in relation to disease burden to ensure equality across country. To say  that we're allocating to larger number of bodies will not be confusing, but clearer. With fewer organisations, you can get more distortion, some practices deal with very high disease burden, others nearby with nothing like. Nuffield Trust doing work on practice-level budget allocation. I don’t currently know how much is spent in public health, will ask ACRA t staff work on public health and burden of disease need.

AL: because of nature of system change, the target of moving to wards fair shares funding formula will no longer be relevant.

Q: Will there be changes to pay bargaining with national terms and conditions?

AL: As well as advice from pay review bodies, NHS FTs can already determine own pay contracts. I am not proposing any changes in the current arrangements.

Q: What about the pay review body structure?

AL: The WP does not propose change in current systems

Questioner: how will the commissioning board be accountable?

AL: To SoS and Parliament. Will be accountable for financial control of cash-limited budget, for overall performance and maintenance of servcies, and through outcomes framework. Consulting on limited outcome measures at outcome level nationally that will be broad, relevant and meaningful enough to represent NHS peroformance as a whole

Questioner: some thought BMA ran rings around last government in contract negotiations. How will you avoid that? Should GPs be paid more, and if so how much?

AL: I'm not showing my hand in financial aspects of negotiation. I think last negotiation leading to 2004 contract substantially failed, which I don’t think was the BMA's fault but there might have been some element. In negotiating QOF, there was a lack of understanding by the last government of what GPs did. Thought GPs would achieve 750 points, but achieved about 950. Need to be clear about aim to achieve.

AL: I don’t start with blank paper. I’ve been clear for long time about what I expect,. and conversations have made clear. GPC chir Dr Buckman said he did not think I would be a softie and he’s right.

Q: Are you considering connecting health premium to age at death of different communities?

AL: Yes. Haven’t got details, but need to focus on what outcomes we expect in life expectancy and health expectancy as measures of public health outcomes, or we won’t capture underlying public health outcomes we’re looking for

Q: How much of your proposed savings are based on public health gain?

AL: I can’t add to Wanless on ‘fully engaged’ gains to be had from improving public health outcomes, showing widening gap on resources and need unless public health engagement and outcomes improve. We are on Wanless’s slow progress trajectory at present. To improve health of nation and healthy life expectancy, will have to do better. Impact of alcohol dependency and obesity.

Q: How can a separate public health service mobilise local authority?

AL: From govt’s POV, heard endlessly of understanding determinants of health wider than healthcare services: socio-economic status, employment far before numbers of hospital beds or GPs. Rhetoric of joining up across govt was there, but not done. I will chair first public health committee to recognise this and wider determinants. Resources of govt at unsustainable levels, have to use money much more effectively. We can recognise where govt spend on cycling, sport, welfare to work or health provision, all have impact on health. If it's better done in the first place, better outcomes – there's powerful feedback in education.

AL: From my POV, not me telling LA what to do, they will have strategic mechanisms, budget, social health and welfare responsibility.

Q: What about the pressure on LA budgets?

A: Will be joint budgets, and directors of public health will account to local authority and public health service. Health premium will be transparent mechanism to support local success, which they can support. From LA perspective, access to additional resources, from NHS budget.

Q: Tension between consortia and LA over social care commissioning and adequate provision.

AL: We've seen that often in past from PCTs and LAs in the past. I see it not as a tension but a driver for greater integration. Audit Commission found disappointing joint commissioning – some for learning disability etc, but nothing like to deliver best results. Consortia will need to integrate commissioning for older people, mental health, disabilities, do with and through LAs.

Q: Could consortia allocate budget to LA?

AL: Could do, now could do more integrated management service, happening in Torbay, Hammersmith and Fulham integrated management health and LAs. Happy for GP commissioning groups to see how can use extant legislation rather than waiting.

Right - got typist's cramp, just summarising point from here on
He's not moving on minimum unit pricing of alcohol, but will send the Committee some Sheffield research. Which is nice

Massive back-pedal on the unpopular Jamie Oliver attack. Problem was school food initiative not seen through to its logical conclusion "not about chasing down level of saturated fats or sugars, it's about changing the relationships with food. Or they will go out and buy the wrong food. It's about taking responsibility ... Jamie Oliver is about not just the quality of the ingredients or about the food, it's about the environment in which it's eaten", Lansley says (as best I can get it). Don;t mebntion Building Schools For The  Future, anyone.

Dorrell moves onto social care consultation, £24 billion for present inadequate current level, £5-6 bn more for acceptable. Is Mr L about funding formula or adequacy standards of care? Lansley likes this question, says looking for partnership, and won;t ore-judge consultation. Extent of public support has to be long-run sustainable and consistent with sustainable fiscal framework. Got Andrew Dilnot, who understands sustainable, but does not address what they think is sustainable in partnership / insurance approaches. They will assess suggestions. Asked them to come back in 2 months, using that in own criteria.

Dorrell says govt is looking at future co-payment model, have to look at funds and also at achievable levels of private funding compatible with principles of equity.

Integrating health and care servivces - AL won't mandate a model as NHS tradition is that if SoS backs one approach, all try to do tomorrow, people need to work it out locally. There are good examples, but Audit Commission showed integration not pursued as much as should, AL does want to see more integration, but no top-down structure, determine locally. Thinks new structure would facilitate integration. Thinks GP consortia will approach integration with different mindset from PCT - not institutional ownership of commissioning.

Oh, back to money, so back into transcript mode.

Q: Will the government use PFI for capital projects or suspend it?

AL: I have no proposals currently to stop the use of PFI for capital investment. I think it’s more a matter for my Treasury colleagues to look at how public-private partnerships (PPPs) work in this sector. I was with the Royal Liverpool and Broadgreen FT recently, who are proceeding with their PFI, we’ve given the permission – and that deal is not structured with same long-term hard and soft maintenance approach, they are adapting to a different kind of PPP. As all providers move to become FTs, I hope they will structure their capital in ways that work best for them

Q: Funding for LAs for social care ring-fenced. Will you increase it?

AL: NHS resources will increase in real-terms in every year of the Parliament, but unfortunately wqas cannot promise the same for the social care budget through local authorities.

Q: Are you leaving LAs to decide what they spend on social care?

AL: As part of spending review, social care spending will be part of that negotiation

ENDS. Dorrell thanks Lansley for his “good humour and clarity”