HL Deb 17 June 1999 vol 602 cc418-24

1 Clause 2, page 2, leave out lines 8 to 11.

Baroness Hayman

My Lords, I beg to move that the House do agree with the Commons in their Amendment No. 1. We had extensive debates on the role of the primary care group in the process of establishing primary care trusts when the Health Bill was previously considered in your Lordships' House. Reflecting on what was said then, I am convinced that there is in fact little difference on this issue between the underlying aim of the Government and that of those on the Opposition Benches.

I have read the official record again, and I agree with much of what was said by the noble Earl, Lord Howe. We share a common objective that the establishment process should be locally owned and driven. We also agree that the voice of the PCGs is crucially important.

My ministerial colleagues and I considered these debates very carefully and our decision to table an amendment in another place was not taken lightly. In our considerations, from whatever perspective we approached the matter, we always came back to the fundamental point of principle—whether or not the views of one local stakeholder, however important, could mean that the views of others are automatically set on one side or ignored. That would be the effect of the amendment that was made in your Lordships' House. It would give the primary care group a statutory right of veto over the views of all other local stakeholders. I believe that that would demean the importance of the views of partners in the local NHS, such as community trusts and their staff, and indeed patient groups.

We also believe that it would be unwise to set down such a rigid rule on the face of the Bill. Complex and difficult situations may well arise which require careful and sensitive handling. I recall that the noble Lord, Lord Clement-Jones, recognised on Report, in the form of what was then Amendment No. 5, that there might indeed be exceptional circumstances which needed to be considered. We are aware, for example, that in some places proposals are under discussion to establish PCTs which cover the area currently covered by several PCGs. While it remains to be seen whether such large PCTs could effectively fulfil the functions that we have set out for them, we would not wish to prevent such proposals from being considered at this early stage.

It is equally possible that such a proposal could have the support of all but one PCG—and perhaps be opposed by a very narrow majority of members of that individual PCG—and enjoy widespread support among clinicians and others in the local area. While very great care and sensitivity would be needed in deciding how to proceed in such circumstances, it is clear that a statutory PCG veto could mean that a very small number of people could potentially block an extremely beneficial development. It is precisely because we cannot fully anticipate all the possible scenarios that could develop, such as this one, that the Government brought forward this amendment in another place.

I would like to make it clear, however, that the Government attach the greatest importance to the successful establishment of primary care trusts. They offer unparalleled opportunities for local stakeholders—including family doctors, nurses, midwives, health visitors, the professions allied to medicine and social services—to shape services to provide better healthcare and to improve health. They will bring significant benefits to patients, clinicians and the local NHS as a whole. But a PCT will work only if it builds on local enthusiasm and local commitment, in particular of those working at the front line of patient care: GPs, nurses, midwives and other health and social care professions.

For this reason the Government have no intention whatsoever of establishing primary care trusts without broad local support from the very professions which will form them and give them the energy they will need to succeed. We believe that a voluntary approach is the only sensible way to proceed. I can be quite clear to the House today that we do not want, and are not encouraging, a headlong rush to primary care trust status. Instead we are looking for measured and evolutionary change. We want progression to trust status to be locally driven at a pace that suits local circumstances.

That desire is reflected in the Government's proposals for the establishment process. We have deliberately left it to the local NHS—the PCG board, GPs, nurses, other professions, a community trust or a health authority—to bring forward a proposal to develop a primary care trust. If a proposal has local NHS support—from a PCG or NHS trust providing community services—the health authority will be required to enter into a formal local consultation. This consultation process will be particularly important to hear the views of the wider community and local patients in particular.

Once the local consultation process is complete, the health authority will submit the proposal to the Secretary of State for his consideration. I can assure the House that we intend that the Secretary of State will not simply be sent a recommendation. We intend that regulations will require all the responses to the consultation to be attached to the recommendation so that the Secretary of State has the benefit not only of the views of the local health authority, but also those of consultees, and at first hand. The views of primary care groups. local GPs and other professions, as well as those of the wider community and the NHS locally, will be key considerations for the Secretary of State in deciding whether to establish a primary care trust.

I go further and say that the support of the relevant primary care group will he a critical factor in our consideration. The Government intend to establish primary care trusts in a way that is sensitive to local views, and primary care groups are key to that. For the reasons I have given and in the light of these assurances I hope that noble Lords will feel able to support the Government in this amendment.

Moved, That the House do agree with the Commons in their Amendment No. 1.—(Baroness Hayman.)

3.45 p.m.

Earl Howe

My Lords, the House will be grateful to the noble Baroness for the clear way in which she has spoken to this important amendment. I am reassured that she feels there is little that separates us on this issue. If I do not misread her, I think that the Minister has modified her position somewhat from that which she adopted on the previous occasion when this issue was debated in your Lordships' House. In particular she seemed to me to have moved away from the guarded form of words that she used several times both in Committee and on Report. She said then that a decision to establish a primary care trust would, take into account all local views". She also said that it was the Government's "assumption" that the support of the primary care group would be required by the Secretary of State before he approved a primary care trust.

Those phrases did not seem to me to reflect one of the essential requirements in any transition to PCT status; namely, the need to have the prior, wholehearted backing of those who are most affected by such a change. The previous Minister, Mr. Milburn, spoke about putting doctors and nurses "in the driving seat". At the time I thought I knew what that meant, but in the light of the Government's antipathy to your Lordships' amendment I realised that I did not. However, hearing the noble Baroness speak in the way she has today, in terms—if I do not misquote her—that referred to measured, evolutionary change, locally driven, I am considerably reassured.

One of the arguments we debated at earlier stages was that it is pointless going out to wide consultation on a proposal to move to trust status if the health professionals themselves do not support it. But the important point is that the degree of support among health professionals should be established. Can the Minister say in what way this will be done? Would it, for example, make sense to involve the local medical committee in organising some kind of a ballot?

I agree with the noble Baroness that when a PCT is established it is in all our interests that it should be a success. Without broad support among GPs and the key professional stakeholders, the chances are that it will not be. But the Secretary of State should, I suggest, be looking for other indicators as well. He needs to ensure that there is competent management in place, with tight financial management and proper accountability. Can the Minister be a little more specific about the criteria that the Secretary of State will adhere to when making his decision? If there is a dissenting group of health professionals among those in the proposed PCT, will he ensure that that fact is made publicly available?

I have a further concern which the Minister may be able to help me with. We understand that the first wave of PCTs are expected to be in place by April 2000. In another place the Minister made it clear that the necessary orders to establish such PCTs would need to be finalised by about the beginning of December. Prior to that the Government are committed to consulting on the draft PCT orders. If that consultation follows the normal pattern it will be a three-month process. But prior to that, regulations will need to be laid, and they, too, will be subject to consultation, again over some three months. Working hack from the early December deadline—when the PCT orders are to be laid—it is clear that the draft regulations will need to be ready shortly indeed. Are those draft regulations ready now and, if they are, can the noble Baroness say why neither your Lordships nor another place has had the benefit of seeing them yet? If we were able to see them, I have little doubt that they would inform our debates considerably. Can the Minister say whether the timetable I have outlined is roughly right, or have I got it wrong?

I thank the Minister for the added reassurances she has been able to give. They are important reassurances. It may be wishful thinking on my part, but in the light of what she has said I am inclined to conclude that we can be slightly more confident than once we were of the procedural safeguards that will be put in place. If the Minister is able to answer my questions satisfactorily I would not propose to recommend to your Lordships that the House's earlier amendment should be insisted upon.

Lord Clement-Jones

My Lords, I thank the Minister for the comprehensive notes that we have had on the amendments that are before us today. The notes have made it much easier to understand the Bill's progress through the other place. I also thank the Minister for what I thought was a considerable degree of movement on this amendment in terms of the broad spirit in which the department suggests that consultation takes place on the progress from PCG status to PCT status. I refer in particular to the Minister's statements that there is no intention of establishing PCTs without broad local support; that there is no headlong rush to primary care trust status; and that the support of relevant primary care groups will be a critical factor. All those statements reassure us that the primary care groups will be an intimate and essential part of the process.

Certain issues should be addressed as we look at the details of the consultation process. It is clear that professional groups still have questions that need to be answered. The noble Earl, Lord Howe, asked a number of questions which it would be useful to address at this stage. We did not vote for the amendment when it was before this House on the previous occasion. We felt that a spirit of consultation was in place. However, we welcome the additional "mile" that the Minister has gone today. The only question I ask, in addition to those asked by the noble Earl, Lord Howe, concerns the reporting of the outcome of the consultation. Will there be a transparent process which makes it clear what objections have occurred during that process? Will that be available for all to see?

Baroness Hayman

My Lords, I am grateful for the welcome that has been given to my statement of the Government's position. I do not think that I have modified my position; I hope that I have expressed myself with more clarity than I did in our earlier deliberations. Perhaps that is because of the time of day at which we are debating these matters.

I wish to respond to one or two of the detailed points that have been raised, particularly by the noble Earl, Lord Howe. He is absolutely right to say that the timetable for the regulations is very tight. We are currently working on them and, although they are not yet ready to go out to public consultation, we hope that it will not be too long before they do. We are very well aware that we have to meet a tight timetable, as the noble Earl so eloquently reminded us.

As to the mechanisms that the Secretary of State will put in place to measure the extent of local support for a PCT proposal, he will direct health authorities to select those proposals to go to consultation under what will be new Sections 16C and 17. We have said that the directions will require health authorities to select a proposal if it has been made or endorsed by a PCG or NHS trust which provides community services locally. This approach allows anyone to generate proposals but ensures consultation on any proposal which is supported by at least one of the relevant local NHS bodies.

The noble Lord, Lord Clement-Jones, asked about consultation. We want the consultation to be open and transparent, with the aim of capturing the views of all local stakeholders. The regulations will therefore specify who conducts the consultation—that will be the health authority—and what essential information must be included in the consultation document so that key stakeholders have sufficient detail to allow them to take an informed view. The regulations will also set out who must be consulted. This will include local GPs, nurses and other health and social care professionals as well as the wider NHS and the local community, including professional and patient representative groups. Finally, these regulations will set out the form and contents of the report which the health authority must make to the Secretary of State on the consultation. As I said earlier, the report will include the responses received.

It will then he for the Secretary of State to consider the responses to the consultation and make a judgment on whether the proposal should proceed. This is a role with which Ministers are very familiar from, for example, consultations on proposals for major service reconfigurations. In considering the results of the consultation, we will of course pay particular heed to the views of local health professionals, on whom the success of a PCT will ultimately depend, if it goes ahead.

The noble Earl, Lord Howe, asked specifically whether the consultation regulations will require or allow for ballots. Ballots are certainly one means of testing opinion, but they are not the only way. We are not proposing to make them an absolute requirement. The Secretary of State's decision on whether or not to establish a primary care trust needs to take account of all local views. Any requirement for a ballot would need therefore to apply to other stakeholder groups and not just, for example, to GPs or nurses. But a proliferation of ballots for so many different interest groups is clearly impracticable and unattractive. It is difficult to see exactly which groups should or should not have a right to be balloted. In some cases, the constituency would he extremely difficult to define. I refer, for example, to whether it should comprise patients or practitioners, who would be working for some sessions in a new trust and working elsewhere in a community trust. Our approach will therefore allow for ballots but not make them mandatory.

We are proposing consultation on proposals to establish PCTs, not on the draft establishment orders. These will be drafted only following the Secretary of State's consideration of the responses to the consultation.

As to the question about the criteria against which PCTs will be assessed, the outline criteria against which my right honourable friend the Secretary of State will consider applications for primary care trust status were set out in the White Paper, The new NHS, and repeated in the paper, Primary Care Trusts—Establishing Better Services, which we issued in April. They are: broad local support for its establishment, including among those GPs affected; a clear vision of the service and health benefits which establishing a primary care trust will bring, backed by agreed standards and targets to make progress towards them: making an effective contribution to the local health improvement programme and working well with partner organisations: effective arrangements for developing clinical standards, including at practice level; proper arrangements for monitoring activity, sound financial management and accountability; a clear assessment of the local impact of change and reconfiguration; access to good, high quality human resources support; and, for level 4 primary care trusts, that the proposals take proper account of the wide range of community health services, including those which are more specialised.

I hope that that gives a sense of the comprehensiveness. We are currently working with the NHS, GP groups and other organisations on developing those criteria. We plan to issue guidance on the application, consultation and establishment process within the next month or so, assuming, of course, Royal Assent to the Bill.

I hope that I have covered the specifics. Perhaps I may now return to the general issue. It is one of principle: whether we should allow the Bill to remain in the position where the views of one local stakeholder, however important, could veto a potentially beneficial development. In his letter on this subject on the 19th February, my honourable friend the Minister of State made clear that, The assumption will generally be that a Primary Care Trust would not be established without the support of the relevant Primary Care Group". I know that that wording does not appear sufficiently robust to some. If it would help to address some of the fears—which I think are about the semantics rather than the realities, although I have set out the reasons why we do not think it would be prudent to put an absolute and blanket prohibition on the face of the Bill—I can assure the House that it is very clearly the Government's general expectation that a primary care trust would not be established if the relevant primary care group opposed it.

I hope that that is sufficiently reassuring and that I have made it clear that we need to reserve the position where we could use the care and sensitivity needed for the sort of exceptional circumstances that potentially could arise. The guidance that we are about to issue on primary care trusts will reflect the expectation I have just described: that a primary care trust would not be established if the relevant primary care group opposed it.

We want primary care trusts to work well. The simple truth is that we cannot afford to alienate the very professionals who will be carrying out the PCTs' functions. On that basis, I hope that I have provided some reassurance to the House.

4 p.m.

Earl Howe

My Lords, I thank the noble Baroness for that very full reply.

On Question, Motion agreed to.