HL Deb 18 March 2002 vol 632 cc1151-73

House again in Committee.

6.14 p.m.

Earl Howe

moved Amendment No. 42: After Clause 2, insert the following new clause— "DUTY OF STRATEGIC HEALTH AUTHORITIES: PUBLIC HEALTH Strategic Health Authorities shall have in place systems of surveillance to—

  1. (a) monitor changes in the health of members of the public within the area of the Strategic Health Authority; and
  2. (b) identify trends arising from the activities of the Primary Care Trusts within the area of the Authority."
The noble Earl said: One of the major questions begged by the Bill is its implications for public health. Public health doctors, including directors of public health, will have to transfer from existing health authorities to PCTs. Strategic health authorities will each have a doctor with responsibility for public health, but not necessarily experience in that discipline. The precise way in which the roles and responsibilities at each tier of the NHS will 'work together is as yet unclear. My purpose in tabling the amendment is to ask the Government to clarify their plans in this extremely important area, on which they have rightly placed a great deal of emphasis.

So far, the plans for NHS reorganisation have not yielded up any clear operational guidance on how the three essential elements of public health—planning, surveillance and service delivery—are to he run and co-ordinated. Ministers have referred in outline to public health networks, but there has been no indication of how such networks will relate to the statutory entities within the NHS. I am worried that, if the PCTs are to be charged with shouldering the lion's share of planning and delivering health protection and health improvement to local communities on top of what is already a huge and in part unfamiliar remit as providers of health services, we could be in a serious situation.

I am also worried that in some strategic health authorities there may be no one with the expertise of a public health doctor and that the person with responsibility for public health will not have the necessary independence that the role demands.

We then look to the regions. Regional directors of public health are to be created. Those directors will address the wider determinants of good health in the regions and will co-ordinate the design of the new public health networks. The new role for regional offices and regional directors of public health lacks a great deal of clarity. In particular, there is concern that the staff working to those offices will be working as employed civil servants, not as professional independent advocates for patients, as consultants work in the NHS.

In their recent document, Getting Ahead of the Curve, the Government have proposed a new national agency, to act as a source of national expertise and to provide key services at national, regional and local level in a range of specified areas of health protection". My noble friend Lady Noakes will have more to say about national co-ordination of public health when she speaks to Amendment No. 99 later. I am not at all clear how the functions of this new agency—yet another new agency—will differ in practice from the functions of the public health networks. How will the agency relate to the regional directors of public health and the strategic health authorities? Where will accountability lie for the success or failure of public health services? It appears at the moment to lie nowhere.

As far as we can understand it, the approach to public health in this reorganisation is piecemeal. It needs to be cohesive. At the least, we ought to have a codified plan from the Government setting out how public health services are to be delivered through the various local and national bodies, as well as a clear idea of where the duties and responsibilities lie. I did not necessarily expect to see anything on the face of the Bill in that regard—although that would have been a bonus—but it is regrettable that at this very late stage in the planning for a far-reaching reorganisation of the health service there is still almost no detailed knowledge within the NHS of how precisely and in practice the priorities for public health are to be addressed across the country. I beg to move.

Lord Clement-Jones

I shall speak to Amendments Nos. 43, 45, 49 and 51, which fall into two categories. Amendments Nos. 45, 49 and 51 are probing amendments to ascertain whether the PCTs are ready for the role that is being thrust upon them.

I must correct the Minister's earlier statements. He seems to believe that if one states that PCTs are not ready for a particular role, that is centralist. The noble Baroness, Lady Noakes, made that point. I should like to reinforce it. The Minister is developing a mantra about centralisation, which needs to be killed at the first possible moment. It is not centralist to query whether such a body is ready. It is not centralist to place a duty on a PCT if the responsibility is performed at that level. However, it must be properly performed, and a PCT must have the resources and expertise necessary to fulfil that responsibility.

There are major implications for public health services in this Bill. There is very little explicit reference to them. Public health directors will soon move from area health authorities to PCTs—on 1st April 2002. Who will fill all these roles? Will they be filled in time? What qualifications are necessary? How will PCTs deal with public health specialisms which have been built up over a number of years? What consultation has there been with public health professionals over these changes? As the noble Earl, Lord Howe, said, how does this fit in with the proposed new national agency?

In a speech which seems to be the one point of reference most public directors have, the Minister plays a considerable role with regard to how reorganisation will take place. That is perhaps flattering for the Minister, but not totally helpful for all the public health professionals affected. It is far from clear what resources PCTs will have.

The King's Fund, in its helpful way, is producing some valuable work, showing the problems that PCTs will have in taking on new public health responsibilities. Its document, launched on 26th March, is entitled Public Health in the Balance. We await that with bated breath. The King's Fund makes a hefty contribution to whatever it espouses. The title alone sounds as though it intends to publish some fairly formidable conclusions.

Devolution of public health functions has been uneven. There are concerns about specialisms being lost. Staff vacancy rates may hamper PCT efforts to deliver public health. Responsibilities for different aspects of public health are blurred, as the noble Earl, Lord Howe, has mentioned. All these difficulties need to be overcome if PCTs are effectively to discharge their public health functions.

I offer the Minister two solutions. First, for a while, exclude public health from the duties of PCTs, so we can get it right in a proper fashion. That would be my preference. Secondly, place on PCTs the kind of duties suggested in Amendment No.43 which is cognate to the amendment put forward by the noble Earl, Lord Howe.

Amendment No. 43 arises from the fact that the arrangements are by no means clear to ensure that health protection and health improvement duties are fulfilled and that the necessary resources allocated. The Government have failed to articulate how these public services should be organised to ensure coordinated delivery of programmes for health improvement, health protection and prevention programmes by the National Health Service at each level.

Who will be the lead public health officer where one local authority is served by two or three PCTs? The current reorganisation of the National Health Service has yet to produce clear operational guidance on how the three key public health functions should be run and be connected with regional and national tiers. Public health networks have been mentioned, but their formal relationship to statutory entities in the National Health Service and local authorities is not clear.

Some key questions remain on public health duties and on how this reorganisation will work. How will the Government ensure that a cohesive and balanced public health service will deliver its challenging policy commitments? How will they ensure that all these components are integrated at local, regional and national levels? The collaborative arrangements between local government and National Health Service bodies are archaic. How and when will the law be updated? What will be the relationship between public health networks and PCTs and how will they be funded?

Baroness Masham of Ilton

It is very important to have the expertise of trained doctors in public health in primary health care trusts and strategic health authorities. Are there enough trained personnel in place to deal with the rising number of cases of tuberculosis in various parts of the country and the worrying rise of the many sexually transmitted diseases, such as chlamydia, gonorrhoea, HIV, AIDS, variant CJD, food poisoning, and water-borne infections such as cryptosporidium, together with an increase in alcohol and drug abuse?

We need an increase in health education, and public health needs should be pushed up the health agenda, not fragmented within inadequate departments with too much responsibility piled on them. There are not enough experts to deal with some of these very difficult and important public health matters. I hope that the Minister will give us some positive assurances tonight that public health will be adequately financed and organised to do its job.

Lord Turnberg

One of the key elements of a public health agenda is to protect the public against infectious diseases: food poisoning, meningitis, HIV, AIDS. TB and so on. A large number of different professionals are involved in that activity, including GPs, primary care trusts, environmental health officers, consultants in communicable disease control and regional epidemiologists. There is also the Public Health Laboratory Service through its local microbiological laboratories, specialist reference laboratories, the Centre for Disease Surveillance and Control, as well as the National Health Service trust laboratories. I declare an interest as chairman of the Public Health Laboratory Service.

Primary care trusts clearly have to have a role. They are right in the middle. But they will have their work cut out to deliver what to them are relatively new activities. My anxieties increase when we know there will be considerable change in the way the PHLS network will run as the new health protection agency takes over in April 2003. The PHLS will cease to exist and the laboratories will be largely handed over to individual local National Health Service trusts.

There will be two almost simultaneous changes in the surveillance for communicable disease; in the primary care trusts taking up their new role and in the laboratory services as these trusts take over. Some degree of caution is required and special attention must he paid to this potentially hazardous transition period. I am encouraged that my noble friend the Minister is acutely aware of these difficulties and that there will be opportunities to discuss how they may be obviated. I very much look forward to that.

6.30 p.m.

Baroness Finlay of Llandaff

Perhaps I may quote the remarks of the president of the Faculty of Public Health Medicine, London, Sian Griffiths. She refers to concern among public healthworkers from multidisciplinary backgrounds and states: Since last April they have not known where they will be working on 1 April 2002. Working in public health requires a long term view". Difficulty arises in relation to the long-term strategies to ensure equity in health and health prevention issues in the nation; and there are the infection control issues that have been referred to. There is also the problem of acute infection, in relation to which public health laboratories must form part of our national defence. We have already had scares about threats to our national defence through infection, so the coordination of these services is crucial.

As Sian Griffiths has said, if this reorganisation is not to weaken the public health function a sustained input of energy, time, and resources will be needed from the government to promote [the agendas required of the service]".

Baroness Pitkeathley

For the avoidance of doubt, I should state that I occasionally act as an adviser to a company providing healthcare. I am also chair of the New Opportunities Fund, which is investing £300 million in about 300 healthy living centres which are examining public health in its widest sense.

I am fully supportive of the idea of making public health central to the NHS. However, I do not believe that the amendments are necessary. It seems to me that the Government have demonstrated their commitment by ensuring that each primary care trust has a director of public health. We must also remember that public health goes far wider than what we normally think of as healthcare. It includes such issues as access to transport, access to information, and the environment, as well as issues of neighbourhood. Having a regional director of public health in each government office reminds us of the much wider agenda on the public health issue.

The duties of PCTs in relation to public health are clearly stated—and I believe that they are understood. Indeed, I am impressed by the number of primary healthcare trusts which are already taking up those responsibilities, and taking them very seriously in terms of being responsive to the health needs in the widest sense of their local community—which is, after all, why they were set up in the first place.

Lord Hunt of Kings Heath

This has been an interesting and important debate. I welcome the opportunity to discuss the amendments. Although I do not recommend that the Committee accept them, I recognise the importance of ensuring a cohesive public health system which enables us to tackle ill health, inequalities, surveillance and public protection. My belief is that our proposals in relation to public health will do just that.

First, the distinct advantage of the organisations that we propose is that there will be a strong public health team in every primary care trust, engaged with its own community, with local authorities and with non-governmental agencies—one that is very much focused on improving health, preventing serious illness and reducing health inequalities in the population that they serve. I believe that the combination of primary care and public health will ensure that they become powerful agencies for public health in the community.

Every PCT will have a director of public health on its board. This will be a high-level appointment. We expect the new posts to be taken up by public health professionals of the highest calibre. Regional directors of public health will have a key role in the selection process for the posts, to provide the necessary quality assurance.

For the first time, the director posts will be open to all suitably trained public health specialists, both medical and non-medical. In relation to the questions raised about the workforce and the numbers, my department is working at national level to strengthen the public health workforce and ensure that high-quality training programmes are in place to deliver the next generation of public health professionals.

As I have said, the new role of public health in primary care has enormous potential. The new directors of public health up and down the country will be the engines of public health delivery. The focus of their activity will be on local neighbourhoods and communities, leading and driving programmes to improve health and reduce inequalities.

It will be the job of the public health teams in primary care trusts to ensure that maximum health improvement is brought about by prevention and other interventions. In addition, the director of public health will be accessible to the local media to explain health inequality issues. The DPH will have a team whose composition will be a matter for local determination. They will seek to ensure that the public health role of the primary care workforce—including health visitors, school nurses, health promotion and other community workers—is fully realised by encouraging practitioners to lead specific programmes.

A number of speakers mentioned the public health networks. I agree that these are of importance. Essentially, the public health networks will provide the specialist expertise which cannot be provided in every single primary care trust. The idea of the networks will be to pool expertise and skills in specialist areas of public health which can then be available to all primary care trusts, to share good practice, to manage public health knowledge and, importantly, to act as a source of learning and professional development.

I want to make it clear that this will not be an additional tier of NHS management; nor will it adhere to rigid professional boundaries. The networks will be flexible and responsive, and they will change and evolve over time. For example, a network will be able to respond to cities for public health advice and action programmes. New NHS structures will not be able to match every local authority boundary, but a flexible, responsive network will, for example, be able to support the Health Cities initiatives, so vital in many parts of the country.

This country has a long and highly respected tradition in academic epidemiology and public health. It has been vital in contributing to the knowledge base for disease prevention. Academic departments of public health in the universities, with and without medical schools, have also played a vital part in education and training. We want to ensure that those academic strengths are preserved and maintained in the changes.

It is important that the existing public health research and development funding by health authorities continues to be spent on public health R&D, and we are considering the most appropriate management arrangements to enable that to happen. Public health networks will also include non-governmental organisations which have a key role to play in improving health and reducing inequalities, and also in dental public health.

One question that is apposite to public health at the primary care trust level—a question asked by the noble Earl, Lord Howe—relates to the lead public health officer in an area where two or more primary care trusts cover the area of one local authority. My understanding is that the directors of public health serving that area, working within the local public health network, decide and agree on the best arrangements for ensuring the high-quality advice to each individual local authority. That will include named lead public health officers.

At the strategic health authority level, there will be a senior public health doctor in every health authority as a member of its top team. They will have a distinctive performance management role in relation to the constituent NHS organisations within their boundaries, including, of course, primary care trusts and the public health role of those primary care trusts.

While not duplicating the work of directors of public health in primary care trusts, strategic health authorities will have responsibility for performance management of public health action within primary care trusts. In order to discharge that, each strategic health authority will need a medical director/public health doctor with the appropriate strategic management skills to undertake this function as a member of its top team.

From April 2002 at the regional level there will be a regional director of public health and a support team in each of the regional offices of government to provide the Department of Health's public health function. The senior officers and the teams will have a wide-ranging role: they will manage and co-ordinate the health protection and emergency planning functions in their regions; they will design, develop and maintain public health networks; and they will tackle the root causes of ill-health inequalities through the health component of cross-government policies in the regions. Overall, regional directors of public health will be accountable for ensuring that appropriate high quality health protection arrangements covering infectious diseases and other risks to health are in place in all locations in their regions. They will also be accountable for managing and co-ordinating the health aspects of the Government's response to emergencies and disasters.

In addition, I refer to the Chief Medical Officer's proposals, which were announced on 10th January and which are designed to streamline the services involved in the prevention and the control of infectious diseases. The proposed health protection agency will provide an integrated approach to all aspects of health protection, including chemical and radiological hazards as well as infectious disease control. The agency will take over functions that are currently performed by the Public Health Laboratory Service to which I pay great tribute. I hope my noble friend Lord Turnberg will convey that to the PHLS. The National Radiological Protection Board, the Centre for Applied Microbiology and Research and the National Focus for Chemical Incidents will also assume responsibility for employing consultants in communicable disease control.

The new agency will work closely with regional and local services and the expert government advisory committees. The new agency will also work with CHI where there are serious deficiencies in standards of infection control in hospitals, primary care or other health service premises.

I recognise the crucial importance of surveillance. The CMO's strategy makes that clear as regards infectious diseases and environmental hazards. We envisage that the new health protection agency, proposed in the CMO's strategy, will have a key role in surveillance of infectious diseases and environmental hazards and, as part of that, will work through the NHS to decide what role other players should have in surveillance.

I do not believe that it is desirable to write the requirement to carry out surveillance into primary legislation. It can be dealt with through secondary legislation, which will allow more flexibility over the precise form that the requirement should take. The responsibility for systems for monitoring the health status of the public is much wider than the role of strategic health authorities. As I have indicated, there is a crucial role to be played at the primary care trust level and at the regional level.

The public health functions of PCTs are set out clearly in the Next Steps paper. To set them out in statute is neither necessary nor appropriate as the achievement of health improvement and reductions in health inequalities cannot be accomplished by PCTs working alone.

I hope that noble Lords will recognise from what I have said that the Government consider that a cohesive integrated approach to public health is important and essential, and that each part of the new public health system, whether at the primary care trust level, in networks, at strategic health authority level or the regional level, or in the new health protection agency, as announced by the Chief Medical Officer, will ensure that we have a safe integrated function.

As my noble friend Lord Turnberg has said. I recognise that a great deal of detail needs to be talked through and developed. I am happy to meet him, and other noble Lords who are interested, between now and Report stage to fill in some more of the details. I am confident that the approach that we are taking will provide a strong public health element at every level of the NHS and the required protection that the public so richly deserve in what I accept is an important area.

6.45 p.m.

Baroness Cumberlege

I thank the Minister for such a clear exposition of how this matter will work in terms of the public health function. However, I am concerned about one point. The Minister said that at the PCT level the public health officer may not be a doctor—it could be anybody. Obviously it would be someone with a good qualification, but not a medical qualification. Is that a wise move? I understand that all kinds of people—geographers—may have an interest in looking wider in terms of public health, but I wonder about the credibility of such people among other medics whom they will have to lead and influence. We know that at times the medical profession can be chauvinistic. I am anxious that the system is robust and that we do not have a woolly social scientist who will have no credibility with the medical profession.

A new agency will be set up and my heart warms to that in terms of the debate that we had earlier in Committee. But I wonder how the Health Development Agency, which was the successor to the Health Education Authority, will work with the health protection agency and all the other bodies that will be set up. Can the Minister tell the Committee what the Health Development Agency has achieved, if anything?

Lord Hunt of Kings Heath

The Health Development Agency has made a good start. The particular focus of its work is in producing evidence-based research in the area of public health. That will be available for public health professions, NHS authorities, local government and other agencies at local level to inform them as to what is likely to work best in terms of public health intervention. I believe that that agency has made a good start. We would expect it to work alongside the grain of these new arrangements.

I was disappointed that the noble Baroness raised the issue of non-medics performing the role of public health specialists. I would have thought that she, of all people, would have welcomed this move—indeed the Faculty of Public Health Medicine has welcomed it—as she was passionate about nurse-prescribing and about developing the skills of non-medics in the health service. I believe that it will enrich the public health profession.

I accept the implication that the people appointed must have the highest public health skills. My understanding is that the non-medical public health specialists who are likely to be appointed would have either a Masters or a PhD in a public health discipline and would have years of experience behind them in the area of public health. In appointing a non-medic to that post a primary care trust would clearly have to take account of the kind of issues that the noble Baroness has raised. I would not cast aspersions on social scientists, as the noble Baroness did. I am convinced that this will be a way of bringing in new people and giving proper career development to people who have gone into public health but are not medically trained. However, I believe that they will receive support from many in the medical profession.

Lord Clement-Jones

Perhaps I can elicit further information from the Minister. I thank him for his initial statement that set out the broad pattern. However, it is regrettable that he has to set it out in that way, whereas on the face of the Bill it would not have been difficult to set out the strategic health authorities, primary care trusts and—

Lord Hunt of Kings Heath

Earlier I said that I would be happy to meet with noble Lords between the Committee and Report stages. If it is helpful to the Committee, I shall set out in some detail how we see the public health arrangements developing and I shall be happy to send that to the noble Lord and to other noble Lords who have spoken in this debate.

Lord Clement-Jones

That would be helpful. I was going on to ask the Minister whether, in addition to the statements made in Next Steps and what he has said today, there would be a clear statement of accountability. I believe that the accountabilities and the responsibilities at each level will be so important in determining who has the lead role on particular matters. Some will be national; some will he regional; and some will be extremely local with the involvement of the health protection agency as well. I welcome the creation of that agency, but one wants to be sure that that scoops up all the current activities in the effective way in which the PHLS has operated. So I think that that would be helpful.

One matter that the Minister did not touch on is the funding of public health networks. How will they be funded? Will it be a matter of PCTs effectively chipping in to the pot, or will there be another source of funding?

Lord Hunt of Kings Heath

I think that it will be very much a matter of PCTs pooling their budgets together. PCTs are deciding that, in some parts of the public health function, it would be better to work together with a number of other PCTs. It therefore seems eminently appropriate that that should be funded from their own budgets.

Earl Howe

This has been a helpful debate. I thank the Minister for filling in a number of the blank spaces that existed in my mind before we began this discussion. It is not so much a matter of including in the Bill anything relating to public health as of setting out for the National Health Service and those who work in it how these arrangements will work. I am aware that, until very recently, many have been ignorant of how in practice these functions are to be distributed and how accountability will work. However, the Minister has explained, in more detail than we have had to date, how in practice PCTs will take responsibility for their public health function. There has been helpful clarification of the role of public health staff at strategic health authority level and in the regions and the role of the health protection agencies.

The Minister used the word "integrated". Although I am sure that that is what the aim should be, going back to those three headings of the public health—planning, surveillance and delivery of services—I would welcome further clarification of how those functions are to be parcelled out across the tiers of the health service. Perhaps between now and Report the Minister can copy me in on whatever he distributes to Members of the Committee.

Workforce planning is a very difficult exercise in the field of public health, especially in a city such as London. I am aware that the King's Fund report which was referred to by the noble Lord, Lord Clement-Jones, will specifically focus on London. The noble Lord, Lord Turnberg, was absolutely right to draw attention to the wide range of professional expertise to be found in public health, from the very specialised expert to those working in the community. This is certainly not a matter of re-arranging in some simple way the roles and the jobs that are currently being performed. The restructuring will deeply affect the way in which public health is delivered.

I am not clear in my mind what the Chief Medical Officer's role will be in terms of the ultimate accountability for public health. I imagine that, in broad terms, that will remain as it is now. However, if there is any change in substance or in nuance, perhaps the Minister could tell me.

Lord Hunt of Kings Heath

The regional directors of public health will have a performance management responsibility in relation to the strategic health authority public health person, who in turn will performance manage the primary care trust. The regional public health directors will be managerially accountable for their public health and health protection functions to the Chief Medical Officer as well as to the relevant director of health and social care. So the Chief Medical Officer is at the pinnacle of those levels, and I think that he or she will keep a pivotal role in ensuring that the overall arrangements work effectively.

Earl Howe

I am grateful. I rather deduced that that would be the case from the Minister's earlier remarks. We may see fit to return to this subject at a later stage, but I think that it is now time to move on. I thank all noble Lords who have taken part. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 43 not moved.]

Clause 3 [Directions: distribution of functions]:

[Amendments Nos. 44 to 51 not moved.]

Clause 3 agreed to.

[Amendment No. 52 not moved.]

Baroness Noakes

moved Amendment No. 53: After Clause 3, insert the following new clause— "PROVISION OF SPECIALIST SERVICES (1) The Secretary of State may not make directions to a Primary Care Trust as to his functions under section 13 of the 1977 Act unless he has made arrangements for the provision of specialist services. (2) The Secretary of State must consult health professionals who have an interest in the provision of specialist services before making the arrangements referred to in subsection (1) above. (3) Specialist services for the purposes of this section are those services which are not provided within the territory covered by the Primary Care Trust. The noble Baroness said: This amendment inserts a new clause after Clause 3 and is designed to ensure that the Secretary of State does not delegate his functions to primary care trusts unless he has made arrangements for the provision of specialist services. Furthermore, the Secretary of State will be required to consult health professionals who have an interest in those specialist services before making the arrangements.

The roots of this amendment lie in concerns that have been expressed not only by many doctors, but, on Second Reading, by the noble Lords, Lord Turnberg and Lord Walton of Detchant. Those concerns centre on whether PCTs will be effective commissioners of tertiary services and other highly specialised services such as neurosurgery, renal dialysis, transplantation cardiac-thoracic services, and many more. The concerns are on several levels. The first is that the new PCTs will simply not be ready for such complex commissioning. The Committee has already debated the readiness of PCTs. Although I for one am not confident that they will be capable of handling the full range of their responsibilities from October 2002, I shall not labour the point in speaking to this amendment.

Secondly, on Second Reading, concerns were expressed by the noble Lord, Lord Turnberg, that specialist services will be "relatively neglected" by PCTs. It is a question not simply of technical readiness for commissioning, but of attitude and orientation. Indeed, I have heard concerns that the acute sector generally could be neglected by PCTs, which have a natural primary care orientation. If there are fears about the acute sector in general, those fears exist in spades for specialist services.

Thirdly, on the first day of consideration in Committee, concerns surfaced about how commissioning will work in practice. The Minister told us that he expected one PCT to take the lead in commissioning within an area covered by strategic health authorities. However, he also said that it might be possible that a PCT would not buy into what he described as the, agreed programme for the commissioning of specialist services". He then said that if a PCT was, not prepared to play ball … the strategic health authority would have the opportunity to intervene and bang heads together". [Official Report, 14/03/02; cols. 1024–25.] It cannot be satisfactory for the commissioning scheme for vital specialist services to depend on the head-banging abilities of strategic health authorities.

I know that some would have been reassured if responsibility for commissioning specialist services were given to strategic health authorities—much as when, in the good old days, regional health authorities were responsible for funding specialist services within their region. However, the Government seem to have an unbending view that they will place responsibility on the least appropriate tier, and then clear up any messes through intervention—or head banging—by the next tier. It is far from self-evident that those arrangements will work effectively.

'The document Shifting the Balance of Power does provide for the continuation during 2002–03 of the existing regional specialised commissioning groups. Will the Minister say what will happen if PCT capacity to take these responsibilities one year hence has not matured sufficiently? Will the Government be prepared to reconsider and keep these regional groups in place?

On our first Committee day last week the Minister said that the Government intended to continue with national specialist commissioning arrangements. Will the Minister say what those arrangements are, and will he say why they could not be extended to provide a more secure commissioning route for a wide range of specialist services?

It would be folly to proceed with the delegation of functions to PCTs if it was not clear beyond peradventure that the commissioning of specialist services would be fully effective. They are vital services and must be protected. I beg to move.

7 p.m.

Lord Clement-Jones

The noble Baroness, Lady Noakes, has very succinctly put the case for her amendment, with which I and these Benches wholeheartedly agree.

The Minister will remember that. I expressed fears about the current pattern proposed by the Government for specialist commissioning when we debated a regional health authority proposal versus a strategic health authority proposal. I could tell that the Minister's mantra was coming on when the noble Baroness, Lady Noakes, proposed the strategic health authority option, and I am sure that it w ill come on again when I mention the regional: health authority option. The point of devolution, however, is that the service is devolved to the point at which it can be best delivered. There is a considerable fear that these proposed consortia are not the most appropriate way of delivering specialist services.

To remind noble Lords, the Department of Health has recognised 35 treatment areas which are considered as specialist areas, ranging from cancer, to heart disease, to haemophilia, to HIV. They are some of the most serious and important conditions that need to be treated by the health service, and certainly require their own commissioning arrangements. There is no guarantee, however, that the consortia envisaged will have a sufficient number of local PCT members to provide for viable services. This could lead to a new postcode lottery for specialised services—something which the Government dedicated themselves against on coming into office—where the availability of treatment for these serious illnesses is decided not on clinical need but on geographical location.

Shifting the Balance of Power: The Next Steps, which seems to be the Bible for this part of the Bill, sets out how PCTs are expected to commission local services. Despite being billed as the definitive expression of government policy, the document does not contain any mechanism for guaranteeing that local commissioning consortia will have a sufficiently large membership to be viable. This system could lead to substantial disruption in the provision of specialised services, as PCT boards decide that local, relatively low-cost, high-volume services are a greater priority for investment than membership of consortia for high-cost, low-volume treatments.

The Government's response to these concerns has been to commit themselves, to maintain service continuity and allow co-ordinated service development", for specialised services. This policy principle is to be delivered by the proposed system of PCT consortia. Although the health service circular guidance states that PCTs, with significant service agreements with the same provider will work together to ensure consistency in the core elements of the service agreements", and that, PCTs will work in consortia to ensure that specialised services continue to be effectively commissioned at StHA and supra StHA levels", they remain unclear how this will in fact operate on the ground.

The Government have committed themselves to a steady state of funding in 2002–03—whatever that means—with PCTs obliged to honour the service contracts of their parent local health authorities and regional specialised commissioning groups. Welcome though that is, it does not guarantee an extra year of funding if service agreements expire next year. There is no clear transitional process to cover circumstances where local health authority service agreements run out and existing consortia do not effectively cover specialised commissioning needs.

The existing regional specialised commissioning groups will continue for an extra financial year, as the noble Baroness, Lady Noakes, has explained, until April 2003 and, will have a specific role in developing PCT capacity to commission specialised services as part of a planned transition to successor arrangements". The regional commissioning groups, however, will have no power to compel PCTs to join consortia. With a large proportion of PCT chief executives still to be appointed, it is not clear how many PCTs are likely to participate actively in their work.

This is rather a confused picture and it is no wonder that there is cause for concern. Local health authorities, who do have the tradition and personnel with experience of commissioning specialised services, will be replaced under the new arrangements with groups led by general practitioners and others, who may well have little experience or indeed familiarity with the priorities for these treatments. Although some personnel will transfer between the two, there is no guarantee that local health authority funding priorities will be shared by their successor PCTs once existing service agreements expire.

Although the existing consortia have had mixed success in attracting health authorities to their membership, even though local health authorities have a tradition of strategic planning for specialised services, this problem is likely to be exacerbated by devolution to PCTs—who will of course have a fairly steep learning curve—for commissioning across the board. It is likely that, under these conditions, the number of opt-outs from consortia will increase and this could undermine the effectiveness of specialised commissioning agreements.

I have painted a fairly bleak picture and I hope that the Minister will be able to dispel some of that bleakness, but those are the fears that many have about the current arrangements and I look forward to his reply.

Lord Turnberg

The problem that PCTs have in being responsible for commissioning specialist services may not be insurmountable but nevertheless will be a problem. The problem is that, by and large, the number of patients requiring specialist care is fairly small in the population for which they are responsible, of something like 100,000.

It poses particular problems for an individual PCT when there are so many more patients requiring its attention and having more pressing problems. For example, two or three patients with a rare, expensive disease such as haemophilia, moving into a new GP's practice can cause enormous problems and havoc for its budgeting. Patients needing renal dialysis or transplantation, for example, may be ill served in this system and such services may become threatened in the process.

The proposal that a lead PCT will act for several PCTs may work, but only if each PCT is willing to fund it. I have spoken to one or two non-executive PCT members and they tell me that there is considerable reluctance to fund in this way. I am not yet convinced, therefore, that specialist services should be the responsibility of PCTs, but rather should be the direct responsibility of strategic health authorities. At least there the population of a million or more provides enough patients with specialist services for them to take a particular interest.

Although I am not in favour of these particular amendments, I would look to a separate system for commissioning those services, which I think would be very much welcomed by the PCTs and by the NHS trusts. There may of course be other ways in which we can ensure that these important services are not damaged and are protected. I very much look forward to hearing how the Minister will reassure us on this.

Baroness Masham of Ilton

I would like to declare an interest. I would not be here today if I had not been treated in a specialised unit—a spinal unit which was classified as a supra regional unit, that is, going beyond the region. I was very grateful to the Minister, who came down to see one of the spinal units when it was experiencing some difficulties.

What will be the national overview with regard to these specialised units? Will Ministers still be able to be involved? I believe that some of the very complicated neurological conditions must be treated in specialised units. Can and will the patients be able to be sent anywhere in the country for treatment? Sometimes their needs are very unique, and there are but a few specialists dealing with such conditions.

I should like to tell the Committee how important it is to get the correct treatment quickly, and how cost effective it is. I had seen so many disasters in the spinal injury field with people receiving the wrong treatment and suffering from horrific pressure sores that I founded the Spinal Injuries Association. Some years ago, we undertook a survey on pressure sores, which cost the country millions of pounds of extra money that could be avoided. We found that the worst pressure sores arose in the intensive care units of teaching hospitals. That may seem surprising, but, while everything is monitored, the basic skin is forgotten. It is often the basic treatment that is so important. Therefore, the expert doctors, nurses, physiotherapists, and all the ancillary staff, have an important role to play.

I believe that such amendments are very significant. It will be interesting to hear what the Minister has to say, because many people throughout the country are worried about these very specialised services. I look forward to hearing his response.

Baroness Finlay of Llandaff

Perhaps I may express my concern over the lack of protection of secondary and tertiary services, as outlined in the Bill at present. The problem is that tertiary services are integrally linked with secondary care services: they cannot be separated. We do not have enough resources to separate tertiary care completely from secondary care. Therefore, within the hospital sector and the specialist sector of the NHS we have the full range of services, of which I should like to give the Committee some specific examples. I should declare an interest here as I am married to a dermatologist. Building on the example of skin, as used by the noble Baroness, Lady Masham, I should point out that dermatologists function as generalists, but within that service there are also highly specialised fields, such as paediatric dermatology, surgery, viral disease, inflammatory diseases, and occupational dermatology clinics, as well as cancer clinics.

I should also declare an interest as I have just been a patient and been in receipt of Mohs surgery, which, until I was on the receiving end of it, I did not know existed. There are a handful of specialist dermatological surgical centres around the United Kingdom, as well as a few photo-dermatology centres; yet there are general services everywhere. The difficulty with not protecting the whole of the secondary care sector in commissioning is that you may well find that you are simply buying a generalist service, and losing the highly specialised expertise that is required in the process.

I also have a concern that we might return to some of the nightmares that occurred under fund holding. At that time, it was an administrative nightmare to find that some fund holders had contracted for certain services while other fund holders had not done so. Therefore, you would have two patients from different areas under separate GPs who, under the commissioning arrangements, were able to access different parts of services. That inequity was terrible for those functioning in the secondary care or tertiary care service sectors.

My other concern is that there may be a misguided view that primary care trust commissioning will somehow act as a form of rationing and control expenditure in secondary and tertiary care. However, there is evidence to show—although it is anecdotal—that unmet needs are revealed where GPs and those in primary care are better educated about conditions. The result is more appropriate referrals, not fewer referrals. There is a need to ensure that the spectrum from high quality primary care into secondary care and on to tertiary care is protected right the way through, thereby securing the highest standard of care for patients who need it at the time that they need it; in other words, not too late when problems have to be undone. I look forward to hearing the Minister's reply.

7.15 p.m.

Baroness Northover

When the internal market was first proposed, I remember a high level civil servant from the Department of Health being asked how the new arrangements would ensure that specialist services would be preserved. She replied that she did not know, and that 15 years would show whether or not they would go to the wall—by which time, of course, it would have been too late. It struck me then, and still does now, that that was a most cavalier approach. Indeed, since the NHS was introduced, specialist services have often sat uneasily in a service that tries to provide everything everywhere and ends up by not doing so. Unless this area of concern is properly addressed in the way outlined, yet again, a civil servant at the Department of Health might, truthfully, be able to say that he or she does not know; and, indeed, such services might well go to the wall.

We all know how important it is to retain specialist units given the huge variation of outcomes according to whether or not people are treated in such units. I was not reassured during the briefing meeting before the Committee stage, which was otherwise most helpful, when the Minister seemed quite unsure as to how decisions would be taken as regards which PCTs would lead in each specialist area. I trust that the Minister will be able to give more concrete guarantees today.

Lord Hunt of Kings Heath

The matter of specialist services is one that has always been of great interest to noble Lords, and rightly so. I am the first to accept that it is important not just to patients but also to the NHS—and to the wider issues of teaching and research in this country—that we support our specialist services with the right kind of resources, and the right kind of agreements, in terms of ensuring that there is appropriate patient referral.

I echo a point made by the noble Baroness, Lady Finlay. My general view on the matter is that part of the approach of getting this right is to recognise the inter-relationship between primary, secondary and tertiary care rather than treating specialist services as an isolated service to be resourced and dealt with in a completely different way from that applied to other services that will be commissioned by PCTs in the future. The care networks under development in a number of important areas involve an integrated approach through from primary to secondary and then to tertiary care. They are very often roughly aligned with the strategic health authority boundaries. I certainly hope that they will provide the sensible approach in terms of commissioning, funding, and the referral of patients that we all seek.

By their very definition, specialist services are those with small patient numbers. Quality can be achieved only by bringing together a critical mass of patients in each specialist centre. Inevitably, relatively few centres will be able to offer treatment, and there will not be a specialist centre in every locality. By concentrating specialist services in a few centres, we hope to achieve the best outcomes, maintain clinical competence, sustain the training of specialist staff, support high-quality research programmes, and ensure that services are cost effective, while making the best use of scarce resources, including expertise, high technology equipment, research and development.

As the noble Lord, Lord Clement-Jones, suggested earlier, typical specialised services include drug treatments for HIV and AIDS, rare cancer services, children's intensive care services, neuro-surgery, secure mental health services, renal services, and so on. Where those services are for exceptionally rare conditions, and where service provision would otherwise be vulnerable, the National Specialist Commissioning Advisory Group will be asked to commission the services on behalf of the whole country. I have a list with me of the designated national services in 2001, which includes over 20 services. Again, I shall be very happy to place a copy of this list in the Library of the House for the convenience of noble Lords.

It is important to stress that national commissioning can and should occur only where local solutions are impossible to achieve. That is why under Shifting the Balance of Power, which contains the principles under which the Bill is brought before the Committee, primary care trusts will be responsible for commissioning health services for their local populations. That principle applies also to specialist services.

However, we recognise that where it makes sense to organise services on a larger population base, so those services will be organised on a larger population base. That is why primary care trusts will be expected to work together on a consortium basis to secure specialised services, except for that list of highly specialised services which will continue to be commissioned at national level.

The noble Baroness, Lady Northover, felt that I was not explicit enough on how a PCT would be selected at local level if it was decided that one PCT would undertake specialist commissioning in relation to one service and another PCT would take on specialist commissioning for another service. I do not believe that I should be explicit, nor that it is my position to be. The point is that this is the kind of arrangement—

Baroness Northover

I thank the Minister for giving way. I was concerned at the briefing meeting about what would happen if no PCT wanted to take a lead in this matter. I would be happy if a PCT wanted to take a lead. That would obviously show an interest and an incentive to do that. However, it seemed to me in the briefing meeting that it was not clear what would happen if no PCT wanted to take a lead.

Lord Hunt of Kings Heath

That is where my "banging of heads" comes together. I shall come to that in a moment in response to the noble Baroness, Lady Noakes.

A number of noble Lords asked about the existing agreements. Perhaps I may state clearly that primary care trusts will be expected to honour existing agreements, financial and otherwise, negotiated by regional specialised commissioning groups and current specialised service commissioners. In future, specialised services will continue to be defined by reference to the national specialised services definitions set. I shall place that information alongside the designated services information in the Library.

In the financial year 2002–03, regional specialised commissioning groups, which will continue in existence for the moment, will have a specific role in developing primary care trust capacity to commission specialised services as part of a planned transition to successor arrangements. We are retaining for the moment the regional specialised commissioning groups to ensure that their capacity and skills can be handed over to primary care trusts as part of a planned transitional arrangement. Although continually in our debate today doubt has been passed on both the capacity and willingness of PCTs to take up that challenge, that is not my experience. From speaking to many primary care trusts, I know that work is already taking place in terms of deciding which PCT will take on a particular role on behalf of other PCTs in developing the specification and in the commissioning of such specialist services.

We expect primary care trusts to work together to ensure that specialised services will be effectively commissioned. If appropriate, that might cover the population size of the strategic health authority or involve going across one strategic health authority boundary to another. I understand the concerns being expressed. I can assure noble Lords that it will not be a question of a haphazard approach with some primary care trusts clubbing together and others staying out. We shall expect primary care trusts to form consortia to take collective decisions about the commissioning of specialist services, and that consortia decisions will be binding on all parties.

My noble friend Lord Turnberg spoke of non-executives who said, "We are not really interested in funding specialist services". However, the reality is that the whole structure we are putting into place will not work if that "head in the sand" approach is taken. Seventy-five per cent of the budget of the National Health Service will be at PCT level. The quid pro quo of that kind of resource being devolved to that level is for primary care trusts to accept that they have a wider responsibility than simply their own primary care trust.

In our debate last Thursday, I said to the noble Baroness, Lady Noakes, that if ultimately a particular primary care trust refused to go into such a consortium arrangement—I do not expect that to happen—I would expect the strategic health authority to call it to order. Perhaps I may say to the noble Baroness that her doubts about the effectiveness of banging heads surprised me. Her reputation in the department as a most effective banger of heads is still as strong as ever within the walls of Richmond House. Surely, the new leadership skill of the strategic health authorities is not to second-guess primary care trusts nor to attempt to micro-manage, but to have an ability to intervene where necessary if there is a problem.

Perhaps I may say to the noble Baroness, Lady Masham, that I am well aware of the issues concerning spinal injury units. Indeed, I would regard the well-being of such units as a test of the new commissioning arrangements in two ways. First, it is to show that PCTs have the ability to commission such specialist services. Secondly, I took the point she made about patients who may have been cared for in such units being further treated in local general hospitals where their specialist needs may not be fully understood. One of the great advantages of primary care trusts is that they can leverage pressure at local level on those district general hospitals.

I have spoken at some length. I am confident that the new arrangements can work effectively. I do not agree with my noble friend Lord Turnberg that to top-slice specialist service commissioning at strategic health authority level is a good thing. I believe that it detracts from both the competence and authority of primary care trusts. I believe that the arrangements I have described with the performance management role of strategic health authorities is the best way to get us through this issue.

Baroness Noakes

I thank the Minister for that response. Indeed, I thank all other noble Lords for taking part in the debate on the amendment. I hear the Minister explain how this will work in practice, but we keep coming back to the fact that he has one view of the world—that is, that there will be PCTs which will do these things and strategic health authorities which will do certain things, largely called "performance management"—and that he seems unwilling to accept that there may be better ways to do things at different levels. He said, for example, that where it would make sense to organise commissioning on a larger population base than for PCTs, the answer—which most of us would think logical—would be to say, "Let's do it at the strategic health authority level or with a group of strategic health authorities, if necessary"—

Lord Hunt of Kings Heath

I am grateful to the noble Baroness for giving way. That was not quite what I said. The responsibility would still be with primary care trusts, but the specialist commissioning might go across strategic health authority boundaries and therefore engage a wider group of primary care trusts.

Baroness Noakes

I thank the Minister for that. I was aware of it. The point was that if the noble Lord was saying that commissioning should be done on the basis of a larger population area the logical answer is to say that several PCTs should do it. The logical answer is to ask whether there is another tier in the service that more naturally can fit with the commissioning need. Yes, there happens to be another layer called the strategic health authority. So it is logical. The Minister starts from the proposition that everything must be put down to PCTs and then be lifted back up again. Some of us see the matter as being much more logical, secure and safer in terms of commissioning coherence and robustness if it was not pushed down and then brought up but was left at a higher level.

7.30 p.m.

Lord Clement-Jones

Will the noble Baroness agree with me that we are now in the second of two debates where we get these rather precarious organisations. We have this consortium of PCTs in the case of commissioning and with regard to public health we have these rather amorphous public health networks. It seems to me that we are building rather a lot of responsibility into organisations which are highly precarious.

Lord Hunt of Kings Heath

Could I—

Baroness Noakes

I completely agree, but the Minister may want to say more than that.

Lord Hunt of Kings Heath

That is why I rose, to try to deal with the issue before the noble Baroness felt that she had to respond. The point is that as dedicated de-centralisers the Government are investing a great deal of faith in primary care trusts. I make no apology whatever for that. Of course there are some areas where commissioning needs to go wider than primary care trusts. I agree with the noble Baroness that we could have taken a different approach. We could have said to strategic health authorities, "You do all the difficult things. Top-slice the money and leave primary care trusts with the routine stuff". But that would have detracted from what we are really trying to do, which is to get decision making down to the primary care level. If one goes down the Government's route, you do—

Baroness Finlay of Llandaff

I express a grave concern. The Minister has expressed that he has great faith. I would call for evidence to support the changes, and evidence that patients' care will not be jeopardised. I have a real concern that while the changes go through—we know that it takes two years for organisations to bed down and find new ways of working —there will be ill patients who miss out on the services they need. There will be arguments between who is commissioning what. In the process of that, services will be destabilised. Destabilised services do not function well.

Lord Hunt of Kings Heath

The evidence that I would pray in aid is: first, I have already described how the current regional specialised commission arrangements will hold for another year while the regional specialised groups work with primary care trusts to ensure that in the future they have the capacity to undertake specialised commissioning.

Secondly, we are working already with primary care trusts which have been in existence for some time. The evidence I have to hand is that they have worked very well indeed. They have delivered improvement to patients. They have not led to huge gaps, risks or failures to commission certain services. In Fact, they have shown that it is perfectly possible to deliver and commission services at the primary care level while at the same time recognising that they are part of a fully integrated national system. It is that balance that gives me a great deal of confidence that primary care trusts will rise to the challenge being set for them.

Baroness Noakes

That, while an admirable expression of faith in whether or not the system will work, is not much more than that. It does not constitute evidence that the system will work. Most Members of the Committee who have spoken in the debate have raised concerns about whether or not these arrangements will work in practice; whether all the PCTs will be ready, able and/or willing to participate in specialised services commissioning, as the noble Lord wishes they would; and whether within a strategic health authority area they will agree on the same things—such as whether there will be effective commissioning or whether there will be a lot of dispute. As the noble Baroness, Lady Northover, said, we really cannot wait until the specialised services have fallen apart to say whether or not this approach is right.

The hour moves on. We have had a good exchange. I thank all noble Lords who have taken part in the debate. I think that this subject will not go away. We shall reflect carefully on what the noble Lord has said. We look forward to the items that he will table for us to read in the Library. I anticipate that we may well return to this matter. I beg leave to withdraw.

Amendment, by leave, withdrawn.

Clause 4 agreed to.

Schedule 3 agreed to.

Lord Filkin

I beg to move that the House do now resume. Perhaps I may suggest that the Committee stage be resumed not before 8.36 p.m.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.