Health Policy InsightEditor's blog Tuesday 5 April 2011: Select committee report - competition confusion and re-inventing PCTs
The new report from the health select committee, Commissioning - further issues, is now online.
It is a thoughtful analysis of issues, and as such, comes up with some points that will scarcely improve the gloomy mood of DH ministers.
They will rhetorically welcome the report, and promise to take due note of it in their forthcoming 'hearing but not listening' exercise.
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However, they cannot adopt its recommendations without putting the Health And Social Care Bill out of its protracted misery.
The committee's report is not a 'Get Lansley' job. It makes proper effort to suggest ways and means of unpicking the dilemmas that are becoming increasingly apparent from the policy turmoil.
Consider a few key points of the Bill: at paragraph 8, it states, "Voters will, however, rightly continue to regard the Secretary of State as accountable for the development of the NHS—there can and should be no doubt that ultimate responsibility rests with him. The Government must therefore put in place structures which enable the Secretary of State to respond to this political reality".
Mr Lansley does not want this: it is antithetical to his vision.
At paragraph 18, the report warns that the Bill's changes "create the danger of an overcentralised system", and calls for "a strong local voice in the commissioning system" - specifically, the report later outlines that every commissioning organisation must have a traditional statutory, public-meeting, paper-publishing board. These boards must be 17-strong, with an independent chair (appointed by the NHS Commissioning Board); a nurse; a hospital doctor; a chief executive; a director of finance; an elected local authority representative; a social care representative; a nominated public health expert and a majority of GPs. (Such boards would of course make the proposed Health And Wellbeing Boards redundant, as the report notes.)
Mr Lansley does not want this: it is antithetical to his vision.
At paragraph 66, the report states, "The statutory governance arrangements for local commissioning bodies should prescribe that Boards have a duty to meet in public and their papers should be available to the public".
Mr Lansley does not want this: it is antithetical to his vision.
At paragraphs 79 and 80, the report states, "the Committee finds that the evidence provided by the Secretary of State and officials runs counter to the direction of policy. If integration of primary and secondary care commissioning is important, then separating them in order to support the proposed system architecture may cause significant harm to the commissioning system as a whole, and should be reconsidered.
"The Committee agrees that confidence in the governance arrangements of local commissioning bodies is key to them taking on greater responsibility for primary care commissioning. The Committee considers that arguments for the complex arrangements set out by the Government fall away if our proposals for significantly strengthened governance in NHS Commissioning Authorities are accepted. Given this, the Committee recommends that NHS Commissioning Authorities should assume responsibility for commissioning the full range of primary care—including services such as pharmacy and dentistry as well as general practice—alongside their other responsibilities".
In short, that all primary care provision should be commissioned locally; not nationally by the NHS Commissioning Board.
Mr Lansley does not want this: it is antithetical to his vision.
Ambiguity on competition regulation
A striking aspect of the report is the surprisingly muted comments on Monitor and competition regulation.
Given that as economic regulator, Monitor will determine how the money goes and lay down the competition rules, Chapter 9's five-and-a-half pages rightly highlight the Bill's dangerous vagueness and ambiguity on the issue of commissioning intentions and willing providers.
However, it reads as if the Committee held three divergent party-political views on competition regulation.
There is a brief reference to Monitor chair David Bennett's Times intervention at paragraph 155, where the report states, "The Committee does not find this comparison between healthcare and the privatised utilities either accurate or helpful. Competition in the privatised utilities helps to create a balanced relationship between individual customers and the utility; the government is not directly involved in the relationship. In the NHS, the position is fundamentally different because the government is directly involved as the commissioner.".
It doesn't offer suggestions - but asks the right questions when it correctly notes in para 612, "The Committee believes that Commissioners should determine the shape of service provision. It follows the extent of choice, the extent of application of Any Willing Provider, and the method of determination of entry into the AWP market all have to be consistent with that core principle.
"Monitor told us that providers operating under Any Willing Provider "are not being commissioned by the GP consortia". The Department needs to explain how it will ensure that commissioners are not simply bill payers where Any Willing Provider applies.
"Is the model driven by patient choice or effective commissioning?"
The Chapter ends with a call for clarity: "statements made to the Committee by the Secretary of State, the Chief Executive Designate, and the Chairman of Monitor have been consistent and clear, and bear only one interpretation: commissioners will have the power necessary to design, commission and monitor integrated pathways of care. We regard this as a vital commitment of principle which must not be prejudiced and which should be written into the Bill to avoid further ambiguity.".
It remains to be seen whether Our Saviour And Liberator is minded to oblige.
The reinvention of PCTs
Paragraph 121, which concludes Chapter 7 of the report, states, "Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities".
Phrased another way, integrating health and social care means a return to PCTs.
We asked committee chair Stephen Dorrell MP about this at the press conference: his reply was that having the above-mentioned diverse board membership representing local interest groups would enable these new commissioning organisations to succeed where PCTs failed.
Labour committee member Rosie Cooper MP, meanwhile, told the press briefing that the committee was uncomfortable that the Secretary Of State would not agree to release his legal advice on the applicability of EU competition law. Cooper also warned about "the dead hand of Monitor and any wlling provider", hinting that the above interpretation of an offstage disagreement on competition regulation is correct.