by Andy Cowper, editor, Health Policy Insight

Meet Patrick Robert Carter - Lord Carter of Coles, a Labour peer. He co-founded and sold Westminster Healthcare, ‘saved’ the Wembley Stadium rebuild, strongly supports Titan prisons, chairs a big list of government committees, lives in Islington and was Jack Straw’s best man at both of his weddings. He is 62.

He’s also the inaugural chair of the new NHS Co-operation and Competition Panel, which may make him the fourth most important person in the NHS.

Oh dear, the insidious matter of lists. Yet what is clear is that after Bill Moyes of Monitor, Andrew Dillon of NICE and Mark Britnell of the DH world-class commissioning team (Baroness Young didn’t make the cut, since the Care Quality Commission doesn’t yet exist), Lord Carter has the most enormous potential power over the direction of NHS reform in the next 18 months.

'The Co-operation and Competition Panel, and its experienced chair, will have immense influence'

As commissioning develops, this will prove a crucial period. Bidders to provide services – be they NHS, third sector, or private sector bidders – may feel that their bids have been rejected without good reason. The Panel has been created to address such concerns. This means that the Co-operation and Competition Panel, and its experienced chair, will have immense influence.

Past form
So how might he use it? Well, he has an interesting track record: indeed, when the New Labour Government has needed a major review, as often as not it seems to have been a case of ‘Get Carter’. These include reviews of the Commonwealth Games 2002; the English National Stadium (Wembley); the National Athletics Review; the Review of Payroll Services; the Review of Identity Fraud; Criminal Records Bureau; Review of Court Estate; Review of Offender Services; Review of Public Diplomacy; Review of the Procurement of Legal Aid; the Review of Online Revenue Services; and reviews of Prisons.

He conducted the major and critical review of NHS pathology services in 2006, and reported back on progress in May 2008 (www.thecarterreview.com).

His Prisons review suggested the creation of the proposed new ‘Titan’ prisons (recently criticised by the Sainsburys Centre for Mental Health), but also suggested that the long-term rise in the prison population in England and Wales, did not just need more and bigger prisons. Carter called for a new permanent ‘Sentencing Commission’, to introduce a "structured sentencing framework". This would be designed to take account of the prison service’s available capacity. It was immediately unpopular with the judiciary, who feared it meant an imposition of mandatory sentencing rules. (http://www.guardian.co.uk/society/2008/aug/20/prisonsandprobation?gusrc=...)

'His Legal Aid report’s main recommendations were for fixed fees per case, regardless of complexity; and for ‘best value’ competitive tendering, to bring down those fees to the lowest possible level.'

Legal lessons
The title of his 2006 Legal Aid review ‘Legal Aid review – a market-based approach to reform’ (www.legalaidprocurementreview.gov.uk/publications.htm) gives further clues. His Legal Aid report’s main recommendations were for fixed fees per case, regardless of complexity; and for ‘best value’ competitive tendering, to bring down those fees to the lowest possible level. It also suggested that “through a process of managed change, a steady-state should be reached by 2009 whereby increased volumes of work should be given to the most efficient and good quality suppliers in return for lower prices”.

In the report’s covering letter to the Lord Chancellor (Tony Blair’s ex-flatmate Charlie Falconer), two quotes stick out which may have great relevance to his views on NHS co-operation and competition:

“I was surprised to discover at the outset that the relationship between the various legal aid stakeholders was often adversarial and sometimes hostile. This has resulted in a fragmented system that has not historically recognised a duty to deliver justice at an acceptable overall public cost. I am pleased to see a growing recognition that a new co-ordinated and collaborative approach is required in which it is no longer acceptable for one part of the system to act in a way that imposes a disproportionate burden on another … The biggest challenge that I have faced is the inadequacy of the management information available. The complexity and the opaqueness of the numbers, their components, the inability to forecast change, and the lack of a comprehensive understanding of the whole system, all contributed greatly to the difficulties I have encountered”

and:

“many in the profession tend to have a natural conservatism towards any move to greater efficiency in the services they deliver. There must be a better understanding of the finite nature of resources, and the need for the taxpayer and government to secure better value for money from the funds it spends”.

The report pulled no punches: “In England and Wales, we spend more on legal aid per capita than anywhere else in the world. Legal aid expenditure has increased from £1.5 billion in 1997 to over £2 billion today. Legal aid costs each taxpayer nearly £100 per year. Although there have been many well-known anomalous and exceptionally high cost claims on the legal aid budget, the scale of the continued rise in spending is not the result of individual or collective wastefulness. It is the result of systemic weaknesses in the way legal aid services are procured and therefore inefficiencies in the way those services are delivered”.

It goes on to suggest that within four years, the reforms will reduce spending on criminal legal aid in real terms by 20%. The report stated that “all reforms are directed towards achieving a market-based outcome. A healthy legal services market should be driven by best value competition based on quality, capacity and price. All three of these factors should lead to the restructuring of the supply market. The option of longer contracts should be available for suppliers, if they are considered to offer a particularly good quality and efficient service. There should be a minimum standard of quality for all legal aid practitioners assured through peer review. … This process alone will cause some restructuring of the market as suppliers of inadequate quality legal services are forced to improve or withdraw from the market”.

It also predicted “an increase in the average size of firms through growth and mergers, rationalisation and harmonisation of the way separate services are delivered”, and added, “there should be a wholesale move towards fixed pricing for work. Fixed pricing rewards efficiency and suppliers who can deliver increased volumes of work. However, pricing should be graduated for more complex work so that cases genuinely requiring more expertise and effort are priced fairly. Exceptionally complex cases should be managed and paid for under individual case contracts with only the most experienced, competitive and competent legal teams providing the service.”

Health and wealth
Health will not, of course, be a new beat to Lord Carter. Along with Martin Bradford, he was the co-founder of the successful Westminster Health Care Holdings PCL in 1985. In 1999, Westminster was sold for £214 million to Canterbury, a firm backed by Goldman Sachs.

Much of Westminster Health Care’s original market was in the nursing home sector. He will therefore be keenly aware of the issues of cost inflation, and of the importance of prioritising the management of long-term conditions.

Health and efficiency
Examining efficiency is not a direct part of the panel’s remit, yet it is instructive to note that in June 2008, Carter was appointed to look at the public sector’s use of land in the wake of the NAO report suggesting tha if the public sector emulated private sector best practice, then £330 million – over one-third of government departments’ spend on offices – could be saved.

This sporting life
So how does Carter work? We may gain some clues to this from his involvement in the redevelopment of Wembley Stadium, which was a financial basket-case prior to his involvement. His investigation into this was generally seen as both thorough and instrumental in restructuring the project in a way that gave Parliament and the city confidence to carry it forward.

"I've been persuading people to take a different perspective rather than staying on the back foot. When things don't go according to plan, at that point nobody is absolutely right and it is a question of helping them to see a way through."

Carter told an interviewer (http://www.independent.co.uk/sport/football/news-and-comment/the-man-who...), "let's say I've been persuading people to take a different perspective rather than staying on the back foot. When things don't go according to plan, at that point nobody is absolutely right and it is a question of helping them to see a way through."

Andy topically, he also reported his concerns about the legacy of London 2012 Olympic development: "I'm not relaxed about it. I don't think anybody should be. The thing that Wembley has taught me - and Athens will teach anybody - is that time is staggeringly short. Above all, we have to make it a national event. Britain has to feel it has a legacy, not just London. We don't want white elephants. If there isn't a use for it, take it down."

Carter was also was chair of Sport England from 2002 to 2006, during its transition to a new regional structure and away from being a service provider to becoming an investor of public and Lottery funds. He told thei interviewer, “when I arrived, it (Sport England) was a monolithic, highly centralised, bureaucratic organisation which had forgotten it was partly about sports development and had just turned into a sort of cash dispenser.

"It had to move closer to the customer, and I think we did that by regionalisation and making it a lot leaner. But it was quite a painful process.”