Regulatory Reform

Jeremy Lefroy Excerpts

Tuesday 9th September 2014 Commons Chamber

[Jeremy Lefroy (Stafford) (Con)]

I rise to support the order in general, while wishing to raise some serious concerns in Stafford and further afield in Staffordshire. I will not rehearse the circumstances there, other than to say that two of our hospitals, Stafford and Cannock Chase, are currently being integrated, the first with the University Hospital of North Staffordshire and the second with Royal Wolverhampton hospital, while at the same time an inquiry is being held into the entire health economy in Staffordshire. It is characterised as a fragile health economy—which it absolutely is—and we await the report, due in the next few days, with keen interest.

Four CCGs in Staffordshire—Stafford and Surrounds, Cannock Chase, Stoke-on-Trent and North Staffordshire —have come together to commission cancer and end-of-life services. Like all Members, I have no problem with the idea of improving outcomes for cancer patients. Together with Macmillan, the CCGs have consulted heavily with local cancer patients, and that extremely valuable work has raised many concerns about the co-ordination of services in Staffordshire that I share—constituents have come to me with the same concerns. That is all well and good and I agree with that work.

We have very strong concerns, however, over the proposal for improving those services. As I understand it, everywhere else Macmillan has worked with CCGs and NHS England, a co-operative and collaborative approach has been adopted to improve the co-ordination of cancer and end-of-life services. CCGs have to commission services from many different providers—37 in Staffordshire, I believe—so it is a complex operation and I understand why they want to simplify it, but in Staffordshire, instead of saying to existing providers, “How can we work better together? Could someone take the lead and work with us to provide better cancer and end-of-life services?”, the services have been put out to tender for 10 years. These services are worth £120 million a year, which is £1.2 billion over 10 years.

I have two major concerns and plan to make a direct request to the Minister at the end of my remarks. First, an extremely large reorganisation and tender process are being imposed on a fragile health economy that is going through an extremely difficult amalgamation of two hospitals into other trusts which we must support and must be done properly to ensure patient safety and quality of care. However, one of the acute trusts, UHNS, which will be taking over Stafford hospital and will effectively—there is no other alternative—be the one providing acute cancer services in the area, has also expressed grave concern.

As a result of that concern, I and other colleagues from Stoke-on-Trent and elsewhere wrote to the CCGs asking them at least to suspend the process until the extreme fragility of the health economy had been made more robust as a result of the dissolution of Mid Staffordshire NHS Foundation Trust. To date, that has not happened. There have been public meetings. I addressed one, with others, on Saturday in Stafford. I do not want to do down the work done with many patients in my constituency and others who want to see improvements in cancer and end-of-life services. I do not want that work to be lost at all, but I believe there are other ways to ensure that the co-operation and co-ordination are better.

My second point is about consultation. The shadow Minister raised important points. Does consultation have to happen independently in each of the CCGs involved in the grouping, or will it be done en masse, in which case, will there be assurances that the consultation will be balanced across all the CCGs involved? In this case, as I say, we have had quite extensive consultation with patients, but at the meeting I addressed in Victoria park in Stafford on Saturday, one cancer patient raised his concern that he had not been consulted. Members of Parliament from the area have not been consulted; nor indeed have the main providers of acute cancer care in the area—the University Hospital of North Staffordshire and, for the time being, the Mid Staffordshire NHS Foundation Trust. They provide very good cancer treatment and care, although the co-ordination and other services such as psychological counselling, financial advice and so forth could be considerably better in some cases.

There are serious questions about the consultation with all relevant bodies. The Health and Social Care Act 2012 states that the clinical commissioning group

“must make arrangements to secure that individuals to whom services are being or may be provided are involved”

in various ways, including

“in decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.”

I believe that that has not happened in this case. It must happen, which is why I am asking for at least a suspension of the process until it has happened.

Page 6 of the fifth report of the Regulatory Reform Committee on the draft regulatory reform order refers to

“concerns about possible loss of protection”

because

“Joint committees would be able to take majority decisions on behalf of their constituent CCGs and NHS England, and so individual CCGs”

might find themselves increasingly concerned during the process, as I know a couple of them are at the moment. They could find themselves still heavily involved, having committed substantial financial resources, but as a result of the consultation and listening to their patients and their members they no longer want to go ahead with the process. They would probably be outvoted.

I conclude by asking the Minister to look very closely at this issue, which was featured in Private Eye this week. I ask that some common sense be brought to bear on the situation, if possible, and I ask for a slowing down or suspension of the process until we have a better health economy in Staffordshire and until we are clearer about the consultation process that needs to happen.

--- Later in debate ---

[Norman Lamb]

I fully understand that we should always be arguing the case for greater openness and for greater legitimacy and accountability. All I am saying is that the system that we inherited had no local legitimacy at all, and that this is a significant improvement.

The shadow Minister talked about alignment with health and wellbeing boards. I think that that will almost always be the case. In my county of Norfolk, there are several CCGs, but all are operating within a health and wellbeing area and a local health economy. There may be circumstances in which more than one health and wellbeing board area is being considered, and I think that that is the case within the Manchester area and the discussions that are going on there. But in most circumstances, the sort of collaboration that we are talking about will be consistent with the health and wellbeing board area.

The shadow Minister also asked how CCGs will be held to account for joint decisions. When they act in joint committee, they will be subject to the same duties as when they act on their own and the accountability they face will be exactly the same. It is very important to reiterate that point.

The hon. Lady also raised concerns about the issues that Healthwatch England has raised, and I stress that the Department, NHS England and Healthwatch England are working together to ensure that CCGs have the materials and resources they need to support their effective and accountable collaboration and that local healthwatch organisations and others are supported to hold the system effectively to account. Everything on our side is about facilitating accountability at a local level, not undermining it.

My hon. Friend the Member for Stafford (Jeremy Lefroy) raised concerns about the issues in his area. I think that it is fair to say that they are not directly related to the proposals under the order, in that his concerns are about issues under the current arrangements rather than any potential impact of the proposed change. I want to reassure him that nothing in the order in any way undermines effective accountability for changes. I think it would be dangerous for me to go down the route of responding to the points he raises about his local circumstances, and I suspect that you, Mr Deputy Speaker, would rule me out of order if I tried to do so.

[Jeremy Lefroy]

The point I wish to make is that in our case the group of CCGs that is seeking to put out to tender the commissioning of end-of-life and cancer services appears to be abrogating its responsibilities for commissioning. These are clinical commissioning groups, yet they seek to put out to tender the commissioning of vital services for our constituents for 10 years. One might be concerned that the groupings would seek to do more like that.

[Norman Lamb]

My hon. Friend expresses a concern about what is happening at present and he is absolutely right as a local Member to challenge, question and hold to account the clinical commissioning groups in his area, but I do not think that there is anything in the order that changes the arrangements about which he is concerned. Indeed, I think that streamlining the system so that there is more effective accountability and less opaque decision making is better for local people.

Concerns were raised that joint committees might not meet in public. Joint working does not need to mean that it will take place behind closed doors and exactly the same responsibilities will apply to CCGs when they work jointly as when they work on their own or through committees in common. Indeed, I understand that committees in common have already on occasion met in public and I would always encourage accountable organisations to operate in public wherever possible. That is the approach that I seek to advocate.

In response to concerns raised by my hon. Friend the Member for Stafford, let me make the point that the requirements for service change that apply to a CCG regarding any major proposal for change will still apply, including that for appropriate consultation. Joint committees might want to consult jointly to co-ordinate their communications to patients and the public where appropriate, but the duty remains on the clinical commissioning group and it must demonstrate that it is meeting it.

The hon. Member for Blackley and Broughton (Graham Stringer) again raised concerns about the process going on in Manchester and he and I debated the matter in the debate to which he referred. I stress that his concerns are about actions taken under the existing regime, with a committee in common, rather than under the proposals in the order.

The hon. Gentleman expressed worry about the appropriateness of the order under the Legislative and Regulatory Reform Act 2006, but both the Regulatory Reform Committee and the Delegated Powers and Regulatory Reform Committee judged that a satisfactory case had been made for the LRO and that the order met the tests under the 2006 Act, so his concerns are misplaced. Although he has legitimate and genuine concerns about the process in Manchester and whether it is right for local people, I suggest to him that accountability will be encouraged and improved if the new system is less opaque and more clearly set out in legislation than the existing one. All the things about which he worries are happening under the existing arrangements.

It is up to CCGs to set out terms of reference for any joint committee arrangement, such as the scope for decision taking, and arrangements for membership or voting. They may also determine situations in which a CCG would wish to withdraw from a joint committee arrangement. The hon. Gentleman was worried that one CCG might feel oppressed or bullied by others, but it could set the terms of reference so that it could withdraw in defined circumstances, so his concern is misplaced.

My right hon. Friend the Member for South Cambridgeshire spoke about important improvements in democratic accountability and clinical leadership in commissioning, and the benefits that that secures. He asked about collaboration on commissioning not only between CCGs, or between CCGs and NHS England, but, critically, with local authorities and public health bodies. Such collaboration is facilitated, and he and I share the view that we should try to promote a more permissive NHS health and care system within which local arrangements may be put in place to ensure that the resources available throughout the health and care system are used as efficiently as possible. We should encourage such joint commissioning, rather than putting blocks in its way.

My hon. Friend the Member for Bedford (Richard Fuller) rightly talked about the tension that exists between local decision making and clinical best practice. This approach is all about managing that tension, rather than trying to pretend that it does not exist. He made the vital point, with which I agree, that people want health decisions to be taken locally, and we should try to facilitate open discussion and debate about the difficult choices that we sometimes have to make, rather than taking power away from people, which just undermines confidence in the system.

My hon. Friend asked about unanimity, so I repeat that if a CCG wants to enter into a joint committee arrangement, and protect its position on behalf of its local community, it can insist that unanimity is the basis on which decisions are taken. That is entirely a matter for the participating CCGs.

My hon. Friend asked about the cost and burden of the existing arrangements. We all understand the possibility of legal challenge, and there can be complex arrangements that involve organisations going through hoops to ensure that they meet their legal duties, perhaps by going back to their CCGs so that a decision taken in a committee in common may be endorsed. The more complicated those arrangements, however, the greater the risk of legal challenge, and therefore the cost, so simplifying in law the basis by which CCGs and NHS England can come together to make joint decisions, should they want to, improves accountability, makes the system less opaque and reduces the risk of unnecessary costs. I totally agree with my hon. Friend that this is not about the burden of localism. Localism is a burden worth carrying; it is not to be avoided. The burden is bureaucratic complexity and the involvement of lawyers—I speak as an ex-lawyer. The more we can keep lawyers out of it, the better, and I am sure many hon. Members would agree.

My hon. Friend made the point that not all consequences may be known at the outset and that things may change, but CCGs can set the terms of reference to provide for that if they choose to. The measure is absolutely permissive; it does not impose anything on anyone.

My right hon. Friend—sorry, my hon. Friend the Member for Totnes (Dr Wollaston). I thought something might have happened as a result of her election to the Chair of the Select Committee, but it will happen in time, I am sure. I am delighted that she supports the measure. She made the perfectly legitimate point that we ought to be encouraging and facilitating working across boundaries, both of CCGs and of the different organisations involved in health and care, to get the best possible use of the resource available for any local area.

Finally, I repeat that we take on board the concerns of Healthwatch England. We intend to work with that body to ensure maximum accountability for the decisions taken as part of these joint committees.

Question put.