Baroness Barker writes… Liberal Democrats protecting the integrity of the NHS

We trust that doctors and nurses will care for us to the best of their ability, and we trust the decisions they make about our treatment are always in our best interest. It is clear that for patients and medical professionals alike, maintaining the integrity of the NHS is essential.

Clinical Commissioning Groups (CCGs) will bring their unique knowledge of the health needs of their patient population to the design and commissioning of health services as part of the proposals contained in the Health and Social Care Bill.

We know that CCGs must be transparent and accountable to the public and patients that they serve, which is why our party made sure that CCGs had to make their spending decisions open and transparent after the ‘pause’ in the Bill concluded.

It is important that we acknowledge that GPs are providers of healthcare services and that there is potential for conflict of interest when members of CCGs make a decision on what services to commission. This was one of several concerns raised by professional bodies, such as the BMA, and the Royal Colleges which we and crossbenchers have sought to address.

In response to this myself and colleagues in the Lords put forward amendments which mean that there must be a register of interests of members of a CCG, the governing body, its sub committees and its employees (including management consultants). This register must be publicly available and kept up to date. CCGs must have a procedure to manage conflicts of interest and potential conflicts of interest.

All this is so that patients can be assured their needs will always come first, a Liberal Democrat principle that Nick Clegg and Shirley Williams rightly recognised in their recent letter to members.

Many people in the medical professions have been worried that commissioning support organisations (CSOs) – social enterprises or private companies which provide services such as IT, legal advice, data management – would take over commissioning of healthcare. As a result of our efforts the Government have stated that the commissioning of healthcare is the responsibility of CCGs, a responsibility which cannot be delegated. CSOs will never have responsibility for commissioning healthcare.

It is also the case that CSOs, via secondary legislation, will be subject to these safeguards around conflict of interest. This means that if a consultancy company provides a CCG with commissioning support, they will also be subject to scrutiny – thus we are ruling out privatisation by the back door.

Ultimately, doctors, working with patients and health and wellbeing boards, will be able to ensure that everyone has access to the best health services. This means that patients will know their health is in the best hands possible.

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31 Comments

  • mike cobley 2nd Mar '12 - 2:43pm

    Right, so once the bill is passed and private sector companies are allowed to bid to provide health services under the strictures and restrictions mentioned above, we can expect these same companies to not try to have the restrictions relaxed or removed in coming years, then? We can be certain that Serco and other corporations will not lobby for easier conditions and less stringent oversight? And we can be sure that no corporate agency will try to corrupt or bribe an NHS decision maker in order to gain preferential treatment? I mean, absolutely none of that is going to happen, is it?

  • Richard Dean 2nd Mar '12 - 3:05pm

    Mike – No system is perfect, including the present one. Is the present system immune from bribery and other forms of corruption? I don’t know, but it looks a lot less transparent than the one proposed in the bill. As democrats, we must allow others to lobby, in the future as well as now, even if we don’t like what they want. The new transparency will surely make such lobbying more visible, and so assist anyone who wants to counter-lobby?

  • Simon Bamonte 2nd Mar '12 - 3:35pm

    This bill is, at its core, completely anti-democratic. The electorate were not given the chance to deliberate about these reforms in the election. They were not in either Tory or LD manifestos, nor the coalition agreement. We were told – promised – there would be no “top-down reorganisations” of the NHS. The most popular e-petition on the government’s own site, over 160,000 signatures calling for the bill to be dropped, has been ignored and will not be debated. The medical profession by and large do not want this bill, nor do the public.

    We are in danger of doing the same thing Blair did over Iraq: putting fingers in ears, ignoring the public and pursuing a path that people simply don’t want to go down. If this bill is all about giving more power to health care professionals, why do we not listen to them when they tell us our plans will be bad for the NHS and bad for public health? Why are we not listening to the public who are overwhelmingly in opposition to this bill?

    To deliberately ignore the public and the experts and insist it is the MPs who are right just goes to show our MPs are just like everyone else and hold the public in contempt whenever there is not an election to campaign for.

    This bill needs to be dropped. The public and medical experts who are against this bill should be listened to. I certainly will never vote LD again if our party continues to push this unwanted bill.

  • mike cobley 2nd Mar '12 - 3:37pm

    “As democrats, we must allow others to lobby, in the future as well as now, even if we don’t like what they want. ” You surely cannot be serious. As a social democrat, I look upon this bill as an exercise in purposefully putting the entire health of the nation at risk. And whatever flaws there may be in the NHS as it has been (possibly excluding the Blairite reforms), it still ranks very highly against equivalent systems in the industrialised world, and is head-and-shoulders above the grotesque mechanism of cruelty currently being endured by the American public.

    Presumably if Baroness Barker could hop into a time machine and go back to 1948, she tell Aneurin Bevan how wrong he was to exclude all those nice market mechanisms from the workings of the NHS. And I’m sure his response would have been notable.

  • “In response to this myself and colleagues in the Lords put forward amendments which mean that there must be a register of interests of members of a CCG, the governing body, its sub committees and its employees (including management consultants). This register must be publicly available and kept up to date. CCGs must have a procedure to manage conflicts of interest and potential conflicts of interest.”

    Come on “really” that is very lame to say the least.

    There is a register of Interests for MP’s and the House of Lords, but that does not stop them being paid consultants, paid for sitting on non-existent boards, Paid for being Lobbied. And they still stand up and argue for policies they have been “lobbied” for and get to vote on legislation.

    This whole bill stinks and it is full of shady back room deals and golden handshakes which will privatise the NHS, allow “private health care providers” to use NHS hospitals and resources to treat up to 49% of it’s private patients, all at the expense and to the detrimental effect of NHS patients and waiting times.

    Conservatives could never be trusted with the NHS and now there Liberal Democrat Colleges are just as bad.

  • Billy Wright 2nd Mar '12 - 4:07pm

    Protecting the integrity of the NHS and Preventing the release of the Risk Register!

    Integrity and transparancy go hand in hand, the fact there is no transparacy shows that the LDP has no integrity at all.

  • @Dave Page

    “matt, that’s halving the amount of services that the NHS can provide to private operators from 100% to 49%”

    Nonsense. NHS providers have status as “preferred providers” at present and Foundation Trusts are restricted to farming out a tiny percentage of their work to the private sector. Both of these safeguards against privatisation are to go under the new bill.

  • I disagree Dave.

    Waiting lists are soaring as it is. Take it from someone who know’s

    I suffer from Ulcerated Colitis and have to attend the hospital on a regular basis “supposed” to be every 12 weeks.

    However I have noticed over the last 18 months, I have had my appointments cancelled time and time again by the hospital for “non clinical reasons” allegedly. In fact, my next appointment was just put back again, i got a new date through the post for “February 2013” yes that is 2013.

    So if waiting times are in chaos as it is, due to shortages of resources, staffing, cuts, whatever the reasons. please explain how letting “private companies” and “Doctors, Consultants” use NHS facilities and resources to treat up to 49% of “private” patients will be anything other than catastrophic for ordinary NHS patients.

  • Daniel Henry 2nd Mar '12 - 5:28pm

    Is the cap the only way to limit private services?
    e.g. won’t local councils and health boards have a say too?

    The cap sounds like the only centralised limit, but there might be local ways to reduce private services if local people are concerned? Does anyone know any more about this?

  • Richard Dean 2nd Mar '12 - 6:19pm

    It is ridiculous to say that this bill is purposely putting the health of the nation at risk. It also also ridiculous to link that claim to social democracy. Syria is an pertinent example of what happens when we forget principles of democracy.

  • Jayne Mansfield 2nd Mar '12 - 6:46pm

    A register of interests? Oh thats all right then. I am sure that that will prevent a conflict of interests between those who both commission services and also provide them!

    Will doctors on CCG’s be granting contracts to themselves or their own surgeries which are already private businesses?

    How is patient confidentiality to be ensured when as a patient I and others are referred to multiple different providers?

    No doubt contributors on here will be able to put my mind at rest on these questions?

  • Jayne Mansfield 2nd Mar '12 - 6:56pm

    Richard Dean,
    I know that you have touched on the issue of eduction in earlier posts which I have followed.

    I would like to point out that The Royal College of Radiologists have today joined the call for the bill to be dropped because the latest amendments to the bill do not address concerns over inequalities, competition, research and training.

  • Richard Dean 2nd Mar '12 - 6:58pm

    I don’t want your mind at rest, Jayne. I want you firing on all cylinders when the bill is passed and the issues you identify need MONITORing! 🙂

  • Richard Dean 2nd Mar '12 - 7:12pm

    Jayne

    I’m afraid I’m going to be very cruel. It’s not my wont, and if I had been in Landsley’s shoes I would have wanted to avoid causing people to create these sorts of issues, and avoid any suggestion of disrepespect to a lot of well meaning but somehwat stifling professionals. Here is the cruelty. Following is the core of the Royal Collge of Radiologist;s obejctions (page 1 of their statement):

    “It is essential the the RCR continues to lead on the professional standards for then training and practice of clinical radiologists and oncologists”

    That is a union saying it wants a closed shop, a monopoly saying it doesn’t anyone to challenge it, a body claiming it is the only one that has the right to define standards. It is proof if anyone wants it that the RCR’s position does not stem from concern for the welfare of the population, but instead from concern for its own welfare.

    http://www.rcr.ac.uk/docs/newsroom/pdf/RCR_Bill_withdrawal_statement_020312.pdf

    Many apologies for this cruelty. It is a great sadness that the RCR have issued this statement, and I hope they withdraw it as soon as possible. It reflects very badly on them. If they have objections on other grounds, by all means they should issue another statement.

  • A register of interests FFS.

    So if Mr Management Consultant sitting on the CCG doesn’t declare that his company is also representing “Hip Replacements Are Us” who happen to have been awarded a £400m 10 year contract that he lobbied hard for what happens?

    A strongly worded letter and an appearance before a standards committee where he might even be suspended from CCG duties for 6 months. I’m pretty sure that would be a risk worth taking.

    And no I don’t “trust my doctor” to work in my best interests. At the moment yes but when they are sending me for a succession of expensive tests at a private operator they happen to be a major shareholder in then I’ll be slightly more suspicious of their motives.

    You are helping to ruin one of the best things about this country and respond with such lame “solutions”

    Stop the bill.

  • @Richard Dean

    Sorry but you seem to be missing the difference between the medical Royal Colleges and a Union (The RCN is a nursing union not a medical royal college which does not help….).

    They are not closed shop unions but more akin to governing bodies for their respective areas. The RCGP’s establishes and maintains the standards for GP’s, likewise the RCR for radiologists.

    This is not self interest but the very system of checks and balances that ensures our medics are such a high standard. The last thing we need is more than one body deciding what skills are needed to become a consultant or associate in each of the areas covered by a royal college. At present whichever deanery a medic is carrying out their postgraduate training in the standards are equal and the exams centrally managed by the respective college.

    I agree that much of the noise from Unions can be discounted, but the system of Royal Colleges in medicine has served us well in spite of successive Governments attempts to “improve” the NHS. They are not rabble rousers but the backbone of our system of medical training and governance.

  • Richard Dean 2nd Mar '12 - 9:42pm

    @Steve Way. They ARE unions, but they are also the nation’s Quality Management System (QMS) for health provision. As such, I don’t see why the should feel threatened by the bill – unless they are not providing their quality management function effectively, and cannot change to do so. As I pointed out soemwhere else, this changes the whole debate. It means, for instance, that these institutions are not complaining about competetion at GP or hospital level, They are complaining about someone competeing with them for their quality management functions. It’s a very serious business to change a nation’s quality management system, and it’s not been presented to us in that way. I think we are owed an explanation, by the institutions, and by Landsley. I’d like to know that all these people understand both the union aspects and the QMS aspects of what they are doing – both in supporting the bill and in opposing it.

  • Richard Dean 2nd Mar '12 - 9:59pm

    The other thing to observe is that there does seem to be opportunities for conflicts of interest between a role as a union and a role as a quality management institution. The two roles really are quite different. Given that the institutions are essentially imperial left-overs, some even with Royal Charters, I wonder if it might be past time they need to be broken into two – one doing the union side and the other the QMS side?

  • @Richard Dean

    Sorry they are not unions.

    I work within a company that employs a number of Physicians, all of whom hold fellowship, membership or associate status with the Faculty of Occupational Medicine. Their union is generally the BMA and most also hold MDU (or similar) membership for legal insurance purposes.

    As a real life example please see the requirements for obtaining membership status of the Faculty of Occupational Medicine (MFOM)

    http://www.facoccmed.ac.uk/library/docs/mfom-r2010.pdf

    To become an MFOM a physician has to commit years of their life and work to the speciality.

    As for the quality aspects, this again is not as simple as you seem to believe. The General Medical Council (GMC) is already responsible for a large part of this for physicians and the new system of revalidation, designed in conjunction with the Royal Colleges, begins this year:

    http://www.gmc-uk.org/doctors/revalidation.asp

  • Richard Dean 2nd Mar '12 - 10:24pm

    @Steve,

    Please then could you explain the RCR’s core complaint, which is:

    It is essential the the RCR continues to lead on the professional standards for then training and practice of clinical radiologists and oncologists

    Isn’t this simply saying they want to be top dog and won’t cooperate otherwise?

  • @Richard Dean
    It’s professional standards, training etc not working conditions or pay.

    For example, the RCGPs states:

    The Royal College of General Practitioners is a network of more than 44,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.

    We need single bodies for setting the standards in each of the clinical areas represented by a Royal College. Varying standards lead to confusion and potentially worse patient outcomes. As another example, whilst the GMC produces a publication “Good Medical Practice”( http://www.gmc-uk.org/guidance/good_medical_practice.asp ) which is to be followed by all practising physicians, this is augmented by individual colleges to ensure that work within their speciality is appropriately carried out. In Occupational Health this is “Good Occupational Medical Practice” http://www.facoccmed.ac.uk/library/docs/p_gomp2010.pdf

    There are also publications on ethics from the colleges, in OH this is “Guidance on Ethics for Occupational Physicians”. This is referred to by the Data Commissioner on the Employment Practices Code http://www.ico.gov.uk/upload/documents/library/data_protection/detailed_specialist_guides/employment_practices_code.pdf (section 4.2.3) to help employers understand the need for and measures to be taken to protect information on workers health.

    We need consistency and guidance, whether on clinical procedures or ethical standards. This is achieved through standards in specialist training (which is carried out by many bodies but validated by the single college). There should only be one standard for each speciality in medicine. It’s one of the best aspects of our healthcare system, it works and should be maintained.

  • @Richard Dean

    Also, I’m not sure the Royal Colleges (as opposed to the Unions) have ever said they will not cooperate. For example after not being invited to the now infamous meeting at Downing Street the RCGPs specifically stated “The RCGP is not a political body, it is here to protect and promote the best possible standards of care, and will remain so whatever happens.”

    http://www.rcgp.org.uk/news/press_releases_and_statements/downing_street_meeting.aspx

  • Richard Dean 2nd Mar '12 - 11:37pm

    Steve,

    In industry, training and standard setting functions come under the heading of a Quality Management System (QMS). So in my industrial language, you describe a network of colleges and other institutions that together form the nation’s QMS, some of which are indeed unions (such as the BMA). On this basis, I have two new questions to start off with …

    First, just to be clear what is what, when these institutions complain about competition, they are complaining about the threats to their positions as monopoly providers of quality management functions, such as standard setting, training, yes? They are not complaining about competition between GPs on the front line, or between hospitals, correct? Would they accept new competitors for quality management functions such as training provision, for instance if the new competitors trained to the standards set by the RCGP or BMA?

    Second, what independent mechanisms are there to ensure that these quality managers are themselves subject to quality management? I’m not sure how this might relate to the bill, but I wonder whether MONITOR might be relevant here?

    Lastly, sorry to be a bother, but you never addressed my question about the core complaint by the Royal College of Radiologists.
    Thanks!

  • @Richard Dean
    Sorry the fact you have put the BMA in the quality context appears to me that you’re still not understanding the differing roles. The BMA is a union their website makes this clear. The distinction is that they claim to represent the professional AND personal needs of their members and clearly state they are a trade union.

    http://www.bma.org.uk/about_bma/index.jsp

    Turning to competition, the Royal colleges already accept competition in delivery. In my area a substantial proportion of Physicians work in the private sector delivering to public and private sector clients. Again in my area of knowledge Physicians holding Consultant Occupational Physician status (MFOM or FFOM) work in both private and public sectors and compete through both competitive tendering and standard marketing for both public and private sector clients. The Faculty does not need to be involved if it is done ethically.

    Quality standards should not be about competition, they should be about standards of practice. Competition does not always produce the best, merely something better than the nearest rival. I don’t think that’s what we want as a minimum standard for, for example, consultant surgeons. We need them to have training geared towards the minimum standard required to perform the crucial tasks they undertake. We need standards in healthcare to be evidence not market based.

    The situation you envisage would require a super body that would in effect provide the service already delivered by the individual colleges for all clinical areas. MONITOR is not that body. MONITOR will ensure that Trusts are effective and compliant in their usage of public funds. The expertise required in each clinical area is not that easily transferable and is held by definition within a relatively small group of people.

    As for your question about who regulates the Royal Colleges. That is like asking why there is only one Monopolies Commission. Every area in professional life has an ultimate arbiter. But again it is not that simple, the GMC is the regulator (possibly sloppy language) for all Physicians operating in the UK. This is explained better here:

    http://www.gmc-uk.org/about/role.asp

    They have the legal powers to restrict or prevent the medical practice of every Doctor in the UK. They work alongside a number of other organisations and regulators

    http://www.gmc-uk.org/about/UK_health_and_social_care_regulators.asp

    This links to the Royal Colleges as can be seen here:

    http://www.gmc-uk.org/about/committee.asp

    As to your final question about the RCR, I believe I did answer that (although I have no knowledge of them directly). I stated “We need consistency and guidance, whether on clinical procedures or ethical standards. This is achieved through standards in specialist training (which is carried out by many bodies but validated by the single college). There should only be one standard for each speciality in medicine. It’s one of the best aspects of our healthcare system, it works and should be maintained.”

    The RCR are responsible for their speciality. Where would the breadth and depth of knowledge come from to replace or compete with them ? Their concern appears to me to be that if they are removed from this role we will lose the arbiter of standards in their speciality. Even a wholly private healthcare system (which is not what this Bill will create, that is Union scaremongering) would need an equivalent of the Royal Colleges, and it will need only one arbiter in each area.

    In my second post I also stated that “Also, I’m not sure the Royal Colleges (as opposed to the Unions) have ever said they will not cooperate.” I do not believe the Royal Colleges have said they will stop carrying out their role within the health service if the changes go through. They have criticised changes before but have continued their important role anyway. You have said they will not cooperate yet I see no evidence of this. The RCGP’s state the opposite as did the RCR specifically in the document you linked to “We aim to engage further with the Government now and in the future”.

    The system of specialist training and education does not need competition, unless of course you have evidence to show that it does. It appears to me to be a by product of the parts of the Bill relating to competition in delivery.

    Finally, quality is not just the preserve of the Royal Colleges, as a growing private company we are currently applying for the accreditation offered by the Faculty. We will also be applying for ISO in the coming year. In addition our Physicians will undergo revalidation, our nurses are required to maintain standards set by the NMC and our Safety Practitioners by IOSH. The varying CPD and audit needs are complimentary to maintaining our quality. But us, and our public sector colleagues need stability in who sets those standards (even though they change, as I’m sure you’re aware in your own field).

    I think this whole debate is confusing two issues. The BMA has a political slant on it, and there is possibly some truth to the Government linking their pensions dispute to the Bill. The RCN and other health unions will never fully support the Bill, and whilst I agree with some of their points I do not totally disagree that the Government will at some point need to disengage.

    The Royal Colleges have professional concerns and on the whole appear to me to be trying to work through them. They have not withdrawn support until they felt they had no choice. There are a couple of AGM’s coming up where more could do so.

  • Richard Dean 3rd Mar '12 - 1:50am

    Steve, Thank you very much indeed for your very clear account. Being outside medicine, I found the details fascinating, but overall you describe the system I was expecting to see.

    I am still puzzled as to why that system should object to this bill. It seems that MONITOR will essentially act as the quality controller for the customer – the taxpayer. That does not conflict at all with general standards being set by other bodies. In my industry, quality standards are set by several institutions. I take their exams and adhere to their written standards, and my clients have quality managers that check that I do. There is no conflict between those managers and the professional bodies. My company is among many who fund research that benefits the whole industry, as well as giving the research sponsors credibility in tenders. The result is a continual increase in quality standards fuelled in part by competition.

    Of course your industry is different, but the fog it is generating does not impress. Right now the fog is coming from the professional instututions, and from many commentators who seem t have been misled about what thereal issues are. The fog contains many contradictions – why do people believe doctors are uncorruptible under the present system but will be immediately corrupted under the new one?

    I am afraid that I have monopolized this dicussion too much, and probably annoyed many people. I apologize for that. I am hoping to be able to resist the temptation tomorrow.

  • Jayne Mansfield 3rd Mar '12 - 12:25pm

    I am still puzzled as to why the government is willing to put the bulk of health service resources in the hands of members of a medical ‘trade union’.

    A medical trade union that they have portrayed as a self-serving group who put personal self- interests before the interests of the patient.

    As for the monitoring of the new NHS, I expect the government to take a more ‘nuanced’ view of the quality of health care that will in future be available to me…. one is never too old to become cynical!

    How you expect someone like me to hold sway in such matters is beyond me, Richard Dean. I was trusting enough to believe David Cameron when he said there would be no top down reorganisation.

    The vast majority of the electorate are like myself, unable or unwilling to pour over the details in the Health and Social Care Bill. We leave others to do that whilst we get on with our daily lives. If you are a political activist, you should be mindful of who the public most trusts at the moment, healthcare workers or politicians.

  • A register of interests isn’t good enough to protect the NHS from vested interests, especially when the head of the Co-operation and Competition panel himself has conflicts of interest of a staggering scale.

    From today’s Mail on Sunday
    “As the chairman of the NHS Co-operation and Competition Panel (CCP), Lord Carter of Coles is paid £57,000 for two days’ work each week. But his other role, as chairman of the UK branch of the American healthcare firm McKesson, is more generously rewarded. Last year it paid him £799,000.
    Even this is not the end of Lord Carter’s private healthcare interests. He is chairman of the Bermuda-registered Primary Group Ltd, a private-equity investment company that owns big slices of other healthcare firms.
    And he is an adviser to Warburg Pincus International Ltd, another investment fund with large health interests. His income from these sources is not publicly disclosed.”

    Full article: http://www.dailymail.co.uk/news/article-2109907/NHS-fairness-tsar-urged-quit-doctors-conflict-following-799-000-payment-U-S-private-health-giant.html#ixzz1o8Ni6pZN

  • Richard Dean 4th Mar '12 - 10:53am

    @Greg Smythe.

    But the discovery of a sinner does not mean the processes that led to the discovery are ineffective! The Register of Interests does not operate in isolation. The Freedom of Information Act seems to have a large role to play in this story, as well as the freedom of the press and the motivations of combatants. The Register helps these other things to operate effectively, and in this case these things have successfully initiated the debate which will hopefully provide a final decision that will indeed help to protect the future NHS.

    On the other hand, these things are also usable for other purposes. Carter is basically a Labour man, so is he being outed to be replaced by someone more convenient to the government? Our cynicism, distrust, and common sense are also useful actors in this drama.

  • Paul Westlake 4th Mar '12 - 5:52pm

    The 2010 Labour manifesto promised to allow NHS hospitals to “increase their private services” – http://bbc.in/9Eoj02

  • Jayne Mansfield 4th Mar '12 - 6:55pm

    Ah yes, Richard Dean, the Freedom of Information Act.

    Under the terms of the Freedom of Information Act, perhaps you could bring pressure to bear on the coalition government so that we can see the Risk Register relating to the NHS and Social Care bill.

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