NHS reforms will be altered significantly and in a Lib Dem direction – Paul Burstow

The NHS Bill will be substantially changed – that was the message from Liberal Democrat MP and Health Minister Paul Burstow at Lewisham Liberal Democrats on Friday night. It won’t just be changed, he said, it will be changed in a distinctively Liberal Democrat direction.

At the heart of the likely changes is the role of Monitor, the proposals for which Paul bluntly said were got wrong first time round. Though he was careful not to directly criticise Andrew Lansley, he did say that the original proposals for Monitor were to adopt the model of regulator used with privatised utilities and apply that to the NHS – and (unmentioned by Paul) Andrew Lansley was previously a civil servant who worked closely on such regulatory plans. The implicit message was that Lansley took a model he was used to and wrongly tried to apply it to the NHS.

Altering the role of Monitor to emphasise integration and collaboration could tackle many of the fears of fragmentation and privatisation, depending on how the details are worked out. Paul Burstow put forward a very upbeat case for this, pointing out how changes in the Bill would in fact end the sort of private provision brought in by Labour that had resulted in private firms being paid for work they did not do.

Paul Burstow gave credit to the spring conference motion in helping to trigger changes to the NHS plans – and was refreshingly frank in saying that what the party is doing in government is changing as a result of the conference vote. I’ve heard many an MP in the past argue for reasons to side-step or ignore or side-line a conference vote; there was none of that from Paul.

The other key influence on the shape of the final plans that he mentioned was the widespread consultation within the health service and with related charities and similar organisations. With over 200 consultation events held in the last six weeks, it is hard to see how the final plans can be ones which do not reflect the widespread views within the health service.

Paul Burstow talked about how the plans for GP commissioning are likely to change, with tighter rules around transparency and more involvement of lay members, including a lay chair for the GP commissioning bodies. As I mentioned in my question to him, the risk is that we end up with PCTs being recreated by the back-door, but Paul was optimistic that the new arrangements would be a substantial improvement on the extremely patchy PCT record due to the central involvement of GPs. In addition, GPs would not  be able to delegate commissioning decisions to others, such as external private firms. Commissioning will stay in the hands of accountable public bodies.

Given Paul’s long standing interest in social care, it was no surprise that he also stressed the importance to him – and in the Bill – of integrating health and social care and of giving local government the key role in promoting public health.

The questions at the end showed a fair degree of scepticism of the plans so far, though many people commented afterwards how impressed they were that Paul took the time to answer every question from someone in the room.

Perhaps the best of those was from a member who admitted they aren’t an expert in the NHS and therefore looks to the views of figures they trust to help judge a policy. So his question was “Will Evan Harris be happy with the changes to the NHS White Paper?” In reply, Paul Burstow pointed out that he had to keep many people happy – including also Shirley Williams – but he expected Evan to be happy with most of the changes. I’m sure Evan will tell us if that turns out to be wrong…

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  • Would the real Paul Burstow please stand up……

    On this site he was championing the changes when they were announced, now they “Got it Wrong”. I’m happy if this is a genuine change of heart by him, less so if he tries to insinuate the blame all at Lansley. He helped draft the Bill, he defended it, and commended it to us. He must admit his own culpability in it being wrong before, then we can trust him to honestly talk to us in the future.

    Personally, I need to see that the private companies, that GP practices mostly are, will not benefit financially from this change, otherwise they are no different from other private companies taking up the role…

  • Incredible U-Turn.

    Paul co-authored these ‘reforms’ – now he claims Lansley is at fault.

    I’ve had numerous discussions on this site where Paul defended his competition plans for the NHS without reservation – and now he wants to reverse them.

    I agree with Steve Way. After voting these reforms through the House in the 1st instance – will the real Lib Dems please tell us where they stand.

  • Andrew Suffield 22nd May '11 - 3:07pm

    I need to see that the private companies, that GP practices mostly are, will not benefit financially from this change

    Your position is that economic growth and tax-paying businesses are bad things which must be stopped? That GPs must be prevented from expanding and taking on new patients, since this would result in them getting more money?

    There is nothing wrong with people deriving financial benefit from the actions of the government – indeed, the main objective of this government is financial benefit for the whole country. Or did you miss all the times they’ve said that the economy is their focus?

    What must be ensured is that this is not simply handing tax money to private companies with no benefit to the taxpayer, and that it gives good value for money.

  • @Andrew Suffield
    No not my position at all, I meant only from the commissioning element, I can see how you felt this as I was not specific. Money saved by using better financial options for treatment must be ploughed back into the system not given to the body responsible for commisioning. This would be a huge conflict of interest, the body selecting service providers should be non profit making.

    Private companies have a large part to play in providing health services, but these must not be at the cost of the service as a whole. For example, cheaper minor operations provided by one company can stop the ability of the NHS to provide more complex operations. Therefore effective commisioning must take account of this. A body that takes profit from individual savings would not have the broader range of services as a priority, or at least could have a clear conflict.

    I part own and run a company in a linked industry so have no problem with businesses growing and making money providing health services. I employ over 50 people all of whom pay taxes and have secure employment. But if my business were to grow at the expense of adequate provision elsewhere it would only be myself and my fellow shareholders rather than the country as a whole that would really benefit.

  • Tony Dawson 22nd May '11 - 5:16pm

    “The other key influence on the shape of the final plans that he mentioned was the widespread consultation within the health service and with related charities and similar organisations. ”

    I see no mention at all, here, of the consultative session at the Liverpool Party Conference in September 2010. The proposals as outlined to Lib Dems there were systematically panned from an audience who included many with considerable expertise and/or experience in the NHS. Maybe if those inputs had powered the Minister’s thinking and negociation with his Tory oppos and the PM/DPM, the oil tanker of the White paper might have been turned around long before the Somali pirates boarded?

  • If I was a Lib Dem, I’m not sure I would be so generous to a politician who has been highly involved in a highly damaging policy and a policy that seems to go against core Lib Dem principles.

  • Nigel Quinton 23rd May '11 - 10:09am

    I agree with the comments above from Tony Dawson and Steve Way regarding Paul Burstow’s apparent change of view. I was at the consultative session in Liverpool and also attended a recent event in London which Paul spoke at.

    On both occasions I was impressed by Paul’s clearly apparent desire to improve the NHS. In Liverpool I felt that he was being far too optimistic about the effect of the changes he was promoting – and he was clearly claiming considerable co-authorship of the white paper at that time – and far too dismissive of the warnings being made by those present that the effect would be very different to what he proposed.

    At the Hackney LibDem garden party earlier this month, he spoke well about the need for integration and coordination of services. He is clearly now between a rock and a hard place. If he is too critical or even contrite about what was published last year then his position will appear untenable, yet he seems to want to see through the changes that most of us are calling for.

    Given the history of this bill over the past 12 months I remain very uncertain that the end result will be fit for purpose. At Sheffield I was one of those who voted to reject the motion completely, not simply to amend it, as I was moved by Andrew George’s call to go back to the drawing board. My gut tells me this would still be the better move. How a bill can be salvaged that would keep both Andrew Lansley and Paul Burstow in their current roles beats me.

    The sad fact is that the NHS white paper and the quiet amendment to the coalition agreement that allowed it to proceed will probably be looked back on as a major blunder and the start of the mismanagement of the coalition by the LibDem leadership. You have to wonder, having secured what was a surprisingly good coalition agreement from a LibDem perspective – just what were they thinking?

  • Andrew Suffield 24th May '11 - 12:05am

    A private company will not want to run the two loss making services at my hospital, they will only want to run the surplus generating services.

    You seem to be suggesting that the amount of money paid for these services is set in stone and can never be changed. Clearly there is an inappropriate distribution of funding in the current system – the surplus services are overfunded while the deficit ones are underfunded – and it is a fortuitous coincidence that the hospital receives roughly the right amount of funding overall. Obviously if these services are to be privatised then the funding must be adjusted to correct this error. Fortunately, if what you say is true, then we have clear and comprehensive evidence about what it actually costs to provide those services, and can set the funding accordingly. That will make these issues very easy to address.

  • I welcome his change of opinion. But I do, like others, wonder why he was previously in favour of the reforms, Clegg signed off on them, went around the country telling us these are great plans, and got the LibDem MPs to vote in favour of the bill on its first two readings.

    I’m glad changes are being made, and I am glad the views of the public are finally starting to be represented concerning the NHS. Shame it took such an electoral shock for LibDems in government to actually do what they were elected to do – represent the people, not companies who want larger profits.

  • Richard Hill 27th May '11 - 7:36am

    Personaly I am all for more private companies running more aspects of the NHS. as long as it is free at the point of use. From what I can see the NHS is inefficent And badly run although a lot of propeganda is put out denying that.

    The goverment spends too much time trying to run things when they should be evolving the laws to make sure they are run properly. Being poacher and gamekeeper does not work.

    If a private company does not preform it loeses the contract and goes out of business and somebody that can do the job gets the contract. What happens if an NHS hospital preforms badly, not much. Normally they say it’s not there fault and they just need more money.

    Grow up, except reality and human nature, competition works. Onca people except those facts we might be able to set up a system that relly works.

  • “Paul Burstow gave credit to the spring conference motion in helping to trigger changes to the NHS plans”

    The Sheffield vote was a tug hitting the tanker at high speed from one side in order to turn it around before it hit the rocks. It should not have been necessary. Nothing in the motion hadn’t been said to Paul by scores of people in the consultative session at the Liverpool conference – and afterwards.

    There is still considerable concern at large that whatever Nick says the DoH is carrying on behind the scenes, implementing what it wants. More importantly, many PCT are dying on their feet, with all the able people (there were a few!) bailing out as fast as they can and finding other jobs. This process can only get worse the longer the NHS Bill is out in the ‘long grass’.

  • “If a private company does not preform it loeses the contract and goes out of business”

    Unfortunately not.

    In the public sector, private firms strip out excess profits, perform appallingly then go bankrupt, leaving someone else picking up the tab. Or they make excuses for ‘mistakes in original contract specification’ and demand (and get) shedloads of extra money. Then the same people come back in a different guise and pick up the same contracts again often at higher price.

  • His fingerprints were all over the original plans. He should resign.

  • Alexandra Ankrah 11th Jun '11 - 8:10pm

    RE: Monitor – we should be taking a leaf out of the Eric Pickles book – If we can scrap the Audit Commission – then why do we need to save Monitor?

    I was grateful to both Baroness Kramer and Paul Burstow for hosting a meeting last night on the NHS Bill in Worcester Park. I can see the hard work that is being done on our behalf and the changes – for the better, that are being hard won through the influence of Liberal Democrats.

    The issue of Disability, tackling health inequalities, promoting fairness and access to services were discussed at the Worcester Park meeting. It was indicated that Monitor, the body which authorises NHS Foundation Trusts – is proposed to emerge with a different role – which would include a responsibility for tackling inequality.

    Though I am grateful for the meeting, as well as the open and honest approach taken by Paul Burstow MP and Baroness Kramer, I am not yet convinced we have the right foundations in place, to advance equality and human rights.

    It is true that I have been concerned around the ongoing lack of clarity in relation to the NHS Equality Deliver System [EDS]. The new EDS which was intended to monitor and assure equality and human rights in the NHS. Was due to come on line in April 2011. Whilst there have been statements on Ministers confirming commitment to the EDS – no concrete timetable for it, a robust programme of engagement around it, or details of funding for this year has been forthcoming.

    On the prospect of Monitor remaining and taking on any role in relation to tackling inequalities creates significant concerns. I fear that we are now colluding with what feels like a new ‘Parlour Game’ – “let’s have a go at finding a role for Monitor and its Board, which is limited to 5 members”. Basic management and planning principles tell us that ‘Function’ first, ‘Form’ second. Monitor the independent regulator for Foundation Trusts, is the body who have struggled with delivery of their own core function. Monitor has continued to authorise NHS Trusts that have not demonstrated compliance with equality legislation or in some cases may have been in breach of equality and human rights legislation .

    Monitor has in the past described itself has having three main strands to its work:
    • determining whether NHS trusts are ready to become NHS foundation trusts.
    • Ensuring that NHS foundation trusts comply with the conditions they signed up to – that they are well-led and financially robust; and
    • supporting NHS foundation trust development.
    The functions and powers of Monitor and the NHS foundation trusts it regulates are set out in the National Health Service Act 2006. It is not only a public body, but it is a body with regulatory powers and a statutory general power to co-operate with other public authorities.

    Though itself a regulator, Monitor as far as anyone can see has been silent where regulatory action has been taken against FT’s by the Equality and Human Right Commission [EHRC]. Indeed in the case of Mid Staffordshire Foundation Trust, despite claims of at least 300 avoidable deaths and Human Rights abuses at the higher end of the scale, it authorised FT status. Monitor only appears to have entered into an investigation when the remuneration packages of the CEO and Chair caused concern.
    There is no evidence that I have seen which demonstrates that Monitor has either collaborated with other regulators including the Equality and Human Rights Commission, to ensure compliance with equality and human rights legislation. I cannot find any evidence to support the view, as advanced by Paul Burstow MP, that Monitor that could have the future capacity or capability to not only collaborate on equality and human rights issue in future – but take a role in tackling health inequalities.

    But how could we expect a body like Monitor, with such a poor recent record in implementing equality and human rights in its own ‘house’, to now get things right and help others put their “houses into order”.
    1. The case of Mid Staffordshire Foundation Trust, which brought into question the capacity and capability of Monitor, discloses significant evidence of breaches of Articles: 2, 3, 6, 8 and 14 of the Human Rights Act 1998. Sadly it also included all too familiar evidence that the Patient Public Involvement Forum did not play the role it should have in protecting the rights of patients to life, safe treatment, good care, respect for private life and a prohibition on discrimination.

    2. Monitor, though a Public Body was not established until 2004, it never published a Race Equality Scheme, or in the spirit of the legislation attempted to put in place any mechanism to evidence how it would have due regard to the need to:
    • eliminate unlawful racial discrimination
    • promote equality of opportunity
    • promote good relations between people of different racial groups.

    3. Monitor did not publish a Gender Equality Scheme. Equal Pay Reviews have not figured in its work, compliance framework or guidance, despite Monitor’s focus on financial management, the market and competition. Whilst Authorisation enables NHS Trusts to depart from ‘Agenda for Change’ – the nationally agreed pay review programme – Monitor has consistently failed to address, or even consider, gender pay gap issues.

    4. Monitor unlike the NHS trusts it regulates, or other regulators such as the CQC, did not take steps to progress a Single Equality Scheme. This was despite there being a strong recommendation made to all NHS trust Boards by the Department of Health to do so.

    5. Monitor did publish a Disability Equality Scheme [DES]. A reading of this raises serious questions around compliance, as well as Monitor’s understanding of its own legal responsibilities as a Public Body. Monitor acknowledges that the Disability Equality Scheme was produced with no involvement, in any form, of Disabled people or those who might be affected. The Scheme did not lead to a Disability Equality Action Plan. Worryingly within the DES, Monitor took steps to try to limit the scope of its own statutory duty, by claiming its contact with the general public was limited.

    “Monitor mainly liaises with professional organisations in the health sector and does not have a great deal of contact with the general public. Accordingly, we approach our duties as an employer and as a corporate entity in a proportionate and focussed way. ” [page 2 Disability Equality Scheme].

    6. There were findings from the Mid Staff’s case on Monitor’s failure to effectively engage with Patients and Carers. It appears that Monitor has no desire to create the means, build expertise or concrete and practical mechanisms to reach the seldom heard, even though they might be most at risk.

    7. Monitor did not undertake and/or publish statutory equality impact assessments.

    8. Monitor’s stance on Diversity – contained in Monitor’s Equality and Diversity Policy of May 2010, does not demonstrate compliance with the law in force at the time – let alone anticipate the Equality Act 2010, which would come into force later that year. The Policy is principally concerned with recruitment, training and promotion and employment procedures at Monitor. In any case any credit to Monitor for having a policy is diminished by the closing caveat – which forms part of the Policy:
    “This policy is for guidance only and does not form part of your contract of employment”.

    9. Monitor’s Corporate Plan for 2009/12 – includes no specific reference to equality, inclusion or human rights. Though it does have corporate actions and targets, none of these expressly set out how it intends to meet its duty under current equality legislation or take a human rights based approach and bring its work within the scope of the Human Rights Act 1998.

    10. Monitor’s Compliance Framework 2011/12 –in effect abdicates responsibility for assessing compliance relating to equality and human rights. The framework for assessing whether NHS FT’s are working within the terms of authorisation provides concrete evidence of a lack of due diligence around equality and human rights by Monitor.

    11. Within Monitor’s own update on progress report post Mid Staff, which followed on from the audit undertaken by KMPG [published August 2010], it acknowledged that over 15 months on and Monitor had still not completed a Memorandum of Understanding with the Department of Health. It had however met its target of entering into a MoU with the CQC. This unacceptable delay is crucial, as the responsibility for the performance management of equality and human rights within NHS trusts rests with the Department of Health and this is undertaken in the case of Non-FT Trusts, through Strategic Health Authorities.

    12. The regulator with responsibility for equality and human rights for Foundation Trusts, is however the Equality and Human Rights Commission. There is no mention or evidence that Monitor had or has taken any steps to include the EHRC as one of the key regulators and stakeholders that it should be working with.

    13. The original report by KPMG Internal Audit Risk and Compliance Services into failings and lessons arising from the Mid Staffs case was presented to the Board of Monitor in May 2009. It is interesting to note it was completed by the same provider of Internal Auditor services to Monitor, who presumably had a pre-existing duty to test systems, risk and advise the Board accordingly on control weakness.

    14. It is not clear from the published report whether they ever examined their own contribution, if any, to the apparent failings and system flaws. However it is clear from KMPG’s Internal Audit report of 2010 that they drew a distinction between control weakness and the issues within the assessment processes.
    ”A report was commissioned at the start of the financial year by the then Chief Executive to consider learning points to be obtained from the events relating to Mid Staffs. While it was not a formal part of the internal audit plan at the start of the year, its findings have inevitably contributed to our evaluation of the state of internal control within Monitor and the opinion that we provide. The report itself was provided direct to Board. While it contained fourteen recommendations for action, these were primarily matters for further development and refinement of the processes relating to assessment, compliance & monitoring and intervention rather than control weaknesses.
    In practice it is our expectation that the actions arising will enable the operation of the regulatory system, including interactions with other NHS bodies, and quality of actions to be improved in the future rather than addressing (past) control weaknesses.”
    Annual Report and Opinion 2009/2010 – KPMG Internal Audit Risk and Compliance Services [July 2010]
    15. Yet given an earlier report issued by the KPMG – [the Audit Committee Self Assessment Report (June 2008)], into Monitor’s own internal governance, catalogued: significant gaps in governance, poor function and understanding of the role of the audit committee, as well as lack of reporting to the Board and lack of clarity on management of risk – it would have been a surprise if there had not been any other wider organisational control weaknesses within Monitor.

    16. The KMPG report into the Mid Staffordshire case, whilst raising issues around liaison with regulators – concentrates on the relationship with the HCC/CQC. The report does however provide strong clues as to how and why a Trust which is in breach of equality and human rights provisions could then and even now be authorised as an FT.

    17. Monitor’s focus was on what is described in the report as “high level review”. Monitor’s review of quality and clinical governance was based on assumptions. The assumption being that if historic information to the SHA, NHSLA or HCC [now CQC] raised no problems, then this equalled compliance.

    18. However we know that in most cases the SHA, NHSLA and HCC provided little independent assurance.

    • With the exception of possibly two SHA’s, there was in this period little evidence of SHA’s commitment to the performance management of equality and human rights in NHS Trusts. Indeed the position was so poor that in 2009/10 the EHRC was forced to take regulatory action for Breach of the Race Duty against at least one SHA. With the abolition of the SHA’s this in future becomes largely academic.

    • The NHSLA framework in places is in conflict with advancing equality – its role as an insurance provider might include advice on prevention, but in the area of equalities its focus is on mitigation. So for example in the area of gender and pay – it provides advice on how to side step FOI requests that could lead to a claim, rather than how to undertake a pay gap audit.

    • The HCC framework around equality and human rights was and largely continues to be based on NHS Trusts self assuring. Not many Trusts were likely to identify themselves as non-compliant – an issue widely publicised by the NHS BME Network.

    19. The credibility of Monitor, with regard to Equality and Human Rights, is additionally compromised because: Monitor has failed to evidence it has met is legal duties, failed to liaise with the relevant regulator, did not appear to employ those with professional expertise and within its compliance framework there continues to be elementary failings around evidence triangulation.

    Perhaps leopards change their spots, but on this occasion – we should be taking a leaf out of the Eric Pickles book – If we can scrap the Audit Commission – then why do we need to save Monitor?

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