The Minister listened!!

I have been a particularly ebullient critic of the Coalition Government's White Paper on Health in the last few months. (see earlier blog entries.)

Today the Government published its formal response document to the consultation process. I was involved directly, taking part in a Consultative session with Paul Burstow at the Liberal Democrats annual conference in Liverpool and in a private session with him later on, and I also helped to frame the official consultation response by Camden Council.

In the published response today Camden get a specific mention -

"Some respondents, for example Camden Council, wanted the Government to “require local authorities and health commissioners to pool resources”. Although we do not think this is practicable, we understand the sentiment. As Solihull Care Trust suggested, “local authorities will struggle to co-ordinate commissioning without a commitment from partners to joint/pooled budgets”. However, we agree with Suffolk and Great Yarmouth LPC when they say that “integrated working depends on the quality of local working relationships and although the Department can outline areas where integrated working is required this should not be too restrictive to prevent local innovation to occur”. This is backed up by the Lesbian and Gay Foundation’s suggestion that “lead commissioning and other flexibilities should be explicitly promoted and supported by the Department for the delivery of high quality community based specialist services”. Staff at Norfolk PCT echoed the views of many NHS respondents when they welcomed “the opportunity to increase dialogue between services and join services together for the good of patients”. The Bill will therefore place a duty on GP consortia and local authorities, through the health and wellbeing board, in drawing up the joint strategy, to consider how to make best use of the flexibilities they have at their disposal, such as pooled budgets. To reinforce this duty, the Department has also decided that the NHS Commissioning Board should be placed under a duty to promote the use of flexibilities by consortia. These duties do not require flexibilities to be used, but they signal the importance of maximising the use of the tools available.

And the views of Southampton City Council were identical to ours on the need for "compliance" of GP Consortia to follow the Joint Strategic Needs Assessment (or JSNA). The relevant sections in the response paper today are these -

"In the reformed system, the process and product of the joint strategic needs assessment takes on much greater importance. The health and wellbeing board will have a role in helping meet the need - expressed by the NHS Confederation and others - for GP consortia to have “access to public health expertise so that they can take a population health viewpoint, in particular access to epidemiological advice and insight into parts of the population that are either unregistered or invisible to general practice”, through for example the Director of Public Health being a member of the board. As Southampton City Council has suggested, the focus on the JSNA will help “ensure that GP consortia take commissioning decisions based on the overall needs of the population in future rather than the needs of their current set of patients”.

5.20 The Government fully agrees with the view of the Association of Directors of Adult Social Services that “all commissioning should be driven by the JSNA or shared assessments across local authority boundaries, whether these are GP commissioning, council commissioning or joint commissioning”. Many respondents, for example the Association of Directors of Public Health, Nottingham City Council, Oldham PCT, and Peterborough City Council, felt that the value of the JSNA could be enhanced by clearer expectations about its use within commissioning plans. The point is well made. At present JSNA obligations extend only to its production, not its application. To remedy this lacuna, the Government is therefore introducing in the Bill a new legal obligation on NHS and local authority commissioners to have regard to the JSNA in exercising their relevant commissioning functions.

Added to this was a commitment to strengthen the distinctive role of Scrutiny Committees, including the ability to scrutinise the decisions of GP Commissioners.

So we made some progress. And it's good to note that the Coalition actually listened to the responses and adjusted their approach accordingly.

JOHN BRYANT

Let's stage a World Premiership instead!

The huge disappointment of England not being chosen as the 2018 host for the World Cup has led on to some angry criticism of FIFA and it's internal workings. Corruption of officials appears to have been fully uncovered by the Sunday Times and BBC's Panorama programme.

However the argument that investigative journalism should be restrained out of patriotic interest is in itself suspect. If we had won the nomination through a corrupt process, then how could we then be proud of the outcome? England offering a friendly against Thailand in exchange for a vote is as corrupt in my book as a brown envelope stuffed with cash to a FIFA representative.

The exhaustive ballot process is also inefficient and suspect. I noticed that in the vote for the 2022 tournament Qatar actually lost a vote between two stages. Use of the Alternative Vote would stop all attempts of later stage tactical voting, as the losing country's votes would automatically transfer to later pre-registered preferences.

Given the total lack of confidence many nations (at least of a democratic variety) now have in FIFA, it is time for English football to replicate its own previous rebellion when the leading clubs rebelled against the Football League and set up their own tournament.

Surely it is time the English FA formed a World Premiership tournament to take place in England during one summer when the Olympics and World Cup will not be taking place - perhaps in 2013? We already have the stadiums and training facilities to stage a tournament. It could be by invitation only to the world's top 16 footballing nations, taking account of the most recent regional tournaments such as the African Cup of Nations, Euro 2012 and the South American and Asian equivalents.

For some countries it might prove to be a useful trial run for the Brazil World Cup in 2014, but it might find its own momentum as a genuine alternative to FIFA's suspect package. After all we had significant splintering of the world titles in boxing some years ago and so the precedent is set for staging an alternative to the "official" tournament.

If FIFA threaten to exclude the top nations who choose to take part in the World Premiership then the top nations should walk. The TV companies know where the money will be and they will choose to show the best football they can to their subscribers.

So does anyone in the English FA have the guts to lead on this?

Who is ready for a public meeting?

It was curious to note that although we had around 80 residents who turned up on a cold night for the Area Forum in West Hampstead on Monday hardly anyone had been attracted to come by reading about the event on Twitter or Facebook. While most of our citizens are using e-mail these days there still seems to be a generation gap between those who are attracted to attend a traditional public meeting to keep up to date with current affairs, and those who aren't. The latter appear to be under-45, and are ready to post their opinions on social networking sites, but won't push through the doors of a community hall of an evening.

The same generation gap is sadly affecting the active membership of traditional residents and amenity groups too. I attend a fair number of community meetings as a councillor but I know there is a significant demographic I rarely come across. Within the boundaries of West Hampstead ward we have a higher than average number of people in the 25-34 age group compared to the population as a whole, but these are precisely the people we don't see taking part in community groups.

Many will be transient because of their work, so do not settle in the area, and therefore take less interest in local affairs. Those who put down their roots by buying a property or by having permanent tenancies are those who tend to join in. The only exceptions to my thesis are those who have children of primary school age and get involved in the local schools as Parent Governors or members of Friends Groups. But I suspect these are also the "settlers", and given the trend to have children later in life, many of these will be approaching 40 before they get stuck in to organising the school tombola or joining the Governors' Finance Committee.

I am not sure whether I should be worried or not. We have gone twenty years or so since a younger generation was catching the headlines with direct action with demonstrations and sit-ins. More recently the demonstration against the Iraq war also caught the imagination although this was across all age groups.

The recent unrest about student tuition fees, although in my view largely misplaced (See my earlier blog) at least shows us that when the right cause comes along the young can still get worked up about it. They are the ones who do use the social networking sites to organise their activities, but it tends not to be an invite to a public meeting in a draughty hall...

The NUS has got it wrong

I have not been blogging for a while because a lot of work has got in the way since last month. In that time the tuition fees issue has taken the headlines in a big way.

I am one of those fortunate enough to have enjoyed a free university education in the 1970's and an almost complete maintenance grant. Grants were means tested then according to your parents' income, and coming from a modest background I qualified for the full grant for my first two years.

Since then we have had the introduction of tuition fees, the withdrawal of grants except for a very small number of poor applicants, and the introduction of top-up fees too, each change made by a Labour Government following manifesto pledges against such moves.

So am I arguing that because Labour reneged on manifesto commitments it's all right for the Liberal Democrats too?

Well there is a big difference between the two parties. Each time Labour made a promise they failed to keep they had secured a working majority in the House of Commons at the General Election that preceded their decisions. So they had the power to fulfil their promises but chose not to do so.

In 2010 the Liberal Democrats did not win the election.

They did not secure the power to implement their manifesto in full, which included in case any reader has forgotten, to phase out tuition fees over six years. Not immediately, but over longer than a parliamentary term.

At the election we secured around 23% of the vote and got about 10% of the seats. Both Labour and the Tories support tuition fees, so whether the Liberal Democrats had done a deal with either party, securing a phase out of tuition fees just wasn't going to happen.

The Coalition Agreement secured the option for Liberal Democrat MPs to abstain on any vote to increase fees, and in practice I expect many will vote against the increase. This is the position taken up by our new party president Tim Farron who was my choice for the role.

However our instincts for fairness has led to the party securing a better deal for graduates than the Browne report (commissioned by the last Labour Government) envisaged. The repayment scheme now being proposed makes sure that the third of graduates taking on the lowest paid jobs (such as in Social Care) will actually pay less back than they do now, and those graduates in the top third of jobs on the highest pay (such as those in financial services) will pay back more. It is the closest one can get to a Graduate Tax without calling it such.

So why is the NUS trying to unseat Liberal Democrat MPs?

I don't think they have thought this through. If we have fewer Lib Dems in the next Parliament we are likely to have more Labour and Tory MPs who actually believe in fees and are not interested in making the system fairer. Labour is very publicly split over the concept of a Graduate Tax already, and as they are a party that has twice reneged on tuition fee commitments when in power they cannot be trusted. The Tories are waving the flag of fairness at the moment, because while they are in coalition with us they have to. But give them a working majority and the fairness principle will soon be lost.

So by supporting the NUS campaign to unseat Lib Dem MPs students will be making sure the opportunities for their fellow students from poor backgrounds are diminished further for another generation.

In fact the opposite would be a better way forward. If students actively campaigned for the Liberal Democrats to win more seats we could extend the fairness principle further.

Whether we can ever recreate the conditions that applied when I was a student, when I was the first person from my family to ever go to university, will always be difficult given the higher proportion of students now qualifying for Higher Education, but it's still a campaign worth pursuing.

So I think the NUS needs to reconsider its position. It would be usual for students to blame the older generation for mistakes that impact badly on them, but this time they could be making it worse for themselves....

We were right, the other parties wrong

Before the General Election Chris Philp, the Tories' candidate for Hampstead & Kilburn led a silly campaign which he described was to save the closure of the Stroke Unit at the Royal Free Hospital. He changed tack several times when the fact of the proposals from Healthcare for London were explored. Rather than shutting, the Royal Free's unit was to have an increase in beds. The excellent rehabilitation work was in fact to expand there. However the new "Hyper Acute Stroke Unit", or HASU, was to be centred on the UCLH site to serve a large part of North Central London rather than at the Royal Free.

Philp was determined to keep his campaign on the road so he managed to get a resolution passed at a full Council meeting, with the support of the Labour and Green parties, critical of the proposal to use UCLH as the HASU.

The Liberal Democrats stood alone in support of the new HASU, largely because we had done enough to study the proposals in detail and recognised they represented a step change in future survival rates from strokes.

Now we have the first figures after the new HASU has been in operation for six months. Some 2,675 patients have been taken by the London Ambulance Service to HASUs across our area. The transport time from home to HASU is less than 30 minutes in 93% of cases. The HASU established in UCLH in April is now ranked second best in the country in the recent RCP audit.

The number of people receiving thrombolysis in our area of London has doubled due to centralisation. Thrombolysis is a lifesaving treatment which can only be given within a strict time period. Previously patients waited up to 72 hours to see a specialist- now they are at the specialist unit in 30 minutes. The in-hospital mortality rate for patients treated through the UCLH HASU is now strikingly low - 6% against the national average of 27%.

This means in practice that if these proposals to centralise emergency stroke care in the HASU at UCLH had not gone ahead, as the other parties wanted, dozens of local people would now be dead. So those that whipped up a stupid frenzy of petty parochialism earlier this year should now hang their heads in shame. Their views were not even supported by key staff at the Royal Free, the hospital they purported to support.

There are times when politicians should properly examine the clinical evidence for change and show leadership on matters of health policy. I am proud to have to got this one right...

The Health White Paper is flawed..

At the end of May I attended the Special Conference of the Liberal Democrats that endorsed, with an overwhelming majority, the Coalition Agreement.

As a Liberal Democrat I was supportive of the principle of democratising PCTs and pleased that this featured in the Coalition Agreement. It specifically mentioned stopping “top-down reorganisations of the NHS” and also promised “We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCTs board will be appointed by the relevant local authority or authorities”. That appeared to follow the spirit of the manifesto we fought the General Election, so hats off to the negotiating team The Conservatives had made much of maintaining funding for the NHS above the rate of inflation whatever else happened to public spending, so bringing these two promises together made sense.

Two months later and the Health White Paper describes one of the biggest structural changes that the NHS has ever faced in its history, at a time of constrained budgets and after a General Election during which both coalition parties gave no messages that such a restructure was likely or indeed warranted.

So who then decided that the Health White Paper should propose top-down reorganisation, including the creation of an NHS Commissioning Board which will take decisions on the allocation of funding to GP practices, a centralisation of a power currently exercised by PCTs locally, and who decided that within two months of the Coalition Agreement that PCTs should be abolished?

While local authorities are given the welcome leadership role in conducting Joint Strategic Needs Assessments (JSNAs), the majority of decisions on commissioning services will be undertaken by GP Consortia. There is no proposal as yet to require GP Consortia to comply with the JSNAs when they commission services.

The needs identified through a JSNA in an authority like Camden would rightly consider the health needs of the many thousands of people who are not registered with GPs because of their transience within the area or because of their uncertain status in the community. These are the people who will attend A&E departments for treatment when necessary, but will not be part of the registered patient lists that GP Consortia will be commissioning for. So there could be a dangerous mis-match between what the Council believes is necessary and what is actually commissioned by GPs.

The White Paper talks about public accountability but proposes to absorb the functions of overview and scrutiny committees into the Health and Well-Being Boards. This new hybrid animal appears to have a mix of roles, which in my view are not compatible with each other. It will have strategic decision-making functions with regard to JSNAs, will be a body to promote “joined up thinking” between health and social care, and have scrutiny functions too. Who scrutinises the Boards is left dangling in the latest consultation paper - “Local Democratic Legitimacy in Health” for in paragraph 50 it states - “A formal health scrutiny function will continue to be important within the local authority, and the local authority will need to assure itself that it has a process in place to adequately scrutinise the functioning of the health and wellbeing board and health improvement policy decisions.”

So scrutiny committees are disbanded and then recreated to scrutinise the Health and Well-Being Boards. That does not look very joined up or logical to me. The separation of Executive and Scrutiny functions within local authorities eight years ago continues to have its critics but this latest proposal blurs these distinct roles, and the loss of effective scrutiny will, in my view, be the result.

Creating GP consortia to undertake commissioning on behalf of patients may have its virtues but there is no evidence that GPs have the inclination or the expertise to undertake the role successfully without themselves delegating many of the commissioning tasks to a range of unaccountable bodies from the voluntary or private sectors. I am not clear how this squares with the Coalition Agreement’s declaration that - “We will significantly cut the number of health quangos”. We might need to redefine what a quango is in this context but if something looks like a duck and quacks like one it will be seen by the general public, and by local politicians as their community champions, as another class of body which spends public money but is unaccountable to the local community.

The recent example CAMIDOC going into liquidation, the GP co-operative that ran out-of-hours services across four boroughs, is not a great example of GPs financial competence. Camden's Health Scrutiny Committee discovered this on 1st September, and this appears to have influenced the way politicians of all parties have grown more sceptical about the GP Commissioning role envisaged in the White Paper.

General Practitioners are the only part of the NHS that cannot be required under current legislation to attend health scrutiny meetings. So if the commissioning of a large part of the NHS is to be transferred to GP Consortia then their public accountability should be through a rigorous scrutiny process conducted by local Councils. Retaining Health Overview and Scrutiny Committees distinct from any decision-making bodies within Councils charged with carrying out public health functions is essential, and any subsequent legislation that flows from the White Paper should retain and enhance local Health Overview and Scrutiny Committees.

So if nothing changes when the White Paper is converted into legislation GP Consortia are to become compulsory in that every GP will have to belong to one to secure a new GP contract. The existing PCTs are expected to ease the transition to the new structure at a time when they have been told to reduce management costs by an average of a third and in NHS Camden's case by 45%. No stress there then.

Another feature of the top-down restructure clearly proposed by the White Paper, (although rigorously denied by the Coalition Agreement), is the creation of the NHS Commissioning Board, which will carry out the function of commissioning specialist services.

In London the recommissioning of stroke and major trauma services across the capital, which has led to 4 identified major trauma centres and 8 Hyper-Acute Stroke Units (HASU’s) followed a rigorous scrutiny of the plans by a pan-London Joint Health Overview and Scrutiny Committee (JHOSC) on which I served. The resultant report highlighted a number of issues that the commissioners needed to take account of when proceeding to implement their proposals.

The reported health outcomes after the first few months of the HASU’s being in place show a significant improvement in survival rates. So how under the new system of commissioning would the important role of scrutiny be undertaken to examine regional or sub-regional proposals for change? Without existing scrutiny committees in place to come together to form JHOSCs, how would such proposals be examined in public?

The title of the consultation document “Liberating the NHS: Local Democratic Legitimacy in Health” suggests that there might be a real democratisation of health functions at local level. Sadly the proposals fall far short of this.

The document openly admits the following - “The Coalition Programme proposed directly elected individuals on the primary care trusts (PCT) board as a mechanism for doing this. However, because of the proposed transfer of commissioning functions to the NHS Commissioning Board and GP consortia, the Government has concluded that PCTs should be abolished.”

I have already commented on the blurred roles undertaken by Health and Well-Being Boards but their composition cannot be described as an advancement in local democratic decision-making. Like the previous Government which created the separate roles for Children’s Trusts and Safeguarding Boards in which the membership is overwhelmingly made up of appointed officials rather than elected representatives, the Coalition Government has fallen into the same trap. The Boards will have some elected councillors but they will be joined by a range of appointed officials

The consultation document states, “the boards would bring together local elected representatives including the Leader or the Directly Elected Mayor, social care, NHS commissioners, local government and patient champions around one table. The Directors of Public Health, within the local authority, would also play a critical role. The elected members of the local authority would decide who chaired the board. The board would include both the relevant GP consortia and representation from the NHS Commissioning Board (where relevant issues are being discussed).”

Later it states, “For the board to function well, it will undoubtedly require input from the relevant local authority directors, on social care, public health and children’s services. We also propose a local representative from HealthWatch will have a seat on the board, so that it has influence and responsibility in the local decision-making process. We recognise the novelty of arrangements bringing together elected members and officials in this way and would welcome views as to how local authorities can make this work most effectively.”

Novelty indeed. This hybrid arrangement has little to do with democracy. If it was ever proposed that key decisions of the National Government’s cabinet would be undertaken by Cabinet Sub-Committee with a mix of ministers, and a built in majority of senior civil servants who had equal voting rights it would be deemed unacceptable by democratically accountable MPs and rightly so. I have no problem with key service Directors having the duty to attend Board meetings to provide proposals and advice but democratic decision-making should mean that only elected councillors should have voting powers on Boards.

Finally the transformation of LINKs into HealthWatch bodies with changed powers (another top-down reorganisation proposal) is not accompanied by any detail on how these bodies can be seen to be truly representative of patients. Presently those who want to be registered as members of LINKs can do so and local committees are largely self-appointed because of the lack of widespread membership. The White Paper suggests a HealthWatch representative would get a seat on Health and Well Being Boards. Most members of Camden’s Health Scrutiny Committee had to convince over 2,000 constituents in their wards to vote for them this year to get elected to the Council for an opportunity to serve on the Committee or become a member of the Council’s Cabinet. How many votes would be needed for a Health Watch representative to gain a place on a Health & Well Being Board?

In conclusion I would strongly argue that the White Paper fails on the twin tests of increasing localism and democratic decision-making. It is a top-down reorganisation which will create more quangos than it abolishes, and it proposes that decision-making powers should be concentrated in the hands of GP Consortia which will not be publicly accountable or subject to the priorities established by Councils’ Joint Strategic Needs Assessments.

Without significant changes when the expected legislation is laid before Parliament this will be a great opportunity missed, and the first example of a Government Department specifically ignoring the Coalition Agreement so successfully negotiated between the coalition parties only two months earlier.

Reflections on Ghana - Four

My final blog about my visit to Ghana is about the politics of the country. While I was there the opposition New Patriotic Party (NPP) was choosing its next presidential candidate to contest the next elections due in 2012.

It appeared that party members were engaged in primary elections based on regional voting across the country. This resulted in a final gathering of party representatives in a public park on a Saturday evening in Accra for the final declaration of results after they had been faxed in from the regions.

The NPP is a centre right party whose avowed aims is to extend human rights and property ownership to Ghanaians while maintaining a strong sense of public accountability. The government party is currently the National Democratic Congress (NDC) which is a left of centre party with ambitions of socialism, but with weak Government machinery it cannot finds ways of implementing its lofty ideals.

As I travelled in taxis and minibuses during and after the final election day I was struck by the animated conversations my guide had with several taxi-drivers and the interest shown by fellow travellers when the bus radio was tuned into a talk station. The eventual runaway winner for the NPP was Nana Akufo-Addo who managed a resounding 79% share of the vote against four rivals for the role. His nearest competitor, Alan Kyerematen, could not even get a clear majority in his own region, and he along with the other losing candidates conceded gracefully.

It was the first time the grassroots members had been trusted to vote in such an internal election and all candidates appeared to be proud of the exercise and the way it was conducted. What struck me was that I was 3,000 miles away from England but the speeches made by the NPP's leaders could all have been made by any party's representatives here after an internal election of this type. For example it was reported in the Daily Graphic that Alan Kyerematen had "pledged to support Nana Aku-Addo in his bid to win the 2012 presidential election and urged all his supporters to also work tirelessly for the party's flag bearer to ensure victory".

The newspapers and airwaves were littered with such statements for several days. A sense of deja vu struck me. I had heard all this before. Politicians the world over still tell the same stories...

What was more striking though was the lack of policy differences between the declared candidates. This contest was surely concentrated on the personality of the contenders.

Although Labour back here in Britain is conducting a similar exercise, I can find little difference on policy between the competing candidates, and where there may be some there is little interest from the press or the public anyway. Only Diane Abbott appears to be trying to seriously broaden the policy debate but as she is favourite to lose we can predict now the "rally round our new leader" speeches at the final declaration. Was it ever thus?