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Howe Now

Howe Now
5 November 2011

In person, Lord Howe is both genial and considered. He reflects carefully on questions put to him and gives steady, measured responses. It’s a professional attribute that makes his recent headline-making remark – that it doesn’t matter “one jot” who provides patient care so long as it is high-quality and free to the patient – all the more surprising.

In person, Lord Howe is both genial and considered. He reflects carefully on questions put to him and gives steady, measured responses. It’s a professional attribute that makes his recent headline-making remark – that it doesn’t matter “one jot” who provides patient care so long as it is high-quality and free to the patient – all the more surprising.

The statement comes from the Conservative health minister’s 7 September speech to an independent health forum, in which he also suggested that the Health and Social Care Bill offers “huge opportunities” to private companies. In a climate of privatisation fears, with the bill set to face further scrutiny in the House of Lords, such comments were unlikely to go unnoticed by the bill’s opponents and, sure enough, a row ensued.

Dave Prentis of UNISON condemned the “provocative” remarks, insisting “survey after survey shows the public care deeply about who delivers care. They do not want private companies coming in and making a profit out of the NHS”. Dr Laurence Buckman, Chair of the British Medical Association’s GPs’ Committee, told the BBC: “Lord Howe’s comments betray how deep the government’s misguided obsession with competition goes”. Shadow Health Secretary, John Healey, seized on the opportunity for political capital, saying: “This confirms what doctors, nurses, health professionals, patients’ groups and Labour have all warned.”

The uproar forced Lord Howe to issue a statement after the speech, in which he insisted that “patients will never have to pay for NHS care and we will never privatise the NHS. The amount of independent sector provision in the NHS will be determined by whether or not patients want it, not government.”

GP Business’ interview took place several weeks before the furore and Lord Howe’s comment that the Future Forum’s listening exercise had “assuaged people’s worries” over competition now seem rather ironic. The Forum, of course, urged the government to remove the duty on regulator Monitor to ‘promote’ competition and to establish stronger safeguards to prevent providers ‘cherry-picking’ services – recommendations that were taken up.

“There was, undoubtedly, enormous concern about the way that Monitor’s duties were framed in the bill as it stood originally,” Lord Howe admits. “The phrase ‘a duty to promote competition’ I think conjured up in people’s minds a vision of competition being promoted for its own sake. That was never the idea. It has always been our belief that competition should serve the interests of patients.”

Peer review
At the time of writing, the Health Bill is to be debated in the House of Lords on 11 October. No doubt discussions will be lively and impassioned – the Liberal Democrats’ Dame Shirley Williams has suggested already that further clarification is needed over the role of Monitor, and suggested in the Observer that the government has been “bewitched by a flawed US system”.

Surprisingly, however, Lord Howe – an elected hereditary peer – says he does not believe competition will necessarily be the big debate in the Lords as a result of the listening exercise (though he may since have revised that view). “That’s not to say we won’t debate the role of Monitor, and I’m sure we should, but I don’t think it’s going to be quite the bone of contention that it might otherwise have been,” he says.

At the NHS Confederation conference in July, Dame Williams told delegates that peers would have “substantial ideas for improvement” of the Health Bill. Labour peer Lord Philip Hunt proposed that clinical commissioning groups’ (CCGs) accountability would be one of the key topics to 
be debated.

Clearly this will be a key stage of the bill’s progress. Indeed, Lord Howe confirms that the legislation is far from a done deal, even after the Future Forum’s report. “We are a listening government, we will listen to any concerns raised by peers who come to the bill from a number of different perspectives and it could well be that we will make changes,” he says. “I can’t predict how big or small they will be but we, as much as their lordships, want to get this legislation right. We are not being precious about the bill and making out that it should be set in aspic as it is at the moment.”

So is the government prepared to make serious amendments? “The detail and the implementation really do matter, so ministers have not got a closed mind to making changes,” he says.

Among the many conjectures put forward about the bill’s fate in the Lords, the cross-bench peer David Owen made the interesting claim that, since the proposed reforms were not included in either the Conservative or Liberal Democrat manifestos at the 2010 general election, the potential for amendments is wide open.

Lord Owen has said that the ‘Salisbury Convention’ – under which peers cannot oppose the second or third reading of government legislation promised in an election manifesto – does not apply to the Health Bill. However, this is a contention that Lord Howe politely rejects.

Describing the reform programme as “generally a blend of what was in the Conservative manifesto and in the Liberal Democrat manifesto”, he says the “unusual situation” of the coalition means this ruling does not apply. “The Salisbury Convention arose after the second world war when the Labour government were elected with a huge majority – there had to be an understanding between the parties that the Conservatives in the Lords, who were of course numerically superior, wouldn’t overturn Labour’s manifesto commitments then,” he says.

“I think we’re in a different situation here. What we’ve seen through the listening exercise is, I think, a buy-in by all political parties to the main principles that we’ve set out. Whether the Labour party would have tackled NHS reform in quite the same way as ourselves we don’t know. But they themselves articulated in their own manifesto many of the things that we are saying about greater clinical autonomy, greater patient power and removing bureaucracy from the system. So I don’t see Lord Owen’s point as a particularly strong one, actually.”

‘Enthusiasm and momentum’
An opposition spokesman for health and social services in the House of Lords from 1997, Lord Howe was appointed Parliamentary Under-Secretary of State for Quality at the Department of Health after last year’s general election. There is something of an unsullied nature about him – not fresh-faced, exactly, but he exudes an air of good-natured optimism that could be explained partly by his short tenure.

Or perhaps his positivity about the health reforms is simply genuine. Speaking of the pathfinder CCGs, for example, he speaks of their “tremendous enthusiasm for the opportunities available.” He quickly tempers this with a reality check. “I’m not saying that every GP is enthusiastic, I couldn’t claim that, but there are sufficient numbers of GPs in each pathfinder who can see what this opportunity could mean for patient care and quality of care.”

But now that the April 2013 deadline for all CCGs to be up and running has been removed, isn’t there a danger of a ‘patchwork’ of progress across England, as was arguably seen with practice-based commissioning (PBC)? Lord Howe says the problem with PBC is that it “didn’t hold out much in the way of a carrot to GPs in terms of giving them real autonomy to decide how best to configure care appropriately – certainly it didn’t give them real budgets.”

GPs now have the “financial power to get things done rapidly”, he says. “It’s always rash for a minister to say that I’m confident, but I’m certainly hopeful we will see the kind of enthusiasm and momentum that I’ve mentioned moving forward. We’re not going to force the pace as tightly as was originally suggested, but we will be encouraging [CCGs] along the way.”

Even the dire financial circumstances that CCGs are facing, with the need to help make cost savings of £20bn in four years’ time, does not dent this optimism. Financial constraint, he says, will be a tough challenge for GPs but not an “insuperable” one: “To deliver high-quality care can often be cheaper to deliver than care that is sub-optimal, and pathfinder commissioning groups I have visited have grasped this notion. They can see that unplanned hospital admissions are not only bad for the patient but also hit the commissioner’s bottom line in a very unwelcome way.”

Quality contention
That bottom line and the proposal for the ‘quality premium’ to reward CCGs financially for reducing it has caused considerable upset, with GPC Chair Dr Laurence Buckman slamming the idea as “disgracefully unethical” (see interview this issue).

As the DH’s quality tsar, isn’t he concerned about this backlash? “We’re still designing what the quality premium should look like,” Lord Howe insists. “The idea of it is to reward CCGs for high-quality commissioning. Quite how that is made real is still being considered. We’re aware of the sensitivity on the part of GPs and I think that has got to be factored into the way in which this is finally designed.”

He expects this will be debated in the House of Lords. “We want to engage with the profession to make sure that anything we do come up with is something that they are comfortable with and that will genuinely incentivise good commissioning without throwing up problems,” he says.

Another major concern from GPs is the question of whether the national NHS Commissioning Board (NCB) could stifle CCGs’ local commissioning plans (see interview with Sir David Nicholson this issue). How can national directives ensure local commissioning quality?

Lord Howe says the NCB will indeed “have its work cut out” in its early days to ensure CCGs are properly authorised and monitored. However, he rejects the idea that the board will impose tight controls over CCGs and says it will aim for a “mutually supportive” relationship with commissioning groups.

“This is not performance management,” he says. “It is something very different in terms of the culture. You get that right then I think everybody’s job will be made a lot easier.”
He dismisses the suggestion that clinical senates could add a further level of imposition on CCGs. “They are not there to breathe down the necks of commissioners, they’re there to support and assist. I think there’s been a lot of unnecessary fear about constraining CCGs in unwelcome ways. We don’t see it that way at all.”

Such comments indicate a belief in harmonious working relationships between healthcare sectors that may in part explain Lord Howe’s September PR disaster. But as the Health Bill undergoes what could be a transformative time at the Lords, he could be fortunate indeed if his peers take quite the same view.

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