Role of health secretary in future NHS is still unclear, says Liberal Democrat peer

“Profound ambiguities” still remain concerning the responsibilities of the secretary of state for health and the role of competition, despite amendments to the proposed Health and Social Care Bill, the Liberal Democrat peer Shirley Williams warned last week at the annual meeting of the NHS Confederation.

And the fact that the parliamentary process allowed for only five days to consider these “huge and far reaching amends” was, she said, a matter of “very great concern.”

Speaking as part of a panel discussion on how the NHS would navigate the healthcare reforms, Baroness Williams welcomed the greater levels of openness, transparency, and public accountability that would now be written into the forthcoming legislation, prompted by the NHS listening exercise.

But serious issues remained, she said. “There are profound ambiguities . . . about the actual position of the secretary of state himself. There is no unambiguous provision for him to be responsible for the provision and security of health services,” she suggested, adding that several leading lawyers she had quizzed on the issue all agreed that the bill did not include any “specific duty” for him in this regard.

Baroness Williams said that the amendments also left the issue of competition and choice “unclear,” despite the shift in emphasis from price to quality, citing by way of example the disappearance of the cap on the number of private beds that foundation trusts would be allowed. It was very important to maintain the NHS as a public service, she said, adding that a series of reports had described it as one of the cheapest, most accessible, and most efficient health services in the world.

When the bill reaches the House of Lords in the autumn, how much sustained pressure it would come under would depend on what the NHS made of the 100 or more amendments; what coherent alternatives emerged; whether the BMA kept up its opposition to key clauses; and whether the Liberal Democrats thought that it was “still in play” or a “done deal,” suggested the shadow deputy leader of the House of Lords, Philip Hunt.

“My own analysis is that we started a year ago with a highly problematic and risky proposal . . . We have now emerged with a potentially less risky proposition, where direction is much less clear and frankly irrelevant to today’s pressing [NHS] challenges,” he said.

“Far from cutting bureaucracy, the outcome of the pause is layer and layer of decision makers all fighting for a share of the cake,” he contended. The Lords would be faced with a difficult task. Lord Hunt added, “It is almost impossible to construct a new edifice on the foundation of a dog’s dinner.”

But he said that there was bound to be further debate on strengthening the accountability of the new clinical commissioning groups and the role of Monitor in driving integration between health and social care, as well as the need to build in protection for specialist and mental health services.

The Lords would also focus on GPs’ performance, he said. “The problem as I see it is that no levers at all have as yet been given to clinical commissioning groups to ensure that constituent GPs actually play their part [in spending wisely on prescribing and referrals],” he said.

Stephen Dorrell, who chairs the House of Commons health select committee, which strongly criticised the government’s original plans for the NHS in its recent report, said that the “sheer enormity” of the need to deliver 4% efficiency gain, four years running, in the NHS had “not been fully understood.”

He said, “When we have a debate about the form of the NHS, it seems to me fundamental that we should begin by understanding the function we are seeking to deliver and then ensure that form follows function. Having a debate where function follows form is to put the cart before the horse,” he said.