PCTs and Lib Dems

Yesterday Matthew D'Ancona wrote an excoriating article in the Sunday Telegraph berating how badly Lansley and Cameron had sold their re-organisation of the NHS. Make no mistake, D'Ancona is not defending the NHS, he says "As it happens, I agree with just about every detail of the Lansley plan" but then again, he is not a health policy expert, he is a political commentator. D'Ancona was commenting on the politics and on this he said:

The clear impression before the election was that there would be no more "structural upheaval" ... it is stretching credulity to claim that the electorate voted for this, or expected it even when the Coalition was being formed.

He then goes on to say:

The trouble is that this has now become a trust issue for the PM, just as tuition fees are for Clegg: you said one thing, and did another.

This is very worrying for the Prime Minister, but it is worse for the Deputy Prime Minister who seems set to push the Lansley Bill through Parliament intact, even though his grassroots (and the majority of the country) are against it.

The government is expecting a tough fight in the House of Lords. Lord Owen has said that him, and many other Lords, are opposed to the Bill and will make substantial changes to it. On his website, Lord Owen has published a pamphlet called Fatally Flawed, in this he says:

There was no mention in either the Conservative or Liberal Democrat party manifestos at the 2010 General Election of an intention to carry forward anything like this revolutionary change. Under the Salisbury Convention the House of Lords is entitled therefore to make substantial amendments to this Health and Social Care Bill.

This is very important because the Salisbury Convention says that if the Commons have a clear mandate then the Lords should not block the Bill, that is, although amendments may be suggested, they should not be designed to wreck the Bill. Owen is suggesting changes that would change the Bill into something very different. The government clearly wants to make sure that they can convince the Lords that they have a mandate for these changes. D'Ancona alludes to this:

It is perfectly true that you can find sentences in this or that pre-election Tory document which, when aggregated, come close to the Lansley plan.

In other words you can cobble together this policy from the manifestos, but it certainly is not a policy that the public will think they were sold (hence the trust issue).

The big problem is Primary Care Trusts (PCTs). Neither the Conservative manifesto, nor the Lib Dem manifesto say that they wanted to abolish PCTs. The Conservative manifesto does not mention PCTs at all, but in their earlier policy document NHS Autonomy and Accountability, Proposals for legislation published in 2007, they say (4.28 – 4.30):

PCTs will remain local commissioning bodies.

Further:

PCTs will also remain, as now, the areas to which NHS resources are allocated, although almost all of these resources will be cascaded down by the PCT to its primary care commissioners.

The Coalition Agreement says the same thing:

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 PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.

The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations.

This says that PCTs will remain. But when the NHS White paper was published  (and now the Bill) it became apparent that Lansley will abolish PCTs. The Secretary of State for Health was asked on the Marr program about this change in policy:

ANDREW MARR: When did you decide that the primary care trusts were going to have to go entirely?


ANDREW LANSLEY: We decided that in late May, early June.


ANDREW MARR: So quite …


ANDREW LANSLEY: After the coalition.


ANDREW MARR: After the coalition agreement?


ANDREW LANSLEY: Yeah, we did. And for a very simple…

The change occurred a few weeks after the election and after the Coalition Agreement. Remember that the Liberal Democrats had a conference to decide whether to accept the Coalition Agreement, and they voted for it. Clearly they voted for the policies outlined in the Agreement document, and not for Lansley to make major changes without their agreement. Yet a few weeks afterwards Lansley produced policy that was in deliberate conflict with the Agreement.

D'Ancona, however, is either not aware of this or is deliberately acting as a mouthpiece for the government's spin machine. In his Sunday Telegraph article he says:

Conservative sources point out that the Lib Dems were explicitly in favour of abolishing Primary Care Trusts – effectively pointing a finger at Nick Clegg and shouting: "It was the crybaby! Blame him!"

This is not true. The Liberal Democrats never said they wanted PCTs to be abolished. The Liberal Democrat 2010 manifesto says this:

Empowering local communities to improve health services through elected Local Health Boards, which will take over the role of Primary Care Trust boards in commissioning care for local people, working in co-operation with local councils. Over time, Local Health Boards should be able to take on greater responsibility for revenue and resources to allow local people to fund local services which need extra money.

This does not say that PCTs will be abolished, it says that they will be replaced, in other words the same layer of management would exist but the boards would be elected rather than appointed. This morphed into the Coalition Agreement's phrase "directly elected individuals on the boards of their local primary care trust".

In Norman Lamb's health policy document The NHS: a liberal blueprint he says:

The commissioning of local health services should be democratically accountable. Boards of PCTs – which should be renamed local health boards – should be elected, not appointed, so that they can be held to account at a local level.

It is very clear that Lamb was not suggesting abolishing PCTs, just renaming them local health boards.

Yet, we hear from D'Ancona that Conservative sources are trying to make it appear that the Lib Dems said something different to what they actually said. Is this the right way to treat a coalition partner?