(13 years, 2 months ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
21:59 - The House divided: - Ayes: 321 / Noes: 235 - Question accordingly agreed to.
The Secretary of State for Health (Mr Andrew Lansley)
I beg to move, That the Bill be now read a Second time.
The purpose of the Bill can be expressed in one sentence—to improve the health of the people of this country and the health of the poorest fastest. While the previous Government increased funding for the national health service to the European average, they did not act similarly to increase the quality of care. We spent more, but others spent better. In important areas, the NHS performs poorly compared with other countries. An expert study found that out of 19 OECD countries that were investigated, the UK had the fourth-worst death rate from conditions that are considered amenable to health care. If NHS outcomes were as good as the EU15 average, we would save 5,000 lives from cancer and 4,000 lives from stroke every year. We would also prevent 3,000 premature deaths from respiratory disease and 1,000 premature deaths from liver disease every year. This cannot go on: things have to change to protect the NHS and deliver better results for patients.
Mr Kevin Barron (Rother Valley) (Lab)
I do not dispute what the Secretary of State says about European comparators, but what does he say to Professor John Appleby, who said last Friday that all those markers, some of which are not direct comparisons, are getting nearer to European targets? Professor Appleby suggested that the disruption that is going to take place in the health service will not help us to do that.
Mr Lansley
I would say two things to Professor John Appleby. First, the latest data published in EUROCARE-4, which I know the right hon. Gentleman will have seen, are clear about the gap between cancer survival rates in this country and others, and in recent years that gap has not diminished as it should have. He can read in last week’s Lancet an authoritative study of cancer survival rates in this country and a number of others demonstrating that the gap remains very wide and that we have to close it. Secondly, the King’s Fund supports the aims of the Bill and Professor Appleby, as a representative of the King’s Fund, clearly understands, as we do, that if we are to deliver the change that is needed, we need the principles in the Bill.
People trust the NHS, and its values are protected and will remain so—paid for from general taxation, available to all, free at the point of delivery and based on need rather than the ability to pay. However, a system in which everyone is treated the same is not one that treats everyone as they should be treated. Our doctors and nurses often deliver great care, but the system does not engage and empower them as it should.
Geraint Davies (Swansea West) (Lab/Co-op)
On the John Appleby point, does the Secretary of State accept that what he actually said was that the rate of deaths from heart disease would be better in Britain than in France by 2012, on current trends, even though France spends 28% more on its health service? Is not that a ringing endorsement of what is happening now rather than a prescription for blowing up the system as the Secretary of State suggests?
Mr Lansley
First, I have just answered the point about John Appleby. It is true in a number of respects, as I have made clear, that although there have often been improvements in the NHS, they have not been what they ought to have been. It was a Labour Prime Minister, back in 2001, who said that we must raise resources for the NHS to the European average, but he did not achieve results that compared with the European average.
Let me give the hon. Gentleman some examples. A recent National Audit Office report showed that as many as 600 lives a year could be saved in England if trauma care were managed more effectively. Too often, the latest interventions, which are routine in other countries, take too long to happen here. John Appleby used heart disease to illustrate his point. Primary PCI— percutaneous coronary intervention—using a balloon and stent as a primary intervention to respond to heart attack was proven to be a better first response years ago. I knew that because cardiologists across the country told me so several years ago. I remember a cardiologist at Charing Cross telling me, “I have a Czech registrar working for me who says that in the Czech Republic PCI as a response to a heart attack is routine, but it hardly ever happens in this country.” Since then, it has been better implemented in this country, but that started to happen only when the Department of Health gave permission for its adoption.
The same was true of thrombolysis for stroke. That happened too late in this country, after such changes had taken place in other countries, because health care professionals there were empowered to apply innovation to the best interests of patients earlier.
Nadine Dorries (Mid Bedfordshire) (Con)
Does my right hon. Friend agree that, given the disparity in survival rates in trauma care and in many illnesses, including cancer care and heart attacks—citizens in this country are twice as likely to die of a heart attack as those in France—the NHS is in desperate need of modernisation?
Mr Lansley
My hon. Friend is right. We need not only to match European spending, as we do now, but to ensure that we achieve European-level results. It is not just about benchmarking, which we know we must do. We must benchmark ourselves against the best in the world if we are to deliver the best results for patients. We must also constantly make sure that we achieve a modernised health service that delivers the best possible care—sometimes going ahead of what others achieve, and applying innovation more quickly.
In some ways, as we know—for example, in mortality rates from accidents and from self-harm, and in equity of access to health care—the NHS leads the world, but our doctors and nurses are regularly hobbled by a system that treats equality as sufficient, when what we need is both equity and excellence.
Mr Denis MacShane (Rotherham) (Lab)
Given the Secretary of State’s praise for health care systems in Europe, which we are all connected to, will he consider allowing British patients to seek such health care in Europe, paid for by the NHS?
Mr Lansley
With his knowledge of European matters, the right hon. Gentleman knows that we are in the later stages of the collective approval through the European Union of the European cross-border health directive, which allows precisely that and makes it clear that the same criteria are applied to patients seeking health care in other countries as would apply were they to seek it through the NHS in this country.
Mr Lansley
In a moment. I have just answered one question.
Why did spending more not deliver better results? We know why that is—[Interruption.] No, better results should have been achieved. Opposition Members need to realise this, because it has been at the heart of their failure in public service reform over the past decade: the Office for National Statistics said a few weeks ago that productivity in the NHS fell in every one of the past 10 years. It fell by 1.4% a year in hospital services.
Despite a huge amount of money rightly invested in the NHS, taxpayers and patients were not getting the service that they should have had. Billions of pounds have also been wasted on an ever-growing bureaucracy, taking money away from the front line and away from patient care. The number of managers doubled under Labour. I give way to the Chair of the Public Accounts Committee.
Margaret Hodge
I thank the right hon. Gentleman. He is right to draw attention to the fact that productivity has fallen in the past 10 years, but should he not consider whether it is wise in those circumstances to distract people from driving up productivity and achieving savings by the unnecessary institution of reform? That is just taking people away from the thing that they should be concentrating on.
Mr Lansley
The right hon. Lady should understand, as I will go on to explain, that we are not distracting the NHS from the need to improve services for patients. We are enabling the NHS to improve services for patients. In her role on the Public Accounts Committee, she should understand that right across the public services, one of the consequences of dealing with the deficit is that we will have to reduce the costs of bureaucracy and administration.
We will do that in the NHS as much as anywhere else, but we will not do it in the way that the Labour party pressed us to do, which was to cut the NHS budget—[Hon. Members: “What?”] Yes, Opposition Members did exactly that. We will increase the NHS budget. As we set out in the spending review, we will increase the NHS budget by £10.7 billion over the life of this Parliament—investment that Labour opposed—and we are determined to get far more for British taxpayers’ money.
Angie Bray (Ealing Central and Acton) (Con)
My right hon. Friend will be aware that there has recently been an excellent reorganisation of stroke treatment in London, with a number of hospitals earmarked as emergency centres, all of which, crucially, are within 30 minutes of every Londoner. Once patients have been through the emergency procedures and are stabilised, they are returned to local stroke centres, which are also earmarked as part of the whole programme. Can he reassure me that that kind of regional organisation of hospitals, which has delivered good results, will not suffer through some of the proposed reforms?
Mr Speaker
Order. I remind Members that interventions should be short. There are 57 Members seeking to speak in the debate, so interventions must be pithy.
Mr Lansley
Thank you, Mr Speaker. I can give my hon. Friend the Member for Ealing Central and Acton (Angie Bray) precisely that reassurance. I was with NHS London at the beginning of last week, and it is clear that GP commissioning groups are coming together with providers to develop those kinds of commissioning plans, going beyond trauma and stroke care, which has already happened in London, to look, for example, at the integration of diabetes care between primary care and hospital services.
Under the Bill, patients will come first and will be involved in every decision about when, where, by whom, and even how, they are treated—“there must be no decision about me, without me.” The 2002 Wanless report called for patient engagement, but that did not happen. Now it will. Because patients cannot be empowered without transparent information, an information revolution will give them more detailed information than ever before, showing them and their doctors the consultants who deliver the best care, giving them control over their own care records and enabling everyone to access the care they need at the right place and at the right time. Patients and their doctors and nurses will be able to see clearly which health care provider offers the best outcomes and to make their decisions accordingly.
Mr Bernard Jenkin (Harwich and North Essex) (Con)
May I assure my right hon. Friend that this is not being greeted by local GPs in my constituency as some disruptive revolution, but as a logical extension of all the debate and development in the NHS over the past 20 years or more on giving patients more power and GPs more control over the allocation of resources?
Mr Lansley
I agree with my hon. Friend. In effect, that gives the lie to what the hon. Member for Wrexham (Ian Lucas) suggested. The coalition agreement states:
“We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.”
Our manifesto stated that we would strengthen the power of GPs,
“putting them in charge of commissioning local health services.”
Mr Lansley
I am sorry, but 57 Members wish to speak, as you have rightly told us, Mr Speaker. I will give way as often as I can, but more than one intervention from each Member is excessive. [Interruption.] I have just quoted from the coalition agreement and our manifesto, so hon. Members have heard both.
Through the outcomes framework, which we published in December, we will stop the top-down, politically motivated targets that have led to real quality being sidelined. We will ensure that we focus on the outcomes that really matter and back them up for the first time with quality standards that are designed to drive up outcomes in all areas of care. Those standards have not been dreamt up in Whitehall, but are being developed by health professionals themselves. Similarly, doctors and other health professionals will not be told by us how to deliver those standards. The standards will indicate clearly what is expected, but it will be up to clinicians to decide how to achieve them. At every step, clinical leadership—that of doctors, nurses and other health professionals—will be right at the forefront. It will be an NHS organised from the bottom up, not from the top down.
The shift in power away from politicians and bureaucrats will be dramatic. The legislation none the less builds on what has gone before. It is not a revolution, but as the shadow Secretary of State said just a fortnight ago:
“The general aims of reform are sound—greater role for clinicians in commissioning care, more involvement of patients, less bureaucracy and greater priority on improving health outcomes—and are common ground between patients, health professions and political parties.”
Emma Reynolds (Wolverhampton North East) (Lab)
The right hon. Gentleman quoted the National Audit Office earlier. Does he agree with the statement in its report that his revolution in and upheaval of the NHS risk undermining the quality initiative—the so-called QIPP programme—that the previous Government introduced?
Mr Lansley
No, far from it—actually, quite the contrary. It is only by virtue of our ability to engage front-line clinicians more strongly in the management and design of care that we will deliver those quality, innovation, productivity and prevention ambitions; and it is only if we cut bureaucracy and the costs of bureaucracy that we will be able to get those resources on to the front line more effectively. I made it very clear, and the shadow Secretary of State endorsed the view, that there is consensus about the purposes of reform, but if Labour now voted against the Bill, although we do not know whether it will, it would abandon that consensus and, indeed, its own policies when in government.
Mr Jim Cunningham (Coventry South) (Lab)
Can the right hon. Gentleman say how many jobs will go in front-line services and how many hospital closures there will be as a result of his policies?
Mr Lansley
I just wish that the hon. Gentleman would look at the latest published data. Since the election, we have reduced the number of managers in the health service by almost 4,000 and increased the number of doctors. For the first time, there are more than 100,000 doctors in the NHS, and we are increasing the number of health visitors, after years of their numbers being reduced under the previous Government. He should get his facts right before he starts flinging accusations about.
Mr Ronnie Campbell (Blyth Valley) (Lab)
Will the right hon. Gentleman give way?
Mr Lansley
No. I am going to make some progress.
The Labour party, when in government, pioneered patient choice; Labour said, “We must have patient choice.” I remember John Reid, when he was a Member, saying that the articulate and the well-off negotiated their way through the health service, and that he wanted to give choice to everybody in the health service. He was right. The social attitudes survey in 2009 found that more than 95% of people felt that they should have more choice, but that fewer than half of patients actually experienced it. The Labour party started down the road of extending choice; we will complete that journey.
Andrew George (St Ives) (LD)
On patient choice in health service design, is the Secretary of State aware that in Cornwall the primary care trust has engaged in the transfer of community hospitals and services without adequate public consultation and at breakneck speed? If “no decision about me, without me” is to apply to service design and patient involvement, is he prepared to intervene to ensure that the public are involved in such important decisions?
Mr Lansley
I am grateful to my hon. Friend for that point. I have not previously been asked to comment on the matter, nor have I received information about it, but from my visits to Cornwall I entirely endorse his view about the importance of community hospitals in accessing services. He will see that, in the Bill, a specific duty is placed on the commissioning board and each commissioning consortium to reduce inequalities in access to health care. He will see also that, through the Bill, we will strengthen accountability where major service change takes place, because it will require not only the agreement of the commissioning consortium, representing as it were the professional view, but the endorsement of the health and wellbeing board, which includes direct, local, democratic accountability. Points have been made about what was in manifestos, but the Liberal Democrat manifesto was very clear about the need for democratic accountability in health service commissioning—and so there will be.
Let me return to the point, because the previous Government also went down the route of practice-based commissioning. It was their policy, but, as the shadow Health Minister, the hon. Member for Leicester West (Liz Kendall) said, many GPs felt that
“they didn’t always get the power, responsibility and resources they might have wanted.”
Well, now they will, and we will give it to them.
On our definition of quality, Opposition Members say “quality matters”. It does, and it was under the Labour Government that Ara Darzi pioneered the thought that quality must be at the heart and an organising principle of the health service. It is we now who are going to make that happen. We are publishing quality standards. We are putting into this legislation a duty to improve quality that extends to all the organisations that commission and provide NHS services.
Mr Ronnie Campbell
Will there be public accountability for the private companies that will come in and do the commissioning for the doctors? I can see their people getting top salaries—the executive getting £200,000 and the financial officer getting £250,000. That is the sort of thing that we are trying to stop. What will happen when these companies run things for doctors?
Mr Lansley
The accountability in the NHS will be for the quality of the service being provided. The hon. Gentleman may not have agreed with the last Labour Government on this, and perhaps many in the Labour party are now changing their view on what was pursued by that Government, but it was that Government who introduced and encouraged a policy of “any willing provider”. In 2003, Alan Milburn said:
“If I can get a private-sector hospital to treat an NHS patient, then for me the person remains an NHS patient.”
Everybody in the NHS who provides NHS services will be accountable through the—[Interruption.] The money will follow. The Chair of the Public Accounts Committee is here. Where public money goes, accountability for its use will follow.
Mr Lansley
Let me complete this point, then I will give way to my hon. Friend the Member for Basildon and Billericay (Mr Baron). On the point of allowing the independent sector to be a provider to the NHS, I should say that it was the right hon. Member for Leigh (Andy Burnham), the shadow Secretary of State’s predecessor, who said that
“the private sector puts its capacity into the NHS for the benefit of NHS patients, which I think most people in this country would celebrate.”—[Official Report, 15 May 2007; Vol. 460, c. 250WH.]
Well, Labour Members are not celebrating it now; they have reverted to type.
Mr Baron
The Government’s increased focus on improving outcomes is long overdue and very welcome, but will the Secretary of State address the issue of cancer networks and the concern that some of the expertise may be lost because of the funding gap between the end of funding for the cancer networks themselves and GP commissioning fully taking effect? Can the Government do anything to bridge that gap so that we allow GP consortia to be better informed in making decisions about what services to commission?
Mr Lansley
My hon. Friend rightly takes a close interest in these matters. When I was with him and other colleagues at the Britain against cancer conference, I made it clear—and he made it equally clear—that the cancer networks funding is guaranteed during the course of 2011-12. There is not a gap, because from April 2012 onwards the NHS commissioning board will take up its responsibilities. There will then be decisions by the commissioning board about how it will structure that.
Let me come back to what the last Labour Government did. They introduced the concept of payment by results. Unfortunately, however, payment tended to be by activity and not by results. We will now make it payment by results and really make that happen.
To complete the picture, I should say that throughout the Bill there are elements of policy that we are taking forward, such as foundation trusts. The Bill follows the brainchild of Alan Milburn and Tony Blair back in 2002. In 2005, the Labour Government said that every NHS trust should become a foundation trust by December 2008. That just did not happen. Again, it will be our task to make modernisation in the NHS consistent and comprehensive.
Mr David Lammy (Tottenham) (Lab)
Will the Secretary of State say how many GP contractors he estimates will be private companies? Will he also make it clear to the House that none of the private medical providers that funded his office in opposition will gain from the change?
Mr Lansley
There are two points to make. First, we have made no estimate of the extent to which GP-led commissioning consortia will contract with independent sector providers, so I cannot give the right hon. Gentleman such an estimate. Secondly, I did not receive money directly from a private health company for my office while in opposition. So there we are.
Labour’s reforms were piecemeal and incoherent. Under the previous Conservative Government, the internal market and fundholding of the early 1990s failed to promote quality and risked conflicts of interest among GPs. We have learned from those mistakes and from the failings of a Labour Government over the past 13 years. This Bill is different. It views the NHS as a whole service, every bit of it geared towards meeting patients’ needs. This Government understand that the best health care comes from the close partnership between patients and their clinicians. Every part of the NHS, every incentive, every structure and every decision must support and strengthen that relationship.
First, we will place the individual needs of each patient above all else, encouraging, wherever possible, a personalised approach to health care, tailoring services to have the greatest individual, and greatest overall, impact. Secondly, decisions made in the consulting room, in local service design, in commissioning, and in the services any particular provider offers, will be local decisions—real autonomy and real devolution of power.
Mr David Blunkett (Sheffield, Brightside and Hillsborough) (Lab)
Will the Secretary of State give way?
Mr Lansley
In a moment. [Interruption.] The right hon. Gentleman’s Front Benchers have been asking me to explain what the Bill does, and I am doing that.
Thirdly, there will be relentless focus on quality, embedded within a new legal duty. Fourthly, there will be a diverse and vibrant social market for health care. We will encourage NHS staff to set up social enterprises and foundation trusts, and we will encourage new capacity in delivering services through social enterprises, charities, private companies, and, indeed, NHS providers.
We want clinicians and their patients to lead the NHS, but they cannot do this while they sit under a vast hierarchy of regional and local organisations, all reporting to Whitehall. Everyone agrees that top-down command and control gets in the way of clinicians doing their job, so we need to dismantle the structures that sustain that interference; that is why we will abolish primary care trusts and strategic health authorities. There are many excellent people working in those organisations. Many will move to be with the new general practice-led commissioning consortia, to local authorities and to the NHS commissioning board. Some will want to set up their own new social enterprises. But even the best people cannot deliver the NHS that patients need if things stay as they are, so we will also introduce direct local democratic accountability. Councillor-led health and wellbeing boards will oversee and work with local NHS consortia, working to bring together the NHS, social care and public health services, and bringing a strategic coherence to the health and well-being of local communities.
Mr Blunkett
On bottom-up decision making at a local level, will the Secretary of State give a guarantee to the House that if the GPs now coming together in consortia decide that they wish to employ the expertise residing in the current primary care trust, he and the future health board will not intervene to stop them doing that? Will he also guarantee that he will not insist on redundancies that cost a fortune and preclude that expertise being available to the existing local consortia, with private enterprises then employing them to do the job that they were doing in the first place?
Mr Lansley
Let me make two points to the right hon. Gentleman. First, in the impact assessment that we published with the Bill on 19 January, we set out very clearly our estimates—they are no more than estimates since they will have to be decided by the general practice commissioning consortia and local authorities—that between 50% and 70% of the staff in primary care trusts would be employed in the successor organisations.
Secondly, the idea that somehow general practice-led commissioning consortia would engage the private sector where that has not happened up until now is, I am afraid, completely contradicted by the facts. Under the Labour Government, in the two years leading up to the election, there was an 80% increase in the use of management consultants, while at the same time the number of administrators and managers in those same organisations was rising dramatically. We arrived at the point where there were 50,000 administrators in primary care trusts, and they were still spending nearly £300 million a year on top for management consultancy. That all has to change.
One thing that Labour abjectly failed to do was to empower patients with a real voice in the health service. Through this Bill we will establish local healthwatch organisations that will represent the patient’s voice in the design of local services and help individual patients, especially the most vulnerable, to make the most of the choices available to them and to help them when things go wrong. Sitting within the Care Quality Commission, the national healthwatch organisation, too, will act as the eyes and ears of the quality regulator, and work to give the local organisations real teeth in their dealings with their local NHS—something that was completely, abjectly destroyed by the Labour Government when they abolished community health councils. Indeed, I know that families of those treated at the Mid Staffordshire hospitals welcome the additional powers for patients to have a voice.
Mr Lansley
I give way to the hon. Gentleman. I will give way to my hon. Friend the Member for Stafford (Jeremy Lefroy) in a moment because I referred to Staffordshire.
Clive Efford
The right hon. Gentleman will know that the Bill introduces European competition law into the national health service, and removes the existing protection once and for all. His Government have just taken the decision to put billions of pounds into stopping Irish banks failing. If a local hospital fails under the new market arrangements, will he step in and save it?
Mr Lansley
Time does not permit me to explain the extraordinary ignorance of that series of points. First, the Bill sets out that the regulator will have a responsibility to establish a failure regime. In 2003, when the predecessors of those currently on the Labour Front Bench took the health legislation through the House, they said that they would introduce a failure regime, to be implemented by Monitor, in legislation. They never did so. At the moment, there is therefore no proper failure regime.
Secondly, European competition law—indeed, competition law—applies in this country. A body was established in the national health service under the previous Labour Government called the co-operation and competition panel, the express purpose of which was to apply competition rules in the NHS. To that extent, all the Bill will do is to ensure that the rules that already apply are applied fairly, consistently and transparently across all providers.
Jeremy Lefroy
The Secretary of State referred to the Mid Staffordshire NHS Foundation Trust, into which an inquiry is taking place. What lessons from the various investigations have been applied in the Bill to address the concerns that have been raised?
Mr Lansley
I am grateful to my hon. Friend for that question. In addition to the measures on healthwatch and patient voice, we are strengthening the responsibilities of commissioners. As I suspect he knows from his local knowledge, general practitioners knew in many cases that the services at Stafford hospital were not meeting the quality of care that they ought to have met. However, there was no transparency in the outcomes, and there was no responsibility collectively among general practices and local health professionals to intervene. There was no mechanism that enabled or incentivised them to do so. We are going to change that. When Sir Robert Francis’s report is published in due course, I hope that the Bill, by strengthening patient voice, commissioning and the regulatory structure, will give the opportunity for whatever recommendations he makes to be implemented rapidly.
Mr Lansley
I apologise, but I have taken longer than I had intended, and 57 Members are waiting to speak.
I will explain further what the Bill will do. Local authorities, with a ring-fenced budget, will bring public health to the front and centre of public policy. This is not just about the NHS, but about improving the health of the whole population. That is why we are putting local authorities at the heart of it. The health of the general public is as much about the environment, the economy, housing and transport as what happens in the NHS. Health and wellbeing boards will make the link between health and social care, which have too often been in silos. We understand how intertwined those things are and how they must work together.
Mr Lansley
No, not at the moment.
The unions, of course, are against this modernisation of our public services. I suspect that they are the “forces of conservatism” that, more than a decade ago, the former Prime Minister told us he had to fight against. They oppose the principles of our plans, or so they say, but do they have an alternative? No. That contrasts completely with the reaction of general practitioners and health care professionals in GP pathfinders.
Mr Lansley
I have given way to the right hon. Gentleman before.
General practitioners and health care professionals in GP pathfinders are, in contrast to the unions, enthusiastic about what we are trying to achieve. For example, Dr Paul Zollinger-Read, a general practitioner and the chief executive of NHS Cambridgeshire, said recently:
“In our area, the GPs got together and focused on quality of care. They looked at diabetic care, for example, and services in this area improved. That means fewer diabetics will need to go to hospital in an emergency, there will be fewer amputations and less heart and kidney disease.”
Far from GPs being reluctant at the thought of taking on new responsibilities, applications to be pathfinder consortia were over-subscribed.
Mr Lansley
No, not at the moment. Sorry.
There are now 141 pathfinders, covering more than 28 million patients. More than half the population are already benefiting from the clinical leadership of their local health professionals. I have met some of the pioneers, such as in Redbridge, where they are pioneering bringing ophthalmology and dermatology services out into the community, and in Bexley, where they have pioneered better access to cardiology services for their patients. [Interruption.] Opposition Members say that they were doing that, but my whole point is that we are turning the exceptional cases in which GPs have had such opportunities in the past into the opportunity for all GPs across the country to do so. The Opposition might like to talk to the new chair of the clinical cabinet in Bexley, one Dr Howard Stoate, whom they will recall as a Member of the House before the election.
It is not only GPs who are anxious to get on with it. We are already working with 25 early implementer health and wellbeing boards that want to start bringing benefits to their communities. By April, we expect to be working with up to half of all local authorities, and the Bill will create that framework. Whereas the previous Government often talked a good game, we will put our ambitions and the new roles into law. The Bill explicitly defines roles and responsibilities that were previously at the discretion of Ministers. Until now, legislation on the NHS has more or less said, “The NHS is whatever the Secretary of State chooses to make it at any given moment.” That was why, in the past, reorganisations took place on a practically annual basis under the Labour Government, without there ever being any consistency or coherence to them. I intend to be the first Secretary of State in the history of the NHS who, rather than grabbing more power or holding on to it, will give it away.
As well as devolving decision making, the Bill will transfer power back to Parliament and strengthen the accountability and transparency of the NHS. It will protect the NHS constitution, ensuring that the rights in it are reflected within NHS commissioning and regulation. It contains a number of new duties, including a duty on the Secretary of State, the NHS commissioning board and each commissioning consortium to seek continuous improvement in the quality of services, and to seek to reduce inequalities in access and health outcomes.
The Bill contains a duty of autonomy, so that politicians allow providers and commissioners to provide the best care as they see fit, minimising burdens wherever possible. There is a duty on Monitor to protect and promote the interests of patients, through competition where appropriate and through regulation where necessary. The role of local authorities will increase greatly, including not only the scrutinising of local health services but a duty to promote integrated working between the NHS, social care services and public health services.
As I have said, in 2003 Labour promised a proper regime in the event of the failure of any provider of NHS care. They did not provide that; this Bill will. Should a provider fail, there will be a transparent process for maintaining designated services, to ensure continuity of services for patients.
Monitor will be empowered to set up a “risk pool”, to which providers will pay a levy that will meet the costs of maintaining key services. There will also be a clear and transparent process for setting the NHS tariff for different services. The National Institute for Health and Clinical Excellence will develop quality standards, give advice and make recommendations on the clinical effectiveness of medicines and treatment. As the shadow Secretary of State said a fortnight ago, the Bill is “consistent, coherent and comprehensive”. It will put patients first and improve health outcomes.
Mr Lansley
I must conclude and allow other Members to contribute to the debate.
The Bill will change structures, abolish bureaucracy and inject added competition, but those are only the means to a much greater end. As large and complex as it is, there is one simple objective behind the Bill—better care for patients, measured not by political targets but by real results for patients. It is about gearing the entire system towards supporting the relationship between doctor and patient—a “meeting of experts”, as Tuckett would have called it, with the patient being an expert on themselves and the clinician being an expert on their clinical management and condition. It is about bringing the two together based on trust, transparency and the best available treatment from the best available provider.
Previous changes have tinkered with one piece of the NHS or another, when what was needed was comprehensive modernisation to create an NHS fit for the demands of the 21st century. That is precisely what this Health and Social Care Bill will deliver. What we see from the Labour party is nothing but opposition for its own sake—opposition to the modernisation that the NHS needs—and most of it is inconsistent with Labour’s own manifesto. It is clear that Labour opposes not only our investment in the NHS and our cuts in NHS bureaucracy but our modernisation of the NHS, which it pursued while in government.
The House knows my passion for the NHS, my respect for those who work in it and my ambition for it to be the best health care service in the world. This Bill, and the modernisation of which the Bill is just a part, are about that passion for the NHS and for securing its future. I commend the Bill to the House.
John Healey (Wentworth and Dearne) (Lab)
The Health Secretary is a man who is struggling to sell his plans. The more people learn about them, the less they like them. The more those in the NHS see, the more worried they become and the less they find to support. Only one in four of the public back him in wanting profit-making companies to be given free access to the NHS. Most GPs neither like nor want these changes, and three out of four doctors do not believe that they will improve services to patients.
Today, for the second week running, the Prime Minister is talking about the NHS changes. He is like a football club chairman stepping in to back a beleaguered manager because everyone else is losing faith in the manager’s judgment. Mind you, the Prime Minister does not always help the Health Secretary, because his words do not ring true with people. Last week, the Prime Minister called the NHS “second rate”. People know that it can be better, but they are proud of the NHS. They have seen big improvements during the last Labour decade, and they know that waiting lists are at their lowest ever and that patient satisfaction is at its highest ever. Those facts are backed up by international comparisons from the Commonwealth Fund, which said last year that Britain’s NHS is one of the very best in the world, and second to none on best value for money.
Nick Boles (Grantham and Stamford) (Con)
The Labour Government introduced foundation hospitals, private sector provision in the NHS, patient choice and payment by results—four things on which we are now building. They also introduced GP commissioning through pathfinders. Which elements of the Blair reforms to the health service is the right hon. Gentleman not repudiating today?
John Healey
It is true that we encouraged many of the GP commissioning models that the Health Secretary now champions, but that process was always within a planned and managed system, and it was never implemented at the expense of other clinicians or patients being in charge. We used private providers when they could add something to the NHS and help it to raise its game, and when they could add capacity so that we could clear waiting lists. Of course there is a role for them in the future, but that is not the question at the heart of the Bill. I will come back to the hon. Gentleman’s question later, however. People saw big improvements in the NHS under Labour, but they now realise that many of those gains might be at risk as a result of the decisions that this Government are taking.
David Miliband (South Shields) (Lab)
Does my right hon. Friend agree that the most significant change in the Bill was not mentioned by the Secretary of State? It is that the Bill introduces price competition into a market that, up to now, has allowed competition only on quality. The London School of Economics, citing academic evidence, states clearly that
“most international evidence suggests that, whereas hospital competition with fixed prices can improve quality, simultaneous price and quality competition can actually make things worse”.
John Healey
Characteristically, my right hon. Friend is absolutely right. These changes to the NHS and the Bill—[Interruption.]
John Healey
I shall answer my right hon. Friend the Member for South Shields (David Miliband), then I will give way.
My right hon. Friend is absolutely right. The Government will talk about some changes, but not about others. The changes are like an iceberg, with big, substantial, ideological changes hidden from public sight.
Mr Lansley
The edifice of an argument from the right hon. Member for South Shields (David Miliband), which is repeated by others, is based on one fact: in December 2009, the operating framework said that commissioners in the NHS could set a maximum price and not just a fixed price. That was December 2009. The right hon. Gentleman and the shadow Health Secretary were in the Government who put that measure into the operating framework. This Government did not put it in; the previous one did.
John Healey
The point made by my right hon. Friend the Member for South Shields is based on page 42 onwards of the Health Secretary’s impact assessment of the Bill, which mentions a premium for private providers of £14 per £100. The Bill allows the system to pay a premium and a bung to private sector providers.
Mr Stephen Dorrell (Charnwood) (Con)
Will the right hon. Gentleman now answer the question put to him by my right hon. Friend the Health Secretary? Does he agree or disagree with the maximum price tariff principle that was set out in December 2009 by the previous Labour Health Secretary?
John Healey
We operated an NHS with a set tariff, not a maximum tariff. In government, we operated an NHS in which price could not be the factor that drove decisions about what services patients received and by whom they were provided. My right hon. Friend the Member for South Shields is absolutely right to point out that the Bill will introduce price competition and the flexing of the price so that there is no longer a set tariff for treatments and patients but a maximum price that can be undercut by providers coming into the field. The Government will not talk about that.
The Prime Minister is not helping the Health Secretary, because the changes the Bill makes were not in his election manifesto, not on his election posters and not in his election speeches. I have the Conservative manifesto here. There is no mention of axing all limits on NHS hospitals treating private patients, so that NHS patients lose out; no talk or mention of undercutting on price, so that established NHS services are hit as new private companies cherry-pick easier patients and services; no mention of guaranteeing only selective hospital services, so that others can be closed and lost to local people without public consultation; and no mention of putting a new market regulator at the heart of the NHS with the principal job of promoting and enforcing competition. There is no mention in the Conservative manifesto of the biggest reorganisation of the NHS since it was set up more than 60 years ago. They did not tell people about their plans before the election and they promised not to introduce such measures in the coalition agreement after the election. There is no mandate from the election or the coalition agreement for this fundamental and far-reaching reorganisation. That is not a debating point, but a point of democratic principle.
Gordon Birtwistle (Burnley) (LD)
I do not remember in the 2005 Labour party manifesto the “Meeting Patients’ Needs” programme that closed the A and E unit and the children’s ward in Burnley. Do not start getting on to us about what we are and are not closing. The right hon. Gentleman closed those things. Does he agree that what he did was a disgrace to the people of Burnley?
John Healey
May I urge the hon. Gentleman to look very closely at the Bill and beyond what he hears the Health Secretary say when he talks about it? I urge him instead to look at how local hospitals could be undercut by private health companies, and at how GPs could be forced to put out work to those companies. That will undermine local hospitals such as the one in Burnley and lead to hospital closures driven not by proper planning and the development of better services in the community, but by hospitals being driven to the point of bankruptcy and closure.
Dan Byles (North Warwickshire) (Con)
The right hon. Gentleman does not seem to understand how the health service operated under his Labour Government. My constituents in Warwickshire have been suffering because NHS Warwickshire, under the rules we inherited from his Government, set up a fixed-price, below-tariff contract with one of the trusts in its area that has led to patients being drained from the George Eliot hospital trust in my area and the area of my hon. Friend the Member for Nuneaton (Mr Jones) to Warwick. It was Labour’s rules that allowed it to undercut the hospital in my constituency.
John Healey
If the hon. Gentleman was worried about the past, he should be a good deal more worried about the future, and, a bit like the Health Secretary, he should spend a lot less time talking about the Labour Government and what we did to the health service and more time talking about the plans and big changes to come.
Geraint Davies
Does my right hon. Friend accept that the core difficulty with the Bill is that it is not about patient choice but about a movement towards general practitioner choice and GP consortia choice? They want to maximise not medical outcomes but profitability. That is what this is about, and the reason is the same as what was said about flexible pricing.
John Healey
My hon. Friend is right. For the first time in the NHS we are facing, first, the potential for profit at the point of commissioning and, secondly, commissioning—in other words, decisions about rationing as well as referral—being made at the individual patient level, not at the collective area level, and we are looking at them being made by bodies and individuals who are not publicly accountable, including to the House.
Mr Lammy
My right hon. Friend is right to press the case about private providers. Is he surprised that the Secretary of State, in response to my question earlier, did not confirm to the House that the wife of John Nash, the chairman of Care UK, funded his office in November 2009 to the tune of £21,000? Does he think that the Secretary of State should put that on the record?
John Healey
I am surprised that the Health Secretary was asked a direct question and did not answer. I would simply encourage my right hon. Friend to keep asking the questions that he feels are important for the future.
Mr Andy Slaughter (Hammersmith) (Lab)
Mr Nash’s wife also bankrolled my opponent at the last election—for all the good it did him. However, something else was not in the Tory party manifesto, and that was cuts in the health service. I have in my hand a letter from the chief executive of my primary care trust that simply states that
“healthcare in North West London will face a £1bn shortfall in funding by 2014/15, given these upward pressures.”
Is that not something else that the Tory party did not tell the truth about, and something on which it is not following the Labour Government?
John Healey
My hon. Friend won his seat at the last election because he helped to expose the truth about the Conservative plans for housing—a truth that it denied but which has now come true. He is absolutely right. The truth about what is happening in the health service now is that patients are starting to see the signs of strain and services being cut, and that is not what they expected when they heard the Prime Minister, before the election and afterwards, promising to protect the NHS.
Andrew Bridgen (North West Leicestershire) (Con)
I thank the right hon. Gentleman for giving way. In my first two weeks as an MP, I paid a visit to the local PCT in Leicester, and in a meeting with the chief executive I asked how the PCT would cope with the immediate 35% cuts in management imposed by the coalition Government. The answer truly shocked me: I was told, “It will be no problem at all, because we have already increased our management by 50% in the past year.” Will the right hon. Gentleman accept that under the previous Government’s watch, the PCTs became the bloated bureaucracies that now need reforming?
John Healey
The problem for PCTs, and the managers and staff who work in them, is that they are being asked to do several things at the same time: to make unprecedented efficiencies at a time when the NHS is being put through its tightest financial squeeze in history; to axe its own jobs; and to guide the reorganisation and ensure that it can take place. That is a tough challenge for anyone. I am sure that the hon. Gentleman will keep on his local PCT’s case.
Andrew George
I am grateful to the shadow Secretary of State for giving way. I would accept his criticisms more openly—I think—were he prepared to acknowledge that the previous Labour Government set up independent treatment centres and rigged the market to hand over 15% of all elective operations in an area such as mine to an independent company that they more or less set up themselves, and which undermined the local acute trust and services with changes that patients had not asked for. That was forced on the PCT and not something for which it asked. It was a rigged market. Would he like to apologise to the House for the practices of the previous Labour Government?
John Healey
I am more interested in what we will be facing in future. I am more interested in the claim by the Health Secretary that there will not be, as he describes it, a rigged market in future, but a level playing field for all providers. However, my hon. Friend—[Interruption.] Well, we will see. The hon. Gentleman is a member of the Select Committee on Health, and he follows such matters closely. I urge him to read page 42 onwards of the impact assessment, because there he will see the preparations for being able to pay for the sort of thing that he criticises in the health service.
As the hon. Gentleman gives me this opportunity, let me say to him and his Lib Dem colleagues that what we are facing is clearly Conservative health policy, not coalition health policy, and certainly not Lib Dem health policy. The main evidence of any influence of Lib Dem ideas on health policy in the coalition agreement was the commitment to
“ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust”.
The Bill abolishes PCTs. The Lib Dem policy priority before the election was to ensure that local people had more control over their health services. The Bill places sweeping powers in the hands of a new national quango—the national commissioning board—and a new national economic regulator, which is charged with enforcing competition, to open up all parts of the NHS to private health companies. The Lib Dems’ principal concern was to strengthen local and public accountability of health services, but the Bill seriously restricts openness, scrutiny and accountability to both the public and Parliament. It will lead to an NHS in which “commercial in confidence” is stamped on many of the most important decisions that are taken. I therefore say to the hon. Gentleman and his Lib Dem colleagues: this is not your policy, but it is being done in your name. The public will hold you—
Mr Deputy Speaker (Mr Nigel Evans)
Order. I know that this debate is attracting a lot of emotion and generating a lot of heat, but will Members please try to speak through the Chair? I have been accused by both sides of doing many things in this debate, and I have not done any of them.
John Healey
I accept that correction, Mr Deputy Speaker. Let me put it in these terms. The policy is not Liberal Democrat policy, but it is being done in their name, and the public will hold the Liberal Democrats responsible if they allow the Tories to do this to our NHS.
Jeremy Corbyn (Islington North) (Lab)
Is my right hon. Friend aware that, in the rush to establish a GP commissioning system, PCTs are being merged, and that large numbers of highly skilled staff are disappearing quickly, as is the ability of PCTs to administer anything, and all this before the Bill has even received a Second Reading? Does he not think that the Secretary of State is culpable in the rapid disintegration and disorganisation of local NHS facilities all over the country?
John Healey
That is one of the things that worries experts and those in the health service the most. It is also one of the things that the right hon. Member for Charnwood (Mr Dorrell) and his Health Committee were most concerned about. [Interruption.] The right hon. Gentleman is nodding. “Disruptive” was one term that the Committee used for the changes.
Mr Dennis Skinner (Bolsover) (Lab)
Why on earth should the health service be changed? We had 13 years. We dragged the health service from the depths of degradation and hoisted it to the pinnacles of achievement. There was £33 billion in 1997; we increased that to £110 billion. All those miners in my constituency and that of my right hon. Friend who wanted those knees or hips replaced—they have all been done, after waiting not for five years, but for a few months. That is what I call achievement, and that is what the people in Bolsover and elsewhere know. That is why the health service was safe in our hands and why, they assume, this one on the Government Front Bench is now going to privatise it.
John Healey
Well, my hon. Friend is right in this respect: people will come to see clearly that they cannot trust the Tories with the NHS; they will come to see clearly what these changes really mean for their services; and they will come to see clearly what the future of the NHS holds.
John Pugh (Southport) (LD)
I cannot follow the previous contribution, but the right hon. Gentleman has mentioned democratic accountability, so will he accept that in 10 years of Labour government, nothing was done about democratic accountability in the NHS? We simply had rule by quangos.
John Healey
No, I do not accept that, but I will tell the hon. Gentleman that the measures in this Bill will undermine many of his principal concerns and policy priorities about opening up the NHS to the public and to Parliament. I hope that he will take a close look at what the Health Secretary really plans.
Alex Cunningham (Stockton North) (Lab)
I hope that my right hon. Friend will agree that the NHS is supposed to be about people and their health, so does he also agree that putting different parts of the health service in competition with one another will lead to fragmented and disjointed pathways of care and undermine innovation and the sharing of best practice, as well as increasing administrative and other costs with public funding being wasted on transaction costs?
John Healey
My hon. Friend is right—and the chief executive of the Patients Association, Katherine Murphy has said just that. Many patient groups are making the same arguments and issuing the same warnings.
My serious concern is that this Government have told only half the story from the start. The Health Secretary and the Prime Minister are happy to talk about GP commissioning and happy to talk about cutting management—the organisational changes—but they downplay or deny the deep ideological changes at the heart of these plans. The Health Secretary mentioned the new economic regulator, Monitor, in just one line in a speech lasting more than 40 minutes. The Prime Minister said last week in his speech on public services that these reforms
“are not about theory or ideology”.
The Prime Minister writes in The Times today, just as the Health Secretary did last week, both of them producing 700 words about their health plans, yet they made not a single mention of competition.
We will explain and expose the truth throughout this debate and the Bill’s passage through Parliament because these changes will break up the NHS; they will open up all areas of the NHS to price-cutting competition from private health companies; and they will take away from all parts of the NHS the requirement for proper openness, scrutiny and accountability to the public and to Parliament. These Government changes are driving free market political ideology into the heart of the NHS, and that is why doctors are now saying:
“As it stands, the UK Government’s new Bill spells the end of the NHS.”
John Healey
The public are being told that the reorganisation is “patient centred”, but patients are being sold a false promise on the NHS. The changes in the Bill come in only in 2013, but patients are already seeing the consequences of the Government’s handling of the health service. The Government have scrapped Labour’s waiting time targets, which were, of course, the patients’ guarantee of being seen and treated promptly. They are breaking the Prime Minister’s promise of a real increase in NHS funding, so Scotland is being short-changed next year by £70 million and Wales is being short-changed next year by £40 million. England, if we take out the double counting of cash to be spent on social care rather than on NHS services, faces a shortfall next year of £1.2 billion on the Prime Minister’s promise.
With this Bill, the Government are now breaking their promise to stop top-down internal reorganisations and they are putting extra unnecessary pressure on the NHS. Patients are starting to see waiting times rise; they are starting to see discharges from hospital delayed; they are starting to see wards mothballed and staff posts cut. That is not what people expected when the Prime Minister promised to protect the NHS. The Prime Minister’s most personal pledge to the public is becoming his biggest broken promise.
Nick de Bois
Will the right hon. Gentleman try to understand—[Interruption.] Perhaps he will. Members suggest that this is ideological. I do not see how it is ideological not to repeat the gross error of 2008-09 when, under the right hon. Gentleman’s watch, managers were recruited at five times the rate of nurses working on the front line—which is not ideological either, and does not serve patients.
John Healey
This is ideological. It is about driving politics into the heart of the NHS, and in some respects breaking what has been a 60-year consensus. Parties on all sides have tried to make decisions about the best interests of patients and better services, and not about their own political ideologies. That has changed today, with this Bill.
John Healey
I want to make a bit of progress before I give way again.
The public are being told that this reorganisation is patient-centred, but most patients’ GPs will not, in practice, be doing what the Government claim they will be doing. GPs spend an average of only about eight minutes with each patient. If they continue as family doctors, the commissioning will not be done by them; it will be done in their name by the managers in the primary care trust who carry out that function now, or by private health companies that are already hard-selling their services to GP consortia. Those consortia are being sold a false promise as well. Because expanded open-ended choice of treatment means funding unused capacity in the system, it is highly unlikely to happen at a time when NHS finances are under pressure.
Despite the boast about putting patients at the heart of everything that the NHS does, there is no place for patients on the bodies that will make the most important decisions on the NHS. There is no place for them on GP consortia, no place for them on the national commissioning board, and no place for them on the regulator, Monitor.
John Healey
The hon. Gentleman has already heard some of my hon. Friends mention the analysis of Dr John Appleby, published in the British Medical Journal online last week. He took to task those who had made the sweeping assertion that somehow Britain’s health service lags behind those of the rest of Europe. It is an argument that the Prime Minister advances. It is an argument for change, he says, because we are still a long way from European standards of care.
Let me read something to the House. We have been told that
“if you have heart surgery in England, you now have a greater chance of survival than almost any other European country – over the last five years, death rates have halved and are now 25 per cent lower than the European average.”
Those are not my words, or even those of Dr John Appleby. They are the words of the Health Secretary, published on ConservativeHome last week.
The Prime Minister argues that this is somehow an evolution and not a revolution. The Bill, however, is more than three times as long as the legislation that set up the NHS in 1948. The NHS chief executive told the Select Committee on Health:
“The scale of change is enormous—beyond anything that anybody from the public or private sector has witnessed”.
The Health Secretary argues that the Bill is somehow an extension of Labour policies. That is wrong, and it disguises again the fundamental changes to the NHS in the Government’s plan. Make no mistake, Mr Deputy Speaker: this is a revolution, not an evolution.
Jesse Norman (Hereford and South Herefordshire) (Con)
I note that the right hon. Gentleman failed to answer the question about the rate of increase in the number of managers. When I last checked, the NHS had 1.3 million employees, of whom almost exactly half were administrators and half were on the front line. Is he really willing to defend such an extraordinary level of overstaffing in management?
John Healey
Oh dear, the hon. Gentleman really has to get a better briefing from his Whips than that.
Clive Efford
Will my right hon. Friend confirm that in order to shoehorn private enterprise into the NHS, the regulations are being written to add a 14% premium into the tariff for private sector companies that will be tendering for work?
John Healey
My hon. Friend may be right. I have not seen the regulations, but that is certainly in the impact assessment, so he is on to an important point.
Government Members and the Health Secretary have spent a long time talking about Labour’s plans, policies and record, but the debate at the heart of this Bill is not about whether competition, choice or the private sector has a part to play in the NHS—they have and they do. The debate at the heart of this Bill is about whether full-blown competition, based on price and ruled by competition law, is the right basis for our NHS. That is why Labour Members oppose this Bill. We want the NHS run on the basis of what is best for patients, not what is best for the market. We want the NHS to be driven by the ethos of public service, not by the economics of forced competition. We will defend to the end a health service that is there for all, fair for all and free to all who need it when they need it.
If the stated aims for the reform were all the Government wanted—we have heard the Health Secretary say that he wants a greater role for doctors in commissioning, more involvement of patients, less bureaucracy and greater priority put on to improving health outcomes—he should do what the GPs say: turn the primary care trust boards over to doctors and patients, so that they can run this and do the job. But there is no correlation between the aims that the Health Secretary sets out and the actions he is taking. There is no connection between his aims and his actions. He is pursuing his actions because his aims are not sufficient. His actions would not achieve the full-scale switch to forced market competition, which is the true purpose of the changes.
Meanwhile, the biggest challenges and changes for the NHS will be made harder, not easier, by the reorganisation. Such challenges include making £20 billion of efficiency savings and improving patient services; ensuring better integration of social care and health care, of primary care and hospital care, and of public health and community health; and providing more services in closer reach of patients in the community rather than in hospital. But the Government will not listen to the warnings from the NHS experts, the NHS professional bodies, patient groups or even the Select Committee on Health.
Mr Anderson
In a disparaging comment earlier, the Secretary of State said that the voices of concern were the voices of the trade unions. They are led by people who were health professionals and they represent 1.3 million professionals. Surely somebody in this place should listen to what they say and not to Government Members, who have a biased reason for doing this.
John Healey
My hon. Friend is right. The more that NHS staff see of the changes and the consequences of this Government’s handling of the NHS, the more concerned they are about the changes and the more they are starting to see the NHS go backwards. But the Government will not listen to these warnings that are coming from all sides. They are in denial about the risks: the risk that patients will see services get worse, not better; the risk that up to £3 billion will be wasted on internal reorganisation; the risk that innovation and improvements in care that come from greater collaboration will be blocked by the Office of Fair Trading, competition courts and the new market regulator; and the risk that the Bill will create the monster of a full-blown market in health care which GPs will not control and nor will Ministers or Parliament.
If patients have been sold a false prospectus, that is true of GPs too. GPs are being told that they will call the shots on deciding who provides care for their patients, but they are being set up by the Government. They are likely to find their hands tied by Monitor and the Office of Fair Trading and by the courts enforcing competition law. They are likely to find their decisions challenged by private companies if they do not accept “any willing provider”, especially one that offers to undercut on price. The chair of the Royal College of General Practitioners recently issued a warning to her colleagues. She said:
“I understood these reforms were about putting GPs at the centre of planning healthcare for their patients, not about making sweeping cuts, which will include shutting hospitals, making enormous redundancies, closing services”.
Because the reorganisation will force doctors to make rationing decisions as well as referral decisions for their patients, they will make treatment decisions with one eye on their patient and the other on their budget and their consortium’s bottom line.
The Government say they are devolving power to front-line services, putting clinicians in control, making the NHS more accountable and improving the integration and quality of services, but in the Bill they are making the forces of competition and centralisation far stronger than those of devolution, democratic accountability or the development of quality in patient services. We will explain and expose the gap between what Ministers are saying and what they are doing in every debate at every stage of this legislation.
Patients and staff are already seeing signs of strain in the NHS. They are starting to ask, “What on earth are the Government doing with the NHS? Why don’t they listen to the warnings? Why is the Prime Minister breaking the very personal promise he made to protect the NHS?” The Bill puts competition first and patients second. That is why we will oppose the Bill tonight and expose this truth in the months ahead. These are the wrong reforms for the wrong reasons at the wrong time.
Mr Deputy Speaker (Mr Nigel Evans)
Order. Because of the popularity of this debate, a six-minute limit on speeches has been introduced, with the usual injury time on two interventions. It is up to you whether you take the full six minutes and whether you take interventions, but, clearly, the more interventions there are and the longer you speak, the fewer people will get in.
Mr Stephen Dorrell (Charnwood) (Con)
I rise to support the Bill. The shadow Secretary of State started by saying that my right hon. Friend the Secretary of State struggled to explain his reasons for introducing the Bill, but I think that the shadow Secretary of State struggled to explain why he opposes it. He struggled from the moment that my hon. Friend the Member for Grantham and Stamford (Nick Boles) intervened to draw his attention to the fact that the Bill represents an evolution of policy that has been consistently developed by every Secretary of State since 1990, with a single exception in the form of the right hon. Member for Holborn and St Pancras (Frank Dobson), who sits on the Labour Back Benches. The question that the shadow Secretary of State has to answer is this.
Mr Dorrell
Let me pose the question and I shall be delighted to give way. Which of the key themes does the right hon. Gentleman oppose? Is it the practice-based commissioning or the “any willing provider” model? Is it the introduction of private sector expertise into commissioning, which was first articulated in the world class commissioning programme, or is it the principle of the maximum tariff? Let me help him by quoting from the operating framework of 2009, to which my right hon. Friend the Secretary of State referred. It states:
“After 2010/11, we shall move to a position where national tariffs represent the maximum price payable to a commissioner, as opposed to the mandated price for a particular activity.”
With which of those four key policies does the right hon. Gentleman disagree?
John Healey
The right hon. Gentleman started by saying that the policies are an evolution. If that is the case, why did he say:
“I thought we were looking to develop existing institutions rather than starting again, and that appeared to be confirmed in the coalition agreement.”
John Healey
The right hon. Gentleman, who is nodding, went on:
“Then in July that approach was changed. That came as a surprise.”
Mr Dorrell
Indeed it did. I offered the right hon. Gentleman four consistent themes of policy. He accurately quoted my comments about a specific element of bureaucracy. One of the questions that the Select Committee addressed was why, since all these broad themes are so broadly supported, we went down the road of replacing the PCTs with the consortia. That is a question that the Select Committee said in its report had not been adequately explained, but that is a relatively minor question of bureaucratic presentation when compared with the broad themes of policy that were articulated in the debate by my hon. Friend the Member for Grantham and Stamford. Which of these key policies does Labour now wish to dissent from?
Mr Dorrell
I give way to the hon. Gentleman, an expert on health policy from the Back Benches, who may able to answer the question that the shadow Secretary of State wishes to avoid.
Hugh Bayley
I wonder whether the Select Committee agrees that private contractors, where they are engaged, should be required to publish the same information about cost, quality and outcomes as NHS providers, to ensure a level playing field and real, true comparison.
Mr Dorrell
I have been here long enough not to presume to speak on behalf of a Select Committee on a question that the Select Committee has not addressed, but I think there would be broad support across the House for the principle that where the private sector provides a service to a public sector commissioner, the private sector provider should be accountable to that commissioner on precisely the same terms as the public sector provider. As my hon. Friend the Member for St Ives (Andrew George) mentioned in his intervention on the shadow Health Secretary, one of the problems about the independent sector treatment centre programme was exactly the point that the hon. Gentleman makes—the accountability expected of a private sector provider was different from the accountability expected of a public sector provider.
Therefore, I agree with the hon. Gentleman and hope that he can persuade his right hon. and hon. Friends on the Front Bench to endorse the principle of common accountability for public and private sector providers providing a service to a public sector commissioner. I see my right hon. and hon. Friends on the Government Front Bench endorsing the principle. I hope that I am not misrepresenting the way that they are reacting to the hon. Gentleman’s question.
This is a consistent set of themes. Why is it consistent? I want to move the debate on. The House of Commons loves debating structures in the national health service. The inference from what I have said so far might be that that means it is all business as usual—that what has gone on, with the exception of the period when the right hon. Member for Holborn and St Pancras was in charge, is a seamless development of policy since 1990.
However, the truth is that during the lifetime of this Parliament the national health service faces a genuinely unprecedented challenge, first articulated not by my right hon. Friend the Secretary of State in the present Government, but by the chief executive of the health service before the general election in May 2009, when he drew attention to the fact that demand for health care should be expected to continue to rise at roughly 4% per annum, as it has done throughout the recent history of the national health service. However, because of the budget deficit, we will not see the health budget continue to rise to absorb that rise in demand, in the way it has over the past decade.
Therefore, during the lifetime of this Parliament, we will have to see, in the national health service, a 4% efficiency gain four years running—something that not merely our health care system, but no other health care system in the world, has ever delivered. The Select Committee has referred to that as the Nicholson challenge, reflecting the fact that it was first articulated by the chief executive and endorsed by the previous Government. Again, this is a case of a shared agenda across the House of Commons.
Given the Budget deficit, the only way we can continue to meet the demand for high-quality health care, which we all want to see, is by delivering an unprecedented efficiency gain in the NHS for four years running. That is why I support the Bill. I support it because to my mind it is inconceivable that we can deliver such an efficiency gain without delivering more effectively than we have done yet on the ideas, which have been endorsed over the past 20 years, about greater clinical engagement in NHS commissioning, which I have been talking about. Commissioning cannot be successful if it is something that is done to doctors by managers; it must engage the whole clinical community. We must address the democratic deficit, because we cannot bring change on the scale that we need to deliver the efficiency gain without engaging local communities.
Finally, the NHS must also be a national service that is accountable through the commissioning consortia, the commissioning board and the Secretary of State to this House, because it is ultimately the taxpayers who pay for it. Those are the principles that were set out by the Health Committee, and it is those that we will seek to review as the Bill goes through Parliament.
Frank Dobson (Holborn and St Pancras) (Lab)
I make no apologies for the policies that were pursued while I was Secretary of State for Health, because I set about implementing every item in Labour’s election manifesto. I know that implementing promises in election manifestos has gone out of fashion on the Government Benches, but it has not gone out of fashion with me. Before I became Health Secretary, while I was Health Secretary and since, most doctors, nurses, midwives and others in the health service have said above all, “For God’s sake, leave us alone, stop diverting our attention into reorganisation and let us get on with the job of looking after patients and raising standards of treatment and care.” Presumably, that was why the Conservative manifesto and the coalition programme both stated:
“We will stop the top-down reorganisations of the NHS”.
They claim that their proposed reforms are not top-down, but I cannot think of anything more top-down than an Act of Parliament set out in 353 pages and 61,344 words, and yet it is still a broken promise.
The NHS, as we all know, is doing better than ever before: waiting lists have come down dramatically; waiting times have been massively reduced; and survival rates are dramatically improving. Most people, in most places, and most of the time, are getting a very good deal from the health service, which is why it is more popular than ever before.
Mr Graham Stuart (Beverley and Holderness) (Con)
Will the right hon. Gentleman give way?
Frank Dobson
No, I do not have time.
Those improvements have come about not as a result of any structural changes, but because the Labour Government put into the NHS more money than ever before, built more new hospitals than ever before, put in more new equipment and, above all, recruited record numbers of doctors and nurses. We also put more emphasis on standards and on trying to ensure that we spread best practice right across the health service.
I accept that we need more clinician involvement in decision making, but we do not need to go to GP commissioning to bring that about. All we need do is get more of them on primary care trusts with more influence there. Why is it just confined to GPs? There is no reference to greater involvement of hospital specialists and there is nothing in the 61,000-odd words about giving hospital doctors a bigger say, and they have some expertise in these matters. Many GPs, as we know, do not support the proposals, and many of them want to get on with just being doctors.
One great deception that is being promoted is saying to patients, “You and your GP will decide where you will get treated.” That is simply not true. Unless the consortium of which the GP is a compulsory member has a contract with a particular hospital, the patient will not be able to go there from their GP.
The NHS is essentially a co-operative organisation in principle and in practice, and now it will be forced to compete: every part of the health service competing with the other parts and the private sector on price. It is rather remarkable, considering all the Eurosceptics on the Government Benches, that the Government are going to force our NHS to comply with European competition rules set out in the Lisbon treaty—the Lisbon treaty that the Tories voted against. Who is most likely to benefit from those rules? The answer is American health corporations, almost all of which have been indicted in the United States for defrauding US taxpayers, doctors, patients and, sometimes, all three. I asked the Secretary of State whether he would rule out any of those outfits obtaining contracts, and I am afraid his answer was, “I can’t say.”
The next question is, how will we know what is going on? How will we and local TV, radio and newspapers know what is being decided? In the Bill, there is no serious obligation for hardly any of the decision-making bodies to hold their meetings in public; there is no obligation on declaration of interests; and there is no obligation on consultation. If anyone says, “Well, freedom of information will cope,” we know what the answer will be, “Commercial confidentiality; you can’t have it.” If we are to have a competitive system, almost everything will be commercial and, therefore, almost everything will be confidential.
These proposals will divert people in the NHS from their job of looking after people. The Government are privatising the NHS, they are fragmenting the NHS, they will cost us a fortune and do little or no good for anybody.
Gordon Birtwistle (Burnley) (LD)
I shall support the Bill, because it will mean an end to the disruption and devastation of local hospital services owing to overpaid, faceless bureaucrats in palatial offices many miles from people’s local hospitals deciding that a particular service is no longer needed or is better off elsewhere. The Bill’s local democratic legitimacy policy strives to ensure that decisions on serious hospital reconfigurations never again ride roughshod over the wishes of the local community.
Rosie Cooper (West Lancashire) (Lab)
When I asked the Secretary of State who would make the decision if the consortium and the health and wellbeing board disagreed on the reconfiguration of hospitals, he said the reconfiguration panel as it exists today—no difference.
Gordon Birtwistle
I am pleased that the reconfiguration board is now studying a decision that the previous Government made to close my local hospital’s children’s ward. The Secretary of State is due to rule on that shortly.
A prime example of the authoritarian nature of primary care trusts can be seen in my constituency. Without proper consultation, we have seen our accident and emergency department closed and our children’s ward transferred to Blackburn. My constituency is seriously deprived, and the decisions made by managers in Manchester have had a disastrous effect on the health and well-being of thousands of my constituents, many being seriously ill children. The proposals before us will ensure that, for the first time, commissioners and all providers of NHS-funded services have to consult the local authority on the proposed substantial reconfiguration of designated services. In my eyes, that can only be a good thing.
I want to bring to the House’s notice a young man called Logan Cockroft, who lives in my constituency. He has cerebral palsy, and he cannot speak or walk. The only thing that Logan can do is smile. His parents live near Burnley general hospital; they moved there because of Logan’s illness. He made many visits to the hospital because of his illness, the nurses knew him, and he was happy to go there. Logan seemed intent on smothering himself with a pillow, so the nurses at Burnley hospital kept a close eye on him and put him close to the nurses’ station. The family were happy with the treatment that Logan received. Unfortunately, under their meeting patient needs programmes, the previous Government closed down our children’s ward. Logan now has to go to Blackburn. The nurses on the children’s ward in Blackburn do not know Logan. They do not know about Logan’s problems.
Helen Jones (Warrington North) (Lab)
The Bill allows private providers to undercut the NHS. What would the hon. Gentleman’s reaction be if an NHS service in his constituency disappeared because it had been undercut by a private provider?
Gordon Birtwistle
The service was removed by the hon. Lady’s Government, so I do not need to worry too much about private services.
As I said, Logan has those problems. When he is in Blackburn, his parents are extremely concerned about the care that he is receiving—not because the care is poor, but because staff there are seriously stretched. An attempt has been made to put the children’s ward in Burnley into the children’s ward in Blackburn, which was already overloaded, and the staff cannot manage. That cannot be right and it would not have happened if the PCT had contacted the people of Burnley, who have signed a 25,000-name petition against the move. Almost every GP is against the move, and the people of Burnley are unanimously against it. The move would not have happened under the new system that we are setting up.
The bureaucrats in Manchester tell me that the reconfiguration is not about money but about what is best for Burnley. I tell them that their unfounded interference will result in deaths. Nobody in my constituency wanted the A and E or children’s wards to close; they were a valued service. The Bill will strengthen democratic involvement by ensuring that the full council decides on whether to refer proposals to the NHS commissioning board or the Secretary of State. The people of Burnley had no say at all in what happened to our children’s ward. The Bill will strengthen the important function of scrutiny and recognise the new enhanced leadership of local authorities in health and social care.
It is about time—[Interruption.] I have been here only six months; if Labour Members cannot win, they start arguing, don’t they? But they never stand up and say anything fruitful.
It is about time that measures were put in place to strengthen the role of local authorities and the involvement of democratically elected representatives. That is how there will be representation. We will have somebody to listen to us who has been democratically elected. I have met no one in Burnley who found anybody in the primary care trust or the palatial offices of the strategic health authority in Manchester to speak to about the closure of the children’s ward. Now the people’s voices will be heard.
I am particularly pleased that the Government recognise that district councils have an important role to play in shaping our local hospitals. I hope that the proposed health and wellbeing boards take into account the recommendations of local hospitals and listen to patients. I trust GPs in Burnley to make the right call about our hospital. I only wish that these measures had been in place before the previous Administration reduced services at Burnley general hospital to the point of non-existence.
I welcome these radical changes. Local democratic legitimacy in decision making about our hospitals is desperately needed. It is time that we gave power back to the people.
Mr Kevin Barron (Rother Valley) (Lab)
I shall move on quickly. We had seven hours and 45 minutes to debate the Bill, but the first hour and 15 minutes was taken up by Front Benchers. Given that the Government have not found time to debate the White Paper that they published in July, we should probably have had two days’ debate on a Bill as important as this. As the shadow Secretary of State said, it is far larger than the 1948 Bill that established the national health service.
I find it difficult to find any justification for such a major reorganisation of our NHS. We have had a decade of major investment and we have seen improving services and major satisfaction ratings given by patients. In November 2009, the then Leader of the Opposition, now Prime Minister, said that
“with the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS.”
He was supported by the now Secretary of State for Health, who said as shadow Secretary of State in July 2007 that the NHS needed no more top-down reorganisation. Indeed, even after the general election, the coalition agreement stated:
“We will stop the top-down reorganisations of the NHS that have got in the way of patient care.”
It went on to spell out the continuing role of PCTs in some detail, pledging:
“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…The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level”.
A few months later, we have this potential chaos thrown on to the national health service. Once again, people are looking at the NHS and trying to change its culture by reorganising it.
We have had 30 years of Governments of different political persuasions trying to change the culture of the national health service by reorganisation. Every time, there have been years-long delays in implementation, performance has been affected in a negative way and there have been costs—particularly on this occasion, when the NHS is being instructed to make efficiency savings.
I agree with the report on commissioning just published by the Health Committee. I am not too sure whether the Chair agrees with it himself; the right hon. Member for Charnwood (Mr Dorrell) spoke earlier. The report states:
“The Coalition Programme anticipated an evolution of existing institutions; the White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy has yet been sufficiently explained given the costs and uncertainties generated by the process.”
The last 30 years should tell the House and the Government exactly that.
Mr Barron
That is an interesting comment, but the Bill does not represent that. In my borough, the PCT—as was; it still is, although it is now Rotherham NHS—will become the GP commissioning consortium. Let us not get away from that. The idea that getting rid of the strategic health authorities or anything else is going to save massive amounts of money is palpable nonsense.
Does anybody think that top-down meddling is going to end because of this reorganisation? If the local GP consortium does not offer provision as it should, the national commissioning board will tell it what to do. If that is not top-down, I do not know what is. Those will be the people responsible for whether local residents, particularly those who need specialised commissioning, are going to get the services or not. The idea that those people are going to be responsible for NHS dentistry in my constituency is nonsense. There has now been a move away from midwifery, and that was going to be commissioned nationally. The changes are nonsense; they have been ill thought out.
Mr Stuart
The Chair of the Health Committee also set out the central challenge, which was recognised by the previous Government: to make major savings, year on year, for the next four years, at a time when budgets will not be able to increase—or at least not by much. How does the right hon. Gentleman think that that issue could best be addressed? Suggesting, as he did at the beginning, that we could just carry on as we were would not be sustainable.
Mr Barron
I am not saying that savings should not be made. Indeed, the Select Committee in the last Parliament took evidence from the chief executive of the NHS on that particular point. The case that I make is about the type of reorganisation. Not only has nobody in the public sector ever been able to get 4% a year in savings, but nobody in the private sector has, in the time scale being predicted now. [Interruption.] The Secretary of State says that that is rubbish—it is not rubbish at all. He should go and talk to his advisers about what happens in the real world, as opposed to the world that has appeared since July last year.
I would like to say something in defence of managers. This Government have been bashing managers in the NHS every week they have been in office, and did so for many months before they got there. How do they think we got waiting lists for things such as new knee and hip joints down from years to months, and even weeks, in areas such as mine? I will tell them. It was not done by taking the surgeons out of theatres to do the administration, but by putting people in to do the administration so that the surgeons could spend more time in theatres seeing more patients. That is the real truth. The management -bashing that has been taking place of people inside the NHS might be popular on the ground, but let me say this to the Government: if they take those managers out and we go back to the waiting lists and waiting times of five or six years ago, they will see where popularity lies.
Mr Barron
No, I will not; I have given way twice. The hon. Gentleman can make his own speech.
The King’s Fund, which the Secretary of State mentioned, supports some parts of the Bill. Indeed, I support a lot of its aims, but I do not support the reorganisation and upheaval that it will create inside the NHS. That is why I will vote against it. The King’s Fund says:
“The Bill abolishes the Health Protection Agency, places a duty on the Secretary of State to promote public health, and transfers responsibility for public health to local authorities.”
I agree with that. However, the Bill does not give me any confidence that GP consortia will have responsibility for the health of the population they cover.
Anybody looking at the history of public health in this country should recognise that we cannot run it on the basis of just handing it over to local government. The issues are far wider than that. The Secretary of State shakes his head, but people should look at the answers to questions that I got a week or so ago about what has happened to smoking cessation since this Government took over. Rates of smoking cessation have plummeted because of the advertising and promotion that is permitted. About 50% of health inequalities are created by smoking. The Government have taken their foot off the accelerator on the main thing that we should be doing to address public health inequalities, and they will suffer at the polls because of it.
Mark Simmonds (Boston and Skegness) (Con)
It is always a pleasure to follow the right hon. Member for Rother Valley (Mr Barron). Although I did not agree with much of his speech, I strongly agree with his last point about the importance of keeping the foot on the accelerator to try to narrow health inequalities. That is right at the top of the priorities of Health Ministers. This is a very important and complex Bill. We all want to see high-quality care and value for the taxpayer in the provision of health care. I think it is fair to say that there has never been a better-informed, more knowledgeable and better-prepared incoming Secretary of State than we have at the moment.
The opening speeches by my right hon. Friend and by the shadow Secretary of State stood in stark contrast to one another. I feel rather sorry for the shadow Secretary of State. He is clearly an intelligent man, but he is cornered by the supplicatory role that his leader is playing to the trade union movement. I am sure that the shadow Secretary of State agrees with the Government’s introduction of independent treatment centres. I am sure that he also agrees with the previous Government’s introduction of the independent sector into provision and into commissioning, “any willing provider”, practice-based commissioning, payment by results—although it was payment by activity then—and national tariff ceilings within quality standard frameworks. However, he could not say so because he is cornered.
Listening to some Labour Members, one would think that there were no improvements to be made—that the national health service was a utopian structure prior to the last general election. Let me point to 10 things that I sketched out this morning: too much money spent on administration and bureaucracy and not enough on front-line patient care; too little patient-centric information to inform decision making; too little innovation; too little clinical input into decision making; too much inertia and hostility to reform, as we have seen today; too much process-driven target culture distorting clinical decision making; falling productivity; poor outcomes across a range of clinical indicators; too often, weak commissioning of servicing; and widening health inequalities in the past 10 years, in addition to the scandals that occurred in Staffordshire and Kent. That is hardly a situation that makes the status quo desirable.
Mr Lee Scott (Ilford North) (Con)
At the risk of being accused of management-bashing, may I point out that somebody in my own trust who worked up a deficit in excess of £100 million was rewarded with a large pay-off when he left the NHS? Can that possibly be right?
Mark Simmonds
My hon. Friend is absolutely right. I remember him fighting tirelessly and vociferously to try to prevent those in the health service and the then Health Secretary from allowing that to happen.
Another thing that Labour Members have to understand is that we must move the NHS towards being a service that is centred on the patient, not one where the patient revolves around the system. To enable that to happen, we must measure and improve outcomes on a continuing basis, and we must do it with patient-centric information that will enhance patient choice, not only about the choice of the provider and the location of their treatment, but about the treatment that they receive for their ailment. This Bill deals with all the failings that were present when the Labour party was in charge.
There are three or four areas where the detail still needs to be discussed, and I want to make some suggestions. There must be an opportunity for integrated care and for improved patient pathways. I would very much like acute clinicians, pharmacists and others who deliver patient care to be involved in GP consortia and the commissioning process. Some of the more forward-thinking consortia are already involving acute clinicians, and this needs to be implemented across the board. We need to find a non-prescriptive architecture to enable consortia to work together to collaborate where appropriate, not only in the all-important area of cancer, as appropriately highlighted by my hon. Friend the Member for Basildon and Billericay (Mr Baron), but in acute stroke services. This has been done successfully, and it must continue to be done.
Performance management is absolutely critical. The Bill seems to make no specific mention of out-of-hours care. My right hon. Friend the Secretary of State will remember only too clearly the terrible case of Mr Gray, who was killed by Dr Ubani, the out-of-hours doctor who flew in from Germany and prescribed him the wrong dose of a drug. That was a performance management failure. The SHA failed to monitor the PCT, which was failing to monitor the provider. We must ensure that GPs are involved in driving improvements in out-of-hours care as well as in-hours care.
We need to look at GPs’ contracts. It is rather perplexing that a PMS—personal medical services—contract could be held by a national commissioning board. Who will be in charge of revalidation, training and performance lists? We must move GPs’ quality and outcomes framework towards one that is outcome-based rather than process-based.
Mr Graham Stuart
Like my hon. Friend, I will support the Bill. Does he hope, as I do, that the Government will look very carefully at any conflicts of interest? As we rightly give the power down to clinicians, we need to ensure that they always take decisions in the interests of the patient and not for their own financial gain.
Mark Simmonds
I entirely agree with my hon. Friend. My understanding is that the NHS commissioning board will have a significant monitoring role to ensure that GPs commission services not automatically from themselves but from providers who provide the best outcomes for the patients they are trying to look after.
I would like to make one final point to the ministerial team. Information is the key that will drive improvements in the NHS, and that information must be comparable, easily accessible and easily understandable in order to inform patients’ decision making processes. It should not just be on the internet. We should not just wait for patients to access information—we have to find ways of taking it to them, particularly those living in socio-economically deprived areas.
The Bill is a significant step in the right direction. It preserves the best of the national health service—equality of access—while creating opportunities to improve the provision of health care in the UK, so that it can become among the best in the world, rather than lag behind. Excellence for all should be the goal.
Jim Dowd (Lewisham West and Penge) (Lab)
It is a pleasure to follow the hon. Member for Boston and Skegness (Mark Simmonds). Although I do not agree with much of what he said—I certainly do not agree with his rationale for supporting the Bill—he made a few genuine points that, in the calmer atmosphere of a Committee, could be looked at in detail.
I agree with the hon. Gentleman that the difference between the two Front Benches could hardly be starker. This is about the view of what the national health service should be. I am not disappointed for one moment that the view of the Labour party is different from that of the Conservative party and its followers from the Liberal camp. Much has been made of that great event on 5 July 1948, when the national health service came into being. Of course, at the time, it was ferociously opposed by the Conservative party. At the beginning, it was also opposed by large parts, although not all, of the medical profession.
Jim Dowd
I will not give way, for one good reason: I might get injury time for it, but others would lose out.
The medical profession has changed its view, as has the Conservative party. The Conservative party has changed its view largely because the NHS and the principles that underpin it resound so clearly with the British people. This has been a difficulty for the Conservative party over the years.
I have seen a few Conservative party reorganisations of the health service. Thirty-five years ago, I was appointed to the Lambeth, Southwark and Lewisham area health authority, which included such hospitals as our local one over the river, St Thomas’s, Guy’s, King’s College and Lewisham. The AHAs were set up as a consequence of the Heath Government’s reforms in the early ’70s. They were abolished, but not before Lord Jenkin suspended the Lambeth, Southwark and Lewisham AHA for refusing to accept the cuts in the budgets that the then Government were trying to inflict.
The Tories reorganised the health service again and brought in district health authorities. I served on Lewisham and North Southwark district health authority for some time, until in 1990 I was thrown off for having the temerity to be a local councillor. I am sure that there are others around the Chamber who suffered similarly. Who engineered that amazing transformation? It was none other than the current Secretary of State for Justice. I think that he just sacked anybody who was not on his Christmas card list, quite frankly, because nothing in that reform of the health service did anything to improve its accountability or performance. It did hand over the health service, more than ever, to central control and direction, which, we are asked to believe, the Conservative party today decries so readily.
The Conservative party, of course, contains members who believe—and who go on foreign broadcasting stations to announce—that the national health service is a 60-year-old mistake. That is what was said by an MEP who was advising Republicans in the United States to oppose the Obama reforms. He was slapped down quite quickly, unsurprisingly. It is the great embarrassment of the Conservative party that it cannot reconcile its atavistic feelings towards the health service and belief in the free market with the feelings of the vast majority of the British people.
In recent years, as my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) pointed out, waiting times for most specialisms have come down almost to the point where they are no longer a consideration. I will tell the House briefly about the experience I had towards the end of 2009. I suffered chest pains of various kinds. I went to A and E at Lewisham hospital on 28 July. I was referred to the chest pain clinic at the same hospital the following week. I went for an angiogram at King’s College hospital two weeks after that, where the consultant advised me that I needed bypass surgery. I asked how long it would take—I did not mean the operation, obviously, but the wait. He said, “When can you come in?” I could not make the first date that I was offered, so I had to put it back. My experience was repeated millions of times across this country when the Labour party had stewardship of the NHS. It is that relationship that is so critically under attack.
The NHS is about patients—of course it is. Everybody knows that patients come first and that it must be patient-centred. Those things are meaningless clichés. Patient care and patient choice matter, but what matters more is patient trust. Patients must trust that any therapy, drug or treatment that is suggested by their clinicians and medical advisers is what is best for them—not what is cheapest or what has been contracted for. It is that critical, basic relationship in the national health service that is most under threat from this Bill and that Government.
Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)
I, too, rise to speak in favour of the Bill. There is a clear divide in the House between the Labour party, which stands by and defends NHS bureaucracy, box-ticking and putting bureaucracy in front of patients, and the Secretary of State and the coalition Government who genuinely want to deliver reforms that will benefit patients. As the Bill says, the people who are best placed to be the advocates of patients are doctors and other health care professionals. Such people are much better placed to be the advocates for their patients than the faceless bureaucrats who have made so many bad decisions, and who have put tick-boxes and targets in front of patient care.
A key issue in this debate was articulated by my right hon. Friend the Member for Charnwood (Mr Dorrell), who said that the NHS, whoever were in government, would face unprecedented strains and problems. One such problem is the ageing population. It is great that people live many years longer, but people consume the majority of their health care in the later years of their lives. Unless we reform the NHS, make it more patient-centred, and cut out the bureaucracy and put the money to better use on the front line, we will not be able to properly look after those older patients.
Stephen Lloyd (Eastbourne) (LD)
I agree that the issue of ageing patients is a fundamental challenge. Does my hon. Friend agree that domiciliary care, which is currently delivered through local authorities and primary care trusts, is a vital service that maintains many people’s health for the longer term and often prevents unnecessary stays in hospital? Does he agree that appropriate steps should be taken by the Government in the Bill to ensure access to high-quality domiciliary care for all?
Dr Poulter
My hon. Friend represents Eastbourne, which has a large elderly population. He is right to make that point. Under the Bill, health and wellbeing boards will be set up, which will deliver a proper partnership between GPs, hospitals and local councils. That will allow, for the first time, properly joined-up thinking about how we deliver social services care that is joined up with NHS care for older people. I am delighted that the Government will put in almost £1 billion to support that initiative, which can only be a good thing.
The second challenge facing the NHS, which my right hon. Member for Charnwood also mentioned, is that we are having to get more and more out of a limited resource, because people expect more and more from their health care, regardless of their age. People want, quite rightly, to be given the latest cancer drugs. They want to ensure that they have top-quality care and access to information that delivers that care. The problem with the bureaucracy that has been in place is that, far too often, it has taken too long to deliver higher quality care and a greater choice in treatment for patients. When we know that a cancer drug works, it should be available as soon as possible. It should not have to go through a process of two, three or four years of bureaucracy to be made available, and the Bill will help to change that. For those reasons, the Bill’s reforms to the NHS will provide an excellent framework in which to deliver better ways of spending limited resources and looking after our ever-ageing population.
A lot of health care professionals will be saying, as I did earlier, that far too often, medicine and health care have been reduced to a tick-box exercise, with targets and top-down bureaucracy getting in the way of patient care. Under the A and E targets delivered by the previous Government, equal priority was given to treating a patient with a broken toe as someone with potentially life-threatening chest pain. That cannot possibly be right. Putting doctors, nurses and other health care professionals in charge of making health care decisions will mean that clinical priorities and better patient care can be delivered.
Grahame M. Morris (Easington) (Lab)
Has the hon. Gentleman made any assessment of the reduction in the number of managers, consultants and other bureaucrats that will be caused by moving from 152 primary care trusts to potentially 500 or 1,000 GP commissioning groups?
Dr Poulter
The Opposition need to take on board the fact that the cost of running PCTs has gone up by about £1 billion a year since they were first put in place. The cost of bureaucracy and management in the NHS is unsustainable, and most of the money that we are putting into the NHS is going on salaries and bureaucracy rather than on front-line patient care. It is surely a good thing to remove the middle strand of bureaucracy—PCTs, strategic health authorities and other quangos that cost a lot of money but do not deliver front-line patient care. That will help deliver more money to the front line and to patients, and Members on both sides of the House should support such an initiative.
I shall elaborate on the point about how PCTs have been a great source of wasted money. In my part of the world in Suffolk, they have spent millions of pounds each year on external consultants to tell them how they should be doing the job that they should have been doing in the first place. There has also been a total disconnect between primary and secondary care and a breakdown in the relationship between them. For example, as the Secretary of State alluded to earlier, hospitals have wanted to put in place outreach clinics for mental health, dermatology and rheumatology, but too often, as in my area, they have been told that the PCT will not allow them to do that.
Hospitals have said that they value and need community hospitals, because they provide an excellent place for step-up and step-down care and for rehabilitation after an acute hospital stay, but PCTs have closed down community hospitals such as Hartismere hospital in my community. We know that that is not a good thing. Far too often, PCTs have been a barrier to joined-up thinking in the NHS between the primary care sector and hospitals.
Dr Poulter
No, I have taken two interventions and I will not take any more.
The Bill will allow health care to become more localised. Some of our constituencies have urban needs and some have rural needs, and allowing GPs to set up localised consortia that are more responsive to the needs of local communities will enable them to recognise those health care needs. For example, the area of my hon. Friend the Member for Eastbourne (Stephen Lloyd) has an ageing population, so the GP consortia and health and wellbeing boards will rightly focus on looking after the older population. In areas of the country such as our some of our inner cities, including parts of Bradford and Manchester where there are huge health care inequalities, the Bill will provide a real opportunity for the health and wellbeing boards and local GPs to tailor their services much more effectively to tackling local problems. For instance, they may face problems such as heart disease, diabetes and obesity more acutely than other areas.
The Bill is a good thing. It will bring to the NHS framework and the national care standards a much more focused, much less bureaucratic and much more patient-centred approach, which will be much more responsive to the needs of local communities. I am proud to speak in favour of it.
David Miliband (South Shields) (Lab)
It is a pleasure to follow the hon. Member for Central Suffolk and North Ipswich (Dr Poulter). I congratulate him on his important and interesting speech, and I wish to pick up his challenge. The choice is not between no reform and reform; it is between good reform and bad reform. I believe that the proposals in front of us represent not a curate’s egg, with some good reforms and some bad, but a set of poison pills for the NHS.
The first poison pill is the massive upheaval that the Bill proposes at the time of an unprecedented efficiency drive. The right hon. Member for Charnwood (Mr Dorrell) said that it was precisely because of the efficiency drive that we should have massive upheaval, but he must know that all the evidence from reorganisations throughout the years is that projected savings are double the out-turn, and projected costs turn out to be half the actual level. When the Prime Minister says that there is a £300 million difference between the costs and the savings—£1.7 billion of savings and £1.4 billion of costs—he is actually treating us to a reorganisation that will end up costing money and causing redundancy costs at a time when hospitals and GPs are trying to get the job done.
The Minister of State, Department of Health (Mr Simon Burns)
May I correct the right hon. Gentleman before he goes too far down that path? The impact assessment suggests that the one-off cost will be £1.4 billion, and that the savings from that investment over the life of this Parliament will be £5 billion. By the end of the decade, the saving will be £13.6 billion, which is £1.7 billion a year after 2013-14.
David Miliband
I am happy to wager the hon. Gentleman that the costs will turn out to be more like double those estimated and the savings more like half.
The Bill is myopic, or “deluded”, to use the word of the British Medical Journal, in three key areas, which I wish to mention. First, it assumes that all GPs are ready now to take on hard budgets in the commissioning framework. It took the previous Tory Government six years to get 56% to be GP fundholders. Secondly, it will deepen the divide between primary and secondary care. The hon. Member for Central Suffolk and North Ipswich raised that matter, which is vital. We all know that in our constituencies, collaboration between primary and secondary care is key, especially for chronic conditions. The Bill will make the divide worse, because collaboration will be deemed anti-competitive.
Thirdly, the Bill has absolutely nothing to say about quality control of GPs. In fact, it will remove the local drivers for improvement that I have seen in my constituency. The hon. Member for Basildon and Billericay (Mr Baron) mentioned cancer survival rates, and the Appleby research shows that we in this country have made more progress over the past 30 years than any other country in Europe, and will overtake France in 2012. It also shows that the extent to which we are behind can be explained by late diagnosis in the first year of cancer, which is the responsibility of GPs. They should focus on improving their cancer treatment, not commissioning care.
David Miliband
No, I have given way once and I want to make some progress. If I have time, I will come back to the hon. Gentleman.
All the matters that I have mentioned are to service a vision of health care as a regulated industry. The Secretary of State has engaged in a ding-dong about which operating framework is more important—the 2009 or the 2010 one. Two points, though, have not been contested. The first is that in 2011-12, for the first time, there will be competition according to price—page 54 of the operating framework says that. The second is that the academic evidence is absolutely clear that price competition results in lower prices, yes, but also in lower quality.
The hon. Member for St Ives (Andrew George) asked the Secretary of State, “What about my community hospitals?”, but of course the Secretary of State does not want to make decisions about community hospitals. His predecessor but six, eight or 10, Nye Bevan, said that he wanted a bedpan falling in Tredegar to be heard in the corridors of Whitehall. The Secretary of State does not want to hear bedpans falling; he wants to say that it is GPs who should be making decisions, or the commissioning board, or, in the ultimate irony that my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) pointed out, the European Court of Justice under European competition law. He pointed out the irony of the Lisbon treaty being critical, but at this very time the House is passing a Europe Bill that calls for referendums when any power is transferred to the EU, including on matters as puny as the appointments system for the Court of Auditors, never mind on a vital part of NHS provision.
Frank Dobson
Does my right hon. Friend agree that the hon. Member for St Ives (Andrew George) is perhaps being a little ungrateful? He might have mentioned that the NHS wanted to close all his community hospitals in Cornwall, and that the dreaded centralist top-down Dobson stopped it.
David Miliband
The benefits of memory are useful in politics, and perhaps my right hon. Friend’s intervention will help the hon. Member for St Ives to decide how to vote in the Lobby tonight.
Many people have asked why the Government are making these proposals at such breakneck speed. Surely it is not to solve a political problem on health. After all, the Conservative party spent the whole of the last Parliament doing everything possible to avoid any policy on health that might hint at radical change. That paid off, because in the last prime ministerial debates before the general election, not a single question on health was put to any of the party leaders. It would be massively in the interests of my party and all Labour Members if the next general election were dominated by debates on the health service. On that basis, we should be urging the Government to plough ahead and make the next general election a referendum on health. Frankly, however, the cost would be far too high, and the consequences would be far too great for the national health service.
The truth is that a radical Secretary of State would do something that too few of his predecessors have been willing to do—namely, to say, “On my watch, there will be no reorganisation of the national health service.” Such a Secretary of State would dedicate himself to implementing the reforms that are working today. It is not the case that the only choice is between no reform at all and the reforms now being offered. According to health experts, there is more reform going on in the English health service now than in other health system in Europe. Our Scottish and Welsh friends might benefit from some of the changes that are taking place in England, because those changes have made the English health service a fast-improving one in Europe.
There is always room for improvement in the national health service to strengthen commissioning, to link health authorities and local government, to get people out of hospitals and to align with social care. The Dilnot commission has just been appointed to review the funding of social care, but it will not report until July. At exactly the time when we are looking at the localisation of health provision, the Government have appointed someone to look at the nationalisation of social care provision and its funding. This is not a Health and Social Care Bill; it is a health without social care Bill.
“The real choice is not between stability and change, but between reforms that are well executed and deliver results for patients and reforms that are poorly planned and risk undermining the NHS”.
Those are not my words but those of the chief executive of the King’s Fund. The Hippocratic oath says that we should “Do no harm”. The Bill fails that test. It aims at irrevocable change and threatens real harm, and that is the reason to oppose it in the Lobby tonight.
Mark Garnier (Wyre Forest) (Con)
It is a great pleasure to follow the right hon. Member for South Shields (David Miliband). I am delighted to be able to speak in support of the Bill, because I believe that it responds to some of the issues that have been affecting my constituency for the past dozen or so years. I want to focus on two elements of it in the relatively limited time available to me.
The first concerns the influence of GPs. Like many hon. Members, I hold constituency surgeries, and barely a week goes by without one of my constituents coming to me with an issue about the national health service. Few of my constituents understand the inner machinations of the NHS, but the vast majority of their complaints are directed towards hospitals and treatments, and the way in which treatment is commissioned. For those with some knowledge of how the system works, it is clear that the problems lie with one of the three organisations that serve Worcestershire—the acute hospitals trust, the primary care trust and the mental health partnership—and the way in which they interface with each other. However, what my constituents never complain about is their GP—[Hon. Members: “What?”] Well, they do not. Most of the problems lie in the fact that the chain of delivery of services is too complicated. For a GP to commission services for their patient, their wishes must cross not one but two organisational interfaces, at the very least. That does not make any sense. Anyone designing a complex system tries to instil the highest possible level of simplicity so that opportunities for mistakes are kept at a minimum.
My local GPs, far from fearing change, have welcomed and embraced the new proposals set out in the White Paper. When I met them last September, they had already formed a shadow consortium serving my constituents. They are enthusiastic to take on the responsibilities of commissioning, and they were disappointed not to have been chosen as one of the initial pathfinder consortia. That has now been remedied with the second tranche, with the Wyre Forest consortium being chosen to act as pathfinder.
It is in the second aspect of the Bill that I have a specific interest. Hon. Members will be acutely aware of the issues surrounding Kidderminster hospital and the changes that affected it in the early years of the previous Government. What started as a removal of blue-light services from our hospital ended up as a downscaling from district general hospital to a mere treatment centre with a minor injuries unit, although I must say that the treatment centre is now well liked locally.
At the time, there was huge protest at this outrage. Public opinion was dead against the downscaling, with local residents marching in force against it, a human chain being formed around the hospital to protect it and finally, and most dramatically, an extraordinary result in the 2001 general election when the people of Wyre Forest demonstrated their anger in the strongest way possible by voting at the ballot box to save Kidderminster hospital. But still they were not listened to, and the hospital was downscaled.
Shortly after I was selected as the candidate in Wyre Forest in January 2004, I arranged the first of many visits from the then shadow Secretary of State for Health, now the Secretary of State. I wanted him to come to Kidderminster to hear at first hand how angry local residents were at not being listened to. He came on many occasions and listened to the staff, to patient groups, to doctors and to nurses. Indeed, he has come so often that he is now on first name terms with the two matrons at Kidderminster. [Hon. Members: “Ooh!”] He is a very popular fellow, I can tell you. He has also been to other hospitals facing closure and downscaling, and he seems to have listened to them as well, because the second key element in this Bill is the proposal for local health and wellbeing boards and the local democracy that they will bring.
Frank Dobson
At a press conference this morning, the hon. Gentleman’s predecessor, Dr Richard Taylor, made it perfectly clear that he was utterly opposed to all these proposals.
Mark Garnier
I am grateful to the right hon. Gentleman for bringing that up. If my predecessor were that upset about the proposals, it would have been good of him to get in touch with his Member of Parliament and voice his concerns to me directly. He has not done that. He is, however, a man for whom I have a great deal of respect, and his views are worth listening to, although I would not necessarily agree with him on this point.
When I look at the Bill, I ask myself a fundamental question. If these provisions had been in place after 1997, would Kidderminster hospital have been downscaled? I am confident that it would not.
These proposals clearly have the full and enthusiastic support of my local GPs, who are willing, ready and able to take on these new responsibilities. I and they believe that the Bill will result in a more responsive NHS that listens to local people in delivering local solutions to local problems. Finally, I can say to my constituents in Wyre Forest, who are still angry because they thought that they were ignored for a decade, that they are being listened to, that it was the Conservative Opposition who listened to their plight, and that it is their anger at being ignored and the response to that anger that lie at the heart of the Bill.
Debbie Abrahams (Oldham East and Saddleworth) (Lab)
Thank you for calling me to make my maiden speech in this debate today, Mr Speaker. I am deeply honoured to have been elected as the Member of Parliament for Oldham East and Saddleworth in the recent by-election—the first woman MP for Oldham. The circumstances for the by-election were indeed unusual, and it is only right to mention that many constituents and colleagues from across the House have remarked on my predecessor Phil Woolas’s intellect, his incredible attention to detail and the kindness he showed to them. [Hon. Members: “Hear, hear.”]
My constituency is a beautiful place with a remarkable history. For example, it was not only where the Independent Labour party was born and where Winston Churchill started his political career, but where the suffragette Annie Kenney originated from. Oldham’s first parliamentary representatives were of course the radicals William Cobbett and John Fielden, and I intend to be equally radical in my own way.
As beautiful and as varied as my constituency is, what I care most about are the remarkable people. During the by-election, I met thousands of constituents from all walks of life, some of whom supported me and some of whom did not. Regardless of their political affiliation, however, they were invariably polite. Of course, there were one or two who chased me down their garden paths, but, fair dos, it was Christmas day! [Laughter.] Their tolerance and decency reflect something very special about our society: a social conscience that values fairness, treating people as they would like to be treated, while recognising that different people have different needs and merits. As we know, both intuitively and from research, fairer societies do better, and are better for everyone. Of course, all political parties have claimed that they are the party of fairness, but I think most people will agree that action speaks louder than words.
I promised the people of Oldham East and Saddleworth that I would stand up for them and fight against unfairness. I believe—there is increasing evidence to support this—that the Government’s policies are deeply unfair and, contrary to their assertions, unwarranted. As history has shown, Governments set the tone for the culture of a society. The tone being set by this Government threatens the country’s sense of fair play and social justice.
I asked to deliver my maiden speech on Second Reading of the Health and Social Care Bill because, as some people will know, my professional background is in health. I am passionate about the NHS. For me, it not only plans and provides our health services, but reflects the very values of our society.
In ’97, the NHS was on its knees. Staff were leaving in droves, and the level of spending on health was one of the lowest in Europe. Labour more than trebled investment in the NHS, enabling us to recruit more doctors and nurses and to improve access to care. Gone are the days when people waited two years or more for a hip replacement or to have their cataracts removed.
The shift to improving health, preventing illness and providing care closer to home has made real, positive differences to the nation’s health. The Bill threatens not just those developments, but the very future of the NHS. I have expressed my concerns in the past about the marketisation of our NHS, but the Bill is in another league—it is about the total privatisation of our NHS. Some fear that all that will be left will be the name.
Where is the mandate for that from the British people? We can all sign up to the Bill’s objectives, but there is no evidence to support the idea that the proposals will deliver better health outcomes. The reforms are based on the notion that increasing competition drives down costs and improves quality. However, the overwhelming evidence from the UK, the US and elsewhere, is that that is not how competition works in health care.
I have heard some Government Members ask, “What does it matter who provides our health care as long as it is free at the point of need?” I say to them that that does matter. I have seen how the decisions about which patients those providers treat are based on whether they are profitable or not; they are not based on clinical need.
The reforms will affect the choice of medicines prescribed, and what type of treatments are provided and what kind of patients are prioritised. Certainly, that will not mean those with complex conditions. Unprofitable patients can expect short shrift from this evolved NHS. At my surgery last week, one of my constituents, who is in remission from leukaemia, came to see me because she fears that the drugs that she has been prescribed will be unavailable under the new reforms. What am I going to tell her?
Abolishing primary care trusts as part of the costly NHS reorganisation is yet another broken promise from this Government. Putting £80 billion of the NHS budget into the hands of a few GPs who enjoy managing a business might sound liberating, but in my experience, the vast majority of GPs want only to care as well as they can for their patients. In reality, the commissioning of health services will also be done by private health care companies, and there are significant conflicts of interests when those companies are both commissioners and providers of care.
The impact on equitable access to health care is another real issue. The Bill does not require GP consortia to work together, which leaves the possibility of neighbouring consortia taking different decisions about services, giving rise to a new postcode lottery. By forcing those GP consortia to put all services out to competitive tender, the Bill encourages any willing provider to cherry-pick profitable slices of NHS services. The introduction of price competition for the first time is a disastrous step, with the potential to undermine the quality of patient care.
In public health, which is my field, I have little confidence that the move of the public health service to local authorities will lead to health gain. That depends on an independent and well-resourced public health work force. The Bill also fails to define what will be covered by the ring-fenced budget that is given to local authorities. Thank you again, Mr Speaker, for calling me.
Henry Smith (Crawley) (Con)
Before I begin my remarks on the Bill, may I say how well the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) made her maiden speech? I suspect that we disagree quite fundamentally on the future of the NHS, but one thing that is true of her and of all right hon. and hon. Members is that we want the very best health care for our constituents; we just disagree on the path that we take to get there.
A fortnight ago, I was privileged to speak on Second Reading of the Localism Bill. The hon. Lady spoke of the desire to be radical, but the Localism Bill is a radical measure that proposes to give power over the future of communities back to the people. The Health and Social Care Bill is very much in concert with the Localism Bill—and legislation on policing that is yet to be introduced—in giving authority, choice and power over the important services that people receive back to them.
Right hon. and hon. Members know that when we engage our electorates, they always—rightly and understandably—express certain priorities such as the future of our communities and law and order. Consistently, people are concerned about the future of health care. Health care is one of those great levellers. It matters not what one’s background is: we are all equally adversely affected when we do not have the right sort of health care available locally. The measures outlined in the Bill go a long way to giving back to people control over that most important public service, on which all of us and our families without exception rely.
I have spoken on many occasions to local GPs in my constituency. They are enthusiastic about their GP consortium pathfinder status. Already, they are brimming with ideas on how they can improve the patient experience in my constituency, which is broadly to be welcomed. Indeed, I have been heartened by the fact that many of my local GPs are enthusiastic about the democratic accountability that the Bill allows. My local GP pathfinder consortium wishes to be a health and wellbeing partnership pilot, working with Crawley borough council—the immediate local authority—and West Sussex county council.
Dr Poulter
I had the pleasure of working at my hon. Friend’s local hospital at Crawley. When I was there, I saw the downgrading of that hospital by the PCT—it lost more and more services. What discussions has he had with his local GPs on how they will improve and enhance services at the local community hospital and generally?
Henry Smith
My hon. Friend is indeed legendary at Crawley hospital, and it is great to take part in this debate with him. Unlike him, I do not have a health background. My wife used to work in the NHS, but my background is as a local elected representative of my community and as a patient, and as someone whose family has had experience of the NHS.
I am afraid that I shared the bitter experience of many in Crawley during the 13 years in which the Labour party was in government. On 1 May 1997, when Labour took office, Crawley had an A and E department and a maternity unit. I am sorry to say that in 2001, Crawley hospital lost the maternity unit. At the time of a rather joyous occasion for my family, it was saddening that my children could not be born in our local hospital.
Hugh Bayley
The hon. Gentleman champions localism, but has he picked up that maternity services will be taken away from GP consortia under the Bill? Is that a good thing?
Henry Smith
I dispute that reading of the Bill. Maternity was taken away from my local community in 2001 and is now 10 miles up the road, in another county, and accessible only by single-carriageway roads, which is at best inconvenient, and at worst dangerous for patients.
The sorry tale goes on. In 2005, under Labour, Crawley hospital lost its A and E unit to East Surrey hospital—10 miles up the road, in another county—which has been seriously detrimental to my constituents, and something that they and I very much regret.
I was struck by many of the comments of my hon. Friend the Member for Wyre Forest (Mark Garnier), because he mentioned things very similar to our experiences in Crawley—and listening to other right hon. and hon. Members, there seem to have been similar experiences across the country as well. I can speak only from my local experience, but there was an eerie resonance in the sort of downgrading of services under the Labour Government.
Geraint Davies
Does the hon. Gentleman accept that what his community, like other communities, will face is a local monopoly—the GP consortia—that will focus on the most profitable lines of treatment, rather than on the best treatment? Surely this is not the right direction.
Henry Smith
I do not see how multiple providers is a definition of a monopoly. However, I must make progress in the short time left to me.
My constituents are pleased that for the first time in many years health decisions will be made in Crawley, rather than, as has happened up until now, on the south coast, in east Surrey or up in Whitehall, and that more decisions will be made by local people.
Henry Smith
I am sorry, but I have not got enough time.
I will support the measures in the Bill, as should all right hon. and hon. Members. However, I would like briefly to ask for clarification on two points from those on the Treasury Bench. First, hospices are greatly valued in our local area—on Friday, I was privileged to visit the Chestnut Tree House children’s hospital, which serves my constituency—so some clarity over future support for hospices would be greatly appreciated. Secondly, I would also like an assurance that the merry-go-round of failing managers in our acute sector will be addressed. I regret to say that on new year’s eve, at East Surrey hospital—the acute hospital for my constituency— 14 ambulances were queuing to get into accident and emergency. That is not good enough. It is another area of the sector that needs to be reformed.
Forgive me, Mr Speaker, because in the seven seconds I have left, I would like to report that there is well-being in Crawley today, because they are due to play at Old Trafford in about three weeks’ time.
Grahame M. Morris (Easington) (Lab)
One thing is clear: from whatever perspective we consider the reforms in the Bill—whether from that of Charnwood or Holborn and St Pancras—there is a serious and worrying lack of evidence base for the Government’s proposals. These are proposals identified by the King’s Fund as without doubt
“the biggest shake up of the NHS since it was established”.
While the Health Secretary was the Conservative party’s shadow health spokesman—from June 2004 until he took office in May last year—he was coy about his real intentions towards the NHS, as indicated by my right hon. Friend the Member for South Shields (David Miliband). When the Government published the Bill, six major health unions and professional bodies wrote in a letter to The Times:
“There is clear evidence that price competition in healthcare is damaging. Furthermore the sheer scale of the ambitious and costly reform programme, and the pace of change, while at the same time being expected to make £20 billion of savings, is extremely risky and potentially disastrous.”
Labour Members welcome greater clinical involvement in commissioning, but GPs are not the sole font of knowledge in best practice and other areas.
Catherine McKinnell (Newcastle upon Tyne North) (Lab)
Does my hon. Friend agree that in any one year some GPs will deal only with one or two patients with, in particular, a neurological condition? GPs might not be in the best position, therefore, to be the providers and commissioners of such services.
Grahame M. Morris
I agree completely with my hon. Friend’s point. According to evidence given to the Select Committee on Health, specialists in secondary care and the nursing and other professions could add their expertise to the commissioning process.
The shake-up of the NHS goes far beyond simply involving clinicians in spending decisions. GP commissioning is a red herring. We were told by the Secretary of State that these reforms are needed because productivity has fallen since Labour’s increased investment. However, after 18 years of mismanagement and under-investment under the Conservative party, it was obvious that on a crude measurement of productivity—inputs versus outputs—there was going to be a decline in supposed productivity, because obviously money had to be directed towards clearing up the mess left by the previous Tory government, to building new hospitals, accident and emergency units and maternity units, and to reducing waiting lists, which in many areas of the country were 18 months and longer.
The Secretary of State raised the satisfaction survey. Indeed, in December 2010, the National Centre for Social Research released its most recent report on British social attitudes. It found that public satisfaction with the NHS was at an all-time high, whereas in 1997, when Labour came to power, only 34% of people surveyed were satisfied with the NHS—the lowest level since the survey began in 1983. By 2009, satisfaction had nearly doubled to two thirds—to 64%. Given that most health unions, professional bodies, think tanks and the public did not call for such reforms, where did the Secretary of State’s motivation come from? These are not patient-led reforms; they are private health care-led reforms.
Pat Glass (North West Durham) (Lab)
Does my hon. Friend share my concerns that these plans will lead to high and low-tariff services, and cherry-picking, and that services such as child and adolescent mental health services, children’s health services and adult mental health services will lose out?
Grahame M. Morris
I agree with the concerns expressed by my hon. Friend. There are concerns about the removal of the tariff floor and the introduction of price competition into the service. That is radical and revolutionary; it is not evolutionary. Rather than open-market health care, the British Medical Association and others are calling for a
“cooperative and coordinated environment where patients are guaranteed the most clinically appropriate and cost-effective care. Price competition and a fully open market will make this impossible.”
Clause 63 allows the Secretary of State to impose requirements on consortia to promote competition between providers, and clause 64 makes it possible for Monitor to investigate any complaint of anti-competitive behaviour made against commissioners by any interested party. That might be a third party or an overseas private health care company, and would make it far more difficult for GPs to ensure that their patient services are integrated, inclusive and carried out in partnership. The Bill also forces trusts to achieve foundation status within three years and will lead to more important priorities, such as safe patient care, being compromised. Furthermore, the abolition of the private patient income cap set out in clause 150, removing the limit on the amount of income foundation trusts can earn from private operations and private health care, will create a two-tier health system. Foundation trusts forced into the market without protection will face financial pressures to turn a profit, and NHS patients will risk being pushed to the back of the queue.
To my mind, and according to evidence submitted to the Health Committee by the Royal College of Nursing in which it identified 27,000 nursing posts that will go, these reforms will result in tens of thousands of job losses and undermine national terms and conditions for NHS staff. The scrapping of targets has left the NHS open to a dangerous postcode lottery. The duty to tackle health inequalities is one of the few remaining powers to be held by the Secretary of State, but he will have nothing to back it up.
There is also no protection for the taxpayer from exorbitant and excessive behaviour by the consortia, an issue raised by my hon. Friend the Member for Blyth Valley (Mr Campbell). It is possible that we will see banker-style bonuses and the import of private sector pay into health care. [Interruption.] The Minister moans from a sedentary position, but there is nothing in the Bill to prevent that from happening. The Bill will also leave us, as Members of Parliament, with no voice in the NHS. This Tory-led Government seem to be trying to de-risk this political hot potato, which the Conservatives have never been able to manage properly. However, if Ministers think that the British public will allow them to wash their hands of the NHS without any comeback at the next general election, they should prepare to be shocked.
I would like to say one more thing in the time left—now that the hon. Member for St Ives (Andrew George) is back in his place and given what the hon. Member for Burnley (Gordon Birtwistle) said—about the combined impact assessment. I have received a letter from a GP saying that the practical significance of the Bill will be such that the many MPs who campaigned to save their local hospitals cannot vote for it in all honesty, knowing that in so doing they will be voting for a measure that is purposefully and expressly designed to prevent them from having any say and which will potentially lead to the very outcomes that they so vociferously campaigned against.
Nadine Dorries (Mid Bedfordshire) (Con)
I rise to support a Bill that I believe is perhaps one of the most exciting, if controversial, Bills to have been put before Parliament in the 62 years since the NHS was established. It is a fact that a resident in this country today is twice as likely to die from a heart attack as a resident in France. In this country, we also fail to reach European averages for stroke care. In fact, 4,000 stroke victims a year lose their lives because our NHS is not up to European standards in stroke care. If we delivered trauma care slightly differently, we could also save 600 more lives a year, but we do not. Those figures alone show that it is now time, 62 years since it was established, for the NHS to be modernised.
In those 62 years, drug research and development have advanced hugely. Medical technologies have advanced in a way that could not even have been imagined 62 years ago. As a result of the internet and the information now available, patients expect and demand to have a say in how their condition is managed. They want more information and they want to discuss their care with their GPs. The Bill will put the patient right at the heart of the NHS, and that is why I so passionately support it. The central tenet of the Bill is: “No decision about me without me”. It will ensure that, for the first time, each and every patient can almost become their own lobbyist, sitting in front of their GP and discussing their condition and treatment in an open way, where they have information and the GP will have to engage with them. That does not happen today, and certainly not in hospitals.
I would like to give an example—something that I heard about this weekend from a patient—that clearly epitomises why the patient has become invisible in the NHS today. That patient was in hospital at the weekend when a doctor walked up to him, lifted his arm, took blood, put his arm back down and walked away without saying a single word to him.
Catherine McKinnell
It strikes me that despite what the hon. Lady is saying about the patient becoming the heart of the NHS, it will instead be the GP who becomes the heart of the NHS. Is she suggesting that the GP will be in the hospital with that patient to hold their hand at every stage of their treatment?
Nadine Dorries
I wish that that had been a more sensible question, because then I would have been delighted to give the hon. Lady an answer.
That patient was in hospital when the doctor walked up, took blood and put his arm back down without even a word of acknowledgment. A nurse then came and put his tray of food at the end of the bed. The patient was attached to a heart monitor and a drip, and could not reach the food. The patient was distressed, vulnerable and in pain, yet he was invisible to the health care professionals who were treating him. He was invisible because what is important in today’s NHS is the process—the management, not the patient. The humanity of the patient has almost been lost, and there is no way to put it back into the NHS other than to tip the understanding of who is important in the NHS on its head. The Bill does that in a way that has never been done before and which is now needed.
Anne Marie Morris (Newton Abbot) (Con)
One of the concerns that I have come across is from health professionals who would be delighted to see red tape removed. I have spoken to directors of nursing who spend more time on red tape than they do with their patients, and they are deeply frustrated. Does my hon. Friend agree?
Nadine Dorries
Absolutely, and the Bill will address that, in as much as care will be more easily accessed by the GP and the patient, in a much more streamlined process.
When nurses sat their medical exams 62 years ago, when the NHS was first established, the answer to each question had to begin and end with the words: “Reassure the patient”. It did not matter what someone said in the answer; if they did not emphasise the fact that the patient had to be reassured, they failed. That has gone. That demonstrates exactly how the patient has become invisible in today’s NHS.
I support the Bill because I support GPs working in consortia. A common myth—an urban myth—that we have heard in the few weeks leading up to this debate, and which has been thrown at us from the Opposition Benches, is that GPs are simply not up to the task of becoming business managers. The truth is that they already are business managers, because they all manage their own businesses. They will not be working as individuals or in individual practices; they will be working as part of a consortium, which is quite different from the impression given by the Opposition. Right now, 141 pathfinder consortia are demonstrating that they are ready and able to take on commissioning, and that they endorse patient involvement in the decision-making process. As a result of the “any willing provider” provisions, there will be a genuinely wider choice of care options available to the GP and the patient.
I would like to rebut the argument that the private sector will come in and undercut the NHS. That is complete nonsense. There will be no undercutting of the NHS whatever. Services will be—[Interruption.] I can only say that Opposition Members have not read the Bill, because there will be a tariff. Charities and the private sector will be able to provide services, but with a tariff. I shall give an example. If a patient requires a surgical procedure, which they discuss with their GP, and the local hospital has no bed available for six weeks, two months or however long, but if the local private hospital can provide a bed the next morning at the same price, are the Opposition really saying that an ideological obstruction should be put in the way of that patient being admitted to that private bed for that procedure the following day?
Nadine Dorries
I cannot, because I have given way twice and I have no more time.
If that patient were in pain, why should they not be admitted into that bed if it were available? That is how the market will be opened up by GPs, to the benefit of patients.
We recently heard from my right hon. Friend the Prime Minister about an extra £60 million that will be available to fund the latest bowel cancer screening technology, with wider deployment of the flexible sigmoidoscope. That does not need to be provided in secondary care in a hospital; it could be provided in the GP practice under the “any willing provider” provisions, perhaps via charities with specialised trained technicians. The Bill will ensure a new approach to providing services to the patient. “Any willing provider” will give patients the choice that they have not had for 62 years, empowering them to make decisions over that choice and opening up health care that patients in this country have not had, certainly for the past 15 years. With new technologies coming on stream and new ways of delivering care, both in the patient’s home and in the GP practice, that has to be welcomed. The Bill has to be welcomed, and Government Members will vote for it because the most important person in the Bill is the patient. That is why I support it wholeheartedly.
Hugh Bayley (York Central) (Lab)
The Government White Paper said some sensible things: it promised to increase NHS spending in real terms, to improve patient choice, to devolve decision making, to reduce management costs and to hold doctors to account for their clinical outcomes. Indeed, the objectives are very similar to many of those of the former Labour Government. The problem, however, is that the Bill will undermine many of those good aspirations.
Health spending is, as we know, falling because the amount by which the Government increased the NHS budget is lower than the rate of inflation. [Interruption.] For my health authority, it is 0.3% lower than the rate of inflation. Patient choice will remain limited to where GPs choose to commission services. Centralising many services under the NHS commissioning board—a new layer of bureaucracy—means that NHS dentistry, community pharmacy, optometry services, regional and sub-regional specialties and, indeed, some more complicated local services will be commissioned at national level by that board rather than at local level by a primary care trust, as in the past, or by a commissioning consortium in future.
I am sure that the Government will try to reduce NHS management costs. Every Government since the creation of the NHS have sought to do so, but this Government need to explain how creating 500 or 600 commissioning consortia—each with the skills to commission services—will cost less than the 150 PCTs that currently do the job. They are likely to lose economies of scale and the decisions taken could well lead to the fragmentation of some services such as dermatology or pathology. Such services are currently commissioned by a PCT for the whole PCT area, but in future could be commissioned in three or four different ways by different consortia. Small, less well resourced GP commissioning consortia will, I believe, be less effective than PCTs and strategic health authorities in controlling the costs of powerful hospital foundation trusts.
The Government are right to stress the importance of measuring clinical effectiveness and outcomes, but that makes it extraordinary that they have put primary care in the driving seat. We know a lot about the work of hospital doctors from the hospital episode statistics, but there are no national data on GP consultation rates or the thresholds they employ before they intervene with treatment or on GP outcomes, yet GPs are being put in charge of demanding this from everybody else.
Running through the Bill is the idea that transparency and accountability will drive up performance, so here are some questions to the Minister, which I hope he will address in his concluding speech. The Bill is designed to reduce health inequalities, yet there are enormous inequalities in GP services. Some GPs are very good; others less so. There are differences in their prescribing and referral rates, so how are the Government going to measure GPs’ clinical performance? How will a GP commissioning consortium hold erring GP practices to account? What sanctions will be employed?
How will patients hold their GPs to account for their commissioning decisions? We are, of course, familiar with GPs being sued for bad clinical decisions, which is why they take out medical insurance and have to pay increasingly more for it each year. Will patients sue their GPs for bad commissioning decisions? How will the consortia hold hospitals to account?
How much will the GP commissioning consortia receive in management allowance per patient, because the Government’s success in making administrative savings will depend on that? What sanctions will be imposed on a GP commissioning consortium to ensure that it commissions effectively and uses a good evidence base for its decisions?
The Government tell us that PCT deficits will be written off before the consortia take over, but what help will the commissioning consortia get in areas such as mine where there has been a difficult structural deficit—brought into balance by the previous Labour Government, but out of balance once again under the new Administration—to stop them falling into deficit? What will happen if they do go into deficit? Will their budgets and the services they provide to patients be cut as a result?
Mr Dorrell
The hon. Gentleman is making a thoughtful speech and asking, if I may say so, some very good questions, with all of which I agree. There is an implication behind his speech, however, which is that if all those questions can be answered, as I hope and believe they can, he will support the Government’s policy. Is that implication correct?
Hugh Bayley
If I were convinced that they could be answered, I would indeed support the Government, but unfortunately I am far from convinced that it is the case.
Let us take another issue. The Government are providing a lesser increase in funding to the NHS this year, which amounts to a cut in real terms when the rate of inflation is taken into account. They think they will get away with this because the NHS staff wage bill is being frozen for a two-year period. What thought have they given to the wage bounce that will inevitably come in two years’ time? There will be enormous wage pressure on the NHS budget; are the Government intending to increase it significantly at that time?
Mr Dorrell
I am anxious to provide the hon. Gentleman with extra minutes so that he can tell us whether he approves, in principle, of the idea of practice-based commissioning, which was originally introduced by the previous Government?
Hugh Bayley
I certainly do not agree with the way in which it is being introduced. The right hon. Gentleman will probably know that before the last election, I made a proposal to strip out one level of NHS bureaucracy—the PCT level—and do commissioning where it was needed at the SHA level. That would have achieved administrative: savings. Instead of that, however, the Government have decided to replace 150 bureaucracies—PCTs as commissioning bodies—with some 500 or 600 bureaucracies: the GP commissioning consortia. I do not think that that will achieve administrative savings. With the NHS budget so tightly squeezed by the current Government, if more money is taken away to meet the costs of bureaucracy, less money will be available for treating patients. That is the crux of the issue.
I believe that those are some very serious questions, which the Government need to answer if they going to convince the public of their plans. There is an intellectual incoherence in many of their proposals. They have not looked either at how some of their goals—on patient choice, for instance—might conflict with other goals such as increasing efficiency. Will a doctor be able to insist that patients have the most efficient treatment even if they do not choose that option themselves? Would it not make sense to pilot these changes before imposing them, untried and untested, on the NHS?
Sarah Newton (Truro and Falmouth) (Con)
Thank you, Madam Deputy Speaker, for calling me to speak in this most important debate. The scope of the Bill is far reaching and other Members have covered many aspects in their contributions, so I want to focus on one area—that of the future governance of the NHS.
The Secretary of State has identified a powerful and simple concept that resonates with people across the country—that “No decisions taken about me should be taken without me.” While this concept is usually applied to the individual relationship between the patient and clinician, I believe it is just as applicable to the communities that the NHS serves in any particular area.
As we have seen from campaigns across the country, people do not want decisions about the health and care services available to them in their community to be taken without the opportunity to get involved in the decision: “No decisions about us without us.” Over the last few years, I have seen the lack of openness, the lack of transparency, the lack of consultation and the consequent fear and suspicion that that brings.
I realise that not everyone will want to become involved in local decision-making and that many are happy to leave it to others, but I believe that we are right to enable more resilient and empowered communities to shape their own futures. Giving more power to the people is as important in the context of decisions about health and well-being as it is in the context of decisions about planning, homes and the environment.
The Bill is nothing short of a revolution in terms of the devolution of decision-making power to people in their communities, accountability, and the governance of health and care services. First, it links two crucial services. For too long the separation of those services, and the silo mentality governing the care delivered by local authorities and health services commissioned by primary care trusts, have prevented care pathways from being developed effectively in a way that works for the patient, which has often closed off the vital role played by families, carers and volunteers in supporting people. There cannot be a Member in the House who has not had personal experience of that, or shared the experiences of elderly constituents who have been bundled around the system, described as bed-blockers and made to feel a burden.
Of course, in some parts of the country health and care services have been integrated, but they are in the minority. The Bill, and the money that the Government are making available to help fund the integration, will enable all parts of the country to develop the high-quality, joined-up services that are currently available only to a few.
Stephen Lloyd
I agree with much that my hon. Friend is saying about integration and the need to work with the community, and I applaud many of the changes made by the Bill. For years we have all talked of using pharmacists in a smarter way. Does not the Bill provide an opportunity for much more integration of community pharmacy with the consortia, and for the Government to support the consortia in that endeavour?
Sarah Newton
As someone who represents a rural area of Cornwall where GPs’ delivery of pharmaceutical services is vital, I think that that is an extremely good idea.
Secondly, the new responsibilities of Monitor and the Care Quality Commission will make possible independent regulation of both quality and safety of care and value for money. I have observed the problems that have occurred in recent years when managers have evaluated their own compliance with standards. Good decisions can be made only with sound evidence. The powers of the National Institute for Health and Clinical Excellence and the Information Centre will be enshrined in legislation for the first time, and their independence from Government will thus be guaranteed.
Thirdly, the Bill creates a new role for local authorities in public health. Directors of public health, jointly appointed by Public Health England and local authorities, will play a leading role in the discharging of authorities’ public health functions. Arguably, it was the initiatives of local authorities in past centuries—such as the introduction of fresh water, drains, sewage management and the controlling of vermin—that led to some of the most significant improvements in life expectancy.
Anne Marie Morris
Is not one of the real strengths of making public health part of the role of local government the fact that housing, which is a critical issue to public health, can be viewed in the round?
Sarah Newton
I entirely agree with my hon. Friend, who has anticipated a point that I was about to make.
The returning of more responsibility to local authorities—along with the considerable social determinants of health for which they are already responsible, such as the availability of good-quality housing and the regulation of places of work, environmental health and leisure services—has the potential to improve health outcomes, and to close the ever-widening gaps in health equalities in this country.
The Bill will ensure that every upper-tier authority establishes a health and wellbeing board consisting of the director of public health, GP consortia, children’s services, adult services, care providers from all sectors, and local health watch organisations. Such boards should provide local leadership and a strategic framework for the co-ordination of health improvement and the addressing of health inequalities in their areas. The joint strategic needs assessment will be integral to the process, and will influence the commissioning of services. The local health and wellbeing boards will, in effect, hold the ring when it comes to the health and care services provided in their communities. Local authorities will maintain and extend their role as scrutineers of all services, whether they are commissioned locally or nationally and whether they involve health or social care. They will also be able to commission complaints and advocacy services from any provider, rather than just from the local or national health watch.
The Local Government Association has warmly welcomed the proposed changes. The best local authorities have good experience of working with public, private and not-for-profit organisations as well as the charity sector in delivering integrated care. They are used to planning person-centred and personalised care.
I believe that—along with the changes that the Secretary of State has already made to the operating framework of the NHS in relation to the reconfiguration of services—the Bill, when effectively implemented in communities across the country, will lead to greater openness, greater accountability, and greater confidence for all those working in health and care, as well as for the ordinary people up and down the land who have lost so much confidence in the way in which decisions are made. These changes will take time, but I am confident that within the next four years, when we ask the people of this country, “Do you feel that decisions are being taken about you and with you?”, many more people will say “Yes” than would do so if asked that question today. That is a result that I shall be proud to have played my part in achieving.
Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op)
As we have already heard today, the public love the NHS. and they are right to do so. Of course it is not universally perfect; of course there are times when it does need reform; but it is still something of which we are right to be proud, and we should not be proud of it just from a moral standpoint.
As economists of many different political persuasions have shown, a centrally funded NHS is a far more efficient way of providing a system of health care than the imperfect market of a system of health insurance. We need only look to America, where, until the recent reforms, more than half all personal bankruptcies were caused by people who were unable to meet their medical bills, to recognise how decent and effective our system of health care really is.
That brings me to the main point that I want to make. In my view, these proposals do not represent an evolution in the NHS reforms of the last Government. The principal goal of the Bill—to transfer commissioning from PCTs to GPs—is, in fact, a dangerous gamble with one of the country’s most-prized institutions. Bringing GPs closer to decision-making did not require the wholesale dissolution of PCTs and the transfer of their responsibility to GPs. When the Government promised no further top-down reorganisation, they should have meant it, because this reorganisation is ill judged and ill advised, as is spending the £3 billion that it will cost. However, now that they have embarked on this revolution, they should be aware of what has come about as a result of it.
Throughout the country, there is a pressure cooker of discontent in the primary care sector as PCTs struggle to balance their budgets and hand over what, on paper, will appear to be their stable financial footing. In order to do that, many have already implemented restrictions on procedures, described in the jargon as “procedures of limited clinical value”. I assure Ministers that they are not of limited value to people who are suffering and in need of care. In a number of areas, PCTs have asked GPs to suspend all but urgent referrals to secondary care. This prompts us to ask what kind of health service GPs will be inheriting. Patients are suffering now as a result of the actions of this Secretary of State.
I also fear that the commissioning of specialised services will create a real gap. For all the faults that some may ascribe to them, PCTs ensured equity for those who, if commissioning had been done on a smaller scale, would have struggled to have had their voices heard. There is a real question of scope here. Many GPs simply do not have sufficient sight of some types of work to commission effectively. The provision of mental health services is a particular concern. As ever with this Government, it seems that the most vulnerable will be most at risk.
If GPs really are better placed to commission services on behalf of patients, why were there shortages of flu vaccines this winter? GPs were responsible for ordering those vital supplies. They had the medical records of the people in their areas; they had the information that they needed in order to make effective provision. In my area it was the local PCT that remedied the situation, but who will be there to do that in future? GPs already have to balance financial and medical considerations. Have they really proved that they can do so effectively?
Finally, we must look at what exactly GPs will be expected to do and how they will go about doing it. In all the contracts they award, someone will have to monitor financial and clinical governance. That requires expertise, which GPs will have to buy in. Who will evaluate the tenders for services and deal with contractual issues? That will require yet more expertise to be brought in. Once we consider all that PCTs do across a wide geographical area, we see that GP consortia doing the same thing over a smaller area will result in an army of consultants, private companies and ex-PCT staff being contracted in by the consortia. We will, in effect, have the expense of PCTs as they work on the same things as now, but without the accountability and economies of scale currently enjoyed. Alternatively, GP consortia might achieve these economies of scale, but they will do so by ceasing to be the community-based practices with which we are all familiar. They will become faceless corporate entities, where doctors will be salaried members of staff with no connection to a specific practice or locality. That might be the Government’s intention, but it is not an evolutionary change to the NHS.
I do not wish to be entirely negative, because there are parts of the Bill—these do not deal with changes to commissioning—that I have to be more positive about. I welcome the ongoing commitment to patient choice, as I have never believed those who say that the public do not want to choose which NHS facilities they wish to use. As with other public services, the NHS must reflect the autonomy people now expect to be able to exercise over their own lives. I also welcome a stronger role for local government in scrutinising health outcomes in their area, provided that that is a real power, not a symbolic one, entailing the ability to force changes when outcomes are not good enough.
However, those are small consolations when we consider a Bill that risks the very future of the NHS as we know it. This is a poor Bill, which has been rushed out without scrutiny and which lacks a democratic mandate. It is not so much a hand grenade thrown into the national health service, as a commercial demolition designed to break the NHS as we know it in order to serve a set of interests which are—
Jonathan Reynolds
I am not going to give way. Other hon. Members wish to get involved in this debate and it is a disgrace that we have only one day to discuss this.
This Bill will break the NHS to serve a set of interests that are not those of NHS patients, not those of NHS staff and not those of my constituents. It is for those reasons that I shall vote against it today.
Mr John Baron (Basildon and Billericay) (Con)
I rise to support the Bill, because I support the two big ideas behind it. The first of those is the increased focus on outcomes, which is long overdue and very welcome. For those who suggest that there is no need to improve the NHS or to worry about the issue of outcomes, I shall just highlight this country’s relatively poor cancer survival rates—as some hon. Members will know, I have a particular interest in cancer. Improvements have been made over the years, but those improvements go back over 30-odd years and other countries have improved, too. This country still flounders in the lower divisions of the international cancer league tables, and that situation has to be wrong.
The all-party group on cancer focused on that issue in 2009, finding that patients who reached the one-year survival mark in this country stand as much chance of getting to the five-year survival point as patients in other countries, but that our one-year survival rates are very poor indeed compared with those of other countries. That tends to suggest that the NHS is as good as others, if not better, at treating cancer once it is detected, but very poor at detecting cancer in the first place.
Part of the problem is in the area of early diagnosis, which is why we recommended focusing on one-year survival rates. We suggested introducing an outcomes benchmark that focuses the NHS on the one-year survival rate, because late diagnosis makes for poor one-year survival figures. If we can get the NHS focused on that, many patients will benefit. Therefore, we are delighted to see that both one-year and five-year benchmarks have been introduced in the outcomes framework for 2011-12. We very much welcome that, but I believe I am right in saying that the 2011-12 outcomes framework covers only colorectal, lung and breast cancer. We have lots of data for other cancers, such as prostate cancer, and I urge the Government to think seriously about extending the cancer types covered in the 2012-13 outcomes framework. The risk is that if we do not do so and we include just a narrow range at a national level, that will make for a lack of priority at the GP level.
As for GP commissioning, bringing commissioning decisions closer to the patient has to be a good idea; patients have got to benefit from that. Some people say, “GPs see only about eight new patients a year. What could they possibly know about commissioning cancer services?” I would turn that around by asking how many cancer patients the chief executives of primary care trusts see. They are commissioning cancer services at the moment. That point needs to be discussed.
Owen Smith (Pontypridd) (Lab)
Given the hon. Gentleman’s interest in cancer, I am sure that he will know that the point is that the cancer networks often aid commissioners at all levels in providing this care and they are dissolving before our eyes right now as a result of these changes. GPs will not have the experience to commission care in respect of rare tumour types.
Mr Baron
I agree with the general gist of what the hon. Gentleman is saying, but I would not say that the cancer networks are dissolving. I have raised this important point many times in the House—perhaps he was not in the House when I intervened on the Secretary of State—and what I would again ask my Front-Bench team about is the funding gap. I understand that the funding for the cancer networks ends in 2012 and there is a gap until the GP commissioning takes full effect. The answer given to me from the Dispatch Box today was that the national commissioning board will be up and running by 2012. The problem with that answer is that the national commissioning board will give guidance but the arrangements for the people who will actually make the commissioning decisions, the GPs at the front line, will not be truly effective until 2013 at the earliest—that will probably happen in 2014.
The worry is that in that gap a lot of expertise could be lost to the cancer community as a lot of expertise within those cancer networks decides to walk out of the door. I again ask the Government whether there is any way in which we could bridge that gap in order to ensure that GPs are better able to make informed decisions about the commissioning of cancer networks, because those networks contain an awful lot of expertise that we would not wish to lose.
I am fated to ask that question of the Minister of State, Department of Health, my hon. Friend the Member for Chelmsford (Mr Burns) again, as we are fated to discuss the issue. I appreciate that cancer is not his specialty, but I would like to get an answer on that point. There is a difference between the national commissioning board taking responsibility for guidance and the GP consortia actually taking responsibility for the commissioning. That point has to be addressed carefully, because various cancer charities have already reported that some 50% of the staff of cancer networks are thinking of leaving or have been told that they will be leaving within the next 12 to 18 months as part of a cost-cutting exercise. We need to address the point sooner rather than later.
In the remaining minute allowed me, may I quickly discuss eye health? I am wearing my hat as co-chair of the all-party group on eye health and visual impairment. I welcome the clauses that place primary ophthalmic services with the national commissioning board, which is likely to devolve enhanced optometry services to GP commissioners. That is the right decision and those working within the medical profession welcome it. However, I suggest two areas where we need to establish a national system. The first relates to glaucoma referrals under the NICE guidelines and the second relates to community-based acute services—in other words, those managing red eye and minor eye problems. The Secretary of State visited the school of optometry in Cardiff and, apparently, he liked what he saw. Can we ensure that those national guidelines are in touch, because otherwise we get a fragmented service and patients may suffer as a result?
In conclusion, I welcome this Bill, which could be transformational, particularly with its focus on outcomes. The Government will therefore have my support in the Chamber tonight.
Clive Efford (Eltham) (Lab)
This is a very dark day for the future of our national health service, particularly for those who have spent most of their political lives campaigning for and supporting the NHS. Some of us remember what 18 years of Conservative government did—the hospital closures and continually increasing waiting times that patients had to endure. One of the first cases that came through my door when I was newly elected to Parliament was that of someone who had been waiting 18 months for open-heart surgery. His wife came on his behalf, pleading for something to be done. I am pleased to say that he was treated under a Labour Government and that he is still alive today.
In contrast, this is a good day for those who have always hated the national health service. I remember a former Tory MP, Matthew Parris, who became a journalist, going on TV at around the time of the 1997 election and being asked, “What is it about the Conservatives and the NHS?” He replied, “It is quite clear—they hate it.” They hate the idea that they pay taxes and that the “undeserving poor” get equal treatment in the NHS, and they do not accept that people should be treated according to clinical need. That is why they continually chip away at the NHS. I do not blame the Tories, because they are just doing what Tories always do to the NHS, but when people went to the ballot boxes and voted Liberal Democrat in the last general election, they did not vote for the destruction of the NHS.
Many Government Front Benchers have campaigned against hospital closures, but the impact assessment for the Bill clearly states that Members of Parliament and local councillors should not be allowed to influence any decisions about hospitals in future. The Under-Secretary of State for Health, the hon. Member for Guildford (Anne Milton), looks surprised, but that is in the impact assessment. Did she not read it? No wonder the Government did not publish it until last Thursday. It says that anyone on the Government Benches who campaigned at the last general election to keep a hospital open will be prevented from influencing decisions in the future. In order to secure a market and prevent it from being unduly influenced by political interference—in order to create a fair marketplace—politicians will be denied the opportunity to influence what is going on. That is in the Bill and the impact assessment. Before any Liberal Democrat votes tonight, I urge them to check that impact assessment, because if they do not, they will be voting for something without appreciating what is coming down the road.
I fully support the idea that GPs will be champions on behalf of their patients, but I am sure that the measures will be a bit of a curate’s egg in that respect. Howard Stoate, a former colleague of ours, supports GP commissioning and I have no doubt that if I were his patient I would be very pleased to have him as my GP, but unfortunately not every GP is a Howard Stoate. The issue with what is going on and what is being changed here is that GPs will not perform in the same way across the board. We saw that with the Tomlinson review and GP commissioning before—a lot of them became property developers. They top-sliced capital money, developed their properties, sold them off at a profit and moved down the road. We have seen all this before.
Clive Efford
No, I am not going to give way.
What about the idea that there will be patient choice and that patients will have some idea of where to go? Are we going to get all the information about private sector providers? Are they going to publish their performance data in the private sector when patients are making up their minds whether to use them or not? I suspect that we will get what we got before with these sorts of changes—commercial confidentiality; we will be told, “We can’t possibly tell you that because that would harm our performance in the marketplace.” That is what we got before and I do not doubt that we will get it again.
Let me address the comparisons that we have heard from Ministers.
Clive Efford
Members can just sit there and listen. [Hon. Members: “Give way!”] They put this ridiculous Bill up—they can sit there and listen.
The comparisons that we have had from the Government about performance on heart disease and cancer involve the selective use of statistics to try to prove their point. The Appleby review clearly states that on current trends, by 2012—[Interruption.] I am not reading my notes; I do not know whether the Minister has noticed. Appleby states that by 2012 this country’s performance in relation to a number of cancer treatments will exceed that of France, which in 2008 spent 28% more than us, as a proportion of gross domestic product, on health. We have only just reached the European average in terms of expenditure on the national health service and, as other hon. Members have said, it is time to let the NHS bed down. The time for change is not now. We should allow that expenditure to have the effect—
Mr Steve Brine (Winchester) (Con)
I should like to say that it is a pleasure to follow the hon. Member for Eltham (Clive Efford), but I think that those watching the debate can make up their own mind about what they have just heard. I speak as a Conservative who loves the NHS; I am sorry to disappoint the hon. Gentleman in that regard. His comments were a great example of the knockabout that we hear in the House, which the public hate so much. I remind him that every day people die, work in and love the NHS, and they deserve better than what we have just heard.
As ever, time is short, so I will not detain the House. I want to focus on the fight against cancer and to share with right hon. and hon. Members the way I view these reforms. The Bill promises to take day-to-day power and responsibility out of the hands of Ministers and managers and to put it firmly into the hands of GPs. This means that decisions about NHS care will move closer to the patient and away from the remote organisations of which few people whom I and others represent have heard. Even fewer of those people would have the first idea what those organisations do, let alone how to contact them.
In an extremely tough financial climate, even for the NHS, we are talking about removing the bureaucracy of the primary care trusts and strategic health authorities and investing that money in patient care. As I have said in my constituency more times than I care to remember, I am concerned only about protecting the services that my constituents rely on. If they are threatened, I will dust down the placards, but I am not going to rummage around in the shed for one that reads, “Save the PCT”; I do not think that “Save NHS Hampshire” trips off the tongue.
The concept of reforming our NHS so that services and decisions come closer to patients is not one that I find disturbing, and I wish that we could at least start the process of debating this Bill by agreeing on that. However, nothing I have said thus far means that I and many others do not have questions about the next few years as we move to full GP consortia commissioning. Some Members will know that I co-chair the all-party group on breast cancer. We have worked hard since the publication of last year’s White Paper to produce a response. In October we held a health inquiry session at Breakthrough Breast Cancer’s “Westminster Fly-In”. Breakthrough’s CAN members and parliamentarians highlighted the breast cancer patient perspective and focused, as ever, on our vision of a future free from the fear of breast cancer.
The public health approach outlined in part 2 of the Bill will encourage people to be much more proactive about their health. I feel strongly that encouraging greater breast awareness is and must be an important part of that. Most breast cancers are found by women who notice a change, take the initiative and subsequently visit their GP. There is strong evidence that being breast aware—knowing the signs and symptoms of breast cancer and the importance of early treatment—and attending NHS breast screening appointments are two of the most important factors in breast cancer survival in the UK. The third is, of course, treatment. When it comes to screening, we have to do much better in this country. This change in public health must give a strong impetus to local authorities, many of which are big employers of women, as well as to GPs and local employers to come together and make sure that we do better. Women should be given time off work to attend breast screening appointments and providers must recognise that access to screening that works does not always mean nine-to-five, Monday to Friday. That is something we have discussed in our group many times.
Locally, GPs should be encouraging women to be much more breast aware and should make sure that no-shows for screening appointments, which are sometimes as high as 50% in my area, are followed up and that those women are given the support they need to get there. As I have said before, the move to pure GP-based commissioning will sharpen efforts in that regard through much more sophisticated data management and use of the lists that are currently poorly used.
Much has been said in the House and outside about the UK’s low placing in the cancer league tables, and it is often the Eurocare series, which the Secretary of State mentioned, that shows that survival for the four most common cancers in our country are lower than in the rest of Europe. As Cancer Research UK said to me and all hon. Members in its briefing ahead of today’s debate,
“commissioning of cancer services is not as good as it could or should be”,
and I know that Cancer Research UK welcomes, as do I, the recently published cancer strategy.
That superb organisation, Macmillan, tells us that more than 2 million people are living with or after cancer in this country, and by 2030 there will be 4 million. As we all know, cancer is a set of 200-plus different diseases, most of which have highly complex care pathways. I have concerns, as others have said, about the low level of GPs currently with a specialism or particular interest in cancer compared, for instance, with diabetes or mental health.
I urge Ministers, as did my hon. Friend the Member for Basildon and Billericay (Mr Baron) so eloquently a moment ago, to look again at the transition period from 2012 to 2014 to protect the cancer networks until GP consortia are in a position to make better decisions about the support and expertise they require. Solid action from the Government in this regard would reassure many cancer charities, patients and Members.
Finally, we are in danger of presenting the argument as “all that exists in the current NHS is bad or failing,” versus “all is sacrosanct and we cannot touch it.” Neither is true, in my opinion. Let us keep what works, protect it and strengthen it. That is what we are about, but let us remove what does not work and be brave enough to replace it. Do we want to give the Bill a Second Reading, find out more and examine it further, or do we want to turn against change and take the easy road? That would be the real risk. I will support the Bill in the Lobby tonight.
Emma Reynolds (Wolverhampton North East) (Lab)
There is much disquiet and concern among health professionals about the speed and scale of the reforms outlined in the Bill, with various respected organisations warning that they are a “significant risk” and “could be disastrous”.
It is important to see the Government’s plans in the context of the progress and the health legacy that this Tory-led Government inherited from Labour—patient satisfaction in the NHS at record levels, a world-class public service transformed by Labour, record numbers of doctors and nurses, and new hospitals. Contrary to some of the claims from the Government Benches about the statistics, survival rates for the most serious conditions are improving, and we will have the lowest mortality rates of any European country for heart disease by next year. The Government would do well to recognise this progress.
One of the Government’s central arguments is that massive restructuring is necessary to drive efficiencies in the NHS. I beg to differ. By overhauling the system, the Government are putting at risk the very drive for efficiencies that we support. According to the Royal Society of Physicians,
“Achieving both efficiency savings and reorganisation simultaneously will be an unprecedented challenge for both commissioners and providers”.
In government we recognised the efficiency challenges that we faced in the NHS. That is why in the last Labour Budget the Department of Health committed to £4.35 billion of savings over two years, with a further commitment to save £20 billion in the next five years. We demanded that primary care trusts reduce their management costs by 30% over a three-year period. The choice between doing nothing or modernising the NHS is a false choice, as I think the Government know.
Evidence from the previous reorganisation suggests that the disruption will extend well beyond the period of the reform. Even one of the Government’s Back Benchers, the hon. Member for Totnes (Dr Wollaston), a GP herself, has said:
“To my mind, it felt a bit like someone had tossed a grenade into the PCTs. These people have so much uncertainty about their position that they are haemorrhaging in a rather uncontrolled fashion.”
The transition process is not only disruptive, but will undermine efficiency and quality. This risk was recognised by the National Audit Office in its report, where it said that the previous government’s initiative, the so-called quality, innovation, productivity and prevention programme, is at risk because of the overhaul proposed by the present Government. What is more, their obsession with driving down costs using price competition carries a very real risk of decline in the quality of care, according to professional organisations such as the BMA, the Royal College of Nursing and the Royal College of Midwives.
Mr Graham Stuart
The hon. Lady is giving a powerful speech, making the case that every Government must look for efficiencies and suggesting that the previous Government did. One of the key failings under the previous Government, who did see improvements in the NHS with vast increases in expenditure, was on productivity. According to the National Audit Office, which the hon. Lady just mentioned, productivity, after improving in the 1990s before Labour came to power, fell during the Labour years, despite the massive investment of additional funds. Turning that around is the central challenge for this Government. What views does she have about how best that can be made to happen?
Emma Reynolds
I have already said that we on the Labour Benches recognise the need to drive efficiencies and, as part of that, we recognise the need to increase productivity. We made massive strides in the 13 years that we were in power, and Government Members would do well to remember that.
The allocation of resources in the NHS is all about economics and the tension created by infinite demands and finite resources. Difficult questions that are at the heart of commissioning need to be answered at a macro level—questions such as how do we value the improvement or lengthening of one person’s life compared with another’s; and what is the cost of investing in one drug compared with another or with an existing treatment? These are not easy questions to answer, and clinicians are making decisions at a micro level.
Faced with a limited budget, clinicians will call for more resources to be allocated to their field. Oncologists will argue for a greater share of the budget to be spent on cancer treatment. Paediatricians will argue for more money for paediatrics. As well as prioritising primary care, GPs might well bid for more resources for treatment or minor surgery that their practice offers—a potential conflict of interests against which the Bill does not safeguard sufficiently.
GPs are trained to be advocates of their patients, and rightly so, treating them as individuals, not as a particular percentage of the population. Their training does not equip them with the tools to make the tough, unpopular decisions about the allocation of limited resources. Perhaps in his winding-up speech the Minister will tell the House what percentage of GPs he thinks have had to grapple with the complexities of the modified Portsmouth scoreboard or the quality-adjusted life years measure. Those are the instruments used day in, day out by people who make commissioning decisions.
As my right hon. Friend the Member for South Shields (David Miliband) said so eloquently, the choice is not between reform or no reform. We are not against reform or driving efficiencies, but we are against the ill-considered, costly, reckless reform contained in the Bill, which will undermine the drive for efficiency, jeopardise quality of care and fails to take into account the fact that GPs do not have the expertise or the training to make the macro-level decisions on the allocation of resources.
Nicky Morgan (Loughborough) (Con)
Thank you, Madam Deputy Speaker, for allowing me to contribute to the debate on a Bill that is essential to implementing the coalition Government’s policies. I had intended to say what an excellent debate we have had so far, with some thoughtful contributions from all parts of the House. The hon. Member for Wolverhampton North East (Emma Reynolds) made a thoughtful contribution, but I am afraid the hon. Member for Eltham (Clive Efford) let his side down completely with his offensive remarks about how Government Members view the national health services.
Although she is not in her seat, I congratulate the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) on her contribution to the debate. I did not agree with it, but she gave her speech extremely well.
I welcome the Bill. It is essential that more power is given to front-line doctors, who are best placed to understand patient needs. It is a tragedy that Opposition Members seem to think that GPs are not capable of stepping up to the mark and taking on those responsibilities. From the conversations that I have had with my GPs, I do not understand why the Opposition believe that; they will be proved wrong.
I support the focus on clinical outcomes. I think that GPs are interested in taking on commissioning and the proposed changes. Three consortia in Leicestershire and Rutland have stepped forward so far. My primary care trust is working extremely closely with them, particularly on transferring community services, and I welcome their close working relationships.
The GPs commissioning arrangements will mean that GPs listen to what patients want. GPs will be responsible for community services in Leicestershire and Rutland, including the walk-in centre in the middle of Loughborough and out-of-hours services, which have not been mentioned in the debate. One of the things that patients feel most passionately about is the fact that some GPs, particularly in the part of the country I represent—I cannot speak for everywhere—are not responsible for delivering out-of-hours services. What patients say to me more than anything else is that when they call someone in the middle of the night, they want their GP or someone who has access to their records to answer the telephone, not a call centre.
Anne Marie Morris
I absolutely support what my hon. Friend says. I have the very good example in my constituency of Devon Doctors, which is effectively a not-for-profit organisation that provides all the out-of-hours service and gives the people of Devon exactly what she has suggested.
Nicky Morgan
I entirely agree with my hon. Friend. It just shows that GPs, if they are given the responsibility, will step up to the plate and deliver what their patients need.
In the limited time available, I wish to focus on what the proposed changes will mean for mental health services. I speak as a member of the all-party group on mental health, and as someone with a family interest in mental health issues. The NHS in England spends more on mental health services than on any other disease category, including cancer and heart disease, and one in four people will experience mental ill health at some point in their lives. The public health strategy has so far not been mentioned in the debate. I entirely welcome the Government’s emphasis on public health and the emphasis on good mental health as well as good physical health. I recently spoke with Charnwood mental health forum, which is based in my constituency, whose members told me that prevention of mental health problems and supporting people who are perhaps heading down the road to depression and more serious conditions is incredibly important.
There are four keys areas that I want to mention in the time available. My first point, which has already been mentioned by the Opposition, is that we must ensure that GPs get proper support to commission effective mental health services and other specialised services. That support can come from the national commissioning board, third sector organisations and patients. That is why I think GPs will step up to the plate, because they will ask their patients and listen to them when designing and commissioning services.
A recent Rethink survey of GPs found that 31% of GPs did not feel equipped to commission mental health services, compared with 75% who felt that they could commission diabetes and asthma services. It also revealed that 42% of the GPs said that they had a lack of knowledge about specialist services for people with mental illness, and 23% said that they had a lack of knowledge about mental illness in the first place. I will cite a recent case study from my Loughborough constituency, in which I was told that one of my constituents was suffering from complex mental health conditions, but his GP appeared to have no knowledge of personality disorders and saw the problem as largely behavioural. The relationship between the constituent and the GP deteriorated and therefore the local Rethink carers group stepped in to help find another GP. With consortia, a GP in a different practice could have that specialisation, and the first GP, realising their limitations, could speak with that other practice and engage with carers groups, such as Charnwood mental health forum or Rethink to ensure that there are special services available for patients.
Emma Reynolds
Is the hon. Lady as concerned as I am that a recent survey by Rethink showed that 95% of GPs did not feel that they had sufficient expertise to commission mental health services?
Nicky Morgan
I was just talking about that, but the point that has been made is that GPs do not feel that they necessarily have the specialist skills to commission mental health services. That says not that the underlying plan set out in the Bill is wrong, but that GPs recognise their limitations. From the conversations that I have had with GPs, I think that they will know where to go to commission those services and they will get the support from the national commissioning board.
Nicky Morgan
I am afraid that I must make some progress.
My second point relates to joined-up care, which carried on from my previous point. People with mental health problems have complex needs and need a clear pathway of care, which might involve the GP, psychiatric care at secondary care level, a social worker and community support services, such as drop-in services. That is essential, and that is what we want to see happen in the NHS.
Tom Blenkinsop (Middlesbrough South and East Cleveland) (Lab)
I applaud the hon. Lady for making such an excellent case for mental health services, but I would like to pick up on a point about expertise. Under the new arrangements for consortia and the massive expansion in programmes, who will provide the funding? Will it be via town halls or local authorities for care at community centre level?
Nicky Morgan
There is already some excellent provision in Leicestershire. I hear the hon. Gentleman’s point, as, I am sure, does the Minister. I am sure that she and her colleagues will look at that in the debate and in future.
I support the “any willing provider” model, which was first introduced by the previous Government. It is often patients with mental health issues who benefit from care at different levels and with different therapies, but it does not all have to be at primary or secondary care level. As I have mentioned, there are organisations, such as Charnwood mental health forum and other drop-in centres, that offer excellent services, and they must be part of GP commissioning and the services that will be provided under the new arrangements set out in the Bill.
Finally, I wish to look at public health involvement through HealthWatch and the local health and wellbeing boards, which is critical. We must ensure that there is broad representation in those organisations. Research from Rethink has shown that stigma and discrimination affect nine out of every 10 people with mental health problems. The boards and those organisations must ensure that the most vulnerable patients are listened to. At a recent meeting of the all-party group, one of the contributors said:
“We all have mental health—it just depends how good ours is.”
Mental health has for too long been a Cinderella service. I am confident that that will not be the case under the new structure because GPs will do their best to understand it or, if they do not, will get in appropriate services. I support the Bill and look forward to hearing how the points I have mentioned will be addressed. I also look forward to the unveiling of the national mental health strategy, which I understand will happen later this week.
Malcolm Wicks (Croydon North) (Lab)
The status quo in British health care is certainly no serious option. Improving the NHS is, of course, a continuing challenge, not least because of the ageing of our population, rising medical costs in many sectors and rising public expectations, which are sometimes fuelled by information on the internet. If one adds to that the new public health agenda and the need to bring health and social care into better alignment, one can see the scale of the challenge. However, that is not to say that a top-down reorganisation is the answer.
I want to ask Ministers some specific questions about how the Bill will impact on some of the values and underlying principles of the NHS. The first is the principle that the health service should be based on need, not income or wealth, which is perhaps the essence of the NHS. How do the proposals relating to private patients in hospitals relate to that ethical principle? The proposal is to remove any limit on the use of NHS beds and staff to treat privately paying patients. Unless the Government somehow envisage surplus hospital resources, spare staff and empty beds—a far-fetched proposition—will not more private patients create longer waiting times for NHS patients and/or poorer care? What is the Minister’s judgment on that?
My second question concerns the profit motive, which jars, at least for many of us, with the principle of patient care. Will Ministers confirm that private companies might in practice commission on behalf of GPs, possibly including US companies, while other companies will be awarded contracts? Have I understood that correctly? What is to stop companies competing on price for relatively straightforward procedures, perhaps initially cherry-picking as a loss-leader while leaving NHS hospitals with, frankly, the more difficult medical territories? What proportion of the NHS budget might effectively be in private hands? Of the £80 billion annual expenditure that we hear about, what sums might end up as profits for private shareholders? Ministers must have some idea of the answers to those questions, so I would be pleased to hear their answers or guesstimates.
Margaret Hodge
Does my right hon. Friend agree that there is another issue with privatisation? If a private, BUPA-run, hospital that provides health care gets into financial difficulties and is forced to close, does it not behove the commissioning body—the publicly run commissioning body—to take over the failing private hospital to ensure that the designated services are available to local people? Is that not an outrageous way of using public money?
Malcolm Wicks
Certainly, I can see that the commissioners might feel that someone had to look after the patients, and the financial implications of that pose another question for Ministers.
Given that the Bill allows for the new commissioning board to make payments to a commissioning consortium if performance is good, what happens exactly to that payment? Who benefits from it? Does it go to improved patient care, which is fine, or to bonuses for those working in the consortiums—the GP practices?
My third set of questions concerns accountability and parliamentary oversight. In this brave new world of competition, profits and privatisation, with the fearsome economic regulator, where does the NHS buck stop? Is the Secretary of State still responsible? Is he or she still accountable to this Parliament? If not, who is? If my Croydon constituent has to wait too long for surgery, are Ministers accountable? Can I ask questions? Will I get answers? If constituents cannot access mental health services, can MPs still expect Ministers to intervene and to act? Are they accountable? Will Parliament and public still be able to access the information, the data, the monitoring and the evaluative statistics to comment on performance? Is the publication and integrity of health statistics guaranteed by the legislation?
A further question concerns the relationship between patients and GPs. The Secretary of State and his colleagues wax lyrical about how decisions will now be taken by GPs and patients, and I remember that refrain during the general election, but what exactly does that mean for patients? How will those decisions be taken by patients as well as by GPs? How will patients be involved in commissioning? Will they be part of the commissioning body?
Moreover, will GP commissioners meet in public, like primary care trusts? If not, why not? Where is the accountability? If a patient wishes to complain about services, to whom do they complain—to their own GP, who does the commissioning? Where is the patient’s complaint procedure in all that?
This Bill—[Interruption.] There is no point in the Minister just whispering at me. We have a winding-up procedure, whereby serious questions can be answered— I would hope—rather seriously by the Minister. [Interruption.] She has not wound me up so far.
The Bill is somewhere between a relapse into market ideology and an untried, untested leap in the dark. For the national health service, it is a fearful time. As we have heard, the Government wish to cut public expenditure, yet they are embarking on this top-down reorganisation that no responsible body seems to welcome.
The Bill will also be shown to be a fearful leap in the dark for the Conservative party, just when in recent years it has been making some headway in convincing the British public that the national health service might be safe with it. It is a fearful step for the Conservatives, and they will learn that in the coming years.
Andrew George (St Ives) (LD)
It is a pleasure to follow the right hon. Member for Croydon North (Malcolm Wicks) and his encyclopaedic questions. I am sure that, from his many years as a Minister, he knows the kind of comprehensive answers that he would like to receive from Ministers. Indeed, I should be interested in some of those answers, so I congratulate him on asking those questions.
Perhaps I should inject a short note of levity into what has been a serious debate so far. I do not have the timing or skills of the late, great Tommy Cooper, but he once told a joke that goes roughly along these lines. A patient runs into a doctor’s surgery and says, “Doctor, doctor, I think I’ve broken my arm. Can you mend it?” The doctor looks at the arm and says, “Yes, I think I can mend it.” Then, the patient says, “Doctor, doctor, will I be able to play the piano?” And the doctor looks carefully at the arm again and says, “Yes, I’m sure that you will be able to play the piano.” To which the patient says, “That’s great. I’ve always wanted to play the piano.”
Doctors often use that joke to emphasise the unrealistic expectations that people have of them, and I have come to the conclusion that there are some unrealistic expectations in the Bill. It is well intentioned and not, as the hon. Member for Eltham (Clive Efford) and others have argued, generated out of malice, dogma or—clearly—ineptitude, but Ministers have perhaps allowed their enthusiasm to get the better of them. There can be no disagreement with the principles that underpin the Bill, in particular greater clinical and patient involvement and driving the quality of innovation, albeit through a number of, admittedly, rather debatable measures. Those are pretty unarguable “motherhood and apple pie” principles that ought to underpin such legislation, but many people are concerned about its timing, when all parties agree that the NHS faces one of its biggest ever challenges: the biggest savings it has been asked to make in its 62-year history. At the same time, however, I see the measures as the biggest shake-up of the NHS in its 62-year history. The Bill is well intentioned, but for it to proceed and not damage the NHS it needs further major surgery in Committee before it returns to the Chamber for Report and Third Reading.
We need to look at reforming the reforms themselves as part of a constructive approach to engagement. It is not that PCTs are the be-all and end-all of future health service delivery; far from it. No one will die in a ditch to defend them, but, given the institutional architecture that they have provided, after many years of coalescing around and amalgamating the primary care groups that were their heritage, we should establish the default position of assuming that we stick to that coterminosity and structure and then graft on wider clinical involvement. Many GPs in my constituency clearly tell me that they are going ahead with the measures before us more out of resignation than enthusiasm for solely GP-led clinical involvement in commissioning. A lot of them are telling me clearly that they want wider clinical engagement. If there are already 141 pathfinders covering just half the population of this country, at the very least there will be somewhere in the region of 300—that is, 300 chief executives against 152. There is a risk that that will generate a great deal more bureaucracy than exists at present in the PCTs.
I am not persuaded by the level of democratic accountability of the wellbeing boards. Monitor will set a maximum tariff and then promote competition, which could easily put quality at risk for the sake of price. That view is shared by many authoritative bodies.
Many questions still need to be addressed—protecting the integration of services, ensuring the accountability of Monitor and looking at the power of the NHS commissioning board. For those reasons, and a number of others that I do not have time to explain, I cannot support the Government this evening.
Rosie Cooper (West Lancashire) (Lab)
I am delighted to follow a fellow member of the Health Committee. I, too, am looking forward to the answers to the very many questions asked by the Select Committee that were not answered comprehensively. The issues have been elucidated today by my right hon. Friend the Member for Croydon North (Malcolm Wicks) and my hon. Friend the Member for York Central (Hugh Bayley), so I will not rehearse the arguments again.
I fear that today marks a watershed in the future of the NHS, and I say that as one who has proudly dedicated 30 years of my life to the service. Today is the day that the broken promises of the Tory-led Government will lead us down a path that, sadly, will end with a broken NHS. I characterise the Department of Health’s policy position on the most far-reaching reforms since the inception of the national health service as, “Don’t ask us about the detail; we haven’t made it up yet.” I am not sure what is more worrying—not having the detail or now seeing an outline of what the Tory-led Administration plan to do with the national health service.
I do not know why it took so long to bring the Bill to the House. It cannot be because of extensive consultation and discussion with professionals and advisers, because we cannot seem to find any body willing to own up to advising or having had discussions with the Secretary of State about the future direction of health services. If he had had such discussions, he would have heard the resounding message that his reform package is not what the NHS needs right now.
We should have built on the best in an evolutionary way. Instead, the Secretary of State has inflicted on the NHS a massive structural change while it has to cope with the Nicholson challenge, which we are led to believe are the 4% compound cost savings for the next four years. As David Nicholson acknowledged to the Health Committee, the scale of the productivity challenge is huge and has never been done on this scale either in the NHS or elsewhere in the world, and it is all taking place during a transition into the new NHS commissioning world.
It now transpires that the feat that the Health Secretary set for the NHS has been made even more improbable—some might say, impossible—to achieve because of decisions being taken below the radar. For example, there is the reduction in the market forces factor, which means a reduction in some NHS hospitals’ budgets. Instead of the 4% that the Government have talked about, the reality of the cuts to some hospital budgets is closer to 5%, and perhaps even 5.5% in some cases—mission impossible.
At the same time, we hear about wards having to be closed because of budget cuts. The NHS Confederation says that some hospitals might need to close under the reforms. Yet this weekend’s newspapers talked about the Department of Health having meetings with private sector providers who have 10,000 beds at their disposal.
When will the Secretary of State stop peddling myths and start dealing with the reality, before it is too late for the NHS? The Bill will deliver a service that is low on accountability and high on autonomy. I do not have time to go into this in detail, but I am certainly not persuaded by the accountability measures in the Bill. I am not convinced by the wellbeing boards, local healthwatch or national HealthWatch. We have no evidence that they will be able to deal with accountability or respond to patients themselves. The issue is very clear. If we as Members of Parliament want to ask questions, whom should we ask?
As far as I am concerned, the Secretary of State has a nice little soundbite that he often wheels out—“No decisions about me without me”. Government Members have stated that over and over, but have not demonstrated any evidence base for it. To me it is clear: the fundamental principles of the Bill are about taking decisions “about me without me”. I am really not persuaded by the democratic accountability provisions. A whole series of decisions have already been made about my health care, our health care and this nation’s health care—and they have been made without us.
It has taken until today for us to be able to debate these proposals properly, and in six minutes I am not able to deal with the points that I should like to cover. This Bill comes to us now after many of the fundamental decisions have already been taken and are being implemented. It is a set of short-term measures that will have long-term consequences for the future of the NHS, the quality of health care, and the accessibility of services available to people in communities across this country.
The Prime Minister and the Secretary of State deny breaking their promises, but like the emperor and his new clothes, they can fool themselves for as long as they like, but they are not going to fool the people. As people’s services disappear, as they wait longer for their operations, and as things get more difficult, they will know who to blame, and Government Members will really need to worry about it. Last time I spoke in this Chamber on health matters, I accused the Secretary of State of glibness; today, I accuse him of hubris.
Dan Byles (North Warwickshire) (Con)
I am grateful for the opportunity to speak in this debate, and declare an interest in that my wife is a general practitioner.
It is an oft-stated fact that the NHS holds a special place in the hearts of British people. That is why it is so important that this vital institution is managed effectively and sustainably so that our children and grandchildren can continue to use and rely on it in the years to come. However, the problem with the cherished position that the NHS holds is that it makes it difficult to discuss and debate its future dispassionately. It is extremely important that we in this House are able to discuss NHS reform sensibly and without the hyperbole and hysteria shown by the shadow Secretary of State in his opening remarks and by the hon. Member for Eltham (Clive Efford), whose frankly disgusting remarks were not worthy of this Chamber.
The previous Government, who undertook considerable, frequent and, dare I say it, well-intentioned reorganisations of the NHS, found that each reorganisation was opposed by a variety of interests for a variety of reasons. Although they spent too much time reorganising the bureaucracy of the NHS, and generally adding to it on each occasion, I welcomed some of their reforms and am happy to say so, with the notable examples of foundation trusts and the greater involvement of private and other providers. In too many cases, however, previous reforms took the form of shuffling the management deck chairs. Strategic health authorities and primary care trusts were reorganised and reorganised again, often before the ink at the top of the old letterheads had dried, while the number of bureaucrats soared relentlessly.
The challenges faced by the NHS are considerable, and to deny the need for further change is dangerous. Cost pressures within the NHS are rising. This has, in part, been driven by the blunt way in which the previous Government pushed up health spending without insisting on robustly improving outcomes alongside that increased spending. As a result, we have seen productivity fall—a trend that must be reversed if the NHS spending model is to be sustainable. That health care inflation has also been driven by outside factors. Costly new drugs and treatments, coupled with an ageing population, have created serious challenges and will continue to do so.
A hard-headed analysis of these demographic changes has led the coalition Government, rightly, to commit to ring-fencing the NHS from Government spending cuts and guaranteeing real-terms increases in NHS spending—a commitment, I might add, not matched by Labour. With the privilege of a ring-fenced budget comes a responsibility on the side of the NHS to maximise productivity and efficiency to ensure the best possible clinical outcomes for patients within that budget settlement.
Mr Anderson
If it is a ring-fenced budget, why does the Royal College of Nursing believe that there will be 27,000 fewer nurses in a year’s time?
Dan Byles
The NHS budget is going up in real terms every year, as the hon. Gentleman can see by looking at the books. We are all aware that the system we inherited had ongoing problems because of the high management costs and other structural problems within the NHS. There will be no shortage of nurses as a result of any underfunding by the current Government—I can assure him of that.
Stephen McPartland (Stevenage) (Con)
Does my hon. Friend accept the figures from the Royal College of Midwives showing that in 1997 there were more midwives than managers in the NHS, and in 2009 there were 18,000 more managers than midwives?
Dan Byles
I am grateful to my hon. Friend for making the point exactly. The NHS cannot carry on with management levels and layers of bureaucracy of the kind that the previous Government put in place. With an ageing population, it is even more important that the largest possible slice of the NHS budget is spent on patient care, and as little as possible on management and administration. Reform of the commissioning process is central to that.
The Bill has been criticised by Opposition Members for doing something that Government Members have been critical of in the past: reorganising the management structures yet again. However, anyone who looks at the Bill honestly and dispassionately will see that it does not reorganise NHS management structures, but sweeps away a whole tier of NHS management structure. It is not another round of shuffling the management deck chairs, but a bonfire of some of those management deck chairs. I strongly welcome the fact that the Bill abolishes primary care trusts and puts general practitioners in charge of commissioning services on behalf of their patients. I criticise nobody who works within PCTs, but I freely criticise the structure that puts health care commissioning in a bureaucratic body that operates at arm’s length from patients and doctors.
I am conscious that many hon. Members still wish to speak, so I will draw my remarks to a close with one plea to the Minister. I understand that under the new GP commissioning process, GP consortia will, in effect, be given control of two budgets: the budget for clinical services and a small budget to cover the management costs of taking over the commissioning process. I also understand that they will not be permitted to transfer unspent funds from the management budget to the clinical budget. If my understanding is correct, I urge the Minister to reconsider that restriction. In giving the consortia a budget for management that cannot be transferred to the clinical budget, there is no incentive for them to drive down their back-office costs. For the process to work most efficiently, GP consortia must have an incentive to drive down their back-office costs in the knowledge that it will allow them to spend more on their patients. To do otherwise gives the incentive to use up the management budget regardless of need—to hire that extra secretary, not because there is a need, but because the budget is there to do so. Such unfortunate incentives from central Governments over the years have led to many productivity problems throughout the public sector and to a use-it-or-lose-it culture. I urge the Minister to look again at that restriction, which seems to go against the new culture of efficiency and responsibility for budgets that we are trying to instil across the public sector.
Margaret Hodge (Barking) (Lab)
I speak both as Chair of the Public Accounts Committee and as the MP for Barking. As PAC Chair, my concerns have not been allayed by the evidence sessions that we have held on these issues. I do not want to be saying in three years’ time, “I told you so.” I urge the Government to think again before they introduce changes that have not been thought through properly, that are incredibly risky, and that could result in long-term damage.
There has been insufficient focus on the risks of the changes. The NHS chief executive said in evidence that
“the risk is higher. If you try and reorganise, the risk becomes higher. I think we’d be kidding you to say that it wasn’t”.
Making Monitor an economic regulator forces it to concentrate on competition, not quality. Its purpose will be to drive down costs, not drive up health outcomes. If the spotlight is on price, the risk is that patients will lose out. The NHS chief executive agreed in his evidence that lowering tariff prices could endanger patients. Opening the health market to any willing provider will undermine the viability of many NHS foundation hospital trusts, which face immovable fixed costs, such as their private finance initiative costs. Again, that risk has not been assessed properly.
The Government appear to be driven by an ideological mission. The NHS needs pragmatism, not dogma. I fear that there is no firm grip on the costs of reform. The NHS already faces the unprecedented challenge of finding £20 billion of savings and its record is poor. Over the past decade, despite assurances to the Treasury, NHS productivity declined, with hospital productivity declining by 1.4% annually. The NHS should therefore concentrate its efforts on the enormous financial challenge, and should not be diverted by an unprecedented organisational challenge. Quality and productivity, not reorganisation and privatisation, should be the priorities.
Robert Flello (Stoke-on-Trent South) (Lab)
My right hon. Friend is making a good-quality speech, as usual. Surely in areas such as Stoke-on-Trent, where the cost of laying people off in the PCT will be tens or hundreds of millions of pounds, the risks that she describes already exist.
Margaret Hodge
Indeed, and I was going to come to that point. As I understand it, Ministers have set aside £1.7 billion to finance their reforms, but as my hon. Friend says, if the costs of redundancy are higher than planned, or if people carry on attending A and E rather than seeing their GP, the costs of reform will spiral and front-line services will have to be cut. I am not convinced that Ministers have transition costs properly under control.
Nor has anybody sorted out to our satisfaction the issue of accountability for public money. For instance, foundation trusts are supposed to be directly accountable to Parliament. With 167 trusts accountable to the PAC and the House, if there is financial failure or poor quality of care, will that accountability be good enough? In the past, Monitor could sack the board of a trust, but under the Bill it will lose that power. How can we hold the permanent secretary to account when there is a plethora of new quangos or new responsibilities for quangos? We have to know where the buck stops. I seek Ministers’ reassurances tonight that there will be clear, practical accountability that enables Parliament to hold the Executive to account.
The Government do not have effective plans to deal with failures, and there will be failures—hospitals bankrupt, GP commissioning consortia overspending. Ministers must explain how they will deal with failure, so that local services will be maintained even when trusts and consortia collapse. So far, officials have been unable to provide us with the confidence that we need to feel that the Government have got a grip.
That matter is of particular importance to my constituents. For years, our NHS trust has been in terrible trouble, and last week it was named and shamed by the Audit Commission for systematic failure on its finances. It has failed to balance its books for years, and it has a projected deficit of £29 million this year. The quality of care has deteriorated, too. In the week of the general election, 99% of people at our King George A and E and 92% at Queen’s hospital were treated within four hours. By 2 January this year, that had dropped to 83% at King George and just over 61% at Queen’s. More than 1,000 people were forced to wait for more than four hours, ambulances were queuing around the block and all but the most urgent cases were turned away. In one case, a patient died because she was sent home.
That hospital trust is not fit to become a foundation trust. Despite a stream of new chairs and chief executives, the underlying problems persist. Now, the only answer that NHS London has is to try yet again to close the A and E at King George. That is health vandalism at its worst, with patients’ needs sacrificed at the altar of financial cuts.
What would happen to my constituents under the proposed NHS reforms? King George A and E would go, forcing my neediest and poorest constituents to spend hours on three buses to get to a hospital. Queen’s hospital would become unviable, and what then? Where is the local hospital ready to meet local needs? Who would want to consider merging with a hospital trust struggling with an impossible financial burden, and even if anyone did, would they ensure that our services remained local? The current health care reforms should put the patient at the heart of the NHS, but it does not feel like that is happening in Barking. I urge the Government to think again before they act to damage the health care of the people who need it most, the people I represent here in Parliament.
Dr Sarah Wollaston (Totnes) (Con)
It is easy to see why politicians continuously want to fix the NHS. The perspective from the green Benches is very different from the perspective one gets as a GP—I say that having worked in the health service for 24 years. My surgeries and postbag, and I am sure those of other Members, are full of stories of delays, frustrations and sometimes really poor practice. The trouble is that not enough people write to their MP to tell them how sensitively or compassionately they have been treated, or how the NHS saved their life. They do feel those things, however, and they do appreciate the NHS. That is why they are understandably wary of any changes, proposed by whatever Government.
Here are the things in the Bill that I welcome. I really welcome clinical leadership. We should be in no doubt about this: there is clear evidence that commissioning works best when there is clinical leadership backed up by excellent management. The Bill will go some way to pushing us towards true clinical leadership in all parts of the NHS.
The provisions will also result in an information revolution. That will involve information about not only whether someone’s treatment worked but what the experience was like—a kind of TripAdvisor for the NHS. We all know that, with information, daylight is the best disinfectant. If people know that their performance is going to be compared with that of others, that is likely to drive up performance in the NHS.
The provisions will allow for that early scan that can make all the difference in an early diagnosis of cancer. When GPs can commission very good early diagnostics much more quickly, we will see a difference. The changes will also give GPs much greater flexibility to respond to their own area. In Devon, for example, community hospitals are really important, but they might not be so important in inner cities. The provisions should also give better choice to services such as mental health, and bring in opportunities for the voluntary sector. I recently met a group of carers for patients suffering from mental health difficulties, and they told me that they wanted better access to talking therapies. Rather than the support that has traditionally been supplied to them, they want better access to other kinds of support. I also really welcome putting public health back where it belongs, with local authorities.
Our spending now matches the European average, and I genuinely congratulate the Labour party on that, but I am afraid that that has also been a wasted opportunity. It is unforgivable that so much of that money was squandered, and that we have seen flat-line productivity. For that level of spending, patients should be able to expect the kind of services that people receive in France or Germany. I am sure that we have all heard instances of people coming back from a holiday on the continent with a minor condition, having had a scan and treatment within a week. We should be able to deliver that here. Health care workers should not have to spend three weeks chasing down a patient’s results. I am sure that we have all heard instances of that, as well.
The challenge is to improve aspects of the NHS, to look at the detail, to listen to patients and professionals and to ensure that we get this right. In Torbay, they have been getting it right for some time. It has been part of a national pilot of integrated care. Baywide, a not-for-profit company of local GPs, commissions health and social care from a pooled budget.
Sarah Newton
My hon. Friend mentions GPs working together on a not-for-profit basis. Does she share my huge disappointment at some of the terribly derogatory comments made by Opposition colleagues about GPs’ motivation, comparing them to the worst kind of bankers in the City? Is it not disappointing that they are so disrespectful to GPs?
Dr Wollaston
I agree with my hon. Friend. We have heard some terrible slurs about GPs profiteering and lining their own pockets. I am absolutely confident that that is not what we are going to see.
Torbay has been highly successful because it has pooled budgets and it can design integrated care. That saves lives and money. No one should be in any doubt that improving the quality of care, and thereby the quality of life, for those with complex, long-term conditions is the key to improving health care and cutting costs.
Andrew George
My hon. Friend talks about the role of GPs in cutting costs. I would be interested to hear whether, from her experience, she believes that the introduction of price competition—in which a maximum tariff would be set, below which there could be competition —will be helpful, or does she believe, as many authorities and other bodies do, that it is likely to put quality at risk?
Dr Wollaston
I am very confident, because I have discussed that question with the Secretary of State, who has assured me that the reforms are about competition not on price, but on quality. All doctors know that if they get it right the first time, they provide not only better care, but better value care.
GPs and PCTs throughout Devon are rolling up their sleeves and getting on with the job in hand, but to deliver the undoubted benefits of integrated care, they need to be able to work closely with colleagues in hospital, as well as with people in the community, to design those logical pathways. As I just mentioned, the Secretary of State has reassured me on the question of price versus quality competition, but it would help to spell out explicitly in the Bill that that will be protected. Professionals are understandably scared, and I hope the Minister will make the position absolutely clear in his winding-up speech.
Commissioners will not feel liberated if they are liberated from the Secretary of State but shackled to Monitor. Fundamental to the outcome of the reforms will be the powers of Monitor. I should like those powers to be carefully constrained in the Bill, so that it does not take on an unintended role. Focusing on quality and not on cost would help to bring all the professionals back into thinking that this is a positive step forward, because that remains a concern.
Mr Graham Stuart
My hon. Friend rightly emphasises quality ahead of cost, but surely both should be considered. In a time of constrained budgets, it is entirely right that commissioners use a service of comparable quality, which can deliver for patients at a lower cost, when they can find one, precisely so that they have additional funds available to look after other patients.
Dr Wollaston
I am confident that commissioners will consider the impact of those decisions across the health care spectrum, which is very important.
In the limited time I have left, I should like to ask the Secretary of State to consider how we will monitor the quality of primary care. Who will be responsible for performers’ lists, audit, and identifying poorly performing doctors? As I understand it, all GP contracts will be held with the NHS commissioning board. What powers will GPs within consortia have to deal with those whom they feel are underperforming if they have no control over their contracts? What will be done about the ongoing, disgraceful situation regarding doctors from the EU with poor English skills, over whom we have few powers to protect patients until there has been a problem?
Professionals are also concerned about the make-up of consortia. Will they have the flexibility to include consultants and other specialists—
Mr Geoffrey Robinson (Coventry North West) (Lab)
I am pleased to follow the hon. Member for Totnes (Dr Wollaston), who speaks with a great deal of experience in such matters. The House will share her aspirations for the positive involvement of GPs in commissioning, for the improvement in the provision of secondary care by involving primary care, and for the organisation of primary care. Those aspirations may be shared, but the Government’s hopes, and the evidence on which they are based, of carrying out this huge reorganisation and achieving its alleged aims are flimsy indeed.
In the history of Government-led reorganisations—it little matters whether they are bottom-up or top-down—this reorganisation is massive. The former Health Secretary, the right hon. Member for Charnwood (Mr Dorrell), referred to the view of the NHS chief executive. He said that the Nicholson challenge is to carry out successfully such a huge, large-scale reorganisation in the time proposed—the two challenges that need to be pulled off. I think I quote Nicholson accurately when I say that the first challenge is to do in four years something so massive that it can be seen from the moon—together with the great wall of China—and that that would be unbelievable. The second challenge—the other inherent part of the two-part challenge—is that that has to be done while achieving a 4% reduction in costs over four successive years; and
“To pull off either of these challenges would therefore be breathtaking; to believe that you could manage both of them at once is deluded.”
I do not know why David Nicholson is still in his position. I do not know how the chief executive of the national health service can think that the Government must be deluded to put forward a proposal such as the one that the Secretary of State has proposed and remain in his place, but he clearly does not believe it. I do not want to cast any aspersions on the Secretary of State’s mental health, although I note that the editorial of the last edition of the British Medical Journal read:
“What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad.”
Government collective responsibility obviously applies.
It is difficult to understand why the Secretary of State is going down this route, because there is no evidence that these sorts of reorganisations—top-down, bottom-up—in the health service or anywhere else bring the benefits, cost reductions and performance improvements expected of them. If any Government Members want to correct that, I will willingly give way, even in the limited time available. However, there simply is no evidence for it. Indeed, the National Audit Office, in looking at nine reorganisations carried out in the last five years of the Labour Government, found no evidence at all. They all cost far more, and the benefits, so far as they could be identified, were much less.
Similarly, it is pretty obvious that the something like 15 structural reorganisations, particularly in primary and secondary care in the health service, were not successful either. We only have to read through them. Kieran Walshe has described the bewildering array of forms and structures put in place to run primary care and commission secondary care—[Interruption.] I see that anybody who does not agree with the Secretary of State is dismissed automatically—that is a sign of hubris and is not a good approach. A similar approach was taken towards Professor Appleby, who was dismissed as someone of no importance. Yet these are people who are looking at the facts—Appleby looked at improvements in the health service. The conclusion is that
“there have been family practitioner committees, health authorities, GP fundholders, total purchasing consortiums, GP multifunds, primary care groups, primary care trusts, and external commissioning support agencies.”
I freely admit that a lot of those came from the Labour Government. However, I cannot imagine why the Government refuse to learn from our mistakes. That applies also to one of the most serious developments in this whole proposed reorganisation relating to the introduction of price competition. It is feeble of the Government Front-Bench team to say, “Well, your Government intended to do it, so we are going to do it.” They spend hours every day criticising everything the Labour Government did. This is one thing they did not do—apparently they intended to do it—but suddenly it is so welcome that the Government insist on doing it. The fact is, however, that it will happen.
We have a huge change but with no evidence that it will bring any good; we have the fact that the NHS has to make savings that nobody believes will be achieved; and we have the fact that we are opening it up to competition. The position of the consortia becomes very questionable, as does the position of the NHS commissioning board itself. Other Members have raised these points. What sanctions have been provided for? To whom will the consortia report? Is the Secretary of State abdicating any responsibility for their performance? It is not clear from the legislation, as far as I can see—there are 61,000 words of it—what the Government’s role will be in the control, functioning and performance of these new boards.
Priti Patel (Witham) (Con)
I am grateful for the opportunity to speak in this important debate. I congratulate the Secretary of State and his ministerial colleagues on this landmark piece of legislation, which I welcome for fundamental reasons that are specific to my constituency. This legislation will put patients and medical practitioners at the centre of the NHS, putting an end to the era of bureaucracy and mismanagement seen under the previous Labour Government. As my hon. Friend and neighbour the Minister will be aware, patients in my constituency have suffered for a considerable period. They have had their care compromised by the excessive layers of NHS bureaucracy that, as far as I can tell, the Opposition seem determined to keep. I have endless examples of where such bureaucracy has had a devastating impact on the very patients whom the NHS is there to serve.
Late last year I raised with the Leader of the House a case involving a teenage girl in my constituency who had been experiencing unacceptable delays in receiving an MRI scan. She was unable to eat, and basically went from being a healthy teenager to being completely bedridden. Despite needing the scan to help to diagnose her condition, she had to wait for more than a month while her case was being handled—incompetently, I should say—by administrators and managers. The delays were exacerbated by what the local PCT described to me as a “broken pathway”. It was only after the matter had been raised directly with the Secretary of State in the Chamber that she received the scan and has since received medical treatment. However, the delays have compounded her illness. Three months later, that young lady is still in a critical condition. Cutting back on such bureaucracy, investing in the front line and giving patients and their doctors more power will prevent such incidents. Instead of managers hiding behind “broken pathways”, we can have doctors held to account by their patients.
I also support the Bill because it will help my constituents to receive the treatment and the drugs they need. As the Secretary of State will be aware, in recent months two constituents of mine who suffer from multiple sclerosis have contacted me because two PCTs—Mid Essex PCT in one case and North East Essex in the other—have refused to allow them the prescribed drug Sativex on the NHS, yet both have prescribed the drug to other residents. My constituents’ doctors have recommended the treatment, yet management and bureaucracy are again standing in their way, and in the way of common sense and the essential health care that my constituents need. Instead of receiving that treatment, they are now having to wade through a convoluted appeals process, which naturally makes them feel extremely despondent and disappointed, as the NHS, which they have supported through their taxes, is letting them down. They believed that they would get the care that they needed when they needed it, and never expected that the requests of their doctors could be ignored in that way.
I want the Government’s reforms to be introduced without delay. Indeed, it will not surprise the Minister or the Secretary of State to learn that, as far as I am concerned, the abolition of the PCTs in 2013 is still a bit too long to wait. I would like it to happen sooner rather than later. I would therefore like the Minister and Secretary of State to accelerate the process and remove that fundamental layer of bureaucracy, which is a barrier to delivering positive health outcomes to my constituents. I would also like the Minister to ensure that PCTs play their part in facilitating an orderly transition to GP consortia, as he will be aware that Mid, North East and West Essex PCTs have come together to form a cluster, with one chief executive. It is now a large organisation that is responsible for a lot of public money.
I have since discovered that between now and 2013, those three PCTs have a target to reduce management costs—that is completely welcome and long overdue—by £13.9 million; they currently stand at some £37 million. However, I should add that that figure is still significantly lower than the £20 million of combined savings that were previously agreed for each PCT by the strategic health authorities. I mention that because that money would naturally make a fundamental difference—a tremendous difference—to those patients being refused treatment on the grounds of cost. When we hear the Opposition questioning whether GPs will be able to handle NHS budgets, they need look no further than the resource-intensive PCTs, which not only need to go, but frankly need to go sooner rather than later.
Because of the shortness of time, I want to highlight one more thing. It is irresponsible of the Opposition to justify the ever-increasing layers of bureaucracy that have been associated with the NHS. I welcome the Bill, which is long overdue. I want to see the patient’s voice put first, greater accountability for public money and proper commissioning of local services. For a new constituency like Witham, that is vital when we face a crisis of out-of-hours health care provision. Fundamentally, the Bill is important because it will put patients first, which, as I said, is long overdue.
Joan Walley (Stoke-on-Trent North) (Lab)
I am pleased to speak briefly about this Bill; I know that many Members on both sides of the House still want to contribute to the debate. It seemed to me that not to speak in this debate would somehow mean not being true to the important issues surrounding the NHS. I have listened to the debate and heard some good constructive comments, but I do not think we have gained a sense of what the NHS was like when I was first elected almost 25 years ago. At that time, people simply could not get treatment because of the underinvestment during the years of the Conservative Government. As for the point about organic change and building on what has been done, it seems to me that this Bill, lengthy as it is, is doing away with the step-by-step improvements that have been made.
Robert Flello
I look forward to hearing more of my hon. Friend’s speech, which I know will be to her usual high standard. Does she agree that, since 1997, Stoke-on-Trent has seen the building of the first new hospital for 140 years, a brand-new oncology unit, a brand-new maternity unit and health centres developing everywhere? Is that not real investment under a Labour Government, which never happened during the previous 18 years of the Conservative Government?
Joan Walley
What we have seen is the university college of North Staffordshire linked to the medical college at Keele. We have never before seen that kind of medical training going on outside London in areas like Stoke-on-Trent. Hayward hospital has been rebuilt and there has been investment in clinics and a huge increase in the number of staff. That does not mean just bureaucrats—like everyone else, I do not want to see unnecessary bureaucrats. I am talking about the number of health personnel trained to do their jobs and to treat people, which has been second to none—despite what the Minister says.
Mel Stride (Central Devon) (Con)
In looking at NHS performance, should we not seek to compare ourselves with international equivalents today rather than with the past? If we look at coronary heart disease, for example, we find that we have twice the death rate of France, and we are also lagging behind the rest of Europe on cancer outcomes.
Joan Walley
I am coming on to public health, as it is the main issue on which I wish to concentrate.
Mrs Jenny Chapman (Darlington) (Lab)
In response to the intervention on the recorded death rates from coronary heart disease in France, I want to observe that France makes much more frequent use of the “unknown” category in the recording of deaths. I have been led to understand that this goes some way towards explaining the apparent difference in death rates between the two countries.
Joan Walley
Statistics can be used in all kinds of ways. I remember the case of a young girl of six who could not get the heart surgery that she needed, even when we had invested in those facilities. The important role of public health is relevant to heart disease, and we need to focus on what can be done to prevent ill health. This Bill is very short on detail in that area, which is why I want to concentrate on it.
I want to stress that what we are seeing in this Bill is dogma. We are replacing the primary care trust layer with the GP layer, but the GPs will not be able of themselves to provide the clinical leadership of which we have heard. They will have to engage with equally bureaucratic agencies or companies to do that work for them. My fear is that the clinical leadership element will get lost when the new provisions come into force.
The provisions will not allow us to build on the work of the previous Government, which did so much to improve aspects of the NHS. I accept that the new Government have come into power and that they have a remit, but that means that they should get what they do right. I fear that what will happen as a result of the Bill will be destructive. I am afraid that it is also risky. We have already heard about the need for pilot projects. Why can we not wait for a proper evaluation of those projects before rushing ahead with a move that might cause us to throw out the baby with the bathwater? What safeguard will we have against that?
I fear that when the public realise that the Bill is not fit for purpose and will not achieve what is claimed for it, they will be not saddened but angered by the knowledge that they will no longer be able to raise issues for which the Secretary of State has previously had responsibility. The Bill will merely transfer responsibility, and it is easy to see who will have that overall leadership and where direct accountability will lie. The hon. Member for Stafford (Jeremy Lefroy) will probably wish to raise issues relating to Stafford hospital. It is important that when things go wrong in hospitals, there is full transparency. When everything is done on a commercial basis, that transparency will not exist in the new health service that the Bill will introduce.
The Government say that the Bill will end inequalities. I am old enough to remember the resource allocation working party, and the “distance from target” money that was to help areas such as Stoke-on-Trent which had received the least investment in health and experienced the most illness. I am not convinced that the Bill will continue that work. Stoke-on-Trent primary care trust is currently £30 million short of its target, and it is difficult to see how the Bill will make amends for that.
Realising as I do that the devil is often in the detail, I want to raise two more points. The first relates to public health. Speaking as an honorary vice-president of the Chartered Institute of Environmental Health, I am well aware that the public health consultation that has invited responses later this year will not be co-ordinated with the legislative changes in the Bill. Will the Government take account of the need for the institute to look in detail at the way in which public health will be integrated with local authorities across the board? That is critical if we are to improve public health services at all levels.
My second point relates to a private Member’s Bill of mine. I have heard that, through the Government’s Bill, the Prime Minister will require hospitals to improve nutritional standards. We all know that poor food leads to ill health. I hope that Ministers will consider the proposals in my Bill, and think about ways in which hospitals could serve high-standard food rather than food that is often linked to ill health. That in itself could make a major difference to people’s health.
I have many other concerns which I have no time to mention, but let me say finally that it is not clear how the Bill will secure the investment in dentistry that is currently needed.
Mr John Leech (Manchester, Withington) (LD)
I am delighted to have an opportunity to speak, given the number of Members who wished to contribute. I will keep my comments brief.
We should all recognise that NHS staff do a great job in looking after our health and well-being, and are constantly striving to improve provision. I refer not just to front-line health workers, but to the office staff managers and professionals who are not always referred to so positively by either politicians or the media. However, we must also recognise that the NHS must continue to improve and do a better job in order to keep pace with rising health care needs. The question we must ask is whether the Bill will allow the health service to continue to improve.
Some positives have come out of the proposals. For too long, unelected officials have made decisions about local health care without listening to local communities, handing contracts for GP practices to private firms or even closing hospitals with local people locked out of decision making. In my constituency, under the previous Government, the PCT closed Burnage walk-in centre without any consultation. It said that this was to save money, despite the centre being more cost-effective than other walk-in centres in Manchester. This was part of the £20 billion efficiency savings demanded by the previous Labour Government. More recently, the PCT has temporarily closed Withington walk-in centre, again without consulting anybody who uses the service. So it is to be welcomed that the Government will not allow a service reconfiguration where the public have not been engaged and where it will reduce people’s health care options locally.
It is also to be welcomed that private sector providers will be expected to appear before local authority health scrutiny committees—that did not happen under Labour’s less democratic system. However, I urge the Secretary of State and Ministers that if private providers remain reluctant to participate, they should be mandated to appear before health scrutiny boards. Getting information on how providers are performing out into the open can only help to improve health outcomes and accountability.
The Lib Dem manifesto promised an end to the rigging of the market in favour of the private sector that we had seen emerge under the Labour Government. The Labour Government pushed for more NHS work to be given to private hospitals, regardless of local decisions on whether it was right for them. Much of the concern about the Bill centres on reforms being seen as being about the break-up of the NHS. Such a view is wide of the mark, because in many ways the proposals will level the playing field for the NHS, which was distorted under the previous Labour Government. They guaranteed that for-profit providers of elective surgical procedures running independent sector treatment centres would be paid a certain amount, regardless of how much work they did, and allowed PCTs to make supplementary payments to new private sector providers to make services more attractive to new entrants. Unfairly stacking the system in favour of the private sector and against public provision was wrong. We cannot allow certain providers to be handed work regardless of what patients want and regardless of the quality of the services provided. I hope that the Minister will confirm that preferential payments and guaranteed payments for new private sector providers will end. Can he also confirm that there will be no target for the proportion of work undertaken by private sector providers, unlike under the Labour Government?
However, there are still areas of concern and many questions remain unanswered. I would be grateful if the Minister explained what will happen to existing PCT-owned provision? Locally, in Manchester, the Labour party has claimed that the PCT-run Withington community hospital will close under these proposals. Of course that is simply not true, but questions do remain over who will own and run the community hospital. When I met the chief executive of Manchester PCT, she made it clear that the new proposals give real scope for widening and expanding provision through the community hospital, but she remained unclear on the model of ownership. I would be grateful if the Minster cleared that up.
Unlike Labour Members, I have no ideological opposition to the idea of allowing hospitals to extend their private provision. Private provision has been extended at the Christie hospital, in my constituency, which is providing millions of pounds extra each year to be reinvested in NHS provision, which surely is a good thing. However, I would be grateful if the Minister assured the House that where private provision is extended, it will not be at the expense of NHS provision. We should allow hospitals to extend private provision—in addition to existing services and certainly not instead of them—so that more money can be reinvested in the NHS.
Questions also remain about the cost of the implementation of change. Manchester used to have three PCTs, but they were merged into one to save money. The new consortia will go back to using the “three model”, and I am not convinced that that will save money. There is also a concern that intense competition for providing services that existing hospitals provide will take away resources and make it more difficult for NHS providers to maintain services or to invest in new technology and equipment. I have run out of time.
Geraint Davies (Swansea West) (Lab/Co-op)
I am glad to be called to speak at this hour, Mr Deputy Speaker. It is my joy to celebrate the achievements of the health service that was started by Nye Bevan from Wales and to celebrate the successes of the previous Government, such as the 2 million extra people a year who are now operated on, the 44,000 extra doctors and the 94,000 extra nurses. The question to ask is: why devastate and break a system that already works well?
The Bill risks stripping out the heart and mind of the NHS, in terms of equality and planning, and replacing it with a market of GP business consortia that will focus increasingly on profit maximisation through negotiation of the best prices, bulk purchasing and threatening to withdraw custom from hospitals that cannot survive without them. Huge health retailers will evolve with local monopolies over patient communities. It is all very well saying that patients will have choice, but there will be big consortia saying, “This is what is best for you—buy this”, focusing on the areas of highest profitability. Those consortia might prefer to deal in cataracts rather than, for argument’s sake, chronic conditions. They might choose to focus in certain demographic areas with different health trends. A business focus will be applied according to the returns that can be gained in different areas rather than simply focusing on what is right for each person.
Neil Carmichael (Stroud) (Con)
Is it not possible that doctors’ consortia will simply make the right decisions for patients, focusing on giving proper value for money and decent care and on responding properly to local requirements and needs? Would not that apply across the piste in terms of community hospitals and acute hospitals?
Geraint Davies
The taxpayer invests in GPs to provide medical and clinical excellence so that they can diagnose people’s health problems. The taxpayer does not invest in them to become small business people who go around trying to maximise profit and work out rates of return on different sorts of health care. That is the problem with introducing privatisation and marketisation: the thought in the back of the business person’s head is how to make money, not simply what is the best diagnosis. The customers whom GPs are facing—patients—are to a large extent ignorant. It is not like buying electricity from npower: patients do not know what is wrong with them. They are in the hands of their GP and they do not know whether what they have been prescribed—perhaps a cheaper drug that makes a higher profit but is not as effective—is right: they just have to guess.
Mr Graham Stuart
Rationing is inevitable in any system, but who should best do it? Should remote managers do it away from patients’ needs, or should GPs do it in a way that involves managing and being aware of a budget but trying their best, within that budget, to deliver the best health outcomes for all their patients? Who is better—PCT managers or GPs?
Geraint Davies
A GP must always ask what the best treatment for the patient is rather than what the best treatment for their business’s profitability is. That is why this is fundamentally wrong.
Geraint Davies
I shall not give way.
The Bill is setting up an incentive system that will make GPs make the wrong choices. It will return the NHS to a sort of pre-Nye Bevan, atomised system of health, rather than a planned system that uses resources efficiently. The system will lend itself, in the new era, to duplication, profiteering, businesses going bust and waste. What is more, there is no political mandate for the Bill; it is a Trojan horse of privatisation that no one knew would come. The changes will probably cost £3 billion or £4 billion to administer and will clearly set us back a number of paces before we move forward—if we do move forward.
A few people have mentioned the excellent work of John Appleby, the chief economist of the King’s Fund, who wrote in the British Medical Journal that the rate of deaths from heart disease is falling much faster here than in any other European country. It is falling to such an extent that it will be lower than the rate in France by 2012 even though we are spending 28% less. In terms of relative efficiency, we are doing well. Breast cancer rates have fallen by 40%, compared to 10% in France. I am not complacent and I do not pretend that there should not be greater productivity. If I had to point to one area in which there should be greater productivity, it would be the fact that we pay GPs too much money. That is the fault of the previous Government for negotiating a situation in which GPs can make more and more money. Now, it seems, we are encouraging them along that track, as though making a load of money were the primary focus.
My basic point is that if it ain’t broke, don’t fix it. Reform, yes: breaking the system, no. The Bill is not evidence-based. We are hurtling ahead, although people do not know the likely downside—the duplication, the amount of profit, the failures and possible hospital closures. The Bill is not economically sound or robust.
I have mentioned other difficulties one of which is that we make GPs subcontractors who want to maximise profit. In Wales, there is a move towards directly employing consultants and GPs, as opposed to giving them free rein on profit maximisation. Assuming that the Labour party wins in the Assembly election in May, we will see over the next five years the emergence of parallel systems, one of which will be a modernised version of the traditional health service and the other a marketised system. There is a conflict of interest between the profit motive and patient care, particularly in chronic conditions.
If aggregate supply is to be provided by a group of GPs, as opposed to a PCT, there is the risk of local shortages—of flu vaccines, for example. There might be local shortages in one area and excess supply and waste in other areas because of the absence of a strategic plan to deliver the right aggregate and match supply and demand.
In terms of customer and consumer watch, something called HealthWatch is to be introduced. Given the Government’s record in getting rid of Consumer Focus and bundling it in with Citizens Advice, I have little faith in the effectiveness of HealthWatch in looking after patients who, as I mentioned, are relatively ignorant of the product they are offered and face a local monopolist.
With reference to lifting the cap on private patients, as my right hon. Friend the Member for Croydon North (Malcolm Wicks) said, there is a risk that BUPA, for example, might suddenly funnel a lot of its patients in one direction because of discounted purchases, crowding out patients in a certain area. That would lead to unpredictability in the system.
We are asked to believe that the abolition of 150 PCTs and 10 strategic health authorities will miraculously save us some 45% of current expenditure. The people of Wales will make the right decision in May.
Julian Sturdy (York Outer) (Con)
It is a privilege to be called to speak in today’s debate at such a late hour. I shall try and keep my comments as brief as possible to allow other Members to get in.
Alongside the economy, crime and employment, the performance of the NHS and the provision of local health care is of the utmost importance to most, if not all, people. Health care is rightly viewed as an indicator of a community’s well-being, prosperity and happiness. I know that some hon. Members may disagree, but I firmly believe that all elected Members, on both sides of the House, share a genuine desire to protect and enhance our NHS. Unfortunately, party politics too often comes into health debates. I fear that some Opposition Members have proved that again today.
We all want to improve our NHS services, cut waiting lists, increase cancer survival rates and improve patient experience. Those are certainly the desired outcomes that my constituents want to see.
I truly believe that doctors, nurses and paramedics carry out tremendous work, often in the most testing conditions. We must get away from the idea that a desire to reform the NHS radically equates to some sort of insult to the commitment, ability and performance of NHS staff, because it does not. I am interested in the Bill’s reforming potential because of the conversations that I have had with concerned, exhausted and demoralised NHS professionals.
The NHS is indeed a national treasure, and I can safely say that I will always support it having a place in our society. Such sentiments echo what has already been said by the coalition Government, who from day one pledged to increase spending on health services and shall now do so by no less than £10.7 billion over the course of this Parliament. However, as my right hon. Friend the Member for Charnwood (Mr Dorrell) noted, future demands on the NHS will be unprecedented. Despite the best efforts of NHS staff, our performance has fallen, compared with other countries in the OECD, on respiratory diseases, heart attacks and cancer survival rates. Too much top-down control, too little patient consultation and too many Government-driven targets have brought unsustainable pressures to those on the NHS front line.
Reform is necessary, and it is clear that this broad piece of legislation contains a host of reforming measures. One of the most discussed aspects of the debate is the abolition of the PCTs and the devolving of commissioning to GPs, which I wholeheartedly support. In North Yorkshire, the local primary care trust has been an issue of concern for some time, and in December I secured a Westminster Hall debate on the matter. Concerns from constituents, the voluntary sector and local practitioners were all raised. In essence, the local PCT has in part inherited and in part created a substantial budget deficit running into millions of pounds. As a result, local services such as the provision of back pain relief injections have been withdrawn, impacting severely on the lives of thousands of residents across the region. The local primary care trust’s bureaucratic approach highlights the overall failures of PCTs. I could go on, but time is pressing.
I will mention one further concern. Although I welcome the specific reform, I believe that what happens during the transitional period from PCTs to GP consortia is vital. Services, patients and performance levels cannot be allowed to slip during that important period. I urge Ministers to ensure that all the preparations are in place so that that does not happen.
In conclusion, I very much welcome this truly reforming Bill and pay tribute to the Secretary of State for the work he has done on it. I care passionately about the NHS and its future ability to provide world-class health services for the whole country. I do not believe that it would be morally right to allow the NHS to continue to suffer from top-down, bureaucratic, state-led management. We should and can put patients first, with a flexible health care service that is able to respond to local needs. The Bill will not endanger the NHS, as some Opposition Members might claim, but it will enhance it through the empowerment of patients and local health professionals.
Mr David Anderson (Blaydon) (Lab)
I rise to speak not only as a former official of Unison, the biggest trade union in the health service, but as a former care worker. Like most other union officials who have been bad-mouthed as the voice of conservatism, I have actually worked in taking care of people. Perhaps once in a while the people who have delivered services to the vulnerable, the sick and those in need in this country might be listened to. The last time the Conservatives were in power, they did not listen to the voices of such people about the health service, which is why we saw the introduction of compulsory competitive tendering, which led to hygiene-related diseases. We saw massive waiting lists and people waiting on trolleys in corridors.
I do not want to put my views tonight, but the views of the people who work in the health service, such as my GP, who asked me this morning how, if we are to go through all these changes, he will be able to take the time off to learn business administration and how to use a computer properly so that he will be able to challenge the people who will run his service. The King’s Fund says that it questions
“the need to embark on a fundamental reorganisation when evidence shows health outcomes and public satisfaction have improved.”
The hon. Member for Totnes (Dr Wollaston) says that
“it does look like somebody has tossed a hand grenade at the PCTs”
and, even more importantly:
“If the expertise isn’t there…inevitably they’re going to be having to turn more to the private sector.”
Dr Hamish Meldrum, chairman of the British Medical Association, says:
“Ploughing ahead with these changes as they stand, at such speed, at a time of huge financial pressure…is a massive gamble.”
He also says:
“We will quickly see failed consortia bought up on the cheap by foreign companies and see bits of the NHS run from abroad.”
Sir Richard Thompson, president of the Royal College of Physicians, says:
“The fragmentation of services would have detrimental impacts on the various areas the reforms seek to improve”.
Dr Peter Carter from the Royal College of Nursing says:
“The RCN is also concerned that the fragmentation could result in unexplained variations in service, a reduction in collaboration and less sharing of good practice—all of which impact on quality care.”
He also says:
“We don’t think it’s been properly thought through… In May last year the average waiting time was nine weeks. Our concern at the moment is that short-sighted false economy will end up costing the public money and result in patient care going backwards.”
The head of Arthritis Care says that
“the Bill risks creating a ‘free-for-all’ situation where only those patients who shout the loudest will get the services they need.”
In a letter to The Times on 17 January, the leaders of six professional health service organisations said:
“The scale and ambitions of the cost-reform programme are extremely risky and potentially dangerous.”
Last Monday, in a letter to The Times, 190 nurses from one trust said that the
“figures from the Royal College of Nursing show 27,000 nursing posts are being cut. These proposed reforms will make matters much, much worse…The proposed reforms will be rapid, costly and staggering in scale: they presage nothing less than the complete reconstruction, if not privatisation, of the NHS”.
This morning, in the Newcastle Journal, 12 doctors representing people from Northumberland in the north to Yorkshire in the south said that
“enforced financial competition, creating a health ‘market’, risks damaging our health service. Forcing GP consortia to tender contracts out…runs the huge risk of seeing large commercial, profit-driven companies entering the market. They will pursue the most profitable contracts…and ignore aspects of healthcare which are not profitable, leaving behind ‘Cinderella’ services. There can be no doubt that the use of their size to undercut on price…could damage local services in the north-east.”
Those are not my words. They are the words of those we as a nation trust to take care of the people who send us here. To rubbish them, like Government Members have done tonight, as the voices of conservatism means just one thing: arrogance. It shows that they are not prepared to listen to those who take our people forward and look after them. [Interruption.] No, I am not going to sit down; other people want to speak. The truth is that the people of this country will never forget that, and they will not forget the human shields in the Liberal Democrats who are giving cover to that policy.
Nick de Bois (Enfield North) (Con)
I am very grateful for this opportunity to contribute to the debate. It is a great relief to note that we are now having a debate, having passed the stage where people, such as the previous Government, believed that pouring in more money improved outcomes. We are now debating reform, and we should welcome its scale, so that we can head towards what patients want—improved outcomes.
Whatever the good intentions of the previous Government, there is no question but that, unfortunately, their measures led to reduced productivity, a massive increase in bureaucracy and a distortion of clinical priorities, which meant that, on the outcomes that we seek, patients were not satisfied. I have been more concerned about health outcomes and the fact that patients were becoming remote from the thing that mattered to them most. That is what the NHS is about. Whom do patients trust? Do they trust a remote primary care trust or their local doctor? There really is no contest, so I welcome these reforms, because they will give commissioning powers to GPs and bring their patients closer to the decisions about their future.
I do not recognise the picture painted by Opposition Members who say that GPs do not welcome the proposals. Already more than half the country is working under the pathfinder shadow consortia, and in Enfield we are already rushing to sign up. We have agreed our consortium, which I warmly welcome. It is keen to seize the opportunity.
Let us turn to local accountability, which goes hand in hand with local commissioning-based services. In the past, it has proved impossible to have genuine local accountability as the NHS processes ultimately all led directly to Whitehall and the Secretary of State. I agree with the Nuffield Trust that the widening involvement of independent providers, the use of social enterprises and community services, and the increase in foundation trusts mean that local accountability mechanisms should indeed be robust.
The right hon. Member for Croydon North (Malcolm Wicks), who, sadly, is not in his place, and the hon. Member for West Lancashire (Rosie Cooper) expressed concerns that the mechanisms would not be robust, but I refer them to clause 170, on independent advocacy services, and to clause 175, which emphasises the scrutiny role of the local health authorities, not to mention the local representation of councillors. [Interruption.] The hon. Member for Leicester West (Liz Kendall) says, “One” from a sedentary position, but I shall not take lectures from a member of a party whose Government carried out no consultation as they tried to reconfigure services in Enfield against the wishes of the public. I shall turn to that now.
It makes no sense that the people who want to hold the health care community to account for their local services should have to go to an intransigent bureaucracy and ultimately up to the Secretary of State. That process is removed from where the local decision making takes place. As I said, in my constituency we are reaching a critical stage now in the future configuration of our acute hospital services. The decision prompted by the previous Government, to downgrade and rip out our vital A and E service and axe the consultant-led maternity services that see 3,000 births a year, is being relentlessly pursued by those same bureaucrats and officials from the health services, despite the fact that the decision will cost lives.
In ignoring the wishes of thousands who took to the streets and the view of the majority of Enfield GPs, those same PCT officials, even at this late hour, are effectively trying to bully the residents into accepting the changes without the consent or consultation of the people. No such arrogance would have been evident if this Bill had been in place. Local people would have been engaged in a genuine process of change because such a proposal would have had to have been agreed by the local health and wellbeing board. As the Secretary of State said yesterday morning, any possible future changes would have to be agreed in the health and wellbeing board of the local authority, which is publicly open and accountable. Gone is the “Whitehall knows best” attitude, to be replaced with local accountability, local engagement and local decision making.
Had the Bill been in place as law, I do not believe that we would have reached the 11th hour for this critical decision in Enfield. The four tests that the Secretary of State rightly requires would have kicked the issue into touch long ago because of genuine local accountability. The local authority, local GPs and, above all, local residents have spoken with one voice. I am grateful that we have a Secretary of State who believes in local accountability and decision making. In future, the voice that was ignored by the Labour party will be enshrined in this legislation. For years, we have suffered from a lack of local accountability in the health service.
Henry Smith
Had the Bill been law 10 years ago, Crawley hospital would not have lost accident and emergency and maternity services. It seems that my hon. Friend thinks the same about hospital services in his constituency.
Mr Speaker
Order. The hon. Member for Enfield North (Nick de Bois) is being generous in giving way, but I remind him that the Front-Bench winding-up speeches begin at 9.39 pm.
Nick de Bois
Thank you, Mr Speaker.
For years, we have suffered from a lack of local accountability in the health service. The Bill delivers that accountability. For the health service, the Bill is evolutionary, building on the successes and correcting the failures of the past, and leading to improved outcomes. This revolutionary Bill decentralises power to local people.
Derek Twigg (Halton) (Lab)
This has been a fascinating debate with some interesting and excellent speeches. Some 17 Labour Members and a similar number on the Government Benches have given a variety of speeches, some showing great knowledge and some not so much. I particularly congratulate my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) on her excellent maiden speech, in which she demonstrated her great knowledge of the health service and her background in it. I am sure that she will make many more such speeches and be a great success in this House.
I would like to thank the NHS staff for all the work they do every day in our health service. That includes those at PCTs; one might sometimes think that they were ogres, given how PCTs are described by some Government Members. They work very hard, and they, too, have to deliver the changes that will take place as a result of this Bill.
The Secretary of State is pushing ahead with the Bill despite criticism from all sides. Patient groups, professional bodies and health experts have attacked the plans as high cost, high risk, a danger to the commissioning of key health services, and a distraction from the need to find efficiencies. The heads of the British Medical Association, the Royal College of Nursing, the Royal College of Midwives and the Chartered Society of Physiotherapy, as well as union leaders, have described the reforms as extremely risky and potentially disastrous. The more they see, the more they become concerned. The clear message that we have been getting is that the proposals have come at the wrong time, they are ill conceived, and a lack of attention has been paid to stakeholders’ concerns.
The Secretary of State has ignored the massive improvements that took place under the Labour Government. One would think that he was talking about a different health service, because we had record numbers of doctors and nurses and record low waiting times. I wonder whether the Minister will confirm, as the Prime Minister and the Secretary of State have not done so, that there will be no increase in waiting times during the life of this Parliament. There have been record levels of patient satisfaction, with 71% agreeing that Britain’s national health service is one of the best in the world—the highest figure on record. That is also evidenced by the satisfaction levels recently recorded across user groups, with, for instance, 91% of GPs and 90% of out-patients satisfied. The argument that the NHS is in crisis and is not dealing with patients’ concerns does not stand up. It is important to look at some of the other improvements that have taken place. In June 2010, 90% of admitted patients and 98% of non-admitted patients were being seen within 18 weeks. The coalition has scrapped the targets that delivered those improvements to patient care.
Several Members referred to international comparisons. Let me take the example of the Commonwealth Fund, which ranked the UK first for efficiency and effective care in a study of seven top health care systems. In its 2010 international survey, it found that 92% of people were confident that they would receive the most effective treatment when sick—the No. 1 figure among comparable nations.
A lot has been said about cancer mortality. From 1997 to 2008, cancer mortality rates in all regions of England decreased by between 17.5% and 23%. Even more pronounced improvements have been observed in mortality from circulatory diseases: between 1995-97 and 2006-08, the mortality rate for England fell by 47%.
There are many uncertainties and unanswered questions about the Bill. There are concerns about who will be involved in commissioning and whether it will include other clinicians such as hospital doctors, physios and, importantly, nurses. How do nurses fit into the structural regime? In an article in today’s edition of The Times, the Prime Minister says:
“Nurses too will continue to play a vital role. GP consortia will have a statutory duty to work with nurses and other healthcare professionals, ensuring they have a real voice in shaping better care for patients”.
The Royal College of Nursing says that it was interested to see this, because it does not believe that the Bill goes far enough for it to be possible to claim that that is a statutory duty. Perhaps the Minister will respond to that, too. The only provision that the RCN believes relates to that matter is new section 14O in clause 22, which states that commissioning consortia must obtain appropriate advice. It does not believe that the Bill goes far enough in ensuring that commissioning consortia have relevant multi-disciplinary expertise to commission appropriate care.
I should like to turn to Monitor and competition—an aspect that has not been much mentioned. An ideological commitment to competition on price and to a massively increased role for the private sector is at the heart of the Conservatives’ proposals, despite their attempts to hide it. On 17 January, in a 700-word article in The Times, the Secretary of State did not mention the word “competition” once, but the Government have had to reveal where the true thrust of this legislation lies. Of course, he did not mention it much in his speech today, either. The Prime Minister told the House that
“what we want is a level playing field for other organisations to come into the NHS.”—[Official Report, 19 January 2011; Vol. 521, c. 831.]
When we appeared together on “Newsnight” a couple of weeks ago, the Minister of State, Department of Health, the hon. Member for Chelmsford (Mr Burns) said:
“It is going to be a genuine market. It is going to be genuine competition.”
The Government have hidden the great bulk of the ideological market and competition changes from public view. There is the introduction of competition on price. Monitor will have the power to direct consortia to put the provision of services out to tender, irrespective of what the GP consortia say. The Minister wants to deny that, but it is what we read in the Bill. Monitor will be driving this, not the GP consortia. Government Members should be reading that part very carefully. NHS resources, such as beds and staff, will be used without limit to treat private patients as the cap on private patients in hospitals is lifted. That means that private patients may jump the queue while NHS patients are waiting for treatment. Services or whole hospitals may be forced to close as the most profitable patients are cherry-picked by private providers.
Robert Flello
Does my hon. Friend recognise the effect when a local MP sets up a big campaign? In my constituency, I may well be doing that with the Sutherland centre, which is under threat. The local MP will have no influence or power at all because of Monitor’s role.
Derek Twigg
The issue of accountability for this House—what we can and cannot do—is important and I will come on to it if I have time.
I turn to the Liberal Democrats. The hon. Members for Burnley (Gordon Birtwistle) and for Manchester, Withington (Mr Leech) suggested that the Bill will protect hospitals and wards from closure. I am afraid that it will not. They need to read the Bill again. Monitor will be driving a lot of this, and they need to be clear about what the Bill actually does. They should join the hon. Member for St Ives (Andrew George), who is taking the interesting stance of not voting for the Bill tonight. He understands it better than other Government Members.
Concerns over fragmentation and obstacles to integrated working have been raised by numerous bodies in the health service and by those who work in the health service. The Commonwealth Fund states that the UK has the best co-ordination between health care providers and professionals, with the lowest percentage of patients having experienced co-ordination problems in their care. Only 10% of patients have received conflicting information. The more privatised, competition-driven systems in Australia and the US experience greater co-ordination problems.
The King’s Fund brief for this debate states:
“The Bill signals a significant shift towards a more competitive market for health care. While we support increased competition in areas where it demonstrates benefits to patients, the Bill appears to move towards promoting competition at the expense of collaboration and integration.”
That is from one of the most respected think-tanks.
One cannot underestimate the huge powers that will be given to Monitor. It will expose the NHS to a rigorous competition regime, with services going out to tender. The explanatory notes state that Monitor will become the
“economic regulator for all NHS-funded health services”,
with the power to
“do anything it needs to in order to exercise its functions.”
In other words, the NHS will become like a utility.
Of course, the Government are full of broken promises. The Prime Minister said that there would be real-terms increases in NHS spending, but there are not. He said that there would be no cuts, but there are. He said that there would be no top-down reorganisations, but we have a top-down reorganisation. David Nicholson said that
“no one could come up with a scale of change like the one we are embarking on at the moment. Someone said to me ‘it is the only change management system you can actually see from space’—it is that large.”
This is a massive change. There are other issues, such as the cuts in staff that are taking place and the vacancies that are not being filled. We are being told about that by people who work in the health service. That is the true nature of the health service under the Conservatives and the coalition.
We are in favour of improving the quality of care, driving up standards, greater clinical involvement and giving a greater say to patients. We are therefore not anti-reform, but we are against this reckless, top-down reorganisation with a cost of £3 billion, which was hidden away during the general election campaign. It is reckless, it is not in our best interests and many believe that it will be the end of the NHS as we know it.
The Minister of State, Department of Health (Mr Simon Burns)
When NHS funding has reached the European average, but the outcomes for care have not; when doctors are seeking to improve the quality of care but are hindered by politically imposed targets; and when the defence of bureaucracy is put above front-line services, we know that something has gone very wrong. That is why the coalition Government will act, act now and act with determination to improve and modernise our national health service. The Bill will create an NHS that puts patients first, that frees clinicians to deliver the best and most innovative care they can, and that focuses on what matters most to patients—health outcomes.
This has been an interesting debate, although at times, sadly, not a well informed one. I begin, however, by congratulating the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) on her fluent debut speech in the Chamber. I wish her every success in her future contributions, although I warn her that she will not get such a quiet ride next time around. I also congratulate my right hon. Friend the Member for Charnwood (Mr Dorrell) on an interesting and incisive speech, and my hon. Friends the Members for Boston and Skegness (Mark Simmonds) and for Central Suffolk and North Ipswich (Dr Poulter). The latter has great experience, having worked in the NHS.
I wish also to congratulate a number of my other hon. Friends on interesting contributions, including my hon. Friends the Members for Mid Bedfordshire (Nadine Dorries), for Basildon and Billericay (Mr Baron)—we will certainly write to him with answers to his questions—for Winchester (Mr Brine) and for Loughborough (Nicky Morgan).
It is always a delight to listen to the Member who, I suspect, is probably best described as the old Labour dinosaur, the right hon. Member for Holborn and St Pancras (Frank Dobson). I also enjoyed the elegant contribution of the right hon. Member for South Shields (David Miliband). Having listened to his fluent speech, all that I can say is, what a difference opposition makes. It is interesting that what he supported as part of a Labour Government in power he now seems to have abandoned in opposition. The hon. Member for York Central (Hugh Bayley) asked a number of intricate questions, and given the time that I have, I promise that I will write to him with answers to all of them.
Hon. Members might find it helpful if I debunk a few of the myths that have sprung up about our plans to modernise the NHS. The first, and perhaps the most insidious, is that they were kept secret and hidden from the electorate. Quite frankly, that is palpable nonsense. In June 2007, my right hon. Friends the Secretary of State and the Prime Minister, when in opposition, published the Conservative party’s white paper, “NHS Autonomy and Accountability”. It laid out our clear intentions, which we reiterated on pages 45 and 46 of our election manifesto. We said, as a commitment to the British people, that we would
“give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers.”
We stated that we would
“strengthen the power of GPs...by...putting them in charge of commissioning local health services”
and
“set NHS providers free to innovate by ensuring that they become autonomous Foundation Trusts”.
We also stated that we would create an independent NHS board. It is quite ludicrous to suggest that we did not tell the British people our plans both before and during the election campaign.
A second myth is that our plans to modernise the NHS are revolutionary. In fact they are evolutionary and an extension of the policies of previous Administrations, notably the Blair and Brown Governments. That is particularly true of the move towards the “any willing provider” principle and patient choice. In 2003, when the Labour Health Secretary Alan Milburn moved to introduce a plurality of providers and patient choice, he argued that
“the NHS cannot be run forever like a 1940s-style nationalised industry”.
He was right. The NHS needs the constant drive of improvements to raise standards and improve outcomes.
More recently—perhaps Opposition Members would like to listen to this—in 2007, the Labour Prime Minister, the right hon. Member for Kirkcaldy and Cowdenbeath (Mr Brown), gave evidence to the Liaison Committee. He stated:
“We have been asking in people from the private sector to review what we can do to give them a better chance to compete for contracts...so the independent sector increases its role, will continue to increase its role and, in a wider and broader range of areas, will have a bigger role in the years to come.”
He said:
“The test at the end of the day is not private versus public, it is value for money, and it is not dogmatic to support one against the other.”
In 2008, he said:
“We will continue to open up acute care with…choice of hospitals trusts across private and public sectors in England…including more than 150 private sector hospitals working as part of the NHS and at NHS cost and standards of quality. We will use all mechanisms available to us to improve our NHS—public, private and voluntary providers can all play their part”.
This Government have also been falsely accused of wanting somehow to privatise the NHS. Privatisation is defined as making people pay for their health care. That is not going to happen under this Government. This Government are totally committed to the values of the NHS: paid for through general taxation; free at the point of need; and always based on clinical need and never on a person’s ability to pay.
Others have erroneously claimed that any involvement of the private sector will undermine the public sector ethos. That is a rather surprising view, considering that it was the last Labour Government who embraced the private sector. I shall quote Dr Howard Stoate, who was recently elected chair of Bexley’s shadow GP consortium. Opposition Members will remember that, until the last election, he was the Labour Member of Parliament for Dartford. In a recent article in The Guardian, he said:
“We have found the idea that services can be offered by any willing provider can actually strengthen the ethos of the NHS rather than weaken it.”
Dr Stoate went on to say that, in his experience, GPs
“reveal overwhelming enthusiasm for the chance to help shape services for the patients they see daily…Far from miring GPs in bureaucracy...GP commissioning can free them to operate more effectively.”
This Government have one simple objective for the NHS: that it should give patients health outcomes that are consistently among the very best in the world, including higher survival rates, greater clinical effectiveness and safer care for patients. Excellence cannot be delivered by having Ministers bark orders down the chain of command. It is done by encouraging innovation and creativity, and by putting the interests of patients ahead of the system and of tomorrow’s headlines.
We will free local clinicians to use their expertise to shape local services. We will free patients to choose the best possible care for their specific needs. We will bring a culture of openness and transparency to the health service, and we will allow any willing provider to compete to provide the best patient care. These plans are consistent, coherent and comprehensive, and they will deliver care that is free at the point of use for all. They will build on the best of what has gone before.
Some say that the reorganisation of the national health service will cost £3 billion, but that is factually incorrect. The impact assessment shows that there will be a one-off cost of £1.4 billion. It also demonstrates how the changes will pay for themselves by 2012-13, saving £5.2 billion by the end of this Parliament. They will continue to save £1.7 billion in every year after that, up to the end of the decade. Every penny of those savings—the equivalent of 40,000 extra nurses, or 17,000 extra doctors or 11,000 extra consultants every year—will be completely and totally reinvested in front-line services, not wasted on back-office costs.
As society evolves, so too must the NHS. The Bill will deliver a modern NHS fit for the 21st century. It is the natural progression of the original vision to deliver the finest health care for all our citizens, remaining true to the founding principles set out by Nye Bevan.
Question put, That the Bill be now read a Second time.