Health and Social Care (Re-committed) Bill

Rosie Cooper Excerpts

Tuesday 6th September 2011 Commons Chamber

[Mr Lansley]

I said that I would come on to the continuing role of the OFT in relation to mergers, and I will.

Returning to this substantial group of Government new clauses and amendments, the purpose of which is to set out the regime for the continuity of services, our new proposals focus on five particular changes. Together, the proposed changes significantly improve upon the existing situation. First, the Bill puts clinically led commissioning at the heart of securing high-quality services for local populations. It is therefore right that commissioners should have a leading role when continuing access to services is threatened. Our amendments therefore strengthen the role of commissioners. For the first time, commissioners will have an explicit role in working with Monitor to agree plans to secure continuity of services.

There will also be an oversight role for the NHS commissioning board. Where issues involve more than one clinical commissioning group, it will be the board’s role to co-ordinate agreement so that a joint plan is agreed. Secondly, commissioners will need to be supported in acting with providers to ensure that they have access to the scope, quality and choice of services they need. It is about promoting high-quality, effective and integrated services, as set out in clause 58. This will be the task of Monitor.

If need be, when continued access to services is threatened because of failure occurring in a particular provider, Monitor will have a range of actions it can take. For example, it could take action to secure sustainability of essential services by adjusting prices. This would be necessary where a provider is otherwise unable to cover the costs of essential services—for example, because of lower patient volumes in more remote areas of the country. That was included in the Bill from the outset, and our amendments strengthen the provisions by ensuring that Monitor must agree the methodology with the NHS commissioning board.

[Rosie Cooper (West Lancashire) (Lab)]

Will the Secretary of State be clear on this issue? Can the enhanced tariff that I think he is suggesting Monitor can use to save a provider apply to private companies as well as the NHS?

[Mr Lansley]

It would apply in any circumstances where it was necessary in order to secure continued access to essential services for patients, so a methodology would be in place. As I have described, the intention is to have a regime through which, although specific mechanisms will be applied to foundation trusts and to other providers—of course, the overwhelming majority of activity is in the hands of foundation trusts—the principles of intervention will be the same between the two sets of providers. We want to arrive, wherever possible, at a consistent application of failure rules. Why? Our concern is to make sure that we deal with this, which has not been the case in the past. Under Labour’s regime, if a private sector or independent sector provider failed financially, there was no appropriate mechanism for intervention and continuity of services.

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[Mr Dorrell]

I am grateful to the hon. Gentleman, who is a member of the Select Committee, because he provides me with a link to my next point—I was beginning to wonder how I was going to get on to it.

The health service has not always provided services from a public sector provider. Until this Bill and the powers it gives to Monitor, regulatory bodies in the public sector had not had the opportunity to inquire into the sustainability of services provided by private sector providers. My right hon. Friend the Secretary of State made the point that the role of Monitor under the Bill is to ensure first—if I may repeat myself—that foundation trusts are of a high quality when they are launched; secondly, that they are accountable for retaining their high standards; thirdly, that we intervene early if they start to go off the rails; and, fourthly, that if they get into serious difficulty, we have the capacity, through Monitor, to continue to deliver continuity of service to those who rely on public health provision, whether from an NHS foundation trust or, as a result of the Bill, for the first time from the private sector. I regard that as a significant step forward in the delivery of continuity of care for NHS patients, whether provided, as the vast majority still will be, by public sector institutions or by some of the independent sector treatment centres introduced by the previous Government.

[Rosie Cooper]

Does the right hon. Gentleman think that standards can be maintained, and be seen to be maintained, in foundation hospitals if they are allowed to do what they are currently doing, which is not to disclose all information relating to, for instance, complaints procedures or whatever? Furthermore, does he not think that board meetings should be held in public?

[Mr Dorrell]

My understanding is that the Government have clarified that foundation trust board meetings should be held in public and that, in future, it will be a requirement of licensing by Monitor. On the much broader point, I absolutely agree—the hon. Lady, who is another member of the Select Committee, knows that I agree—that providers of care to NHS patients, whether public or private, ought to have an obligation to provide information on the outcomes that they achieve and certainly on any complaints and other processes initiated by patients about the care they receive. That was one of the strong recommendations that the Select Committee made following its work on complaints. I think that that obligation ought to rest on all providers of care to NHS patients, whether they are foundation trusts or any other form of provider.

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[Grahame M. Morris]

I am afraid I do not agree with the hon. Lady, as she might expect. The Secretary of State said that it was a question of communication, but I suspect that part of the problem with the Bill is that, far from there being additional clarity, the more that Members of Parliament, the medical profession, health care workers, members of the public and informed commentators have examined the proposals in detail, the greater the number of concerns that have arisen.

If the Secretary of State had been open and honest about the direction of travel and the motivation for these health reforms, perhaps we could have avoided some of the confusions that have arisen. There is no electoral mandate for a huge structural review and reorganisation. I suspect that there is something seriously wrong with the whole privatising agenda and philosophy, which the Secretary of State denies.

[Rosie Cooper]

Does my hon. Friend believe that misinformation and emotive language almost began and ended when the Prime Minister said that the NHS was safe in his hands? The misinformation began when he fooled the British public into thinking that the NHS was safe. This is the result.

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[Grahame M. Morris]

I am grateful for that example. It illustrates the importance of that improvement, the value that people place on it and how critical it is to people’s health and well-being.

I know that we shall come later to the clauses that lift the cap on private patient work, which the Minister mentioned in his opening remarks. If the cap on private patient work in NHS foundation trusts is lifted and those trusts are under financial pressure—those of us who are in touch with our hospital trusts know that they are under financial pressure, with the reductions in the tariff and other issues—the level of private sector involvement in NHS trusts will increase.

[Rosie Cooper]

The hon. Member for Central Suffolk and North Ipswich (Dr Poulter), who is also a member of the Select Committee, pointed out that Labour reduced waiting lists and private providers were involved. Does my hon. Friend agree that the general public now face longer waiting lists and more private providers?

[Grahame M. Morris]

This is the danger. Labour Members have attempted to highlight it, and people are increasingly aware of it.

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[Mark Simmonds]

I will not get into the nuances and the legal battles that other hon. Members have raised. Professor Steve Field and his team did an excellent job thoroughly and comprehensively in a relatively short time. To be fair to the Secretary of State and his team, they looked carefully at the suggested changes and have incorporated some of them in the clauses before us. I agree with many of them, and I highlighted some of these points on Second Reading—a greater emphasis on integration, wider engagement with a broader range of clinical commissioning teams, and greater protection for services which, in financial or quality terms, may not be providing the service that patients expect. All those have been changed in the Bill.

Almost all the Members on the Government Benches would not support the Bill if it was about privatisation of the national health service. It is not. It tries to ensure that the national health service has a future, and that the organisation that is in the best position to provide a particular service in a particular geographical locality has the ability to do so. That is not just the private sector; it is the voluntary sector, the charitable sector, the not-for-profit sector and the social enterprise sector. The mantra coming from the Opposition seems to dictate that those organisations should not be allowed to provide health care—that unless health care is provided by the state, it should not be allowed. That clearly is wrong. What is important is not the delivery mechanism, but patient outcomes and the quality of service provided.

I shall deal specifically with new clause 2 and amendments 100 to 104, 106 and the subsequent related amendments. They ensure that equity of access continues, irrespective of whether the provider is in a good financial state or not. My right hon. Friend the Member for Charnwood (Mr Dorrell) put his finger on exactly the right point, as he so often does. What matters is continuity of service, but not necessarily from the same provider.

The national health service has always changed in that way. It has always reconfigured services to make sure that the patient receives care of the best possible quality. New clause 2 puts in place an essential mechanism to ensure continued access for patients to NHS services. It is right that the Government are putting in place safeguards to protect patients and taxpayers, but the clause does more than that. It also enables commissioners to replace services with higher quality and better value options. Among the major failures of the last decade in which Labour was in charge of the national health service was not only the decline in productivity, but the fact that there was insufficient decommissioning of poor services and insufficient replacement and improvement of poor-quality service provision. Nowhere is that more marked than in Tunbridge Wells and Stafford.

The primary purpose is to enable Monitor to support commissioners to access services and place conditions on a licence holder. Some of those conditions are set out in the Bill. All hon. Members know that there is considerable variation in performance of organisations within the national health service. Providers who are providing excellent services should be allowed to thrive, innovate and drive the quality of clinical care. Those that are under-performing will require challenging, and support where necessary. Ultimately, if they cannot respond to that support and that challenge, they should be replaced by an alternative provider. That should apply both to the independent sector and to state sector provision. It is not acceptable that, purely because a service is provided by the state, it should be allowed to continue as a substandard service.

Some of the key changes in the new clauses and amendments allow that to happen. They make sure that funding is much more transparent. The existing framework has allowed hidden bail-outs to take place, which all too often have hidden poor management, poor service provision, and the need for clinically appropriate and evidence-driven reorganisation. All too often that has not happened, to the detriment of patient care.

I was pleased to see that the Secretary of State had allowed a safety valve in this part of the Bill, which would enable tariffs to be topped up, particularly for the provision of services in rural areas, such as my constituency in Lincolnshire. This must not be seen as an opportunity for the Department of Health to support and subsidise inefficient management and service provision. All too often there are inefficient cost bases and money could be transferred instead to front-line patient care.

I would be grateful if the Minister, when winding up, confirmed some specific points relating to new clause 2 and the subsequent amendments. Will he confirm that the new system will ensure that innovation is not inhibited—that providers and clinicians will have to configure services not only to satisfy patients, but to improve the quality and productivity of services, which, as we all know, have been very poor in the past decade or so? Will he confirm that the structure set out in the new clauses will enable Monitor to intervene early to ensure that the service provided is safe and provides good-quality, patient-centric services?

Will the Minister also confirm that the proposals build on the system set out in the Health Act 2009, which is in line with the Secretary of State’s consistent assertion that the Bill is about evolution, not revolution? Ministers must not allow the importance of integrated services, vital though they are, to be an excuse to maintain poor-quality providers. In the interests of patients, underperforming incumbents must be challenged and continued innovation must be facilitated and incentivised.

If the Minister has time when winding up, I would like him to address the point that I made to my right hon. Friend the Member for Charnwood, which is that the new clauses seem to ensure that Monitor will maintain minimum-based standards, particularly as they relate to acute foundation hospital trusts. We need commissioners, the Care Quality Commission and Monitor to work together to ensure that there is continuing improvement in patient care and continuing determination and drive to make sure that services are better the next year than they were the previous year. It is unclear from the amendments who will be responsible for co-ordinating that effort to drive up standards continually.

I have two final questions. What will happen if Monitor has to step in to provide advice, shore up a service or provide an alternative service provider, but the commissioners cannot agree on who should be the subsequent service provider? Who will resolve disputes between two commissioning consortia? Will it be the NHS commissioning board, Monitor or the Department of Health? Where a provider delivers a service to more than one commissioner, and one of the commissioning groups has access to an alternative provider already in existence but not another, who decides who will provide the service that has failed?

I will draw my remarks to a close. I am, as I believe are most Government Members, an avid supporter of the national health service. I defer to no other group more than I do to those who work tirelessly in the NHS to provide the excellent care that, more often than not, is delivered, and not only in the state service but across the range of NHS providers. However, if we are to continue the NHS, free at the point of delivery and based on need, not ability to pay, it must reform and change. We cannot allow it to stand still. I believe that these clauses and amendments provide an essential framework to ensure continuity of access to service, value for money for taxpayers and better quality patient care.

[Rosie Cooper]

Members of the public listening to Government Members this afternoon might wonder whether we were having this debate in a parallel universe, because they have heard the Prime Minister promise that there would be no top-down reorganisation of the NHS, and what did we get? We got the biggest reorganisation in the history of the NHS. The Prime Minister said only recently that everyone was on board and behind the Bill, and yet we find that clinicians, professionals and the public are far from being on board. The Government talk about the protection of services, but the public will have read only yesterday that the Government are meeting McKinsey about the possible transfer, albeit a slow transfer, of up to 20 hospitals.

[Mr Simon Burns]

indicated dissent.

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[Rosie Cooper]

The Minister keeps saying no, but the reality is that, as I told the Secretary of State, you may very well be fooling yourselves, but you are not fooling the public, and the Bill was wrong. That was followed by a pause, and when you admitted that you had got various bits of it wrong, you then said—

[Mr Deputy Speaker (Mr Nigel Evans)]

Order. The hon. Lady must desist from using the word “you”, as it refers to the Chair.

[Rosie Cooper]

I apologise, Mr Deputy Speaker. Each time I said “you”, I meant the Secretary of State.

The Secretary of State simply threw the Bill at the British public after the Prime Minister had promised that this would not happen. I have been very clear in the speeches I have made so far on the Bill that the only people the Secretary of State is fooling are those in the Tory party. He has made changes to the Bill, but we are now beginning the great mix-up and going back to exactly where we were.

The hon. Member for Boston and Skegness (Mark Simmonds) said that Labour did not want progress and good value, and that the coalition programme was all about ensuring that the NHS survived and getting a good return for the taxpayer. Let me tell him that I am absolutely passionate about the NHS. I expect value for money, cutting-edge treatment, efficiency and the best possible care for everyone in this country. The lives of every taxpayer and every family depend on the care they get from the NHS. Second rate will not do for me at all.

However, I do not believe that throwing a grenade into the NHS systems will achieve that. Even breaking big promises will not achieve that, because that will break the trust. I suggest to the Conservative party that the Great British public gave tentative support during the general election and will now withdraw that support rapidly as the Bill progresses. The Conservatives expect the public to believe that the party that promised no top-down reorganisation and then broke that promise can be trusted when it says that there will be no privatisation of the NHS, yet evidence comes to light via freedom of information requests that that is not the case.

What are patients out there actually experiencing? Again, Conservative Members can fool themselves. When they went to accident and emergency units they saw that the four-hour waiting time was being exceeded, so they abolished it. It is already taking longer to treat fewer people, which does not strike me as particularly efficient or good value for money. It took 13 years of a Labour Government to rebuild the NHS after what the previous Conservative Government did to it. Labour reduced waiting lists from two years to 18 weeks. It has taken the coalition Government less than a year to wreck it all again. Broken promises are leading us to an NHS that is broken again.

Let us look at what is currently happening in the NHS. There are two different processes at work: financial efficiency gains and structural reform. The idea was to ask the system to make efficiency gains of 4% each year for four years. On top of that there is the reorganisation, which a Conservative Member has likened to tossing a grenade into the system. We have had muddle, pause, fog and are now effectively back to where we were some time ago.

The reforms do not address the financial challenges, especially the Nicholson challenge. This is costly—making people redundant, throwing organisations into disarray and telling people, “You don’t have a future, you might have a future,” “Let’s have a cluster, let’s not have a cluster,” “Where are you going to work?”, “It’s all going to disappear by 2013,” “There are no PCTs—well, they’re there really, but clusters will do the work,” “No, we don’t have strategic health authorities—well, okay, we’ll keep four of them.” The Marx brothers would be proud of the stops, turns, U-turns, pauses and muddle that there have been. But the bottom line is that the great British public have to watch those antics and are worried about their health service.

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

Does my hon. Friend have any idea of how much the reorganisation is going to cost? The hon. Member for Boston and Skegness (Mark Simmonds) made a very reasonable speech, but I noticed that he was confessing at the end that he did not know how some of the central parts would work, and he posed those questions. Does my hon. Friend have any idea of how it is all going to work at this stage, and what it will cost? If not, does she think it conceivable that enough members of the public can know, and have any confidence in the changes?

[Rosie Cooper]

I can categorically say that we have asked the questions over and again and we do not get any answers.

[Mr Burns]

The impact assessment.

[Rosie Cooper]

How much? I will give way if the Minister tells me exactly how much it is all going to cost. I shall happily sit down; there you go. [Interruption.]

[Mr Deputy Speaker (Mr Nigel Evans)]

Order. This is not a conversation but a debate. I do not think that the Minister indicated that he wished to intervene.

[Rosie Cooper]

Thank you, Mr Deputy Speaker. You will forgive me; my lip reading was obviously slightly wrong. He looked as if he was trying to tell me something, and I hoped that it might be the answer.

In all such situations I always say, “Follow the money.” What is actually going to happen? If this is costing a lot of money—there is a lot of muddle—it has to be really clear that the driver of the reforms cannot be, as the Secretary of State has previously said, the idea that the NHS is unaffordable; we seem to be able to afford a lot of other things. If the reason is not financial efficiency, it has to be purely ideological.

I understand that 85% of respondents to the NHS Confederation survey were very clear: the hardest job that they could have is to deliver both NHS changes and savings simultaneously. That makes it harder for them to deliver objectives for improving efficiency and quality—but that is what I am told that Government Members are all about; the Bill is supposed to improve efficiency and quality.

Who is going to deliver the health care? The Royal College of Nursing suggests that 27,000 front-line jobs, equivalent to nine Alder Hey children’s hospitals, will disappear. I asked the NHS Confederation whether we would see hospital closures, and it is clear that we will; we are seeing that in various reports. The Bill is three times longer than the Act that created the NHS, and it leaves more questions than answers. I say to the Government that if they believe that the great British public will be fooled by any of this, they are sadly wrong.

I do not normally make personal statements about anybody, but Roy Lilley, a former NHS professional, writes a blog in which he refers to the Secretary of State as “LaLa”; I am sure the Secretary of State has seen it. I have been hearing “La la” all afternoon. This is just nonsense. Just because the Secretary of State or the Tory party says that the world is square, that does not mean that it is. They are insulting the public if they think that they will go along with them.

Monitor makes decisions about the future sustainability of individual services and the patterns of local health services under the failure regime. It is unclear how those decisions would be made, and how and to whom Monitor is accountable. Technically it is an independent body and it should be responsible to Parliament and the Secretary of State, but perhaps the Secretary of State will clarify that.

As the economic regulator, Monitor is given a whole series of powers that ultimately focus on enforcing competition in the NHS. There are still fundamental gaps in how that organisation will be held to account. There is a lack of clarity about how health services can engage with and influence the work of Monitor. Having been chair of a foundation trust hospital, albeit only for a month—because I stood for Parliament and had to resign—I can say that Monitor was a law unto itself. And before the Health Committee, Monitor likened the NHS to utility companies, which does not give me any confidence whatever.

I want to talk about Monitor not consulting commissioners on changes to enhance tariff. Private providers can apply to Monitor for an enhanced tariff to preserve the services that they, as private businesses, are providing to the NHS.

[Tom Blenkinsop]

One essential point that we have to raise about Monitor is that it is a replica of an economic regulator of the utilities. The four to six companies in the energy sector have just raised gas prices by 18% and electricity by 11%. How does my hon. Friend think Monitor will be able to cope with private companies and health?

[Rosie Cooper]

I would suggest that it is a failing model, and not one that we should be looking at.

I should like to look at the idea of risk pooling, in which Monitor will have a role. Monitor will be required to top-slice the budgets of foundation trust hospitals to obtain that pool of money. The problem is that if the trust is already in financial difficulty, the fact that Monitor needs to top-slice the FT hospital’s budget could tip it into being unsustainable, and then Monitor would have to act. Does that not seem back to front? It needs looking at. If the foundation trust is unsustainable, Monitor has a duty to take action, yet Monitor may well have precipitated the situation; there seems to be a conflict at the core of that relationship. There is no clarity about how top-slicing will be calculated, or what it will involve. Will the Secretary of State please comment on that?

I shall bring my comments to a close with a quotation that I used in a speech I gave a while ago. In “This Week”, Michael Portillo was asked by Andrew Neil why the Government had not told us before the general election about their plans for the NHS. He replied:

“Because they didn’t believe they could win the election if they told you”—

the public—

“what they were going to do. People are so wedded to the NHS. It’s the nearest thing we have to a national religion—a sacred cow.”

He could not have been more clear. The Government intended to misrepresent their position and mislead voters. I believe that this is the latest stage of that misrepresentation, and the Government must be held to account if they force the Bill through in its current form.

[Dr Poulter]

I was hoping to begin on a more consensual note, picking up on a few things that have been said around the Chamber on which I thought we could all agree. However, I will first remind the hon. Member for West Lancashire (Rosie Cooper) of why the Government are introducing this Bill. We do have problems in the NHS. Far too much money—about £5 billion a year—is wasted on bureaucracy and could be much better spent on front-line patient care. Over the past 10 years, the number of managers in the NHS has doubled, going up six times as fast as the number of front-line nurses; the hon. Lady is very concerned about that. A lot of things need to change in the NHS so that the service can become more patient-focused and patient-centred. That is why we are making these changes and why the reforms in this Bill have to go through the House.

Particularly important—this has come out of the pause for reflection and the Future Forum report—has been an increased focus on one of the key challenges for the health service and for adult social care: better care of our growing older population. People are living a lot longer and living longer with multiple medical conditions, or co-morbidities as they would be termed in medical parlance. That is a very big human challenge for the NHS, and also a very big financial challenge. We must have a service that better meets and better responds to those challenges. The pause for reflection has led to much more focus on improved integration of care, and that will be very much to the benefit of the older patients and frail elderly whom we all care about.

We have had a lot of discussion about the benefits, or otherwise, of using the private sector. The case for the private sector may have been made much more eloquently by Labour Members than by members of the Government. The hon. Member for Easington (Grahame M. Morris) argued that because the previous Government used the private sector to reduce waiting times, it was effectively used to improve patient care for patients with cataracts and for those needing hip operations or waiting for heart operations. That, in itself, was a good thing, but the problem was that the previous Government used the private sector far too much in a way that allowed it to make profits but not to look towards the integrated care that Government Members would like to see as a result of these health care reforms. As regards looking after the frail elderly, for example, there was cherry-picking of hip operations as part of orthopaedics but without the follow-up care that was required—the physiotherapy, occupational therapy and social services that those older people so badly needed. Yes, the private sector can bring value and benefits to the NHS, as the previous Government recognised, but it has to be done in an integrated way, and that is what we will do as a result of these health care reforms.

Why else do we need to reform the NHS? Are we really happy with the status quo?