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Mr. Bayley: I have listened with interest to the hon. Lady. She mentioned a considerable list of service improvements at the Queen Elizabeth II hospital over a five-year period and said that during that time the hospital's income had increased by only 3 per cent. in real terms. Earlier this afternoon, the Secretary of State said that the NHS had received a real terms increase of 3 per cent. in each of those years. Which figure is right? Is it 3 per cent. per year or 3 per cent. over five years?
Mrs. Roe: I was absolutely clear, but I shall repeat what I said so that the hon. Gentleman does not misunderstand me. He will find that I said that while various developments were taking place, the revenue funding available to East Hertfordshire NHS trust rose by only 3 per cent. Those in Hertfordshire complained because they did not believe that they were being generously over-funded, and colleagues from Hertfordshire have brought that to the attention of the House on numerous occasions.
Mr. Simon Hughes (Southwark and Bermondsey): This debate is rather like pass the parcel, with everyone hoping to get in before the match starts later on. For the information of the House, it is still nil-nil between France and the Czechs in the second half of extra time.
The debate was started by a set of assertions in the Labour motion that I hope the Government--although they would generally be unhappy about agreeing to them--will accept. These include the statements that NHS services are overstretched, however many resources are put in; that there is a shortage of intensive care beds, certainly where they are needed; that waiting lists are over-long and people cannot get the service at the place or time they want; that there are still people waiting on trolleys in accident and emergency departments; and that there is great pressure on community health services. There can be no honest dispute about those matters.
Whether or not it is the Government's policy, it is a fact--as the hon. Member for Peckham (Ms Harman) rightly said--that many people are driven to private health care, even though they would not choose to do so, simply because they cannot be treated in time. Although there will always be rationing in the health service, and the debate is not about "whether" but "how", the test of whether we have a national health service is whether it has the capacity to meet the clinical needs of people throughout the UK.
The key debate tonight is about whether we are spending money on unnecessary bureaucracy at the expense of and to the detriment of patient care. All the evidence and submissions that I have seen for this and other debates make it clear that we are. Bureaucracy has been growing and, in the words of my party's amendment--which was not selected--
I accept that the Government have always made additional capital investment in the NHS, and that there has been real terms growth throughout their period of office, but it is getting a bit thin. It is now down to an increase of 0.1 per cent. this year over the last, but the Government are just about making their manifesto commitment. The test that matters to people outside is whether that growth results in money being diverted to the patient.
There are issues that the Government have not yet accepted and addressed. For example, many people have experience of a two-tier health service. It does make a difference whether one is the patient of a fundholder or not, and one often does get seen more quickly as a patient of a fundholder. The reason for that is that the trust will take the fundholding patient because it wants to keep the
fundholder's contract rather than that of the commission or local health authority, because the trust can be more secure about the future of the commission's contract.
There is a real debate about making sure that money is properly spent and not wasted. The Government accept privately--although they may not do so publicly--that an unnecessary amount has been spent on bureaucracy as a result of the changes. We must all have constituency experiences--I certainly have--of local GPs and people working at, for example, Guy's hospital in my constituency who have given examples of bureaucracy gone mad in terms of the way in which people move from the moment their need is expressed to treatment. No one can be satisfied with that in the health service.
I shall refer to, rather than elaborate on, the professions I cited in an earlier intervention on the Secretary of State, who say that the system is far too bureaucratic and add that they are suffering under it. They are suffering not just because it is costing money, but because it is diverting resources and time, and demotivating them from the service that they want to provide.
First--the hon. Member for Peckham referred to this event also--a news conference was organised by the British Medical Association on 16 May, the report of which stated:
According to the RCN, the number of nurses fell by 2 per cent. in 1992-93 and by 1.27 per cent. in 1993-94. More worryingly--I hope that this concern is shared across the House, and I know that the Select Committee has declared its concern--the number of pre-registration students has gone down considerably, from 37,000 qualifying in 1983 to 14,000 in 1995. There is real concern about the future of people coming into the health service to train as GPs or nurses.
The RCN suggested two matters of particular concern. First, the introduction of local pay bargaining is extremely time-wasting and debilitating. There are now 488 sets of local pay negotiations--what a waste of time and effort. There should be a minimum guaranteed pay scale for nurses across the NHS. If one wants to top up that scale as a result of extra bonuses for work done--rather than negotiated pay--then that can be done.
It is noticeable that, as of a couple of weeks ago, out of the 488 employers in the NHS, only 111 had concluded negotiations four months after the pay review report. That is the first thing we could do to save an enormous amount of time and effort, and to stop distracting people.
Secondly, every year now, the commissioner, which is the local health authority, and the trust, as the supplier, must negotiate the contract. Contract negotiations year in,
year out, are the most time-consuming and frustrating exercises. Nobody in the public service wants a one-year contract, and we should get away from the idea that that is the way to run the NHS. That is what takes all the time, and that is where all these extra people are employed.
That is also what produces all the paperwork referred to by the hon. Member for Peckham. We must move very quickly, and I hope that the Government will introduce regulations so that we have much less frequent contract renegotiations.
The BMA has made some additional points. It says that there has been a huge duplication of administrative effort and a large diversion of resources into administration. GPs around the country--the Minister will have heard this from GPs in Winchester--tell us that the thing that bugs them the most is the paperwork. The Minister knows that that is the case whether it is our survey or his, private or public.
The Minister for Health (Mr. Gerald Malone):
They are bogus surveys.
Mr. Hughes:
They are not bogus, but they are consistent in saying that what bugs GPs most is paperwork. GPs went into general practice to be doctors, not administrators. The most recent survey of GPs' work load, which was conducted by the British Medical Association, showed that the average weekly time spent on practice administration had risen 85 per cent. since 1985-86. Claim forms, recording data, commissioning, fundholding and the patients charter were regarded as bugbears.
I accept that the Government have addressed some of those concerns, and that the NHS executive report "Patients not Paper" made 65 recommendations, which are being implemented. I hope that we go on down that road, because we have to reduce the administrative burden on our doctors.
I hope that the Minister will reply to the representation of the National Health Service Consultants Association. Its executive committee met the Secretary of State in March. It was asked what it would recommend, given that the Secretary of State would not concede that the 1990 reforms should be torn up. It wrote to him in May, but had had no reply to its propositions by 20 June. It is clear about the problem. I shall quote its view, because it is up to date and on the ball.
The association states:
The association says that there is no justification for the explosion in the use of external management consultants to report on every problem that occurs. The investment in newsletters and public relations departments to present
policies in the most favourable light is a bad use of money. The Minister has received 12 recommendations from the association to reduce bureaucracy and divert resources. I ask that the Government reply as soon as possible and accept, as far as possible, its proposals, which are based on experience and put reasonably, and which include many good ideas.
A constituent of mine, in discussing the local council and its services, told me in a letter last week that he was busy fighting cancer and did not have time to fight bureaucrats. That is what people in the health service want to do. I shall put the central allegation to the Government and then make suggestions for progress. I shall do so quickly, for the twin purposes of letting other hon. Members speak and releasing myself.
I hope that the Government accept that it is unarguable that administration costs have risen from 6 to 11 per cent. of spending since the 1990 reforms were introduced. We have gone from 500 general managers--I know that there has been some redefinition--to some 20,000. Redundancy payments have risen from £12 million to £114 million a year. That shows the extent of managerial upheaval.
My first proposal for change is that the contract period be extended from one to three years. That is no good unless the people involved know how much money is coming down the tracks. It is no good if the budget is given, whether in west Hertfordshire or elsewhere, on a year-by-year basis. The same complaint applies to local government.
A clear idea is needed of the money that will be available over the next few years. Of course circumstances change and there has to be flexibility, but it would be possible to have a financial framework within which one could know the parameters of the money that was to be given. Within that, there could be adjustments, but it would allow people to plan. Will the Government consider extending the one-year contract period to three years?
Can we avoid having to price everything? It is quite possible to give a round figure price for the day cost of conventional care in a hospital. We should not have to cost separately the bedpan, the sheets, use of the fan and breakfast. There must be a day rate, as with paying hospital beds or private hotels. It is nonsense to go down to such particulars. We could avoid much costing by having a more generalised process.
There must be a return to a sense of the public service ethos. One problem is that many managers have not come up from the national health service. Many people in the health service feel that managers do not understand what they have to manage. Let us train people from inside the health service--people who know about managing the service. When we need efficiency cuts, let us not imagine that cutting senior managers is necessarily the best way to achieve cuts.
Thirdly, can we have longer staff contracts? Short-term staff contracts are demoralising and demotivating. It is not good employment practice, but it is more bureaucratic. It means that many agency staff are employed. It is possible to move efficiently and quickly to longer-term contracts that give everyone a sense of security and the institution a sense of coherence.
Fourthly, staff planning needs must be better met. That used to be the responsibility of regional health authorities, but they have gone. We have regional health chairmen
with nothing to chair; that is nonsense. Local trusts or health authorities cannot plan staff levels because they are too small. They are having to form consortia. We need to return to regional planning of health service staff needs.
Fifthly, can we end the nonsense of local pay negotiations? Sixthly, can we end the system that requires the health service negotiating process to be rather like the United Nations Security Council? When health authorities, trusts and other players must all agree something, it takes only one agency to say no to veto the whole thing. Perhaps a regional tier or national inspectorate could cut through that. Whichever is needed, we must avoid having to get everyone to sign up to everything before anything can go ahead.
Penultimately, it is not right to attack management. I agree with the hon. Member for Broxbourne (Mrs. Roe), who chairs the Select Committee, that many managers do a good job. I was in Harrogate hospital at a conference recently. They are doing an excellent job in managing that trust. It is not the managers who are the problem, but the systems that we have imposed. I agree with her and the hon. Member for Peckham that it is the bureaucracy that we have introduced that is debilitating all the players.
"excessive, expensive and often unnecessary"
bureaucracy has resulted from the 1990 reforms.
"Flagship hospital trusts are reportedly seeing their once-efficient departments slowly destroyed by government requirements for trusts to make year-on-year efficiency savings of 3 per cent. But they are not allowed to use any surpluses to increase capital resources, such as beds, in the following financial year. Instead they have to use them to cut prices."
The Royal College of Nursing has signalled certain specific concerns, and has made the point that it is a bad economy to cut out senior nursing posts--one of the consequences of the Government's reductions in certain budgets at a time of nursing shortages. If there are nursing shortages and less experienced groups of nurses, we need the senior nurses in post to be able to make sure that they manage less experienced staff and plug the gaps better.
"the great weight of evidence presented to us indicates that features of the Act and what has developed from it are the prime causes of the current low morale in all branches of the medical profession and indeed throughout the NHS."
The association is frustrated because the service is fragmented. Loyalty to the concept of the NHS is being replaced by corporate loyalty to the local individual unit, which encourages destructive rivalries and antagonisms, lack of openness and interference with rational strategic planning. A major source of dissatisfaction is that the pricing system is patently arbitrary, is at the mercy of creative accounting, and produces clinical absurdities that bring the system into disrepute.
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