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Sir George Young (North-West Hampshire): The hon. Member for Bedford (Mr. Hall) made a good point when he said that we need to look at the whole picture and that we should not be too constrained by the elements that appear in the Bill. I hope that the Government will put some of the missing pieces of the jigsaw puzzle on the table in Committee so that we can begin to assemble the bigger picture.
Before I turn to the two sections of the Bill that I want to talk about, may I ask the Minister to say a little more about the prospects of this important Bill reaching the statute book? The Government have made some controversial changes to our procedure with the objective of injecting some certainty into the legislative programme. I therefore think that this is a reasonable request to make.
We know the immediate plans for the Bill, because they are in the motion that we shall debate later. However, the Bill is already in a queue behind other Bills that have already had Second Readings. It is behind another Bill that has little relevance to most of our constituents. The House, those who run the health service and those who will benefit from the changes in clause 48 would like to know whether the Bill--which is quite long and controversial--now has a realistic prospect of completing all its stages by, say, the end of March.
I mention in passing the proposals on CHCs. I attended the meeting chaired by the hon. Member for Bedford. I also listened to the excellent speech by my hon. Friend the Member for Eddisbury (Mr. O'Brien) in Westminster Hall in November. I have been in touch with the Basingstoke and North Hampshire CHC and the Winchester and Central Hampshire CHC--both quality organisations. I do not oppose reform of the CHCs; nor does my own CHC. It is quite sanguine about the prospects for change, although somewhat bruised by the
My CHC wanted a resource or organisation that brought together the four or five strands into which the CHCs are to be split. It was worried about the loss of cohesion and co-ordination, and about the shortage of volunteers in the new structure. It was also doubtful about getting the new structure up and running by April 2001.
I want to discuss clause 1 and clauses 45 to 47. Clause 1 looks innocuous but represents an important victory for the Treasury, which has long wanted to cash-limit the whole NHS budget and remove the safety valve that exists for services that are demand-led and therefore not cash-limited. The explanatory notes, perhaps wisely, do not explain the policy quite so bluntly as I have just done. They use more emollient words, such as
Clause 1 does not directly cash-limit those demand-led services, but it enables the Secretary of State to reduce funds for the cash-limited services in the same area if he thinks that too much is being spent on primary care. That is clearly aimed at exerting downward pressure on primary care in those areas in which he thinks there is overspending, even though that might represent very good value for money and reduce demand on other parts of the NHS.
There are a number of difficulties with that proposal. GPs are the gatekeepers to the NHS and the Government are in the process, quite rightly, of driving up the standards provided by GPs, in terms of minimum waiting times and so on. Bringing this key part of the NHS within the warm embrace of the Treasury's cash limits is a bold strategy for the Government to adopt when they have ambitions--which I share--for driving up the standards of care. Crucially, it means that someone will have to work out in which part of the country GPs are overspending, and that will mean a formula.
I must warn the House about the impact of formulae, because they can lead to problems. In north and mid-Hampshire, the formula for the cash-limited services requires us to be 20 per cent. healthier than average. In other words, for every £100 spent on the NHS nationally, £80 is spent locally. As a result, while the Secretary of State was launching the NHS plan--with all its promises of extra funds, real benefits for NHS patients, less waiting and faster and more convenient care--my health authority was consulting on a different document called "Meeting the Challenges".
"Meeting the Challenges" takes £13.5 million out of what it calls the local health economy. Andover hospital is pencilled in for savings of £200,000, when it needs substantial extra investment. Locally, we are not promised a better health service. The task is described as making
It is certainly not the case that we are doing well at the moment. I visited the Labour party website and tapped in my postcode to see what was happening to the health service in my constituency--a facility that it offers. This is what I found.
The independent panel also made the following comments about Ministers, and I shall read them out to complement what my right hon. Friend the Member for South-West Surrey (Mrs. Bottomley) has said. This might help the Government to understand why the public are reluctant to believe what Ministers tell them. I repeat that this panel was chosen by the Secretary of State. It stated:
Ministers might say that increased funding was announced in November, which it was. After the Secretary of State wrote to all right hon. and hon. Members on 14 November telling us about next year's funding allocations, I asked my health authority whether that meant that extra services could be planned or some of the cuts abandoned. The answer was no. It had anticipated the allocation, and it made no difference.
I return to clause 1. The formula that, in the words of the Secretary of State's independent panel, is at the heart of the problem is to be extended. The one area that everyone agrees is working well is primary care. It is certainly working well in my constituency. We have good health centres, high-quality general practitioners and support staff, low staff turnover and a high level of satisfaction. The squeeze on the hospital sector in my constituency might be extended to the primary care sector if, under clause 1, we apply the formula to primary care. It might also mean that downward pressure on primary care spending is exerted elsewhere in the country. With the experience of north-west Hampshire in mind, I urge the House to treat clause 1 with the utmost care.
The second set of clauses that I want to touch on are, I believe, the most radical in the Bill. Clauses 45 to 47 deal with the establishment of care trusts, implementing chapter 7 of the NHS plan. I understand and support the case for joined-up government generally, in particular at the interface between the NHS and social services. The patient is not interested in bureaucratic boundaries--he or she wants a seamless service. We began to break down these barriers with joint funding and the present Government are continuing the process.
The Government should answer a few questions raised by this initiative. Have they put the clauses in a broader context and asked what they mean for local government? Some 85 per cent. of the education budget goes straight to schools. I have no difficulty with that. The next largest service is social services, for which these proposals have dramatic implications. They cover not just services for the elderly--the care trusts could take over responsibility for those with learning difficulties, for mental health and for the physically disabled. If no further changes are made to education and this reform for social services is introduced, a large question mark will hang over local government, particularly the county councils. Has there been some joined-up thinking on this aspect with the Department of the Environment, Transport and the Regions?
Related to that question is one about the democratic deficit. Social services are delivered locally, are partly funded locally and are accountable locally. Transferring social services to a care trust, which is a creature of central Government, is a step towards centralisation rather than decentralisation. With specific grants, the social services inspectorate and the right to intervene and take over social services departments, Ministers are taking over from councillors responsibility for social services. This is a further step down a centralising road, and it makes the democratic deficit worse.
Issues of accountability have been raised by other right hon. and hon. Members. The way in which the care trust works involves the social services department handing over its budget to the care trust. How are councillors to be accountable for the spending and, indeed, the discharge of their statutory responsibilities if control rests with the trust on which they have but a small voice?
I am sure that the Minister will say that the proposals are welcomed by some directors of social services, and I will tell him why. The directors have looked over the fence and seen that the grass is greener. They have compared the increase in resources for the NHS with the much more modest increases in revenue support grant for the counties.
Local government is under pressure to deliver the Government's first priority--education. Social services are having a tough time. Some 75 per cent. of social service departments, according to the Association of Directors of Social Services, are struggling to cope. Directors see the possibility of solving the problems that confront them with inadequate resources by transferring the problems to the NHS, which has a bigger budget. If the difficulties with community care are primarily those of resources, is it right to tackle them by making a structural change quite soon after the changes in 1993?
I think that funding is at the heart of the problem. Beds were blocked in my constituency not because we did not have a care trust but because the Government had not allocated enough money to social services. The
I have two final points about care trusts. The NHS and social services have different cultures--one is free at the point of use, the other is not. More important, the NHS copes by having waiting lists. That is the cushion, the safety valve, the way that it survives. However, social services are not allowed waiting lists--the Gloucester, Sefton and Macgregor judgments put paid to that. An individual is entitled to an assessment; if the assessment shows that he or she is entitled to services, they must be provided. A care trust seeking to provide a joint service would have to merge and manage the two different cultures within a fixed budget.
Secondly, under a care trust, a cottage hospital that provides post-operative care or convalescent treatment could be redesignated as a nursing home, exposing patients to charges. That cannot happen at the moment--people know where they stand. However, this issue worries organisations such as Age Concern.
There is much else in the Bill that I would like to talk about, and much that I welcome, but time does not permit. I hope that I may have an opportunity to develop some of my other concerns in Committee.