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8.13 pm
Denzil Davies (Llanelli): I will address my brief remarks to the specific parts of the Bill that deal with Wales. Health is a devolved responsibility and the National Assembly for Wales does not have the power to introduce primary legislation, so we have to legislate in the Bill to enable the Assembly to fill in the details by subordinate legislation.
I do not share the enthusiasm of the hon. Member for Brecon and Radnorshire (Mr. Williams) or my hon. Friend the Member for Bridgend (Mr. Griffiths) for the proposals in the Bill. There have been consultation papers and there has been considerable controversy about the proposals in newspapers and on the television in Wales. I recently received a paper from the National Assembly and the NHS directorate headed "Improving Health in Wales—Structural Change in the NHS in Wales" and it sets out the proposals for which authorisation is being asked.
We learn from that paper that the bureaucratic and administrative changes in Wales will start from 1 April 2003. Unfortunately, when I read the paper, it became quite clear that, if the proposals are put into effect, Wales will have from that date the most bureaucratic health service in western Europe.
The Bill provides for the establishment of 22 local health boards. They are to be statutory bodies, with all the bureaucratic paraphernalia and expense that that implies. We have 15 hospital trusts and three regional assemblies—a kind of sub-assembly of the National Assembly—will be established. If my mathematics are correct, that takes us to 40 bodies. Because there will be so many bodies, there must be some co-ordination between them and partnerships will have to do that.
Therefore, some people believe that there will be a further 12 partnerships engaged in co-ordination. That means that 52 bodies will be involved.I am describing devolution and not the central system in Wales. My right hon. Friend the Secretary of State talked about the devolution of power, but those 52 bodies will be at the lower level. On top of them, we will have the Assembly with its Committees and the administration and bureaucracy that it inherited from the old Welsh Office. All that in a small country of 3 million people where most of the people do not use the health service more than once or twice in their lifetimes.
I am glad to assure the House that the health boards will be inclusive. Inclusiveness will mean that the membership of the boards at the county level will read like a who's who of the health bureaucracy in an area. Skilled and scarce professionals, such as doctors, nurses, midwives and physiotherapists, will have to give up their valuable time to sit on meeting after meeting and committee after committee.
The committees' working day will end at 4 o'clock and the working week on Friday. None of them will meet in the evening and they will certainly not meet on Saturday morning, because that in the jargon of the new political bureaucracy is known as "quality time". Because so many people will be represented on the committees, decisions will take a long time to reach and, very often, they will be based on the lowest common denominator. In all these structural changes, there will be winners and losers. I have no doubt that, in this case, the winners will be the local health bureaucracies.
For the provisions to come into force by 1 April 2003, there must be implementation. I have a splendid paper that sets out the structure and the steps necessary for implementation. If the House will bear with me, I shall briefly refer to a few of the steps that are mentioned. However, the language of the paper and the structure that it sets up for implementation tell us much about the bureaucratic cast of mind of the new political bureaucratic class that oversees and puts through these bureaucratic changes.
The paper describes the implementation plan, and 12 bodies will be created to carry it out. We start with something called a "national steering group" which
- "oversees the process of implementation".
- "oversees the management of the implementation".
In addition to the implementation group, there will be nine task and finish groups. Apparently, they will "scope" the implementation. These days, I understand reasonably well the jargon of the new political bureaucratic class. I understand the terms "dynamism", "renewal", "partnership" and even "stakeholders" and "inclusiveness", but the verb "to scope" is not one that I have heard before. Perhaps because I learned English as a second language, it is not part of my vocabulary. However, the nine task and finish groups will scope the implementation.
So we start with a process that is followed by the management and then the scoping of the implementation. At the end of the day, when the 12 groups have sat down
and done their work, we have 52 bodies plus the Committees of the National Assembly and its bureaucracy to control and administer the health service for a small nation of 3 million people.I came into the House a long time ago in 1970. In those days, we had the Welsh Board of Health, which sat in Cardiff, and a few local management committees looked after a collection of local hospitals. The bureaucracy was light, but those were happy days. My constituents did not have to wait up to two weeks to see a general practitioner or a year or more to see a consultant. They certainly did not have operations cancelled five or six times, which has sometimes happened after they have been pushed into the operating theatre. Since then, however, the bureaucracy has increased.
The right hon. Member for Charnwood (Mr. Dorrell) talked about the changes. Indeed, the internal market caused a massive increase in the bureaucracy of the NHS. My right hon. Friend the Secretary of State tried to tell us again that my party has abolished the internal market. I am not convinced of that, but there is no point in arguing about it now because we are changing some of that bureaucracy, although in Wales it might be made considerably worse. The winners will be the bureaucrats and I am afraid that the losers may well be the patients or the customers, or whatever we call them these days.
The House knows that Wales has a democratically elected National Assembly. Its Committees and the Administration, working together with local hospital trusts, should find it fairly easy to administer and control the health service in Wales. Those who drew up the proposals in the paper should tear them up and start again. Frankly, there is little support for them in Wales. I am surprised that two hon. Members from Welsh constituencies spoke so enthusiastically about the proposals. Perhaps they, like the political bureaucratic class, are in denial. My constituents understand the situation well and they do not like it. They do not want the bureaucracy. They see it as creating problems for them.
The proposals will not be changed, though. We will get the 22 statutory local health boards, adding up to a total of 52 bodies. Despite the warm words—I know these, too—of accountability, democracy and consultation, the new political bureaucracy is extremely inflexible, extremely insensitive and often extremely arrogant. The proposals for Wales will do little to improve the delivery—the word that we have to use today—of health and medical services in my constituency. That is why I will not support them.
8.23 pm
Sandra Gidley (Romsey): Tempting though it is to indulge in political football, I will concentrate on aspects of the Bill that deserve the greatest attention in Committee. I should declare an interest: I am a member of the Royal Pharmaceutical Society and the Bill will have an impact on my profession, although I might not have time to get to that.
It has been highlighted that one problem that the NHS has had to face in recent years is the culture of continued reorganisation. The right hon. Member for Charnwood (Mr. Dorrell) put it well. He listed the reorganisations under the previous Government, and it is surprising that the Conservatives have the nerve to criticise another change. Unfortunately, I have yet to see a patient who is better off as a result of the reorganisations.
I find the proposed changes baffling. For example, in recent years we have moved towards regional structures, which Liberal Democrats support, but the Bill moves us sharply into reverse gear. There is no clear justification for the number—28, 30 or whatever—of strategic health authorities. I am puzzled why the Government were not radical by simply basing the strategic health authorities wholly on the regions, thus making it far easier to co-ordinate policy and liaise with other Departments.
I have some queries on primary care trusts. Many of my local GPs are excited about what PCTs might offer. They see them as a chance to think creatively and purchase care imaginatively and believe that they will be able to fine-tune decisions so that their patients benefit on a locality basis. However, that is providing they are left free to act. Initiative after initiative, although well meaning, has meant that there is a huge amount of central direction. I am not convinced that that will go away when we have PCTs. The Government will still set targets. Some local doctors have a shock coming because their hands will be tied in a way that they have not anticipated. They will have the money, but they will not be as free to spend it as they would like.
Hon. Members have commented on the fact that many PCTs are concerned that they will start with a deficit because those deficits currently owed by health authorities will be reallocated rather than written off. I seek some reassurance that PCTs will start with a clean balance sheet.
The British Medical Association also believes that PCTs hold great promise but, like the Secretary of State, I can also quote Ian Bogle, who said that
- "they will require sufficient resources to allow all the local budgets to operate properly".
Primary care trusts will also have to fund a variety of services. They will have to contribute towards child protection services and some did not realise that they will have to contribute towards emergency ambulance and patient transport services. The latter has come as news to some PCTs locally and, I suspect, elsewhere. Concerns have been raised that they will all be locked into an unseemly haggling process at a time when everybody's energy should be directed at delivering a top quality ambulance service. That is a particular concern for Hampshire.
Another problem is the lack of pharmaceutical input in primary care trusts. There is no direct requirement for that, which is short-sighted because problems with ineffective prescribing will not readily be tackled.
Hon. Members have raised public health concerns, and the Minister gave a welcome response to the suggestion by my hon. Friend the Member for Northavon (Mr. Webb)
that health should be monitored. Public health doctors would have a vital role to play in that. It is good that every primary care trust will have a director of public health at board level, but that person does not have to be medically qualified, and it would be useful if that important provision were tightened up.On community health councils, I had to smile when I was sorting through my post because I found a letter from the Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), which, in reference to a consultation process, says:
- "I am pleased to say that many CHCs were among those who responded."
Much attention has been paid, rightly, to making sure that patients have an independent voice. On the face of it, there is a strong patient focus in the Bill. I understand the fears that patient advocacy and liaison services and patients forums seem very in-house, but the NHS culture is changing very slowly, and there is a growing recognition that it is in the interests of both hospital and patient to learn lessons from complaints and treat them constructively. Some trusts have taken that on board.
Less attention has been paid to the CHC function of overseeing service reconfigurations, such as the proposed closure of a small maternity unit. Currently the CHC has a statutory right of referral over such decisions; it can take them away from the local health authority and refer them to the Secretary of State. It is not clear in the Bill whether that responsibility will be fully taken over by the local authority overview and scrutiny committees.
To muddy the waters a little further, the Government are in the process of setting up an "independent review panel". The chair has just been appointed, without interview, by the Secretary of State. That action alone calls into question the panel's independence, and other questions about it remain unanswered. No one seems to know what its remit is, to whom it is ultimately responsible or even how it affects the Secretary of State's responsibility to Parliament. More importantly, what power does the average person in the street have to hold anyone to account on matters of local reconfiguration?
As there appears to be so much fudge and fog, would it not be prudent to delay the abolition of the CHCs until the new structures are fully functioning? Several aspects require clarification. For example, how will the people on patients forums be chosen? Many people have wide-ranging experience of primary care, and it would be relatively easy to provide a balanced overview. With secondary care, things become more problematic, as different departments of a hospital suffer from different problems. How will a balanced representative body be structured? There seems to be little guidance on that, and we run the risk of people coming in with a lot of baggage, for want of a better word.
Patients forums could be compared to the citizens panels operated by many local authorities, which have found it useful to change the membership every few years
because the citizens involved generally become very close to the council and perhaps understand it too well. If patients forums are to be at all effective, we need to consider training their members, in much the same way that school governors have been trained in the past. The health service is extremely complex and bureaucratic, and patient representatives need to be helped to be effective.If effectiveness is the aim, which is not clear, where is the funding for that training? Who will pay for it all? The whole issue of funding has, to a certain extent, been glossed over. There appears to be little acknowledgement that local authority overview and scrutiny committees will require training and funding, and that work is difficult on an already constrained budget—
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