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14 Nov 2002 : Column 193—continued
3.12 pm
Dr. Evan Harris (Oxford, West and Abingdon): It is a pleasure to follow the right hon. Member for Tyneside, North (Mr. Byers), whose speech reflected the usual tone of Queen's Speech debates—that new thinking is the order of the day, as well as more profound reflections on the topics in the Queen's Speech. In contrast, Front-Bench Members are forced to deal with the detail of the proposed measures and with party political differences. The right hon. Gentleman was correct in his view that the Government need to think about reform and to have fresh ideas, and that requires courage. However, the same applies to Opposition parties. It is a particular challenge to Opposition parties, who could just about get by simply criticising the Government. That is tempting in many ways, but democracy—particularly with a lower turnout—requires us to provide an alternative option where we disagree. I have heard the Secretary of State say, when presented with opposition to some of his reforms, XWhat was the alternative?" That is a question that he has fairly asked the Liberal Democrats and the Conservatives. We have now developed our policies and I shall share them briefly with him, as he will probably want to oppose them. The right hon. Member for Tyneside, North referred to the challenge of recognising that times are changing and that there is a need for reform, and that challenge applies to Opposition parties, too.
Before getting into the detail of NHS reform, I want to say how much I welcome the remarks of the Secretary of State about the mental health Bill. It is wrong for an Opposition party to call for a measure to be withdrawn for further consideration and then to attack the Government for doing just that. My right hon. Friend the Member for Ross, Skye and Inverness, West (Mr. Kennedy) stressed the need for wider legislation on mental health and said that the matter should not be shelved simply because the Government were experiencing difficulties in attempting to tackle what it perceives as an unreasonable risk to the community. The Government are taking the right approach in looking at the consultation and, we hope, bringing back the Bill in a more acceptable form. I accept that we will still have disagreements, but Opposition parties need to recognise that these are difficult issues.
It is not the case, as the hon. Member for Woodspring (Dr. Fox) suggested that there is no organisation in support of the Government's proposals on people with severe personality disorders who pose a potential danger to the public. The Zito Trust, which was founded as the result of a homicide by someone who was mentally ill, supports those measures. As the Secretary of State said previously, such incidents create difficulties for the Government, who are under pressure to ensure that the public feel safe—and, indeed, are safe. So the
disagreement is not over the principle of the need to do something, but whether the need is as serious as the Government seem to state it and whether the particular way in which they wish to tackle it is right. I agree with the hon. Member for Woodspring that it is wholly wrong. Part of the problem is that there is a perception, stated previously by the right hon. Member for Holborn and St. Pancras (Mr. Dobson) that community care has failed so we have to do something. I hope that the right hon. Gentleman has had a chance to reflect on that pronouncement, which he made at the Dispatch Box. Many people would argue that community care was never tried properly because it was never properly funded. In that respect, I welcome the resources that the Government are putting in. It would be unfortunate to say that the die is cast and the sentence has been passed even before those resources work through the system.
Mr. Dobson: We are talking about reality, not about what we might have liked to happen when the Tories were in government. The fact is that there was not enough money to make care in the community work and that was one of the reasons why it failed.
Dr. Harris: The point that I was trying to make is that saying that because care in the community had failed—mainly due to lack of resources—we needed to lock people up, and that providing care in the community for people who may pose a danger, mainly to themselves rather than to other people, is wrong, seems to be the wrong approach. We should try putting in more resources, because, as the right hon. Gentleman knows, most of the homicides—which have not increased in number over many decades—are due to the failure of services to connect with vulnerable people who need support, not to people being maintained on care plans in the community who then go out and commit these acts. The resources have to be given a chance to work.
Dr. Fox: Does the hon. Gentleman accept that it is a fair representation of the position to say that there is an overwhelming consensus that we need to update our mental health laws and that that would be entirely possible in a very constructive spirit, but that the stumbling block is the Government's inflexibility and their insistence on putting severe personality disorders and a specific way of dealing with them at the centre of the Bill?
Dr. Harris: The hon. Gentleman is quite right about that. Mental health legislation is rather like measures on adoption and children, in that there should be no need for significant cross-party oppositionitis—[Interruption.]—although some people still manage to disagree on party political issues. It is a good thing for the hon. Member for North-East Hertfordshire (Mr. Heald) that there will be no need for him to miss out in participating in a mental health Bill now. He has been most assiduous in his work on the subject and I congratulate him on his promotion in the recent shadow Cabinet reshuffle.
On the general issues regarding reform, there is a temptation to call the Government's latest NHS reform Bill the Xre-re-re-reform" Bill as it is the Government's fourth attempt. That is not to say that we are opposed to reform, although we are opposed to serial structural
changes when they are the wrong reforms. However, the onus is on Opposition parties to come up with alternative reforms.To use the same language as the Government, the Liberal Democrats are proposing decentralisation and democratisation, of the commissioning function in particular. We believe that whether or not it is the case at the moment, the key decisions in the health service should be made by commissioning bodies in charge of the strategy for the health service and what it should or should not provide. It is not a provider issue, but a commissioning or, to use an old-fashioned term, a purchasing issue. That function needs to be more decentralised and more in touch democratically with the local community.
The hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Select Committee on Health, unusually is not here today. I understand that he is away on Select Committee business. He has said clearly that if local authorities can decide what social services to commission, there is no reason why they cannot also decide what local health services to commission. It would do away with the so-called XBerlin wall" if the same local authority committee was dealing with the commissioning of both health and social services. Two further things are needed for that to work. First, there must be tax-raising powers locally so that commissioning bodies have the ability to increase or, possibly, decrease taxes according to what the public want. It would be wrong and inconsistent to call for more decentralisation of responsibility for commissioning without giving those concerned the ability, through fair local taxation, to raise the resources needed, as they see fit, to increase the amount of services that can be provided.
Secondly, those bodies must be explicit and honest about rationing and what can and cannot be afforded. I know that there are Conservative Members who have come round to this view, most notably the right hon. Member for Maidstone and The Weald (Miss Widdecombe) while she was shadow Secretary of State for Health. Part of the problem at the moment for those of us who want to see the NHS grow is that people think that that can happen without putting in the resources.
It would be easier for the Secretary of State and me to promote the idea of paying for a bigger, wider and more universal NHS through fair taxation if the voters knew that because they were not providing enough through that means, certain things were not available. Hiding behind rationing decisions made by organisations such as the National Institute for Clinical Excellence or local clinicians leads to an unfortunate side effect, which is that people do not recognise how much rationing there is.
We want decentralisation to democratic regional bodies that can look after the strategic role in decision making, and we want the decentralisation of commissioning to local authorities. The problem with primary care trusts is that there is no democratic local representation on them, and that is required. Local authorities need to be informed by a strengthened public health function, bringing together all public health functions including housing and environmental health, which are currently already the responsibility of local
authorities. They also need to be informed by the PCTs and by patient stakeholders. However, the responsibility must lie with decision makers.I understand that the Secretary of State has to leave shortly and I am grateful that he has listened so far, if only so that he is better able to attack the policies that I have proposed, rather than the personalities involved. We see the need for greater diversity in provision, so we are with the right hon. Gentleman in respect of the Government's proposal of foundation hospitals as new public benefit organisations and their move away from the one-size-fits-all approach to the question of who provides NHS care. We see a role for public benefit organisations, but they must not be top-down. The fact that the Government are centralising as they claim to decentralise is unfortunate. Why force that status on a select group of hospitals? Why not allow local communities—whatever the star status of the hospitals in these sham performance ratings—to choose whether the hospitals are public benefit organisations? There should be no cash incentives or bribes for that status because that would create the sort of inequity that has been referred to already by a number of hon. Members. That is not the way in which public benefit organisations should develop—just as it is wrong that the private sector should have any advantage, such as not having to train the health service workers whom it employs. The private sector should not cherry-pick or poach them from the health service. In the same way, new public benefit organisations should not have advantages handed down.
The next criterion is that foundation hospitals must be independent from the Department of Health, if the Secretary of State is serious. I question how independent from Department of Health policy they will be. In a press release on 22 May, the Secretary of State talked about NHS foundation hospitals being established as
- Xfree-standing legal entities, free from direction by the Secretary of State for Health."
In the same vein, the Secretary of State will admit—because he has written it in a document—that the hospitals will not be independent because they will be subject to performance monitoring from the commissioners. I have nothing against that, but the right hon. Gentleman has admitted that the commissioners, the PCTs, who are contracting with the foundation hospitals, will have to commission to the targets that he sets. In a document on foundation hospitals that was published in the summer, he talks about:
- XHard-edged cash for performance contracts with commissioners"
- XCommissioners will be able to hold NHS Foundation Trusts to account for service delivery and for their contribution to delivering on local health strategies and meeting targets through
- legally enforceable 'arm's length' contracts. Contracts will encompass both incentives for good performance and penalties for poor performance."
The mark of a sensible politician is to say that a Secretary of State from his party would not be allowed to set these targets. I know that that is tempting when the Secretary of State says that the first concern of patients is the amount of time that they have to wait. However, there is an added onus on politicians and those who provide the service, which is to treat the sickest quickest. The problem with maximum waiting time targets—even in terms of coronary heart disease, which the Secretary of State just mentioned—is that the most urgent patient is the one coming up to the politically imposed deadline. As the hon. Member for Woodspring said, the people who need more urgent surgery—for example, people with left main-stem disease or critical ischaemia, who are at risk of dying if they are not treated within a week—may well find their operations postponed so that the political targets are met first. In those two respects, the Government have still to demonstrate how foundation hospitals will be as truly independent of Whitehall control as the Government's rhetoric suggests.
There are a number of issues about foundation hospitals on which I would like clarification. First, what will be the constituency for elections to the boards? That point has been made also by the hon. Member for High Peak (Mr. Levitt). How truly democratic will the elections be when one will have to elect to be a member of the public benefit organisation? As the hon. Member for Hampstead and Highgate (Glenda Jackson) rightly said, that will mean that the middle classes—who tend to have the luxuries of time and health which enable them to be more involved in these issues—will tend to dominate. How will the Secretary of State tackle the democratic deficit and the mismatch between the accountability of provider organisations and the commissioning organisations—the PCTs—which are professionally run and accountable only, and too much, to the Department?
Will the Secretary of State answer the question about the disposal of assets of these organisations? For example, he said in a press release on 18 April that the first foundation hospitals would have freedom and flexibility within the new NHS pay systems to reward staff appropriately—I shall come back to that—and full control over all assets and retention of land sales. Some hospitals often have greater land assets than others. That is not because they deserve them; it is a quirk of history. In some areas—for example, the south-east—that land value will be greater than in other areas. Is it equitable that the revenue from those sales is not redistributed according to need, rather than history, as seems to be the proposal?
We are concerned about freedom over pay. There is a need to ensure that there can be more local pay flexibility, but it seems rational to avoid cherry-picking by foundation hospitals by allowing local pay only where there is local revenue raising. If communities want to respond to the labour market, they should recognise that they may have to do so through higher local taxes, feeding into higher pay in those hospitals. That is a consistent approach, and must be better than simply giving money to certain hospitals and allowing them to cherry-pick. Not only the British Medical Association and the Royal College of Nursing but the NHS Confederation is equally concerned about that.
For the commission for health care audit and inspection to be truly independent, it must be allowed—from the beginning, not some way down the road—to set its own targets rather than simply measuring how hospitals jump through hoops set by central Government. I hope that there will be cross-party support, perhaps in another place, to ensure that it has that true independence. It is unfortunate, to say the least, that this is now the fourth reorganisation of inspectorates. The first NHS reform Bill set up the Commission for Health Improvement, which we supported, with reservations on its independence, then the National Care Standards Commission was set up under the Care Standards Act 2000, then the next NHS re-reform Bill amended the provisions affecting CHI, and as soon as the NCSC was set up the Government agreed to merge the inspectorates so that private and NHS hospitals, for example, have the same inspection regime. If media reports that Sir Ian Kennedy has been appointed to head the new commission are correct, I have more confidence that it will be truly independent, but if the statute says that it must do the bidding of the DOH in its performance monitoring, independence will be a major concern.
It is important to consider the delayed discharges measures. Not a single organisation supports the proposals. If there is no capacity, there is no capacity. Fining hard-pressed local authorities and social services departments for the failure of investment from the time of the Conservative Government until 1999–2000, which marks the end of cuts in real terms for social services, is not only unfair but an insult to those local authorities who work so hard to make ends meet.
We have already heard about some of the distortions that the fines will create. There will be a distortion of resource allocation, as local authorities seek to avoid losing money overall. In some areas where there is still discretion within the tight standard spending assessment boundaries, some services will be de-funded in favour of social services, because of the double jeopardy created by the fining. There will also be a distortion of resource allocation within social services, as the vulnerable young, the mentally ill and the disabled suffer cuts in their allocations by local authorities desperate to avoid losing money through fines for delayed discharges. There will also be a distortion of resource allocation within care services for the elderly, as money is provided for intermediate care and care packages for elderly people leaving hospital at the expense of other provision for the elderly.
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