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14 Nov 2002 : Column 210—continued
Dr. Tonge: I am a little puzzled, because I seem to remember that when the right hon. Gentleman's party ran the health service, although there was an internal market, the patient followed the money in the form of a contract from the health authority and had very little choice, except in the occasional extra-contractual referrals.
Mr. Lilley: Unlike the hon. Lady, I do not think that everything my party did was right and that we cannot
learn from experience. I spelled out in my speech and pamphlet both the ways in which I thought that some of the changes that we introduced had unforeseen consequences which we did not approve of, and the improvements which should be made in future. I hope she will give credit for that rather than make silly, knocking points about the past.I am not sure that the Government have substantively changed their policy on this issue, certainly not as much as I would hope. To harness the dynamo of choice within the NHS would need four things. First, there is the need to restore the right of patients to choose which hospital they are treated at. Sadly, there is no proposal to repeal circular 117. Secondly, we need to give patients information about waiting times, hospital outcomes, cleanliness and so on. There was no mention of that in the Secretary of State's speech. Thirdly, we have to make money follow the choice. Again, there is no reference to that in the financing mechanisms for new foundation hospitals or otherwise. Fourthly, we have to make hospitals genuinely independent. There was reference to greater independence for hospitals in the Queen's Speech and the Secretary of State's speech, but it seemed to be an element of typical new Labour tokenism rather than the mark of substantive change.
The Secretary of State spoke only about new control mechanisms and new accountability at democratic local level in addition to centralised control. There was nothing about greater freedom or replacing centralised control by local control. He said nothing about removing the application of the several hundred targets. My local hospitals have 248 targets applying to them. Are they to apply to foundation hospitals? The Prime Minister strongly defended the use of targets, so I must suppose they are. There was no indication of whether the ring-fencing of funds by Ministers for certain applications is to apply to local trusts. There is no indication whether the star-rating system is to apply to foundation hospitals.
It looks as though the Government are talking essentially about a change in local democratic representation on hospital boards, to which I have no objection—indeed, I am rather sympathetic to it, although I appreciate that there are enormous difficulties in working out where the electorate lies—but not about any serious independence for NHS hospitals.
In practice, we observe that the Government are in the business not of widening choice and diversity for patients but of narrowing it. Throughout the country, they are busy closing and merging hospitals. They always claim that such decisions are medically driven. Theoretical arguments exist that bigger hospitals may in certain circumstances provide better standards of care, but where is the practical evidence that those mergers and closures work and produce improved outcomes for patients?
I have repeatedly asked Ministers to carry out such studies. Indeed, there is a Minister on the Front Bench now whom I have previously asked and who has previously refused to give us that evidence or to commission research that would provide evidence of whether or not mergers which have taken place have worked. In Hertfordshire, we saw the merger some years ago—the hon. Member for St. Albans (Mr. Pollard) will remember it—of the accident and emergency and acute services of St. Albans with those of Hemel Hempstead.
Although I have asked for evidence repeatedly year after year, no evidence has ever been provided that a merger has resulted in the improvements in medical care that every consultant who advocated that merger said it would bring about. Now we are seeing more proposals for mergers and centralisation, including the closure of what remains of St. Albans hospital. We should have the evidence first, before we see any further mergers and closures.I want to see a new teaching hospital in Hertfordshire, but not as an excuse or a way of dressing up the centralisation of existing capacity in one place. We are told that the proposal for a new hospital will simply siphon off capacity from existing hospitals and result in no extra beds.
In practical terms the Government are talking about choice, but they are reducing choice. They are talking about decentralisation but they are taking decisions centrally. In substance, there is still the bureaucratic centralism which the right hon. Member for Holborn and St. Pancras clearly still believes in and at least has the integrity and honesty to defend.
I welcome the constructive and interesting speech on pensions from the hon. Member for Stalybridge and Hyde (James Purnell). Pensions are in crisis, yet there is nothing in the Government's programme to deal with that. The Government ignore this issue at their peril. In my time in Parliament, the largest single postbag I have ever had was when it was rumoured that the Government were going to change the taxation treatment of pensions. It was larger than that received on any other subject in my 20 years here. People now are concerned because they are seeing the damage done already by the #5 billion tax change imposed on pension funds.
Kevin Brennan (Cardiff, West): Did the right hon. Gentleman have a large postbag at the time of the Tories' mis-selling of pensions scandal?
Mr. Lilley: No I did not. That was partly because the regulator ensured and guaranteed that no one would lose from that scandal. I had a large postbag at the time of the Maxwell scandal when the hon. Gentleman's former colleague stole #500 million from the pension funds—a feat only ever exceeded by the Chancellor of the Exchequer, who steals 10 times that amount every year from current pension funds with his Robert Maxwell memorial tax.
We are told that the reason why the Government are not proceeding with any relevant measures is that they are looking for a consensus. That is usually a symptom of indecision or an attempt to silence criticism. Although many people think that our adversarial mode of parliamentary government leads an incoming Government to uproot everything that has gone before, that rarely happens. It has never happened with pensions. Governments have always built on the measures introduced by their predecessors rather than reversing them. Therefore, the Government do not have a need for a prolonged royal commission to achieve consensus. They should go ahead and act now to improve the current situation. They can be sure that an incoming Conservative Government will build on that rather than simply uproot any new measures that the
Labour Government introduce. It will be our duty, however, to criticise the proposals that they put forward and that, I am sure, we will do in a constructive spirit.4.29 pm
Ross Cranston (Dudley, North): I had intended to contribute yesterday, but I fell off the end at 10 o'clock last night. I apologise to the respective Front-Bench spokesmen for the fact that because I did not anticipate being here today as well as yesterday, I will not be able to stay for the winding-up speeches.
I want to talk about the philosophical underpinning of important measures in the Queen's Speech. Because of the subject matter of today's debate, I shall illustrate that with references to the health service.
As has been the case for the past six years, the programme set out in the Queen's Speech continues a commitment to social justice. The objective is a more equal, inclusive society, where marginalisation is reduced and the vulnerable are cared for but where citizens have duties and responsibilities as well as rights and opportunities. Crucially, the programme continues to reflect the belief that Government intervention—notably, but not exclusively, in the form of public services such as the NHS—is necessary to achieve that objective.
Social justice and equality remain critical concerns because inequalities still exist in our society between socioeconomic groups, ethnic groups and regions, and along a range of dimensions that include income and wealth, educational opportunities and health. My right hon. Friend the Secretary of State mentioned the recent Office for National Statistics figures on health, and an independent inquiry into inequalities in health was chaired by Sir Donald Acheson. As a result of that inquiry, the Government last year announced two targets. The first target was to reduce the differences in mortality rates between manual groups and the population as a whole, and the second was to reduce differences in life expectancy between people in different geographical areas.
At its simplest, our reaction against such inequalities originates in the belief that it is unfair for people who cannot be held responsible for their poverty, physical disability, state of health and so on to be disadvantaged. The equality that we pursue is quite straightforward in some areas. An example is equality before the law, or when people are treated as being of equal worth. In other areas, we are dealing with equality of opportunity. However, there are circumstances in which it is not sufficient for everyone to be at the same starting post despite having different handicaps.
In yet other areas—such as protection against crime and access to good health care—equality has more to do with outcomes. However, it is important to stress that equality is not the same as uniformity, and that it is not always equality of outcome. Moreover, equality is not inconsistent with difference, or with the pursuit of and rewarding of excellence.
In his great lectures of 1929, which were later published in his book XEquality", R.H. Tawney made that much clear. He was passionate about achieving a more equal society, but he spoke about the need to
respect excellence. He deprecated mediocrity. He argued that progress depended on the recognition of the outstanding, although he had contempt for unfounded pretences to it. There needs to be a balance between recognising difference and excellence on the one hand, and the pursuit of a fairer society on the other. It is against that background that we can better appreciate proposals such as the foundation hospital idea.I shall turn from those philosophical underpinnings to deal with three themes that run through the Queen's Speech. The first theme is the economy. It is not surprising that the Queen's Speech should begin by setting economic stability as one of the Government's three main priorities. My right hon. Friend the Chancellor has delivered that stability, with inflation, interest rates and public debt all low. That economic success feeds through to higher employment, and to welfare assistance such as tax credits. Importantly for this debate, it has also fed through to the huge additional investment that has been made in the health service.
The second theme of the Queen's Speech is public services. We must invest in public services, but we must also refurbish them to ensure greater flexibility and transparency and greater responsiveness to the needs of consumers and patients. Public services have long had a role in ameliorating inequality. At one point in his lectures, Tawney says that the standard of life of the great mass of the community depends not simply on income from work but on the social income that people receive as citizens. As I have said, public services have to be financially viable. One of the challenges is to provide first-class public services that are affordable.
Another challenge is universality, which allows everyone in society to benefit, for example, from good health. One problem in redressing inequalities in service provision is that there is a burden of the past. My right hon. Friend the Secretary of State mentioned that, and the primary care trust in my area faces an immediate financial strain in meeting need because services have historically been skewed to other, wealthier parts of the borough.
Public service reform has to be at the core of the Government's agenda if the health service and other public services are to deliver a service that responds to individual need. One aspect of reform is countering the conservatism of bureaucracy. Not surprisingly, producers of a service are attached to the comfortable ways of doing things, even if that is not in the interests of the consumers of that service.
A second aspect of reform is the need to overcome the natural tendency of bureaucracies to operate as silos. There has been some discussion today about the need for health authorities and social services to deal better with the problem of delayed discharges. A third aspect is possibly the most important, and it involves liberating from the dead hand of bureaucracy the innovative health official or institution. Obviously, that entails consumers of public services—in the NHS, that means patients—having a larger say.
I have no philosophical objections to high-performing hospitals becoming foundation hospitals, as long as equality of access to good quality services is continued and the ethic of public service is maintained. We cannot go back to having a postcode lottery for
public services. There is a need for high minimum standards around the country, enforced by targets and inspection. I particularly welcome the establishment of the commission for social care inspection anticipated in the Bill on health and social care reform.However, I repeat that people who think that uniformity in the NHS is possible or even desirable are missing three factors. The first has to do with practicalities: it is simply not possible to control tightly from the centre an organisation as vast as the NHS, which in terms of size is a rival to the Chinese army or the Indian railways.
The second factor involves the health inequalities that I mentioned earlier. Unequal treatment is needed to address those inequalities. Thirdly, and as Tawney recognised, there is no philosophical inconsistency between social justice and the rewarding of excellence.
The third theme of the Queen's Speech involves responsibilities. Social justice confers rights and opportunities, but also imposes on citizens duties and responsibilities. In that respect, there has been an historical failing in our thinking. People such as Tawney recognised that rights involved duties, and they spelled out the implications for people with power and privilege, but they did not deal with the implications for people who benefited in a more equal society.
One area identified in the Queen's Speech where responsibilities are crucial is the welfare state. People have the responsibility to work if they can, and the responsibility not to defraud the system. Responsibility has links with social justice. On the one hand, we must make sure that people get a fair return and, on the other hand, we must deny rewards to those who cheat.
The notion that citizens have responsibilities is most evident in those parts of the Queen's Speech that deal with criminal justice, but the notion also has an application in the context of the health service. Patients have responsibilities— in simple matters such as turning up for appointments, for instance, and in more important matters such as access to particular services.
The three themes are linked. We need a sound and growing economy to fund the health service and other public services. In turn, good public services such as the NHS mean that trust in Government, and thus social cohesion, increases. Thirdly, the hope must be that that will generate a greater public-spiritedness and a renewal of civil society that will lead to a more socially just society. I recognise of course that that cannot be achieved by Government alone. It depends on a range of decisions by individuals in their vast network of everyday activities. The measures in the Queen's Speech will make a welcome contribution to social justice.
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