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Dr. Fox: Does the hon. Gentleman agree that the most important factor in considering whether a trust should move to foundation status should be the quality of care that it gives and the clinical outcomes? The basic problem is that the star-rating system is largely a management tool that is concerned with management of trusts, rather than with quality or outcomes as they apply to patients.
Dr. Harris: Yes, I am more than willing to endorse that entirely. I shall come to the question of what the Commission for Healthcare Audit and Inspection is supposed to be doing in a moment.
For those of us who want hospitals freed from central control, one of the many problems with the Government's proposals is that there are at least three ways in which they are still controlled. In order to get foundation hospital status, they are forced to follow Government bidding on the star-rating system, which relates only to Government political targets and has nothing to do with clinical outcomes. Secondly, they will still be subject to inspection by the new Commission for Healthcare Audit and Inspection, which will be forced to measure performance according to the star-rating system, and according to standards and priorities that are set nationally, so there is no escape. Thirdly, such hospitals will be forced to enter into contracts with commissioners, who are subject to exactly the same national priority setting and political target setting as the rest of the hospitals. So there is nowhere for foundation hospitals to hide from the overweening control of central Government, despite this veneer of freedom.
This point is recognised by the NHS Confederation itself, which one would have expected to be particularly eager to acknowledge the freedoms that the Government offer. Its briefing states:
- "Foundations appear still to be subject to most DH data collection and star ratings, and PCTs, CHAI and the regulator will be responsible for a very rigorous oversight of the organisation."
I shall give the Secretary of State another example in addition to that of cardiology. Would it give him pause if he read in the published literature that the two-week wait policy for breast cancer patients was damaging their welfare because they were not being referred and had to wait much longer than they used to wait before he introduced that policy? King's College hospital has provided clear evidence that about 40 per cent. of breast cancer patients who are not referred under the two-week wait policy—because diagnosis is difficult, or because some suspicion exists in respect of primary care—have to wait 12 weeks, as they do not qualify under that policy. Potentially, that is killing patients, and the Secretary of State must say whether he will stop the star rating of quality assessments if he is given clinical evidence that it damages patient outcomes. It is a simple question: if he is shown evidence that targets kill patients, will he stop insisting on those targets? [Interruption.] He can answer that question yes or no. His refusal to do so suggests that he has made up his mind that he will carry on no matter what.
What does the Secretary of State do when a hospital with a three-star or two-star rating is subject to a scandal, a bad Commission for Health Improvement report or a very low rating from Dr. Foster? Does not the star-rating system get torn up whenever CHI condemns a hospital for failures? Is not the Secretary of State a man with three watches? He has the league tables from Dr. Foster, which his Department partly sponsors, CHI performance ratings and inspections, and the star-rating inspections. Those three never match because only one—the existing, independent Commission for Health Improvement and its rigorous inspections—has any credibility.
I turn to the issue raised by the hon. Member for Stroud (Mr. Drew). We want a mixed economy of providers in the mutual sector, but we have several criteria. That status must not be imposed by central Government; they must not be seen as an elite that is better than everyone else; they must not be given powers to poach staff until all local health economies—through the ability to raise resources locally via tax-varying powers—are able to respond in kind if there is competition through pay at local level for staff. That is the sort of system that we want. We have already put in print our wish to see more mutuals providing services, but they must come forward; the system must not be imposed in a falsely elitist way from the centre. That has been the problem with the Government's approach.
We have set out our policy, and the Government can disagree with it—I know that the Secretary of State agrees with large chunks of it—but it cannot be said that we do not have an alternative reform policy. We have set out the ways in which we disagree with significant parts of the Bill, particularly in respect of the Commission for Healthcare Audit and Inspection and the foundation hospitals proposal. We look forward to working in Committee on those aspects of the Bill about which we agree, but I hope that the Government will change significant parts of it. We will oppose it on Second Reading because there are certain measures in it that we
are against. [Interruption.] The Conservatives have not explained what their policy is—we have. The proposals in the Bill differ from our policy, which is why we oppose it.I pay tribute to the Health Committee, the hon. Member for Wakefield (Mr. Hinchliffe), and the proposers of the reasoned amendment that was selected for debate. All the criticisms were made in measured terms, and we share many of those made in the reasoned amendment by the Select Committee, and by the hon. Member for Stroud and the right hon. Member for Holborn and St. Pancras (Mr. Dobson) in previous contributions. For that reason, we will support the amendment in the Lobby tonight.
2.39 pm
Mr. Frank Dobson (Holborn and St. Pancras): It is always worth reminding the House that, whatever the problems are with the national health service as it stands, it is the most popular institution in the country—more popular than any politician, more popular than the BBC, more popular than the Church, more popular than the monarchy, more popular than the Co-operative movement and more popular than elected local authorities.
I believe that the Government's proposals for foundation hospitals are the very last thing that the NHS needs, first, because they would impose another round of structural upheaval on the NHS, when most of its managers and staff just want to be left alone to get on with their jobs.
Secondly, I believe that foundation hospitals would harm non-foundation hospitals and set back the integration of hospitals with local primary and community health services. Thirdly, foundation hospitals represent part of a reintroduction of competition into the NHS, deliberately setting hospital against hospital in a way that, sadly, reflects the lamentable and failed policy of the Conservatives, who introduced division and expense into the NHS.
Endless reorganisation has harmed the NHS for years. Each round of structural upheaval has followed so hard on the heels of its predecessor that NHS management and staff have seldom been able to concentrate on treating patients. Instead, their efforts have been diverted into contemplating and taking part in another reorganisation. That has caused staff a great deal of stress and dissatisfaction, and it has harmed patients.
We know that change consumes resources and management attention in any organisation. When an organisation is reorganised, output is likely to fall during the process, and to rise again when people get used to the new system. If the reorganisation is a good idea, output may, in fact, rise above the original level, but in the NHS, time and again, just as performance is beginning to pick up, someone comes along with another demand for modernisation, reorganisation and reform, and the whole debilitating process starts all over again.
Since 1997, the Government have introduced revolutionary changes in the NHS—with, I emphasise, the support of the professions. For the first time in the history of the health service, local management is
responsible for promoting high-quality treatment. National standards have been introduced for treating illnesses such as heart disease and diabetes, or for caring for patient groups such as the elderly, integrating primary and hospital services to the benefit of patients.The Commission for Health Improvement has been introduced to monitor, advise and help. Primary care trusts have been established in an effort to give all GPs the advantages once enjoyed only by fundholders, involving nurses and social services in setting local priorities both for themselves and for local hospitals. The training and career development of nurses and midwives has been modernised. The medical profession has accepted the concept of revalidation, keeping doctors up to date with recent developments.
Everyone working in the NHS is now committed to making those things work. Wherever I go, staff say, "Give us a break. For God's sake, just let us alone to get on with the job. We may or may not like the new structure, but we just want to be left alone." They want to be spared another reorganisation and, as far as I can gather from most people who approach me, they certainly do not want this one.
Foundation hospitals would be a cuckoo in the local health nest. With more funds, they would be able, in the Government's own words,
- "to offer new rewards and incentives to staff",
It has also been said that foundation status will be available to everyone in four or five years' time, so that is all right then. Well, it is not. Let us consider this as a marathon race. The back markers will only get to the start line in five years' time, but they are apparently expected to catch up with Paula Radcliffe, who starts in about a year's time, and I do not think it likely that they will do so. She will be permanently in front, and so will the foundation hospitals.
If foundation hospitals' borrowing, which has been mentioned already, counts against the NHS global total, the more that they can borrow, the less will be available for everyone else. If they get their borrowing wrong—we know that some of them will—other parts of the NHS will have to give up money to bail them out of their problems.
That brings me to the problem of competition. If we look at what happened when the Tories introduced their internal market, we can see the damage that competition can do to the NHS. When they introduced the internal market, the bureaucratic costs of hospitals doubled, waiting lists exceeded 1 million for the first time in the history of the health service and hospitals stopped co-operating with neighbouring hospitals. I remember going with my fellow MPs from Camden and Islington to meet the chief executives of the various local hospitals. When I asked, "Why can't you co-operate on this?", I was told, "It's dog eat dog now in the national health service, Mr. Dobson." It will be dog eat dog again if we go through with this.
There is a lot of talk about how the present system stifles innovation. I do not think that it stifles innovation. If hon. Members go to practically any hospital in this country, they will see someone doing something new. The health service's problem is spreading the useful innovations, and evidence shows that competition stifles the spreading of innovations. If a new technique was developed at a hospital, management often believed that it gave the hospital a competitive advantage, so they kept quiet about it; they did not spread it to the next hospital in case that undermined their competitive advantage.
Worst of all, there has been only one reputable academic study of the impact of the internal market on the NHS. It was undertaken by Bristol university, which looked at death rates following emergency admissions after heart attacks, and those who undertook the survey said:
- "Our central finding is that competition is associated with higher death rates—in other words, competition is associated with lower quality."
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