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3.3 pm
Mr. Francis Maude (Horsham): This has been a rather frustrating debate in lots of ways. It should have been rather interesting with cross-currents and dynamics working within it. Instead, rather oddly, we have heard a Labour party with a centre of gravity that is rather out of sympathy with the principle that underlies the Bill argue for the Bill, while the Liberal Democrats and the Conservative party have argued against it, although their centres of gravity support its direction. That is all very confusing for a simple chap such as me. The Bill is flawed and imperfect, despite the fact that its intentions are good. My hon. Friend the Member for Woodspring (Dr. Fox) made a telling case for how it must be dramatically improved.
Stephen Hesford (Wirral, West): Will the right hon. Gentleman give way?
Mr. Maude: I am sorry but I really do not have time.
The Bill will probably not succeed on foundation hospitals because it is too beset by red tape and interference. It will not liberate people in hospitals that
achieve foundation status to create the improvements of which I believe that they are capable and that the Secretary of State hopes for. A good idea will end up being damaged by being inadequately effected.The question of where an institution is accountable has little to do with formal structure and the debate about how the governance structures will affect foundation hospitals is something of a red herring. What matters is where people feel that accountability lies. I was struck by how little difference the creation of supposedly self-governing trusts under Conservative reforms in the 1990s made to accountability in reality. People continued to feel that the system was centrally planned and bureaucratically driven. When I returned from a sabbatical from politics, I was surprised to learn how little the culture of the national health service had changed as a result of the reforms.
There was, however, a dramatic improvement to the accountability of fundholding general practices. Most were small enough and close enough to the patients whom they served to mean that people thought that they were more genuinely accountable. There was no pretence at any democracy, but to echo the vivid way in which the right hon. Member for Copeland (Dr. Cunningham) put it—he would not call it competition but he described something that sounded like competition—there was a competitive process because general practitioners needed to keep their patients. They responded immediately to what their local patients required.
The Government have drawn the wrong lessons from experiences in the 1990s and the Bill represents a failed opportunity. It contains a good idea that is hamstrung by a lack of faith in it. We have heard about the patients' journey, and the Secretary of State has made a journey in, by and large, the right direction. He talked about that in an article that I found on a website. He said:
- "Over these last six years, however, I . . . have been through a steep learning curve. Whitehall dictat does not and cannot deliver public service improvement"—
There is real gut hostility in the Labour party to the principle that underlies the Bill, and that comes out in the most repellent phrase in the new Labour lexicon: earned autonomy. That phrase is a contradiction in terms because it like saying, "Yes, you can have the key to the door but only if you promise to be back by 10 o'clock every evening and meet only the people who I say you can meet." Earned autonomy is not genuine autonomy because those who have the supposed autonomy will always be on the end of a string that can be twitched at the Secretary of State's diktat, to use his phrase.
Mr. Dorrell: My right hon. Friend might not have noticed that while he made his analogy about keys and returning by 10 o'clock, there were many nods of approval among the forces of conservatism on the
Labour Benches. Those Labour Members think that the state has a parent-child relationship with the citizen, and that is a telling fact.
Mr. Maude: That is very revealing. The Bill is a real muddle that will not deliver the benefits that it is designed to deliver, and that also shows why the worries of the Labour rebels who signed the amendment are misplaced: because the Bill will not work. If it did work in the way that is planned, many of their concerns would be justified because it would then remove any pretence of central Government's ability to guarantee equity and the equality of outcome, although that cannot actually be done.
The fact is that if the most highly rated hospitals are given their freedom first, which is what is proposed, and they do much better because of that liberalisation from central control, they will not be catchable-up-with—I think that was the phrase used by the hon. Member for Manchester, Central (Mr. Lloyd) yesterday—by other hospitals. The aim of the Labour model seems to be to cap the good hospitals to prevent them from getting any better so that the others can catch up, but what sort of outcome is that? It seems that there is something reprehensible about good hospitals getting even better, but I want good hospitals to get much better. We should want all hospitals to improve and genuine freedom will enable that to happen.
One of the Bill's flaws is that the proposal is the wrong way around. If the Secretary of State believes that freedom will liberate and allow improvement, he should liberate the worst hospitals first. That would allow him to appease some of his hon. Friends who are so worried about the Bill, because those hospitals would be able to catch up. The problem is, however, that the Bill will not allow any hospital to do much better. It is a wasted opportunity. If the right hon. Gentleman is to implement his change, he should at least discover the courage of his and the Prime Minister's new convictions and go back to what he said a year or so ago about central diktat not working. What does work is liberating people. If he believes that, let him act on it, because the Bill will not achieve that.
3.11 pm
Mr. Robin Cook (Livingston): I am conscious that my last speech in the House was not received with universal welcome on the Government Benches. I rise today in the modest hope that what I am about to say in support of the Bill will be more welcome.
I was the Opposition health spokesman in the 1980s when Lady Thatcher was Prime Minister, which was an immensely rewarding time to be in that role. We used to scour Britain and return to the House with cases of individual patients who had been badly treated and turn them into household names overnight. Now that I am in a more reflective phase of my career, I recognise that although that activity had immense value as a campaigning tool, I am more doubtful about its value as a contribution to national policy.
It is not our job to micro-manage hospital services. Whether we are in Westminster or Whitehall, it is our job to get the structure and funding right and then to
provide the maximum local freedom to local NHS units to get on with the job. The nub of the debate is how much local freedom we can provide while recognising—I say this candidly to my hon. Friends—that there will be differences if we give them maximum freedom. We cannot provide local freedom and then deny hospitals the right to be different—not necessarily better, but different.My right hon. Friends the Secretary of State and the Member for Holborn and St. Pancras (Mr. Dobson) have made immense changes for the better in the NHS. It is remarkable that for the first time in a generation we are experiencing an increase in the number of general acute beds in the NHS, which is dramatically different from the steady decline in the 1980s and 1990s. My right hon. Friend the Member for Holborn and St. Pancras was right to remind us that there have also been major changes of structure. The creation of primary care trusts and the transfer of three quarters of NHS funds into the hands of GPs and community services were particularly strategic changes. They reflect a remarkable shift of power to the people who are most representative of the patient and most commonly in touch with them.
The rational background of the debate is that the NHS is improving and will continue to improve, but can be made better. It is important that we have that background fixed in our minds because nothing makes the staff more demoralised or resentful than the sense that their immense strides of progress are not recognised politically or in public. That background is also important to inform our debate in the House, and in particular, perhaps, on the Labour Benches. What worries some of my hon. Friends is that the rhetoric of reform occasionally appears to imply that the NHS model is failing rather than succeeding. They worry therefore about supporting reform because to do that might be seen as rejecting the basis of the NHS, which they support and to which their electors are greatly attached. I argue, however, that we should support the Bill precisely because the NHS is strong and successful, and the proposals will continue that improvement.
I have every confidence that a public health service free at the point of use will continue to be popular throughout the century. I have to say that I am less confident that any state-run institution will command affection for the rest of the century. The Bill addresses two fundamental issues that the NHS must face if it is to retain that affection. First, we need to give it more local identity and less of a national image, and that is done in the Bill. One of the Bill's most radical elements is that it transfers control and ownership of local hospitals to local bodies that are locally accountable. I do not think that it is fair to argue that that is a step towards privatisation. If any future Government wishes to privatise those hospitals, the first thing that they will have to do is to introduce a Bill to nationalise back the buildings and hospitals. I do not think that it would be politically feasible for any Government to attempt that.
The second issue that the Bill addresses, which is essential to the NHS, is that it provides for local hospitals to exercise more initiative. I read a lot of twaddle in the press in recent years about the superiority of private sector management. The last decade is littered with some spectacular collapses of private sector companies in which the private sector management have
appeared to walk away with pay-offs that are in inverse proportion to their success in managing the company. If any one of those scandals had occurred in the public sector, the Government in office would have been swept out of office in a tide of public outrage.The strength of the NHS is that it has an ethos of professional commitment. It attracts staff by the sense of reward of serving fellow citizens. I am not saying that that ethos is superior to the private sector, but it is valuable. It is worth preserving and should not be reformed out of the system. But the private companies have one strength that we should try to bring to the public service: they have a model that provides the capacity to permit initiative and to promote innovation. The model in the Bill of a public benefit corporation, providing a form of mutual social ownership, is an interesting worthwhile stab at a model that will give local management more room for manoeuvre, wider space for initiative and greater flexibility to reward and encourage innovation by the hospital staff. It is commonplace to complain that there are too many targets in the NHS, but my right hon. and hon. Friends flood the NHS with targets because the only way to get change in a top-down management system is to set national targets. If we want fewer national targets, we have to encourage more local initiatives.
I understand my hon. Friends' concern about the original proposals promoting two-tierism. I encourage them to recognise that they have made progress by getting the commitment to provide more resources and support to underperforming hospitals within five years so that they, too, can become foundation hospitals in that time scale. Frankly, if we want to address the problem of underperforming hospitals, I suggest to my hon. Friends that the best way to get the leverage to do that is to support the Bill. That will force the issue on the Government as a greater political priority and ensure that they tackle underperformance and enable every hospital to have the same chance.
I have spent much of my time—indeed, lately rather more of my time—travelling in Europe visiting our sister parties. I know well the parties of the left in Scandinavia, Germany and the Netherlands. Most of them regard themselves as well to the left of the Labour party, and I leave it to individuals to decide whether that is something to celebrate or regret. But all those parties will be mystified at the idea that handing hospitals over to mutual social ownership is abandoning leftist principles. Most of them have done precisely the same thing. Indeed, I suspect that some of them might welcome such a move as a sign that Blairism is moving to the left, although I would not want to get my right hon. Friend the Secretary of State in trouble by suggesting that that might be true. However, there is nothing in the Bill to cause us trouble by undermining our principles or by being hostile to the values of the NHS.
I want the NHS to be there for the rest of my life. The Bill will give us a better prospect of an NHS that is popular throughout that period and able to fulfil its potential. For that reason, I support the Bill and urge my hon. Friends to do the same.
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