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Dr. Reid: Is the hon. Gentleman telling us that the Conservatives do not know how much the scheme will cost, do not know where the money will come from, do not know whom it will go to and think that it is compatible with equity and equal access, even though it depends on how much money people have?
Mr. Burstow: I had hoped the right hon. Gentleman would direct that question to his Conservative opposite
number. Unfortunately, he did not take the opportunity proffered to him. I would not presume to comment further on Conservative policy, except to say that I look forward to the outcome of the consultation and the publication of the details. Since the policy was published 12 months ago or more, we have been told, "The details are coming. The details are there. Look on the website. Look for the background papers. It's already out there." It is not out there. It is a bit like the secret files that we see in television programmes. Perhaps we need to get the FBI in to look for the X-file details.Another topic that the Government plan to introduce over the next couple of years, and which they are piloting in foundation trusts, is payment by results. I hope that before rolling it out across the NHS, various issues will be addressed. The first is the decision to introduce a fixed-price tariff. The Government want competition on the basis of quality, not price, but the problem with the tariff in its current form is that trusts that for some reason—in some cases purely for historical reasons—have costs that are 20 per cent. below the average tariff will receive a substantial sum for no extra procedures or extra activity—a bonus for them at the taxpayers' expense.
I ask the Government to think again about whether that is the best way to use the extra investment that is going into the NHS, and whether there is some scope even now for a maximum tariff, rather than an average tariff, to allow flexibility and to allow local commissioners to ensure that taxpayers get good value for money, alongside good quality care.
The second concern about the plan is that everything appears to be tied to the tariff, which could undoubtedly trigger some of the problems that arose from the Conservatives' internal market, where trusts find themselves above tariff, unable to make a transition back to the average within a reasonable time and consequently get into serious financial difficulties. There has been talk of transitional arrangements. Will those apply to the entire NHS, rather than just the pilots?
The third concern arises from the way the system focuses on rewarding activity, which is not necessarily the way to measure a system designed to promote good health. The system currently provides an incentive for more procedures and more treatment, rather than rewarding the postponement and prevention of ill-health. That brings me to the Wanless report and prevention, on which the Government and the House should focus more.
I was surprised that in his Budget statement last week, the Chancellor made no reference to the report by Derek Wanless, which, if I read the foreword to the report correctly, was commissioned by the Chancellor, the Secretary of State and the Prime Minister. The first report published by Wanless set out three scenarios. It predicted a gap between the best and the worst-case scenarios of £30 billion by 2022. It said that the NHS would cost £30 billion more if we failed fully to engage people in their own health. His second report sets out with great clarity the fact that the NHS is, by its very nature, focused on treating and curing ill health, rather than on preventing it. Wanless records that we have known for 30 years or more the determinants of ill health—economic, environmental and social factors—and the fact that poverty, poor housing, poor
environment, bad diet and lack of exercise are the underlying drivers of much of the ill health that turns up in accident and emergency units and GPs' surgeries.The inequalities that the right hon. Member for Darlington (Mr. Milburn) mentioned came across very powerfully in some recent work done in Leicester on health inequality. It found that within a distance of only seven miles, life expectancy varied by 20 years. How can such a difference be acceptable in 21st century Britain? Today's debate has so far failed to recognise that we need to move back upstream and tackle the underlying causes of ill health.
Dr. Andrew Murrison (Westbury) (Con): What conclusion does the hon. Gentleman draw from the fact that health inequalities appear to have widened in the past few years, rather than contracted?
Mr. Burstow: The conclusion drawn from the work done by Derek Wanless is that the failure over the past 20 years to make dealing with poverty a priority has driven health inequality, and that poverty is at the core of much of that health inequality. It was an underlying driver of health problems in the past, and it is now. It was a failure by the Conservatives when they were in office—[Interruption.] If there is no objection, I would like to develop the point as I see fit. When the Conservatives came to office in 1979, they inherited the Black report from the previous Labour Government, but they shelved it because they were not prepared to incur the up-front costs of shifting emphasis, doing what was necessary and investing in prevention.
Dr. Murrison: I have a point of information for the hon. Gentleman: the Black report was published in 1980, so we could not possibly have inherited it in 1979.
Mr. Burstow: That is a very pedantic point. The hon. Gentleman knows full well that the report was commissioned under a Labour Government, but came on to the desk of a Conservative Minister, who shelved it. It was not until 1992 that the Conservative Government finally woke up to the needs that existed and published a White Paper. That is the record of the Conservative Government.
In my judgment, the current Government's record is not much better. When they came to office in 1997, they initiated work through Acheson and they published a White Paper the following year, but they ditched most of the targets from the 1992 White Paper that could have made a difference. There seems almost to have been a period of boom and bust in activity on prevention and public health. We need sustained investment and reform of the sort that the Government rhetorically describe in relation to other aspects of health.
When I asked the Secretary of State about investment in research, he gave me the same answer as the Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson), who is responsible for public health, gave me in the Select Committee on Health a couple of weeks ago. Effectively, they both said, "You'll have to wait for the White Paper; we are not saying anything just now." Last December, however, the Department of Health announced the
establishment of a £3.5 million public health research consortium. My concern is that the scale of the task and the lack of an evidence base, which are documented by the Wanless report, necessitate urgent action. Welcome though the £3.5 million is, it is not enough, and the opportunity should be taken to invest further. I hope that, when the Secretary of State publishes his White Paper, he will give that commitment and roll out a programme of investment.I want to mention two final issues. The problem with creating a shift from a sickness service to a health service is that the gains are very long term and do not impact on the Government of the day—unless they are so good that they stay in power for 30 years, but that does not happen very often. For example, in respect of cancer deaths, it takes 30 years after giving up smoking before the individual in question has reduced their risk of cancer to the same level as that of somebody who has not smoked in the first place. Welcome though the reported reduction in cancer deaths is, it is the consequence of action taken by Governments over the past 30 years, not only by this Government in the past five years. That is an important and perhaps salutary lesson for us all, and it needs to be borne in mind when we are trying to build a consensus on public health.
I want also to ask the Minister about the four-year delay in taking forward a key measure on smoking. The Health and Safety Commission's draft approved code of practice clarifies the implementation of the Health and Safety at Work, etc. Act 1974 in respect of passive smoking. It is four years since that measure was introduced, but the Government have remained silent. The measure does not go so far as to say that there should be a ban on smoking in enclosed public places, but it puts in place arrangements that could make a difference to the workers in those places, as well as to the public who do not wish to be victims of passive smoking. When will the Government act on that measure? As Wanless says, education will manifestly not change behaviour enough, because as those who have smoked know, addiction means that the habit is very hard to shake.
The timing of the comprehensive spending review is crucial, but the White Paper will be published in the summer. Clearly, the Government have already made quite a few decisions about the additional resources that they might need to earmark in order to roll out a public health agenda. If they have not done that, the White Paper proposals that are published this summer will take a considerable time to implement. I hope that I can be reassured on that point and that things will move forward more rapidly.
My final point concerns chronic disease. The right hon. Member for Darlington was right to focus on long-term morbidity, as the focus must shift not only to preventing ill health, but to the fact that the success of the NHS means that more people are living for longer with disease. The national service framework is in the pipeline and it will do something in that regard. But is it not curious that there has been a failure to commission any work on the prevalence of most of the chronic diseases that the national service framework on long-term medical conditions is attempting to do something about? There has also been a failure to undertake an
audit of the work force to find out where the gaps are so that we can start to plug them. As a consequence, the framework will be hamstrung from the day on which it is published in terms of delivering on the very worthy words that I am sure it will contain.The large proportion of NHS staff coping with long-term medical conditions is an important factor. Some 17 million people have long-term medical conditions, and they account for 60 per cent. of GP consultations and hospital resources, so it is important that the NSF delivers not only resources, but the clarity that is necessary for planning at a local level. We need to move from an episodic view of health care to one where patients are equal partners in respect of their own health and care. Nothing in the Secretary of State's speech gave people the sense that the Government want to reorientate the NHS around the needs of those with long-term health conditions.
We support the investment that is being put in, not so much by this Budget as by the previous one. It is essential, but not sufficient. We need to shift the focus from the treat-and-cure system that we have had since the 1940s to one that is much more about preventing and postponing ill health. We need to lift the burden of the targets and tick boxes that bog down the national health service. Above all, we need to bring health and care closer to home. Accountability must be local, because that is the only way in which we can make the NHS responsive to local needs, rather than to what is dictated by Whitehall.
After seven years of Labour government, this Budget has failed to set a framework to ensure that our constituents have access to a world-class health care system that not only treats them when they are sick, but ensures that they can enjoy opportunities for good health.
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