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Dr. Richard Taylor (Wyre Forest) (Ind): It is an enormous privilege to have secured this debate, and I am delighted to see the Minister in his place. He will know from my dealings with him that I have no hesitation in supporting the Government when they are right and no hesitation in telling them when they have got something wrong.
I welcome the tremendous sums that the Government are putting into the health service and many of the reforms that they are introducing to ensure that that money has an impact. Those reforms include better services for cancer patients and cardiac surgery, the instituting of overview and scrutiny committees, the National Institute for Clinical Excellence and the Healthcare Commission, and the publication of "Keeping the NHS Local", which I welcome. However, I have no hesitation in saying where some of the proposals have gone wrong.
Today, I shall give my views as an ex-NHS consultant and one who is acutely aware of the patient's voice. Indeed, now that I am an MP, I am hearing the patient's voice as much as I did when I was a practising doctor. First, however, it is necessary to give a short history lesson to those who have not been around the NHS for as long as I have.
During the campaign that brought me into the House, I had to endure several nicknames. I was called a militant activist, as well as King Canute, although that is actually a great compliment, because King Canute was essentially a humble chap; he did not believe that he could prevent the sea from coming in, and sought to demonstrate that he could not do so. I was also called a medical dinosaur, and at the risk of justifying that title, I want to take hon. Members back a few years.
Right hon. and hon. Members on both sides of the House have implied that the choice initiative will give people choice for the first time. In his speech to the New Local Government Network, the Secretary of State said:
That is just not right. Before the period from the late 1980s to 1990, when the internal market came in, patients had absolute choice over where they were referred, and doctors had absolute choice over where to refer them. I always remember treating a patient with an extremely difficult muscular condition. At the time, the expert in muscle diseaseshe is now a member of the House of Lordsworked in Newcastle upon Tyne, which was rather a long way from Kidderminster. Yet, I was able to get that lady to see that expert in Newcastle without any problem, either with contracts or red tape. So, that sort of choice is not new, although, unfortunately, the internal market put an end to it.
My views are reinforced by those of another chap who probably would not mind being called a medical dinosaur. Dr. Peter Fisher, the president of the National Health Service Consultants Association, writing in Hospital Doctor this week, says that in the
I would add that the relationship between the patient and the GP was also untrammelled by concerns over contracts, in whatever sense one uses the word "contract". Dr. Fisher asks the crucial question:
What does the patient really want? As we all know, patients are very aware of cleanliness in hospitals and the risks of methicillin-resistant Staphylococcus aureus. They desperately want clean hospitals and local hospital servicesI know that as well as anybodyand for them to be well resourced. They are prepared to travel if there are long waits, particularly for elective treatment. It is unlikely that anybody ever has real choice on emergency admissions in any case, because they are taken to the nearest available place that can cope with them. The choice for patients would be to have that local service as close as is possible.
In this week's British Medical Journal there are references to a MORI poll that showed that 25 per cent. of people would be willing to travel anywhere in the United Kingdom for treatment by the NHS when there were long waits locally. The snag is that the survey was talking only about people with means of transportpeople with their own cars.
To try to get a glimpse of what ordinary people want by way of choice, I turn to the letters page in The Guardian yesterday. A writer from Preston, who I checked is not a doctor and is not in the medical directory, describes choice as
There was an article in The Independent on Sunday written by the noble Lord Haskins, who used to be an adviser to the Prime Minister. He describes his own illness and his reasons for first choosing private health care, but later moving to the NHS when the service he needed was available on it. He pointed out that he had the ability to choose and that choice helped him a great deal.
"The person who is best placed to exercise choice on behalf of the patient is the GP, who, when practicable, does that at present. There is a strong case for strengthening the GP-patient relationship".
"should concentrate on what it has been doing successfully in the past few yearsproviding more staff, and better technology and improved facilities which are available to everyone, without undue delay."
David Taylor (North-West Leicestershire) (Lab/Co-op): The hon. Gentleman makes the serious point that choice will, in many circumstances, effectively be one that is taken on the advice of the GP. Is it not the case
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that more than two thirds of patients, including elderly people and those with mental health problems, will find themselves at an information disadvantage and will be unable to make an intelligent choice?
Dr. Taylor : I thank the hon. Gentleman for that intervention. I shall return to that point towards the end of my speech; he has obviously been reading the study showing that 65 per cent. of people do not have the advantage of choice.
I turn to the limitations on choice in the existing system. First, targets are centrally imposed; in the past, those targets had to be met in order to decide on star ratings. Such central diktats take away local choice, but that is in direct competition with the Government's laudable aim of devolution. Overemphasising targets is leading to problems for patients and reducing their choice. I shall give two examplesone general, and one local.
The general example is of NHS treatment centres. The centres were designed with a large capacity because it was recognised that separating emergency and routine work would offer hospitals better control of waiting lists and help to fulfil the aim of delivering routine care more rapidly. Probably for the right motives, the Government arranged huge contracts with treatment centres in the independent sector; the problem is that those contracts have to be fulfilled before patients can be allowed real choice about where to go, and people are worried that they will not improve quality. Primary care trusts are under pressure to use the independent centres; they thus have relatively limited resources available for use on the NHS treatment centres. I am sure that the Minister is aware of worries about the independent sector treatment centresworries about standards of care, loss of training on routine matters for junior NHS staff, follow-up and the treatment of complications.
The local example shows how choice has been taken away by overemphasising the targets for cardiac surgery. Because the major centre for cardiac surgery in Birmingham could not meet the targets, the local strategic health authority ruled in its wisdom that patients from my part of the world, from the Wyre forest and south Worcestershire, should go to Coventry cardiac surgical centre rather than Birmingham. That would be all right if patients were given the choice of going either 50 miles or 20 miles. I can honestly say that both probably provide services of an equally good standard, but that ruling has been interpreted in such a way that patients and the local cardiologists are left with no choice.
I have to declare an interest; I know of that problem because a good friend of mine is involved. The distance to Coventry by the most convenient route is 51 miles, and to the Queen Elizabeth hospital in Birmingham it is 18 miles. In emergencies, the ambulance journey for my friend was 51 miles of agony. The only ambulance that could take his heart machinery was an old ambulance with archaic springing, and he had to lie upon an unsprung canvas stretcher. That is one example of choice being taken away from both clinicians and patients.
I turn to a second limitation on choice, the availability of services. The Health Committee has recently reported on allergies, palliative care and sexual health. Those
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reports all show limitations in the services providedunderstandably sobut those limitations also reduce patients' choice. Even the choice of whether to die at home, which many people would like to be able to make, is limited by the amount of support available.
Another local issue is maternity care. The Health Committee produced a report in 200203 on "Choice in Maternity Services". The services that should be available are, obviously, home birth services, midwife-led birth centres, and a consultant unit. A recommendation in the report was that
Our birth centre was rightly closed after some unexplained and totally unacceptable baby deaths. The inquiry that looked into it exposed faults in that stand-alone birth centre that dated back to the loss of the acute district general hospital that previously supported it. Despite questions of safety at the time, the health service managers did not put the safety measures into place, with the consequences that have ensued. Stand-alone birth centres are safe and viable with the right protocols, as is demonstrated in "Keeping the NHS Local", which I have mentioned before.
Another factor that limits choice is the availability of staff. The Government are to be commended for their efforts to increase staff, and their success in some other fields of activity, but there are still huge gaps. I shall give two local examples. In the county of Worcestershire there is only one specialist available for a particular complicated but relatively commonly needed procedure. That specialist was called away on jury duty. Doctors used to be exempt from jury duty and I have no brief to recommend that for doctors as a group, but where a service depends on a single high-powered specialist it does not seem right that he or she should be called away to jury duty. There can be no choice in that case, because there will be no service.
Similarly, in my area we have only one specialist for essential biopsies of the prostate. When that specialist is off sick there is no service. That instance resulted purely from lack of co-operation and lack of a true partnership across the county, which I believe has been sorted out.
The last factor that I want to mention as limiting choice is another that I lay at the door of the Government; it involves magnetic resonance imaging scanners. There is spare capacity in MRI scanners in the NHS, but the Government have signed a huge contract with a private supplier and therefore the choice of the GP to use the local NHS scanner is eroded, as is the choice of the patient. The motive is bulk buying for cheapness, and that is certainly a consideration. I tabled
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a written question to try to find out what the savings would be, but, surprise, surprise, the answer that came back stated:
David Taylor : Does the hon. Gentleman agree with the chairman of the council of the British Medical Association, who was recently quoted as saying that the planks of the current reformspatient choice, the inclusion of patient providers and the delayed system of payment by resultswere in chaos and causing real difficulty for several acute hospitals?
The fact that MRI scans are being contracted out to the private sector in large numbers again points to the Government's lack of awareness of some aspects of what goes on in the real world. MRI scan reporting is not as simple as reporting a pathology blood test. It is always an opinion, and it cannot be a one-way process. There must be input from the clinician, and he or she needs to know the radiologist to know to what extent they can rely on the report. Discussion often helps. Throughout my professional life, one of the most useful aspects of my ward rounds were visits to the X-ray department with juniors to meet the radiologist and discuss the scans. Obtaining a balanced view and a correct opinion were of immense benefit, to say nothing of the teaching opportunities.
I fear that the wholesale use of private sector MRI scanners is a false economy. It certainly removes choice. There are reports that University hospital, Lewisham has stopped referring patients to the private scanner services because of inaccurate reports and delays in reporting.
Dr. Evan Harris (Oxford, West and Abingdon) (LD): I am listening carefully to what the hon. Gentleman is saying. Does he know the name of the private company supplying the MRI scanners, and whether it has any connection with the Government, who have contracted it in secret for a figure that we do not know because it is shrouded by commercial confidentiality? [Interruption.] I see that the Minister is sensitive about the subject.
Much has been written recently about the low uptake of the choose-and-book system, about the doubts over what the necessary integrated IT system will achieve, and about GPs' doubts that they will have the time to operate it. I hope that the Minister will understand that I am trying to be helpful when I say that it is pretty impracticable to give people a choice of four to five providers. The GP is, and must be, the one who decides where a patient should be referred to. That is one of the crucial aspects of the GP-patient relationship.
I referred earlier to the King's Fund and Bristol university study, which was published in the British Medical Journal. The study showed that 92 per cent. of
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the population have two hospitals within 60 minutes' travel time. Other members of the Health Committee and I saw a demonstration of this really complicated choose-and-book system at the Department of Health. It reminded me of an intensive care unit monitoring system that I demonstrated to the public before the local hospital's league of friends bought it some 20 years ago. The model worked beautifully, but it did not work when we put it into the ICU and we had to sue the provider to get the money back. What we need instead is a simple system that would be readily available.
With two clicks of his computer keyboard or mouse, a GP could easily pull up on a single screen, updated every day, the specialty at the two hospitals within an hour's journey, the consultants in the field in which he was interested and the waiting times for those consultants. He could decide with the patient, which is his job, which of those the patient would like to go to. The appointment could then be made not by the GP, which takes time, but by the receptionist outside.
I move on to the way forward, because I am desperately trying not only to be critical. I cannot say that it is a real ambition because I do not think that I will ever become Secretary of State for Health, but if I were I would be tempted to investigate ways to abolish the market. People might say that that was going back years and it would not work, but, as I will not get into that position, at least it is unlikely that I will have the chance to suggest that. So, on to practical steps.
First, we need to recognise that virtually all clinical staff, nurses and doctors in the health service are absolutely dedicated to the NHS and to its patients and that there are some extremely good managers. If the managers are responsive to the people who work for them and to the patient groups who now have a voice, the health service could improve tremendously without the Government's interference. When we produced the Health Committee report on foundation trusts, we were staggered to find a list of major governmental reorganisations of the health service since 1982. Between 1982 and 2003, there have been 18 major reorganisations. We should leave the competent, capable, dedicated staff and their managers a bit of freedom to get on with things.
Secondly, I would remove targets. I welcome the Healthcare Commission's approach to assessing hospitals on standards to aspire to rather than on actual targets. I hope that they will continue to work for real ways of measuring health outcomes. Thirdly, I would sort out the potential conflict between the implementation of NICE guidance and of national service frameworks and local priorities.
Last week there were some dramatic headlines in the papers. On 3 February, The Times headline read "Patient power may close failing hospitals". What was meant by failing? To my mind, it meant failing financially rather than clinically, largely because patients are not allowed to choose the hospital that they would like. The money is channelled away by Government pressure on PCTs so that some of the work is done in the private sector. Contracts with the private sector have to be taken up.
On the same day, the headline in The Independent said that the Secretary of State was "ready to close NHS hospitals that prove unpopular." The Guardian had a similar headline, but reported comments from a
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Department of Heath spokesman that were very revealing. The spokesman said that the Secretary of State's
To me, that betrayed a fatal lack of understanding of the situation in the NHS by the Department of Health. If we take away entirely non-emergency treatment from an acute hospital, that hospital system will collapse. We can separate NHS elective care into treatment centres as long as they are integrated with the acute hospital, as a result of which the orthopaedic surgeons are kept in place. However, if we close down emergency services and lose them entirely, the hospital will not be viable.
I want the Department of Health to go out into the real world and talk to practising GPs, hospital doctors, managers at the coal face and patients' representatives. At present, there are some effective patient forums and patient organisations, such as HealthLink, which has carried out a study into the aspect of choice. I want the Department to talk to people with mental health problems, with long-term conditions, the elderly and the vulnerable because they are pretty much excluded from that choice, to which reference has already been made.
David Taylor : A moment or two ago, the hon. Gentleman was careful to distinguish between the concepts of clinical failure and financial failure. Does he agree that the real risk of the Gadarene rush into market mechanisms and therefore into the hands of the private sector could leave the NHS facing the fact that financial failure and clinical failure will be seen to be interchangeable and indistinguishable by the Government?
Was there really a threatened revolt by chief executives at strategic health authorities against the second wave of independent sector treatment centres last autumn? Choice is certainly a laudable aim in the long term, but it is not the correct, immediate aim. To repeat the words of Dr. Peter Fisher in the leader of Hospital Doctor:
Patients want local hospitals that are clean and well resourced. The Government have actually put in the money to achieve that, if clinical staff, managers and patients' representatives were allowed to direct the money to where it is most needed, according to local priorities. If patients are to be given real choice, in the words of Dostoevsky, "What man wants is simply independent choice".
Dr. Evan Harris (Oxford, West and Abingdon) (LD): It is a pleasure to take part in the debate. It reminds me of old times when I was on the Front Bench. There is a Liberal Democrat Opposition day debate and other activities in the House today, so I kindly offered to help out on the Front Bench. I am pleased to see the Minister looking as cheerful as everyes, no smile.
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We should thank the hon. Member for Wyre Forest (Dr. Taylor) for obtaining the debate and giving us the chance to discuss many of the most topical issues in health care. He carried out a wide-ranging survey of some health care issues and placed particular emphasis on choice. I agreed with much of what he said, especially the need for all of us, across party, to identify how to ensure that there are mechanisms that give more choice, or give more control, as I prefer to describe it, to the patient that will improve quality, access and equity. Those are our three most important aims.
Choice or control is best viewed as a means to the end of obtaining a more equitable, higher quality, and more accessible health care system, with access leading to fairness and quality, too. There is too much rhetoric about choice and some of the mechanisms that are designed to demonstrate that the Government are seeking to maximise choice undermine the other end points of fairness, quality and improved access, particularly for the sickest patients who ought to have the fastest access. There is also a significant opportunity in setting up mechanisms that can be seen to raise the profile of choice as an end in itself, rather than as a means to an end. The hon. Gentleman spoke about choose and book, which is one of those expensive and time consuming mechanisms that have yet to demonstrate any advantage in terms of access, quality and fairness.
I do not believe that the Government are opposed to recognising that the key issues are improved access, a fairer health care system and a fairer burden of ill healthif that is the right termand ensuring that there is good quality, but they are distracted by an obsession with trying to outflank the Conservative party to the right in respect of worshipping the mantra of choice. I should like to give a few examples of where their promotion of choice as an end in itself is damaging to what really needs to happen and to what we can say, given that we are in Westminster Hall and still some distance from an election, are ideals shared by all parties in terms of trying to obtain those three outcomes.
It is probably wise to start with choose and book, because that focuses the question on the opportunity cost. We should not be too critical of the NHS programme for IT. Clearly, there is scepticism about Government IT programmes, but if scepticism prevented us from doing things, we would never make any progress. The head of the IT project made it clear that he was aware of the record of failure on delivering big IT projects and was keen to ensure that the programme about which we are talking delivered the hardware and software. I recognise that big steps have been made. The flip side to that, which is perhaps inevitable, is that there has not been as much engagement with the health care professionalsnot just doctors and GPsthat there might otherwise have been. That conscious decision was taken by the head of the NHS IT programme, because he thought that it was most important to get credibility by delivery, but it is not easy to say in retrospect whether that was wise, given that there is now a big need to engage with the medical profession.
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The NHS programme for IT is seeking to do things as rapidly as possible in a catch-up way. The Minister will recognise that the remarks that I am making on this matter are not designed to be over-critical. However, the problem with choose and book is that GPs do not understand why the Government chose the numbers in terms of the range of choices, regardless of whether there was a question of access, or whether it was appropriate to provide choice.
I spoke to a GP in Bristol recently who could not understand why the other choice for cardiac care for his patients was in Winchester. It is not realistic that patients in Bristol will want to go to Winchester, especially those with the greatest health needs who will find it most difficult to operate that choice. Such people want to be near their families and treated near their homes. That GP was also of the view that there was a significant time requirement to use choose and book, which meant that he could not see as many patients as he needed and wanted to see and who needed seeing. He thought that the Government had not costed properlyhad not even started to costthe time impact of forcing people to use such a system in the surgery and were hoping that they would engage with it.
Clearly, there will be slowness during the pilot phase, if the system is to be piloted. I shall rephrase that; "pilot" implies that there will be an evaluation and a reconsideration. Do the Government think that, when people are proficient and the system is fully online, there will be a time cost? How will that be factored into GP work loads? The Government have done a huge amount to try to address concerns about GP work loads with the GP contract. It would be a pity to lose what has been reasonably successful, as far as these things go, in giving GPs the recognition that they wanted of their time-pressure issues. It would be a pity if the good will that emerged from that were put at risk by the imposition of a system that took a lot of time.
I should like to probe the Government on whether within this choice arrangement they will still provide the freedom of choice that GPs, and through them their patients, have for referral to a consultant or specialist of their choosing. I was interested in the hon. Gentleman's remarks on that issue. He was explaining that when he worked in the health service prior to the internal marketthat was a little before I started working therethere was effectively freedom to refer to any specialist in the country through the GP. That was lost during round one of the internal market, which was introduced by the Conservatives in the late 1980s. The question is whether that still applies now. Will GPs and patients be able, outside of contracts, to go to consultants of their choice? It is worth exploring how the Government's new tariff-based system and payment by results affects how we judge whether there is an internal market at the moment. It is fair to say that the Government have created an internal market, and a better, more effective one than the Conservatives did, for reasons that are clear.
Under the Government's system, money will follow individual patients; that is the way it is set up. Under the Conservatives' system, whether by design or because of a problem with the system, patients followed contracts and there was very little in the way of incentives to get extra patients; the incentive was not to lose the contract. However, it is difficult to take huge contracts away from
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a hospital without that hospital going bust. We were rightly critical of the old internal market, and I do not understand why the Government refuse to call what they are doing a better, more effective market version of the Conservatives' internal market, a version in which the moneyI have heard Ministers use the expressionwill follow patients as hospitals try to attract extra work.
That must be a good thing for people who see the health service in that way. I am not sure that that is how I would like to see the health service in its entirety, but one can recognise that a system in which good work and attracting more patients gets more resources is an effective market. I cannot understand why the Government are not proud of the fact that they have improved on what the Conservatives tried to do. With practice-based commissioning, there has clearly been a return to GP fundholding, which the Government were proud to say they had abolished, even though they made large multifunds when they created primary care groups.
I ask whether there will still be patient choice because in my Oxfordshire constituency we have been told that the mechanisms for choice, in reference to the large contract that has been awarded to an independent-sector treatment centre for cataract operations, will be called managed choice. I do not know whether that will be managed choice, massaged choice or pretend choice, but the patient referrals will go to a central PCT-run hub and be allocated to the treatment centre without the patients or their GPs having any say-so in the default situation. Patients will not be asked, "For your cataract operation, do you want to go to a car park near you in the next three months, or to the Oxford eye hospital?", but will be allocated to one or the othermost likely the treatment centre. I cannot understand how the Government dare to define that as choice, but I can understand why they are doing it.
The reason, as the hon. Gentleman said, is that those private sector treatment centres, and perhaps even the NHS ones, have an agreed amount of work sent their way. No money will follow the patient, but the Government have set up huge contracts, five years in advance, when the money has already gone, at exactly the same time as saying that they want the money to follow the patients. It is possible that no patients will be referred to the centres, but the centres will still be paid. They have to find the patients to follow the money.
I do not see how that gets over the problems of the Conservatives' flawed internal market, which the Government are rightly keen to criticise, for that and other reasons. I would therefore like the Minister to explain how he sees five-year contracts in advance of guaranteed work going to those treatment centres when he says that the issue is about the money following the patient and rewarding units for attracting more patients, rather than giving them a huge dollop at the outset.
I think that the Minister recognises that GPs do not have much faith in some treatment centres, particularly where there is a good-quality NHS service. I would be the first to accept that, in my area, not all the NHS services are good. However, there have not been complaints about either the quality of the service offered on the NHS for cataracts or failing to meet the three-
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month maximum waiting time target by the end of last year, flawed though that target is, as the NHS has indeed met it.
It is hard to understand why the system was imposed in the way that it wasit certainly was not a choice for the local population. In order to get the PCTs to sign the legal agreement, the Government had to guarantee that they would fund through the SHA the extra costs involved in patients not going to the private provider and sticking with the high-quality, easily accessible and fair service offered by the Oxford eye hospital.
The hon. Gentleman hit on another issue, which is that quality is not just about the here and now. We must find ways to ensure quality for the future. One of the key questions is how the Government see training being provided in independent treatment centres, which is done, I guess, to pass muster with the district auditor or the National Audit Office, at a rock-bottom rate. The centres cream off the easiest cases and do not have to do any training. Everyone knows that training slows down the process. I am sure that the hon. Gentleman will recognise that from having medical students to train who slowed him down, even though they were probably not as bad as I was.
Dr. Richard Taylor : The hon. Gentleman makes a valid point. As more and more surgery is done at a day case level and in treatment centres, the integration of treatment centres with the acute hospital is vital, otherwise juniors will not receive the training that they need for the work in day-case centres that they will do when they become consultants.
Dr. Harris : That is quite right. Independent providers in my area now say that they are renegotiating and increasing their prices, now that they do not have the contract, to take trainees. It is certainly important that trainees are trained, but we are talking about a rush job, where the long-term situation was not considered. If the Minister can correct me on that, I will be interested to hear his comments. If he persuades me, I will revise my views, but I am describing what I have heard from people involved in training on the ground.
The rush to the private sector also seems reckless as to the unintended consequences. For example, I understand that a system called evercare has been introduced to the community system, again in the Avon area, which has involved the provision of community matrons. The system is operating on a pilot basis, although I understand that it has been rolled out before evaluation and that is not a pilot to me, but an early starter. Under evercare, a private health care company called UnitedHealthcareperhaps the hon. Gentleman is aware of the companywill employ community matrons to assess patients, in particular regular attenders at hospital with more than two recent admissions, to see whether there is a way of keeping them at home. That is a laudable aim, but two negative points can be made. First, there is no evidence that it is cost-effective. That is why evaluation of these schemes is so important; Britain is not California for all sorts of reasons, even if the Minister wishes it was. Secondly, GPs say that all their H and G grade district nurses have been stripped out of the system in order to fill these posts funded by the NHS through this contract with a private company. Is that a sensible use of resources, and are the Government taking account of that?
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These are genuine issues and questions to do with choice, and we come back to the fundamental question of what choice is for. If it is for improved quality, better access and fairness, it seems reasonable to try to use choice as a means of increasing access where there is a problem to do with waiting times or access to treatmentsin isolated areas, for example. I have no ideological objection to choice being used in that way. However, in order to try to realise the mantra of patient choice in the NHS, the Government too often take control away from patients and GPs, and pick areas where there are not as large access or fairness problems as in some other areas. Even if one accepts that the Government's motives are right, it seems that they are operating the system in a way that enables them to say, "We are maximising choice, and we do not really care about evaluating how that has been achieved."
We need to be a little more rational and sophisticated in how we use choice to increase the control patients have over their treatment. We must recognise that that is not simply about a choice of hospitals. If it is about a choice of treatment, that is integral to the doctor-patient relationship; doctors have a duty to explain the treatment choices to patients. If the Government are saying that that is a problem at present because doctors are not giving patients an adequate choice of different treatments, they should say so. If they think that time is a factor, they should provide adequate time and space for clinicians. However, I do not think that the Government are saying that. They are using a geographical choice as a proxy for talking about a choice that already existsthe choice that patients and their doctors make together about what is the best treatment, regardless of where it takes place. There are far too many mixed messages on choice, and that confuses the issue.
In the run-up to the election, I would like the Government to talk more about fairness and quality, and to ditch some of the rhetoric around targets and choice. That often simply stigmatises parts of the NHSoften those parts with the highest work load or, because of the way the cake is divided, inadequate resources. Morale is already low in those areas, and it is driven lower by criticism on the basis that they are not meeting some of these central targets.
I hope we get some answers on what the Government's real position is on this, and I thank the hon. Gentleman for taking us through some of the situations that concern him in this important area of health care.
Dr. Andrew Murrison (Westbury) (Con): I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing a debate on this subject. I think that I can say on a non-partisan basis that it is a pity that we have not been better supported by our Back Benchers on this occasion. This is a crucial issue and I am sure that it will form a central element of what the parties talk about in the run-up to the general election.
I will be a little more charitable than the hon. Gentleman has been because, broadly speaking, the choice agenda is the official Opposition's agenda. It is
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our agenda because we believe it to be right in principle, and because we feel that, mechanistically, choice will drive up quality. On both counts, we support the general thrust of the Government in promoting choice in the national health service.
The hon. Gentleman, no doubt unintentionally, revealed in some of his remarks what one might call the patrician strand of NHS doctoring. I say that with the greatest respect, and I hope that he will not take offence. However, people now expect to be more closely involved in the decisions relating to their medical care and are, perhaps, less willing than they once were to be directed by "the system". The choice agenda is all to do with encouraging the patient empowerment that, going by his contribution, concerns the hon. Member for Oxford, West and Abingdon (Dr. Harris).
Mr. Harry Cayton has said, very eloquently, that patient choice is no gimmick. It changes people's lives, gives them control and improves the responsiveness of the NHS. With those words, I could rest my case and sit down. However, I shall not do that because I should like to ask the Minister about some aspects of choice. I agree with Mr. Cayton's sentiments; they are put extremely well in very few words. Choice drives up standards and responsiveness. I commend the Social Market Foundation report of September 2004, "Choice: the evidence", which poses a number of questions. Let me paraphrase three of them. It asks whether, when it has been offered, choice has been taken upthe answer is yes, but a support package is required in order for that choice, where offered, to be taken up; it asks whether the population that takes up the choice is socio-economically skewed, and it concludes that it is not; and it asks whether choice has helped to improve quality and efficiency and, crucially, answers yes.
The report bears close scrutiny, and I am probably doing it a gross injustice by summarising it. However, that is, essentially, what it says. It does not askI think that it should have donewhether health care professionals feel threatened by choice. The answer to that is probably yes. I would also say that the Government have not helped matters by, until recently, choosing to ignore health care professionals in going forward with the cornerstone of choice, the national programme for IT in the NHS. I shall deal with that in a few moments. I entirely endorse the comments that have been made about choice not being just between hospitals. It is between treatments and between specialists. As the MP for a rural constituency, I would say that people would, in effect, be choosing between, at most, two hospitals. However, they would also be choosing from a raft of specialists and, I hope, from different forms of treatment. For rural areas, the choice agenda will mean a great deal more than choices between hospitals. It will mean choices between specialists and between different sorts of treatment.
Mental health has been mentioned, but only once, in passing. That is a great pity. If I were to pick out an area of health care in which I felt that choice could be particularly useful, it would be mental health. Empowerment and choice are therapeutic. Lack of choice and lack of control are anti-therapeutic for many patients. That is probably why those who concern themselves with mental health issues, as well as patients,
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respond positively to the Government's choice agenda, and agree that it is right for the official Opposition to have at the heart of their agenda the notion of choice.
I encourage the Minister to say a little more about mental health in the context of choice. I say that in all candour. It has not been spoken of enough, and it should be. I fear that the right hon. Gentleman and his right hon. and hon. Friends do not appreciate that the NHS means considerably more than elective surgery. He might wish to take the opportunity to say a few words about how he thinks that his choice agenda will help those with mental health problems. I should also be grateful if he would clarify where we are with choose and book. Last month, the National Audit Office reported that only 63 patients had used it, although more than 200,000 had been expected to do so. Is the Secretary of State's expectation of 100 per cent. usage by the end of the year as ambitious as his plans for NHS dentistry were? Clearly, those have collapsed, with the result that my constituents have considerably less choice than they had eight years ago.
Will the Minister share some of the difficulties that the national programme for IT in the NHS is experiencing? We know that there are a great deal of problems, but, sadly, we have to learn about most of them from the redoubtable Computer Weekly, which has done a good job in keeping us up to date, despite the Government's attempts to bar its reporters from briefings. Why has it proved necessary, at this late stage, to throw bucket-loads of cash at primary care trusts in an attempt to bring GPs online and on message?
"On 19 January 2005, my right hon. Friend, the Secretary of State, announced a £95 million incentive scheme to recognise and reward the key role that PCTs will need to play in engaging primary care stakeholders and encouraging and supporting general practitioners to use choose and book."[Official Report, House of Commons; 2 February 2005; Vol. 430, c. 995W.]
That seems sinister. How does the Minister anticipate that PCTs will use the £300,000 per trust to bend GPs to his will? We understand that NPfIT will deliver two things: the vestigial national spine, and choose and book, yet each choice booking so far has cost £52,000. The Minister should know that GPs are thoroughly fed up at having invested in kit and training that they are now told will be redundant. Crossing their palms with silver at this late stage is a poor substitute for carrying them along from the start. The slow and clumsy choose and book is becoming something of a laughing stock among GPs. The Minister is fighting a rearguard action.
Will the Minister clarify the Secretary of State's announcement last week that his choice agenda will cause some hospitals to close? I am sure that he will be keen to do that. The press are full of speculation, and a great deal of confusion has been caused. I have my own thoughts on what the Secretary of State meant, but it would be extremely useful if the Minister clarified those remarks so that we are left in no doubt as to what he meant.
The NHS Confederation points out that patients may well vote with their feet, but from specific departments and on elective procedures only. That is right. As others have pointed out, if elective hip surgery goes, trauma will quickly follow, which will, in turn, be followed by
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accident and emergency; that would spell doom for an acute hospital. What has not been pointed out as much is that critical mass is needed in an acute hospital for training and accreditation. If one little bit of that is lost, the whole edifice is lost. Insufficient thought has been given to that. Indeed, there is no evidence that any thought has been given to it in any Minister's utterance that I have heard. Perhaps the Minister can correct me.
I have no doubt that patients will vote with their feet. By and large, that will be a wake-up call to hospitals. I suspect that that is what the Secretary of State should have saidand that it would rarely result in the closure of an institution. Surely to goodness that is what he meant.
There has been mention of the way in which money follows patients, or patients follow money. I share some of the concerns raised, for example that the targets set by the Government to bring down waiting lists have resulted in contractual arrangements that will end up hampering rather than improving patient choice. Labour has set a target that 10 per cent. of operations should be carried out by independent treatment centres. That target is arbitrary, distorts patient choice and prevents NHS hospitals from attracting patients on a level playing field. Again, it would be useful to have the Minister's comments on that.
James Johnson of the British Medical Association is not a great fan of independent treatment centres. He claims that they are destabilising the entire hospital system. He blames the inability of the NHS to withstand surplus capacity, and claims that it is leading to a failure in plurality of provision. I shall press the Minister separately on that issue, but if he voices his thoughts at this stage, we might avoid correspondence of the protracted sort that we are currently having on NPfIT.
I finish, Mr. Deputy Chairman, with a few quick questions, and I would be grateful if the Minister could address them. NHS trusts are facing substantial deficits because of the sheer number of demands placed on them by the Government. Given his recent remarks about closure, would the Secretary of State consider hospitals in those trusts to be failing? Many of them are clinically excellent, and I offer the example of my very own Royal United hospital, Bath.
References to the choice agenda readily fall from the Ministers' lips, but that agenda is not appreciated by a sizeable portion of their own party, including ex-Health Secretaries. How will the Secretary of State deal with such people? That is not really any of my business; I am just interested to know.
Finally, the Government's idea of choice is restricted to a list of four or five hospitals, chosen by PCTs. Why will they not give that choice directly to patients and their GPs? Why is it restricted to bricks and mortar, and not extended to individual specialists and options for the range of treatment?
The Minister of State, Department of Health (Mr. John Hutton) : I, too, congratulate the hon. Member for Wyre Forest (Dr. Taylor) on allowing us to have this important debate about choice and what it
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means. I congratulate all hon. Members who have made a contribution, because they have all raised perfectly fair and reasonable points.
As I listened to the debate, I was struck by the fact that, with one or two exceptions, most comments were confined to the issue of choice over routine operations or elective procedures. In recent years, the Government have rightly taken an important step forward on the issue by giving patients more choice over routine operations, and I shall obviously want to speak extensively about that.
However, the concept of patient choice goes much wider than simply access to routine operations. One should remember that 90 per cent. of all patient journeys in the NHS begin and end in a GP's surgery and that, fortunately, only a small minority of NHS patients need the services of a surgeon or specialist in an acute set-up. When we talk about choice, therefore, it is important that we try not to confine ourselves to the choice of hospitals, and the Government have certainly done that. Hospitals are only the tip of the iceberg, and we need a concept that goes beyond simply providing more choice about operations.
For example, it is important for primary care patients to have more choice, and we can deal with the issue in several ways. NHS Direct has been an important additional service for NHS patients; it is widely used, it is making a significant difference and it is saving patients' lives. Of course, there are people who criticise it, and I understand that. Most NHS services are criticised at the beginning for a variety of reasons: people do not like them and are not familiar with them. However, NHS Direct has proven its worth day after day because of the outstanding work that the nurses do in providing medical advice to patients who ring up. As we approach the electionsI am sure that we are all looking forward to themwe shall all want to look carefully at what the parties are saying about the future of NHS Direct. The hon. Member for Westbury (Dr. Murrison) said, quite fairly, that he had some questions for me, and we shall be asking him and his parliamentary colleagues about some of these issues.
On primary care, the walk-in centres have proved to be very useful. My daughter recently used one, and I have nothing but praise and tributes for the staff who run them, because they do a very good job. We shall shortly be expanding walk-in centres into new territory. There will be several GP-led commuter walk-in centres at some of England's largest transport hubs, bringing our services closer to where patients are. Commuters, in particular, are bound to experience serious issues in trying to access the services of their family doctor, because many of them get up early and come home late, and most of the surgeries will, sadly, be shut by the time they return home. So, we have to find a better way of taking our services to where the patients are, and commuter walk-in centres will be one way of doing that.
Another area in which we need greater choice is patient access to medication, and that could be at several different levels. For example, there is the issue of getting repeat prescriptions. By common consent, the process has been far too bureaucratic, and we have found some important ways through that bureaucracy. Improvements could, for example, also mean access to
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medications over the counter, on which we are making progress. We are the only country in the European Union in which patients obtain access to some of the new anti-cholesterol drugs, the so-called statin group, over the counter. That, too, is important. The Minister of State, Department of Health, my hon. Friend the Member for Doncaster, Central (Ms Winterton), has been making progress with proposals for freeing up some of the restrictions on the location of new pharmacies.
Those are two important spheres of activity in which a flourishing debate about choice is needed, and there are others that hon. Members have raised today. One of those is maternity services, which the hon. Member for Wyre Forest raised in connection with his constituency, and another is mental health, which was mentioned by the hon. Member for Westbury.
I agree that mental health is an area in which it is important for us to take a critical look at ways of expanding patient choice. The hon. Gentleman will probably know that the National Institute for Mental Health in England is considering, with patient organisations and groups, ways of expanding patient choice in mental health. Certainly, patients have been telling us that they want a greater range of choices about the services to which they gain access during times of illness and recovery. That is right and proper and I understand that the Department will, later in the year, publish a mental health discussion document on how we implement choice in local communities. I am sure that hon. Members on both sides of the House will look forward to that publication.
The focus of our discussion today has been choice over routine operations, and it has been quite an interesting debate. I am sorry that my hon. Friend the Member for North-West Leicestershire (David Taylor) is not here, because I received a strong sense from him that he was not an advocate of patient choice or any of the reforms that the Labour Government have implemented, even though they were all in our manifesto. However, that is a debate for another occasion.
The hon. Member for Wyre Forest began his remarks by describing a golden age in the NHS. There are only one or two people who can ever remember things happening in the manner of such descriptions; it has certainly not been my experience in 50 years of using the NHS that there was ever a golden age when I could see my GP and be bundled off on a train to see a specialist in Cheltenham, Birmingham, Manchester or somewhere else. On the occasions when I have needed to see a specialist I do not remember being given any choice.
The hon. Gentleman finished his remarks by saying that we should not be attending to that matter nowthat there were other things to get on with and that choice was a longer-term aspiration rather than a short-term priority. I take issue with him about that fundamentally; he is wrong to say that we must make a choice between developing minimum standards and the higher-quality care that he arguesand I agreeis essential, and providing greater patient choice. I consider the latter an equal priority. To think that we can achieve only one, at the expense of the other, is to make a false dichotomy.
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The hon. Member for Oxford, West and Abingdon (Dr. Harris) made a characteristic good cop-bad cop speech, but seemed, on balance, to be in favour of choice, although I think that he wanted to reserve his position on the matter as far as possible. I do not have the energy today to make any cheap, below-the-belt remarks about the Liberal Democrats. However, it is striking that although one would expect that party, of all the political parties on the British political scene, to be in favour of choice, the hon. Gentleman has, in much of health policy, allowed it to be captured by a group of vested interests who are not in favour of reform at all. In the House of Commons in particular there has been a series of flip-flops from the Liberal Democrats about whether they are in favour of or against treatment centres, payment by results, or choice. There will come a time when they have to make up their mind about where they stand on the issues.
Dr. Murrison : I do not want to make cheap political points either, but does the Minister recall the famous remarks of the hon. Member for Cheadle (Mrs. Calton) in which she appeared to condemn foundation hospitals in this place while praising them to the skies in her constituency?
Dr. Evan Harris : I am used to the Minister attacking me in my presence or absence, but when it comes to attacking my hon. Friend the Member for Cheadle (Mrs. Calton) in her absence, I should explain, if only to the hon. Member for Westbury (Dr. Murrison), that the problem that faces him and us in this placeit is the same in local government with the private finance initiativeis that you can disagree with the policy nationally, but once it goes through the House and is the only game in town locally, there is the question of whether you support your local community or local council in seeking to achieve the best for people locally, even through the perverted scheme that has been imposed by the Government. That is simply realistic. The hon. Gentleman can live in an ideological bubble rather than in the real world, and can imagine that there is no Labour Government doing these things, but practical politicians must recognise that Government policy imposes choices on us.
The hon. Member for Oxford, West and Abingdon made several observations about some of the reforms. At one point, he described practice-based commissioning as GP fundholding. It is certainly not that for three essential reasons: no price negotiation is involved in practice-based commissioning because we have a single national tariff; no additional bureaucracy or transactional costs are associated with it, because the
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primary care trusts will be responsible for the contracting process; and, most importantly, practices that take on the responsibility of practice-based commissioning will not have the additional top-up resources that GP fundholding had. GP fundholding was a genuine two-tier system in which some practices gained at the expense of others. No one will do that under practice-based commissioning. To set the record straight on practice-based commissioning, the Government committed themselves to it back in 1998, under the wise leadership of my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), in our very first White Paper.
On the subject of community matrons, UnitedHealthcare does not employ any community nurses; they are all employed by the national health service. The hon. Gentleman also referred to suggestions on how we should conduct our general election campaign, but I am sure that he will not want me to take any of them up.
We talked extensively about the ideology of choice. For me, choice is not so much an ideology as the right thing to do in principle, so I agree with the hon. Member for Westbury on that point. Many of us may have been struck by the words of Terence Leahy, who spoke at last weekend's debate, which was sponsored by The Guardian, on the future of public services. He said:
"The ability to make a choice gives you power in your life. They may be small choices but they can add up to a sense of control and purpose. People draw tremendous self-esteem from being asked to choosefrom being trusted."
That is absolutely right, and puts the essential argument very effectively for choice in the public services. Choice puts patients in the driving seat, and it requires providers to respond to the preferences of patients or public services users. It can also help to drive up quality and equity in access as well as the overall efficiency of the service. Those are very important objectives for the Labour Government. We do believe that choice can support equity in access and outcomes, and not destabilise them. I shall return to that point in a moment.
A point that may have escaped the hon. Members who expressed their concerns about choice is that we know that it is what patients want. Many right hon. and hon. Members often say that patients do not want choice, but the best way of finding out whether patients want choice is to ask them. That is precisely what we have done, but the hon. Members for Wyre Forest and for Oxford, West and Abingdon seem to have no recollection of the two years of experience of the coronary heart disease pilot on choice, the London pilot on choice and the work that we have done in the area of cataracts.
The number of patients who exercised the right to move to a different provider was very high. The figures are available on the record, so I shall not go into them today. We know from MORI poll surveys, the work of the Picker institute and many other respectable, bona fide organisations that patients want choice. Why should they not want choice? It is a defining characteristic of citizenship in a modern society. We have often characterised choice in this place as the ability to elect the Government. Well, fine. That is obviously a crucial plank of an effective democracy.
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However, matters go much wider and deeper than that. In every other sphere of our life, we, as informed consumers and citizens, expect to be provided with choice. Why therefore, when it comes to the public services, is there a desperate poverty of ambition that leads us to say, "No, we cannot have choice. It is too complicated. The patients will be confused. The services might be destabilised. Let us do what we have done for 50 years and tell people where to go to get their treatment."
As a social democratsomeone who believes in the value of public servicesI do not accept that we can possibly build and sustain support in this country for public services if we believe that we must direct patients to certain types of providers, give them no choice about what they can receive and give them no control over what happens to them. We must challenge that system and giving patients choice does precisely that.
Another matter has been completely missing from the debate. We have talked about choice as though it were something new in health care in the United Kingdom. It is not. Leaving aside the argument about whether it has been in the NHS before, we know that, since the beginning of the NHS, some patients have had choice and they are the people who can afford to go private. Yet, here we area group of Members of Parliament who claim to support the public services and the NHSsaying that there should not be choice in the public sector, but that it is all right to have choice if people can afford to have better-quality care or faster treatment in the private sector. It is impossible to imagine anything less equitable than tolerating that gulf in which personal wealth determines personal health. That is completely unacceptable. I say without hesitation that it is right in principle and right in practice for us to look at how we can extend choice to the national health service.
Choice should not be confined to the few who have money. That is how things used to be. It should in future be extended to those who have need. That is a powerful message of reform. If we leave aside the argument about choicethere is an argument to be had about whether it is a good or a bad thingwe must understand choice in the operational sense.
What are the crucial elements in the debate about extending choice in the national health service? There are three essential pillars to expanding choice. First and most obviously, additional investment must be put into the health service because the second crucial element is extended capacity, so that we can allow real contestabililty between providers and give patients the real option of going elsewhere if their local provider cannot accommodate their requirements. Finally, as the hon. Member for Westbury drew attention to, we must give powerful, effective and timely information to patients and clinicians so that they can make informed choices about precisely where to go to receive treatment.
It is important that the three essential pillars of capacity, information and investment are all in place and lined up to support choice, which is why I take issue with the proposals of the hon. Gentleman and the Conservative party that we can have unlimited choice by the end of the year. We cannot do that because the necessary capacity will not be in place to make those choices effective. We could do that if we wanted to
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extend waiting times. I do not think that that is quite what the hon. Gentleman had in mind, but there is no short cut. We need capacity to exercise unlimited choice and the capacity will not be there if we want waiting times to be kept to a minimum.
The other problem with the hon. Gentleman's policies is investment. I do not want to argue about the James report and associated aspects. There will be a time and a place for that during the next few weeks. However, one aspect of the hon. Gentleman's policies is inescapable: if he wants to take £1.2 billion away from the NHS and use it as a subsidy for patients who can afford private medical treatment and want to go outside the NHS commissioning arrangements with the private sector so that they are willing to pay any price for operations in the private sector, that would take £4 million a year from every primary care trust in the country to use as an effective subsidy for private medical insurance. It would be the equivalent of taking £20 million from NHS patients in the hon. Gentleman's constituency to subsidise the cost of private operations for the rich. It is impossible to imagine how capacity plans, which are essential to allowing choice for the NHSin other words, for the manyare to be met if money is taken away to subsidise the private medical insurance schemes of the well-off. That is a subject for future debate, and I look forward to it, but the hon. Gentleman has not a cat in hell's chance of winning it.
I looked at the Conservative party's website todayI look at it whenever I want to cheer myself upand it shows the party's five priorities for the NHS. Strangely, there is not a single mention of the patient's passport. I wonder why. It is the Tory health policy that dare not speak its name. However, others are prepared to do it for them. We will certainly be talking about the patient's passport and how it comprehensively undermines the Tory party's bogus rhetoric on its commitment to the national health service.
Dr. Murrison : That was great rhetoric from the Minister. I look at the Labour party website, if only to see the latest iteration of the various posters. It is fascinating, and it seems to change daily.
I take the Minister back a couple of moments to choose and book. Does he share the view of the National Audit Office that, to use his words, there is not a cat in hell's chance of choose and book being up and running by the end of this year, as previously envisaged by the Secretary of State?
Capacity, information and investment are the three essential pillars needed to construct a policy of choice for routine operations for NHS patients. They would all be compromised by the hon. Gentleman's proposals.
A number of essential operational mechanisms are also important. One is payment by results, which we have discussed extensively today. To those who follow the history of such things, it is interesting to discover, as I did recently, that back in 1950s Aneurin Bevan advocated payment by results as the right way to fund the NHS. It has taken us 55 years to get round to doing it. We shall start this year for routine operations and
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elective procedures. It is the right place to start, because that is when choice in the context that we have been using the word today is most likely to have an impact.
We have only touched the surface of the matter today, but choice needs to be supported. The hon. Member for Wyre Forest was right to raise the risk of overcapacity in the NHS. Incidentally, it is equally likely that all the extra capacity in the NHS will be used, which will pose a threat to NHS budgets. There are two risksovercapacity and the overuse of capacity. That is why it is essential that we have effective practice-based commissioning alongside payment by results as an effective way for GPs in primary care to influence how resources are used.
Secondly, we need to use IT to the best of our ability to support patient choice. The choices that we are talking about are incapable of being properly activated or used unless GPs and patients have access to waiting times data, clinical quality data and so on. That is the information database that choose and book will eventually support.
Dr. Evan Harris : I did not mention my concern that choice has to be informed. Does the Minister think that the quality of data on outcomes available now is adequateit is reproduced by Dr. Foster in his league tables of death rates, without patient stratificationor does he regret the fact that some of the better units and the better surgeons are often at the bottom because they treat sicker patients? Is that good information, or is it worthless?
Mr. Hutton : It confirms how difficult it is to portray the information sensibly. We have a large amount of data in the NHS. Every day, we collect information by the barrel loadabout the clinical outcomes for surgical teams, surgeons and hospitals. It is often difficult to balance that raw data with the point rightly made by the hon. Gentleman. He referred earlier to concerns about access to specialist care; it is certainly true that in some of our specialist hospitals, which is where the more complex work inevitably tends to gravitate, surgeons often have to deal with the hardest cases. It is therefore not unreasonable to assume, on a like-for-like basis compared with surgeons doing less complex work, that their outcomes might look poorer. That would be a travesty of the real facts. That is why we are continuing to work with many medical organisationsthe Society of Cardiothoracic Surgeons, for example, has led the way and I am grateful for what it has doneto enable us to present the information in a sensible, patient-friendly way.
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