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I must pay tribute to Christian Aid. I was pleased that I went with its representatives on my two visits,
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rather than just being with the ambassador and people from the Foreign Office, because I saw far more than I would have otherwise. Christian Aid has played a good role in local civil society by trying to educate people about the elections. That process needs to continue.

In view of the Queen’s Speech, the other issue I should mention is forestation. One of the polling stations that we visited was in a tropical rainforest clearing, where we were told that 513 out of 517 potential voters had voted in the first ballot. I am envious of those turnout figures, although I am not sure what lessons we could learn. We could try to make our elections more interesting; special material was provided for everyone to wear for the Congolese elections and the returning officers were kitted out in election robes, so perhaps we should add a bit more entertainment and life to our elections, as that might encourage more people to participate.

The Queen’s Speech highlights the importance of a climate change Bill. Preserving the Congolese rainforest is thus important. There are not many roads in the country, so it is not easy for the logging companies to get to such areas. As soon as there are more roads, that will become easier. It is essential that we put pressure on people and give support to stop deforestation, given its potential effect on the world’s climate.

We need to pursue a number of issues. I started by discussing health and education, but these things are all tied in together. It is a scandal that there are children in that country with illnesses that we should be able to prevent and that they cannot go to school. Providing what is needed should be possible, given that country’s resources; it certainly should be possible with our assistance. The situation requires us to keep our eye on the ball.

We spend our time being obsessed about Iraq, Afghanistan and the middle east, which is understandable because they are all crucial aspects of foreign affairs, but we should remember the 4 million people who died and the fact that, in effect, an African world war has taken place. There is potential for stability in Africa. It is the one continent that has been going backwards, which is why we reasserted such a commitment to it in the Queen’s Speech. We must thus ensure that we take on board these good governance issues.

I hope that the contenders in the presidential election do not allow the situation to descend into further conflict, but take the opportunity offered to ensure that any potential flaws in the election are examined seriously and that the result is seen to be fair, and then start to work to put their country right. We must not forget the work that we are doing there. We have put a huge amount of effort into the elections and into trying to make the candidates and the country run them in a way that works. We must maintain our commitment.

I am concerned that the EUFOR troops—the European troops that back up the UN forces—have reasserted that they will leave that country. I do not think that many people are aware that the UN peacekeeping force there is the largest in the world. We must keep up the work that we are doing so that the children there get the education and health resources that they need and the Congo’s resources are used to put it on a good footing. That will assist us in getting
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stability in Africa. I urge our Ministers and our Government to continue to do what they have been doing well up to now. They must not let the issue slip off the agenda. It must be kept at the forefront of our minds, along with all the other difficult foreign and home affairs.

12.43 pm

Steve Webb (Northavon) (LD): It is a pleasure to follow the hon. Member for Amber Valley (Judy Mallaber), who made a thought-provoking, well-informed and, in some senses, sobering contribution about her recent experiences in the Democratic Republic of the Congo. She reminds us of the global context of our debate and I am sure that the House is grateful for her comments.

I am sure that hon. Members will forgive me if I focus principally on domestic matters, particularly those in the sphere of health. I am still trying to work out from my notes whether the Secretary of State said that the Leader of the Opposition was “pretty lightweight” or “pretty and lightweight”; I suspect that it was the latter, which is a noteworthy way of kicking off the debate. I am not sure, but that might say something about the state of NHS opticians.

There is one sentence in the Queen’s Speech that will probably strike fear into the hearts of the 1.3 million people who work in the national health service, despite the fact that it has not really received any attention. It gives us the promise of—guess what—more reform. The sentence reads:

we support that—

Yet again, we have the promise of another year of reforms. Lord Warner, the Government’s Health Minister in another place, was initially given the title of Minister for delivery. It seemed reasonable for a Minister to be responsible for delivery in the national health service. However, Lord Warner’s title has now changed to Minister for reform, because, obviously, reform is an end in itself. I have remarked to him that if I were the Minister for reform, I might wake up every morning thinking, “What can I reform today?” He seemed to nod at that suggestion and implied that he did such a thing.

I suggest that the Department should have a Minister for leaving things alone for a bit. As the hon. Member for Sunderland, South (Mr. Mullin) said, the NHS has suffered seriously due to permanent revolution. People sometimes say, “All the money has gone in, so why haven’t we seen more output?” I would be the first to welcome the progress that has been made and I appreciate the work that has gone into achieving it, but why has not more been done? Part of the reason why is that too many people in the NHS have had to take their eye off the ball to deal with constant reform.

For example, my hon. Friend the Member for Somerton and Frome (Mr. Heath), who was in the Chamber at the start of the debate, has asked me whether the new primary care trusts are up and running. When I assured him that they were, he pointed out that his PCT had not a permanent chief executive, but an acting one, because the new chief executive was still working for the previous body that
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was in the process of being abolished. A body that is presumably trying to sort out deficits in its region and to get the Government’s health reform agenda in place does not even have a chief executive, despite the fact that it has been created due to yet another reform to a body that was created only a few years ago. Such constant turmoil and reform is undermining the effective spending of the money that has been invested.

What would be the value of a period of stability? We could—I will use a dirty word here—evaluate the reform that has already gone on, instead of fiddling and tinkering with it, changing it and reforming the reform. When one makes a change, is it not worth determining whether that has worked before changing it again?

Ms Hewitt indicated assent.

Steve Webb: I welcome the fact that the Secretary of State nods her head. However, primary care trusts were created and then merged. I have seen the abolition of bodies that had not even been created when I first became a Member of Parliament, which was less than 10 years ago. The equivalent of county-level health authorities have been disaggregated and then re-aggregated. Such constant fiddling and meddling leads to waste.

We need stability so that we are able not just to evaluate, but to plan effectively. The hon. Member for South Cambridgeshire (Mr. Lansley) said that too many PCTs were not effectively able to manage their budgets. Part of the reason why is that their budgets are constantly changing. We have already heard that London’s PCTs have been top-sliced—to use the jargon—not once, but twice.

Sarah Teather (Brent, East) (LD): My PCT is one such body that has been top-sliced several times. I went to the opening of a new community hospital just six months ago, but proposals are now on the table to downgrade that hospital to a nursing home so that the PCT can make the severe cost savings that it must achieve in a short space of time.

Steve Webb: My hon. Friend cites a pertinent example. If one puts something in place, but is then faced with a stricture saying that a specific financial target must be met at short notice, one makes the cut that enables one to meet that target most quickly, rather than making the best cut, the most rational long-term decision, or even the cut that delivers the best service improvements or avoids damaging services. Such instability in services damages the morale of people in the NHS. Many of us will have met NHS employees during the recent mass lobby of Parliament. They gave me the clear message that the Government are doing damage to the goodwill and morale of people working in the NHS, who are its greatest resource. If we undermine their goodwill and willingness to go the extra mile—there is often no financial or professional reward for doing so, given that innovation is regularly stifled—we damage the NHS. Such regular top-slicing cannot go on. We cannot have a situation in which people’s budgets are radically altered halfway through the year; that is no way to manage a health service.

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I accept that the national health service will never stand still. No one is suggesting that we set it in aspic. We need a long-term direction of travel, but what should be its key features? We have heard one suggestion from the hon. Member for South Cambridgeshire: that we should have an independent NHS and that is what the Queen’s Speech should have introduced. However, I think that that is the wrong answer to the right question. Yes, there is worry about over-centralisation, meddling and constant tinkering—I fully agree with the hon. Gentleman on that—but his conclusion that we should have an NHS board to carry out commissioning independently confuses me, because at the same time he says that he would make sure that drugs such as the bone cancer drug Velcade were available. If his independent board declined to commission such treatments, what would he, as Secretary of State, do?

Mr. Lansley: To be precise, I have not said that I would make such drugs available if I were Secretary of State. What I have said is that NICE or an NHS board responsible for commissioning should examine whether it can negotiate on the price of the treatment—in the case of Velcade, with Johnson & Johnson. That seems to me to be a perfectly reasonable way to proceed. The response of Ministers is to say that if the drug company wants to ask about that, fair enough. My point is that NICE takes the price of a drug as given, and it has no power to negotiate.

Steve Webb: I cannot let the hon. Gentleman get away with that. Even with the best will in the world, with the best negotiators getting the best prices, there will be always be drugs on which NICE or a national NHS board says no. Then, his constituents and mine will raise a political clamour to get the drug prescribed anyway, because a lot of people want it. Is he saying that, in his vision of the NHS, politicians would have no power to overrule the independent board?

Mr. Lansley indicated assent.

Steve Webb: The hon. Gentleman nods. What he is saying is that if we—the electorate—vote Conservative, we will get an NHS whose activities we will not be able to determine. I understand his argument that the board would set broad strategy, but he also said that, whatever the price negotiated, the commissioning board, like NICE, would decide whether the NHS provides certain drugs. Either there is a political override in that respect, or there is not. Which is it?

Mr. Lansley: The answer is that one has to give responsibility for appraisal of drugs to an independent body and one has to accept its judgments. I am not saying that one should override NICE. Ministers and the hon. Gentleman know that, on Alzheimer’s drugs, there is a tough call. Ministers set the legislative framework. Within that framework, Alzheimer’s drugs and drugs such as Velcade raise similar issues, such as what benefits to take into account. However, we should also consider whether the independent body in question should have to take the drug price as a given. In my view, it should not. It is a matter of setting the legislative framework: once that has been done and an independent body has been set up to undertake
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appraisal, one should not then simply give Ministers the ability to override its decisions.

Steve Webb: I am not sure that I understand the hon. Gentleman’s argument. He has given people the impression that he would ensure that people could get drugs such as Velcade. Now he is saying that we will try to ensure that we ask the right question and get the best price, and he is right about both those things. However, even if we ask the right question and get the best price, a line will have to be drawn somewhere; on some things, the answer will be no. In essence, he is saying, “Vote for me, and I can’t guarantee to deliver anything, because the decision won’t be mine—it will be for an independent board to make.” In certain respects, that is the opposite of the direction in which I think the NHS should go.

People think, not that there is too much accountability, but that there is not enough accountability. That is the heart of the difference between my party and the Conservatives. Both the hon. Gentleman and I go around the country talking to local health campaigners and the recurring message that we hear everywhere is that they are not being listened to.

Andy Burnham: The hon. Gentleman is developing an interesting argument. Does he, like me, find it interesting that the Opposition talk about independence in the NHS when NICE—the body that we ask to take the most complex decisions on behalf of the Government and society on how to use taxpayer’s money most efficiently—is the best example today of exactly that. The shadow Secretary of State for Health said on television that he would ensure that Velcade was prescribed. Either one accepts the independent model of NICE, or one does not; one cannot face both ways and pick off certain treatments and technologies. Does the hon. Gentleman agree?

Steve Webb: I do. The record will show that when an early-day motion is tabled that states “This House disagrees with NICE and we should ensure that drug X is prescribed,” I do not sign it. I do not believe that, having set up NICE, we should overrule it simply because sometimes it says no, although I have written to NICE in relation to Alzheimer’s drugs and others to probe whether the correct questions have been asked and the proper procedures followed. In Health questions recently I asked the Minister of State to examine the reasons why health services in other European countries reach different conclusions. That is an important and legitimate question. In the cut and thrust of monthly questions, he did not really answer it, but I hope that he will come back to me on it.

I do not want to dwell too long on the Conservative’s hypothetical policy, but what is the alternative? The alternative has to be real local accountability. The Government will cite foundation trusts—the brave new world of accountability in the NHS. The previous Secretary of State for Health but several, the right hon. Member for Darlington (Mr. Milburn), said:

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He said that they were about

he sounds like Jim Hacker—

The reality is anything but that.

When the hon. Member for Amber Valley was talking about slightly dubious elections, I wondered whether she was thinking of foundation trust board elections, which we have been examining. If that is the governance structure of the future health service—we must remember that every trust will be a foundation trust—I have grave concerns about the existence of proper local democratic accountability in the health service. Let me give a few examples.

In February 2006, the snappily named Basildon and Thurrock University Hospitals NHS Foundation Trust held elections for 13 governors: nine were elected unopposed, as were four staff governors. Rather than getting people engaged in the cut and thrust of vibrant democracy in which competing views on local health services are aired, the trust could barely get enough people to stand, so it held more elections. A few months later, in April, the trust issued 4,000 voting papers of which 1,000 were returned—1,000, from a population of 310,000. I calculate that one third of 1 per cent. of the people of Basildon chose the governors of their local trust, yet that is what the Government mean by local democratic accountability. I know that local government turnouts are not great, but when we get to one third of 1 per cent., we have problems.

Were that the only such example, we might say, “Well, that’s only Basildon,” but it is not. In Gloucestershire in April 2005, 18 of the 20 positions were filled unopposed. In Homerton in September 2006—only a couple of months ago—half of the eight positions were filled unopposed. In August, there was no competition for seven of 10 posts at the Liverpool Women's Hospital NHS Foundation Trust. At the Royal Berkshire NHS Foundation Trust, eight positions were uncontested. In the 2006 elections to the Rotherham NHS Foundation Trust, 12 of the 14 posts were uncontested. The story is the same elsewhere. That is the revolution of democratic accountability in the national health service—the way in which every hospital will be run.

When people are elected, what do they do? They are not being elected to the board; they are being elected as governors, but the governors are not the people who make the decisions. The board makes the decisions. I have come across trusts that are saying that now they have local people elected as governors, they do not need local authority representatives on the board. The end result might be less local democratic accountability, rather than more. The national health service’s direction of travel should be toward real local democratic accountability, not sham accountability, which is what we find in too many foundation trusts.

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