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there has to be more transparency, openness and accountability.
The Government welcomes the call for a more rational and objective debate about the Private Finance Initiative...and accepts the Governments role in this.
A later section dealt with the management of risk. I am sure that the Minister will remember that we concluded that the evaluation of risk was as much of an art as a science. We wanted more realism about the public sector comparator. We wanted more expertise in negotiating bodies from the health service point of
view. My PFI was one of the early ones, and it is blamed for £7 million of the trusts overspend. I do not know whether the following provision was worked into all the early PFI contracts, but if the bed occupancy goes above 90 per cent., which it regularly does, there is an extra fee to pay. Over the past few days, I have seen newspaper reports that new borrowing regimes are coming in for trusts from 1 April. The trust in Plymouth has decided to abandon its plans for a PFI, because it thinks that it can get its money from the public sector under those borrowing arrangements.
I shall begin to draw to a conclusion, as I am aware that I have been speaking for a long time already. In the rush to open the provision of hospital services to private providers, we must be sure that that is appropriate, that it is wanted by patients and that it will not lead to the downfall of the NHS as we knew it. There was an article in the British Medical Journal last September headed Where are the medical voices raised in protest? It bemoaned the fact that, whereas in the 1980s medical voices were raised strongly against the Thatcher Governments changes, things appear to have changed, stating:
In the past six years we have seen reform on a scale never before attempted in the NHS. The prime minister continues to say he wants to increase the pace of reform; however, it is not just the sheer speed of reform that makes it distinctive, but also its breadth and depth.
The article includes a nice photo of Aneurin Bevan admiring a new hospital back in 1948, with two very posh gents with winged collarswe do not see many of those aroundon either side of him. The photo is captioned, Would Aneurin Bevan recognise todays NHS? The article went on:
These reforms seem more radical than commentators in this journal dared imagine...If we add in the vagaries resulting from the PFI process, then we have a reform agenda that seems to sweep away Bevans NHS across the board, blurring the boundary between public and private not only in financing the service but also in the provision of care.
Medical voices are raised and have been all the timein particular those of the NHS Consultants Association, the Keep Our NHS Public organisation and the well-known Professor Allyson Pollockalthough they have tended to be disregarded, but stronger voices are emerging. The royal colleges are beginning to speak outin particular, the Royal College of Surgeons. There was a good report about Bernard Ribeiro of the Royal College of Surgeons in the Health Service Journal only last week, which said that he is determined to have a say in the political aspects of the NHS.
I have been drawn to voice my medical protest now as loudly as I can by the fact alluded to by the hon. Member for St. Ives (Andrew George). The best report on that, I think, was in the February edition of the British Journal of Health Care Management by Nicholas Timmins, the highly respected public policy editor of the Financial Times, who is not prone to raising groundless alarms. He quotes Ken Anderson, who was recently the Governments commercial director:
My personal conviction, he told the Financial Times, is that once you open it
up to competition, the ability to shut it down or call it back in passes out of your hands. At some point European law will take over and prevail, and that is not something that can be rolled back. In my opinion we are at that stage now.
Mr. Timmins went on to report that the Department of Health has taken legal advice, which states that for various reasons, health services are exempt from compulsory tendering under EU law. However, other legal advice runs contrary to that, and he quotes reports that the European Court has decided that
if a national health system embraces competition, then competition law will apply.
I fully accept that the Government are committed to maintaining a health service that is free at the point of delivery, but if we continue to encourage the increasing provision of health services by private providers, we will not end up with a national service. It risks being fragmented across the country. The Guardian published a brief letter last September, when the NHS Logistics Authority was privatised. It stated:
The sale of NHS Logistics means privatising, at the stroke of a Hewitt pen, a 20th of the NHS. It is yet another huge step away from Bevans integrated, public NHS in which everyone was on the same team.
Surely, we can all resist the rush to unquestioned involvement of the private sector in NHS provision before it is too late. The Minister is a free-thinker and he has been given a certain amount of leeway to think for himself. I very much admire the way in which he went out immediately after his appointment to work in the NHS and I hope that he was able to talk to some of the staff without managers and civil servants present. I therefore make an appeal to him. Abraham Lincoln once said:
My paramount object in the struggle is to save the Union.
Mr. Martyn Jones (in the Chair): Order. The debate must finish at 4 oclock, as hon. Members will be aware. If those who want to speak can keep their contributions as short as possible, we might get everybody in.
Tony Baldry (Banbury) (Con): One day at Horton general hospital in Banbury, we suddenly discovered that we were going to have a new independent treatment centre. I am sure that Capio does a wonderful job as an orthopaedic treatment centre, but no one asked for itwe certainly did not. All that it seems to have done is undermine the excellent, world-leading Nuffield orthopaedic centre in Oxford, which provided an excellent orthopaedic service for years.
My concern, to follow on from the excellent speech by the hon. Member for Wyre Forest (Dr. Taylor), is that there seems to be no coherent philosophy or steer from the Government as to what they expect the NHS to achieve, and I think that the Minister recognises that. I hope that he has not been misquotedindeed, I think he has been quoted correctlybut I understand that he wrote to the Secretary of State, saying:
The irony is that the process of change necessary to secure long-term public support for the NHS risks driving a wedge between the coalition of its strongest supporters...There is a feeling of nervousness among NHS staff about being on a journey without knowing where the end point is...Some are concerned that the values of the NHS are in some way up for grabs.
What we have seen is a circular reorganisation of the NHS: it started in 1997, and we are now back where we began. We have seen PCTs come and go. At one stage, we had five PCTs in Oxfordshire, but we are now back to a single Oxfordshire PCT, which looks very much like the old Oxfordshire district health authority. There is also no indication of what local voice there now is in the NHS. All the non-executive members of trust boards are appointed by the Secretary of State and clearly believe that they are beholden to her. When we had concerns about the reconfiguration of services at the Horton general hospital, I wrote to all the non-executive directors of the Oxford Radcliffe Hospitals NHS Trust, but none of them responded. I think not that they were being discourteous, but that they felt entirely beholden to the Secretary of State. There is now no local voice, and without a strong steer from the Secretary of State and Ministers as to what they expect from the NHS, everyone else is completely adrift.
There is an incremental movement towards acute super-hospitals, and the Horton has been told that that is because there is a shortage of middle-grade doctors in disciplines such as paediatrics and, possibly, maternity. We are then told, however, that 30,000 middle-grade doctors are looking for 20,000 posts. I cannot believe that there are no middle-grade paediatricians among the 8,000 who will not get a post under the new systemthe Government have announced that they will review itbut who could come to the Horton to ensure that we maintain a paediatric service. That service was set up as a consequence of a Government review that Barbara Castle initiated as Secretary of State for Health after a child died in Banbury.
As we come to the 60th anniversary of the NHS, the Government seem to have no coherent philosophy, other than bandying around the word reform, as if doing so is, in itself, a good thing. I am a child of the NHS and I was born shortly after it came into being. Both my parents spent their whole working lives in the NHSmy mother as a theatre assistant and my father as a doctor. I seemed to spend every Christmas day until I was 18 somewhere on my fathers wards and I spent most of my university vacations working as a hospital porter.
As an integrated entity, the NHS worked, and there was a clear philosophy about how it worked. Of course improvements can be made to how GPs commission services and so forth, but the permanent revolution in the NHS is incredibly demoralising and confusing. Unless the Minister can give some rational public policy explanation for why the Nuffield is being undermined and a treatment centre is being put in Banbury, Ministers will need to stand back and say that it is perhaps time to stop trying to reorganise the NHS and to start giving clinicians and communities a chance to get on with delivering services in the way that they want to. If Ministers do that, they will be surprised to find that those services are often delivered very well.
Ministers must avoid being contemptuous of public concerns about what is happening in the NHS. Last autumn, 15,000 people in my constituency and throughout Oxfordshire signed a public petition
expressing concerns about how NHS resources are allocated. As I am sure the right hon. Member for Oxford, East (Mr. Smith) will explain to the Minister, we in Oxfordshire are paranoidsome more than othersabout the allocation of resources. Although I readily accept that I am paranoid, whether about resources for the police or the NHS, there was a petition, and I presented it to the House in the usual way. Yesterday, the Clerk of Public Petitions, who had referred the petition to the Department in the usual way, sent me a note:
I have now been told that no government observations will be issued on the petition.
The petition was organised in part by George Parish, who is a Labour district councillor in my constituency the Keep the Horton General campaign is a cross-party community campaign. The fact that Ministers cannot even be bothered to respond to a public petition illustrates the confusion they have got into.
As we come to the 60th anniversary of the NHS, I hope that the Government can understand and get back to where the NHS startedas a public national service free at the point of delivery and available to all. I hope that we shall not have all this reform for reforms sake, because it is causing confusion, consternation and division in the service.
Tim Farron (Westmorland and Lonsdale) (LD): I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this important debate. I shall try to be brief; indeed, I have already made a couple of my points, because he kindly let me intervene.
Like the hon. Gentleman, I do not speak from a position of outright ideological opposition to private sector involvement. However, I have a concern about my constituency in south Cumbria, where a rather rushed and belated consultation on clinical assessment, treatment and support centres is under way. As I said, the consultation is about how rather than whether CATS is delivered, and we are concerned that the arrangements are being imposed in ignorance of the local situation.
As I also said, we have no waiting times for rheumatology, and it appears that many local consultants in a range of disciplines have not been consulted. The stated aim of the CATS centres is to reduce waiting times, but it appears that waiting times are not an issue in many disciplines, at least in my area. We should be grateful that they are notindeed, the Government should claim credit for that, rather than trying to make us change local operating circumstances to deal with a problem that perhaps does not exist.
We also have a concern about the preferred bidder, Netcare. Local trusts were of course not given the opportunity to bid to provide the CATS centre services because the bid is entirely national. That is a matter of concern because of the impact that we believe CATS may have on local hospitals. We are told that there will be three CATS centres in Cumbria: one in Ulverston, one in, I think, Whitehaven, and one in Penrith. None of them, certainly not in south Cumbria, is on the site
of, or even close to, an existing hospital. For a relatively small general hospital such as Westmorland general, the prospect of losing perhaps 60 to 80 per cent. of the demand for out-patient services because of the CATS centre undermines the hospitals very existenceit could take away demand and staffing. We already face the possibility of losing acute services at Westmorland general because of another consultationand incidentally, 26,000 people signed a petition opposing those cuts, but the trusts ignored it.
If we are forced to have a CATS centre in our area, we shall have to make the best of a bad job. I am concerned that we should ensure that the centres are situated close to hospitals, so that resources can be shared, rather than existing services being undermined. I am concerned also that the proposed removal of acute wards at Westmorland general coincides with the introduction of surgical provision from the independent provider Capio. My fear is the same as that of many of my constituentsthat Westmorland general will cease entirely to provide emergency services and become simply a surgical centre. That is clearly not the vision for our hospital that local people, including local clinicians, share.
I would be grateful, incidentally, if the Minister looked into and responded fully to talksome of it, I believe, informedof Netcare, the provider of CATS services, being owned by the same venture capital company that owns Capio. As there is a possibility that the CATS centres will refer people on to surgical services provided by Capio, there is a clear potential conflict of interest. I am willing to be told that that is nonsense, but I would be interested to find out about any current linksor historical links, which are also importantbetween Capio and Netcare.
As there are problems with retention and recruitment in the NHS in Westmorland, a question that people will want me to ask is where the staff for Netcare and CATS service provision are to come from. Also, although it is clear from answers to written questions that the staffing of the CATS centres will have to comply with minimum standards, we are told that the employers do not need to comply with NHS terms and conditions. Two possibilities thus arise: Netcares terms and conditions could be better than those of the NHS, which would give rise to the risk of losing staff to the private sector, or they could be worse, in which case, whatever the minimum standards might say, we would run the risk of lower-quality provision.
My final comment is about value for money. The Governments major case, apart from the 18-week waiting timesI think that that can be undermined, because of the local situationis that what is happening is all about value for money. As a general point, money may go from NHS primary care trusts into acute hospital trusts, but under the arrangements involving independent sector providers, money from the PCT will go at least in part into the pockets of shareholders. That is not an ideological objection; it is just an objection to wasting moneyto money leaving the NHS, which is clearly inefficient and something to avoid.
The argument for involving the private sector in public sector contracts is often that it is somehow good at taking risks and using its private sector fleet-footedness. However, the NHS is taking the risk in this case, not the private sector provider. Netcare is being
given a minimum income guarantee of £4 million a year, irrespective of whether it does any work. That is not an incentive. We take the risk and it appears that Netcare takes the profit.
Why are the Government doing this? I do not know. I do not believe that the Minister is ideologically driven on the point. I share the admiration for him that the hon. Member for Wyre Forest voiced, and I believe that he is a free thinker, committed to the NHS. Perhaps the Government are panicked about the apparent lack of return on their investment in the NHS, which has been considerable. However, if we want to increase capacity, why not build it in the NHS to provide the services in question? If the Government were to do that, they would find that they had much more support.
Mr. Andrew Smith (Oxford, East) (Lab): I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. He covered a vast terrain and in the limited time remaining I can focus on only one aspect of his contribution. He said that there has been a long and successful partnership between independent, private, voluntary and charitable provision and the NHS. So there has, but as plurality of provision develops it becomes all the more important that the terms of the interaction between the different partiesparticularly with reference to the impact of innovations such as independent sector treatment centresare fair.
I want to concentrate on specialist orthopaedic centres. The Nuffield Orthopaedic Centre NHS Trust in my constituency is affected by the issues that I shall outline, and so are the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust in Oswestry, the Royal National Orthopaedic Hospital NHS Trust, the Royal Orthopaedic Hospital NHS Foundation Trust in Birmingham and the Wrightington, Wigan and Leigh NHS Trust. The essence of the problem is that all those trusts are affected in varying degrees by the inability to date of the Department of Health to arrive at a national tariff that adequately recompenses them for the costs of carrying out complex orthopaedic treatments. Of course, as more of the routine work has gone to the ISTCs, the problem has been brought more into focus.
It should be stressed that the orthopaedic specialist centres have co-operated with the ISTCs and have not sought to block the arrangement. They went along with it on the understanding that talks would resolve the question of fair recompense for the work that they undertake. So far that has not been achieved. As was mentioned, the hospitals do important training work as well as much needed specialist and complex operations. Often treatment is expensive. The operation to save the limb of a patient with bone cancer might cost £7,600 but attract a payment of only £1,700, whereas, interestingly, the alternative of amputation, which I understand might cost £8,500, is adequately reimbursed under the tariff. There is a danger of perverse incentives. More importantly, the hospitals need to do the workthe patients need ityet there is financial pressure.
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