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It is impossible to explain to my constituents that taking away consultant-led maternity services, special care baby units and 24/7 paediatric cover in a general hospital that has had those services for yearsBarbara Castle set up the inquiry that led to
24/7 paediatrics at Horton general hospitalis an improvement in NHS services. Conservative Members are not making partisan points, and the campaign in Banbury involves Labour councillors and others. We just want to maintain the existing level of NHS services.
Alan Johnson: I understand the hon. Gentlemans point. As constituency MPs, we all face those pressures. The difference is that Conservative Members say the process is driven by financial constraints or by people in Whitehall; we say that the changes are necessary, as I have set out, for reasons such as medical advances, technological change and demographic change. There has always been reconfiguration in the NHS, and we must ensure that the NHS is capable of meeting todays challenges and not the challenges of 1948. The decisions should be clinically driven, and they should not be driven by politicians.
There is the question of how the public feel about the issue. Those who have not experienced the changes at first hand are not convinced that they are getting value for the extra money that they have contributed, andthis answers the point raised by the hon. Member for North Norfolkthere is more to do before the NHS achieves everywhere the levels of efficiency and effectiveness that are essential if we are to cope with the huge challenges that I have set out.
Mr. Simon Burns (West Chelmsford) (Con): Will the Secretary of State help me? My local hospital has experienced a degree of financial pain after reaching the targets laid down by the Government on treatment times. Now, an independent treatment centre is going to be placed within eight miles of its location. The hospital trust, the consultants and the staff are fearful that in some of the specialties in which they meet all their targets, patients will be diverted away from the local hospital to the ITC, which over a three-year period will cause significant financial problems for the trust and the loss of staff, who may move to the ITC because that is where the work is going. Why will that necessarily be good for efficiency and for my constituents?
Alan Johnson: I am willing to consider the hon. Gentlemans particular case. Such developments should occur only where there is a capacity problem. If the hon. Gentleman contacts me, I will look at the case.
There is no question but that developments in recent years have damaged staff morale, with deficits in some health trusts placing unwanted additional strain on hard-working NHS employees. As we move to the next phase of the NHS transformation, there should be a much greater focus not on top-down reforms but on stimulating change among patients and practitioners. I want to maximise local autonomy for the doctors, consultants, nurses and managers who actually do the job, day in and day out. The policy framework that we set will be right only if the views of staff and patients are properly incorporated.
A modern NHS must move from a public sector monopoly to a truly patient-led public service. That means doing more than changing the relationship between Ministers and senior managers; it means transforming the entire relationship between the NHS
and the public and creating a system that is publicly accountable locally, as well as through the elected Government. My predecessors have already taken significant steps towards creating an independent, self-improving NHS, steadily removing power from the hands of politicians and transferring it to clinicians. In 1999, we created the National Institute for Health and Clinical Excellence to give clinical guidance on what the NHS should and should not do. We also established the Commission for Health Improvement, which is now the Healthcare Commission and is soon to merge with the other independent regulatory bodies that we have created. There are now 67 foundation trusts independent of Whitehall, accountable to their members and making their own decisions on how best to serve their patients.
That increased transparency and independence has brought undoubted improvements, but it has also had a short-term effect on confidence, revealing what was previously hidden. That has made our lives in Government more difficult because transparency always does, and that is no bad thing, but we were right to introduce these changes. In the internet age, transparent information is not only a powerful spur to improvement but a part of what the public expect. Patients need staff to take the time to explain the condition and the treatment options. Citizens need to know what is going on and to be properly involved in collective decisions.
However, it would be foolish to pretend that we have not also introduced more centralisationmore top-down direction and more command and control. We introduced national targets to eradicate the unacceptably long waiting lists. Without those targets, the NHS would not have seen the transformation of services that I described earlier. However, the treatment needed for the NHS then, when the whole system was in intensive care, is not the same as the treatment that it needs now, when it is well on the road to recovery. Of course targets have their limits. With targets, there is always a risk that Governments end up improving only the health care standards that they can measure. Targets can also have adverse effects if they are not properly researched and informed; and the top-down performance management that goes with them leads the NHS to look up to Whitehall rather than outwards to its patients and local communities. That is why we are determined to move away from targets as we transform the NHS from a top-down bureaucracy to a bottom-up, self-improving organisation with power in the hands of patients, their advocates, crucially GPs and other primary care staff, and of course staff themselves.
The heart of the NHS will always depend on effective collaboration by professionals around the needs of patients. That is why we placed a duty of collaboration on all providers in the NHS family. In future, a key measure of the quality of care given by every provider will be not only performance but the partnership established with the rest of the health service. With more than 600 organisations in the NHS, we need to ensure that each patient has a clear path to follow so that they can obtain the right treatment at the right place and time. Primary care trusts have already been given the authority and finance to develop and commission services around local needs, meeting national quality standards without being locked into historical practice.
Sandra Gidley (Romsey) (LD): The Secretary of State mentioned patients having a clear path to follow. Many patients find it difficult these days to find an NHS dentista subject that he seems to have avoided. How will access be increased rather than decreased, as has happened so far?
PCTs need to work with their GPs to devolve decision making and ensure that practice-based commissioning transforms services for patients. The NHS now looks very different from the way that it looked 10 years ago. [Hon. Members: Or 10 months ago.] Very different from 10 months agovery different indeed. Like many in the country, I do not believe that the Conservatives conversion to the principles of the NHS are credible. I think that my hon. Friend the Member for Grantham and Stamford (Mr. Davies) put it very well recently in his letter to the Leader of the Opposition. Only last month, the Cornerstone group of Tory Members of Parliament published a paper that called for the abolition of a tax-funded national health service. Of course, the party voted against extra investment in health. Its policy of sharing the proceeds of growth means that £21 billion less would be spent on public services this year.
Alan Johnson: I was saying that the NHS is safe in the Governments hands. The Labour party has no equivalent to Cornerstone and, to be fair, neither do the Liberal Democrats. It exists only among Her Majestys official Opposition.
As we move into the next phase of transformation, we will have created a modern NHS, in which its traditional values of care, compassion and universality remain enshrined, building the confidence of staff and public alike, so that that precious national asset is preserved for future generations.
Norman Lamb (North Norfolk) (LD): I join in welcoming the Secretary of State and the rest of the ministerial team to their new roles. I believe that we all agree that the national health service is so vital that it is important that they do well in their respective roles. The Secretary of State is right to say that there is some history between us. I remember the Employment Bill in the previous Parliament and my role then as Department of Trade and Industry spokesman. He has always been good and courteous to deal with and I wish him well.
The Secretary of State was also right to allude to the state of the NHS in 1997. The proportion of GDP spent on health in 1997 was 6.8 per cent., compared with 9.1 per cent. in the rest of the European Union.
That was an enormous gap, which amounted to almost criminal neglect of the health service. The results were clear for all to see. I remember people coming to see me who had to wait three or four years for hip or knee joint operations; the cancer survival rates were appalling compared with other European countries and so on. The Conservative party has nothing of which to be proud in its record in government. However, the picture that the Secretary of State painted of what has happened since is too rosy, and I want to raise some specific issues. I hope that he will take them seriously and reflect on them, especially the important matter of equitable access to services, which the motion rightly covers.
The motion is broadly uncontroversialit is pretty much motherhood and apple pie. I am sure that the Government will vote against motherhood and apple pie, but we will support the motion because we agree with its content. Of course, it is easy to make the commitment, but much more difficult to achieve the motions objectives. It is crucial to consider the way in which policies and proposals affect and influence the prospects of achieving equitable access. Like the Conservative spokesman, I want to acknowledge the extraordinary role that staff play in the NHS. We are remarkably lucky as a country to have such a dedicated work force, and we all rely on their work. They are a dedicated group of professionals.
Before considering equitable access, I want to highlight a part of the motion about which I am concerned. It is the Conservative proposal in their policy document, which I have read, and in the motion for a shift towards practice-based commissioning. There are limits to the extent to which it is sensible to proceed in that direction. Several organisations have expressed concerns about the impact of too much reliance on that. A couple of years ago, the Sainsbury Centre produced a report on the potential impact of practice-based commissioning on mental health. It stated:
Plans to allow GPs to commission a wider range of mental health treatments will result in substandard care.
The report referred especially to the previous fundholding scheme, which operated under the Conservative Government, and the risk of neglect of patients with severe and enduring illnesses. If we are holding a serious debate, it is important that the Conservatives understand and recognise the potential risks of practice-based commissioning.
In June last year, the Audit Commission criticised the Governments plans for practice-based commissioning. It said that the scheme risked exacerbating financial pressures, widening inequalities and wasting money. Those conclusions were based on where practice-based commissioning had been initiated and appeared to be working well. There are, therefore, concerns about the scheme, and conflicts of interest could arise when GPs can commission services from organisations that they set up.
Let me deal with equitable access to services and the related issue of health inequalities. The Secretary of State referred in his deputy leadership campaign to his specific concerns about health inequalities. I therefore know that he genuinely takes that seriously and I hope that the need to reduce inequalities will be a top priority for him. In 2002, the Government made a commitmentwith which, I am sure, he is familiarthat by 2010 they would reduce inequalities in health outcomes by 10 per cent., as measured by infant mortality and life expectancy at birth. That is a legitimate direction in which to try to move.
However, this years departmental report highlights a shift in the other direction: health inequalities in our country are increasing. On infant mortality, it stated that the gap had widened and that the rate for routine and manual workers was 18 per cent. higher than that for the total population, compared with 13 per cent. in 1997-99. The Departments statistics for 2001-03 show that among the most affluent, there were 2.9 infant deaths per 1,000 live births compared with 8.9 per 1,000 live births among the poorest members of our community. That is a stark contrast between the life chances of people born in good circumstances and those born in our most disadvantaged communities. I am sure that all Members are concerned about that and we need to find ways to reduce that gap.
The gap in life expectancy has increased, and it has done so most among women. The relative gap among women has increased by 8 per cent.; among men, it has increased by 2 per cent. Again, the Departments statistics for 2001-03 found that in the best area in the countryeast Dorset, for some reason; it is a reasonably affluent areamen could expect to live to the age of 80, whereas in Manchester they could expect to live to the age of 71.8. That is a stark difference, which we should all find unacceptable.
Do those differences have anything to do with the health service or are they all to do with much broader factors? Clearly, many factors such as poverty, deprivation, lifestyle and so on, play a part, but health care is relevant. Let me draw the Secretary of States attention to programme budgetinga new development that the Department has pursuedwhich enables us to compare areas and consider not only how much is spent on each specialty, but the outcomes in each specialty. We can therefore ascertain the effectiveness of the money in each area of the country. A recent report concluded that there was a clear link between spending and health outcomes. If we commit resources where they are most needed, we can achieve improvements in health and longer life expectancy.
On the same issue of equitable access, I want to deal with access to GPs. In the least deprived PCT areas there are 62.5 GPs per 100,000 of the population, while in the most deprived there are just 54.2 per 100,000. Thus the areas with the greatest health problems have the fewest GPs as a proportion of the population. It is the wrong way around. All that points to a failure of policygiven that the Government highlighted the importance of the matter and set a target for reducing health inequalities in 2002, moving in the opposite direction is unacceptable.
What are the prospects for reversing those trends? I would like briefly to look at the issue of choice. There is a risk, which many people highlight, that increasing
choice actually has the effect of accentuating inequalities, the argument being that the middle classes can exploit those opportunities while others cannot. There is a very good report by the Institute for Public Policy Research, called Equitable Choices for Health, which highlighted the potential risks. It referred to a pilot in Londonthe London patient choice projectin which disadvantaged people were given help with transport and given advice by patient care advisers about how best to exercise choice of hospital, treatment and so forth. The conclusion was that the pilot had had a positive impact on reducing inequalities. It had empowered people, particularly those at the bottom end of the income scale.
However, the report also pointed out that when the Government rolled out patient choice nationally, none of those support mechanisms was in place. There was no help with transport and no guidance on how people should exercise choice. The IPPRs conclusion was that under the Governments scheme, choice was likely to increase inequality. I hope that the Secretary of State will further examine those conclusions from the research and consider how best to ensure that choice actually empowers the least powerful in society, rather than accentuating differences in health outcomes.
I need to deal with the impact of deficits. The Secretary of State has perhaps arrived at a good moment because his predecessor had a pretty tough year. She made a political commitment to ensure that the NHS as a whole was in balance by the end of the financial year. She achieved that, but there are questions about the price that was paid to do so. The Health Committee drew attention to the fact that in the efforts to clear deficits some serious soft targets were hit. Particular attention was drawn to mental health services, which have been cut back in many parts of the country, including my own county of Norfolk. It is the same with public health programmes. Cutting back on alcohol prevention work, smoking cessation work and other programmes often hits the most disadvantaged people and again has the effect of accentuating inequalities in health outcomes. If the Secretary of State is serious about his commitment to reducing inequalities, those are the sorts of issues with which he needs to deal.
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