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Mr. Andrew Lansley (South Cambridgeshire) (Con): Once again, I welcome the Secretary of State to his new responsibilities. When he went to the Department for Culture, Media and Sport, he said that it was his dream job. I am sorry that we may turn his short tenure at the Department of Health into a bit more of a nightmare, but I hope that he will maintain the merit of consistency. As I noted in an intervention, the Secretary of State has already taken a consistent approach in trying to restrict foundation trusts from extending their private income cap.
The Secretary of State is consistent on a number of issues. When he first went to the Department for Culture, Media and Sport in February last year, he gave an interview to The Daily Telegraph. Surveying the artwork on the wall of his new office, he told the journalist:
Thats very Purnell, and its going to have to go.
I welcome, too, the Ministers of State, the hon. and learned Member for North Warwickshire (Mr. OBrien) and the hon. Member for Lincoln (Gillian Merron), to their new responsibilities. I wish the new Secretary of State for Culture, Media and Sport, the hon. Member for Exeter (Mr. Bradshaw), well in the Secretary of State for Healths former dream job and I wish the Minister for Children, the right hon. Member for Bristol, South (Dawn Primarolo), well in her new responsibilities.
I am sure that he is far too busy to listen, but I say a fond farewell to the right hon. Member for Kingston upon Hull, West and Hessle (Alan Johnson), who has gone to the Home Office. Of course, Labour Members may be wishing that the new Home Secretary occupies his post for only a short period before he goes on to other things. When Kirsty Young asked the duly modest right hon. Gentleman whether he thought he had leadership potential, he said:
I dont think I would have been good enough, frankly. I dont think Ive got the capabilities.
I had not quite understood that the new Home Secretary was so in tune with what was happening in the national health service. So in tune was he that he must have noticed that the average tenure of a chief executive in the NHS is now 23 months. Lo and behold, 23 months after he took up his post at the Department of Health, he left to go elsewhere.
Mr. Lansley: Yes, I must. The Secretary of State said that he sees the promotion of health and the prevention of disease as his top priority. The Opposition have been making suggestions to the Government for a long time, and they have accepted many of our proposals. May I make a proposal about something we have been on about for a long time? As Secretary of State, he should not make public health the responsibility of another Minister in his Department, but should make it his responsibility. Although I hope that his tenure as Secretary of State is short, he will realise that none the less there is an opportunity to do good if he takes public health into his own hands. There are certainly issues about the development of Change4Life and the public health programme that need to be pushed forward quickly if it is to have the success we all wish for it.
The Bill owes something to the Secretary of States past tenure at the Department of Health. He followed one of the proposals my right hon. Friend the Leader of the Opposition and I made about greater operational independence for the NHS and the need for it to have a constitution. He echoed those thoughts, and said that a constitution and more operational independence for the NHS would be a good thing.
Mr. Lansley: Before the right hon. Gentleman interrupts, I should point out that he went on to differentiate operational independence from a constitution and ended up saying that a constitution would be a good thing but that although he wanted operational independence it did not seem to be such a good thing.
Andy Burnham: I found myself getting very frustrated on the many occasions when, while doing my dream job down the road, I heard the hon. Gentleman claim credit for the NHS constitution. If he looks at the record, he will see that I proposed it a long time before he first spoke of it. I would be grateful if he did not keep making the wrongful claim that he was the originator of the NHS constitution. If he looks back, I think that he will see that I first proposed it a good year before he did.
Mr. Lansley: Let me agree this with the new Secretary of State: we will not have a debate about who proposed a constitution; we will just agree that there should be one, but let us agree that it ought to be a real constitution. The new Secretary of State embraces the thought that there should be a constitution, but what he has found in the Bill that he has inherited is not really a constitution at all but a declaratory statement. It simply declares that there are a range of legislative provisions and promises made by the Government that apply to the national health service, that those should be published in a document, and that the document should be called a constitution. As hon. Members will know, a constitution has to have certain characteristics. When the Government see a constitution in Europe, they deny that it is such a thing. When they see something that is not a constitution and it suits their political purposes to decree that it is a constitution, they do so.
What we are being offered in the Bill is not, in truth, a constitution, but that is what we ought to be offered. The new Secretary of State wanted greater operational independence for the NHS and believed that it would be important; it is precisely what he said was needed, but it is not enshrined in the constitution in the Bill. In effect, for the NHS, the constitution still enshrines the same principle of the legislative relationship between the NHS and the Secretary of State, which is that the NHS is at any moment whatever the Secretary of State chooses to make it. The Secretary of State can change the definition with the stroke of a penliterally.
Mr. Redwood: Does my hon. Friend agree that if hon. Members read the constitution to see whether their constituents will have any more rights under itfor example, more rights to high-quality service or faster or better treatmentthey will see that it is all such weasel words that there is no enhancement of constituents rights to a decent service?
Mr. Lansley: Yes, my right hon. Friend is quite right about that. Let us take one example: where in the constitution, if rights to treatment are so important, is the right of access to NHS dentistry? It does not exist. The Secretary of State says that there is a right of access to NHS treatments as recommended by the National Institute for Health and Clinical Excellence, but that is only precisely the same legislative provision that was put into a statutory instrument years ago, and it is a right that all our constituents have had breached time and again. There is nothing new whatever in the constitution that changes that statutory provision.
If one wants a constitution, it has to do what constitutions do: define the duties, responsibilities and accountabilities of the organisations within the NHS. I am afraid that that opportunity has not been taken in the Bill. In that sense, it is a clear wasted opportunity. We know that we will need to restore to patients the clear voice that was abolished when the community health councils were abolished, that was further undermined under patients forums, and that has not been restored under local involvement networks, or LINks, especially at a national level.
We will have to create the mechanisms by which commissioners and providers can be properly separated, because the legislation to do it is simply not there. We know that primary care trusts in parts of the country
are trying to create a separation between their commissioning activities and their provider activities, but legislation prevents them from doing so. Have the Government created an opportunity in the Bill for that important constitutional change to be made? No, they have not. Have they put back into legislation what they took out in 1999the opportunity for general practitioners on the front line to be able to exercise real commissioning responsibilities? No, they have not. They leave that with primary care trusts.
I am afraid that the Governments approach in the Bill has not been to take the opportunity to entrench in constitutional form the kind of accountabilities and responsibilities that would go with the reform process that the NHS is really looking for. The new Secretary of State must remember his former boss, Tony Blair, making a speech about the character of what was required for reform in the national health service, because he became a Minister in the Department of Health at almost the same moment. If I recall correctly, that speech was made in June 2006, just when the Secretary of State took up his post as Minister. It was probably part of his instructions from No. 10 to go in and try to push the reform process. I think that was part of his responsibilities as a Minister. It was about accelerating patient choice, extending practice-based commissioning, completing the transfer of NHS trusts to foundation trusts, and stimulating additional capacity for the NHS through the independent sector. Those were the four drivers of reform that Tony Blair talked about.
What has happened? All four have stalled. The last Secretary of State did not deliver on patient choice. It went up by just 3 per cent. Only 3 per cent. more patients believed that they had patient choice. Most of the time, less than 50 per cent. of patients felt that they had choice when they were offered elective operations.
The Audit Commission has demonstrated that practice-based commissioning has stalled. I talk to GPs across the country who say that it is not happening. The primary care trusts, in effect, feel that they have been told by the Department of Health that they can take complete control of commissioning again and close GPs out of it. The NHS trusts were all supposed to have become foundation trusts by December 2008, but they are coming through only one at a time.
The independent sector has been dissuaded from additional investment because the recently departed Secretary of State told them that, as far as he was concerned, the issue was one of capacity, not of competition. The Government believed that in many parts of the country they had sufficient capacity in the hospital sector and therefore that they did not need the independent sector any more. They feel that they can turn the independent sector on and off like a tap.
The reform processes for which the new Secretary of State used to be responsible have all stalled. The Bill does nothing to drive any of them forward or to provide the drive, the pace and the institutional architecture that would help to entrench the reform process for the longer term.
I turn to what is in the Bill, as opposed to what should be but is not in it. On direct payments, if the new Secretary of State and I are debating who was in favour and who was not in favour of parts of the Bill, he will
concede that in January 2006 the then Health Secretary, the right hon. Member for Leicester, West (Ms Hewitt), flatly rejected the possibility of extending direct payments from social care to embrace aspects of health care, which we were arguing for at the time. She said that that was inconsistent with the NHS principles and that it was revisiting the patients passport. The right hon. Gentleman says that as a Minister he considered direct paymentsbut presumably turned down the ideaso he was no doubt embracing that thought. I am glad that there has been a change of view on his part and that of the Government. We will support the proposal, but we must make sure that it is done wellnot only cautiously, but welland that the institutions in the health service that are charged with it do not try to frustrate it.
I am seriously worried that, in their commissioning of NHS continuing care and some of the joint purchasing of social care, PCTs are going through purchasing structures like reverse e-auctions, the effect of which is to deny those who enjoy personal budgets the possibility of using them in ways that are flexible and responsive to their needs, rather than precisely as predetermined by the primary care trust.
On quality accounts, the Secretary of State knows that we share the view that quality needs to drive the activities of the national health service, but we must be aware, as must the right hon. Gentleman, that too often commissioning in the NHS has been on the basis of cost and volume not quality. After his predecessors unhappy experiences with the Healthcare Commissions reports on Maidstone and Tunbridge Wells and on the Mid Staffordshire Foundation Trust, it is clear that in both cases the primary care trust was pursuing an approach of commissioning for cost and volume, not for quality. Quality is very important.
It is difficult to be sure that quality accounts will, of themselves, deliver such quality. Let us take an example. In the case of the Mid Staffordshire Foundation Trust, we know that many organisations, including the Department of Health, treated compliance with a four-hour target as a measure of quality in the handling of admissions to the emergency department at Stafford general hospital. The Department and its fellow organisations, such as Monitor, published a document to tell us what quality accounts might look like. It is helpfully entitled, The Sunnyview University Hospital Trust. I have a copy.
In the Departments lexicon of communications, if something is called the Sunnyview document, everybody will no doubt treat it as an optimistic document. Unfortunately, when one looks at the document to see what quality accounts on emergency care would mean, one sees that it focuses on targets. It says that the measure of quality is adherence to the four-hour target, but we know that that target is only one measure, and an insufficient measure in the experience of the Stafford general hospital, because the staff there said that in order to meet that measure, they had to compromise the quality of patient carenot support quality or deliver that care, but compromise it.
Mr. Redwood: Has my hon. Friend noticed that there is now only one Labour Back Bencher in the Chamber for this important Bill on the Governments flagship subject? Does he think that they are unaware that their Prime Minister would like them to be here supporting the new Secretary of State?
Mr. Lansley: I am grateful to my right hon. Friend. I think Labour Members are more concerned with the health of their party than they are with the health of the population. That is a matter of regret. Let us recall that the Bill was meant to be a flagship piece of legislation, but they decided some time ago that it was not a flagship, but a rather small tender. [Laughter.] The silent one on the Government Bench found his voice.
When the Secretary of State was a Minister, he said that from 2009 there should be fewer national targets. One of the things that he could do, even in the space of the next few months, if he has so long, is dispense with those targets. If he believes, as he said in the past that he does, that people in the NHS felt frustrated by the weight of central top-down targets and bureaucracy, he should let go. Let him take away the four-hour target and see what can be arrived at by way of a series of measures of quality of emergency care in emergency departments agreed between commissioners and hospitals. Let us see whether the result is an improvement or a reduction in quality of care. My belief is that it would be an improvement.
Among other measures, the Secretary of State referred to trust special administrators. He will recall from the 2003 legislation that the Government promised to put in place a transparent failure regime. They have not done so. It was always clear that what was required was a failure regime that made transparent to those who were lending to the NHS and were the potential creditors of the NHS what would happen in the event of a financial failure. The Government have simply said that, in place of a presumption under existing legislation that all the protected assets of a foundation trust would be taken under control and the creditors left with virtually nothing, the whole of the foundation trust would be de-authorised, turned back into an NHS trust and taken back into the control of the NHS.
It is clear that we must protect the assets and services that are necessary for the delivery of NHS care. Alongside that, if there is to be an opportunity for foundation trusts to do as the Government originally intended and to behave with greater freedom and independence, a transparent failure regime is needed so that those who are creditors of foundation trusts will know that even if they do not have control of assets or services, they can at least be clear about the basis on which the liabilities to them are to be discharged in the event of the financial failure of the foundation trust.
Andy Burnham: I apologise to the hon. Gentleman for rewinding a little, but I should like to return to targets. He correctly quoted my remarks of a couple of years ago, but today let me say to him quite clearly that, where targets are superfluous, I shall look to get rid of them. When I was in my ministerial job and doing the work-shadowing exercise to which I referred, I spoke directly to staff in A and E who said that the four-hour target was a crucial part of making the whole system workof moving people through the hospital.
When I did that job, I said on record many times that, once met, targets should become standards and points from which the NHS should not retreat. Did I really hear the hon. Gentleman correctly when he said that he would remove the four-hour A and E target? Would that not take us back to the A and E chaos and lack of hospital through-flow that we saw in the past?
Mr. Lansley: The Secretary of State appears not to have remembered some of our exchanges, because I have been very clear about the matter: I would remove a central, top-down, four-hour process target. Commissioners and providers of service in the national health service need to arrive at a contract that makes clear the standards that they will meet. In emergency care and other aspects of care, however, the Governments objective should be to move from targets to outcomes. He might like [ Interruption. ] I shall explain the issue to the right hon. Gentleman, because, since he became Secretary of State, he will not have had the opportunity to read the latestfurtherreport by Dr. David Colin-Thomé, the national clinical director for primary care, on what happened at Stafford general hospital. He makes clear both the distinction between targets and outcomes and his belief that the Governments and Departments responsibility should be to focus on those outcomes.
The job from the centre is to specify the outcomes that we are trying to achieve, so, for example, emergency admissions for stroke might indeed embrace 30-day mortality. The quality of subsequent stroke care might include the proportion of patients who go on to live independently, and we can benchmark that against performance in other countries and determine, as we should, the quality of care in this country as compared with other countries. We cannot compare the four-hour target to other countries, however, because they do not define the quality of care that is provided by simply measuring how long people wait in an emergency department.
Processes, including the standards that support outcomes, must be determined between those who purchase services on behalf of patients and those who provide them. That might well include a question about the length of time that patients wait, but it would be negotiated and exist in a culture of continuous improvement. Some places would say not 98 per cent. but less than 98 per cent. Others would say, more than 98 per cent. If the Secretary of State talks to people in emergency departments, he will know that they might say, Actually, we should have quite a different time in emergency departments for those who present with minor conditions as compared with major conditions. In a contract with a hospital, one might quite properly have specified standards that set a much shorter waiting time for children than for adults.
Mr. Lansley: No, they are not targets; they are normal things that happen in normal life. Those who are responsible for contracting services have a responsibility with those who provide services to specify in the contract
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