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Although the Minister has returned to the Department, having spent a year there previously, I am on my fourth Secretary of State and it is getting quite tiresome to have to explain endlessly to a succession of Secretaries
of State that there is a real world out there, where people who want services contract for them in a culture of continuous improvement. The Government should focus on measuring the overall outcome.
Andy Burnham: I do respect the hon. Gentleman’s experience in the job, but he did not explain his policy when I was first in the Department and he has not done very well this time. He described a different standard for children and more serious cases, but there already is one in A and E departments. He seems to envisage a world of much more rigid, locally set standards, but the four-hour commitment is simply a cut-through standard—the minimum standard—that helps the whole system to work so that everybody knows where they stand. He is describing just basic, good clinical practice to bring through children and those in more serious need first. If he will forgive me, I do not think that he is putting forward a policy that will deliver clarity; it is a recipe for confusion.
Mr. Deputy Speaker (Sir Alan Haselhurst): Order. This cannot be a duologue. We want to open the debate up at some stage, and that was rather a long intervention.
Mr. Lansley: Thank you, Mr. Deputy Speaker. I must confess that I prefer dialogue to monologue, but we are under your direction.
Let me at least make this point just one more time. What the Secretary of State said is simply not true. Patients who present with minor conditions and could be seen and treated are often not; they wait a long time. One Healthcare Commission report on emergency departments noted that that situation bears particularly on the elderly, who often wait almost four hours before they are discharged by the emergency department to avoid a breach. There is a range of such measures, and if, as he says, the proposal is already normal clinical practice, hospitals will have no difficulty building it into the structure of their performance measurement.
The Secretary of State made an interesting point, however, because I remember that Kettering general hospital was one of the original pilots of the four-hour target. The hospital said that the target helped it to deliver change in order to expedite the treatment of patients. I said, “Fine. Do you think therefore that you should go from 95 per cent. to 98 per cent?” The hospital said no. I then asked whether it thought it should go from four hours to three hours. The hospital said no.
Subsequent to my conversation with that hospital, which took place almost six years ago, the Government imposed the shift from 95 to 98 per cent., which the College of Emergency Medicine and many emergency medicine practitioners do not support. The Government did so in the belief that it was the right way to secure continuous improvement, but the right way to do so is to start performance management with the four-hour target and to move to an understanding that a range of quality metrics should be a part of the culture of continuous improvement. If it is not, we end up with 98 per cent. and four hours, and that is it. At Staffordshire general hospital and many others, it has become obvious that the focus on a single target for the delivery of
emergency medicine leads to an immense range of distortions, many of which diminish the quality of care provided to patients.
We talked briefly about the exceptions to the private income cap. The Secretary of State should not listen to the siren voices, who have now left the Chamber, on the Government Benches. If one were to abolish the option to provide private medicine alongside NHS medicine, one would cripple hospitals such as the Royal Marsden. If anybody wants to see how being able to offer private health care alongside NHS care is to the benefit of NHS patients, they should go to the Royal Marsden hospital, because, with the Healthcare Commission’s ranking of double excellent year after year, it has demonstrated how it can reinvest the benefit of its private work in the NHS patients it looks after. The Opposition will be very critical if Ministers use a review as an excuse not to put into this Bill the opportunity for Ministers to introduce regulations to make exceptions to the private income cap. Ministers will know that Monitor feels that foundation trusts are highly constrained by the 2003 legislation. It can be changed only through this amending legislation; if it is not, the Government’s review will take place at some point in the summer or autumn—after the primary legislation opportunity has disappeared.
The Secretary of State talked about innovation, but, frankly, I am not sure whether we can give much credence to the way the Government have gone about innovation. The Darzi review, in an interim report in October 2007, said that there would be an innovation council. It met, but the Department’s website says that it last met in April 2008. The council seems to have disappeared since then. The fund that was supposed to be set up with the Wellcome Trust on a 50:50 basis—£50 million each—seems to have just disappeared, too. The provision is in the legislation simply so that the Secretary of State can give money to people who have already done something. However, he already has the power to incentivise people to do things in the future; he does not need legislation to do so.
I am sure that the hon. Member for Romsey (Sandra Gidley) will want to talk about pharmacy. The Government pursued dispensing doctors in an abortive attempt to remove some of their dispensing rights, and I worry that the Government are now seeing pharmaceutical needs assessment as a way, through primary care trusts, of arriving at a similar conclusion by a different route. We have to make sure that pharmaceutical needs assessments are real things that deliver real benefits, but the documentation that I have seen supporting such assessments simply says that primary care trusts should go away and work out what requirement there is for pharmacy services in their areas and commission according to that requirement. Where is the scope for patient choice, capacity building or a range of independent sector providers? Where is the freedom for pharmaceutical services to develop in response to need? We do not need primary care trusts to take to themselves more and more power over dispensing in their areas.
I come now to what I think will prove to be the most contentious issue in the Bill: I am thinking of the Government’s proposals on the point-of-sale display of tobacco. Time does not permit me to talk about the evidence at length, but I should say that my noble Friend Earl Howe and other Members of the House of
Lords did a sterling job of considering the Bill and amending it in two important respects. They entrenched the constitutional principles of the NHS and put exceptions to the private income cap into the Bill.
My noble Friend set out at length the difficulties with some of the research evidence that is prayed in aid by the Government on point-of-sale tobacco display. In truth, comparisons between Canadian provinces such as Saskatchewan, which went down the route of a display ban, and other Canadian provinces, which have not had a display ban but have taken some of the other measures, show that the latter provinces have made similar progress—sometimes even greater progress.
I hope that we will have a substantial discussion in Committee on the subject. I hope that Government and Conservative Committee members will contrive to take evidence for that purpose, because our approach should be evidence-based and the evidence should be tested in Committee. When the Bill comes back here on Report, I hope that the Government, like us, will give Members a free vote. Hon. Members, including the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, will well recall that, in itself, the giving of a free vote energised the debate about the ban on smoking in public places; in part, it led to the conclusion that we came to, rather than the one that would otherwise have been imposed by Ministers. I hope that, like us, the Labour party will give a free vote on these issues relating to public health and allow the evidence to determine Members’ views on the subject.
Although we will have a free vote, I should say that we on the Conservative health team strongly believe, like the Secretary of State, that smoking is still the greatest avoidable cause of premature mortality and that the rate of new smoking among young people is still far too high. We need to do whatever we can—if it is supported by the evidence—to ensure that as few young people as possible smoke. In that respect, we need to do more to combat smuggling and to act on nicotine replacement therapy, although those issues are not the subject of the Bill. We must ensure that the prescription and strength of NRT are optimised for the purposes of smoking cessation services.
Furthermore, we want two measures that could be in the Bill to be looked at. The first is the banning of tobacco vending machines from public areas of licensed premises; at the very least, we should structure the legislation so that we can ensure that young people do not have access to these machines in such areas. Secondly, there is an anomaly between the proxy purchasing of tobacco and the proxy purchasing of other products, alcohol in particular. If adults buy alcohol for children, that is a criminal offence, but the same does not apply to the purchase of tobacco. We see absolutely no grounds for such a perverse anomaly; it is important that adults should not give young people alcohol, but it is probably even more important that they do not give them cigarettes. We will press for the ban on proxy purchasing to extend to tobacco.
The Bill is a collection of measures that are not all bad; some are good. The incorporation of the principles of the NHS into legislation is a step forward, for which we have asked in the past. It has not been done precisely according to the NHS principles expressed in the NHS plan 2000; perhaps the Minister responding will explain
why that is. Why has the principle that the NHS supports and values its staff been left out? That is rather curious. None the less, it is important that the principles are there.
The Bill is a missed opportunity to create a real constitution for the NHS. Most of all, however, it is a missed opportunity to entrench the reform process in a way that would show that the Government are committed to a vision of a health care system that is at least as good as that of any other country in the world. The system’s outcomes should be benchmarked against the outcomes of other countries’ systems, not against a small number of narrow process targets that distort the activity of the NHS.
We should create a framework that delivers reform and incentivises providers of NHS care to deliver a rise in productivity rather than the fall that we have seen in the past decade. We should see the delivery of real patient choice, with the information flows that make that happen. The Secretary of State said that there was a right to information in the constitution; actually, there is only a pledge that the NHS will strive to provide information—nowhere is it said that the information will be that which patients really need for choice to be supported.
Furthermore, there is no evidence that Ministers want to create the kind of information revolution and marketplace for information in health care that would deliver the real empowerment of patients. We want a structure in which decisions are increasingly made at the front line, but the Government are still trying to have it both ways. They talk about devolution in health care, but they are actually entrenching a structure that is all about top-down command and control; it is still all about command and control at the Department of Health. Health Ministers’ response to what I was saying about targets illustrated even more the fact that they cannot get their heads around the thought that their job is not to decide precisely what should happen to every patient who arrives at an emergency department.
The issue is about those who are responsible for care. [Interruption.] The Secretary of State says from a sedentary position that he remembers what it was like. The change in capacity and the increase in resources are important, but it is to traduce NHS staff to suppose that if the Government did not impose a four-hour or 18-week target, NHS staff would say, “Oh well, patients can wait any amount of time—it doesn’t really matter any more.” NHS staff care more than any of us about the quality of care that they provide patients. If they have the resources, freedom, opportunity and an incentive structure that helps to make it happen, they will be potentially capable of delivering the best health care in the world.
We know that the NHS is founded on the principle of equity, and we will not compromise on that principle; indeed, we need to do more to deliver it. However, in the past decade, under this Government, the NHS has become less efficient as productivity has fallen. It needs to become more efficient. Most of all, we must have excellence alongside equity. We will not achieve excellence in the NHS unless we focus on the outcomes and compare the health outcomes and health gain in this country with those of the very best health economies anywhere else in the world.
I conclude with a motto: “Nil satis, nisi optimum.” As the Secretary of State will know, it is the motto of Everton, his favourite football club. It means “Nothing
but the best is good enough.” That is our motto for the national health service; I hope that, in the Secretary of State’s short tenure, it will also be his.
6.19 pm
Mr. Kevin Barron (Rother Valley) (Lab): Could I first say— [ Interruption. ] I have to tell hon. Members on the Opposition Front Bench that I have got quite broad shoulders; I have had them for 26 years in this place, and they will remain.
Let me first say to my right hon. Friend the Secretary of State—I congratulate him on getting his new position on the Front Bench—that I support the Bill. It is quite wide-ranging and pulls a lot of things together, but not targets, which the hon. Member for South Cambridgeshire (Mr. Lansley) talked about. He mentioned an 18-week wait. Nowadays, everybody talks about patient choice in our national health service. In my local hospital, just five years ago, somebody wanting orthopaedic surgery was offered waits of months, if not years, for procedures on things such as knees and hips—or if they had a few thousand pounds, they could go to an independent hospital in Sheffield and have it done the following week by the same surgeon. Targets have got rid of that type of patient choice, which has been offered, wrongly, for very many years.
The hon. Gentleman says that we should not have such targets and we should let health professionals get on with it. With all due respect, some of them—a minority, I have to say—were getting on with it, and getting away with it, for years by using long waits in order to be able to increase their earnings in the independent sector. This Government have stopped that, not just in South Yorkshire but up and down the land. They should be congratulated by every Member of this House, in the knowledge that many of their constituents are not covered by health insurance. Many of those people discovered that if they wanted to get a better quality of life quicker, they would be asked to go and get bank loans or dip into savings. That situation has gone, and the waiting list target alone has done more than anything else to achieve that. Of course, there has also been increased capacity because of investment.
One of the aspects that I want to focus on is the national health service constitution. I know that that is, and will continue to be, a bit of a rolling programme. Nevertheless, having served on the Health Committee since the last general election, I know that many people up and down the land are frustrated when they see drugs going through the NICE process, whereby they are assessed and it is agreed that people should have them and it is accepted that they would be good clinically and cost-effective, and then those drugs are denied to them by the local purchasers—the primary care trusts. Through the constitution, people will have the right to a drug that has been through the NICE process; that is progress indeed.
NICE was set up many years ago—in my view, to get rid of so-called postcode prescribing. That is an inequitable system, because whether people can have drugs that have gone through the NICE process varies from one constituency, covered by one commissioner, to the next. This will be a major step towards introducing what it was intended that NICE should do—although I know that it does many other things as well.
I look forward to the Public Bill Committee’s reaction to this debate, although I should say to my right hon. Friend that I am not volunteering to serve on it; I have other things to do on a Thursday morning with the Health Committee. I look forward to seeing what the constitution is going to mean—not only to patients, although it does have an effect particularly in that respect, but to staff. It also covers rights and responsibilities. Rights are very important in our health care system, but so are responsibilities. What responsibilities do we have as individuals, or do patients have in terms of their health care? What will the NHS ask of them as regards what they have to do to contribute to their own good health, besides what the health service does for their ill health? I look forward to that debate.
My right hon. Friend will have heard me say on many occasions that in the 21st century the issues that will affect health care in this country, in particular, are not those that dominated public health in centuries and decades gone by. It is not about housing now, although we have to accept that there is still some poor housing around. It is certainly not about sanitation or fresh water supplies. I was one of those born into the first generation that could be immunised against many things that used to kill tens of thousands of people in previous generations. Now, at the beginning of the 21st century, we are immunising young women against cancer—just one type of cancer, I accept. That is an extraordinary step for medical science. The real threat to the health of the public in the 21st century will be about what the individual does or does not do—how much alcohol they drink, what food they eat and in what quantities, and whether they take exercise. Many things done by individuals will impact collectively on the health of the public. I look forward to the NHS constitution starting that important debate very early on in this century. It is the debate for the 21st century, come what may in terms of the health needs of the nation. It is no longer just about treating ill health, which the NHS has been doing very well for the past 60 years.
I am interested in the concept of the innovation prize. The hon. Member for South Cambridgeshire said that money is given to people who have achieved something. As I understand it, the innovation prize is about doing things differently from what happened in the past when money was given to people to carry out research within the NHS. Innovation is vital. It is the reason the NHS has improved, and continues to improve, the health of this nation in many respects, and it should be encouraged. However, we need to examine the idea that if someone makes an application and gets a pot of money to do research, it goes ahead, but if they make an application and do not get the pot of money, it does not go ahead.
I have here the Library research paper on the Bill, which discusses the innovation prize, saying that clause 14
“enables the Secretary of State to award prizes to promote innovation (including research) in the provision of health services in England, including prizes for work done before the Bill currently before Parliament becomes law. It also enables the Secretary of State to establish a committee to advise about awarding such prizes and to pay the committee’s members.”
My understanding—I hope that my hon. Friend the Minister of State will clarify this when he winds up—is that this is not just about reaffirming what happened in the NHS in years gone by, when getting a grant to do research was the only thing that ever happened. The paper continues:
“Debates in the House of Lords on innovation prizes were short; there was no debate at all on Report. There were no amendments in Grand Committee or on Report but on Third Reading, in response to arguments made in particular by Lord Walton and Lord Patel, the Government successfully introduced an amendment to clarify that innovation prizes would include research.”
I understand that that is to make the provisions consistent with the National Health Service Acts and what happened in the past.
If we are to improve the health care system and the NHS, we should recognise that one of the major quests that has been going on for the best part of 60 years is about how to spread best practice. I have always said, sometimes with my tongue in my cheek, that we tend to do that by wanting to reconfigure the NHS. We tend to say, “Well, if it’s not working in that shape, let’s look at another shape for it. Let’s look at another way to approach it.” In fact most reconfigurations, certainly in the past few years when I have been on the Health Committee and examined in detail what is happening in the health service, have been intended to spread best practice and get things working better in various parts of the NHS.
Instead of thinking of the prizes as structural changes, we should realise that they are about incentivising people to do things themselves. In the past, somebody would get a grant for research and then do it. I hope that my hon. Friend the Minister will tell me that the prizes are about using the high levels of skills that we have at all grades—not just among hospital nurses and doctors but in other, related professions—to ensure that innovation is encouraged in a more constructive and flexible way.
Various organisations have produced briefings for this debate and for the debates in the House of Lords, and I should like to read out some of their concerns. All of them represent the health professions at some level, and they ask questions about the innovation prizes. In a briefing for Second Reading in the other place, the British Medical Association stated:
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