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"cooperative and coordinated environment where patients are guaranteed the most clinically appropriate and cost-effective care. Price competition and a fully open market will make this impossible."
Clause 63 allows the Secretary of State to impose requirements on consortia to promote competition between providers, and clause 64 makes it possible for Monitor to investigate any complaint of anti-competitive behaviour made against commissioners by any interested party. That might be a third party or an overseas private health care company, and would make it far more difficult for GPs to ensure that their patient services are integrated, inclusive and carried out in partnership. The Bill also forces trusts to achieve foundation status within three years and will lead to more important priorities, such as safe patient care, being compromised. Furthermore, the abolition of the private patient income cap set out in clause 150, removing the limit on the amount of income foundation trusts can earn from private operations and private health care, will create a two-tier health system. Foundation trusts forced into the market without protection will face financial pressures to turn a profit, and NHS patients will risk being pushed to the back of the queue.
To my mind, and according to evidence submitted to the Health Committee by the Royal College of Nursing in which it identified 27,000 nursing posts that will go, these reforms will result in tens of thousands of job losses and undermine national terms and conditions for NHS staff. The scrapping of targets has left the NHS open to a dangerous postcode lottery. The duty to tackle health inequalities is one of the few remaining powers to be held by the Secretary of State, but he will have nothing to back it up.
There is also no protection for the taxpayer from exorbitant and excessive behaviour by the consortia, an issue raised by my hon. Friend the Member for Blyth Valley (Mr Campbell). It is possible that we will see banker-style bonuses and the import of private sector pay into health care. [ Interruption. ] The Minister moans from a sedentary position, but there is nothing in the Bill to prevent that from happening. The Bill will also leave us, as Members of Parliament, with no voice in the NHS. This Tory-led Government seem to be trying to de-risk this political hot potato, which the Conservatives have never been able to manage properly. However, if Ministers think that the British public will allow them to wash their hands of the NHS without any comeback at the next general election, they should prepare to be shocked.
I would like to say one more thing in the time left-now that the hon. Member for St Ives (Andrew George) is back in his place and given what the hon. Member for Burnley (Gordon Birtwistle) said-about the combined impact assessment. I have received a letter from a GP saying that the practical significance of the Bill will be such that the many MPs who campaigned to save their local hospitals cannot vote for it in all honesty, knowing that in so doing they will be voting for a measure that is purposefully and expressly designed to prevent them from having any say and which will potentially lead to the very outcomes that they so vociferously campaigned against.
7.1 pm
Nadine Dorries (Mid Bedfordshire) (Con): I rise to support a Bill that I believe is perhaps one of the most exciting, if controversial, Bills to have been put before Parliament in the 62 years since the NHS was established. It is a fact that a resident in this country today is twice as likely to die from a heart attack as a resident in France. In this country, we also fail to reach European averages for stroke care. In fact, 4,000 stroke victims a year lose their lives because our NHS is not up to European standards in stroke care. If we delivered trauma care slightly differently, we could also save 600 more lives a year, but we do not. Those figures alone show that it is now time, 62 years since it was established, for the NHS to be modernised.
In those 62 years, drug research and development have advanced hugely. Medical technologies have advanced in a way that could not even have been imagined 62 years ago. As a result of the internet and the information now available, patients expect and demand to have a say in how their condition is managed. They want more information and they want to discuss their care with their GPs. The Bill will put the patient right at the heart of the NHS, and that is why I so passionately support it. The central tenet of the Bill is: "No decision about me without me". It will ensure that, for the first time, each and every patient can almost become their own lobbyist, sitting in front of their GP and discussing their condition and treatment in an open way, where they have information and the GP will have to engage with them. That does not happen today, and certainly not in hospitals.
I would like to give an example-something that I heard about this weekend from a patient-that clearly epitomises why the patient has become invisible in the NHS today. That patient was in hospital at the weekend when a doctor walked up to him, lifted his arm, took blood, put his arm back down and walked away without saying a single word to him.
Catherine McKinnell: It strikes me that despite what the hon. Lady is saying about the patient becoming the heart of the NHS, it will instead be the GP who becomes the heart of the NHS. Is she suggesting that the GP will be in the hospital with that patient to hold their hand at every stage of their treatment?
Nadine Dorries: I wish that that had been a more sensible question, because then I would have been delighted to give the hon. Lady an answer.
That patient was in hospital when the doctor walked up, took blood and put his arm back down without even a word of acknowledgment. A nurse then came and put his tray of food at the end of the bed. The patient was attached to a heart monitor and a drip, and could not reach the food. The patient was distressed, vulnerable and in pain, yet he was invisible to the health care professionals who were treating him. He was invisible because what is important in today's NHS is the process-the management, not the patient. The humanity of the patient has almost been lost, and there is no way to put it back into the NHS other than to tip the understanding of who is important in the NHS on its head. The Bill does that in a way that has never been done before and which is now needed.
Anne Marie Morris (Newton Abbot) (Con): One of the concerns that I have come across is from health professionals who would be delighted to see red tape removed. I have spoken to directors of nursing who spend more time on red tape than they do with their patients, and they are deeply frustrated. Does my hon. Friend agree?
Nadine Dorries: Absolutely, and the Bill will address that, in as much as care will be more easily accessed by the GP and the patient, in a much more streamlined process.
When nurses sat their medical exams 62 years ago, when the NHS was first established, the answer to each question had to begin and end with the words: "Reassure the patient". It did not matter what someone said in the answer; if they did not emphasise the fact that the patient had to be reassured, they failed. That has gone. That demonstrates exactly how the patient has become invisible in today's NHS.
I support the Bill because I support GPs working in consortia. A common myth-an urban myth-that we have heard in the few weeks leading up to this debate, and which has been thrown at us from the Opposition Benches, is that GPs are simply not up to the task of becoming business managers. The truth is that they already are business managers, because they all manage their own businesses. They will not be working as individuals or in individual practices; they will be working as part of a consortium, which is quite different from the impression given by the Opposition. Right now, 141 pathfinder consortia are demonstrating that they are ready and able to take on commissioning, and that they endorse patient involvement in the decision-making process. As a result of the "any willing provider" provisions, there will be a genuinely wider choice of care options available to the GP and the patient.
I would like to rebut the argument that the private sector will come in and undercut the NHS. That is complete nonsense. There will be no undercutting of the NHS whatever. Services will be- [ Interruption. ] I can only say that Opposition Members have not read the Bill, because there will be a tariff. Charities and the private sector will be able to provide services, but with a tariff. I shall give an example. If a patient requires a surgical procedure, which they discuss with their GP, and the local hospital has no bed available for six weeks, two months or however long, but if the local private hospital can provide a bed the next morning at the same price, are the Opposition really saying that an ideological obstruction should be put in the way of that patient being admitted to that private bed for that procedure the following day?
Rosie Cooper: Will the hon. Lady give way?
Nadine Dorries: I cannot, because I have given way twice and I have no more time.
If that patient were in pain, why should they not be admitted into that bed if it were available? That is how the market will be opened up by GPs, to the benefit of patients.
We recently heard from my right hon. Friend the Prime Minister about an extra £60 million that will be available to fund the latest bowel cancer screening technology, with wider deployment of the flexible
sigmoidoscope. That does not need to be provided in secondary care in a hospital; it could be provided in the GP practice under the "any willing provider" provisions, perhaps via charities with specialised trained technicians. The Bill will ensure a new approach to providing services to the patient. "Any willing provider" will give patients the choice that they have not had for 62 years, empowering them to make decisions over that choice and opening up health care that patients in this country have not had, certainly for the past 15 years. With new technologies coming on stream and new ways of delivering care, both in the patient's home and in the GP practice, that has to be welcomed. The Bill has to be welcomed, and Government Members will vote for it because the most important person in the Bill is the patient. That is why I support it wholeheartedly.
7.10 pm
Hugh Bayley (York Central) (Lab): The Government White Paper said some sensible things: it promised to increase NHS spending in real terms, to improve patient choice, to devolve decision making, to reduce management costs and to hold doctors to account for their clinical outcomes. Indeed, the objectives are very similar to many of those of the former Labour Government. The problem, however, is that the Bill will undermine many of those good aspirations.
Health spending is, as we know, falling because the amount by which the Government increased the NHS budget is lower than the rate of inflation. [Interruption.] For my health authority, it is 0.3% lower than the rate of inflation. Patient choice will remain limited to where GPs choose to commission services. Centralising many services under the NHS commissioning board-a new layer of bureaucracy-means that NHS dentistry, community pharmacy, optometry services, regional and sub-regional specialties and, indeed, some more complicated local services will be commissioned at national level by that board rather than at local level by a primary care trust, as in the past, or by a commissioning consortium in future.
I am sure that the Government will try to reduce NHS management costs. Every Government since the creation of the NHS have sought to do so, but this Government need to explain how creating 500 or 600 commissioning consortia-each with the skills to commission services-will cost less than the 150 PCTs that currently do the job. They are likely to lose economies of scale and the decisions taken could well lead to the fragmentation of some services such as dermatology or pathology. Such services are currently commissioned by a PCT for the whole PCT area, but in future could be commissioned in three or four different ways by different consortia. Small, less well resourced GP commissioning consortia will, I believe, be less effective than PCTs and strategic health authorities in controlling the costs of powerful hospital foundation trusts.
The Government are right to stress the importance of measuring clinical effectiveness and outcomes, but that makes it extraordinary that they have put primary care in the driving seat. We know a lot about the work of hospital doctors from the hospital episode statistics, but there are no national data on GP consultation rates or the thresholds they employ before they intervene with treatment or on GP outcomes, yet GPs are being put in charge of demanding this from everybody else.
Running through the Bill is the idea that transparency and accountability will drive up performance, so here are some questions to the Minister, which I hope he will address in his concluding speech. The Bill is designed to reduce health inequalities, yet there are enormous inequalities in GP services. Some GPs are very good; others less so. There are differences in their prescribing and referral rates, so how are the Government going to measure GPs' clinical performance? How will a GP commissioning consortium hold erring GP practices to account? What sanctions will be employed?
How will patients hold their GPs to account for their commissioning decisions? We are, of course, familiar with GPs being sued for bad clinical decisions, which is why they take out medical insurance and have to pay increasingly more for it each year. Will patients sue their GPs for bad commissioning decisions? How will the consortia hold hospitals to account?
How much will the GP commissioning consortia receive in management allowance per patient, because the Government's success in making administrative savings will depend on that? What sanctions will be imposed on a GP commissioning consortium to ensure that it commissions effectively and uses a good evidence base for its decisions?
The Government tell us that PCT deficits will be written off before the consortia take over, but what help will the commissioning consortia get in areas such as mine where there has been a difficult structural deficit-brought into balance by the previous Labour Government, but out of balance once again under the new Administration-to stop them falling into deficit? What will happen if they do go into deficit? Will their budgets and the services they provide to patients be cut as a result?
Mr Dorrell: The hon. Gentleman is making a thoughtful speech and asking, if I may say so, some very good questions, with all of which I agree. There is an implication behind his speech, however, which is that if all those questions can be answered, as I hope and believe they can, he will support the Government's policy. Is that implication correct?
Hugh Bayley: If I were convinced that they could be answered, I would indeed support the Government, but unfortunately I am far from convinced that it is the case.
Let us take another issue. The Government are providing a lesser increase in funding to the NHS this year, which amounts to a cut in real terms when the rate of inflation is taken into account. They think they will get away with this because the NHS staff wage bill is being frozen for a two-year period. What thought have they given to the wage bounce that will inevitably come in two years' time? There will be enormous wage pressure on the NHS budget; are the Government intending to increase it significantly at that time?
Mr Dorrell: I am anxious to provide the hon. Gentleman with extra minutes so that he can tell us whether he approves, in principle, of the idea of practice-based commissioning, which was originally introduced by the previous Government?
Hugh Bayley: I certainly do not agree with the way in which it is being introduced. The right hon. Gentleman will probably know that before the last election, I made a proposal to strip out one level of NHS bureaucracy-the PCT level-and do commissioning where it was needed at the SHA level. That would have achieved administrative savings. Instead of that, however, the Government have decided to replace 150 bureaucracies-PCTs as commissioning bodies-with some 500 or 600 bureaucracies the GP commissioning consortia. I do not think that that will achieve administrative savings. With the NHS budget so tightly squeezed by the current Government, if more money is taken away to meet the costs of bureaucracy, less money will be available for treating patients. That is the crux of the issue.
I believe that those are some very serious questions, which the Government need to answer if they going to convince the public of their plans. There is an intellectual incoherence in many of their proposals. They have not looked either at how some of their goals-on patient choice, for instance-might conflict with other goals such as increasing efficiency. Will a doctor be able to insist that patients have the most efficient treatment even if they do not choose that option themselves? Would it not make sense to pilot these changes before imposing them, untried and untested, on the NHS?
7.18 pm
Sarah Newton (Truro and Falmouth) (Con): Thank you, Madam Deputy Speaker, for calling me to speak in this most important debate. The scope of the Bill is far reaching and other Members have covered many aspects in their contributions, so I want to focus on one area-that of the future governance of the NHS.
The Secretary of State has identified a powerful and simple concept that resonates with people across the country-that "No decisions taken about me should be taken without me." While this concept is usually applied to the individual relationship between the patient and clinician, I believe it is just as applicable to the communities that the NHS serves in any particular area.
As we have seen from campaigns across the country, people do not want decisions about the health and care services available to them in their community to be taken without the opportunity to get involved in the decision: "No decisions about us without us." Over the last few years, I have seen the lack of openness, the lack of transparency, the lack of consultation and the consequent fear and suspicion that that brings.
I realise that not everyone will want to become involved in local decision-making and that many are happy to leave it to others, but I believe that we are right to enable more resilient and empowered communities to shape their own futures. Giving more power to the people is as important in the context of decisions about health and well-being as it is in the context of decisions about planning, homes and the environment.
The Bill is nothing short of a revolution in terms of the devolution of decision-making power to people in their communities, accountability, and the governance of health and care services. First, it links two crucial services. For too long the separation of those services, and the silo mentality governing the care delivered by local authorities and health services commissioned by primary care trusts, have prevented care pathways from
being developed effectively in a way that works for the patient, which has often closed off the vital role played by families, carers and volunteers in supporting people. There cannot be a Member in the House who has not had personal experience of that, or shared the experiences of elderly constituents who have been bundled around the system, described as bed-blockers and made to feel a burden.
Of course, in some parts of the country health and care services have been integrated, but they are in the minority. The Bill, and the money that the Government are making available to help fund the integration, will enable all parts of the country to develop the high-quality, joined-up services that are currently available only to a few.
Stephen Lloyd: I agree with much that my hon. Friend is saying about integration and the need to work with the community, and I applaud many of the changes made by the Bill. For years we have all talked of using pharmacists in a smarter way. Does not the Bill provide an opportunity for much more integration of community pharmacy with the consortia, and for the Government to support the consortia in that endeavour?
Sarah Newton: As someone who represents a rural area of Cornwall where GPs' delivery of pharmaceutical services is vital, I think that that is an extremely good idea.
Secondly, the new responsibilities of Monitor and the Care Quality Commission will make possible independent regulation of both quality and safety of care and value for money. I have observed the problems that have occurred in recent years when managers have evaluated their own compliance with standards. Good decisions can be made only with sound evidence. The powers of the National Institute for Health and Clinical Excellence and the Information Centre will be enshrined in legislation for the first time, and their independence from Government will thus be guaranteed.
Thirdly, the Bill creates a new role for local authorities in public health. Directors of public health, jointly appointed by Public Health England and local authorities, will play a leading role in the discharging of authorities' public health functions. Arguably, it was the initiatives of local authorities in past centuries-such as the introduction of fresh water, drains, sewage management and the controlling of vermin-that led to some of the most significant improvements in life expectancy.
Anne Marie Morris: Is not one of the real strengths of making public health part of the role of local government the fact that housing, which is critical issue to public health, can be viewed in the round?
Sarah Newton: I entirely agree with my hon. Friend, who has anticipated a point that I was about to make.
The returning of more responsibility to local authorities-along with the considerable social determinants of health for which they are already responsible, such as the availability of good-quality housing and the regulation of places of work, environmental health and leisure services-has the potential to improve health outcomes, and to close the ever-widening gaps in health equalities in this country.
The Bill will ensure that every upper-tier authority establishes a health and wellbeing board consisting of the director of public health, GP consortia, children's services, adult services, care providers from all sectors, and local health watch organisations. Such boards should provide local leadership and a strategic framework for the co-ordination of health improvement and the addressing of health inequalities in their areas. The joint strategic needs assessment will be integral to the process, and will influence the commissioning of services. The local health and wellbeing boards will, in effect, hold the ring when it comes to the health and care services provided in their communities. Local authorities will maintain and extend their role as scrutineers of all services, whether they are commissioned locally or nationally and whether they involve health or social care. They will also be able to commission complaints and advocacy services from any provider, rather than just from the local or national health watch.
The Local Government Association has warmly welcomed the proposed changes. The best local authorities have good experience of working with public, private and not-for-profit organisations as well as the charity sector in delivering integrated care. They are used to planning person-centred and personalised care.
I believe that-along with the changes that the Secretary of State has already made to the operating framework of the NHS in relation to the reconfiguration of services-the Bill, when effectively implemented in communities across the country, will lead to greater openness, greater accountability, and greater confidence for all those working in health and care, as well as for the ordinary people up and down the land who have lost so much confidence in the way in which decisions are made. These changes will take time, but I am confident that within the next four years, when we ask the people of this country, "Do you feel that decisions are being taken about you and with you?", many more people will say "Yes" than would do so if asked that question today. That is a result that I shall be proud to have played my part in achieving.
7.26 pm
Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op): As we have already heard today, the public love the NHS. and they are right to do so. Of course it is not universally perfect; of course there are times when it does need reform; but it is still something of which we are right to be proud, and we should not be proud of it just from a moral standpoint.
As economists of many different political persuasions have shown, a centrally funded NHS is a far more efficient way of providing a system of health care than the imperfect market of a system of health insurance. We need only look to America, where, until the recent reforms, more than half all personal bankruptcies were caused by people who were unable to meet their medical bills, to recognise how decent and effective our system of health care really is.
That brings me to the main point that I want to make. In my view, these proposals do not represent an evolution in the NHS reforms of the last Government. The principal goal of the Bill-to transfer commissioning from PCTs to GPs-is, in fact, a dangerous gamble with one of the country's most-prized institutions. Bringing GPs closer to decision-making did not require the wholesale dissolution
of PCTs and the transfer of their responsibility to GPs. When the Government promised no further top-down reorganisation, they should have meant it, because this reorganisation is ill judged and ill advised, as is spending the £3 billion that it will cost. However, now that they have embarked on this revolution, they should be aware of what has come about as a result of it.
Throughout the country, there is a pressure cooker of discontent in the primary care sector as PCTs struggle to balance their budgets and hand over what, on paper, will appear to be their stable financial footing. In order to do that, many have already implemented restrictions on procedures, described in the jargon as "procedures of limited clinical value". I assure Ministers that they are not of limited value to people who are suffering and in need of care. In a number of areas, PCTs have asked GPs to suspend all but urgent referrals to secondary care. This prompts us to ask what kind of health service GPs will be inheriting. Patients are suffering now as a result of the actions of this Secretary of State.
I also fear that the commissioning of specialised services will create a real gap. For all the faults that some may ascribe to them, PCTs ensured equity for those who, if commissioning had been done on a smaller scale, would have struggled to have had their voices heard. There is a real question of scope here. Many GPs simply do not have sufficient sight of some types of work to commission effectively. The provision of mental health services is a particular concern. As ever with this Government, it seems that the most vulnerable will be most at risk.
If GPs really are better placed to commission services on behalf of patients, why were there shortages of flu vaccines this winter? GPs were responsible for ordering those vital supplies. They had the medical records of the people in their areas; they had the information that they needed in order to make effective provision. In my area it was the local PCT that remedied the situation, but who will be there to do that in future? GPs already have to balance financial and medical considerations. Have they really proved that they can do so effectively?
Finally, we must look at what exactly GPs will be expected to do and how they will go about doing it. In all the contracts they award, someone will have to monitor financial and clinical governance. That requires expertise, which GPs will have to buy in. Who will evaluate the tenders for services and deal with contractual issues? That will require yet more expertise to be brought in. Once we consider all that PCTs do across a wide geographical area, we see that GP consortia doing the same thing over a smaller area will result in an army of consultants, private companies and ex-PCT staff being contracted in by the consortia. We will, in effect, have the expense of PCTs as they work on the same things as now, but without the accountability and economies of scale currently enjoyed. Alternatively, GP consortia might achieve these economies of scale, but they will do so by ceasing to be the community-based practices with which we are all familiar. They will become faceless corporate entities, where doctors will be salaried members of staff with no connection to a specific practice or locality. That might be the Government's intention, but it is not an evolutionary change to the NHS.
I do not wish to be entirely negative, because there are parts of the Bill-these do not deal with changes to commissioning-that I have to be more positive about. I welcome the ongoing commitment to patient choice, as I have never believed those who say that the public do not want to choose which NHS facilities they wish to use. As with other public services, the NHS must reflect the autonomy people now expect to be able to exercise over their own lives. I also welcome a stronger role for local government in scrutinising health outcomes in their area, provided that that is a real power, not a symbolic one, entailing the ability to force changes when outcomes are not good enough.
However, those are small consolations when we consider a Bill that risks the very future of the NHS as we know it. This is a poor Bill, which has been rushed out without scrutiny and which lacks a democratic mandate. It is not so much a hand grenade thrown into the national health service, as a commercial demolition designed to break the NHS as we know it in order to serve a set of interests which are-
Stephen Lloyd: Will the hon. Gentleman give way?
Jonathan Reynolds: I am not going to give way. Other hon. Members wish to get involved in this debate and it is a disgrace that we have only one day to discuss this.
This Bill will break the NHS to serve a set of interests that are not those of NHS patients, not those of NHS staff and not those of my constituents. It is for those reasons that I shall vote against it today.
7.32 pm
Mr John Baron (Basildon and Billericay) (Con): I rise to support the Bill, because I support the two big ideas behind it. The first of those is the increased focus on outcomes, which is long overdue and very welcome. For those who suggest that there is no need to improve the NHS or to worry about the issue of outcomes, I shall just highlight this country's relatively poor cancer survival rates-as some hon. Members will know, I have a particular interest in cancer. Improvements have been made over the years, but those improvements go back over 30-odd years and other countries have improved, too. This country still flounders in the lower divisions of the international cancer league tables, and that situation has to be wrong.
The all-party group on cancer focused on that issue in 2009, finding that patients who reached the one-year survival mark in this country stand as much chance of getting to the five-year survival point as patients in other countries, but that our one-year survival rates are very poor indeed compared with those of other countries. That tends to suggest that the NHS is as good as others, if not better, at treating cancer once it is detected, but very poor at detecting cancer in the first place.
Part of the problem is in the area of early diagnosis, which is why we recommended focusing on one-year survival rates. We suggested introducing an outcomes benchmark that focuses the NHS on the one-year survival rate, because late diagnosis makes for poor one-year survival figures. If we can get the NHS focused on that, many patients will benefit. Therefore, we are delighted to see that both one-year and five-year benchmarks have been introduced in the outcomes framework for
2011-12. We very much welcome that, but I believe I am right in saying that the 2011-12 outcomes framework covers only colorectal, lung and breast cancer. We have lots of data for other cancers, such as prostate cancer, and I urge the Government to think seriously about extending the cancer types covered in the 2012-13 outcomes framework. The risk is that if we do not do so and we include just a narrow range at a national level, that will make for a lack of priority at the GP level.
As for GP commissioning, bringing commissioning decisions closer to the patient has to be a good idea; patients have got to benefit from that. Some people say, "GPs see only about eight new patients a year. What could they possibly know about commissioning cancer services?" I would turn that around by asking how many cancer patients the chief executives of primary care trusts see. They are commissioning cancer services at the moment. That point needs to be discussed.
Owen Smith (Pontypridd) (Lab): Given the hon. Gentleman's interest in cancer, I am sure that he will know that the point is that the cancer networks often aid commissioners at all levels in providing this care and they are dissolving before our eyes right now as a result of these changes. GPs will not have the experience to commission care in respect of rare tumour types.
Mr Baron: I agree with the general gist of what the hon. Gentleman is saying, but I would not say that the cancer networks are dissolving. I have raised this important point many times in the House-perhaps he was not in the House when I intervened on the Secretary of State-and what I would again ask my Front-Bench team about is the funding gap. I understand that the funding for the cancer networks ends in 2012 and there is a gap until the GP commissioning takes full effect. The answer given to me from the Dispatch Box today was that the national commissioning board will be up and running by 2012. The problem with that answer is that the national commissioning board will give guidance but the arrangements for the people who will actually make the commissioning decisions, the GPs at the front line, will not be truly effective until 2013 at the earliest-that will probably happen in 2014.
The worry is that in that gap a lot of expertise could be lost to the cancer community as a lot of expertise within those cancer networks decides to walk out of the door. I again ask the Government whether there is any way in which we could bridge that gap in order to ensure that GPs are better able to make informed decisions about the commissioning of cancer networks, because those networks contain an awful lot of expertise that we would not wish to lose.
I am fated to ask that question of the Minister of State, Department of Health, my hon. Friend the Member for Chelmsford (Mr Burns) again, as we are fated to discuss the issue. I appreciate that cancer is not his speciality, but I would like to get an answer on that point. There is a difference between the national commissioning board taking responsibility for guidance and the GP consortia actually taking responsibility for the commissioning. That point has to be addressed carefully, because various cancer charities have already reported that some 50% of the staff of cancer networks are thinking of leaving or have been told that they will
be leaving within the next 12 to 18 months as part of a cost-cutting exercise. We need to address the point sooner rather than later.
In the remaining minute allowed me, may I quickly discuss eye health? I am wearing my hat as co-chair of the all-party group on eye health and visual impairment. I welcome the clauses that place primary ophthalmic services with the national commissioning board, which is likely to devolve enhanced optometry services to GP commissioners. That is the right decision and those working within the medical profession welcome it. However, I suggest two areas where we need to establish a national system. The first relates to glaucoma referrals under the NICE guidelines and the second relates to community-based acute services-in other words, those managing red eye and minor eye problems. The Secretary of State visited the school of optometry in Cardiff and, apparently, he liked what he saw. Can we ensure that those national guidelines are in touch, because otherwise we get a fragmented service and patients may suffer as a result?
In conclusion, I welcome this Bill, which could be transformational, particularly with its focus on outcomes. The Government will therefore have my support in the Chamber tonight.
7.39 pm
Clive Efford (Eltham) (Lab): This is a very dark day for the future of our national health service, particularly for those who have spent most of their political lives campaigning for and supporting the NHS. Some of us remember what 18 years of Conservative government did-the hospital closures and continually increasing waiting times that patients had to endure. One of the first cases that came through my door when I was newly elected to Parliament was that of someone who had been waiting 18 months for open-heart surgery. His wife came on his behalf, pleading for something to be done. I am pleased to say that he was treated under a Labour Government and that he is still alive today.
In contrast, this is a good day for those who have always hated the national health service. I remember a former Tory MP, Matthew Parris, who became a journalist, going on TV at around the time of the 1997 election and being asked, "What is it about the Conservatives and the NHS?" He replied, "It is quite clear-they hate it." They hate the idea that they pay taxes and that the "undeserving poor" get equal treatment in the NHS, and they do not accept that people should be treated according to clinical need. That is why they continually chip away at the NHS. I do not blame the Tories, because they are just doing what Tories always do to the NHS, but when people went to the ballot boxes and voted Liberal Democrat in the last general election, they did not vote for the destruction of the NHS.
Many Government Front Benchers have campaigned against hospital closures, but the impact assessment for the Bill clearly states that Members of Parliament and local councillors should not be allowed to influence any decisions about hospitals in future. The Under-Secretary of State for Health, the hon. Member for Guildford (Anne Milton), looks surprised, but that is in the impact assessment. Did she not read it? No wonder the Government did not publish it until last Thursday. It says that anyone on the Government Benches who campaigned at the last general election to keep a hospital
open will be prevented from influencing decisions in the future. In order to secure a market and prevent it from being unduly influenced by political interference-in order to create a fair marketplace-politicians will be denied the opportunity to influence what is going on. That is in the Bill and the impact assessment. Before any Liberal Democrat votes tonight, I urge them to check that impact assessment, because if they do not, they will be voting for something without appreciating what is coming down the road.
I fully support the idea that GPs will be champions on behalf of their patients, but I am sure that the measures will be a bit of a curate's egg in that respect. Howard Stoate, a former colleague of ours, supports GP commissioning and I have no doubt that if I were his patient I would be very pleased to have him as my GP, but unfortunately not every GP is a Howard Stoate. The issue with what is going on and what is being changed here is that GPs will not perform in the same way across the board. We saw that with the Tomlinson review and GP commissioning before-a lot of them became property developers. They top-sliced capital money, developed their properties, sold them off at a profit and moved down the road. We have seen all this before.
Clive Efford: No, I am not going to give way.
What about the idea that there will be patient choice and that patients will have some idea of where to go? Are we going to get all the information about private sector providers? Are they going to publish their performance data in the private sector when patients are making up their minds whether to use them or not? I suspect that we will get what we got before with these sorts of changes-commercial confidentiality; we will be told, "We can't possibly tell you that because that would harm our performance in the marketplace." That is what we got before and I do not doubt that we will get it again.
Let me address the comparisons that we have heard from Ministers.
Clive Efford: Members can just sit there and listen. [Hon. Members: "Give way!"] They put this ridiculous Bill up-they can sit there and listen.
The comparisons that we have had from the Government about performance on heart disease and cancer involve the selective use of statistics to try to prove their point. The Appleby review clearly states that on current trends, by 2012- [ Interruption. ] I am not reading my notes; I do not know whether the Minister has noticed. Appleby states that by 2012 this country's performance in relation to a number of cancer treatments will exceed that of France, which in 2008 spent 28% more than us, as a proportion of gross domestic product, on health. We have only just reached the European average in terms of expenditure on the national health service and, as other hon. Members have said, it is time to let the NHS bed down. The time for change is not now. We should allow that expenditure to have the effect-
Madam Deputy Speaker (Dawn Primarolo): Order. Time is up.
7.45 pm
Mr Steve Brine (Winchester) (Con): I should like to say that it is a pleasure to follow the hon. Member for Eltham (Clive Efford), but I think that those watching the debate can make up their own mind about what they have just heard. I speak as a Conservative who loves the NHS; I am sorry to disappoint the hon. Gentleman in that regard. His comments were a great example of the knockabout that we hear in the House, which the public hate so much. I remind him that every day people die, work in and love the NHS, and they deserve better than what we have just heard.
As ever, time is short, so I will not detain the House. I want to focus on the fight against cancer and to share with right hon. and hon. Members the way I view these reforms. The Bill promises to take day-to-day power and responsibility out of the hands of Ministers and managers and to put it firmly into the hands of GPs. This means that decisions about NHS care will move closer to the patient and away from the remote organisations of which few people whom I and others represent have heard. Even fewer of those people would have the first idea what those organisations do, let alone how to contact them.
In an extremely tough financial climate, even for the NHS, we are talking about removing the bureaucracy of the primary care trusts and strategic health authorities and investing that money in patient care. As I have said in my constituency more times than I care to remember, I am concerned only about protecting the services that my constituents rely on. If they are threatened, I will dust down the placards, but I am not going to rummage around in the shed for one that reads, "Save the PCT"; I do not think that "Save NHS Hampshire" trips off the tongue.
The concept of reforming our NHS so that services and decisions come closer to patients is not one that I find disturbing, and I wish that we could at least start the process of debating this Bill by agreeing on that. However, nothing I have said thus far means that I and many others do not have questions about the next few years as we move to full GP consortia commissioning. Some Members will know that I co-chair the all-party group on breast cancer. We have worked hard since the publication of last year's White Paper to produce a response. In October we held a health inquiry session at Breakthrough Breast Cancer's "Westminster Fly-In". Breakthrough's CAN members and parliamentarians highlighted the breast cancer patient perspective and focused, as ever, on our vision of a future free from the fear of breast cancer.
The public health approach outlined in part 2 of the Bill will encourage people to be much more proactive about their health. I feel strongly that encouraging greater breast awareness is and must be an important part of that. Most breast cancers are found by women who notice a change, take the initiative and subsequently visit their GP. There is strong evidence that being breast aware-knowing the signs and symptoms of breast cancer and the importance of early treatment-and attending NHS breast screening appointments are two of the most important factors in breast cancer survival in the UK. The third is, of course, treatment. When it
comes to screening, we have to do much better in this country. This change in public health must give a strong impetus to local authorities, many of which are big employers of women, as well as to GPs and local employers to come together and make sure that we do better. Women should be given time off work to attend breast screening appointments and providers must recognise that access to screening that works does not always mean nine-to-five, Monday to Friday. That is something we have discussed in our group many times.
Locally, GPs should be encouraging women to be much more breast aware and should make sure that no-shows for screening appointments, which are sometimes as high as 50% in my area, are followed up and that those women are given the support they need to get there. As I have said before, the move to pure GP-based commissioning will sharpen efforts in that regard through much more sophisticated data management and use of the lists that are currently poorly used.
Much has been said in the House and outside about the UK's low placing in the cancer league tables, and it is often the Eurocare series, which the Secretary of State mentioned, that shows that survival for the four most common cancers in our country are lower than in the rest of Europe. As Cancer Research UK said to me and all hon. Members in its briefing ahead of today's debate,
"commissioning of cancer services is not as good as it could or should be",
and I know that Cancer Research UK welcomes, as do I, the recently published cancer strategy.
That superb organisation, Macmillan, tells us that more than 2 million people are living with or after cancer in this country, and by 2030 there will be 4 million. As we all know, cancer is a set of 200-plus different diseases, most of which have highly complex care pathways. I have concerns, as others have said, about the low level of GPs currently with a specialism or particular interest in cancer compared, for instance, with diabetes or mental health.
I urge Ministers, as did my hon. Friend the Member for Basildon and Billericay (Mr Baron) so eloquently a moment ago, to look again at the transition period from 2012 to 2014 to protect the cancer networks until GP consortia are in a position to make better decisions about the support and expertise they require. Solid action from the Government in this regard would reassure many cancer charities, patients and Members.
Finally, we are in danger of presenting the argument as "all that exists in the current NHS is bad or failing," versus "all is sacrosanct and we cannot touch it." Neither is true, in my opinion. Let us keep what works, protect it and strengthen it. That is what we are about, but let us remove what does not work and be brave enough to replace it. Do we want to give the Bill a Second Reading, find out more and examine it further, or do we want to turn against change and take the easy road? That would be the real risk. I will support the Bill in the Lobby tonight.
7.51 pm
Emma Reynolds (Wolverhampton North East) (Lab): There is much disquiet and concern among health professionals about the speed and scale of the reforms outlined in the Bill, with various respected organisations warning that they are a "significant risk" and "could be disastrous".
It is important to see the Government's plans in the context of the progress and the health legacy that this Tory-led Government inherited from Labour-patient satisfaction in the NHS at record levels, a world-class public service transformed by Labour, record numbers of doctors and nurses, and new hospitals. Contrary to some of the claims from the Government Benches about the statistics, survival rates for the most serious conditions are improving, and we will have the lowest mortality rates of any European country for heart disease by next year. The Government would do well to recognise this progress.
One of the Government's central arguments is that massive restructuring is necessary to drive efficiencies in the NHS. I beg to differ. By overhauling the system, the Government are putting at risk the very drive for efficiencies that we support. According to the Royal Society of Physicians,
"Achieving both efficiency savings and reorganisation simultaneously will be an unprecedented challenge for both commissioners and providers".
In government we recognised the efficiency challenges that we faced in the NHS. That is why in the last Labour Budget the Department of Health committed to £4.35 billion of savings over two years, with a further commitment to save £20 billion in the next five years. We demanded that primary care trusts reduce their management costs by 30% over a three-year period. The choice between doing nothing or modernising the NHS is a false choice, as I think the Government know.
Evidence from the previous reorganisation suggests that the disruption will extend well beyond the period of the reform. Even one of the Government's Back Benchers, the hon. Member for Totnes (Dr Wollaston), a GP herself, has said:
"To my mind, it felt a bit like someone had tossed a grenade into the PCTs. These people have so much uncertainty about their position that they are haemorrhaging in a rather uncontrolled fashion."
The transition process is not only disruptive, but will undermine efficiency and quality. This risk was recognised by the National Audit Office in its report, where it said that the previous government's initiative, the so-called quality, innovation, productivity and prevention programme, is at risk because of the overhaul proposed by the present Government. What is more, their obsession with driving down costs using price competition carries a very real risk of decline in the quality of care, according to professional organisations such the BMA, the Royal College of Nursing and the Royal College of Midwives.
Mr Graham Stuart: The hon. Lady is giving a powerful speech, making the case that every Government must look for efficiencies and suggesting that the previous Government did. One of the key failings under the previous Government, who did see improvements in the NHS with vast increases in expenditure, was on productivity. According to the National Audit Office, which the hon. Lady just mentioned, productivity, after improving in the 1990s before Labour came to power, fell during the Labour years, despite the massive investment of additional funds. Turning that around is the central challenge for this Government. What views does she have about how best that can be made to happen?
Emma Reynolds: I have already said that we on the Labour Benches recognise the need to drive efficiencies and, as part of that, we recognise the need to increase productivity. We made massive strides in the 13 years that we were in power, and those on the Government Benches would do well to remember that.
The allocation of resources in the NHS is all about economics and the tension created by infinite demands and finite resources. Difficult questions that are at the heart of commissioning need to be answered at a macro level-questions such as how do we value the improvement or lengthening of one person's life compared with another's; and what is the cost of investing in one drug compared with another or with an existing treatment? These are not easy questions to answer, and clinicians are making decisions at a micro level.
Faced with a limited budget, clinicians will call for more resources to be allocated to their field. Oncologists will argue for a greater share of the budget to be spent on cancer treatment. Paediatricians will argue for more money for paediatrics. As well as prioritising primary care, GPs might well bid for more resources for treatment or minor surgery that their practice offers-a potential conflict of interests against which the Bill does not safeguard sufficiently.
GPs are trained to be advocates of their patients, and rightly so, treating them as individuals, not as a particular percentage of the population. Their training does not equip them with the tools to make the tough, unpopular decisions about the allocation of limited resources. Perhaps in his winding-up speech the Minister will tell the House what percentage of GPs he thinks have had to grapple with the complexities of the modified Portsmouth scoreboard or the quality-adjusted life years measure. Those are the instruments used day in, day out by people who make commissioning decisions.
As my right hon. Friend the Member for South Shields (David Miliband) said so eloquently, the choice is not between reform or no reform. We are not against reform or driving efficiencies, but we are against the ill-considered, costly, reckless reform contained in the Bill, which will undermine the drive for efficiency, jeopardise quality of care and fails to take into account the fact that GPs do not have the expertise or the training to make the macro-level decisions on the allocation of resources.
7.58 pm
Nicky Morgan (Loughborough) (Con): Thank you, Madam Deputy Speaker, for allowing me to contribute to the debate on a Bill that is essential to implementing the coalition Government's policies. I had intended to say what an excellent debate we have had so far, with some thoughtful contributions from all parts of the House. The hon. Member for Wolverhampton North East (Emma Reynolds) made a thoughtful contribution, but I am afraid the hon. Member for Eltham (Clive Efford) let his side down completely with his offensive remarks about how Government Members view the national health services.
Although she is not in her seat, I congratulate the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) on her contribution to the debate. I did not agree with it, but she gave her speech extremely well.
I welcome the Bill. It is essential that more power is given to front-line doctors, who are best placed to understand patient needs. It is a tragedy that Opposition Members seem to think that GPs are not capable of stepping up to the mark and taking on those responsibilities. From the conversations that I have had with my GPs, I do not understand why the Opposition believe that; they will be proved wrong.
I support the focus on clinical outcomes. I think that GPs are interested in taking on commissioning and the proposed changes. Three consortia in Leicestershire and Rutland have stepped forward so far. My primary care trust is working extremely closely with them, particularly on transferring community services, and I welcome their close working relationships.
The GPs commissioning arrangements will mean that GPs listen to what patients want. GPs will be responsible for community services in Leicestershire and Rutland, including the walk-in centre in the middle of Loughborough and out-of-hours services, which have not been mentioned in the debate. One of the things that patients feel most passionately about is the fact that some GPs, particularly in the part of the country I represent-I cannot speak for everywhere-are not responsible for delivering out-of-hours services. What patients say to me more than anything else is that when they call someone in the middle of the night, they want their GP or someone who has access to their records to answer the telephone, not a call centre.
Anne Marie Morris: I absolutely support what my hon. Friend says. I have the very good example in my constituency of Devon Doctors, which is effectively a not-for-profit organisation that provides all the out-of-hours service and gives the people of Devon exactly what she has suggested.
Nicky Morgan: I entirely agree with my hon. Friend. It just shows that GPs, if they are given the responsibility, will step up to the plate and deliver what their patients need.
In the limited time available, I wish to focus on what the proposed changes will mean for mental health services. I speak as a member of the all-party group on mental health, and as someone with a family interest in mental health issues. The NHS in England spends more on mental health services than on any other disease category, including cancer and heart disease, and one in four people will experience mental ill health at some point in their lives. The public health strategy has so far not been mentioned in the debate. I entirely welcome the Government's emphasis on public health and the emphasis on good mental health as well as good physical health. I recently spoke with Charnwood mental health forum, which is based in my constituency, whose members told me that prevention of mental health problems and supporting people who are perhaps heading down the road to depression and more serious conditions is incredibly important.
There are four keys areas that I want to mention in the time available. My first point, which has already been mentioned by the Opposition, is that we must ensure that GPs get proper support to commission effective mental health services and other specialised services. That support can come from the national commissioning board, third sector organisations and
patients. That is why I think GPs will step up to the plate, because they will ask their patients and listen to them when designing and commissioning services.
A recent Rethink survey of GPs found that 31% of GPs did not feel equipped to commission mental health services, compared with 75% who felt that they could commission diabetes and asthma services. It also revealed that 42% of the GPs said that they had a lack of knowledge about specialist services for people with mental illness, and 23% said that they had a lack of knowledge about mental illness in the first place. I will cite a recent case study from my Loughborough constituency, in which I was told that one of my constituents was suffering from complex mental health conditions, but his GP appeared to have no knowledge of personality disorders and saw the problem as largely behavioural. The relationship between the constituent and the GP deteriorated and therefore the local Rethink carers group stepped in to help find another GP. With consortia, a GP in a different practice could have that specialisation, and the first GP, realising their limitations, could speak with that other practice and engage with carers groups, such as Charnwood mental health forum or rethink to ensure that there are special services available for patients.
Emma Reynolds: Is the hon. Lady as concerned as I am that a recent survey by Rethink showed that 95% of GPs did not feel that they had sufficient expertise to commission mental health services?
Nicky Morgan: I was just talking about that, but the point that has been made is that GPs do not feel that they necessarily have the specialist skills to commission mental health services. That says not that the underlying plan set out in the Bill is wrong, but that GPs recognise their limitations. From the conversations that I have had with GPs, I think that they will know where to go to commission those services and they will get the support from the national commissioning board.
Hugh Bayley: Will the hon. Lady give way?
Nicky Morgan: I am afraid that I must make some progress.
My second point relates to joined-up care, which carried on from my previous point. People with mental health problems have complex needs and need a clear pathway of care, which might involve the GP, psychiatric care at secondary care level, a social worker and community support services, such as drop-in services. That is essential, and that is what we want to see happen in the NHS.
Tom Blenkinsop (Middlesbrough South and East Cleveland) (Lab): I applaud the hon. Lady for making such an excellent case for mental health services, but I would like to pick up on a point about expertise. Under the new arrangements for consortia and the massive expansion in programmes, who will provide the funding? Will it be via town halls or local authorities for care at community centre level?
Nicky Morgan: There is already some excellent provision in Leicestershire. I hear the hon. Gentleman's point, as, I am sure, does the Minister. I am sure that she and her colleagues will look at that in the debate and in future.
I support the "any willing provider" model, which was first introduced by the previous Government. It is often patients with mental health issues who benefit from care at different levels and with different therapies, but it does not all have to be at primary or secondary care level. As I have mentioned, there are organisations, such as Charnwood mental health forum and other drop-in centres, that offer excellent services, and they must be part of GP commissioning and the services that will be provided under the new arrangements set out in the Bill.
Finally, I wish to look at public health involvement through HealthWatch and the local health and wellbeing boards, which is critical. We must ensure that there is broad representation in those organisations. Research from Rethink has shown that stigma and discrimination affect nine out of every 10 people with mental health problems. The boards and those organisations must ensure that the most vulnerable patients are listened to. At a recent meeting of the all-party group, one of the contributors said:
"We all have mental health-it just depends how good ours is."
Mental health has for too long been a Cinderella service. I am confident that that will not be the case under the new structure because GPs will do their best to understand it or, if they do not, will get in appropriate services. I support the Bill and look forward to hearing how the points I have mentioned will be addressed. I also look forward to the unveiling of the national mental health strategy, which I understand will happen later this week.
8.6 pm
Malcolm Wicks (Croydon North) (Lab): The status quo in British health care is certainly no serious option. Improving the NHS is, of course, a continuing challenge, not least because of the ageing of our population, rising medical costs in many sectors and rising public expectations, which are sometimes fuelled by information on the internet. If one adds to that the new public health agenda and the need to bring health and social care into better alignment, one can see the scale of the challenge. However, that is not to say that a top-down reorganisation is the answer.
I want to ask Ministers some specific questions about how the Bill will impact on some of the values and underlying principles of the NHS. The first is the principle that the health service should be based on need, not income or wealth, which is perhaps the essence of the NHS. How do the proposals relating to private patients in hospitals relate to that ethical principle? The proposal is to remove any limit on the use of NHS beds and staff to treat privately paying patients. Unless the Government somehow envisage surplus hospital resources, spare staff and empty beds-a far-fetched proposition-will not more private patients create longer waiting times for NHS patients and/or poorer care? What is the Minister's judgment on that?
My second question concerns the profit motive, which jars, at least for many of us, with the principle of patient care. Will Ministers confirm that private companies might in practice commission on behalf of GPs, possibly including US companies, while other companies will be awarded contracts? Have I understood that correctly? What is to stop companies competing on price for
relatively straightforward procedures, perhaps initially cherry-picking as a loss-leader while leaving NHS hospitals with, frankly, the more difficult medical territories? What proportion of the NHS budget might effectively be in private hands? Of the £80 billion annual expenditure that we hear about, what sums might end up as profits for private shareholders? Ministers must have some idea of the answers to those questions, so I would be pleased to hear their answers or guesstimates.
Margaret Hodge: Does my right hon. Friend agree that there is another issue with privatisation? If a private, BUPA-run, hospital that provides health care gets into financial difficulties and is forced to close, does it not behove the commissioning body-the publicly run commissioning body-to take over the failing private hospital to ensure that the designated services are available to local people? Is that not an outrageous way of using public money?
Malcolm Wicks: Certainly, I can see that the commissioners might feel that someone had to look after the patients, and the financial implications of that pose another question for Ministers.
Given that the Bill allows for the new commissioning board to make payments to a commissioning consortium if performance is good, what happens exactly to that payment? Who benefits from it? Does it go to improved patient care, which is fine, or to bonuses for those working in the consortiums-the GP practices?
My third set of questions concerns accountability and parliamentary oversight. In this brave new world of competition, profits and privatisation, with the fearsome economic regulator, where does the NHS buck stop? Is the Secretary of State still responsible? Is he or she still accountable to this Parliament? If not, who is? If my Croydon constituent has to wait too long for surgery, are Ministers accountable? Can I ask questions? Will I get answers? If constituents cannot access mental health services, can MPs still expect Ministers to intervene and to act? Are they accountable? Will Parliament and public still be able to access the information, the data, the monitoring and the evaluative statistics to comment on performance? Is the publication and integrity of health statistics guaranteed by the legislation?
A further question concerns the relationship between patients and GPs. The Secretary of State and his colleagues wax lyrical about how decisions will now be taken by GPs and patients, and I remember that refrain during the general election, but what exactly does that mean for patients? How will those decisions be taken by patients as well as by GPs? How will patients be involved in commissioning? Will they be part of the commissioning body?
Moreover, will GP commissioners meet in public, like primary care trusts? If not, why not? Where is the accountability? If a patient wishes to complain about services, to whom do they complain-to their own GP, who does the commissioning? Where is the patient's complaint procedure in all that?
This Bill- [ Interruption. ] There is no point in the Minister just whispering at me. We have a winding-up procedure, whereby serious questions can be answered- I would hope-rather seriously by the Minister. [ Interruption. ] She has not wound me up so far.
The Bill is somewhere between a relapse into market ideology and an untried, untested leap in the dark. For the national health service, it is a fearful time. As we have heard, the Government wish to cut public expenditure, yet they are embarking on this top-down reorganisation that no responsible body seems to welcome.
The Bill will also be shown to be a fearful leap in the dark for the Conservative party, just when in recent years it has been making some headway in convincing the British public that the national health service might be safe with it. It is a fearful step for the Conservatives, and they will learn that in the coming years.
8.14 pm
Andrew George (St Ives) (LD): It is a pleasure to follow the right hon. Member for Croydon North (Malcolm Wicks) and his encyclopaedic questions. I am sure that, from his many years as a Minister, he knows the kind of comprehensive answers that he would like to receive from Ministers. Indeed, I should be interested in some of those answers, so I congratulate him on asking those questions.
Perhaps I should inject a short note of levity into what has been a serious debate so far. I do not have the timing or skills of the late, great Tommy Cooper, but he once told a joke that goes roughly along these lines. A patient runs into a doctor's surgery and says, "Doctor, doctor, I think I've broken my arm. Can you mend it?" The doctor looks at the arm and says, "Yes, I think I can mend it." Then, the patient says, "Doctor, doctor, will I be able to play the piano?" And the doctor looks carefully at the arm again and says, "Yes, I'm sure that you will be able to play the piano." To which the patient says, "That's great. I've always wanted to play the piano."
Doctors often use that joke to emphasise the unrealistic expectations that people have of them, and I have come to the conclusion that there are some unrealistic expectations in the Bill. It is well intentioned and not, as the hon. Member for Eltham (Clive Efford) and others have argued, generated out of malice, dogma or-clearly-ineptitude, but Ministers have perhaps allowed their enthusiasm to get the better of them. There can be no disagreement with the principles that underpin the Bill, in particular greater clinical and patient involvement and driving the quality of innovation, albeit through a number of, admittedly, rather debatable measures. Those are pretty unarguable "motherhood and apple pie" principles that ought to underpin such legislation, but many people are concerned about its timing, when all parties agree that the NHS faces one of its biggest ever challenges: the biggest savings it has been asked to make in its 62-year history. At the same time, however, I see the measures as the biggest shake-up of the NHS in its 62-year history. The Bill is well intentioned, but for it to proceed and not damage the NHS it needs further major surgery in Committee before it returns to the Chamber for Report and Third Reading.
We need to look at reforming the reforms themselves as part of a constructive approach to engagement. It is not that PCTs are the be-all and end-all of future health service delivery; far from it. No one will die in a ditch to defend them, but, given the institutional architecture that they have provided, after many years of coalescing around and amalgamating the primary care groups that were their heritage, we should establish the default
position of assuming that we stick to that coterminosity and structure and then graft on wider clinical involvement. Many GPs in my constituency clearly tell me that they are going ahead with the measures before us more out of resignation than enthusiasm for solely GP-led clinical involvement in commissioning. A lot of them are telling me clearly that they want wider clinical engagement. If there are already 141 pathfinders covering just half the population of this country, at the very least there will be somewhere in the region of 300-that is, 300 chief executives against 152. There is a risk that that will generate a great deal more bureaucracy than exists at present in the PCTs.
I am not persuaded by the level of democratic accountability of the wellbeing boards. Monitor will set a maximum tariff and then promote competition, which could easily put quality at risk for the sake of price. That view is shared by many authoritative bodies.
Many questions still need to be addressed-protecting the integration of services, ensuring the accountability of Monitor and looking at the power of the NHS commissioning board. For those reasons, and a number of others that I do not have time to explain, I cannot support the Government this evening.
8.19 pm
Rosie Cooper (West Lancashire) (Lab): I am delighted to follow a fellow member of the Health Committee. I, too, am looking forward to the answers to the very many questions asked by the Select Committee that were not answered comprehensively. The issues have been elucidated today by my right hon. Friend the Member for Croydon North (Malcolm Wicks) and my hon. Friend the Member for York Central (Hugh Bayley), so I will not rehearse the arguments again.
I fear that today marks a watershed in the future of the NHS, and I say that as one who has proudly dedicated 30 years of my life to the service. Today is the day that the broken promises of the Tory-led Government will lead us down a path that, sadly, will end with a broken NHS. I characterise the Department of Health's policy position on the most far-reaching reforms since the inception of the national health service as, "Don't ask us about the detail; we haven't made it up yet." I am not sure what is more worrying-not having the detail or now seeing an outline of what the Tory-led Administration plan to do with the national health service.
I do not know why it took so long to bring the Bill to the House. It cannot be because of extensive consultation and discussion with professionals and advisers, because we cannot seem to find any body willing to own up to advising or having had discussions with the Secretary of State about the future direction of health services. If he had had such discussions, he would have heard the resounding message that his reform package is not what the NHS needs right now.
We should have built on the best in an evolutionary way. Instead, the Secretary of State has inflicted on the NHS a massive structural change while it has to cope with the Nicholson challenge, which we are led to believe are the 4% compound cost savings for the next four years. As David Nicholson acknowledged to the Health Committee, the scale of the productivity challenge is huge and has never been done on this scale either in
the NHS or elsewhere in the world, and it is all taking place during a transition into the new NHS commissioning world.
It now transpires that the feat that the Health Secretary set for the NHS has been made even more improbable-some might say, impossible-to achieve because of decisions being taken below the radar. For example, there is the reduction in the market forces factor, which means a reduction in some NHS hospitals' budgets. Instead of the 4% that the Government have talked about, the reality of the cuts to some hospital budgets is closer to 5%, and perhaps even 5.5% in some cases-mission impossible.
At the same time, we hear about wards having to be closed because of budget cuts. The NHS Confederation says that some hospitals might need to close under the reforms. Yet this weekend's newspapers talked about the Department of Health having meetings with private sector providers who have 10,000 beds at their disposal.
When will the Secretary of State stop peddling myths and start dealing with the reality, before it is too late for the NHS? The Bill will deliver a service that is low on accountability and high on autonomy. I do not have time to go into this in detail, but I am certainly not persuaded by the accountability measures in the Bill. I am not convinced by the wellbeing boards, local healthwatch or national HealthWatch. We have no evidence that they will be able to deal with accountability or respond to patients themselves. The issue is very clear. If we as Members of Parliament want to ask questions, whom should we ask?
As far as I am concerned, the Secretary of State has a nice little soundbite that he often wheels out-"No decisions about me without me". Government Members have stated that over and over, but have not demonstrated any evidence base for it. To me it is clear: the fundamental principles of the Bill are about taking decisions "about me without me". I am really not persuaded by the democratic accountability provisions. A whole series of decisions have already been made about my health care, our health care and this nation's health care-and they have been made without us.
It has taken until today for us to be able to debate these proposals properly, and in six minutes I am not able to deal with the points that I should like to cover. This Bill comes to us now after many of the fundamental decisions have already been taken and are being implemented. It is a set of short-term measures that will have long-term consequences for the future of the NHS, the quality of health care, and the accessibility of services available to people in communities across this country.
The Prime Minister and the Secretary of State deny breaking their promises, but like the emperor and his new clothes, they can fool themselves for as long as they like, but they are not going to fool the people. As people's services disappear, as they wait longer for their operations, and as things get more difficult, they will know who to blame, and Government Members will really need to worry about it. Last time I spoke in this Chamber on health matters, I accused the Secretary of State of glibness; today, I accuse him of hubris.
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Dan Byles (North Warwickshire) (Con): I am grateful for the opportunity to speak in this debate, and declare an interest in that my wife is a general practitioner.
It is an oft-stated fact that the NHS holds a special place in the hearts of British people. That is why it is so important that this vital institution is managed effectively and sustainably so that our children and grandchildren can continue to use and rely on it in the years to come. However, the problem with the cherished position that the NHS holds is that it makes it difficult to discuss and debate its future dispassionately. It is extremely important that we in this House are able to discuss NHS reform sensibly and without the hyperbole and hysteria shown by the shadow Secretary of State in his opening remarks and by the hon. Member for Eltham (Clive Efford), whose frankly disgusting remarks were not worthy of this Chamber.
The previous Government, who undertook considerable, frequent and, dare I say it, well-intentioned reorganisations of the NHS, found that each reorganisation was opposed by a variety of interests for a variety of reasons. Although they spent too much time reorganising the bureaucracy of the NHS, and generally adding to it on each occasion, I welcomed some of their reforms and am happy to say so, with the notable examples of foundation trusts and the greater involvement of private and other providers. In too many cases, however, previous reforms took the form of shuffling the management deck chairs. Strategic health authorities and primary care trusts were reorganised and reorganised again, often before the ink at the top of the old letterheads had dried, while the number of bureaucrats soared relentlessly.
The challenges faces by the NHS are considerable, and to deny the need for further change is dangerous. Cost pressures within the NHS are rising. This has, in part, been driven by the blunt way in which the previous Government pushed up health spending without insisting on robustly improving outcomes alongside that increased spending. As a result, we have seen productivity fall-a trend that must be reversed if the NHS spending model is to be sustainable. That health care inflation has also been driven by outside factors. Costly new drugs and treatments, coupled with an ageing population, have created serious challenges and will continue to do so.
A hard-headed analysis of these demographic changes has led the coalition Government, rightly, to commit to ring-fencing the NHS from Government spending cuts and guaranteeing real-terms increases in NHS spending-a commitment, I might add, not matched by Labour. With the privilege of a ring-fenced budget comes a responsibility on the side of the NHS to maximise productivity and efficiency to ensure the best possible clinical outcomes for patients within that budget settlement.
Mr Anderson: If it is a ring-fenced budget, why does the Royal College of Nursing believe that there will be 27,000 fewer nurses in a year's time?
Dan Byles: The NHS budget is going up in real terms every year, as the hon. Gentleman can see by looking at the books. We are all aware that the system we inherited had ongoing problems because of the high management costs and other structural problems within the NHS. There will be no shortage of nurses as a result of any underfunding by the current Government-I can assure him of that.
Stephen McPartland (Stevenage) (Con): Does my hon. Friend accept the figures from the Royal College of Midwives showing that in 1997 there were more midwives than managers in the NHS, and in 2009 there were 18,000 more managers than midwives?
Dan Byles: I am grateful to my hon. Friend for making the point exactly. The NHS cannot carry on with management levels and layers of bureaucracy of the kind that the previous Government put in place. With an ageing population, it is even more important that the largest possible slice of the NHS budget is spent on patient care, and as little as possible on management and administration. Reform of the commissioning process is central to that.
The Bill has been criticised by Opposition Members for doing something that Government Members have been critical of in the past: reorganising the management structures yet again. However, anyone who looks at the Bill honestly and dispassionately will see that it does not reorganise NHS management structures, but sweeps away a whole tier of NHS management structure. It is not another round of shuffling the management deck chairs, but a bonfire of some of those management deck chairs. I strongly welcome the fact that the Bill abolishes primary care trusts and puts general practitioners in charge of commissioning services on behalf of their patients. I criticise nobody who works within PCTs, but I freely criticise the structure that puts health care commissioning in a bureaucratic body that operates at arm's length from patients and doctors.
I am conscious that many hon. Members still wish to speak, so I will draw my remarks to a close with one plea to the Minister. I understand that under the new GP commissioning process, GP consortia will, in effect, be given control of two budgets: the budget for clinical services and a small budget to cover the management costs of taking over the commissioning process. I also understand that they will not be permitted to transfer unspent funds from the management budget to the clinical budget. If my understanding is correct, I urge the Minister to reconsider that restriction. In giving the consortia a budget for management that cannot be transferred to the clinical budget, there is no incentive for them to drive down their back-office costs. For the process to work most efficiently, GP consortia must have an incentive to drive down their back-office costs in the knowledge that it will allow them to spend more on their patients. To do otherwise gives the incentive to use up the management budget regardless of need-to hire that extra secretary, not because there is a need, but because the budget is there to do so. Such unfortunate incentives from central Governments over the years have led to many productivity problems throughout the public sector and to a use-it-or-lose-it culture. I urge the Minister to look again at that restriction, which seems to go against the new culture of efficiency and responsibility for budgets that we are trying to instil across the public sector.
8.32 pm
Margaret Hodge (Barking) (Lab):
I speak both as Chair of the Public Accounts Committee and as the MP for Barking. As PAC Chair, my concerns have not been allayed by the evidence sessions that we have held on these issues. I do not want to be saying in three years' time, "I told you so." I urge the Government to think
again before they introduce changes that have not been thought through properly, that are incredibly risky, and that could result in long-term damage.
There has been insufficient focus on the risks of the changes. The NHS chief executive said in evidence that
"the risk is higher. If you try and reorganise, the risk becomes higher. I think we'd be kidding you to say that it wasn't".
Making Monitor an economic regulator forces it to concentrate on competition, not quality. Its purpose will be to drive down costs, not drive up health outcomes. If the spotlight is on price, the risk is that patients will lose out. The NHS chief executive agreed in his evidence that lowering tariff prices could endanger patients. Opening the health market to any willing provider will undermine the viability of many NHS foundation hospital trusts, which face immovable fixed costs, such as their private finance initiative costs. Again, that risk has not been assessed properly.
The Government appear to be driven by an ideological mission. The NHS needs pragmatism, not dogma. I fear that there is no firm grip on the costs of reform. The NHS already faces the unprecedented challenge of finding £20 billion of savings and its record is poor. Over the past decade, despite assurances to the Treasury, NHS productivity declined, with hospital productivity declining by 1.4% annually. The NHS should therefore concentrate its efforts on the enormous financial challenge, and should not be diverted by an unprecedented organisational challenge. Quality and productivity, not reorganisation and privatisation, should be the priorities.
Robert Flello (Stoke-on-Trent South) (Lab): My right hon. Friend is making a good-quality speech, as usual. Surely in areas such as Stoke-on-Trent, where the cost of laying people off in the PCT will be tens or hundreds of millions of pounds, the risks that she describes already exist.
Margaret Hodge: Indeed, and I was going to come to that point. As I understand it, Ministers have set aside £1.7 billion to finance their reforms, but as my hon. Friend says, if the costs of redundancy are higher than planned, or if people carry on attending A and E rather than seeing their GP, the costs of reform will spiral and front-line services will have to be cut. I am not convinced that Ministers have transition costs properly under control.
Nor has anybody sorted out to our satisfaction the issue of accountability for public money. For instance, foundation trusts are supposed to be directly accountable to Parliament. With 167 trusts accountable to the PAC and the House, if there is financial failure or poor quality of care, will that accountability be good enough? In the past, Monitor could sack the board of a trust, but under the Bill it will lose that power. How can we hold the permanent secretary to account when there is a plethora of new quangos or new responsibilities for quangos? We have to know where the buck stops. I seek Ministers' reassurances tonight that there will be clear, practical accountability that enables Parliament to hold the Executive to account.
The Government do not have effective plans to deal with failures, and there will be failures-hospitals bankrupt, GP commissioning consortia overspending. Ministers must explain how they will deal with failure, so that local services will be maintained even when trusts and
consortia collapse. So far, officials have been unable to provide us with the confidence that we need to feel that the Government have got a grip.
That matter is of particular importance to my constituents. For years, our NHS trust has been in terrible trouble, and last week it was named and shamed by the Audit Commission for systematic failure on its finances. It has failed to balance its books for years, and it has a projected deficit of £29 million this year. The quality of care has deteriorated, too. In the week of the general election, 99% of people at our King George A and E and 92% at Queen's hospital were treated within four hours. By 2 January this year, that had dropped to 83% at King George and just over 61% at Queen's. More than 1,000 people were forced to wait for more than four hours, ambulances were queuing around the block and all but the most urgent cases were turned away. In one case, a patient died because she was sent home.
That hospital trust is not fit to become a foundation trust. Despite a stream of new chairs and chief executives, the underlying problems persist. Now, the only answer that NHS London has is to try yet again to close the A and E at King George. That is health vandalism at its worst, with patients' needs sacrificed at the altar of financial cuts.
What would happen to my constituents under the proposed NHS reforms? King George A and E would go, forcing my neediest and poorest constituents to spend hours on three buses to get to a hospital. Queen's hospital would become unviable, and what then? Where is the local hospital ready to meet local needs? Who would want to consider merging with a hospital trust struggling with an impossible financial burden, and even if anyone did, would they ensure that our services remained local? The current health care reforms should put the patient at the heart of the NHS, but it does not feel like that is happening in Barking. I urge the Government to think again before they act to damage the health care of the people who need it most, the people I represent here in Parliament.
8.39 pm
Dr Sarah Wollaston (Totnes) (Con): It is easy to see why politicians continuously want to fix the NHS. The perspective from the green Benches is very different from the perspective one gets as a GP-I say that having worked in the health service for 24 years. My surgeries and postbag, and I am sure those of other Members, are full of stories of delays, frustrations and sometimes really poor practice. The trouble is that not enough people write to their MP to tell them how sensitively or compassionately they have been treated, or how the NHS saved their life. They do feel those things, however, and they do appreciate the NHS. That is why they are understandably wary of any changes, proposed by whatever Government.
Here are the things in the Bill that I welcome. I really welcome clinical leadership. We should be in no doubt about this: there is clear evidence that commissioning works best when there is clinical leadership backed up by excellent management. The Bill will go some way to pushing us towards true clinical leadership in all parts of the NHS.
The provisions will also result in an information revolution. That will involve information about not only whether someone's treatment worked but what the
experience was like-a kind of TripAdvisor for the NHS. We all know that, with information, daylight is the best disinfectant. If people know that their performance is going to be compared with that of others, that is likely to drive up performance in the NHS.
The provisions will allow for that early scan that can make all the difference in an early diagnosis of cancer. When GPs can commission very good early diagnostics much more quickly, we will see a difference. The changes will also give GPs much greater flexibility to respond to their own area. In Devon, for example, community hospitals are really important, but they might not be so important in inner cities. The provisions should also give better choice to services such as mental health, and bring in opportunities for the voluntary sector. I recently met a group of carers for patients suffering from mental health difficulties, and they told me that they wanted better access to talking therapies. Rather than the support that has traditionally been supplied to them, they want better access to other kinds of support. I also really welcome putting public health back where it belongs, with local authorities.
Our spending now matches the European average, and I genuinely congratulate the Labour party on that, but I am afraid that that has also been a wasted opportunity. It is unforgivable that so much of that money was squandered, and that we have seen flat-line productivity. For that level of spending, patients should be able to expect the kind of services that people receive in France or Germany. I am sure that we have all heard instances of people coming back from a holiday on the continent with a minor condition, having had a scan and treatment within a week. We should be able to deliver that here. Health care workers should not have to spend three weeks chasing down a patient's results. I am sure that we have all heard instances of that, as well.
The challenge is to improve aspects of the NHS, to look at the detail, to listen to patients and professionals and to ensure that we get this right. In Torbay, they have been getting it right for some time. It has been part of a national pilot of integrated care. Baywide, a not-for-profit company of local GPs, commissions health and social care from a pooled budget.
Sarah Newton: My hon. Friend mentions GPs working together on a not-for-profit basis. Does she share my huge disappointment at some of the terribly derogatory comments made by Opposition colleagues about GPs' motivation, comparing them to the worst kind of bankers in the City? Is it not disappointing that they are so disrespectful to GPs?
Dr Wollaston: I agree with my hon. Friend. We have heard some terrible slurs about GPs profiteering and lining their own pockets. I am absolutely confident that that is not what we are going to see.
Torbay has been highly successful because it has pooled budgets and it can design integrated care. That saves lives and money. No one should be in any doubt that improving the quality of care, and thereby the quality of life, for those with complex, long-term conditions is the key to improving health care and cutting costs.
Andrew George: My hon. Friend talks about the role of GPs in cutting costs. I would be interested to hear whether, from her experience, she believes that the introduction of price competition-in which a maximum tariff would be set, below which there could be competition -will be helpful, or does she believe, as many authorities and other bodies do, that it is likely to put quality at risk?
Dr Wollaston: I am very confident, because I have discussed that question with the Secretary of State, who has assured me that the reforms are about competition not on price, but on quality. All doctors know that if they get it right the first time, they provide not only better care, but better value care.
GPs and PCTs throughout Devon are rolling up their sleeves and getting on with the job in hand, but to deliver the undoubted benefits of integrated care, they need to be able to work closely with colleagues in hospital, as well as with people in the community, to design those logical pathways. As I just mentioned, the Secretary of State has reassured me on the question of price versus quality competition, but it would help to spell out explicitly in the Bill that that will be protected. Professionals are understandably scared, and I hope the Minister will make the position absolutely clear in his winding-up speech.
Commissioners will not feel liberated if they are liberated from the Secretary of State but shackled to Monitor. Fundamental to the outcome of the reforms will be the powers of Monitor. I should like those powers to be carefully constrained in the Bill, so that it does not take on an unintended role. Focusing on quality and not on cost would help to bring all the professionals back into thinking that this is a positive step forward, because that remains a concern.
Mr Graham Stuart: My hon. Friend rightly emphasises quality ahead of cost, but surely both should be considered. In a time of constrained budgets, it is entirely right that commissioners use a service of comparable quality, which can deliver for patients at a lower cost, when they can find one, precisely so that they have additional funds available to look after other patients.
Dr Wollaston: I am confident that commissioners will consider the impact of those decisions across the health care spectrum, which is very important.
In the limited time I have left, I should like to ask the Secretary of State to consider how we will monitor the quality of primary care. Who will be responsible for performers' lists, audit, and identifying poorly performing doctors? As I understand it, all GP contracts will be held with the NHS commissioning board. What powers will GPs within consortia have to deal with those whom they feel are underperforming if they have no control over their contracts? What will be done about the ongoing, disgraceful situation regarding doctors from the EU with poor English skills, over whom we have few powers to protect patients until there has been a problem?
Professionals are also concerned about the make-up of consortia. Will they have the flexibility to include consultants and other specialists-
Mr Deputy Speaker (Mr Lindsay Hoyle): Order. Time is up.
8.48 pm
Mr Geoffrey Robinson (Coventry North West) (Lab): I am pleased to follow the hon. Member for Totnes (Dr Wollaston), who speaks with a great deal of experience in such matters. The House will share her aspirations for the positive involvement of GPs in commissioning, for the improvement in the provision of secondary care by involving primary care, and for the organisation of primary care. Those aspirations may be shared, but the Government's hopes, and the evidence on which they are based, of carrying out this huge reorganisation and achieving its alleged aims are flimsy indeed.
In the history of Government-led reorganisations-it little matters whether they are bottom-up or top-down-this reorganisation is massive. The former Health Secretary, the right hon. Member for Charnwood (Mr Dorrell), referred to the view of the NHS chief executive. He said that the Nicholson challenge is to carry out successfully such a huge, large-scale reorganisation in the time proposed-the two challenges that need to be pulled off. I think I quote Nicholson accurately when I say that the first challenge is to do in four years something so massive that it can be seen from the moon-together with the great wall of China-and that that would be unbelievable. The second challenge-the other inherent part of the two-part challenge-is that that has to be done while achieving a 4% reduction in costs over four successive years; and
"To pull of either of these challenges would therefore be breathtaking; to believe that you could manage both of them at once is deluded."
I do not know why David Nicholson is still in his position. I do not know how the chief executive of the national health service can think that the Government must be deluded to put forward a proposal such as the one that the Secretary of State has proposed and remain in his place, but he clearly does not believe it. I do not want to cast any aspersions on the Secretary of State's mental health, although I note that the editorial of the last edition of the British Medical Journal read:
"What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad."
Government collective responsibility obviously applies.
It is difficult to understand why the Secretary of State is going down this route, because there is no evidence that these sorts of reorganisations-top-down, bottom-up-in the health service or anywhere else bring the benefits, cost reductions and performance improvements expected of them. If any Government Members wants to correct that, I will willingly give way, even in the limited time available. However, there simply is no evidence for it. Indeed, the National Audit Office, in looking at nine reorganisations carried out in the last five years of the Labour Government, found no evidence at all. They all cost far more, and the benefits, so far as they could be identified, were much less.
Similarly, it is pretty obvious that the something like 15 structural reorganisations, particularly in primary and secondary care in the health service, were not successful either. We only have to read through them. Kieran Walshe has described the bewildering array of forms and structures put in place to run primary care and commission secondary care- [Interruption.] I see that anybody who does not agree with the Secretary of
State is dismissed automatically-that is a sign of hubris and is not a good approach. A similar approach was taken towards Professor Appleby, who was dismissed as someone of no importance. Yet these are people who are looking at the facts-Appleby looked at improvements in the health service. The conclusion is that
"there have been family practitioner committees, health authorities, GP fundholders, total purchasing consortiums, GP multifunds, primary care groups, primary care trusts, and external commissioning support agencies."
I freely admit that a lot of those came from the Labour Government. However, I cannot imagine why the Government refuse to learn from our mistakes. That applies also to one of the most serious developments in this whole proposed reorganisation relating to the introduction of price competition. It is feeble of the Government Front-Bench team to say, "Well, your Government intended to do it, so we are going to do it." They spend hours every day criticising everything the Labour Government did. This is one thing they did not do-apparently they intended to do it-but suddenly it is so welcome that the Government insist on doing it. The fact is, however, that it will happen.
We have a huge change but with no evidence that it will bring any good; we have the fact that the NHS has to make savings that nobody believes will be achieved; and we have the fact that we are opening it up to competition. The position of the consortia becomes very questionable, as does the position of the NHS commissioning board itself. Other Members have raised these points. What sanctions have been provided for? To whom will the consortia report? Is the Secretary of State abdicating any responsibility for their performance? It is not clear from the legislation, as far as I can see-there are 61,000 words of it-what the Government's role will be in the control, functioning and performance of these new boards.
8.54 pm
Priti Patel (Witham) (Con): I am grateful for the opportunity to speak in this important debate. I congratulate the Secretary of State and his ministerial colleagues on this landmark piece of legislation, which I welcome for fundamental reasons that are specific to my constituency. This legislation will put patients and medical practitioners at the centre of the NHS, putting an end to the era of bureaucracy and mismanagement seen under the previous Labour Government. As my hon. Friend and neighbour the Minister will be aware, patients in my constituency have suffered for a considerable period. They have had their care compromised by the excessive layers of NHS bureaucracy that, as far as I can tell, the Opposition seem determined to keep. I have endless examples of where such bureaucracy has had a devastating impact on the very patients whom the NHS is there to serve.
Late last year I raised with the Leader of the House a case involving a teenage girl in my constituency who had been experiencing unacceptable delays in receiving an MRI scan. She was unable to eat, and basically went from being a healthy teenager to being completely bedridden. Despite needing the scan to help to diagnose her condition, she had to wait for more than a month while her case was being handled-incompetently, I should say-by administrators and managers. The delays were exacerbated by what the local PCT described to me as a "broken pathway". It was only after the matter
had been raised directly with the Secretary of State in the Chamber that she received the scan and has since received medical treatment. However, the delays have compounded her illness. Three months later, that young lady is still in a critical condition. Cutting back on such bureaucracy, investing in the front line and giving patients and their doctors more power will prevent such incidents. Instead of managers hiding behind "broken pathways", we can have doctors held to account by their patients.
I also support the Bill because it will help my constituents to receive the treatment and the drugs they need. As the Secretary of State will be aware, in recent months two constituents of mine who suffer from multiple sclerosis have contacted me because two PCTs-Mid Essex PCT in one case and North East Essex in the other-have refused to allow them the prescribed drug Sativex on the NHS, yet both have prescribed the drug to other residents. My constituents' doctors have recommended the treatment, yet management and bureaucracy are again standing in their way, and in the way of common sense and the essential health care that my constituents need. Instead of receiving that treatment, they are now having to wade through a convoluted appeals process, which naturally makes them feel extremely despondent and disappointed, as the NHS, which they have supported through their taxes, is letting them down. They believed that they would get the care that they needed when they needed it, and never expected that the requests of their doctors could be ignored in that way.
I want the Government's reforms to be introduced without delay. Indeed, it will not surprise the Minister or the Secretary of State to learn that, as far as I am concerned, the abolition of the PCTs in 2013 is still a bit too long to wait. I would like it to happen sooner rather than later. I would therefore like the Minister and Secretary of State to accelerate the process and remove that fundamental layer of bureaucracy, which is a barrier to delivering positive health outcomes to my constituents. I would also like the Minister to ensure that PCTs play their part in facilitating an orderly transition to GP consortia, as he will be aware that Mid, North East and West Essex PCTs have come together to form a cluster, with one chief executive. It is now a large organisation that is responsible for a lot of public money.
I have since discovered that between now and 2013, those three PCTs have a target to reduce management costs-that is completely welcome and long overdue-by £13.9 million; they currently stand at some £37 million. However, I should add that that figure is still significantly lower than the £20 million of combined savings that were previously agreed for each PCT by the strategic health authorities. I mention that because that money would naturally make a fundamental difference-a tremendous difference-to those patients being refused treatment on the grounds of cost. When we hear the Opposition questioning whether GPs will be able to handle NHS budgets, they need look no further than the resource-intensive PCTs, which not only need to go, but frankly need to go sooner rather than later.
Because of the shortness of time, I want to highlight one more thing. It is irresponsible of the Opposition to justify the ever-increasing layers of bureaucracy that have been associated with the NHS. I welcome the Bill, which is long overdue. I want to see the patient's voice
put first, greater accountability for public money and proper commissioning of local services. For a new constituency like Witham, that is vital when we face a crisis of out-of-hours health care provision. Fundamentally, the Bill is important because it will put patients first, which, as I said, is long overdue.
9 pm
Joan Walley (Stoke-on-Trent North) (Lab): I am pleased to speak briefly about this Bill; I know that many Members on both sides of the House still want to contribute to the debate. It seemed to me that not to speak in this debate would somehow mean not being true to the important issues surrounding the NHS. I have listened to the debate and heard some good constructive comments, but I do not think we have gained a sense of what the NHS was like when I was first elected almost 25 years ago. At that time, people simply could not get treatment because of the underinvestment during the years of the Conservative Government. As for the point about organic change and building on what has been done, it seems to me that this Bill, lengthy as it is, is doing away with the step-by-step improvements that have been made.
Robert Flello: I look forward to hearing more of my hon. Friend's speech, which I know will be to her usual high standard. Does she agree that, since 1997, Stoke-on-Trent has seen the building of the first new hospital for 140 years, a brand-new oncology unit, a brand-new maternity unit and health centres developing everywhere? Is that not real investment under a Labour Government, which never happened during the previous 18 years of the Conservative Government?
Joan Walley: What we have seen is the university college of North Staffordshire linked to the medical college at Keele. We have never before seen that kind of medical training going on outside London in areas like Stoke-on-Trent. Hayward hospital has been rebuilt and there has been investment in clinics and a huge increase in the number of staff. That does not mean just bureaucrats-like everyone else, I do not want to see unnecessary bureaucrats. I am talking about the number of health personnel trained to do their jobs and to treat people, which has been second to none-despite what the Minister says.
Mel Stride (Central Devon) (Con): In looking at NHS performance, should we not seek to compare ourselves with international equivalents today rather than with the past? If we look at coronary heart disease, for example, we find that we have twice the death rate of France, and we are also lagging behind the rest of Europe on cancer outcomes.
Joan Walley: I am coming on to public health, as it is the main issue on which I wish to concentrate.
Mrs Jenny Chapman (Darlington) (Lab): In response to the intervention on the recorded death rates from coronary heart disease in France, I want to observe that France makes much more frequent use of the "unknown" category in the recording of deaths. I have been led to understand that this goes some way towards explaining the apparent difference in death rates between the two countries.
Joan Walley: Statistics can be used in all kinds of ways. I remember the case of a young girl of six who could not get the heart surgery that she needed, even when we had invested in those facilities. The important role of public health is relevant to heart disease, and we need to focus on what can be done to prevent ill health. This Bill is very short on detail in that area, which is why I want to concentrate on it.
I want to stress that what we are seeing in this Bill is dogma. We are replacing the primary care trust layer with the GP layer, but the GPs will not be able of themselves to provide the clinical leadership of which we have heard. They will have to engage with equally bureaucratic agencies or companies to do that work for them. My fear is that the clinical leadership element will get lost when the new provisions come into force.
The provisions will not allow us to build on the work of the previous Government, which did so much to improve aspects of the NHS. I accept that the new Government have come into power and that they have a remit, but that means that they should get what they do right. I fear that what will happen as a result of the Bill will be destructive. I am afraid that it is also risky. We have already heard about the need for pilot projects. Why can we not wait for a proper evaluation of those projects before rushing ahead with a move that might cause us to throw out the baby with the bathwater? What safeguard will we have against that?
I fear that when the public realise that the Bill is not fit for purpose and will not achieve what is claimed for it, they will be not saddened but angered by the knowledge that they will no longer be able to raise issues for which the Secretary of State has previously had responsibility. The Bill will merely transfer responsibility, and it is easy to see who will have that overall leadership and where direct accountability will lie. The hon. Member for Stafford (Jeremy Lefroy) will probably wish to raise issues relating to Stafford hospital. It is important that when things go wrong in hospitals, there is full transparency. When everything is done on a commercial basis, that transparency will not exist in the new health service that the Bill will introduce.
The Government say that the Bill will end inequalities. I am old enough to remember the resource allocation working party, and the "distance from target" money that was to help areas such as Stoke-on-Trent which had received the least investment in health and experienced the most illness. I am not convinced that the Bill will continue that work. Stoke-on-Trent primary care trust is currently £30 million short of its target, and it is difficult to see how the Bill will make amends for that.
Realising as I do that the devil is often in the detail, I want to raise two more points. The first relates to public health. Speaking as an honorary vice-president of the Chartered Institute of Environmental Health, I am well aware that the public health consultation that has invited responses later this year will not be co-ordinated with the legislative changes in the Bill. Will the Government take account of the need for the institute to look in detail at the way in which public health will be integrated with local authorities across the board? That is critical if we are to improve public health services at all levels.
My second point relates to a private Member's Bill of mine. I have heard that, through the Government's Bill, the Prime Minister will require hospitals to improve nutritional standards. We all know that poor food leads
to ill health. I hope that Ministers will consider the proposals in my Bill, and think about ways in which hospitals could serve food that was of high standards rather than food that is often linked to ill health. That in itself could make a major difference to people's health.
I have many other concerns which I have no time to mention, but let me say finally that it is not clear how the Bill will secure the investment in dentistry that is currently needed.
9.8 pm
Mr John Leech (Manchester, Withington) (LD): I am delighted to have an opportunity to speak, given the number of Members who wished to contribute. I will keep my comments brief.
We should all recognise that NHS staff do a great job in looking after our health and well-being, and are constantly striving to improve provision. I refer not just to front-line health workers, but to the office staff managers and professionals who are not always referred to so positively by either politicians or the media. However, we must also recognise that the NHS must continue to improve and do a better job in order to keep pace with rising health care needs. The question we must ask is whether the Bill will allow the health service to continue to improve.
Some positives have come out of the proposals. For too long, unelected officials have made decisions about local health care without listening to local communities, handing contracts for GP practices to private firms or even closing hospitals with local people locked out of decision making. In my constituency, under the previous Government, the PCT closed Burnage walk-in centre without any consultation. It said that this was to save money, despite the centre being more cost-effective than other walk-in centres in Manchester. This was part of the £20 billion efficiency savings demanded by the previous Labour Government. More recently, the PCT has temporarily closed Withington walk-in centre, again without consulting anybody who uses the service. So it is to be welcomed that the Government will not allow a service reconfiguration where the public have not been engaged and where it will reduce people's health care options locally.
It is also to be welcomed that private sector providers will be expected to appear before local authority health scrutiny committees-that did not happen under Labour's less democratic system. However, I urge the Secretary of State and Ministers that if private providers remain reluctant to participate, they should be mandated to appear before health scrutiny boards. Getting information on how providers are performing out into the open can only help to improve health outcomes and accountability.
The Lib Dem manifesto promised an end to the rigging of the market in favour of the private sector that we had seen emerge under the Labour Government. The Labour Government pushed for more NHS work to be given to private hospitals, regardless of local decisions on whether it was right for them. Much of the concern about the Bill centres on reforms being seen as being about the break-up of the NHS. Such a view is wide of the mark, because in many ways the proposals will level the playing field for the NHS, which was distorted under the previous Labour Government. They guaranteed that for-profit providers of elective surgical procedures running independent sector treatment centres
would be paid a certain amount, regardless of how much work they did, and allowed PCTs to make supplementary payments to new private sector providers to make services more attractive to new entrants. Unfairly stacking the system in favour of the private sector and against public provision was wrong. We cannot allow certain providers to be handed work regardless of what patients want and regardless of the quality of the services provided. I hope that the Minister will confirm that preferential payments and guaranteed payments for new private sector providers will end. Can he also confirm that there will be no target for the proportion of work undertaken by private sector providers, unlike under the Labour Government?
However, there are still areas of concern and many questions remain unanswered. I would be grateful if the Minister explained what will happen to existing PCT-owned provision? Locally, in Manchester, the Labour party has claimed that the PCT-run Withington community hospital will close under these proposals. Of course that is simply not true, but questions do remain over who will own and run the community hospital. When I met the chief executive of Manchester PCT, she made it clear that the new proposals give real scope for widening and expanding provision through the community hospital, but she remained unclear on the model of ownership. I would be grateful if the Minster cleared that up.
Unlike Labour Members, I have no ideological opposition to the idea of allowing hospitals to extend their private provision. Private provision has been extended at the Christie hospital, in my constituency, which is providing millions of pounds of extra each year to be reinvested in NHS provision, which surely is a good thing. However, I would be grateful if the Minister assured the House that where private provision is extended, it will not be at the expense of NHS provision. We should allow hospitals to extend private provision-in addition to existing services and certainly not instead of them-so that more money can be reinvested in the NHS.
Questions also remain about the cost of the implementation of change. Manchester used to have three PCTs, but they were merged into one to save money. The new consortia will go back to using the "three model", and I am not convinced that that will save money. There is also a concern that intense competition for providing services that existing hospitals provide will take away resources and make it more difficult for NHS providers to maintain services or to invest in new technology and equipment. I have run out of time.
9.14 pm
Geraint Davies (Swansea West) (Lab/Co-op): I am glad to be called to speak at this hour, Mr Deputy Speaker. It is my joy to celebrate the achievements of the health service that was started by Nye Bevan from Wales and to celebrate the successes of the previous Government, such as the 2 million extra people a year who are now operated on, the 44,000 extra doctors and the 94,000 extra nurses. The question to ask is: why devastate and break a system that already works well?
The Bill risks stripping out the heart and mind of the NHS, in terms of equality and planning, and replacing it with a market of GP business consortia that will focus
increasingly on profit maximisation through negotiation of the best prices, bulk purchasing and threatening to withdraw custom from hospitals that cannot survive without them. Huge health retailers will evolve with local monopolies over patient communities. It is all very well saying that patients will have choice, but there will be big consortia saying, "This is what is best for you-buy this", focusing on the areas of highest profitability. Those consortia might prefer to deal in cataracts rather than, for argument's sake, chronic conditions. They might choose to focus in certain demographic areas with different health trends. A business focus will be applied according to the returns that can be gained in different areas rather than simply focusing on what is right for each person.
Neil Carmichael (Stroud) (Con): Is it not possible that doctors' consortia will simply make the right decisions for patients, focusing on giving proper value for money and decent care and on responding properly to local requirements and needs? Would not that apply across the piste in terms of community hospitals and acute hospitals?
Geraint Davies: The taxpayer invests in GPs to provide medical and clinical excellence so that they can diagnose people's health problems. The taxpayer does not invest in them to become small business people who go around trying to maximise profit and work out rates of return on different sorts of health care. That is the problem with introducing privatisation and marketisation: the thought in the back of the business person's head is how to make money, not simply what is the best diagnosis. The customers whom GPs are facing-patients-are to a large extent ignorant. It is not like buying electricity from npower: patients do not know what is wrong with them. They are in the hands of their GP and they do not know whether what they have been prescribed-perhaps a cheaper drug that makes a higher profit but is not as effective-is right: they just have to guess.
Mr Graham Stuart: Rationing is inevitable in any system, but who should best do it? Should remote managers do it away from patients' needs, or should GPs do it in a way that involves managing and being aware of a budget but trying their best, within that budget, to deliver the best health outcomes for all their patients? Who is better-PCT managers or GPs?
Geraint Davies: A GP must always ask what the best treatment for the patient is rather than what the best treatment for their business's profitability is. That is why this is fundamentally wrong.
Geraint Davies: I shall not give way.
The Bill is setting up an incentive system that will make GPs make the wrong choices. It will return the NHS to a sort of pre-Nye Bevan, atomised system of health, rather than a planned system that uses resources efficiently. The system will lend itself, in the new era, to duplication, profiteering, businesses going bust and waste. What is more, there is no political mandate for the Bill; it is a Trojan horse of privatisation that no one knew would come. The changes will probably cost £3 billion
or £4 billion to administer and will clearly set us back a number of paces before we move forward-if we do move forward.
A few people have mentioned the excellent work of John Appleby, the chief economist of the King's Fund, who wrote in the British Medical Journal that the rate of deaths from heart disease is falling much faster here than in any other European country. It is falling to such an extent that it will be lower than the rate in France by 2012 even though we are spending 28% less. In terms of relative efficiency, we are doing well. Breast cancer rates have fallen by 40%, compared to 10% in France. I am not complacent and I do not pretend that there should not be greater productivity. If I had to point to one area in which there should be greater productivity, it would be the fact that we pay GPs too much money. That is the fault of the previous Government for negotiating a situation in which GPs can make more and more money. Now, it seems, we are encouraging them along that track, as though making a load of money were the primary focus.
My basic point is that if it ain't broke, don't fix it. Reform, yes: breaking the system, no. The Bill is not evidence-based. We are hurtling ahead, although people do not know the likely downside-the duplication, the amount of profit, the failures and possible hospital closures. The Bill is not economically sound or robust.
I have mentioned other difficulties one of which is that we make GPs subcontractors who want to maximise profit. In Wales, there is a move towards directly employing consultants and GPs, as opposed to giving them free rein on profit maximisation. Assuming that the Labour party wins in the Assembly election in May, we will see over the next five years the emergence of parallel systems, one of which will be a modernised version of the traditional health service and the other a marketised system. There is a conflict of interest between the profit motive and patient care, particularly in chronic conditions.
If aggregate supply is to be provided by a group of GPs, as opposed to a PCT, there is the risk of local shortages-of flu vaccines, for example. There might be local shortages in one area and excess supply and waste in other areas because of the absence of a strategic plan to deliver the right aggregate and match supply and demand.
In terms of customer and consumer watch, something called HealthWatch is to be introduced. Given the Government's record in getting rid of Consumer Focus and bundling it in with Citizens Advice, I have little faith in the effectiveness of HealthWatch in looking after patients who, as I mentioned, are relatively ignorant of the product they are offered and face a local monopolist.
With reference to lifting the cap on private patients, as my right hon. Friend the Member for Croydon North (Malcolm Wicks) said, there is a risk that BUPA, for example, might suddenly funnel a lot of its patients in one direction because of discounted purchases, crowding out patients in a certain area. That would lead to unpredictability in the system.
We are asked to believe that the abolition of 150 PCTs and 10 strategic health authorities will miraculously save us some 45% of current expenditure. The people of Wales will make the right decision in May.
9.23 pm
Julian Sturdy (York Outer) (Con): It is a privilege to be called to speak in today's debate at such a late hour. I shall try and keep my comments as brief as possible to allow other Members to get in.
Alongside the economy, crime and employment, the performance of the NHS and the provision of local health care is of the utmost importance to most, if not all, people. Health care is rightly viewed as an indicator of a community's well-being, prosperity and happiness. I know that some hon. Members may disagree, but I firmly believe that all elected Members, on both sides of the House, share a genuine desire to protect and enhance our NHS. Unfortunately, party politics too often comes into health debates. I fear that some Opposition Members have proved that again today.
We all want to improve our NHS services, cut waiting lists, increase cancer survival rates and improve patient experience. Those are certainly the desired outcomes that my constituents want to see.
I truly believe that doctors, nurses and paramedics carry out tremendous work, often in the most testing conditions. We must get away from the idea that a desire to reform the NHS radically equates to some sort of insult to the commitment, ability and performance of NHS staff, because it does not. I am interested in the Bill's reforming potential because of the conversations that I have had with concerned, exhausted and demoralised NHS professionals.
The NHS is indeed a national treasure, and I can safely say that I will always support it having a place in our society. Such sentiments echo what has already been said by the coalition Government, who from day one pledged to increase spending on health services and shall now do so by no less than £10.7 billion over the course of this Parliament. However, as my right hon. Friend the Member for Charnwood (Mr Dorrell) noted, future demands on the NHS will be unprecedented. Despite the best efforts of NHS staff, our performance has fallen, compared with other countries in the OECD, on respiratory diseases, heart attacks and cancer survival rates. Too much top-down control, too little patient consultation and too many Government-driven targets have brought unsustainable pressures to those on the NHS front line.
Reform is necessary, and it is clear that this broad piece of legislation contains a host of reforming measures. One of the most discussed aspects of the debate is the abolition of the PCTs and the devolving of commissioning to GPs, which I wholeheartedly support. In North Yorkshire, the local primary care trust has been an issue of concern for some time, and in December I secured a Westminster Hall debate on the matter. Concerns from constituents, the voluntary sector and local practitioners were all raised. In essence, the local PCT has in part inherited and in part created a substantial budget deficit running into millions of pounds. As a result, local services such as the provision of back pain relief injections have been withdrawn, impacting severely on the lives of thousands of residents across the region. The local primary care trust's bureaucratic approach highlights the overall failures of PCTs. I could go on, but time is pressing.
I will mention one further concern. Although I welcome the specific reform, I believe that what happens during
the transitional period from PCTs to GP consortia is vital. Services, patients and performance levels cannot be allowed to slip during that important period. I urge Ministers to ensure that all the preparations are in place so that that does not happen.
In conclusion, I very much welcome this truly reforming Bill and pay tribute to the Secretary of State for the work he has done on it. I care passionately about the NHS and its future ability to provide world-class health services for the whole country. I do not believe that it would be morally right to allow the NHS to continue to suffer from top-down, bureaucratic, state-led management. We should and can put patients first, with a flexible health care service that is able to respond to local needs. The Bill will not endanger the NHS, as some Opposition Members might claim, but it will enhance it through the empowerment of patients and local health professionals.
9.28 pm
Mr David Anderson (Blaydon) (Lab): I rise to speak not only as a former official of Unison, the biggest trade union in the health service, but as a former care worker. Like most other union officials who have been bad-mouthed as the voice of conservatism, I have actually worked in taking care of people. Perhaps once in a while the people who have delivered services to the vulnerable, the sick and those in need in this country might be listened to. The last time the Conservatives were in power, they did not listen to the voices of such people about the health service, which is why we saw the introduction of compulsory competitive tendering, which led to hygiene-related diseases. We saw massive waiting lists and people waiting on trolleys in corridors.
I do not want to put my views tonight, but the views of the people who work in the health service, such as my GP, who asked me this morning how, if we are to go through all these changes, he will be able to take the time off to learn business administration and how to use a computer properly so that he will be able to challenge the people who will run his service. The King's Fund says that it questions
"the need to embark on a fundamental reorganisation when evidence shows health outcomes and public satisfaction have improved."
The hon. Member for Totnes (Dr Wollaston) says that
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