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Lord Clement-Jones: I congratulate the noble Baroness, Lady Cumberlege, on introducing this subject. We have already heard three notable speeches. My congratulations are not purely because the noble Baroness quoted from my Second Reading speech—although that is always very welcome.
One of the points on which many of us agree is that the Government's scheme of devolution as set out in the Bill is inadequate. That has been pointed up in the speeches so far. The inexorable centralisation that has taken place in the NHS over the past 10 years will not be reversed by the terms of the Bill as it stands.
We have only to look at the position of the chief executive of the NHS over the years. We had Sir Andrew Foster, followed by Sir Alan Langland, followed by Mr Nigel Crisp. If we look at the way in which each of those individuals carried out their job and the constraints to which they were subject, it is extraordinary how much more centralised the NHS became in that period and how more power has gone to the Secretary of State. The Secretary of State has progressively taken more power over the NHS, mostly in the name of performance management but also in terms of funding. That has been the case in every single area of the NHS. Discretion at local level has been reduced inexorably over time.
A number of previous speakers have referred to the plethora of targets. The taunt which the Government like least is being accused of micro-management. But micro-management is what this Government do. As the noble Baroness, Lady McFarlane, made clear, it leads to a loss of morale. If professionals do not have a discretion to operate and are constantly subject to intervention, that leads to a loss of morale. I agree entirely that the structures proposed in the Bill will not lead to the liberation of the health professions. They will lead to more constraints. In that respect, the Bill is
entirely flawed. One has only to ask the question: what will the Bill do to boost the morale of those who work in the health service? The answer is: very little, if anything. Therefore, the grounds on which the amendment is based are extremely strong.Clearly, any scheme of devolution of responsibility for the NHS must be genuine. The current scheme proposed by the Government actually gives more power to Ministers rather than less. On those grounds, I do not believe that it is a genuine attempt at devolution. For devolution to be effective and genuine, there need to be one or more strong, accountable bodies responsible for health service strategy, supervening between government and local delivery. There also need to be geographical entities with clear and common boundaries, which would enable joined-up strategy with a range of other public services, such as housing, education, transport, environment and social services.
In the view of the Liberal Democrats, those conditions are clearly met by regions. When regional assemblies are created, a further benefit of accountability would be met. Regional health authorities or regional assemblies would have the critical mass to ensure sufficient expertise in specialist commissioning and public health, where the new structures in the Bill give rise to particular concern.
That is one model. There is clearly a need for further debate. I have a great deal of regard for the work of the King's Fund and its recent report, which has been mentioned by all the previous speakers. It is a very thought-provoking piece of work, which does not necessarily exclude other regional models of organisation. In particular, its emphasis on the need for decentralisation of real power to acute trusts and PCTs is important, as is its perception that the NHS is over-politicised, too centralised and lacking in responsiveness.
I am not yet convinced that a single, monolithic, quasi-government body is a great deal better at the top level than the one we have at present. We need to think of a more varied and diverse model. That is why I believe that we should go for the regional model. Directionally, the King's Fund report and the amendments are right. However, in addition to the structure of devolution, there needs to be a clear commitment at the same time to simplification of our structures and of our clinical governance procedures. That would help morale enormously. A great difference would be made not just by the structures, but by their quality and simplicity. On Second Reading I quoted 21 different methods of clinical governance by which health professionals are governed. We have to simplify that to make a difference.
There is a great deal more to debate. The Liberal Democrats have made no bones about our belief that the Bill is premature in the way in which it tries to tackle current NHS structures, introducing a half-baked solution to the issue of devolution and the need to increase the morale and autonomy of professionals and managers. There is a whole debate to carry on. As
I said on Second Reading, the Government should take away their structural proposals and allow that debate to continue.5.45 p.m.
Baroness Carnegy of Lour: It is not clear whether the Liberal Democrats are in favour of the amendment or of the Government's idea. The noble Lord seemed to speak in favour of both sides. Perhaps we should not be too surprised by that—I am not sure.
I was not able to speak on Second Reading, but I listened to a lot of the debate, including the speech of my noble friend Lady Cumberlege, and I read the rest with enormous interest. There is a great deal to discuss on the Bill. My noble friend Lady Cumberlege, who moved the amendment, together with the noble Lord, Lord Desai, and the noble Baroness, Lady McFarlane, who amplified what my noble friend said so ably, have done a great service to Parliament by highlighting the root cause of the mess that the National Health Service is now in. There are many problems, but the root cause is undoubtedly that there is too much involvement of Ministers in the running of the National Health Service.
I am told by people who work in the National Health Service—including some in Scotland, although we are not discussing Scotland—that, as one would expect, the points made by the noble Baroness, Lady McFarlane, are accurate. There is a widespread view among professionals in the National Health Service that that is the problem. People do not talk about the problem out loud because they do not know the answer and they do not want to upset Ministers, naturally. They cannot suggest anything positive, so they do not express that view.
The King's Fund has done a great service in analysing the situation and coming up with a similar idea. I was involved in the universities during the period when they were adjusting to the fact that the Government were not dealing with them directly, but doing so through the funding council. I was also involved with further education colleges when they stopped working directly with local authorities and their funding moved to a funding council. It took a bit of time, but the effect was not far from miraculous. I am sure that the noble Lord, Lord Desai, will confirm that people at all levels began talking realistically, sensibly and responsibly about how they were spending their money and, in the case of universities, how they could preserve academic freedom within that process.
The Scottish funding council is on such good terms with the universities that there are no complaints. Having said that, I suspect that I shall immediately get a shoal of letters, but I have noticed that the universities are really rather pleased with how the system is working. Imagine what a similar system would be like in the health service.
The National Health Service is an enormous organisation, with 1 million employees. It is ridiculous to think that it can be run centrally. It would of course
be ridiculous if an agency such as that proposed by my noble friend tried to do that. However, the agency would not have the imperative to do that. The criterion for its success would be that the National Health Service operated gradually better for patients and professionals and that everybody felt freer to run the thing in the right way. The agency would not have to be doing things every day, along the lines of Mr Blunkett's philosophy of "An initiative a day or a day wasted". That is what currently happens in the National Health Service. The system would not depend on new initiatives; it would depend on the ability of the agency to show that it had arranged things in such a way that everybody was taking responsibility better. Then it really would be possible to devolve, because there would be no pressures not to do so. The Government would have no need to be frightened, because under my noble friend's proposals the Secretary of State would be able to place constraints on the agency if he felt that he had to do so.The proposal should be taken very seriously as a possible way forward. The Government should not find it too difficult. Although they have not come up with the suggestion, it has clearly been rumbling around as an idea in the health service for some time. If the Minister has "Reject" written on his briefing notes, I hope that he will not follow that line, but will stand up like a very experienced man and accept that a lot of wise things have been said—not by me, but by people who know much better than I do what they are talking about—and that the idea should be followed up. I support the amendment.
Baroness Pitkeathley: I am a great admirer of the noble Baroness, Lady Cumberlege, and of the King's Fund, but I am afraid that I am not able to support the amendment. My view, which sounds heretical in the context of this debate, is that there is no getting away from the fact that the provision of healthcare is a political issue. As long as the noble Baroness and others ask questions such as, "Is the taxpayer getting value for money?"; as long as we have a health service that is funded out of general taxation, to which we are all committed; and as long as patients are represented by the political process, we cannot take politics out of the NHS. At least we cannot depoliticise the strategy of the NHS. We can, however, depoliticise the running of the NHS.
The Bill offers us the opportunity to do that because of its emphasis on primary care and putting most of the power at primary care level. We have been saying for years that power in the NHS should be as near as possible to the patient and his or her family. I think that the Bill will do that. Primary care trusts will make it much more possible than ever before to achieve the sense of ownership that the noble Lord, Lord Desai, described, and to help patients become more responsible for their own health. The "inexorable centralisation of the NHS" described by the noble Lord, Lord Clement-Jones, also can be dealt with by devolving power to primary care trusts, where patients will have much greater access and much greater control. That is also what the NHS professionals want.
Nowadays, whenever one speaks to NHS professionals, almost all of them—with the exception of one or two old pockets of resistance—say that the real emphasis must be on what patients want. As that is what the professionals want, I think that the proposals will deliver both improved morale and improved delivery.
I have one other concern about the amendment. I hope that, as we make progress on the Bill, because it is an NHS reform Bill, we shall not forget that the NHS is inextricably intertwined with the provision of social care by local authorities and others at local level. Although the point is made explicitly in the unfortunate term "bed blocking", it obviously also arises before the patient is admitted to hospital. In addition to health care provision, social care provision is enormously important. I do not know how the amendment would address that issue, which remains a concern for me. I oppose the amendment.
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