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After Gordon Brown’s announcement in the summer that the Government would be doing away with top-down targets from Whitehall, it is somewhat extraordinary that the biggest target of the lot—the 18-week referral to treatment target—is still something that Ministers are pursuing so doggedly.
Labour Ministers often claim that this is the first Government to recognise and to tackle health inequalities. I happen not to agree with that. But how are they doing it? One of the public service agreement targets in 2004 was to reduce health inequalities by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth. Using the figures that we have so far, both measures have got worse, not better—that is to say, worse in terms of the gap that exists between the least affluent groups in society and the population as a whole. Again, the constant raiding of public health budgets cannot possibly be conducive to achieving these targets.
What about staffing? Last spring we had the debacle over modernising medical careers. It is doubtful whether any policy failure in the last 60 years has had such a devastating effect on the morale of medical staff as the failure of MTAS. The criticisms levelled at the Government by Sir John Tooke make pretty devastating reading. MTAS has been abandoned but, if anything, competition for training places looks set to be even fiercer next year than it was this year. At PCT level, the Healthcare Commission survey has found over the past four years steadily declining levels of job satisfaction.
Where are we now heading? In July, the Prime Minister gave his vision of the health service by promising,
I have to say, looking at the gracious Speech, that it is hard to identify anything that is designed to take us
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There is nothing wrong with the idea of creating a single regulator for health and social care out of those that exist at the moment; indeed, I remember that when we first debated the creation of CHAI and CSCI I advocated just that. However, one thing we can be clear about: there is bound to be disruption in the regulatory process. If we want a recent lesson in how mergers cause operational disruption, we need only look at PCTs. The Healthcare Commission’s annual health check for 2006 reported that out of all the healthcare bodies, reconfigured PCTs came out worst on quality of services.
Some of us fear that within the new, all-encompassing regulator, the dominant activity will be the regulation of healthcare and that the regulation of social care will emerge as the poor relation. That may happen for a number of reasons, not the least of which is that the business of regulating healthcare has a much higher public profile and will tend to suck funding away from other activities. There are three main ways in which that can be avoided: the way in which Ofcare’s management reporting lines are structured; the way in which its budgets are internally allocated; and the character of the individuals who are in charge. Even though none of those things will feature in the Bill, we will want to be reassured on all of them. By itself, a change of structure does not lead to success; the culture and the people within the organisation do that.
I should be grateful if the Minister, when winding up, could clarify two points about Ofcare. The first is whether Ofcare will have the job of assessing commissioning undertaken by PCTs. The second is whether it will retain the role currently performed by the Healthcare Commission in relation to complaints made against the NHS.
Culture is also a central issue to the reform of the GMC. In many respects, it is possible to argue that the culture change within the GMC has already taken place under the able leadership of Sir Graeme Catto. The trouble is that, as he has recognised, that change has not been enough to satisfy the public. Despite the fact that lay people now make up 40 per cent of the council, public perceptions of the GMC are of a body that, in the final analysis, looks to protect its own—hence the proposals that are coming before us.
There are perhaps two main areas of contention in the proposals. The first is the disappearance of the professional majority on the council, which some regard as the death knell of professionally led regulation and standard setting. The second is the change from the criminal to the civil standard of proof in fitness-to-practise cases. Personally, I am unsympathetic to the first complaint, but I am by no means unmoved by the other. The fear is that the change will lead to defensive and unadventurous medicine.
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We are assured that in very serious fitness-to-practise cases the civil standard of proof will amount to “beyond reasonable doubt” under the so-called sliding scale. We are also told that six out of the nine professional regulators already use the civil standard without apparent problem. Yet we know that, in the family courts, child protection cases are judged on the balance of probabilities precisely because unacceptable risks must not be taken with the safety of the child. We will want a lot more detail about how the sliding scale will operate in practice before we can feel relaxed about it, especially as decisions in fitness-to-practise cases will be taken not by the GMC but by a new and completely separate adjudication body.
The backdrop to all this is the question of how we should define professionalism and, in particular, how we should encourage and foster it. Fostering professionalism is achieved not only by the threat of disciplinary proceedings and corrective action; it is also done by tapping into the sense of pride that doctors have in their own performance and by enabling doctors themselves to recognise where they may be falling short. The Minister may be aware of the Maastricht experiment, under which doctors could look at their own performance on a graph. Their performance was measured against that of their peers but was confidential. It would be interesting to know whether anything similar is being contemplated in this country.
It is perhaps good to end on a more upbeat note. I mentioned culture change. One culture change too far would have been to go ahead with the Government’s proposed amalgamation of the HFEA and the Human Tissue Authority. The arguments against doing so were overwhelming and I am glad that Ministers have agreed with the advice of the Joint Committee on this issue. The Second Reading of the Human Embryology and Fertilisation Bill is due shortly and I do not propose to say much about it now; other noble Lords who are more expert in the subject will in any case deal with its provisions. Two matters are, however, likely to occupy us particularly. The first is the whole issue of embryos containing both human and animal material and the ethical considerations surrounding that idea. The second is the extent to which the regulator should be given discretion in judging which entities may be created for research under licence. We may also be occupied, although I hope that we are not, with issues relating to abortion. On this side of the House, the Bill will be debated on the basis of a free vote. It would be very helpful to hear from the Minister that the same will apply to those on the government side.
We have an interesting Session ahead of us. For my part, I look forward to giving what help I can to the task that we are privileged to have: scrutinising the legislation before us and, where appropriate, suggesting improvements. I have more than just a feeling that a few such improvements may be forthcoming along the way.
11.46 am
Baroness Barker: My Lords, it is, as ever, a privilege to open this part of the debate on the gracious Speech on behalf of those on these Benches. I, too,
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These occasions provide a rare opportunity to consider key policy themes, as well as giving your Lordships a chance to probe the Government’s wider intentions behind their legislative programme. This year, it is particularly difficult to do so, in part because much of the attention has already been focused on the detail of the substantive issues in the two pieces of legislation mentioned by the noble Earl, Lord Howe—the Human Fertilisation and Embryology Bill to regulate embryology and the Health and Social Care Bill to merge health and social care regulatory bodies—which have already provoked a great deal of detailed debate. One can, however, detect two themes that have run through the commentary on the gracious Speech. The first is trust: trust in the integrity of science and scientific research; trust in professionals, whose responsibility it is to apply that scientific knowledge to the difficult physical and mental conditions in which human beings live their very different lives; the trust which professionals, clinicians, social workers and teachers place in government to provide the resources that enable them to do their jobs; and, above all, the extent to which people and communities trust government to steward public resources to meet emerging demographic needs.
The second theme is the extent to which professionals have the freedom to pursue what they know to be right for those whom they seek to serve. Those two key issues are difficult to assess in this gracious Speech for two reasons: first, because of the reform of the NHS proposed by the noble Lord, Lord Darzi; and, secondly, because of the future funding of social care. Neither is addressed anywhere in this speech or in this legislative programme. Those two matters are the key backdrop to all that we will discuss over the coming 12 months. Therefore, it is difficult to assess exactly how much the Government can be trusted to deliver high-quality public services.
Resources are the other issue. The Comprehensive Spending Review for 2007 was the worst settlement for local government for 10 years. Although it is true that there was 1 per cent real growth, most of that will be used to meet PFI liabilities. The projections in CSR07 assume efficiency savings in local government expenditure of £5 billion. In the last spending review, local authorities managed to find savings of £3.5 billion. Local authorities currently spend £7.8 billion on social care, but with a growing number of older people and people born with severe disabilities who will have a lifelong need for high levels of social care, there is a real crisis. The crisis is most evident at local level. For the past four years Sir Derek Wanless has told us that we will not be able to assess the state of the NHS and future demand for services until that issue is satisfactorily addressed.
I was interested that the noble Earl, Lord Howe, did not mention the White Paper that the Conservative Party published last week, in which the main proposal is to establish an independent health board for the NHS. I am sorry that he did not
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We on these Benches have realised that the centralised model of public services is exhausted. Now it is the job of politicians who are committed to finding ways of increasing the quality of public services to find ways of enabling the politicians responsible for the resources, the professionals with the scientific and professional knowledge and the people who use the services to engage in a debate about strategy and the deployment of the resources to meet the emerging needs. My colleagues and I are therefore pursuing the idea of establishing local health boards which would be democratically accountable to local communities and would provide a forum in which social and health care needs could be properly addressed. That is the model in other parts of the world, such as in New Zealand, and the idea has much to commend it. It has proved to be successful in tackling health and social inequalities—politicians’ key role in health.
I shall deal with the health and social care aspects of the gracious Speech and my noble friend Lady Sharp will address those on children. As someone whose maiden speech in this House was on the subject of young people leaving care, delivered in a debate initiated by the noble Earl, Lord Listowel, I am delighted to see the inclusion of a Bill dealing with children in care. I know that many noble Lords, not least the noble Earl, will give the Government a hard time over any legislation that falls short of delivering the means necessary to equip these young people for life well after they have left care. As we are beginning to realise from research, those needs continue throughout their lives.
The Health and Social Care Bill has long been trailed, ever since the then Health Secretary, John Reid, announced the merger of the Healthcare Commission and CSCI just after CSCI opened its doors. Many of the Bill’s provisions were debated in your Lordships' House on 18 April, in a very good and crisply focused debate on the document, Good Doctors, Safer Patients. We on these Benches will support measures to improve professional standards and increase public confidence in the medical profession. It would be regrettable, however, if Parliament were to undermine professional self-regulation, which in all but exceptional circumstances is a powerful force exerting discipline on highly skilled professionals and goes far beyond that made possible by formal lay involvement.
There has been much discussion about the Government’s proposal to change the standard of proof for medical practitioners from the civil
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I turn to the merger of CSCI and the Healthcare Commission. As Ministers will be aware, there is widespread concern that this body will be medically dominated and that social care will be the poor relation. Like the noble Earl, Lord Howe, I want Ofcare to be well resourced and to do a good job. In particular, I hope that the new body will be able to clear up one anomaly—that although independent-sector social care providers are subject to regulation, they are not subject to the Human Rights Act. This loophole affects many in residential care and the House should pay due attention to that.
It is self-evident that the system of pre-legislative scrutiny, which we welcomed when it was introduced, has proven its worth in the field of human fertilisation and embryology. I am glad that the Government accepted almost all the recommendations of the Joint Scrutiny Committee. However, one topic remains to be further explored in detail. Individuals have an overwhelming right to know their identity, including their genetic identity. Although this may be a very small part of one’s overall social identity, it is important. We will therefore need to spend considerable time on the issue of how those conceived by means of donors can find out who their genetic parents are. We should not stray from the absolute right of donor-conceived children to know their genetic identity, should they choose to find it.
It is ironic that much of the commentary on the gracious Speech has focused on abortion, an issue that was not mentioned in the gracious Speech and is not actually part of the legislation. The noble Earl, Lord Howe, indicated that there will be a free vote on this issue for those on the Conservative Benches. There will be for us, too. This is one of the most contentious issues and everyone comes to it with their own predisposition. Some are implacably opposed to any measure that would change the law, and others take the completely contrary view. I suspect that many noble Lords, like many members of the public, do not approach the issue from a position that is hard and fast but wish us do something important, once every generation, to consider the changes in science and technology, and to decide the ethical and moral framework within which these developments are evaluated. I commend to noble Lords the report of the House of Commons Science and Technology Select Committee, which examines only the scientific aspects. Noble Lords, particularly those concerned about the crucial issue of foetal viability, will find evidence in the report of which they should take note.
It is also ironic that today we will not be discussing the most important health measure in the Queen’s Speech—the Climate Change Bill, the one measure
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12.01 pm
Baroness Finlay of Llandaff: My Lords, perhaps I may start by congratulating the Government. I have had the privilege to be on the End of Life Care Strategy Advisory Board, and as noble Lords know, I introduced a Bill on palliative care in the last Session which completed its passage through this House. The thrust of my Bill was to ensure that each strategic health authority and trust would have to develop a palliative care strategy and report on it to the Secretary of State. So I am delighted that the Government have already called on SHAs to do exactly that, even though the overall national strategy itself will not be published until the summer. I am also delighted that the Minister has already done so much himself to foster such important initiatives. But if the Government do not maintain universal improvements in palliative care as a central theme, I assure the House that I will be seeking support again.
What was missing from the gracious Speech? Every year, around 200,000 deaths are reported to coroners, but where is the long-awaited coroners Bill? The Government have dropped it for the second year running. There is a need for a chief coroner, a need for full-time medical examiners, and for powers to conduct more effective investigations to detect unnatural deaths. I seek an assurance that the Government will use this time to work with the Royal College of Pathologists and others who want such a Bill in order to iron out the more contentious aspects so that, when it is eventually brought before Parliament, the long-overdue coroners Bill will have a smooth passage.
The gracious Speech made much of the need to harness the workforce. Many want to work part time and thus combine work and family life. The Chief Medical Officer rightly identified the changes in the medical workforce in the chapter entitled “Opportunity Blocks” of his 2006 report. In medicine, around two-thirds of graduates are now women, yet the hurdles remain to block careers. Although within medicine and surgery work already undertaken has identified problems and possible solutions across all the different specialties, that intelligence needs to be brought together to change management attitudes and to make part-time work work. It will solve many problems.
Doctors are needed at weekends and at all times of the day and night, so why not harness weekend and evening working? The Medical Women’s Federation has been calling for each NHS trust to have a bank of registered vetted babysitters who can be called on in an emergency if other childcare arrangements fail, so that the parent can go to work secure in the
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Yet while the working arrangements may keep women in the mainstream of medicine for the benefit of patients, I fear that the proposed changes in regulation of the medical profession may benefit no one. The most damaging proposal is the move from the criminal to the civil burden of proof in cases against doctors. At this juncture, I simply remind your Lordships that the Bristol inquiry concluded:
“The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved. The system of clinical negligence is part of this culture of blame. It should be abolished”.
The report on Bristol went on to say:
“For a culture of openness to succeed, those who work in the NHS must be confident that they will be supported by the organisation at all levels. Openness must be valued and rewarded. Otherwise, healthcare professionals will understandably be reluctant to embrace it”.
Yet the Government’s proposals go towards blame and stigmatisation, which will drive the professionals into defensive practice and encourage cover-up and we will have abandoned the lessons that we so sadly had to learn from Bristol.
The Human Fertilisation and Embryology Bill introduced today will be debated soon. I am deeply disappointed that, with all the talk of creating embryos, there are no proposals to deal with the tidal wave of unwanted pregnancies and teenage pregnancies. Why are there no proposals to make oral contraception available over the counter? The safety data support such a move, so why does it not feature here? This is a topic that I will address more fully at Second Reading.
Another glaring omission is any action on our poor record on intrapartum deaths, which are often unexplained and no longer fully investigated. Our record is considerably worse than that of North America and Australasia.
The Government seem to have ignored large tranches of their own Chief Medical Officer’s report. His excellent report this year highlighted the appalling shortage of donor organs, yet we see no Bill here on organ donation. Last year, more than 3,000 patients had their lives saved or improved by an organ transplant. Of these, 2,385 received an organ from a deceased donor and, in addition, 2,402 patients had their sight restored through cornea transplant. There are currently 7,474 people waiting for organ transplant: 74 of those are awaiting a heart transplant, while a staggering 6,587 are awaiting a kidney. The average waiting time for a kidney transplant is now two years.
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