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My first question to Her Majesty's Government is: why, for heaven's sake, when a tenant does not reply to their letters for month after month, does a housing authority not do what an ordinary person would, in common decency, and send someone round to see if

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he is all right? That would have saved a huge amount of money let alone anxiety. Of course, computers do not have common decency unless it is programmed into them-we are talking of institutionalisation here.

Your first reaction to the eviction notice is to go round to St Mungo's to see whether it will find room for you and to make a small pile of essential belongings to take with you-but at last, and with encouragement, you go to your local authority customer advice centre. The lady at the desk is kind, knowledgeable and patient. Your benefit has stopped because the system shows that you are getting working tax credit. You reply that you would not qualify for it and are not getting it in any case. You are asked to prove it. Nobody explains how you can do that, even if your Post Office account had not already been closed. A second lady, equally kind and knowledgeable, joins the first and rings the Department for Work and Pensions, which says that it can only discuss it with you in person, so you speak to it directly, giving your correct address and correct date of birth. "No", it says, "That is not what we've got on our records", and cuts you off.

The ladies now agree that it looks as if somebody else is getting the money. They advise you to apply again for benefit and to apply to the court for a stay of execution of the warrant. Close to tears, you take the ladies' advice and go to the local police station to report a suspected crime. You aren't very welcome. The person receiving you, who is not in uniform, tells you from behind a plate-glass window that if there was a crime you are not the victim and sends you to an airless waiting room, furnished only with a bench. The door, which can only be opened remotely by someone else, closes behind you-and there you wait with nothing but anger and depression to occupy you for one hour and 52 minutes while other, later arrivals are called forward to interviews ahead of you.

Eventually two courteous policemen, having taken lengthy advice, confirm that you cannot be recorded as a victim of a suspected crime. This has taken a total of two hours and 40 minutes. Is that normal? Or could it be that this treatment is because you are black and your obvious accomplice, a do-gooder who wants to see what treatment you get, does not declare himself as a Member of your Lordships' House? I leave the question in the air, perhaps to be picked up by the Metropolitan Police.

With the welcome help, which I acknowledge, of the then Minister, the noble Lord, Lord McKenzie of Luton, a senior official in DWP agrees to take an interest, accepting the probability of identity theft. Meanwhile, you get and complete the application for a stay of execution and, on Thursday the 30th, less than 24 hours before eviction is due, you get it, somewhat out of breath, into the court office. It costs you £35 and, for someone with feet like yours, it is a £2 bus ride away from home. You, too, are expected to spend money you have not got.

The bailiffs are now temporarily in baulk, but tomorrow you have to persuade the court to leave them there. On that day you learn that DWP's involvement has enabled your local authority to resume paying your housing benefit. This does not give you spending money but it

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does pay your rent and offer the prospect of payment of arrears in due course. That is not enough for them, though-they still want you out. Luckily, unlike many, you have been able to obtain the loan of a substantial amount, interest-free, as a subordinate debt. Offered this, the local authority agrees not to object to your application for delay. That afternoon, the court gives you six weeks in which to get things sorted out. Long enough, you think.

How wrong you are. It takes all of that to get from HMRC, which pays WTC, a letter for the court admitting that it had been paying WTC to someone else. Unfortunately HMRC compounds the difficulty by confusing your identity with that of the man who stole it. Eventually, in mid-August, the court orders payment of arrears at £3.25 a week, which in your circumstances is a significant amount, and suspends the warrant. It still hangs over your head today.

I skip a whole nine-month rollercoaster ride of other difficulties till we get to May this year when, reassessed and transferred to ESA benefit, your housing and community tax benefits are automatically stopped. That is how it works. It ought to take six weeks to get them restored but, although you fill the form in at once and it is taken in over the counter at the Jobcentre where you fill it in, it somehow gets lost and the money is not there in six weeks. The suspended warrant is threatened and you are again told that you are going to be evicted.

In fact that friend of mine is still in place, and is now in receipt of benefit, but I ask my noble friend only my second question: can the Government possibly do anything about this, and will they accept any help that I can give them to get it done? I am talking not about that individual case but about the system that allows these things to happen.

4.03 pm

Lord Patel: My Lords, I congratulate the noble Earl, Lord Howe, on his well deserved ministerial appointment. When it comes to health policy, he is undoubtedly the most experienced member of the health team, having done the job in opposition for over 10 years and seen off several Ministers in that time.

On several occasions I have heard the Secretary of State, Mr Andrew Lansley, speak of his vision for better healthcare, and I have had an opportunity to discuss with him how the quality and safety of healthcare can be improved. I believe him to be concerned about the poor quality of care and to have a genuine commitment to making it better.

The gracious Speech outlined several areas where government legislation is to come. The Coalition: Our Programme for Government outlined several areas of possible health policy changes, many of which I find myself in support of, including the creation of an independent NHS board, a department of public health and a greater voice for clinicians and patients. While we have to wait for the legislative details, I hope, as a Cross-Bencher, to continue to help to improve the legislation in these areas.

While I believe reducing administrative costs in the NHS by a third to be right and possible, I am disappointed not to see mention of specific cost savings in the coalition manifesto. I hope the Government will look

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again at the role of strategic health authorities, their current size and budgets, and their function, particularly following the creation of the NHS board, and at the National Quality Board, the Care Quality Commission, the role of Monitor, PCTs and other organisations. There is also a need to look at the number of PCTs, which is currently in the region of 152. The number could easily be reduced to 30 or 40 and, given enhanced powers, they would bring efficiency and cost reduction.

The coalition Government's health programme outlines quality and safety of healthcare to be important in delivering better outcomes. The key driver to achieve this will be the quality of commissioning, so the first and foremost task will be to develop good commissioning for quality and safety. Currently both are woefully done. Commissioners should be expected to promote quality and safety improvement. They should ensure that provider quality accounts-published by healthcare providers-properly reflect the concerns of patients and the public, and are properly scrutinised. Commissioners should provide assurance that the services commissioned are of appropriate quality to detect early warnings of potential decline, and intervene where standards are not met. Commissioners should be responsible for improving the scope and effectiveness of quality and safety. They should also promote innovations, with financial incentives and penalties for patient-safety incidents defined as "never events", similar to those operated by Medicare and Medicaid in the United States. Poor quality and unsafe patient care is expensive. The key to delivering high-quality, safe care is good documentation, as I witnessed recently in several hospitals in the United States.

The Government also intend to bring in GP-led commissioning and to improve the quality of general practice. I hope that, in doing so, account will be taken of lessons learnt from previous experience of GP-led commissioning to ensure that the prime purpose of commissioning will be to deliver benefits to the patients and efficiency savings; and to ensure accountability of public expenditure. Can commissioning GPs be accountable officers, as CEOs are in NHS trusts and PCTs? Does the Minister agree that greater clarity is required in the respective roles of regulators, commissioners and the National Quality Board in promoting and ensuring quality and safety?

The Government's commitment to tackling health inequalities is very welcome. However, the key determinants of poor health are economic and social. To succeed will require effective working across several government departments-a key test for the coalition Government. There is in the Government's programme for health a distinct lack of any mention of public health and preventive health measures, apart from the creation of a department of public health. Could the Minister comment on which policies the Government will bring in to reduce harm related to alcohol, tobacco and nutrition? Increasing obesity, related to the high sugar and fat content of foods, now affects nearly 30 per cent of children. The high salt content of ready-made foods accounts for significant health problems in the older population. What is the Government's strategy in these areas?



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I finish on a positive note. I find nothing wrong in the ambitions of the Government's health programme. I hope we will now have appropriate legislation and policies to deliver it. Cutting bureaucracy and useless administration, and delivering safe patient care in a safe environment, with more of the care delivered by competent professionals, will-to borrow a phrase that the Minister may well recognise-deliver,

I hope the Government commit themselves to that.

4.09 pm

Baroness Sharp of Guildford: My Lords, I shall concentrate my remarks on education. The opening words of the gracious Speech state:

"My Government will seek to build a strong and fair society".

As the noble Lord, Lord Hill, reminded us in his opening speech, that fair society depends a great deal on education. I was rather surprised at how well the coalition of the Liberal Democrats and the Conservatives managed to put their two education policies together. The noble Baroness, Lady Morgan, referred to the pupil premium. Some years ago, I travelled with Nick Clegg to Holland to look at the way in which the Dutch funded education. We found that disadvantaged children were given special extra funding which they carried with them as they moved from school to school. The pupil premium was based very much on the research work that we carried out on that expedition and I was delighted to see that it plays a substantial part in the policies which the coalition is putting forward.

I am also pleased at the emphasis that we are giving to rolling back bureaucracy. Both parties agree that schools and colleges-and universities, for that matter-are overwhelmed by bureaucracy. Last year a seminal report was produced by the Merits of Statutory Instruments Committee, which found that each year the average head received well over 700 pieces of paper comprising directives and guidance. That is roughly three for each working school day and is an impossible amount to manage. When I inquired of a local comprehensive school head how much time he allocated to interpreting the bureaucracy that he received from the centre to his staff and parents and governors who needed to know about it, he said that on average he thought it took him roughly half the week, which is an astonishing amount of time. The more that we can roll back that bureaucracy and allow our school leaders and teachers to give time to front-line services, the better it will be. It is important that we, as a Government, practise what we preach. It is too easy to talk with one breath of freeing up teachers from bureaucracy and then to declare with the next that they must use synthetic phonics to teach reading.

I confess that I am also somewhat worried at the thought of Ministers laying down the law on what the history curriculum should be, even if they call in eminent historians to advise them. We were very worried by what Stalin and Hitler did to the history curriculums of their countries. I am not suggesting that democratic Ministers would behave like that, but it is important to beware of too much political influence over the curriculum.



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The flagship measure of this Government that we shall see within the next week is the Academies Bill. It will not surprise noble Lords on all sides of the House to hear that I have reservations about the Bill as it stands. However, I shall leave my thoughts on the proposals in that Bill until its Second Reading on Monday. I echo the point made by the noble Baroness, Lady Morris of Yardley. If we are looking to create a fair society, it is very important that we concentrate not on structures but on process. Taking the issue of process somewhat further, one aspect of lessening bureaucracy that is agreed is to change the role of Ofsted. The schools that consistently perform well will be inspected less often and, as the Minister mentioned, the Government are proposing to reduce the number of performance indicators. But in that case it is vital that we use the right measures of performance and it is difficult to know what they are, because any school's performance is also closely linked to its socio-economic profile. Our high-performing schools are predominantly in middle-class areas with middle-class intakes. Poorly performing schools serve disadvantaged populations. It is this gap in performance that both the coalition and the previous Government have sought to close, and will seek to close, so that there is genuine equality of opportunity.

It is no good just whipping the schools to produce better SATs and GCSE results. First we must find a way of compensating those coming from disadvantaged homes for the disadvantages that they suffer; hence the importance of programmes such as Sure Start, and the children's centres frequently associated with Sure Start, which combine education and parenting. Programmes such as Every Child a Reader are crucial because they provide one-to-one tutoring for six and seven year-olds who are having difficulty in mastering reading. At secondary school level, it is very important to find and provide a curriculum that excites and motivates those who at present are often turned off by the overacademic approach of GCSEs. Diplomas were supposed to be the answer to this problem, but I worry that, as currently developed, they are too much of a hybrid, satisfying neither the vocational nor the academic side of education. This is why I am very excited by the prospect of university technical high schools that the noble Lord, Lord Baker, spoke about. They would combine first-class vocational training with dedicated equipment and teachers, but keep open the door both to jobs and to higher education. That seems to be a much better way forward than shunting pupils around from school to college for the odd half day here and there.

Education remains the key to unlocking our potential. The UK must raise its game, both to maintain international competitiveness and to help to build a society that is fair and more at ease with itself. This is recognised within the coalition agreement by the priority given to education, and the ring-fencing of the schools budget. There are real savings to be gained from reducing bureaucracy and concentrating managerial resources on the central tasks of teaching and learning; but let us not waste these gains on fruitless restructuring. Rather, let us give our teachers and school leaders space and time to innovate and excel.



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4.17 pm

Baroness Murphy: My Lords, I, too, warmly welcome the noble Earl, Lord Howe, to his role on the Front Bench. I am sure that he will forgive me for saying that he has been practising diligently for this role for more than 10 years. We now have a Secretary of State and a Minister leading in the Lords in health who have a solid understanding of health policy. That is a great good fortune for those of us who work in this area. While I suspect that parts of the policy are still a work in progress-social care is probably the fuzziest at present, and I hope that noble Lords were listening to the noble Lord, Lord Sutherland of Houndwood, on this point-I welcome strongly the direction set down in the gracious Speech, and the indication that we shall now speed ahead to reverse the unhelpful dithering and procrastination of the past two years.

I declare an interest as a member of the board of Monitor, the NHS foundation trust regulator, and chairman of St George's Hospital Medical School, University of London-although not for long, as I am retiring this summer from both roles. The future agenda is exciting, both for improvements in healthcare and for the impact that such policies are likely to have on health sciences education. I welcome and will support the intentions of the forthcoming health Bill. The coalition agreement, based on pre-existing Lib Dem policy and the Conservative Party publication NHSAutonomy and Accountability, is entirely welcome.

First, I will highlight the news that research into the dementias has become a government priority. This is music to my ears, as it is my specialty, and makes economic as well as clinical sense. I look forward to seeing how it will be effected in reality, given the inevitable pressures there will be on research council funding.

I welcome strongly the intention to complete the shift to a health system where decisions are made locally by patients and professionals rather than centrally, to complete the separation of commissioning and provision, to get all hospitals to foundation trust status, to improve the information available on the quality of care so that better decisions can be made and to put the setting of incentives in the system on a more professional basis by establishing an independent economic regulator of health care. For a system of tax-funded healthcare to be sustainable in the long run, we need better incentives and more local decision-making and innovation. These changes will be very helpful for that.

There is now incontrovertible evidence that competition between hospitals and between service providers improves both innovation and health outcomes if the system is well regulated to ensure a financial level playing field and the quality of care is subject to rigorous monitoring and improvement. Too often in the past, the internal market was left to its own devices and subject to central interference. It worked to keep down costs but did not necessarily improve quality. The BMA and other professional bodies have been rightly critical of it. However, recent evidence from the Centre for Economic Performance at the LSE and other independent studies by US-based researchers of health outcomes in heart disease treatment in English hospitals have confirmed that a properly regulated market has a positive effect

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on outcomes, including saving lives-about 400 lives in heart disease treatment. This is especially true when clinicians are in real and powerful leadership roles.

I am sure that we will have many happy hours scrutinising the details as the Bills come before the House. We do not yet know what some of these details will look like. In particular, I do not really understand what the relationship will be between a national commissioning board and local GP commissioners. Finding the best way of organising how we spend £100 billion on healthcare continues to be the most significant unresolved question in the reforms. Commissioning decisions need to be made at a sufficient scale to support the right level of analysis and expertise but also close enough to the clinicians who actually make the spending decisions to influence their behaviour and to reflect local circumstances. How will we prevent groups of GPs from delegating their commissioning to junior administrative staff, as they consistently have done in the past? The benefit of small-group GP fundholding has proven extraordinarily difficult to replicate on a larger scale and I look forward to hearing how that can be done.

How will we get all hospitals to foundation trust status? Only half the acute hospitals and three-quarters of mental health services have so far managed to demonstrate that they are sufficiently financially robust and well governed to stand on their own feet and to operate independently. Strategic health authorities have truly struggled in preparing applicants, so we will need a better approach to help the remaining trusts to get up to the required levels of competence. FT status is not about achieving some label; it is about putting the management and finances of the trusts on a sound footing for the challenges ahead.

Will FTs be subject to Treasury spending controls? If so, this will significantly reduce their freedom from central interference and undermine the intention of the Bill to allow more local decision-making. A way of preventing that would be to adjust the FT regime sufficiently to allow the trusts to be taken off the Government's balance sheet. We could have, as an alternative to Treasury controls, strong regulation and a clear failure regime to ensure sound finances.

I am challenging the Government to show the kind of bravery that will really move the health service forward. When the Blair Government took office, they had some very good ideas and it is not surprising that the new Government are trying to improve on those good ideas. However, the Blair Government did not implement them quickly enough-it took them five years to get started-and latterly the policy sank into the doldrums, besieged by old party slogans. Although this Government now have the opportunity to act, they must truly get on with it. They cannot improve care directly; only front-line clinical staff can do that, as the noble Lord, Lord Kakkar, said in his maiden speech. However, they can provide the structural context in which improvement of care is likely. I disagree that all structural change is unnecessary or unhelpful. Sometimes structural change is necessary to ensure that something completely different is delivered. In this case, I think that we should continue the structural changes that have been begun but do so more quickly. Therefore, I urge the Government to go as fast as they can; it is our health and our lives that are at stake.



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4.24 pm

Lord Warner: My Lords, it is a great pleasure to follow the noble Baroness, Lady Murphy, with whose speech I largely agree. The Government would do well to take heed of many of the remarks that she and the noble Lord, Lord Patel, have made.

I shall speak today on adult social care and the NHS but, first, I congratulate the two Ministers on their new appointments. As one of the Ministers that the noble Earl, Lord Howe, has seen off, I congratulate him on his strong grasp of health and social care. Even when he was skewering me as a Minister, it was always done with elegance and with a sense of doing so in the best interests of the NHS.

I greatly enjoyed the maiden speech of the noble Lord, Lord Hill. It reminded me that it was one of his former boss's ideas on GP fund holding that I pinched and turned into practised-based commissioning. I have never owned up to that publicly but this seems an appropriate occasion to do so.


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