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House of Lords

Tuesday, 11 October 2011.

11 am

Prayers-read by the Lord Bishop of Wakefield.

Health and Social Care Bill

Main Bill Page
Copy of the Bill
Explanatory Notes
18th Report from the Constitution Committee

Second Reading

11.06 am

Moved By Earl Howe

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, this is a Bill of profound importance for the quality and delivery of health and care in England, for patients and for all those who care for them. As such it has been, quite rightly, the subject of intense scrutiny, not only in another place, but also more widely. Indeed, the intensity of the spotlight directed at its content over the last few months is borne out by the number of your Lordships who wish to speak today and tomorrow. I look forward to the debate ahead of us.

In approaching this Bill, I believe it is instructive to look backwards to its roots as well as forward to what it seeks to achieve. In opposition, the two coalition parties asked themselves the same simple question: "How can we make the NHS better?". In asking that question we were clear about several things. We were clear that the founding principles of the NHS-that it should be a comprehensive service, free at the point of use, regardless of ability to pay, and funded from general taxation-should remain sacrosanct. We were also clear that we should reject any system that discriminated between rich and poor. The NHS should aspire to the highest standards of service for all our citizens, but in seeking ways to make the health service better, it was necessary to identify the challenges that it faces. What are they?

The first, and most obvious, is rising demand for healthcare from a growing and ageing population and the increase in long-term conditions. The second is the rising expectations of patients about what should be on offer to them from a health service in the 21st century, including new drugs and technologies. The third is the financial challenge-the inexorably rising costs of providing services against an increasingly constrained budget.

Two key principles emerge from this analysis: the need for maximum efficiency in the way the health budget is spent; and the need to make the service patient-centred. For many years, politicians have spoken of the NHS as a patient-centred service, but how can a service be truly patient-centred if decisions about the treatments and pathways of care that are available to patients are taken at several removes from those who know best what the needs of patients are-namely, the patients themselves and the healthcare professionals who look after them?

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How can a health service be patient-centred if the measures of its performance overlook what for patients matters most, namely the outcomes that it achieves and the quality of care that patients receive? What of NHS efficiency, when so much of its budget is consumed by layers of administration, when its productivity over the last few years has fallen, and when patients experience poor handovers between different parts of the NHS and between the NHS and social care?

There is a fundamental problem, too, in NHS accountability. The original National Health Service Act 1946 provided for a comprehensive health service, but it did so by employing a simple legal precept-that responsibility for everything that happened in the NHS should lie with the Secretary of State. That may have held good in the 1940s, when the challenges facing the NHS were largely the management of acute short-term conditions, but it does not hold good now. The Secretary of State has for decades delegated his functions for the commissioning and provision of healthcare services to other bodies. The reason for that is simple: managing the range of healthcare needs for our diverse population is now so complex that no one would argue that it is a task best carried out from Whitehall. This has resulted in a vacuum in NHS accountability, with no measures or mechanisms whereby PCTs and trusts can be held locally to account. We in Parliament can only turn to the Secretary of State: he in turn can only give one answer-PCTs and trusts are autonomous organisations, their decisions are taken independently, in accordance with local priorities, and it is not appropriate for these decisions to be subject to interference from the centre. So the fact that the Secretary of State is responsible for making sure that there is an NHS available to all clashes with the fiction-for that is what it is-that he is somehow responsible for all clinical decision-making in the NHS. This results in a poor deal for the person at the centre of things-the patient.

During the last few years, it became clear to politicians of all persuasions that there was another nettle that the NHS had to grasp: the need to improve quality. We know that, measured against accepted benchmarks, the outcomes experienced in the NHS sometimes fail to match up to those achieved in comparable countries. The OECD has reported that if the NHS were to perform as well as the best performing health systems, we could increase life expectancy in the UK by three years.

Towards the end of the previous Government, the noble Lord, Lord Darzi, sounded a clarion call to managers and clinicians around the quality imperative. The focus of the noble Lord's work-to define what quality means and to drive forward that agenda by fostering innovation, transparency, and choice, by strengthening regulation and by encapsulating the rights and legitimate expectations of patients and staff in an NHS constitution-was unarguably right. But his time in office was short. There was much more that still needed doing.

Our plans for the NHS therefore focused on three main themes: accountability, efficiency and quality-keeping at the centre the most important theme of all, the interests of patients. Modernisation of the health

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service, we were clear, had to involve a fundamental shift in the balance of power, away from politicians and on to patients themselves through increased choice and information, and on to doctors and health professionals, giving them real budgets and empowering them to use those resources in a cost-effective way to drive up quality. That shift would have two advantages: it would serve to depoliticise the NHS; and it would promote efficiency and quality by making those who take clinical decisions on behalf of their patients responsible for the financial consequences of those decisions. Both GP fundholding in the 1990s and, more recently, practice-based commissioning showed that empowering clinicians directly could improve the quality of care that patients experience. The potential is truly enormous: allowing doctors, nurses, hospital specialists, social services and other professionals the freedom to design care pathways that are integrated, and to commission them on behalf of their patients, will, we firmly believe, transform the quality of care and treatment that the service delivers.

At the same time, the clinicians on whom this greater autonomy is bestowed should be held accountable as never before-not only for their use of public money but also for the outcomes they achieve for patients. Unlike the largely illusory accountability of the present system, we were clear that doctors should be held to account in a transparent way by the patients and the communities whom they serve. Success and failure have to be measured in better and more meaningful ways, by reference to outcomes, not processes. For their part, elected politicians should be held accountable in a dual fashion: first, to Parliament, for the performance of the health service as a whole, defined principally in terms of outcomes; and, in parallel, for directly overseeing and delivering the public health agenda so critical for the long-term health of the nation-an agenda which, too often, has tended to assume a lower priority for government at times when the NHS budget has come under strain.

The fruits of this deliberation were laid out in various Conservative and Liberal Democrat publications from 2006 onwards, including a White Paper, in our manifestos at the last election, the coalition agreement and, finally, a government White Paper from which this Bill directly stems. The democratic mandate for our proposals is absolutely clear.

This brings me to the amendment tabled by the noble Lord, Lord Rea. It is important that we remember what the Labour Party manifesto said on health at the last election:

"We will continue to press ahead with bold NHS reforms. All hospitals will become Foundation Trusts ... Failing hospitals will have their management replaced. We will support an active role for the independent sector working alongside the NHS in the provision of care ... Patient power will be increased".

Even Labour accepted at the last election that doing nothing is not an option for the NHS. Many of the principles in this Bill were ones that they wholeheartedly embraced. But the nature of the change must be different. Instead of putting in tiers of management and controlling everything from the centre, we are removing bureaucratic structures so that the front line is empowered as never before to deliver better patient

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care. This Bill achieves that by means of a better framework which allows power to be devolved from the centre so that innovation is unleashed-

Lord Clinton-Davis: Why was none of this mentioned in the Conservative manifesto at the election?

Earl Howe: I commend the manifesto to the noble Lord because our plans were very clearly set out in it. It allows power to be devolved from the centre so that innovation is unleashed from the bottom up, supported by clear lines of accountability. It is, in fact, the inverse of a topdown reorganisation.

The Bill is long and complex because for the first time in statute it seeks to define the functions and duties of every element in the chain of accountability within a reformed healthcare system, and to join up those functions and duties into a coherent whole. Whereas in the past it has been possible for a Government to change the NHS simply by direction, in the future it will be impossible to do so without recourse to Parliament. Much that was defined in regulations and directions is now to be covered clearly in statute. Daunting as it may seem to some of your Lordships, we were clear that this was an ambition whose realisation was well worth the effort. At the same time as introducing change, it is a Bill which seeks to build on much of the existing and therefore familiar features of the NHS architecture put in place by the previous Administration. Noble lords will know of the Nicholson challenge: to deliver up to £20 billion of savings in the NHS over the next four years, all of which money will be ploughed back into patient care. Savings on this scale are not possible to achieve without system-wide change, and the measures in this Bill are inseparable from that process.

Let me now focus on its content. This Bill is about several things. It is about liberating the NHS and those within it to enable them to work better and more accountably in the interests of patients. It is about streamlining the architecture of the NHS to make it more efficient and transparent. And it is about creating a public health service that is configured to tackle the major challenges to the nation's health and well-being that face us over the years ahead. The key to achieving this, we believe, is a strengthened and more logical spread of accountabilities. Put simply, the Bill provides that the Secretary of State should remain accountable to Parliament, as he has been since 1948, for promoting a comprehensive health service and for the funds voted each year by Parliament for the health budget.

Let me be clear-the Bill does not undermine the Secretary of State's ultimate accountability for the NHS or the responsibility that he carries for a comprehensive service. I am fully aware of concerns raised on this point, and I respectfully refer your Lordships to the response we published yesterday to the Lords Select Committee on the Constitution on this very matter. We are unequivocally clear that the Bill safeguards the Secretary of State's accountability. However, we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put the matter beyond doubt.

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The duty to commission and provide healthcare day to day, which hitherto the Secretary of State has delegated to the NHS, will instead be conferred on NHS bodies directly. Clause 6 proposes that below the Secretary of State there should be a new body, the NHS Commissioning Board, directly responsible for holding and distributing the NHS commissioning budget and for assuming many of the functions now performed by strategic health authorities and patient care trusts, which will be abolished. But the board will not operate without political oversight. The Secretary of State will issue a mandate detailing the outcomes for which the board will be held accountable. The mandate will be subject to public consultation and laid before Parliament, creating a clear line of political accountability. Unlike the current operating framework, the Bill gives the Secretary of State an explicit duty to report on how the board has performed against the mandate. But, as an independent body, the board will be a buffer against the short-term, politically motivated whims of government.

Clause 7 creates clinical commissioning groups as statutory bodies authorised by the board which will commission local healthcare services. CCGs, consisting of groups of GP practices and with doctors in control, will be stewards of the bulk of the NHS commissioning budget and will be held transparently and rigorously to account for the use of those funds against a set of quality and outcome measures. The defining characteristic of CCGs as compared to PCTs will be their clinical ethos. It is doctors and their fellow clinicians, not managers, who know the needs of patients best. By making clinicians financially responsible for the clinical decisions that they take, we will not only drive efficiency but also achieve a step change towards a genuinely patient-centred service.

Real accountability to the patient will be achieved in a number of ways. It will be achieved by empowering patients with information and involving them in decisions around their care. But it will also be achieved by empowering local groups of patient representatives to be involved in how services are commissioned, provided and scrutinised. Clauses 178 to 186 propose the creation of HealthWatch. Local HealthWatch will be based on the existing local involvement networks, or LINks, but with added clout. Funded through local authorities, they will act as the independent eyes, ears and voice of patients and service users in a local area. At the national level, a new body, HealthWatch England, will be established to support local HealthWatch and to act as the national care watchdog wherever quality of care is called into serious question. By making HealthWatch England a committee of the Care Quality Commission, as is proposed in the Bill, we will enable the voice of patients and the public to be heard at the very heart of health and social care regulation.

But liberating the NHS goes further. It means enabling the governors of foundation trusts, who represent the public, patients and staff, to exercise more meaningful influence over strategic decisions made by their trust boards. It means freeing foundation trusts from the private income cap; a constraint which they repeatedly tell us is arbitrary and unnecessary, and whose removal will enable them-without jeopardising their NHS focus-to generate income which can be deployed for

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the benefit of NHS patients. Clauses 148 to 177 cover these proposals. Noble lords will recall the debate we had on this subject two years ago.

In developing healthcare provision, the previous Government began to champion the cause of patient choice as a driver of quality, and in doing so moved us in the direction of a more plural service with the introduction of independent sector treatment centres, social enterprises and charities operating alongside mainstream NHS providers. We have long agreed that this was the right direction of travel. Competition and choice will no doubt prove a major theme in some of our later debates on the Bill, but let me say for now that we are absolutely clear from past evidence that where competition can operate to improve the service on offer to patients, or to address a need that the NHS fails to meet, we should let the system facilitate it. However, competition only has a place when it is clearly and unequivocally in the interests of patients.

This is where we were critical of one aspect of the previous Government's policies. The playing field was levelled against the NHS. ISTCs were given guarantees and price subsidies that were not available to public sector providers. That is why we want to ensure that all providers of healthcare operate to the same clear rules. This, in turn, necessitates an independent body capable of holding the ring. That body, we propose, should be Monitor in its new guise as a sector-specific regulator for the health service, with functions and duties framed to enable it to bear down on unfair competition, conflicts of interest and unsustainable pricing. It will operate in accordance with the principles and rules for co-operation and competition, which were introduced by the previous Administration.

For a long time now, the idea of a local democratic mandate for healthcare provision has been a pipedream of many. For the first time, this Bill imposes duties on local authorities that will see the creation of health and well-being boards, bodies charged with assessing and addressing the health and social care needs of a local area. This represents a huge opportunity for improving the commissioning of health and social care. Health and well-being boards will consist of, as a minimum, representatives from clinical commissioning groups, social care, public health and patient groups including local healthwatch, plus elected representatives. They will provide a forum for joined-up decision-making on service configuration and local priorities. Joint health and well-being strategies will not simply inform clinical commissioning in a local area, CCGs will also be required to have regard to them when preparing their commissioning plans, with safeguards in place should they fail to do so. The democratic underpinning this gives to service provision is a major and exciting change.

At the same time, the Government's clear focus on public health will usher in a new public health architecture. At a local level, for the first time since 1974, local authorities will become the hubs for commissioning and delivering public health services, led by directors of public health and supported by a ring-fenced budget. At the centre, under the direct auspices of the Secretary of State, a new executive agency, Public Health England, will bring together health protection functions currently

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distributed between a number of different organisations. In driving forward public health strategies at a national level, it will inform and support local authorities in their work, thus ensuring a joined-up system. We believe it is of vital importance that public health should receive the emphasis due to it, if we are to tackle the long-term challenges to the nation's health and well-being that currently face us.

Alongside this, we will modernise and streamline the Department of Health's arm's-length bodies. The Bill abolishes bodies that are no longer required, thus releasing more money to the front line. At the same time, NICE and the NHS Information Centre will have their future secured by being established in primary legislation for the first time.

The changes we have set out will be introduced in measured stages over a period of years, and our plans for transition will ensure that the health service is well prepared; for example, no clinical commissioning group will be authorised to take on any part of the commissioning budget until it is ready and willing to so; Monitor will continue to have transitional intervention powers over all foundation trusts until 2016 to maintain high standards of governance during the transition; and to avoid instability, there will be a careful transition process on education and training.

In framing the provisions of this Bill, Ministers have talked and listened to a great many people; not only before the election but since, with a public engagement on our White Paper in 2010 and, in the spring of this year, the very productive two-month listening exercise. Throughout this time we have encountered consistent and widespread agreement for the key principles underpinning our policies; in particular, since the listening exercise, a shared view among professionals about the way those principles should be put into practice. At the same time, reform of the NHS is seen not just as an option but as absolutely essential for its future.

In addition to this consultation and engagement, this Bill has also undergone significant scrutiny in the other place. The Bill's first Committee stage lasted 28 sittings-longer than any Bill in nine years. Following the Future Forum's report, the Bill was recommitted for a further 12 sittings. The Bill was therefore scrutinised over more sittings in the other place-40 in total-than any other Public Bill in the whole period from 1997 to 2010. I direct that point in particular to the noble Lord, Lord Rea.

I conclude with a brief word about the Motion tabled by the noble Lord, Lord Owen, which I shall speak to in detail when I wind up the debate. Suffice it to say for now that while I fully recognise the strength of his concerns, I regard the proposal he has made as posing an unacceptable risk to the passage of this Bill and hence to the Government's programme for the health service. He is proposing an unusual process. The only basis on which such a process might be workable would be with the prior reassurance, for the Government, of a strict time limit on the Bill's Committee stage as a whole. Regrettably, I was unable to reach agreement with the noble Lord that this was a reasonable basis on which to proceed. I therefore do not think that his Motion should be supported.

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The case for change is clear and compelling, and I am personally in no doubt that the changes set out in this Bill are right for our NHS and-more importantly-right for patients. I hope very much that your Lordships, in reserving your powers to scrutinise the detail of the Bill with your usual care, will wish to endorse the ideas and the vision that it presents. This is a Bill with but a single purpose: to deliver, for the long term, a sustainable NHS, true to its founding principles. It is on that basis that I am proud to commend the Bill to the House, and I beg to move.

Amendment to the Motion

Moved by Lord Rea

11.32 am

Lord Rea: My Lords, the noble Earl, as always, gave us a carefully crafted and elegant speech, much of which I agreed with. However, I will start by raising one point. In the letter he sent to Peers last week, he repeated verbatim the words in the White Paper that claim that Britain's health record is worse than that of other EU countries, especially France. It appears that he has not read the paper in the British Medical Journal by John Appleby, the chief economist at the King's Fund, which demonstrates that these claims are false, that Britain's health is improving faster than that of any other country in the EU, and that we will shortly overtake France, whose health expenditure is far greater as a percentage of GDP than ours.

I will explain why I put down my amendment. I did not do this lightly. I realise that it is very unusual for your Lordships' House to oppose a Bill that has passed all its stages in another place. However, the Library tells me that it has happened 13 times since 1970-about once every three years. The Salisbury-Addison convention aims, of course, to ensure the primacy of the House of Commons. The convention that has evolved is that in the House of Lords, a manifesto Bill is accorded a Second Reading and is not subject to wrecking amendments. Over the years, the convention has been discussed at length and in depth. In the case of a coalition Government without a joint manifesto-as we have now-the clearest indicator of the policy to be followed lies in the coalition agreement.

The noble Lord, Lord Strathclyde, said on 20 January in a debate on coalition government secured by the noble Baroness, Lady Symons:

"The Salisbury convention applies to manifesto Bills, but this Government did not contest the election as a single party under a single manifesto. However, the Government ... were formed and are sustained on the basis of the confidence of the House of Commons. This confidence has been secured on the basis of a programme set out in the coalition agreement".-[Official Report, 20/1/11; col. 600.]

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That agreement contains the words I included in my amendment. I will repeat them:

"We will stop the top-down reorganisations of the NHS that have got in the way of patient care".

The agreement contains no words suggesting that this enormous Bill was in the pipeline. Nor was it mentioned in either the Conservative or Liberal Democrat manifestos.

An indication of Conservative policy that reached far more people than the number who read the 110-page manifesto was David Cameron's widely reported statement made to the Royal College of Pathologists in November 2009. He said:

"It's true, with the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS".

Instead of having a Bill that was in a manifesto, we have one that was expressly ruled out by the words of David Cameron's speech, and subsequently by the coalition agreement. So the Salisbury convention, if relevant here, applies in a reverse direction. If we allow the Bill to pass, we will be voting directly against the words of the coalition agreement.

It seems that there was deliberate concealment of what was planned. The Bill-or something like it-must have been in gestation for months if not years before the election. Michael Portillo said, on Andrew Neil's late-evening politics programme, that it was not put into the Conservative manifesto because it would have lost the election, as the NHS is almost a religion in Britain. That implies that it had to be slipped in by the back door. How patronising that is. It says that we, the Conservatives, know what people need better than they do. In fact, it is possible to trace the development of the ideas behind the Bill in Conservative think tanks dating back more than 20 years.

What is proposed is probably the most far-reaching reorganisation of the NHS ever undertaken. It now has 320 clauses and 22 schedules, in two volumes, with 353 pages. It is longer than the Bill that created the National Health Service in 1946.

The White Paper, Equity and Excellence: Liberating the NHS, which is full of euphemistic phrases that everybody can agree with, did not prepare us for the Bill. Neither the White Paper nor the Bill expressed clearly the underlying intention of the Bill, which many think is to open the door wider-it is already ajar-for the market and the independent sector to play a bigger role in the National Health Service. The process was made possible first by the compulsory tendering of domestic services in the 1980s, followed by the introduction in 1990 of the internal market, which was retained by the Labour Government. They brought in the private sector to provide some clinical services, reduce waiting lists and provide certain other services.

Many have argued, with evidence and from experience, that this could have been done within the National Health Service. Short-term political gain has resulted in us now reaping the whirlwind of greatly increased costs, nowhere more so than in the private finance initiative, referred to by the BMA as "perfidious financial idiocy". This assessment has now been confirmed by the Public Accounts Committee. Since 1990, the proportion of the National Health Service budget

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devoted to administrative costs has risen from 5 to 14 per cent, according to the Centre for Health Economics at York University. That is an extra £10 billion a year.

This Bill, despite its stated effects of saving administrative costs, is likely to increase them further. The Government say that the financial difficulties of the NHS are such that the Bill must be enacted quickly. However, there is no evidence that the changes suggested by the Bill will reduce costs-rather the reverse. A recent research review by a team at the London School of Hygiene and Tropical Medicine showed that competition in the health sector, far from improving National Health Service costs and clinical outcomes, had the reverse effect.

Clinicians in the proposed clinical commissioning groups will find that commissioning is a highly complex task. They will need the assistance of experienced administrators, statisticians and public health specialists, as well as competent clerical support. These experts are already being lined up. They are not experienced PCT staff who are available without extra expense, and who are now anxious about their future, as David Nicholson pointed out yesterday. They are mainly from commercial health companies. A freedom of information request revealed a list of 40 organisations, most of them private, which have been invited to bid for contracts to train GP consortia, now clinical commissioning groups. For this role, in London alone, £7 million has been allocated for the initial phase, taken from funds originally allocated for postgraduate education.

It will be argued that changes on the ground are too far down the road to reverse. However, PCTs are still in existence and could be re-established in a leaner and more efficient form, with enhanced clinical membership, perhaps bringing in pathfinder groups. A similar suggestion has just been made by Andy Burnham, our new shadow Health Minister, in a letter to Andrew Lansley. Many of us would like to know the Government's justification for starting to implement the changes before the Bill has passed through Parliament. An inquiry might find this to be unconstitutional, if not illegal. The noble Baroness, Lady Williams of Crosby, suggested as much in a powerful article in the British Medical Journal this week.

In conclusion, I ask Liberal Democrat and other government Peers who are unhappy with the Bill to seriously consider voting for my amendment, or at least abstaining if a Division is called. The Bill is not in the coalition agreement, and it is always open to coalition parties to disagree on some issues. The coalition will not fall if the Bill is lost. I assure the noble Lord, Lord Owen, and other Peers, that if my amendment is not carried I will certainly vote for his amendment, and I urge all Peers to do so. Of course, I know that I can count on the support of my noble friends.

There are many aspects of the Bill that I have not covered. However, I am sure that others among the many speakers will fill in the gaps. I shall be guided by the course of the debate on whether to divide the House. However, I know that many thousands of people throughout the country-not only health professionals by any means-oppose the Bill and want the House to reject it. The large, peaceful demonstration

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on Westminster Bridge on Sunday was an example of this. They will be bitterly disappointed with the House if I do not call for a vote, and I will not ignore them.

Baroness Anelay of St Johns: My Lords, it may be helpful to the House if at this stage I give some guidance on an advisory speaking time. There are 100 speakers signed up for the whole of the debate, including the Front Bench spokespersons. If Back-Bench contributions were kept hereafter to eight minutes, the House should today be able to rise at about 11.30 pm. For the avoidance of doubt, perhaps I may emphasise that the next speaker is the noble Baroness, Lady Thornton, who is a Front Bench spokesperson for the Opposition. Therefore, my advice is for all speakers subsequent to her.

11.45 am

Baroness Thornton: My Lords, along with everyone in the House, I thank the Minister for his most competent and coherent introduction to the Health and Social Care Bill 2011. The Labour Benches have a great team dedicated to working on this Bill. It includes my noble friends Lord Hunt, Lord Beecham, Lady Royall and Lady Wheeler; our new Whip, my noble friend Lord Collins, who recently retired as the general secretary of the Labour Party and joins us as our junior member of the health team; and, of course, a galaxy of experience behind us.

I became so desperate to see this legislation that I even got involved with the Localism Bill in the summer, so desperate was I to be doing something. Long awaited, the delayed Bill we are considering today is in its fourth version so far. Indeed, it may not be the last. The first was definitely the Conservative version. It was prepared before the election based on the ideology of markets and regulation. It is now a much more complex Bill but the core intent remains the same. This Bill, with its 303 clauses and 24 schedules, creates a framework that will fundamentally change the nature of the NHS. It will change the NHS from a health system into a competitive market. It will turn patients into consumers and patient choice into shopping. Most crucially, it will turn our healthcare into a traded commodity.

Therefore, I start with a fundamental and simple point. People did not expect, did not vote for and do not want these changes. The Government were not elected to do this. They do not have the electorate's mandate. I know we will hear arguments about whether or not this Bill is a mere continuation of the work of my former Government. I assure noble Lords from the outset that this is a specious argument, which I urge them to put aside. Our reforms were in our manifesto. They helped to improve and strengthen the NHS. They most certainly were not this Bill.

This Bill was not mentioned in anyone's manifesto; nor was it in the coalition agreement. As for the democratic mandate mentioned by the Minister, top-down reorganisation, which is what the Prime Minister said, does not seem to be a mandate. One can scour the manifestos of the Conservative Party and the Liberal Democrat Party, and the coalition agreement, for anything

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that suggests a fundamental change to the powers of the Secretary of State for Health. Nothing suggested wholesale dismantling of the structures of the NHS; nothing about the biggest quango in the world being created, the NHS Commissioning Board; nothing about the intention to allow £60 billion of taxpayers' money to be spent by GPs, originally on their own and now through clinical commissioning; nothing about the creation of a huge bureaucratic economic regulator, the new Monitor; and nothing about many other parts of this Bill, some of which is good and some less so. There is no mandate for this Bill. That is a serious constitutional issue for this House, which is signalled to us by, for example, the Constitution Committee report.

In the context of the most draconian changes for 60 years, the least we could have expected was a raft of analysis and evidence that would form a convincing and arguable case for the direct benefits of these changes to patients. If the evidence exists-I would say that it does not-it has manifestly failed to convince those who work in our NHS, those who study our NHS and certainly those who use it: so, no mandate, no evidence and no support. In addition to that, there has been one of the worst impact assessments that most experts have ever seen, showing no cost benefits. I suggest that this is not much of a basis for a change programme, which, to quote David Nicholson, is so large that it can be seen from space.

It is a sad day for this House and for Parliament that we are being urged to expedite this Bill. As informed commentators keep telling us, the state of disorganisation in the NHS is past the point of no return. Indeed, the Minister circulated a letter minutes before this debate started in which the last paragraph points to and emphasises the need for us to get on with this rather than the need for us to scrutinise this Bill.

There has been a breathtaking disregard for the democratic process. The reforms are being implemented in such a way that there is now paralysis, uncertainty and lack of leadership in the system. This has been inflicted on the NHS by this Government. Is it too late for a fresh look? I do not think so. I urge noble Lords not to be panicked, bullied or browbeaten. Our job is to scrutinise and improve this Bill, because it is certainly the most significant legislation that we are going to see in the whole of this Parliament.

On these Benches, we take this responsibility very seriously-indeed, I think that all noble Lords feel this responsibility-because we must not fail. All eyes are on us. If the Bill proceeds into Committee, these Benches will not delay this Bill in its passage through the House. I have promised the Minister this. In return, the Government must make as much time available as noble Lords need to give this huge and complex Bill the scrutiny that it deserves. The public and the NHS would not understand if we did anything less.

I pay tribute to the noble Baroness, Lady Williams, and others, such as Evan Harris, for their steadfast campaign and I hope that we can work together to improve this Bill. I promise that these Benches will be here to support sensible amendments to this Bill from wherever they come and I hope that noble Lords will do the same.

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Perhaps I might gently remind my Liberal Democrat friends that for many years the NHS has been a toxic political issue for the Conservative Party and it never was for them. In fact, the Liberal Party was in at the birth of the NHS: you were part of its genesis. I would just ask: why would you put that legacy and that history in such jeopardy? As for the Conservative Party, people wanted to believe David Cameron when he promised before the election to protect the NHS. He promised to guarantee a real rise in funding and to stop top-down NHS reorganisation. I put it to noble Lords that every one of his promises is now being broken.

At a time of austerity, the NHS needs co-operation, collaboration and integration, not experiments with the extension of competition. So we are keen to scrutinise this Bill: we support the greater involvement of clinicians in commissioning; we support the devolvement of public health to local authorities with the right safeguards and financial support, and independence at a national level; and we support the creation of health and well-being boards and local accountability. We believe that the Bill needs to enhance the patient's voice because we think that that is very inadequate at the moment. We believe that accountability and transparency need to be addressed from top to bottom of this Bill.

In addition, we believe there are matters concerning mental health, children's safety and well-being, training and workforce planning, research and many other issues that will be raised by noble Lords across this House, which will need plenty of time in which to be debated and given the scrutiny that they deserve.

The wider context of this, of course, is the need for the NHS to deliver the Nicholson challenge and find the £20 billion of efficiency savings. We on these Benches believe that that is a priority and is enough in itself. Our concerns with this Bill are many and serious but the core of the Bill around regulation and the failure regime did not receive proper scrutiny in the other place. Indeed, the failure regime received no scrutiny whatever because it was introduced too late. We will be seeking major changes to Part 3, which we regard as dangerous as well as unnecessarily complex, bureaucratic and expensive. We do not support making our NHS into a regulated market, as advocated by some. Whatever the merits of competition and quasi-markets-we will hear a lot about these during the course of the Bill-they cannot be the basis for the delivery of healthcare. Indeed, there is a role for regulation, but the role and nature of the regulator has to be a lot clearer than it is in this Bill at the moment. I am giving noble Lords a very rapid summary of our major concerns and the areas of the Bill which we think need attention.

I now wish to address the procedural and constitutional challenges posed by the Bill. I would like to be very clear to the House: my right honourable friend Andy Burnham made a serious offer to the Secretary of State over the weekend. He asked the Government to withdraw the Bill and committed Labour to co-operating with the Government to implement the clinical commissioning agenda using existing powers, and doing it as quickly as possible. I repeat that offer to the Minister now. However, frankly the omens do not look good.

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My party will support the amendment of my noble friend Lord Rea not to proceed any further with the Bill. We invite all those who love their NHS to join us. We do this with a heavy heart because it is this House's job to scrutinise and improve legislation. However, we believe we have no option because there is no doubt that there is an overwhelming call for us to stop the Bill from the royal colleges, the professions, doctors, nurses, thousands of health workers, patients and, indeed, non-patients. However, there is an alternative before us today, and we think this offers a way forward if the Bill is not withdrawn or stopped. It is an alternative offered by the amendment in the name of the noble Lord, Lord Owen. The idea that we can have double the scrutiny going on at the same time is very attractive. We believe that it will expedite the process of scrutiny and we urge the Minister to accept this proposal. We know from previous experience that issues referred to a Select Committee help the House enormously in taking decisions.

Why did 100 noble Lords want to speak in this debate? Why did the noble Lord, Lord Owen, feel moved to put a significant amount of his time over the summer into working out a constructive way to maximise the scrutiny of the Bill? Why has the noble Baroness, Lady Williams, spent an enormous amount of her time since the spring trying to work out a way forward for the Bill? Why have dozens of noble Lords attended seminars and briefings since March better to understand this Bill? Why do we think thousands of people have written letters and sent e-mails to Peers across the House expressing their concern about the future of the NHS? Indeed, I pay tribute to the GPs, clinicians, nurses, midwives, physios and other ancillary therapists, mental health workers, care workers, trade unions, patient groups and health charities for the time and attention they have given to the detail in the Bill. The majority still do not like it. All of this has happened because our NHS is precious to every family and every person in the land, whether or not we use it. Everyone knows that whatever happens to them, wherever they are and however serious it may be, they can get healthcare. This is possible because we pay for it together and it is part of the social fabric of our nation. The NHS, in Bagehot's terms, has a dignified as well as an efficient side and a specific role in the psyche of the nation as a symbolic guarantor of fundamental decencies. Any prospective reformer would have to respect those. I suggest that Andrew Lansley has not done so.

Our NHS was built on the principles of co-operation and integration as a genuinely national system with a properly accountable Secretary of State answerable to Parliament-a system working for the benefit of patients. This is where I end because the only real test of these reforms is their impact on patients. We are good in this House at hearing patients' experiences and acting on them. We will have to listen very carefully indeed in the coming months. There is huge expertise in this House: medical, legal, organisational, charitable, and, often the most important, a great deal of common sense and practical experience. We will need to bring every bit of this wealth of talent to bear on this Health and Social Care Bill. I look forward to working with noble Lords across the House and with the Minister in the coming months.

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11.59 am

Baroness Jolly: My Lords, we have heard well-argued speeches, as we would expect, from my noble friend Lord Howe and from the noble Baroness, Lady Symons, the Opposition Front Bench health spokesman-

Noble Lords: Thornton!

Baroness Jolly: Apologies to the noble Baroness, Lady Thornton. I have that name written down but the wrong one came out. They have provoked thought. At the debate on the Future Forum, called by the noble Baroness, Lady Wheeler, before the conference recess, I flagged up many of my concerns with this Bill, but time did not allow me to share them all. I fear that I will have the same problem today, but I am sure that my noble friends on the Benches behind me will be happy to fill in any gaps I may leave; in particular, areas of inequality, mental health, and the role of Monitor in competition and integration.

For the record, my areas of concern which I flagged up in that debate were the accountability of the Secretary of State-this needs to be right from the beginning and completely unambiguous, and he or she needs to be hands off and responsible at one and the same time; the need for clarity within the local government and clinical commissioning groups and democratic accountability; the role and status of the director of public health within local government, which will be critical and will need work; and the need for clarity about education, training and workforce development within local government.

I am delighted that this Bill is designed to promote integrated care-acute and community services working as one with social care. The patient and carer must be totally woven into these new networks and clinical senates. In future, patients and carers should not have their care packages worked out in isolation.

As I was working out how I was going to come up with this speech, I realised that it is nine months to the day since I was introduced to this House. In the maiden speech I made two days later, I told the House about my time on various NHS trust boards. From that time, I offer your Lordships an example of why the Secretary of State must be hands off.

We needed extra capacity to deal with cataracts in my area and made the appropriate arrangements through a local hospital. Before this could be finalised, we had the project pulled and replaced by a new treatment centre, run by the private sector, which would also offer terminations and endoscopic diagnosis. This would be based in a new build-not particularly where patients wanted to go-and we were given patient target numbers not only to meet but to pay for whether they were met or not. We did not need all that provision and it was in the wrong place. We respectfully told the powers that be that we were happy with our original solution, thank you. We were then told, in very blunt language, that it would happen with or without our decision, and that if our board did not approve it, another would be found that would. So that is a result of the Secretary of State with a power to intervene. Fortunately, under this Bill, this proposal would come before Monitor

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and the privately run hospital would be deemed not to be in the best interests of local patients and it would not proceed.

I must have sat through hundreds of board meetings, not to mention audit committees, clinical governance groups and remuneration committees. They were all about the structure of the NHS. There were times, as we discussed systems and processes, that the patient never got a mention and was certainly rarely there at the table.

By their own admission, the Government want to put the patient at the centre of the NHS-"No decision about me without me" is a laudable and catchy strap line. We welcome that, but I fear that at times this patient is still sidelined. Care will have to be taken to embed a serious culture change.

I fear that this Bill, as it stands, has areas which are about process; engineering the system for desired outputs and outcomes while Mrs Smith or Mr Patel is forgotten. Just how much within the Bill needs looking at again from the perspective of individual care and not making the individual fit what is being designed?

There are three distinct areas for patient involvement. First, at the time of a consultation with a professional they need to be involved in their care plan and look at any options. There is evidence-there has been a lot said today about evidence-that 75 per cent want involvement and that if they become involved they do better. Incidentally, that goes some way towards reducing health inequalities. This needs to start upstream and it needs to be built into commissioning.

Secondly, we can look at a patient as an expert patient, offering insight and refection in how their experiences can help the care of others, as can patient organisations. Again this needs to be built into the commissioning process, into senates and into local networks. Finally, as a member of a local healthwatch or HealthWatch England, these replaced the old LINks groups and, as yet, do not have a sufficiently robust structure with the ability to challenge. Here I disagree with the Minister. They do need more clout.

We are faced with two amendments to the Motion, one tabled by the noble Lord, Lord Rea, and the other by the noble Lord, Lord Owen. I will take them separately and explain why I am not supporting either. First, on that of the noble Lord, Lord Rea, as a Liberal Democrat I know only too well that many areas of this Bill, for the most part, fall outside the coalition agreement, which I voted to support in May 2010. In fact, it drives a coach and horses through the agreement. This leaves us the opportunity on these Benches to revert to our manifesto and policy document in deciding amendments. When I arrived in this place, the Bill was already printed and starting its passage through the other place. History will tell us whether there was a Blue Peter here's-one-I-prepared-earlier moment and who the main players were. I expect it to be silent on the matter of wire coat hangers, cereal packets, and sticky-backed plastic.

It is the Government's Bill and it is not without fault. One of my early lessons here was that it is our role to improve and not to reject Bills. We need to take those faults and work to take them out. As a junior member of the coalition, I have found Ministers'

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doors have been open, and there has been a willingness to listen and engage. I welcome the invitation of the noble Baroness, Lady Symons, to work together in the interests of the public and the NHS.

Noble Lords: Thornton.

Baroness Jolly: Thornton-I beg your pardon. It is the first time I have made that mistake. You know who I mean. I apologise to the noble Baroness, Lady Thornton. I welcome her invitation.

Next, the amendment of the noble Lord, Lord Owen, is more nuanced, but puzzling. The noble Lord calls for those issues raised by the Constitution Committee report dealing with powers and responsibilities of the Secretary of State to be extracted and given to a Select Committee to work on while the remainder remain within the House in Committee in this Chamber. Thanks to the hard work of the noble Baroness, Lady Thornton-I have it right-in pulling together a really well attended series of fascinating seminars about all aspects of this Bill, followed by a similar series arranged by noble Earl, Lord Howe, the opportunity to question think tanks, Royal Colleges and senior civil servants was made available to all Peers and was taken up by many. Peers are well informed about this Bill and are able to deliberate, scrutinise and amend in the usual way-in a Committee of the whole House. This is the general custom and I see no reason to do otherwise.

I ask noble Lords to reject both amendments. Let us get on with doing what we are praised for doing worldwide: scrutinising difficult and complex legislation as a House, with a view to producing a better, workable Bill.

12.08 pm

Lord Birt: My Lords, there is probably no one in your Lordships' House who does not have cause to be grateful for what the NHS has done for them or their families. Recently, as my own parents entered the final chapter of their long lives, I witnessed at close hand the expertise, dedication and sheer good cheer of the care that they were fortunate enough to receive.

However, I also saw the many ways in which the NHS could improve. That is no surprise. All organisations can improve. All need to adapt and develop in the light of the continuously shifting circumstances they encounter. Technology will offer radical opportunities for improving effectiveness and efficiency. Science will uncover previously unthought-of ways of addressing old problems. Citizens and consumers will make new and different demands. The private sector offers examples of organisations of every size that have transformed their effectiveness, often at times of great adversity. They have had to develop new capabilities, to create new structures or, to define a new focus or accountability.

The test of all health reform is: will the proposal create better health outcomes? Can the UK match or improve on best international practice? Will the reform enhance patient choice, experience and convenience? Will GP surgeries be encouraged to be open when a population largely in work is most free to visit, furthermore relieving an unnecessary burden on A&E? Will the

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reform promote efficiency, and thus optimise the health outcomes for any given level of available resource? Will it foster and reward innovation? Will it enable a diversity of providers, competing on quality, on clinical effectiveness, and on patient satisfaction, as well as efficiency of provision? As treatment possibilities change, will the new system be flexible enough to enable the supply of the relevant service to be lodged at the appropriate level, whether local, regional or national? The recent welcome improvement of stroke care in London is a case in point. Will the reform encourage greater collaboration and, where appropriate, integration?

My best understanding of the reforms before us today is that they form a continuum, building on the modernisation process begun under John Major, and-with stutters and starts-continued under Tony Blair. Here I declare an interest as I was the Prime Minister's strategy adviser at the time. Taken together, these reforms are comprehensive and coherent and should address the challenges I have just outlined. They simplify the architecture of the whole health system and lodge accountability for who is responsible for what at every level. In particular, I welcome that they define the role of the Secretary of State not as Minister for the "Today" programme, but as holding ultimate responsibility for the strategic direction and overall effectiveness of the whole system.

These reforms create an arm's-length commissioning board with the responsibility and the powers to ensure that commissioning is effective. They maintain a system of advice and supervision to promulgate best practice and to safeguard the quality of health service providers. They bring greater openness and transparency, and they allow greater scrutiny of both the system's marching orders-the three-year mandate-and of the performance of the system overall. They set up, in Monitor, a regulator which can set tariffs to promote best practice and guard against anti-competitive behaviour of any kind. They introduce a failure regime which will maintain essential services for patients while enabling an orderly transition to a more effective alternative. Most welcome of all, they lodge the prime spending responsibility at the front line with GPs and other clinicians, who are far better placed than bureaucrats to make the very difficult trade-offs, and to optimise patient welfare.

These reforms will not be the last word. The NHS will-must-continue to adapt and to change. No doubt the Bill can be further strengthened in its passage through this House. In the round, these measures seem to be another welcome step on the way to the ever more effective NHS that all here desire and want to see.

12.14 pm

The Lord Bishop of Bristol: My Lords, what is clear from the vast volume of correspondence that has arrived in my office in recent weeks is that there is something deep in the psyche of our nation which is extremely anxious about the reforms to the NHS being proposed by the Government in this Bill. Some of that concern is based on a misunderstanding of what is being proposed, but much of it is, in my view, substantive criticism and, significantly, often being voiced by organisations that represent thousands of

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healthcare professionals. The Government have argued with force that reform is necessary given that the projected costs of the health service going forward are not sustainable. In varying degrees, this observation carries some support. Their stated aim to improve the quality of care is to be welcomed.

The Government made a number of welcome changes to the Bill following the first report of the NHS Future Forum in June 2011. Those changes went some way to addressing concerns, particularly with regard to the composition and remit of commissioning groups, and to the expansion of competition within the NHS. Some outstanding issues, however, still remain to be resolved.

First, despite the reassurances given by the Minister, I wish to make a foundational point which I hope the noble Earl will take into account in his further deliberations on this matter. The Health and Social Care Bill as is runs the risk, I believe, of breaking the obligation of the Government to take responsibility for healthcare in the nation. This is not merely a matter to be judged on the grounds of efficiency or effectiveness, although both are important and, of course, as yet there is no evidence that the proposed changes set out in the Bill will promote either. Rather, the Government's responsibility for the welfare of the people, including healthcare, is part of the fundamental legitimisation of the state, and a main reason why individuals should subordinate themselves, within limits, to the state. Is it too much to say that a state which withdraws from the responsibility to deliver the welfare of the people loses its legitimate claim on the lives of its citizens? There can be no more fundamental aspect of welfare than healthcare. For this reason, as well as for reasons of practical accountability, it is absolutely essential that the Secretary of State for Health retains final executive authority for the delivery of healthcare and does not relinquish ultimate responsibility either to Monitor or to the NHS Commissioning Board.

Moving on to the NHS Constitution, the Bill now places an onus on both the NHS Commissioning Board and the clinical commissioning groups, formerly the GP consortia,

The NHS Constitution contains seven key principles which include providing a "comprehensive service to all", and providing services that,

This new role of promoting the NHS Constitution through commissioning strategies and decisions is to be welcomed. It means that the commissioning of services cannot be based solely on a traditional medical model of care. The whole needs of patients and others must be met through the provision of comprehensive services. This includes, among other things, meeting their spiritual needs. For many people, spiritual needs may be met only through the provision of religious care. Chaplains are uniquely trained and qualified to provide both religious and spiritual care and, as such, it ought to be explicitly understood that both commissioners and providers should take into account the need for spiritual care where appropriate.

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Similar consideration ought also to be given to ensuring that the range of services provided by allied health professionals are maintained and protected, and that the viability of small specialist departments is not compromised through financially driven reorganisation. In a proposed environment of competition, there is a real risk that providers may compromise the quality of their services in order to obtain a contract. It is essential that the requirements of the NHS Constitution are rigorously adhered to by both commissioners and providers in order to minimise this risk.

Concern with regard to providers cutting corners in order to obtain contracts extends also to the nursing profession. Both the Queen's Nursing Institute and the Royal College of Nursing have noted the real risk of underskilled staff being used by providers in the community and in care homes, partly to enable their bids to be competitive. Commissioning bodies, in order to provide adequate services, need to understand the breadth and quality of nursing care required to meet patient and carer needs.

I have an anxiety about the complexity of the NHS structures that will be created by the Bill. Part of the rationale for reconfiguring the NHS was to simplify its structures and management. At present, the Bill envisages a health service that has a much more complex structure and a greater array of interlocking organisations than before. In addition to the Secretary of State, whose function is to become one of oversight rather than of direct involvement, the new look NHS will encompass the NHS Commissioning Board, clinical commissioning groups, health and well-being boards, Monitor, the Care Quality Commission, the National Institute for Health and Care Excellence, HealthWatch England, Public Health England, clinical networks and clinical senates. In addition, local authorities will have direct input into both public health and the proposed health and well-being boards.

The main problem with the proposed structure is that it may render it difficult to determine precisely where, in practice, decision-making powers lie. The proposed remits of these organisations not only interlock, but frequently overlap. There is a twin danger of the NHS Commissioning Board retaining too much control so that the clinical commissioning groups and health and well-being boards are stripped of any real decision-making powers, or conversely of the checks and balances within the system becoming so cumbersome that decision-making becomes frustratingly difficult to achieve. For example, local authorities and health and well-being boards will, on occasion, be at variance with clinical commissioning groups. The proposed mechanisms for resolving such disputes are complex and may result in the NHS Commissioning Board being drawn into a level of micromanagement that it never envisaged. There is a real danger that the complexity of the proposed structures could lead to a paralysis in decision-making that would be reflected in compromised patient and client safety and care.

I want to make a further point about clinical commissioning groups. The change from GP consortia to clinical commissioning groups reflects the need for the involvement of other health professionals as well as patients and clients in the commissioning of services.

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The proposed establishment of governing bodies within each clinical commissioning group is to be welcomed both for governance and transparency reasons. So, too, is the requirement that these governing bodies must include two lay members, at least one registered nurse and one secondary care specialist. The failure, however, to prescribe in detail the wider professional membership or the ratio of GPs to other professionals is an error. While there ought to be flexibility to co-opt members according to the requirements of local need, it is important that all clinical commissioning groups have the same core membership. There is a huge difference in having a place at the table by right and being invited to sit there by a pre-existing statutory group. Professionals such as pharmacists, allied health professionals, chaplains and psychologists provide valuable and essential insight into the health needs of populations. This ought to be reflected in the core membership of clinical commissioning groups.

There is much more I could say, but I will adhere to the time limit by concluding that I believe, along with many noble Lords, that some reform of the NHS is necessary to enable it to face the challenges of the future. Aspects of this Bill are to be welcomed, such as the desire to bring greater transparency and patient choice into healthcare, and the desire to involve health professionals more fully in commissioning services. None the less, there are still major problems with the Bill, including those outlined above, that require to be addressed before it can be supported.

12.24 pm

Baroness Bottomley of Nettlestone: My Lords, I am delighted to follow the right reverend Prelate and relate to him the advice first given to me when I was one of the two people who planned to speak in this debate along with another former Secretary of State for Health. I look forward to hearing what my noble friend Lord Fowler says towards the end of it. The advice I was given was first to find the chaplain as he will tell you what is really going on in a hospital or health institution.

I give this Bill an unequivocal and extraordinarily warm welcome. For someone who has spent the best, hardest and most rewarding years of her life as a Health Minister and then a Secretary of State, I enjoy hearing people say, "The Secretary of State should be hands on". I do not think that many of the people who work with me would think I was anything other than hands on, but I have discovered that five years of sleeping four hours a night still does not mean you can cover the full detail of everything that is going on within the National Health Service.

I welcome this clarity of the roles, responsibilities and institutions which I believe will lead to a much more effective and better managed health service. We may spend £128 billion a year on the health service and there may be nearly a million people working in it, but I remind the House that in the past 13 years there have been six Secretaries of State. That means a massive organisation getting ready for one Secretary of State, then another Secretary of State, then another, and any number of junior Ministers, all with their special pet projects, all disrupting and trying to leave their mark

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on the National Health Service. Some in this House dislike comparisons with the commercial world but I am going to make one. One of our successful businesses in the United Kingdom, which is very consumer-responsive, is Tesco. Tesco has half the number of people and half the budget but remains a huge and complex organisation. The chief executive has been on the board for 19 years and he was the chief executive for 12 of those years. It is romantic poppycock to think that the Secretary of State should be personally involved in all these various issues. Aneurin Bevan said that whenever a bedpan drops, the noise reverberates down Whitehall. The point is, it is not the bedpan that the Secretary of State should be concerned with but the much broader strategy, accountability to this House and greater clarity about commissioning, Monitor, public health and patient involvement. I believe that the Secretary of State and his team have addressed many of the knotty problems and conundrums which, as many have said, have been the prime preoccupations of those leading the health service for many years.

The only area where I fall out with the Secretary of State and his team is in describing this as radical, revolutionary and the greatest change the NHS has ever seen. That is total nonsense. Those of us who have been involved in the very close detail of the health service over the years have all tried to get the balance right. We have tried to get the balance right with local authorities. That is very difficult with regard to continuing care. The budgets of local authorities and of the NHS are entirely different. The accountability is different. Why do we have so many people in prisons? That is not least because there is cost shunting away from social services into the Home Office. I see that the former Chief Inspector of Social Services knows exactly what I mean. Cost pressures arise between social care and the health service. The health and well-being boards and the role of the director of public health are excellent recognition of the areas where local authorities can and should be in a powerful position but should leave the health service to deliver this highly complex challenging work for the 21st century.

Patients are not mild, obedient, good and kind and are not as deferential as they were in the past. There are more hits on the internet on health than on any other subject. Patients are experts. They go to see their doctors and say, "I have looked you up on the internet and these are the research papers I have seen. Why haven't you produced this or that?". It is a totally different relationship-a partnership. It is a good relationship but it is a very different world, particularly if you are a clinician. The development of HealthWatch and the information available for patients has got the balance right.

My noble friend Lord Howe said that this Bill has already had the most unprecedented amount of scrutiny-40 sessions in another place and 100 Peers hoping to discuss it. During this period and during the listening exercise, there have been some very informed and clear improvements. I dare say that we might have achieved them in Committee but the listening exercise has provided many of them. The role of Monitor has been excellently refined. It has allowed the transitional phases to develop, but the health service needs a bit of

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muscular intervention. During my time, a thousand years ago, we had regional chairmen. Sir Donald Wilson in the north-west sorted people out and banged their heads together. He was a farmer. If you were very good you got a cheese and if you were very, very good you got a sack of potatoes, but he knew how to intervene when the different forces-the tribes of the feudal tendency in the NHS-were at a logjam. Last week, Monitor intervened in Manchester regarding the seven provider hospitals to the Christie. We need that mechanism where intervention can occur.

I support the Secretary of State and his team. Too many people in this House are in their anecdotage but I need to pass on two anecdotes. The two people who used comprehensively to beat me up in a close encounter with Jeremy Paxman or John Humphrys were the head of the BMA, Jeremy Lee-Potter, and his successor, Sandy Macara. Jeremy Lee-Potter was based at a hospital in Poole. I was always hearing that the changes would lead to rack and ruin, the end of the health service and that the terrible, wicked, infernal market would be ghastly, so I visited the Poole hospital. I said that I wanted to meet a team of people, young and old, to ask how things were going. Universally, they all said, "These trusts are really good. They are really working". I bumped into Jeremy Lee-Potter in the haematology department and told him what I had heard. He said, "I know, Virginia, it is very good at Poole but everywhere else there is a problem".

My other example concerns Sandy Macara, a public health doctor. I was passionate about public health and am so pleased at what we are doing with public health. Sandy Macara comprehensively beat me up on the "Today" programme and spat me out the window. I had to go home covered in bandages. On my way out of the studio, he said, "I do hope that will help, Virginia". There is an institutional belief that if you make a big noise about the Health Service it will attract more resource, so going quietly is never an option because people have to make a great noise to make sure that they continue to be properly recognised.

I am pleased to speak after the noble Lord, Lord Birt. When he was running the BBC I felt that he was a kindred spirit in that if you mind about the mission, you have to do unpopular things. If you did not care, you could give everybody what they wanted all the time, but if you care you have to tackle the difficult problems. A former BBC chairman, who was also chairman of an NHS trust, used to cite Burke. Goodness knows, our Secretary of State has given dedicated, committed attention to this issue over many years. Edmund Burke said that you must be,

I have had correspondence-as we all have-from any number of people who are frightened by the Bill. One correspondent says:

"Please ensure my grandchildren can have the same benefits that you and I have received from the NHS since 1948".

I do not want my grandchildren to have the same benefits; my grandchildren have high standards. Like everybody else in this House, I want my grandchildren

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to have a better, more responsive, more effective and cost-effective NHS. Only through this Bill will we achieve that.

12.34 pm

Lord Darzi of Denham: My Lords, we live in a time of rising fear. We fear losing our jobs, we fear riots in the streets and we fear that our economic future and our country's place in the world are no longer secure. A little over 60 years ago, the National Health Service was founded to take away the fear that getting sick meant going broke, and growing old meant becoming poor, with rising healthcare bills.

Today, people need our NHS more than ever. It remains this country's most cherished institution. One might conclude that, since our NHS is so precious, it should be protected from change. That is untrue. The NHS must embrace change. To believe in the NHS is to believe in its reform. Healthcare exists at the edge of science. We are constantly finding new drugs and treatments, and innovations in what we do and how we deliver care. The history of medicine has been the history of progress. People rightly expect the latest treatments in the most modern settings. In modern healthcare, to stand still is to fall back.

I will address the three most important features of the Bill before the House. The first is the meaning of competition. The second is the relationship between quality and clinical commissioning. The third is the leadership and management of the NHS. First, there has been much unreasoned debate on competition and choice. They are two sides of the same coin, arrived at from very different starting points. One starts with the ideology of faith in free markets and the responsiveness of corporations to competition in the thirst for profit. The other starts with faith in people and in their capacity to make good choices for themselves, supported and empowered by professionals.

When I was a Minister we introduced free choice, public or private, for all patients. Competition was a means, not an end in itself. With prices fixed and patients empowered, professionals could compete to provide the highest quality care for patients. The right competition for the right reasons can drive us to achieve more, work harder, strive higher, and stretch our hands and reach for excellence. It can spark creativity and light the fire of innovation.

I will also tell noble Lords what I know to be true. There has always been choice in the NHS-but for the few, not the many. Those in the know have always known where to go and how to get there. The reforms of recent years have been about extending choice to the many, not introducing choice for the first time. I fear that the debate today has lost its mind. I have been shocked by the ability to take a pragmatic concept and apply it to the point of absurdity.

I will make one final point on competition. I am tired of the victim mindset in the NHS. It is absolutely wrong and we need radical cultural change to change it. Let us be clear: we have an enormous depth of clinical talent; we have world-leading research; and we provide excellent quality care. In the past decade, waiting times have dropped from 18 months to just a few weeks. In 2009, 92 per cent of our patients rated their care as good, very good or excellent.

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Secondly, we must not lose sight of our purpose: raising the quality of care for patients is what inspired me throughout my career. It is an ambition that I share with colleagues across the NHS. It is our collective purpose and common endeavour. I summed it up in the title of my review of the NHS, High Quality Care for All. Today, the NHS faces the huge challenge of raising the quality and efficiency of its services. Fortunately, in healthcare, quality and efficiency are two sides of the same coin. This twin challenge seems to have been lost in the technocratic debate on commissioning.

If clinical commissioning is about empowering clinicians to reshape and reform services in order to improve the quality of care for patients, it has my wholehearted support. However, I need Ministers to give their reassurance that all clinical professionals-GPs, community services and specialists working together-will undertake commissioning. As a surgeon, I would not know where to begin if I was asked to commission community podiatry services. I expect my GP colleagues would find it equally challenging to commission the highly specialised cancer services that my organisation delivers. In the 21st century, we need more integrated care, not more division. We need a health service that harnesses the talent of all our professionals, with a focus on integration and quality above all else.

Finally, I address the question of leadership and management in the NHS. The question is: how do you get the health service to change? How can reform lead to improvements in patient care? My first point is that we in both Houses must stop our frequent assaults on NHS management. If the newly appointed chief executive of a FTSE 100 company came into office and announced that he was firing half the company's management, shareholders would rightly revolt. Attacking NHS management may be good politics, but it is bad policy-and in the long run it will be self-defeating. Change in the NHS happens when coalitions of patients, clinicians and managers come together to break the status quo and to make the difficult decisions that are required to improve patient care. I say "difficult" because changing services is rarely popular. Given the demonisation of those making the changes, that is not a surprise.

Secondly, nothing in the Bill explains how strategic changes will be made to the NHS. With perhaps 300 consortia, how will the necessary changes be made on a regional level? The programme that I led, Healthcare for London, built an alliance of hundreds of clinicians and managers across the capital to improve care. It led to London becoming the world leader in stroke and cardiac care, and dramatically improved the quality of primary care provision. How will similar improvements happen in future?

We had "too big to fail" in the banking sector. Now, healthcare faces a set of reforms that are striking in their managerial complexity, with many changes begun prior to the Bill. We now have health and well-being boards, clinical commissioning groups, clinical senates, local Healthwatches, the NHS Commissioning Board, a quality regulator and an economic regulator-the list goes on. Is this now "too complex to quit"? At the end of the day, who is responsible for making sure that the NHS saves more lives this year than last? Who is accountable for how its budget is spent? Who will

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improve quality at system level, rather than in an individual organisation or consulting room? Who will inspire NHS staff to lead the difficult changes? What is coming next?

I am a surgeon, so perhaps I may be allowed a surgical analogy. It is the area I know best. The patient-the NHS-is on the table. It has been put to sleep and we have spent the past 18 months worrying more about new commissioning structures than about raising quality and productivity. The incision has been made, the old structures have been swept away and the new structures are beginning to form. The team could not agree on what operation to do. We have already had time out, and the Future Forum have made some good suggestions after the Government failed to listen to the concerns of patients and staff from the start. The question is: what next?

Is more waiting around what the NHS needs? The answer is no. We need to know where we are going and how and when we will get there. This has been a bumpy journey and it would be cruel to refuse to put the end in sight. That is why I find it difficult at this stage to support the amendment of my noble friend Lord Rea. I stand before noble Lords not as a politician but as a surgeon working in the NHS, with the needs of my patients and colleagues at the front of my mind. Our NHS needs leadership. We must never lose sight of our purpose. We aspire to high-quality care for all. The obligation of the Members of this and the other House is to support the NHS to do the things that are tough because they are right.

12.44 pm

Lord Clement-Jones: My Lords, it is a privilege to follow that superb speech by the noble Lord, Lord Darzi, and I agree with almost every word he said.

First, I declare an interest as a member of the College of Medicine advisory board and as chair of the council of the School of Pharmacy. What the noble Lord, Lord Darzi, has said reinforces my view that this is a classic "I would not have started from here" situation. After all the major structural changes under the last Government, I am more than ever convinced that constant structural change is damaging to the NHS. I believe that reforms designed to achieve changes of culture more than complex changes in structure are far more effective in the long run at meeting challenges.

With much improved treatments and longer lifespans, coping with long-term conditions in health and social care is now the greatest challenge for the NHS. As a result, we need a health system that is capable of meeting huge challenges such as diabetes and obesity. As the Future Forum says, we need a reassessment of the "old model" of hospital care, where domiciliary and community care are available and adequately resourced. Patients must be able to take more responsibility for their own health. They must have more power and choice in the system, both as citizens and consumers. There must be much better integration of health and social care.

The current NHS is by no means perfectly adapted to tackling these future health needs. This is compounded by a financial context in which we need

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to meet the Nicholson challenge of productivity savings of £20 billion over the next five years in order to be able to meet future patient needs. However, this has been poorly communicated. We need transparency about how and why money is being saved in the NHS. At present, to many in the health service, it looks as though cuts are being made rather than resources being redeployed.

However, let me be clear: I welcome many of the elements in the Bill, particularly the improvements conceded after the Future Forum report. I congratulate Professor Field and his colleagues on their work. I welcome the recognition that the paramount duty of Monitor as health regulator must be,

and that where appropriate Monitor must exercise its functions in an integrated way to achieve this both within the NHS and between health and social care.

On these Benches we have long supported devolving power to local communities. I welcome the fact that through health and well-being boards, health and social care will be brought together in local communities and local authorities will take on new responsibilities for securing and improving public health. I also welcome a less aggressive timetable for the reforms and commissioning closer to the clinicians.

Therefore, I believe that the Bill is heading in broadly the right direction but there are several elements that I hope to see examined very carefully during its passage. Are the new structures too cumbersome and complex? Will the CCGs and clusters have sufficient weight and expertise when commissioning from foundation trusts? How will CCGs work together in commissioning for less common conditions?

In particular, I want to probe the role that community pharmacists can play in these new NHS structures. There is absolutely no doubt about the contribution that community pharmacies can make. However, there is much untapped potential and many underused facilities, despite pharmacies gearing up to deliver enhanced services such as screening, health checks and medicines management. What will their place be within the new health and well-being boards? What representation of and consultation with community pharmacy will there be throughout the new commissioning system, at NCB and CCG level? Should there be a duty on these commissioning groups to consult widely as there is currently with PCTs? My noble friend the Minister recently told the Royal Pharmaceutical Society that pharmacists will be "at the heart of the new commissioning arrangements"-in what way?

There is the future place of the health networks, in particular their funding for cancer, cardiac and diabetes. Do they have a long-term future? Then there is the fraught area of competition. Generally I support the ambition of commissioning any qualified provider in appropriate areas subject to a system of local and national tariffs. Under the previous Government, procurement by PCTs from the private and voluntary sector was encouraged in a number of areas such as podiatry, psychological therapies and wheelchair services. The right sort of competition between providers can

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drive improvements in quality and efficiency and hence patient care and choice. However, this is definitely not the case in all services and the challenge is ensuring that this can happen in selected areas without opening up the NHS to legal action in a way that lets European competition law rip and dismantles the fundamentals of the health service as we know it.

European competition law could bite in unexpected ways. The application of competition law to the NHS under existing law has been a grey area for some years. It is not a new issue but we should not do anything to exacerbate it. It is crucial that for the purposes of EU law applied by the Competition Act and the Enterprise Act, publicly funded trusts are not regarded as "undertakings", otherwise the full rigour of competition law will apply. The limited European case law seems to indicate that it will not if services are provided on a universal basis on the principle of solidarity.

Therefore, I welcome some of the changes that have already been made to Monitor's duties, mentioned earlier. However, there are other aspects that I and others believe, and are advised, are less positive and will lead to the risks that I have described: the lifting of the cap on foundation trusts' private patient income, which could set foundation trusts directly in unfettered commercial competition with the private sector and risk claims of cross-subsidisation; and the termination of foundation trust regulation in 2016. I also have my doubts about whether putting the Principles and Rules of Co-operation and Competition on a statutory footing will be a step in the right direction since this could amount to an admission that the full rigour of competition law is to apply. We need to examine all these matters in depth as the Bill progresses.

Finally, of course, we have the issue that has attracted the greatest attention in recent weeks. The Constitution Committee asked whether the change in the Secretary of State's duties and powers under the Bill threatens the operation of a comprehensive health service. I do not believe in substance that it does but we will want to consider this extremely carefully during the passage of the Bill and in particular the autonomy provisions.

The House has yet to hear from the noble Lord, Lord Owen, but I am convinced that we absolutely do not need a Select Committee to examine this matter. A Committee of this House sitting in this Chamber is perfectly competent and capable of examining this issue with great care. On that basis, tomorrow I shall be firmly voting against the proposition put forward the noble Lord, Lord Owen.

12.52 pm

Lord Owen: My Lords, I speak, obviously, in favour of the Motion in my name but also to explain how it has come about. My noble friend Lord Hennessy and I have been involved with the Government, and particularly the noble Earl, Lord Howe, for over two hours of very serious negotiations on two occasions. He treated us at all times with great consideration, as we would expect, and we explored the concept of a different form of Select Committee than had been earlier envisaged. We changed our position and I think it would not be unfair to say that he changed his position. As he said, we came very close to agreement.

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The only reason we have not been able to come to an agreement is, as he said, that we were not able, Lord Hennessy the noble Lord, and I,

Now let me explain. We are individual Cross-Benchers and so do not take part in discussions on the allocation of time. We were ready to go with the Leader of the House as far as we could, in that we said that if this went to a Select Committee and we changed the Select Committee's remit just to relate to the issues raised by this all-party report of the Constitution Committee, we were ready to take account of all these things. But the one thing we could not do is form a judgment on how much time this House should spend on the whole of this Bill. We went one step further. We said that, since they were thinking in terms of two days on the Floor of the House early in January, after the report of the Select Committee came back to the House on 19 December, then that would be a fair allocation of time. But we could not go that step further. We came back and talked to the Convenor of the Cross-Bench Peers and he went immediately to speak to the Leader of the House, the noble Lord, Lord Strathclyde, to say that this was not the role of Cross-Benchers and that he would not be happy for Cross-Benchers to get involved in this area. So that is the reason.

But let me explain to the House, the Select Committee and, particularly, to the last speaker. I would like to go to the essence of the health service. I got into trouble when I was Minister of Health for using the words "a rationed health service". I have repeated that on many, many occasions. Health spending is almost unlimited. We ration the health service and yet it remains enormously popular with the public. It is the one institution which no political party up until now has really threatened. Why is this? There are many reasons, but I do believe that a deep reason is that the public think that the rationing process is fair: that it is rooted in democracy, it is rooted in Parliament.

The purists have got at this Bill. I am a reformer. I was the first person to advocate an internal market in the National Health Service, but I never believed that it would lead to an external market-a pure market. Health is not a public utility. Health is different. Sometimes the health professions have talked too much about money to Ministers of Health, as Enoch Powell said, in a classic speech. We must cherish the fact that it is a pool of altruism in our society. It is different. People commit hours of time-surgeons and porters, nurses and physiotherapists-far beyond the call of duty, ignoring the EU directives, time after time. Are we going to foster that; are we going to keep it?

The other purist issue of this Bill is first to go for an external market and secondly to think that you can separate out the running of the health service entirely, in its production, from the Secretary of State. The Secretary of State's role has never been, for many years, to manage the health service, in the strictest sense. This Bill has, in my view, some good provisions relating to decentralisation of the health service and it is, of course, right that there should be some re-adjustment of the management role of the Secretary of State, making it a bit more explicit about that which is going to be delegated. But you must preserve a role for the Secretary of State.

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I am very worried that this Bill does not deal with what would happen in a pandemic. In a pandemic that suddenly grips this country we will not be able to accept that the health service is managed by the chairman of the National Health Service Commissioning Board. We will instinctively come back to the Houses of Parliament. When inflation was running at nearly 28 per cent in the early 1970s, we had to adjust area health budgets not just on a monthly basis but on a weekly one. That dialogue with the Treasury had to take place between Ministers. Barbara Castle was a Minister who was formidable in extracting money almost day after day to deal with the inflationary situation. The Secretary of State cannot stand aside from all these things. I see a former Chancellor of the Exchequer, the noble Lord, Lord Lawson. He knows too that in a rationing process it is not just what you spend by the state, it is also what you spend privately. It is the total budget that health takes. And if it gets too high, as it has undoubtedly done in the United States, it takes away from other private or public sectors. So this rationing process is one in which we are all involved. A Select Committee is the only procedure that can look at the complexity of this new relationship that we are trying to establish. If we get it wrong, we will be in very serious trouble.

The whole process of how we deal with failures must be dealt with. We admit there are going to be failures in some trust hospitals. There are going to be failures in some commissioning groups. If there was widespread failure, I think the public would find it very difficult that the issue was only being dealt with by the chairman of a quango - the largest quango we have ever created in this country.

I therefore beg the House to seriously consider this Motion. It is not a blocking measure, as my noble friend and I have made it absolutely clear. We accept that this is a reforming Chamber. Outside, at this moment, people are assembling a petition to support the idea of a Select Committee looking at the role of the Secretary of State. It is gathering momentum as I speak and I hope the House will listen to that before it goes and rejects this Motion. I am surprised by the tone of the Government's reply to the Select Committee, which I got just this morning before we started. I stress this is an all-party, unanimous Select Committee. I leave it to the chairman of that committee, who is speaking after me, to deal with these issues.

Cherish the fact that the NHS is one of the most popular public institutions in our country. Look hard at how we can retain that. Do not believe that, in adversarial debates across the floor of this House, you can get the balance right-the new balance that is needed for the Secretary of State for Health.

1 pm

Baroness Jay of Paddington: My Lords, I am delighted to follow the noble Lord, Lord Owen, and I will pursue the points he raised about findings of the Select Committee on the Constitution on the role of the Secretary of State. However, I start by also following the noble Lord in speaking briefly about what I see as the underlying principles of the NHS and the public understanding of them.

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Almost exactly 15 years ago, in November 1996, I was proud to introduce a debate in your Lordships' House to mark the 50th anniversary of the founding of the NHS, which also sought to reassert its public values. As so often happens in general debates in your Lordships' House, the debate attracted a wide range of speakers, some of whom I am delighted to see are also speaking today. There was general agreement on that occasion that, although healthcare and people's expectations of it, as the noble Lord, Lord Darzi, reminded us, have changed vastly since the 1940s, the old values of social solidarity and collective responsibility must be maintained into the 21st century. On that day for me and, I think, for many others present, the argument was given special force and passion by the late Lord Bruce of Donington, Donald Bruce, who was Aneurin Bevan's Parliamentary Secretary and helped to steer the original founding Bill through Parliament.

As today we are beginning our scrutiny of a Bill promoted as the biggest shake-up of the NHS since it began, I do not think it is irrelevant to look back at the principles which Donald Bruce and his parliamentary colleagues created. Recently I found again my family's somewhat dog-eared copy of Aneurin Bevan's testament, In Place of Fear. I am glad to echo the words of the noble Lord, Lord Darzi-in place of fear. The first sentence in the chapter on a free health service reads:

"The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health".

I say "hear, hear!" to that in 2011, as I would have done in 1946. He goes on later to say:

"A free NHS is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst".

I want to repeat those words not because I have any desire at all to see the NHS preserved in a kind of post-war aspic. Like other noble Lords who have spoken from these Benches, and indeed around the House, I am entirely in favour of change. But it is legitimate, when today's Government assert that they are proposing fundamental change while at the same time maintaining those underlying values, to test their proposals against some simple and original principles.

Let me say at the outset that I have never been a Bevanite or an old Labour purist about the provision of health services. I have long believed in a mixed economy of providers, and noble Lords around the House have correctly drawn attention to the changes made by the Labour Government in that direction. I could say anecdotally, to coin the phrase of the noble Baroness, Lady Bottomley-I hope that I am not being anecdotal in a negative sense, but in order to be illustrative-that right at the beginning of Tony Blair's Government, my right honourable friend Alan Milburn and I, as Ministers of State in the Department of Health, argued-I have to say unsuccessfully-that a private sector company should be allowed to build and equip a renal dialysis centre in a part of the country where the existing services were inadequate. Had that service happened-as I say, it did not-the centre would, of course, have been staffed and managed by the health service. When Alan Milburn later became Secretary of State, he did indeed allow some aspects of

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private sector involvement, as well as the voluntary and charitable sectors, to intervene in order to extend and improve local patient care. I am delighted that my noble friend Lord Hutton of Furness is to speak later in the debate because I am sure that he will record from his own history the way that programme was taken forward by the previous Government. However, I supported it only if-this was the central underlying condition-those providers were appropriately managed and planned for in the interests of patients and not the providers, based exclusively on quality and not on price competition, and remained firmly within the framework of NHS accountability.

Today, I have to say there is already an expectation, perhaps in anticipation of this Bill's passage, that a free market is opening up in a completely different way. I was alarmed to learn only 10 days ago, for example, that in Surrey a private company owned by the Virgin corporation is now the preferred bidder to run community health services in a deal worth about £500 million. The particularly disturbing aspect of the Surrey decision is that Assura Medical, the Virgin company, is preferred over a well respected local social enterprise mutual organisation, appearing to confirm fears that large multinational businesses will win out over smaller, less commercially sophisticated providers. I must say to the noble Baroness, Lady Bottomley, that I was not encouraged by her invoking the Tesco example.

If this is the future the Bill will create, it is a revolutionary and unwelcome system. This is a completely free, competitive market-a long way from the mixed economy of publicly accountable provision within the NHS set-up which I can accept as consistent with the original principles of the service. However, with the leave of the House I shall take a few minutes to come back to the principles of accountability, particularly the democratic accountability of the NHS. I want to refer to the recently published report of your Lordships' Committee on the Constitution, which I am privileged to chair, and to which the noble Lord, Lord Owen, and other speakers have already referred. As the Minister has said, we have already had a response to the report, but I am afraid to say that I only received it this morning and therefore he and the House will understand that the committee has had no chance to consider it in detail. However, I echo the concern of the noble Lord, Lord Owen, that although the Minister has been encouraging in private conversation and in his speech today about the possibility of amending the Bill so as to counter the concerns of the committee about accountability, the wording of his letter written to me last night states:

"We do not consider any amendments necessary to put this matter beyond legal doubt",

which is an exact contradiction of what the committee has said and what I understood the noble Earl to say in his opening remarks. Perhaps that can be clarified.

The primary concern of the committee is the question of the duties of the Secretary of State and his legal responsibility. To emphasise the point picked up by the noble Lord, Lord Clement-Jones, it is not that the Secretary of State and the Department of Health currently provide health services which under the Bill would be provided instead by clinical commissioning groups-everyone understands that Ministers have never

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directly provided services-but that under existing legislation, the Secretary of State is constitutionally and legally responsible for the provision of healthcare, whoever provides it and wherever it is provided. There are new so-called safeguards in the Bill in Clauses 49 and 50, but the Constitution Committee regards them as only a modest contribution towards a new form of accountability, and your Lordships may not regard them as sufficient.

Of course, the Constitution Committee has already proposed a simple solution; that is, to retain the existing wording in the current Act which in our view reflects the founding provisions established in 1946. I was surprised that in many exchanges in the House of Commons, Ministers seemed to be dismissive of concerns about these constitutional matters, simply suggesting that their words and the Department of Health statements were sufficient to guarantee that established health service principles were, to use the cliché, safe in their hands. Frankly, that arouses my suspicions. If the Government feel it is so obvious that the words in the Bill are irrelevant to the long-standing commitment of the Secretary of State to his responsibilities, there really is no reason why they should not accept the existing words as they are set out in the existing Bill. Perhaps I may find the quotation from the Minister's letter which suggests that he would be unable to deal with that fact. I ask the forgiveness of noble Lords. I received the letter only this morning and I may have lost the relevant page. However, I am sure we will return to this in Committee or at a later stage, but I was not encouraged by the Government's response to the Committee's report. As the noble Lord, Lord Owen, said, it was a thorough cross-party recommendation. If my suspicion that the Government are perfectly content to dilute their legal and constitutional responsibilities is correct, that is in order-as it states in another important clause, Clause 4-to promote "autonomy"; in other words, to promote a completely free, competitive market.

I apologise for the length of my contribution, but in conclusion I have been surprised by the volume of public correspondence precisely on the points raised in the Constitution Committee's report. There is clearly a widespread fear that this Bill will erode the democratic accountability of the NHS as well as the ethical co-operative foundations of the service. In my view, the Bill will need to be properly amended to allay those fears, and I would be grateful if the Minister will make it clear in his concluding remarks whether the Government are still open to that, and to be true to the founding principles. As a first step, I will certainly support the Motion put forward by the noble Lord, Lord Owen, that a special Select Committee should be established.

1.12 pm

Lord Kakkar: My Lords, I thank the Minister for his thoughtful introduction of this Bill and in so doing declare my own interest as professor of surgery at University College London and as consultant surgeon to University College London Hospitals NHS Foundation Trust. It is as a practising surgeon that I recognise the need for Governments to attend to the question of the National Health Service through the introduction of Bills that ensure its long-term sustainability.

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I also welcome the personal commitment to the National Health Service of the Prime Minister, the Deputy Prime Minister and the Secretary of State for Health. Those commitments, however, and indeed the introduction of this Bill, are themselves not sufficient: as we have heard from the noble Earl, Lord Howe, any Bill addressing the future of healthcare in our country must address the serious challenges that all healthcare systems around the world face.

These challenges represent the demographic change in society, with an ageing population attended by more chronic disease requiring ever greater intervention; the need to improve clinical outcomes to ensure that our patients receive the best healthcare possible and that this is done with due attention to the introduction of innovation, technology and new methods of treatment to achieve those improved outcomes; and, finally, that the provision of healthcare is delivered in the most cost-effective fashion to ensure that the vital funds available for healthcare are used most appropriately, recognising that the our economy faces a very serious challenge and will do so for many years to come and that the funds available for all public services, including healthcare, will therefore be limited.

How are we to chart these dangerous and difficult waters? I believe that our north star should be the patient and our road map the National Health Service Act 1946. That Act has defined the way that healthcare has been delivered in our country for six decades-and rightly so. But the legacy of Bevan's settlement has some important problems today with regard to the delivery of healthcare, specifically with regard to a particularly centralised approach to decision-making and the failure to engage at the outset primary care practitioners.

This Bill has the opportunity to deal with those two important issues in such a way that the foundations of the NHS, laid in 1946, can be built upon. If those two issues are addressed successfully, then local talent and innovation, driving the development of new therapies and new ways of delivering care, will help improve clinical outcomes. Full engagement of our colleagues in primary care, in the management of the service and its resources, will better help us connect with patients, the focus of our service.

There remains considerable anxiety about this Bill, not only among healthcare professionals, but among the people of our country more generally. As we have heard, this Bill comes for consideration at a time when our nation faces considerable challenges and difficulties. The national state of mind is one of anxiety, but there is also professional anxiety because of the scope and potential complexity of this Bill, which may be attended by unintended consequences that could disrupt the provision of universal healthcare. The profession is also concerned because previous reorganisations and upheavals, although well meaning, have not always delivered the benefits that were intended, and sometimes have had detrimental consequences.

It is the responsibility of your Lordships' House to move forward with careful consideration of all matters in this complex Bill to allay those anxieties, having undertaken very effective scrutiny and, where necessary, appropriate amendment of the Bill.

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I have a number of specific concerns beyond the accountability of the Secretary of State and how competition on the basis of quality will be promoted. I am concerned about how the new clinical commissioning groups are going to discharge their responsibilities in accordance with the Nolan principles of standards in public life. These are new public bodies and they will potentially be in a conflicted situation in their localities. These standards in public life need to be strongly promoted and maintained.

I am concerned also about how we are going to focus on outcomes in primary care and ensure that the delivery of primary care meets the very highest standards within the structures that are proposed. As a surgical academic, I am concerned about the potential impact on teaching, training and research, although I believe that there are opportunities for the Bill to address those issues and ensure that the vibrant academic basis for medicine in our country is strongly promoted.

Finally, I am concerned about how we will deal with failures of entire organisations and failure of services within those organisations before they reach a point where the welfare of patients is put into jeopardy.

Beyond legislation, Her Majesty's Government need also to outline their strategy for implementation. It is fine that we have a Bill, but the two fundamental issues that need to be addressed will be the question of culture change in the NHS and the development of leadership to ensure that the changes necessary to protect and promote the interests of our patients are properly delivered.

Beyond culture change and leadership, I am also concerned that this Bill is subjected early to appropriate post legislative scrutiny. It is an important Bill with important consequences and I hope that a mechanism will be found to establish a committee that would follow this Bill, through its implementation, to determine that what was anticipated is actually achieved.

Healthcare has always been a highly charged and somewhat political issue. The birth of the National Health Service in 1946 was a highly political issue and every reorganisation since has been attended by controversy. Your Lordships' House, however, has never felt it necessary to deny a health Bill a Second Reading, although in the health Bill in 2003, there was a vote at Second Reading. Nor has your Lordships' House felt it necessary to send parts of a Health Bill to a Select Committee. It has always felt itself able, with its vast expertise ranging from previous Secretaries of State for Health, constitutional lawyers, current and former medical and other healthcare practitioners, regulators and those more broadly involved in public life to provide the necessary scrutiny for a health Bill. Indeed, I believe that the people of our country expect us to provide thorough, vigorous but thoughtful scrutiny of this Bill to ensure continued universal healthcare, free at the point of delivery, for all the people of our country.

1.21 pm

Lord Naseby: My Lords, all my political life of some 40 years plus, I have been involved in debating the National Health Service. Reflecting on that time,

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this Bill is probably the most important debate on it over those years. I want to make it clear that I support the Bill. More importantly, I support the need for the Bill. The need is clear because we do not today have an NHS that is the envy of the world, which is something to which all of us in this Chamber would aspire.

Numerous problems need to be tackled, many of which were not tackled by the previous Government. Unless they are tackled in the near future, the outcomes for NHS patients will deteriorate. I compliment the previous Government on what they did as regards funding; namely, to increase the NHS budget, bringing it up as a percentage of GDP that is fairly comparable to France and Germany. But, sadly, whatever the noble Lord, Lord Rea, may think, read or say, we do not have a health service comparable to either of those countries.

However, the crying shame and legacy of that increased expenditure is that it was not achieved with productivity at the same time. The result is that the service is not able today to handle the demand, nor is it able to properly control its budgets and expenditure. We know therefore that, as a result, there is the problem of £20 million of efficiency savings left by the previous Government for the coalition to deal with.

The first challenge is how to get a real grip on expenditure to ensure that money is spent on patient care and not on bureaucracy. That is at the heart of the strategy of why my ministerial friends have produced this Bill. I personally welcome the end of PCTs, the removal of the other layers of bureaucracy and their replacement by GP commissioning. After all, we previously had GP fundholding, which worked really well for those who took part, particularly for patients as waiting times were driven down and minor surgery blossomed. But the problem was that it was not compulsory.

I recognise that this is a Second Reading debate. Therefore, we need to look at all the many representations that I and others in your Lordships' House have had in Committee, but not today. But I want to highlight some of the key issues that are sitting there writ large. Nursing standards in the NHS have fallen. The evidence is there for all to see. Somehow, the NHS and the Royal College of Nursing have to get a grip on this issue and have a total review of the training, the responsibilities, the supply for general nursing and for specialists, and, above all, the attitude of those nursing patients.

On the speaking of English, for too long the NHS has gone out and recruited doctors and nurses in huge numbers overseas and, allegedly, someone has checked their English. But we all know that that has not happened properly. There now needs to be a rigorous system of the checking of qualifications and the ability to speak English, particularly the ability to understand English in a medical context.

Perhaps more controversially, we need to have a long look at medical students. There is a clear need to review the number in training of doctors, nurses, physios et cetera. I have to say that, for one reason or another, today's medical school intake-the majority of whom are now women-is not working. I do not know why women do not stay in medicine but the majority of them do not. Medical schools need to

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look at this. The net result is that we have too few senior doctors because the female medical students have not stayed for too long in the service.

Why do we still have mixed wards in this country? We must be the only leading country in the world that still has mixed wards. I say to my noble friend on the Front Bench that I hope he will have a mission-for as long as he is on the Front Bench-to get rid of all mixed wards.

I have spoken previously on medicine, which I know something about in detail. GPs are one of the key gatekeepers and they are assisted by modern medicines, thus reducing the problems for hospital care. It is interesting that the money spent on medicines as a percentage of total healthcare spending has not changed very much over the decades. The NHS has to resist buying always at the cheapest level. It also needs to stop making its own medicines, as it does in certain hospitals. I am very sorry to say that an increasing problem is one of false and counterfeit medicines, to which somehow we need to find an answer.

There needs to be a better understanding of the appropriate relationship between the pharmaceutical industry and the NHS. There needs to be an understanding that incremental improvements in drugs are to be valued and not rejected. If we are not careful and do not get that relationship right, we shall end up with more problems similar to Pfizer's withdrawal from Sandwich.

Frankly, I think that there is something wrong with NICE. Why does it take longer than any other comparable body? Why does it refuse medicines that are accepted in Europe and even accepted in Scotland? I will not comment on community care, other than to say that it is a key issue in the Bill, which we all know needs to be looked at in huge depth.

Finally, competition is good for any industry. It makes it possible for new innovations, for better value for money and for solutions to be found. Competition gives people pride and responsibility. Even within the NHS there are numerous examples. To highlight eye care, what a transformation there has been from 20 or 30 years ago. The state does not have to undertake everything. It has to be a demanding purchaser, an experienced demanding purchaser, and vigorously assess outcomes.

I welcome this Bill and the Government's attempt to carry out change in a single, coherent programme, rather than a series of piecemeal initiatives, which is what we have had recently. The idea of having a Select Committee is totally inappropriate. I hope that the noble Lord, Lord Owen, will recognise what the noble Lord, Lord Darzi, said. We need to move forward. The NHS needs to know where it is going. Yes, the issue is important but it does not need a separate Select Committee to find an answer.

Lord Owen: The noble Lord must accept that this will not delay the Bill in any stages. The recommendations will be made by 19 December and the House will be considering this Bill into January at the very least.

Lord Naseby: I am sure that the House will be debating the Bill but the noble Lord cannot guarantee exactly when he will come back. He has already said

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that he could not. I am very sorry, but that would be a further delay, which would stir things up and provide some means of making it more difficult for the Bill to go through. This Bill needs to make progress to improve patient care and it does not need to be thwarted by delay. It is a unique opportunity, which we should grab with both hands, to give the NHS some real leadership. Above all, we should remember that the patient has to come first.

1.30 pm

Baroness Bakewell: My Lords, it is the genius of this country that in recent history it has enacted concepts of major significance in human progress. The Reform Act 1832 transformed our democratic process. The Education Act 1870 inaugurated an era of universal state education. In 1929 the creation of the BBC set the global template for world public service broadcasting. In 1946 the National Health Service was just such a bold and significant leap forward. As we consider how it might be improved, we need to bear in mind what we are changing: one of the finest, most highly regarded and valued institutions of British life, with a global reputation. The enduring essence of the NHS must not be yielded up to the transient imperatives of an external free market.

We must examine this Bill in the light of this conviction. We in the Lords enjoy the privileged opportunity of safeguarding what is so widely cherished. We must be vigilant to deliver improvement without sacrificing the underlying principle, that the NHS belongs to the people and is there to serve their interests.

We must also bear in mind that this Bill is not needed. There is no call for it throughout the country. Levels of satisfaction with the NHS were high and improving. Commissioning improvements were already under way under the last Government. No such proposals as now face us were spelled out in any party manifesto, nor in the coalition agreement. This Bill is in breach of a basic democratic contract.

What is more, many elements of the Bill are already being implemented before the Bill has been enacted. On 19 July Andrew Lansley let slip-it was a good day to bury bad news-that from next April £1 billion worth of NHS services, including wheelchair provision for children and a range of talking therapies, will be opened up to competitive bids from the private sector. The reputable Daily Telegraph blogger, Max Pemberton, who is also a doctor, called it,

Such changes are already in progress. This, when the Bill is not yet enacted, is surely constitutionally dubious.

The National Health Service is the victim of its own success. It has kept people healthier for longer and, together with science and public hygiene, delivered a population living years longer than in 1948. Meeting the needs of an ageing population is the biggest challenge that lies ahead. The old are not well served by current provision, or by the proposed changes.

We have before us already a comparison between the NHS and private provision in this country: healthcare for the old is provided by the NHS; social care, the

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care of the frail and failing, provided in their homes or in care homes, is subject to the market. For social care, either the state pays for the private provider or individuals and families do. We have already seen two things happen when private finance buys too far into care. First, the service itself can be deficient and the monitoring is poor. Local authorities putting out tenders for care services too often chose the cheapest on offer, risking low standards provided by a shifting population of carers on the minimum wage and with inadequate training. There is already evidence of this happening. Secondly, the care of the elderly becomes a market commodity. The company that first invests moves on and others move in to asset-strip the enterprise for their own gain; then they too move on.

The story of Southern Cross shocked us all. The 33,000 old people in the care of the former company that ran some 750 care homes have been passed from hand to hand. The homes themselves were owned by the Qatar Investment Authority, which charged exorbitant rents to Southern Cross and salted away its profits in the Isle of Man and the Cayman Islands. Southern Cross could not sustain its business model. A Unison report in June 2011 assessed that the care industry was worth £4 billion to private equity investors, but it is considered by them a high-risk investment, with many investors inclined to resell at the highest price in the shortest time. That is what Blackstone Equity had done with Southern Cross. The care of the frail and the needy is far from their first priority. The old are seen as a resource to be milked for profit.

The old are not well served by this Bill and yet they are overwhelmingly the most frequent users of NHS services. Patients over 65 account for 60 per cent of admissions and 70 per cent of day beds in NHS hospitals. Following the recommendations of the Dilnot inquiry into how to pay for social care, the NHS Commissioning Board should now call for a fundamental review of how the NHS assesses, prioritises and commissions health services to meet the needs of an ageing population, and what place competing private providers will have.

Private providers have long had a place in the NHS and are important to it and its commissioning process, but let us not go down the American route. A Harvard-led study found that 62 per cent of all bankruptcies in the United States in 2007 were due to medical bills, an increase of 50 per cent in six years. Most of those affected were well educated middle-class home owners. Astonishingly, three-quarters of them had had their finances destroyed by medical costs even though they had insurance. The latest figures from the World Health Organisation suggest that the US spends 2.4 times more on health per person than in Britain, yet British men live on average two years longer and British women one year longer than in the States.

The NHS has been doing much that is right for 60 years. Every institution can be improved, monopolies can get complacent, and people want choice. However, that does not mean switching the fundamental principle on which this great institution was built. It belongs to the people of this country and they do not want it run on a competitive model.

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1.38 pm

Lord Rix: My Lords, before I make my contribution to the debate, it is appropriate that I declare an interest as president of the Royal Mencap Society. In recent years, the NHS has made much progress in how it treats people with a learning disability. However, there remains plenty of scope for further improvement in its performance. It is important to emphasise that my concerns about the content of the Bill should not be interpreted as implying that I have full satisfaction with the status quo: far from it. However, I fear that positive steps that have been made could be undermined as a consequence of the Bill.

As many noble Lords will be aware, Mencap's interest in campaigning on improving the health chances of people with a learning disability is long-standing-with much reason. Research consistently shows that people with a learning disability still experience worse health outcomes and greater inequalities than the rest of the population. They have a shorter life expectancy and an increased risk of an early death. Their overall level of health is also generally poorer. Yet they find it harder to access the health services that for them are so much more of a necessity.

For example, annual health checks for people with a learning disability are vital. They are carried out by GPs, funded by the Department of Health, and are a recognition that people with a learning disability have additional problems with their general health. Yet latest figures show that in England only one in two such people takes up their right to these annual checks, meaning that more needs to be done to ensure that they access the health services to which they are entitled. This is an area where I am concerned that much of the progress over recent years could be undermined if, during a period of major reorganisation in the NHS, we lose focus on making this a priority.

General practice and the promotion of annual health checks are not the only areas of the NHS where progress has been made, but more needs to be done. Mencap's groundbreaking report, Death by Indifference, published in 2007, highlighted six premature and totally avoidable deaths of people with a learning disability in the care of the NHS. Your Lordships will recall that, as a consequence of the report, the previous Labour Government established an independent inquiry led by Sir Jonathan Michael, which published a report entitled Healthcare for All. This set out the steps that should be taken to prevent similar avoidable deaths in future.

In 2010, Mencap launched its Getting it Right campaign, which encouraged NHS institutions to sign up to a charter setting out reasonable adjustments that they should make to provide equality of health outcomes for people with a learning disability. The charter included steps such as producing materials in accessible formats, employing learning disability liaison nurses, and improving awareness of learning disability among healthcare staff. These steps, and others, have led to many changes in the way people with a learning disability are treated in the NHS. However, while some progress has been made, too often provision remains geographically dispersed and inconsistent. As the Department of Health's Six Lives: Progress Report, published in 2010,

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revealed, there continue to be concerns around the poor use of mental capacity legislation and the lack of reasonable adjustments to health services.

This is why I believe the real challenge during a period of change and reform in the NHS is to make sure that where progress has been made in driving up better health outcomes for people with a learning disability, that progress is not lost. This is particularly the case for those with more specialist needs, such as people with profound and multiple learning disabilities-PMLD. There is a great deal of concern about the commissioning of health services used by people with PMLD. The specialist services are often extremely expensive and will not offer the economies of scale that other, more profitable or locally attractive health needs can secure. As the number of people with PMLD is relatively small, what incentives will local clinical commissioning groups have to commission such services? Will other, more popular requests prove to be more appealing? What role will the NHS Commissioning Board play in ensuring that the needs of people with PMLD are not ignored?

As noble Lords will be aware, a key element of the Bill, and a fundamental principle of the Government's intentions, is the extension and promotion of patient choice in the NHS. However, "choice" can mean different things and has different connotations for different people, with widely different outcomes. Will those with the most persuasive elbows and articulate voices have greater opportunities for choice than those without? How will people with PMLD exercise choice under the new structures? What support for locally run advocacy services will be provided? What safeguards do the Government intend to put in place to ensure that some of the most vulnerable people in society, such as those with PMLD, can have their voices properly heard?

As I have made clear in my speech, too many people with a learning disability continue to face prejudice and discrimination when trying to access equal healthcare, yet their needs are much greater. I therefore ask the Minister how the Bill aims to tackle the health inequalities to which I have just referred.

Mention was made by my noble friend Lord Owen, who regrettably is not in his place, of Enoch Powell when he was Minister of Health. In 1962 I had occasion to visit him to ask him for an increase in NHS services for people with a learning disability. He told me that it was totally unnecessary and that progress had been made. Of course, he was talking arrant nonsense then, and I would hate to see this Bill reverse the progress that has been made on the implementation of high-quality services for people with a learning disability.

With so many speakers clamouring to have their heartfelt concerns about the Bill heard today and tomorrow, I cannot believe that the Minister will be able to satisfy all our demands in his summing up. Therefore, could he possibly afford the time for a further meeting with those of us who are interested in the world of learning disability?

1.46 pm

Baroness Billingham: My Lords, the overwhelming response to this Bill is: why? Given all the promises made by David Cameron prior to the general election, why is he now supporting such a dire, top-down

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reorganisation? Why is he reneging on his pledge to support the NHS fully? Why does he turn his face against the most comprehensive criticism from all major organisations and participants in the field of health, or against the opinion of the OECD and the Commonwealth Fund that the NHS is recognised as one of the most efficient and least costly in the world? It can make no sense unless there is an underlying sinister motive to advance the market philosophy into the NHS, which will ultimately destroy it. The cherished principles of the NHS as a universal service will indeed be lost forever.

Today I speak as one of many in this House who are raising fundamental objections to the Bill. The speakers' list is full of the most knowledgeable Members on NHS matters, Members who have given a lifetime of service to the NHS and to the community. I leave to them the forensic analysis and demolition of this Bill. I have no competence compared to them, but I can and will speak on behalf of those who have no voice here and who have written to me in their dozens, and on behalf of those who will rely on the NHS for their health provision in the future.

I also speak as one who very recently saw first hand the outstanding excellence of the NHS in all its separate parts and stages. The tumour on my lung was diagnosed by clinical excellence and co-operation, from my GP in West Hampstead to my local hospital, the Royal Free, and finally to my surgeon at the Royal Brompton Hospital. At every stage, from detection to operation, those involved were totally competent and professional. I was kept fully informed of every procedure. There were no delays and every piece of evidence was gained through the use of the most advanced technology available. I witnessed the result of years of investment in the NHS by the previous Government. How dare anyone question the value of the millions of pounds invested? The results speak for themselves and should be celebrated.

My personal journey, just 12 weeks ago, led to an eight-hour operation, carried out by three surgeons, which, I am thankful to be able to tell you, resulted in the complete removal of the tumour and the subsequent analysis that showed it to be non-malignant. I am a very lucky woman. This leads me to highlight one of my main concerns with the Bill: the effect it is having on the morale of those who deliver the service for us. Already in the midst of a pay freeze, with pensions threatened, the impact on existing staff of the threat from the Bill cannot be overestimated.

I saw at first hand the excellence of all parts of the service: the superb nursing staff; the administrators who make the system work; the teams of doctors and surgeons, working co-operatively, who ensure that the service is so outstanding. With GPs and many agencies working together, the service succeeds, but the Bill threatens that very ethos. How will the Bill affect the people involved in my experience, Dr Michael Beckles and his outstanding team at the Royal Free, or Mr Eric Lim at the Royal Brompton Hospital, people who made my recovery possible? Are they going to accept the draconian changes that the Bill inflicts on them or will they walk away and take their outstanding skills elsewhere? That, indeed, would be too high a price to pay and the loss would be immeasurable.

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No one denies that some rationalisation may be necessary. In fact, some changes are already under way. However, this sledgehammer of a Bill is blind to the fact that the quality of the service is dependent upon the people who work in it. To suggest that market forces, competitiveness-yes, and even greed-are a solution to the NHS's problems is nonsense. So I add my plea to the Government: think again. Listen to the knowledgeable critics and do not destroy the NHS, which has been an icon for the British people. Unless you do listen, you are wilfully signing the death warrant of the NHS and for that you will not be forgiven.

1.52 pm

Lord Mawson: My Lords, I am a social entrepreneur who, for 25 years, has danced with the dinosaur-like structures of the NHS. I have had my feet trodden on many times, as colleagues and I have attempted to bring some innovations into primary care. We know from personal experience how difficult it is to bring about a more integrated service and innovation within such bureaucratic and out-of-date structures. The vested interests in the BMA and elsewhere in keeping things unchanged and unchallenged are considerable. At the same time, a nostalgic view of the NHS prevails which is anti-business, but which fails to recognise that most GP practices are small businesses and always have been. Let us be honest. I, for one, wish the Government well with their difficult task in bringing much needed change to the NHS.

While many colleagues will have a lot to say about the new proposed structures in primary care, I will make a few simple but fundamental points that appear to have been overlooked. In my experience, trying to change very large organisations-in this case one of the largest in the world-takes time and a great deal of patience. It will involve getting behind those more entrepreneurial doctors who embrace innovation and a more integrated view of the world. In the experience of my medical colleagues, the offer of the biomedical model alone in primary care is too limited an approach for the kinds of health needs that are presented daily. A more integrated and holistic approach is needed, one which sees a human being as not just a bio-medical machine but a fully rounded integrated person set within a social context. Yet many GPs who are committed to positive changes and who are working with the Government to attempt to bring them about are feeling bamboozled by the torrent of paperwork that is being thrown at them by out-of-date anachronistic structures which only know one game-the old game.

In a culture where people are increasingly, through the use of technology, living in an integrated world where at the push of a button many choices present themselves, it will be difficult for this new generation of entrepreneurial GPs to create a flexible structure and innovative culture in the NHS, which is still dominated by silos and an ideology of health inequalities-an ideology which sounds very fine in theory but which, in practice, has many unintended practical consequences that do not favour the patient.

The entrepreneur Steve Jobs, founder of Apple, who has just died knew that technology can be the way into culture change and his technology has created a

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wholly new generation who no longer want silo-like responses to their problems but at the touch of a button to find an integrated solution.

I would like humbly to suggest a few small simple innovations that the GPs I work with inform me could make an enormous difference to both practice and culture as we seek to push the NHS forward. I have found that the way into large, seemingly immovable structures and organisations, as an entrepreneur, is often through small, simple things that make a big difference. I therefore ask the Minister the following simple, but vital, questions. First, why has the iPad not been used in hospitals and by GP practices and district nurses as a simple integrated communications tool? Secondly, why is it that a GP in Tower Hamlets cannot Skype a consultant in the London Hospital with the patient by their side? Everyone is increasingly using Skype in the real world to communicate and it is free. My medical colleagues tell me that 99 per cent of their patients see no problem with confidentiality rules. We need to remove a system and ideology that makes simple, obvious tasks so complicated. Thirdly, why is it that chest X-ray forms are different everywhere you go in the country. Why are they not uniform and available everywhere online? Fourthly, why have neither the Department of Health nor NICE produced a standard referral form for all types of referral to hospital?

I am a great supporter of the Government's decision to go local, but as an entrepreneur I know, as do my GP colleagues, that there is a whole raft of things that do not need to be developed in every part of the country. It is too expensive and unnecessary. I am told that there is a whole raft of rules stopping the modernisation of the NHS. When innovators like me attempted to cut through these rules in east London in some of the poorest housing estates in Britain, I was told by some at the time that the sky would fall in. It did not and the offer to patients improved. This institution desperately needs innovators, not more bureaucrats.

My colleagues and I are attempting at this time to build a new health centre in one of the most difficult housing estates in London-and here I must declare an interest-which is part of an integrated project on a particular estate that includes both a new school and 500 new homes. Every key partner is supporting the project but it is the outdated, overly bureaucratic systems and processes of the PCT that are simply getting in the way. There are some good people in this PCT, but I cannot imagine how they keep their sanity in such structures. I know this is a widespread problem as many people are retiring early across the country and there is far too much sick leave in the NHS. Ill structures make people ill.

How do we make the simple things happen that catalyse the changes that are necessary and make it worth coming to work for? How do we modernise the NHS and give GPs the tools to do it? I suggest that some of this is about enabling them to just use the simple tools of technology that you and I use every day. It is about giving civil servants permission to get behind innovators.

I would like to leave your Lordships with a final clue. Steve Jobs at Apple did not go around asking all his customers what they wanted. He did not consult them to death. He believed that if the product was

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good enough for him, it was good enough for them. The real test for those who oppose this Bill is: would you walk into the average inner city London GP practice and register yourself as a patient? Would you as a patient rank the quality of care provided there as high? If the answer to these two questions is no, then you need to embrace change within the NHS. Jobs achieved what few politicians do. He embraced entrepreneurship and innovation and created real and sustainable change. He focused on creating small innovations in technology that worked well, and then offered them to the world. On his sick bed, he showed a commitment and attention to detail that I have yet to see in many politicians and civil servants. The easiest way into the NHS impasse is simply to back those GPs and nurses who are not threatened by this new emerging world but who embrace it and grasp it with both hands.

We must back the innovators with a sense of purpose. Learn from those who make change happen. Is change going to be difficult? Will this Government get some things wrong? Yes. Innovation is always like that. The question is: can the organisation learn from mistakes? Can it learn by doing? Can it start walking instead of talking? You cannot hold back the ocean; let it flow.

2 pm

Lord Ribeiro: My Lords, I am pleased to follow the noble Lord, Lord Mawson, with his robust defence of entrepreneurship and innovation. The Health and Social Care Bill presents a once-in-a-lifetime opportunity to deliver a patient-centred health service. The Bill builds on the reforms of the last Labour Administration, but in a much more comprehensive manner. As a surgical registrar at the Middlesex Hospital in 1972, ward rounds consisted of doctors, nurses, physiotherapists, social workers and the lady almoner. Coffee in the sister's office provided an opportunity to plan the progress of patients from hospital to home care and support in the community. This was an example of hospital care working closely with social care. Subsequent reviews and reforms of the NHS have entrenched the separation between social care and health care, and this Bill addresses a need for an integrated service led by clinicians who should have a greater say in how the service is commissioned and delivered, but must also be prepared to accept the responsibility and accountability that this autonomy provides.

For too long, political interference in the day-to-day management of the NHS, occasioned by the need for politicians to account for taxpayers' money, has bedevilled the NHS. Micromanagement and top-down diktats imposing targets and guidance, often with no sound clinical evidence to support them, have frustrated clinicians over the years, stifling leadership and innovation. I should know, because I have often been at the receiving end. The emphasis placed on quality outcome measures by the noble Lord, Lord Darzi, as he eloquently outlined today, and in his NHS review of 2008, indicated for the first time a move from politically driven targets which were process-based to evidence-based practice supported by research.

The Government's White Paper Equity and Excellence: Liberating the NHSwas widely welcomed in July of this year by the profession. It noted that:

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"The primary purpose of the NHS is to improve the outcomes of healthcare for all".

It went on to say:

"Building on Lord Darzi's work, the Government will now establish improvements in quality and healthcare outcomes as the primary purpose of all NHS-funded care".

Clause 2 does just that. It talks about outcomes, the effectiveness of the services, measured by clinical outcomes and patient-reported outcome-something which is already happening within surgery, the safety of the services and the quality of the experience undergone by the patient. The inclusion of research as a new duty for the Secretary of State puts an onus on him or her to promote the use of evidence obtained from research, a duty which also relates to the NHS Commissioning Board and the clinical commissioning groups. Other noble Lords will, I am sure, speak about the importance of research, but it is important that the Chief Medical Officer who, as the Chief Scientific Adviser and Director of the National Institute of Healthcare Research, must be given the independence of action to ensure that the Commissioning Board and the clinical commissioning groups take account of the evidence of research.

In a debate on the NHS Futures Forum on 15 September, I raised the issue of the independence of the Commissioning Board and the need to free it of political interference. I referred to the King's Fund report Reconfiguring Hospital Services as an example of how hospital services can be reconfigured without political interference, making reference to the experience in Ontario. The decision to close the A&E and maternity services at Chase Farm was an example of how the evidence for reconfiguration has been available for many years-17, I believe-but the political will to use it was lacking. Freed from such pressure, the Commissioning Board should be able to make decisions which politicians find difficult to make, even when the evidence for change is there for all to see.

The White Paper also called for clinical leadership and this was echoed by the Future Forum. Now is the time for the medical profession to stand up and be counted. The Royal College of Surgeons, of which I am a Fellow and a patron, has said very firmly that the time for delay has passed. It is nine months since the Bill was first read; an in-depth review by the Future Form, taking evidence from more than 7,000 people and receiving 25,000 e-mail comments, has been accepted almost entirely by the Government and many amendments reflecting their concerns are now included in the Bill.

As a surgeon, I am aware that we must do more to deal with the demand for healthcare. Much of this relates to public health. The problems relate to obesity. Britain has among the worst levels of obesity in the world and it is increasing. Smoking claims over 80,000 lives a year, and alcohol dependency is a problem for 1.6 million people in the UK. These are all public health issues which put enormous strain on the capacity of the NHS to cope. Diabetes, cardiovascular disease, respiratory diseases and cancer are some of the non-communicable diseases which are on the increase and they require prevention rather than cure.

Public health, in the form of clean air, clean water and sanitation and vaccination against communicable diseases, improved the health of the nation during the

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last century. It has increased the quality and the extent of life. We need to make provision for our elderly population, through greater integration of our health services, dealing with social care as well as acute care, and focusing on a care pathway, not just the condition. The Secretary of State's responsibility for public health is welcome and is a clear indication that the Cinderella service has come of age and can take its place alongside acute care in terms of the total care of the patient.

Like many noble Lords, I have received countless e-mails about today's debate. An abiding theme is privatisation and the Americanisation of our health service and the threat of cherry-picking by American companies. It might be helpful to put the term "cherry-picking" in context. It was first used in a submission I made as president of the Royal College of Surgeons to the Health Select Committee of the House of Commons when we were meeting on the independent sector treatment centres in February 2006. On 10 January 2006, the Secretary of State said of the independent sector:

"But I recognise that other reasons for using the independent sector to add to the innovations already happening within the NHS and to introduce an element of competition and challenge to under-performing services is a harder argument to win, so we will continue to respond to legitimate concerns, for instance to ensure that training for junior doctors is provided within the independent sector treatment centres"-

that still has not happened-

That was five years ago. In my oral submission to the Health Select Committee on 9 March 2006, I welcomed the Secretary of State's statement as it sought a level playing field. "Any qualified provider"-with the emphasis on "qualified", as the noble Baroness, Lady Jay, required-seeks to ensure that competition within the NHS will be fair. It is not a new concept and I believe that the Bill addresses the concerns raised in 2006. In Committee, I will seek to explore in more detail how post-operative complications arising from surgery by qualified providers will be managed, to ensure that they do not place an unfair burden on the NHS. For many years, the medical profession has called for an end to top-down management, targets and political diktats on health, and they remain frustrated with the workings of the PCTs.

This Bill heralds a shift from central command and control to patient and professional power. It provides an opportunity to improve health outcomes for patients and remove layers of bureaucracy which have built up, at great cost to the NHS. No change is not an option. Doing nothing will see health costs rise to £130 billion by 2015. We need to act now to safeguard the NHS for future generations.

2.09 pm

Baroness Williams of Crosby: My Lords, I agree completely with the noble Lord, Lord Ribeiro, that major changes have to be made. Those of us who are raising major issues in this debate are not arguing against change; we are not bound to the status quo. But I want to say right away that one of the things that I find deeply depressing about this long debate on the

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National Health Service is the number of references to the NHS as if it has somehow failed. One of the most remarkable assessments of the NHS, a copy of which I have left in the Library, is made in a report by the Commonwealth Fund of Massachusetts. It shows that on every issue from access, value for money, share in expenditure and patient satisfaction-which achieved 92 per cent-puts Britain uniquely ahead of everyone else in reply to the question, "Are you confident that you will receive the most effective treatment if sick?". It is a staggering statement about this remarkable public service.

First, I want to underline and repeat what was said by the noble Baroness, Lady Jay. Those of us who take the view that this Bill needs to be looked at carefully, not least the issue of the responsibility of the Secretary of State, are not saying for a moment that there is no role for the independent sector, for innovators or for those with radical ideas, but straightforwardly that that must be within the framework of the National Health Service as a public service, which is what many of us believe in so profoundly.

My second point is one that I also believe to be very important. We have referred repeatedly to patients in the debate, but patients are also people. As people, they have registered time and again their belief and trust in and commitment to the NHS. We want to carry them with us through some of the biggest changes that have to be made. Those changes reflect our ageing population, which is one of the greatest successes of the NHS, along with the survival of many people with inherited or chronic illnesses. All this can be directly attributed to the work of the NHS over the past 65 years. However, now they have become a problem because we have to find ways to pay for them. Even so, they are a direct consequence of success, not of failure.

What also needs to be said loud and clear is that patients have indicated their trust in the NHS. We need that trust deeply in order to bring about the changes that must be made. I agree with the Minister, the noble Earl, Lord Howe, that those changes require that the NHS should become, among other things, more community based and that we should move away from an essentially curative, hospital-directed form of health service. But in making that huge change with all the exciting possibilities it offers, we have to carry the public of England with us. We will not carry them if their single greatest fear appears to be sustained. It was put beautifully this morning by the noble Lord, Lord Hennessy, on the "Today" programme: it is to move away from the concept of an altruistic health service to one that is essentially market based.

I have spent the past week in the United States and returned yesterday. The first thing I read when I got there was the estimate of the Kaiser Family Foundation, probably one of the best of the private health services in the United States, that the cost of health insurance has doubled since 2001, has increased by 9 per cent since last year-much more than the rate of inflation-and that the average cost of a family insurance package in 2010 was over $15,000. Not all of that is paid by the insuree as some is paid by employers, but they are running away from those costs as fast as they know how. I also read a proposal from the National Institutes

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of Health that great care should be taken about offering tests for prostate cancer in men when one of the side-effects is probably incontinence and impotence. Despite the advice of the central authorities, the attitude of many doctors is that they cannot give up these tests because they happen to be extremely profitable. For those who wish to read more about it, I have left the story in the Library. It is a frightening account of the conflict between medicine and its values and the pursuit of profit.

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