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I turn now to the four big issues that confront us, and in doing so I pay tribute to the noble Lords, Lord Darzi and Lord Owen, and to others who pointed to them. The first was referred to by the noble Baroness, Lady Jay. It flows from the findings of the Constitution Committee, which has specifically raised concerns about the responsibility of the Secretary of State. At the beginning of his remarks, the noble Earl, Lord Howe, whose empathy and understanding is known throughout the House, spoke as if there might still be some meeting of minds on this crucial issue. But the letter he sent us all this morning appears to sound a little different. Why are we so concerned about this issue? It is because it remains ambiguous, unclear and obscure. Let me give one example. I think that I have been pursuing the issue of the accountability and responsibility of the Secretary of State for at least a year, and time and again I have gone back to the Department of Health and talked about the need to make it absolutely clear. Why is it not absolutely clear?
Those noble Lords who have a copy of the Bill need only look at Clause 4, which sets out a specific commitment to the autonomy of the bodies, the quangos -Monitor and, even more important, the NHS Commissioning Board-which now have responsibility for our health. The Secretary of State makes a specific pledge to the autonomy of those bodies in the phrase:
"In exercising functions in relation to the health service, the Secretary of State must, so far as is consistent with the interests of the health service, act with a view to securing ... that any other person exercising functions in relation to the health service ... that it considers most appropriate, and ... that unnecessary burdens are not imposed on any such person".
In legal language, "any such person" is very wide indeed. The autonomy clause indicates that only in the rarest circumstances would the Secretary of State interfere in that autonomy. So where would he interfere? The answer is that he would interfere if there was evidence of a significant failure. But my legal colleagues tell me that "significant failure" is a difficult bar to reach and that it is normally interpreted by the courts as meaning almost totally essential.
We all know about the danger of reactions to such things as necessary hospital closures, mergers and so on. But if the Secretary of State is unable to take any part in those until the failure becomes significant, heaven help us in making the changes that lie in front of us as effectively, cheaply and sensibly as we can. I wish very much that I could ask the Minister of State to tell the House at the conclusion of this debate that the ministry will now reconsider the autonomy clause in the light of the responsibilities of the Secretary of State. To put it simply, the expenditure of £128 billion of taxpayers' money requires the presence of a Minister who is responsible and accountable for that huge sum.
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That does not mean to say for a moment that I do not wholly agree with the noble Lord, Lord Ribeiro, about the dangers of micromanagement; all of us recognise that. Endless interference with the discretion of clinicians, GPs and the professions ancillary to medicine runs against the need for change and for sensible outcomes. But there is no reason whatever why micromanagement cannot be ruled out-much of the rest of the Bill suggests it-without having this vast reorganisation thrust upon us. So let me say to the Minister of State, for whom I and the rest of the House have immense respect, that I hope that before the debate concludes he will be able to say something more about the autonomy clause and the responsibility clause.
There are several other issues of crucial importance: the failure of the Bill to address the education and training of doctors in any serious way at a time when those services are in chaos, and the Bill's failure actually to be clear about the duties towards inequality, because the phrase "have regard to" is, in legal parlance, paper white. It does not mean very much at all. There are other points, but given the time I will not pursue them. I simply beg my friends and colleagues on whatever Bench they may sit on in this House to put the responsibilities of parliamentary democracy and accountability ahead of the detail of the Bill and recognise the significance of what has been addressed by the noble Lord, Lord Owen, and the noble Baroness, Lady Jay.
To ask Her Majesty's Government what steps they are taking to encourage small businesses by revisiting the qualification threshold for the regional growth fund and by establishing a small business bank created with initial bonds funded by the Monetary Policy Committee.
The Parliamentary Under-Secretary of State, Department for Business, Innovation and Skills (Baroness Wilcox): My Lords, we see no need to revisit the qualification threshold for the regional growth fund. In round 1, a third of funding allocated-some £150 million-was targeted at SMEs. It is not the job of the Monetary Policy Committee to establish a
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Lord Harrison: My Lords, the Government seem more interested in giving cheap phone access to Ministers for big businesses than getting cheap loans access to small businesses that are starved of funds. I ask the Minister again to look at the regional growth fund, the qualification for which is a £1 million claim by any small business. I ask her to look at some fresh ideas, like those of Professor David Blanchflower, for creating within the Bank of England, through the MPC, a bank which is capable of offering loans to small businesses at low rates of 2 per cent.
Baroness Wilcox: If the noble Lord will wait for the Chancellor of the Exchequer to explain what he is going to do about credit easing, the noble Lord might take comfort from that. In the mean time, there is no doubt that the fund is accessible to SMEs; it is available through specific bids from organisations with experience of the SME sector that will be able to help make small grants, below £1 million, available to projects that support the fund's objectives.
I have a couple of examples which might help. The Plymouth University and Western Morning News growth fund was announced in the summer, which targets that money directly at SMEs in the south-west of England. That will work well. Contracts have recently been finalised on the majority of engineering projects in the RGF-supported SME energy cluster in the north-east, headed by Chirton Engineering Ltd. That will be delivering 140 jobs. Although £1 million sounds too high for a small organisation, it would have been impossible to look at every one of those small applications. If anyone wishes to phone the regional growth fund, they will be helped and guided as to how they can come together with other small businesses to take this money. As your Lordships can see, we have already made available some nice amounts of funding-almost a third-to the SMEs.
Lord Howarth of Newport: My Lords, we certainly look forward to the Chancellor of the Exchequer explaining what he intends by credit easing. Would it not be the case that credit easing would tend to increase the public sector deficit to the extent that Government-backed loans to small and medium-sized enterprises underperformed? What would be the costs to SMEs in professional fees and regulatory burdens of issuing bonds? Is not the proposal to package up, securitise and sell into the marketplace loans to SMEs that banks are not otherwise willing to make all too reminiscent of the US sub-prime disaster?
Baroness Wilcox: I have listened carefully to what the noble Lord has said, but, as he well knows, I cannot say anything in response at the moment because
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Lord Cotter: My Lords, manufacturing accounts for 12 per cent of GDP but 50 per cent of our exports. Can I ask the Minister to give an assurance that the Government will concentrate in the future on financial support for manufacturing, which is very complex-there is a need for seed capital and a need for support for research and development in new technologies in particular? There is also great concern that the private banking sector is not sufficiently delivering on lending, which is a disappointment following the Merlin initiative.
Baroness Wilcox: The ECGD covers all of that, of course. Today I am delighted to say that the Government are funding manufacturing research in a drive for future growth: a £170 million package to sharpen the UK's competitive edge has already been given out; a high-value manufacturing technology and innovations centre is receiving £140 million over a six-year period; and the TSB and the Office for Low Emission Vehicles will be running a £15 million competition for investment into the research and development of low-carbon vehicles. I am delighted to be able to announce that today.
Baroness Wall of New Barnet: Can the noble Baroness give us any more details on the Government's intention to support the BAE Systems workers? She will know that it was announced earlier this year that 3,000 workers were to be made redundant and that, in both Yorkshire and north-west England, very highly skilled people are being displaced as a result. The Government promised support. Please can you update us on that?
Baroness Wilcox: We have of course created a new enterprise zone in that area especially for this. These are terrible times, and the idea of seeing any jobs go at the moment, certainly in the private sector, goes against everything we wish for growth. That enterprise zone is there and we will put every help we can into that area. The Government's economic policy objective is to achieve strong, sustainable and balanced growth that is more evenly shared across the country and among industries. We will therefore look very carefully at any other incidence of this happening.
Baroness Wilcox: It is quite amazing how much demand there is from small businesses for loans. The great thing about small and medium-sized businesses is that they tend to be very optimistic. I grew up in the world of small and medium-sized enterprises, where, against all the odds, you would very often see someone setting up a business in an area where everybody else said it could not possibly have happened. Yes, we are very encouraged by the amount of requests we are getting.
Baroness Royall of Blaisdon: My Lords, in her answer to my noble friend about what the Government are doing to assist those workers who were so tragically being made redundant from BAE Systems, the Minister mentioned local enterprise zones. Can she tell us exactly what the local enterprise zones are going to do to assist in finding jobs and supporting small and medium-sized enterprises in those areas of the country? Would it not have been better to have retained the RDAs?
Baroness Wilcox: The RDAs were enormously expensive and were not value for money. I am very glad that we are finished with the RDAs, although one or two of them were extremely good. I hope that the local enterprise initiatives will enable people to take themselves forward so that they do not always turn round and depend on the Government, which is not a good way to take forward the private sector-the sector that will actually start to bring our country out of this deep depression that we find ourselves in.
The Parliamentary Under-Secretary of State, Department for Communities and Local Government (Baroness Hanham): My Lords, the Government do not have any particular definition of multiculturalism. They welcome the strength that the people of many nations, religions and cultures who live in this country derive from their common heritage. By sharing and understanding these differences in our communities, we can draw on the full range of their talents and find those things that unite us. Segregation for any reason is contrary to the need for all communities to integrate and live together in harmony.
Lord Harries of Pentregarth: I thank the Minister for her reply, but would she not agree that it is very important to have a clear definition? In an important speech in Munich earlier in the year, the Prime Minister mentioned multiculturalism in a key paragraph but gave no definition of it. However, he implied by the end that it encouraged separate development. Multiculturalism is what philosophers used to call a "boo word", or "hurrah word", so would it not be helpful for everybody if the Government had a very clear definition and made clear what they approved of and what they did not approve of?
Baroness Hanham: My Lords, in talking about people living together and communities coming together, it is very hard to say what one approves of and what one does not approve of. It is absolutely essential that we all understand that in this country we have an enormous number of different nationalities and cultures. The
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Lord Popat: My Lords, does my noble friend agree that, while cultural diversity and tolerance towards other cultures and religions is a good thing, the Government's position as set out by the Prime Minister -in Berlin, not Munich-of supporting an overriding and unifying national identity and not appeasing or supporting extremist organisations who undermine British culture and values, is the right approach?
Baroness Hanham: My Lords, I think that is what I have been trying to say in my two previous answers. The Government are fully aware of the tensions that there can be between communities; they are extremely anxious to see that those tensions are lessened and will use whatever methods they can to make sure that integration comes about and that people are content to live together in this country which, on the whole, has been blessed with fewer tensions than elsewhere.
The Lord Bishop of Blackburn: My Lords, my own responsibility includes Burnley which, some 10 years ago, had its own local disturbances. Therefore, I welcome all moves towards greater multicultural working, especially through the near neighbours scheme that has recently been introduced. Could the Minister confirm that, subject to satisfactory assessment when the three-year trial period for the near neighbours scheme has expired, the scheme will continue?
Baroness Hanham: My Lords, it is a three-year scheme, so at this stage I cannot absolutely confirm that it will continue, but I can confirm that we attach enormous importance to it and are extremely grateful for the church's involvement in that fund. We will certainly want to assess its results. Following its successful launch this summer, we are going to scale up the scheme next year to give up to 30,000 16 year-olds the chance to meet with young people from different backgrounds. The church is providing a very strong lead on this.
Lord Hannay of Chiswick: My Lords, would the noble Baroness agree, having wisely ducked the request to define multiculturalism, that it might really be better if everyone including Ministers-and including the Prime Minister-stopped talking about this as an "ism" at all? It is utterly misleading to do so. It would surely be better, as I think the noble Baroness has started to do in her replies, to address the issues, in a society that is necessarily, and will continue to be, multicultural.
Baroness Hanham: My Lords, "ism" or not, the word is in the vernacular one way or another. I do not think it matters whether it is an "ism"; it matters what we mean about trying to ensure that people are supported in their own cultures so that, by definition, they are
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Lord Knight of Weymouth: What is the Government's policy towards multiculturalism in schools? Given the current concerns about the curriculum being squeezed out by the EBacc, is the noble Baroness in conversation with Ministers in the Department for Education about making sure that there is room in the curriculum for citizenship and that schools are continuing to promote community cohesion, as is their statutory duty?
Baroness Hanham: Schools have a statutory duty to support cohesion, and I think most schools do that. One of the most important aspects of bringing up children in this community is that they should speak English. There is a very strong commitment to ensuring that children are given English lessons at an early stage to ensure that they can not only participate in school but understand where their friends who are living here are coming from.
The Department for Education will answer for itself about citizenship, but I can say that we will continue to fund classes that encourage English. In general, we think that one of the biggest strengths that comes from multiculturalism is speaking English, which is the common language. We should bear in mind that people will want to continue to support their own ethnic languages, but they must do that in a way that ensures that their children and, where possible, the elders all speak English.
To ask Her Majesty's Government, in the light of the number of asylum decisions overturned on appeal, in particular among female asylum seekers, what steps they are taking to ensure that women fleeing gender-based persecution receive fair asylum decisions.
Earl Attlee: My Lords, the Government recognise that women can face particular forms of persecution that are quite often different from those faced by men, and are committed to ensuring that women's claims for asylum are dealt with as fairly and sensitively as possible. The UK Border Agency is working closely with a range of key corporate partners in developing improvements to the asylum system. This will increase gender awareness throughout the asylum process.
Baroness Bakewell: I thank the Minister for his reply, and for implying that there is still space for improvement. Perhaps he knows the case of the playwright Lydia Besong, who sought asylum here in 2006 having been imprisoned and raped in Cameroon for being a member of the Southern Cameroons National Council. She has been refused asylum and is under threat of removal. Does the Minister agree that women such as Lydia-and there are several-who suffer gender-related persecution should be protected rather than sent back to face further risk, and that early access to legal representation for appeal would reduce the costs of the asylum process?
Earl Attlee: My Lords, Miss Besong is a failed asylum seeker, having had her appeal and further submissions dismissed by the courts, not by UKBA. She became appeal rights exhausted this year and therefore subject to enforced removal action if she refuses to leave the UK voluntarily. On the noble Baroness's second point, about leaving it to appeal, it is open to legal and other advisers to introduce new evidence to the UKBA at any point between the original decision and the appeal hearing. Asylum could then be granted before the appeal is heard. It is not clear to me why this does not happen more often.
Lord Avebury: Does the noble Lord accept that at the asylum stakeholders' meeting on 4 August the UKBA said that it had not released any victim of gender-based violence from the detained fast-track and did not consider it a reason for releasing a person? Is this not a breach of the undertaking that was given to the High Commissioner for Human Rights at the Council of Europe that:
Does my noble friend accept that as the success rate of appeals by women against refusal of asylum is running at 50 per cent, it is clear that the improvements in procedures for dealing with gender-based violence in the criminal justice system have not read across to the UKBA?
Earl Attlee: My Lords, I think I have already explained why there can be very good reasons for the overturn rate at appeal. As regards the noble Lord's question about detained fast-track, I am confident that legal protections for the detainee must be in place, but I shall write to the noble Lord on that point.
Lord Martin of Springburn: My Lords, there were more asylum seekers in my previous constituency of Glasgow North East than in any other part of Scotland, with 90 per cent of the cases at my surgery being asylum seekers. They were made most welcome by some of the poorest communities in the United Kingdom, but should there not always be monitoring in these communities to ensure that enough resources are going in to help where there is strain on local health services, schools and housing departments?
Earl Attlee: My Lords, the noble Lord makes an important point about the need for care. One reason why you see concentrations of certain nationalities in certain places is that communities tend to become established, and it is natural for asylum seekers to go and join their own community in the UK.
Baroness Kennedy of The Shaws: My Lords, perhaps I may return to the issue of gender. The running rate of 50 per cent of women succeeding in appeals, which is almost double that of men, is suggestive that there is poor decision-making and a culture of disbelief at the first instance in relation to women. Is that therefore not a signal, first, that there is poor training and, secondly, that there should be legal representation when the women are first interrogated and questioned because they are having to deal with sensitive matters such as sexual violence?
Earl Attlee: My Lords, I largely agree with the noble Baroness. The problem is that the matters that the applicant has to explain to the UKBA officers are extremely sensitive and the applicant has not yet acquired confidence in the machinery of our state because the machinery of their home state has totally failed.
Baroness King of Bow: My Lords, following on from the noble Baroness's point, is the Minister aware of Asylum Aid research which stated that there was a "striking failure" of understanding what was happening to these women on the part of those making the decisions? Would the Minister be prepared to meet me and other interested Peers to discuss how the UKBA training could be improved? Women deserve better than they are currently getting.
Earl Attlee: My Lords, I entirely agree that women deserve better, and we are working at improving our performance. We are not saying that we are perfect but often new evidence is introduced at a later stage when the applicant becomes more confident or has better legal advice. I shall of course be delighted to have a meeting with all noble Lords who are interested in this matter and I shall take steps to make sure that that happens.
The Parliamentary Under-Secretary of State, Department for Business, Innovation and Skills (Baroness Wilcox): My Lords, the simple answer is that this Government already have a strategy. The Plan for
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Lord McFall of Alcluith: My Lords, having witnessed almost zero growth during the 17 months of this Government and with pleas from influential Conservative Back-Benchers and sympathetic industry bodies for a coherent economic plan, is it not time for a radical response from the Government to what the Governor of the Bank of England has described as possibly the worst ever financial crisis by the establishment of a national infrastructure and investment bank to generate jobs and employment in this country? I remind the House that we have a duty to the more than 1 million young people in this country-a record level of unemployment not seen since the 1980s-to help them to inherit a worthy future rather than an economic and social graveyard.
Baroness Wilcox: The noble Lord has outlined exactly what we are striving to achieve. Without doubt, we are looking across the whole of the education and skills system to consider how to maximise economic growth and we shall be reporting on that in the autumn. He asks what we have achieved. As I have already said, the Business Secretary, Vince Cable, has today announced a £170 million package to drive future growth in manufacturing; we have reduced the main rate of corporation tax from 28 to 26 per cent and it will go down to 23 per cent; a £2.5 billion business growth fund has been launched; and we have already announced 24 enterprise zones in the country, helping to create thousands of new jobs by 2015, which will attract hundreds of new start-up firms with simplified planning rules, superfast broadband and more than £150 million in tax breaks for new businesses over the next four years. I have a longer list, but I am sure that someone else will wish to ask a question. I hope that the noble Lord feels encouraged by my answer.
Lord Low of Dalston: My Lords, is it not the case that the Government have got their policies in the wrong order? Instead of pursuing deficit reduction in the short term and growth in the medium to longer term, should they not be pursuing growth in the short term and deficit reduction in the medium to longer term?
Baroness Wilcox: Reduction equals low interest rates, my colleague beside me murmurs. Without doubt, we are trying to get Britain back on track. It will take time, but we are determined to do it deeply and well. The Plan for Growth is based around four ambitions: creating the most competitive tax system in the G20; making the UK the best place in Europe to start, finance and grow a business; encourage investment and exports as a route to a more balanced economy;
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Lord Forsyth of Drumlean: My Lords, is not the truth of the matter that it is extremely difficult to get growth in a situation where half the national income is being spent by the Government and the national debt has been doubled in every Parliament? That is the inheritance which this Government have been handed. Has my noble friend seen the ideas put forward by Sir Brian Souter, who started with nothing but a loan from a parent, and who has built a major business in our country? He suggests that the enterprise allowance scheme should be extended so that loans that are provided by relatives are eligible for the scheme. As almost anyone who starts a business knows, it is very hard to get money other than from a relative, and yet they are excluded from the scheme. Is this not an idea that could actually make a difference?
Baroness Wilcox: I am very interested to hear what my noble friend has said. We are looking at all sorts of ideas to start bringing us forward. As you say, Brian Souter would have said, "Get on your bus", not, "Get on your bike".
Lord Barnett: If the noble Baroness cared to have a word with her noble friend Lord Sassoon, who is sat next to her, he would explain that there is no chance whatever of her growth strategy working while the deficit reduction plan is so inflexible. As the noble Lord, Lord Low, has said so well, without growth we have a growing deficit. Please have a word with the noble Lord, Lord Sassoon. If he is being honest, he will tell the noble Baroness the truth.
Baroness Wilcox: I am very lucky indeed to have a colleague like my noble friend Lord Sassoon to work with and to depend on. The Plan for Growth lays the foundations for a stable and rebalanced economy. As the Prime Minister said last week, we have a plan to achieve strong, sustainable and balanced growth and we are sticking with it.
Lord Newby: Does the Minister agree that Whitehall has a very poor track record in getting major infrastructure projects moving forward expeditiously? Can she therefore tell us what steps BIS is taking to support the initiative of the Chief Secretary to kick start 40 major infrastructure projects?
Baroness Wilcox: He is doing everything he can. It is a good question and I am happy to respond to it. We are obviously committed to an export-led recovery,
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Lord Higgins: My Lords, third time lucky. I welcome the recent decision to increase quantitative easing since an increase in the money supply is essential if growth is to be sustained. Does my noble friend agree that fears that this will increase inflation need at least to take into account the very high level of excess capacity in the economy, which will be used if the Government adopt a policy of quantitative easing?
Baroness Wilcox: I absolutely agree with my noble friend. Quantitative easing is a positive move to help the British economy. The evidence shows that it should keep interest rates low and boost demand, which will help families, too, at a very difficult time.
Lord Risby: My Lords, I understand that no amendments have been set down to this Bill and that no noble Lord has indicated a wish to move a manuscript amendment or to speak in Committee. Unless, therefore, any noble Lord objects, I beg to move that the order of commitment be discharged.
Baroness O'Loan: My Lords, prior to the drafting of the Bill, we had assurances from government that there would be no top-down reform of the National Health Service, a service which is so highly regarded internationally, as the noble Baronesses, Lady Billingham and Lady Williams, said earlier.
The level of concern about this Bill must surely be virtually unprecedented. Representations have been received on a massive scale from hospital consultants, the College of Occupational Therapists, health service managers and, in one case, 1,000 doctors writing to a
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"The Bill will do irreparable harm to the NHS, to individual patients and to society as a whole. It ushers in a significantly heightened degree of commercialisation and marketisation that will fragment patient care; aggravate risks to individual patient safety; erode medical ethics and trust within the health system; widen health inequalities; waste much money on attempts to regulate and manage competition; and undermine the ability of the health system to respond effectively and efficiently to communicable disease outbreaks and other public health emergencies".
In the creation of the internal market so many years ago, we saw change of a much lesser kind, and it resulted in the creation of hundreds of new bodies which accelerated the cost of NHS administration over the years. I sat on a health board at that time and recall vividly the perplexity and inefficiencies which resulted. Those changes had to be undone at immense cost. There is significant concern that the current proposals are even more unthought-out in their formation. We cannot afford unplanned and ill-thought-out change at a time of economic turbulence with the ongoing threat of global recession.
The NHS is not broken; it is simply being tasked to carry out more and more work for a rapidly expanding population, which is also living longer in a world in which science is providing the answer to many medical problems which were previously insoluble. All this involves rapidly increasing costs. Nobody denies that more resources have been put into the NHS. What is necessary is that we acknowledge that the NHS is meeting huge levels of demand and that will not change.
The proposal in this Bill is that the Secretary of State will no longer have to account to Parliament for the delivery of a service that is key to the United Kingdom's economic, financial and social stability. There will be new structures for service delivery, for example, which will permit Monitor to determine that an NHS provider is not meeting the needs of its service users and to use taxpayers' money to buy those services from the private sector. This is effectively unplanned, unstructured privatisation, with the attendant enormous difficulties of regulation. Regulation is no substitute for good governance structures and planning.
The complexity of national demand-of access to clinical specialities and training and management change required by the Bill-are as yet unquantified. The potential for challenge in the courts in the context of service delivery are enormous. This will involve more loss of resources for the delivery of patient care. I have great concern over the proposal to place primary
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Undoubtedly an organisation of the size, scope and range of responsibilities of the NHS must be in a constant process of change. What is profoundly important is that reform is carried out following proper consultation with a clear mandate with properly costed and analysed resourcing decisions and with the support of service users-or patients if you want to refer to them that way-and of the professional bodies that will have to implement the change. I have not seen the evidence to suggest that that is the case in the Bill. Its current deficiencies have been and will be widely articulated in the Chamber today. In the interests of brevity, I will save any further comment for the later stages of the Bill. I will simply state my support for the proposal of the noble Lords, Lord Hennessey and Lord Owen, for a Select Committee.
Lord Patel of Bradford: My Lords, we are faced with only two options in the debate. We can seek to dramatically improve the Bill-and make no mistake, it needs dramatic improvement-or we can reject it out of hand. Neither option is without consequences. However, if the Bill passes through the House without significant amendment, the consequences will be even more severe. Noble Lords who have already spoken have covered many aspects of the Bill which cause all of us concern. I also have serious reservations about the impact of the Bill in a number of areas: on commissioning, public health, integration with social care, service-user engagement and quality and safety. As time is limited, I will focus my contribution today on the implications for mental health services. I declare that I was the former chairman of the Mental Health Act Commission.
We are told that commissioning will improve by being led by doctors and nurses. On the surface it is a reasonable assumption that relies on the simple idea that a doctor or nurse knows best what an individual patient needs. However, there is a problem; commissioning is not done for the individual, but is about the whole community. Commissioning is a process by which decisions are made on the most appropriate level and quality of services for a population. This is not an easy thing to do, as we see very clearly with respect to secondary mental health services and, particularly, specialist mental health services. It is widely acknowledged that this has been one of the weaker aspects of PCT commissioning over the past few years. However, the Bill as it stands can only make matters worse.
What is really worrying is the potential for confusion about roles and responsibilities for disputes in funding decisions. Oversight of service providers and commissioning will lie with the newly created NHS Commissioning Board, but local commissioning of many mental health services will be done by clinical
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"The separation of commissioning responsibilities for mental health services could lead to divergence in strategy and commissioning intent, and increase commissioning disputes to the detriment of service users".
But it is not just the confusion in commissioning that makes me concerned. I am also worried about the implications for continuity of care planning. One of the most important things that we could get right in psychiatric services is care planning. You can see this from almost any inquiry report into the deaths of psychiatric services users, or into a homicide involving a service user. But to plan care in a holistic way, you need to have a holistic service and the Bill appears to create conditions where such joined-up services will be ever more difficult to achieve.
That is especially so with respect to aftercare and I have grave concerns about the amendments proposed to Section 117 of the Mental Health Act 1983, which concerns the provision of aftercare once a detained patient is discharged from hospital. I cannot see how patient care will be improved by the amendment that either the health or social care partner in the provision of aftercare can unilaterally decide to withdraw from the provision of services. But most worrying, the amendments seem to be designed to enable the charging for services provided to patients who have been detained under the Act.
The Law Society has quite correctly called for this to be prevented through an explicit statement in the Bill. It is nearly a decade since the Appellate Committee of this House, in the Stennett case, recognised some sort of reciprocal aftercare duty towards those whom the state has detained for healthcare reasons. In many cases, continued engagement with aftercare services is a de factocondition for discharged patients-are we to support patients being charged for services that are imposed on them?
What about the voice of service users, their carers and the public? I have spent many years developing and managing service user and community engagement programmes at local, regional and national level that have produced significant change for services and commissioning.
Perhaps the noble Earl can tell us what these plans consist of? Three questions spring to mind. How is this to be accomplished? What resources are the Government providing to make this happen and, most importantly, where is the expertise? While I agree that those who use services should be at the forefront of driving up standards of care, there must also be adequate safeguards of independent monitoring and inspection. I am concerned that the Bill threatens to weaken such safeguards.
At the end of my tenure as chair of the Mental Health Act Commission, I was responsible for seeing it merge into what is now the Care Quality Commission. I continue to watch the CQC closely. The merger was designed to simplify the regulatory landscape, but the Bill seems to create yet more complication. Under the Bill, Monitor and the Care Quality Commission have oversight over service providers, but responsibility for overseeing commissioning will lie with the newly created NHS Commissioning Board. So we are back to having different bodies monitoring different aspects of health and social care.
In the case of the CQC, the Bill further reduces its independence: Clause 287 requires the Secretary of State's permission for the CQC to conduct special reviews. The Health Service Journal reported, on 6 October, that according to the CQC's own internal review, doubts have been expressed that it can sustain its current workload.
The CQC has a third less funding than those bodies it replaced and has had to cut generic inspections by around 70 per cent last year because of pressures in registering services. It is currently being asked to cover 18,000 care homes and 400 NHS trusts and will now be asked to take on responsibility for GP practices and the yet-to-be-determined number of "any qualified providers" who may be pressing for registration, all of which will once again distract the CQC from its vital inspection role.
I am pleased to see that, so far, the CQC has not reduced its visits to detained patients. It must be congratulated on that, but I question how that can be sustained, given the immense additional pressures to be produced under the current proposals in the Bill. I would like to be assured, if the Minister can, that the gains envisaged in the merger of the Mental Health Act Commission, the Healthcare Commission and the Commission for Social Care Inspection will be realised. We do not want any more horrors like Winterbourne View in mental health services. I hope that noble Lords will recognise the immense amount of work that is still to be done, and that the Government will concede that we must take the appropriate time to do that. Failure to take that time will risk lasting and, most importantly, irreversible damage to one of our greatest post-war achievements: a National Health Service that works in the interests of patients and the public, not in the interests of ideology.
I share all the concerns which the experts have articulated as flowing from the marketisation of healthcare along American lines: that is to say, in the direction of a system that is twice as expensive and much less efficient than ours. There is the impossibility of rational planning, the fragmentation of purchasing and procurement arrangements among hundreds of different entities, with the consequent loss of economies of scale. There is the embedding of incentives to physician-induced and supplier-induced demand-which the noble Baroness, Lady Williams, illustrated so graphically-leading to unnecessary tests and treatments, the diagnosis of minor problems as major, and over-aggressive treatments that might actually harm the patients subjected to them, all undertaken to increase provider income. That is not to mention the proliferation of bureaucracy required to administer the byzantine commissioning and contracting process.
The noble Lord, Lord Hennessy, said on the radio this morning that the NHS was about the nearest thing we had to the institutionalisation of altruism. The Bill, laden as it is with incentives for opportunistic behaviour, drives in entirely the opposite direction and bids fair to dismantle that system.
As Dr Lucy Reynolds and Professor Martin McKee have said, the ethics of the medical profession may provide a safeguard against patient exploitation, but unnecessarily putting temptation in doctors' way is surely unwise. How much more is that the case-as the noble Baroness, Lady Bakewell, demonstrated earlier to such devastating effect-with healthcare providers whose sole objective is to turn a profit, with all the dangers that that presents of asset-stripping and cherry-picking among the low hanging fruit, in the clearest illustration of the conflict between commercial and social values, of which the noble Baroness, Lady Jay, spoke earlier, echoing the words of Aneurin Bevan?
There is already the risk of destabilisation as a result of the Government's determination to charge ahead. If ever there was a case of implementation before legislation, with consultation coming a poor third, this is it. Only this weekend, someone wrote to me saying:
"Some of our close friends are now experiencing not only lengthening waiting lists but inefficient follow-up procedure appointments as the cuts deepen and changes are already being made in many areas of the health service".
There is little I can add in this vein to what those better versed in these matters have said. Instead, I will concretely illustrate the problems to which the legislation gives rise by reference to the field of eye health. Your Lordships would not expect me to speak without alluding to eye health. While declaring my interest as a vice-president of the RNIB, I have no compunction in doing so because it provides such a good illustration of many of the concerns held by critics of the legislation.
There are four particular concerns about eye health services that I would like to put to the Minister. The first is that of fragmentation. We currently have eye departments across England and Wales that provide a generally high level of care. They offer a comprehensive range of treatments for the main eye conditions, including cataracts, age-related macular degeneration, diabetic eye disease and glaucoma. However, with any qualified provider, this is likely to be quickly eroded with the
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Who, for example, will deal with the more complex operations and the inevitable complications? How do eye departments put together full and efficient operating lists? How can a smaller and fragmented eye department provide effective training for the next generation of ophthalmologists? How is an effective and comprehensive eye emergency service to be delivered?
A second concern relates to the failure so far to place eye health at the centre of the Government's public health agenda. With an ageing population, visual impairment and blindness are now a bigger public health challenge to quality of life and cost-estimated at £22 billion in 2008-than the major killer diseases. It is all the more galling that 50 per cent of this is estimated to be preventable through early diagnosis and intervention.
The UK Vision Strategy, a coalition of all the major players in the vision impairment sector-the Royal College of Ophthalmologists, the Optical Confederation and the RNIB-has been arguing strongly for an ophthalmic public health indicator for avoiding blindness in the national framework. This would provide focus for clinical commissioning groups, health and well-being boards and Public Health England in this important area. However, it is increasingly concerned that such an indicator will not be included in the final framework when it is published later this year. That would be a major opportunity missed.
My third concern is about integrated planning and delivery across health, social care and health-related services. The establishment of local health and well-being boards to promote co-ordinated planning is to be welcomed. It is here that commissioners of health, social care and public health services will come together to develop the local joint health and well-being strategies adumbrated in Clauses 190 and 191. However, whether this can be an efficient and effective process with two to three times as many commissioning groups as at present-300 to 450 clinical commissioning groups in future, compared with 152 PCTs-must be in doubt.
My fourth concern relates to the role of NICE within the new framework. In their response to the NHS Future Forum, the Government confirmed that the funding direction requiring NHS commissioners to fund drugs and treatments in line with NICE's recommendations would still apply until at least 2014, when value-based pricing will be introduced. However, enforcing the funding direction is already proving difficult-for example, in relation to anti-VEGF treatments used for the treatment of wet age-related macular degeneration. What reassurances can the Government offer patients that, from 2014, value-based pricing will not restrict access to innovative treatments? How will the funding direction be enforced in the event that a clinical commissioning group chooses to exercise local autonomy-for instance, where it faces serious cost pressures? It would be very helpful to have this clarified so that patients who develop eye problems and other health conditions can have confidence that drugs or treatments recommended by NICE will still be available to them.
Baroness Wall of New Barnet: My Lords, it was my intention to focus in my contribution on healthcare assistants and their regulation. I focused on that issue because of its importance in patient care. However, I have an opportunity to raise that in the Question that I have tabled for 24 October and I give due notice to the Minister that I will be doing so.
I have listened carefully to almost every contribution, and the three or four for which I was not in the Chamber I listened to in my office. Many of these contributions have come from eminent and experienced noble Lords, all of whom present very plausible arguments for their particular suggested outcome of how the House deals with this important and complex Bill. In relative terms I am quite new to this House and certainly would not describe myself as an eminent Member, but I am the chairman of a two-hospital provider trust. I know that most noble Lords who have an interest in health and have participated in debates on it in this House will know that only too well, and they are probably weary of me mentioning my trust, Barnet and Chase Farm-but I shall resist doing so today. I am a champion and advocate not only for my trust but for the principles behind the formation and continuation of the NHS. However, as noble Lords have said, the NHS that we are dealing with today is very different. The expectations placed on it-from patients, clinicians and all professional staff and support workers-are different. Those employed in this service are caring for patients. As someone who takes her role very seriously, I find that challenging but also very exciting.
We have heard today about advances of technology in medicine and many other areas which have improved the lives of thousands of patients. This is happening increasingly and it is wonderful. However, it also brings challenges of affordability and the necessity to ensure that we have the most skilled and caring workforce. These are real challenges which mean that we cannot stay as we are.
I have been in my role as a chair for five years, and in that time I have been delighted by many of the changes and improvements that my party introduced during its time in government. Most people who serve our patients have valued those extensions and improvements to the service. When the coalition Government were formed, I was keen for many of these initiatives to be carried on and improved. Many have indeed been carried on, and it is proposed that they should move even further. This will benefit patients.
The only barometer I need to test the benefits of the Bill is whether it makes a difference to patients. Like others, I have had the opportunity to speak to the Minister about my anxieties and expectations over the way forward, and like others, I was treated with warmth and politeness. However, we need action now. I have received lots of correspondence, as have most other noble Lords, from all kinds of organisations and individuals. I am not sure whether I am unique, but I was privileged to have discussions with groups of staff and patients from my hospital when I advised them that I intended to speak in this debate. They asked for a meeting and I was delighted to provide it. They told me that they had some worries about parts of the Bill.
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More than anything, what they want from the Government is clarity about the importance of patient experience and the emphasis on whether patients should come into hospital or be treated in the community. That emphasis is not as good and deep in the Bill as it should be. I am sure that the Government are concerned about patients' experience. I urge all of us to use the time that we have not only to persuade the noble Earl, Lord Howe, that we believe that he cares and wants better healthcare, but to listen further to suggestions to improve the Bill. What everybody said to me was, "Please, Baroness Wall, whatever you do, don't kick this into the long grass". We do not need to do that, and I have no intention of voting to do so.
Baroness Masham of Ilton: My Lords, we have before us a monster of a Bill. It is complex and confusing. Many people who depend on the NHS are concerned about what the results will be when it becomes law. There are improvements that should be made to the NHS but it will be a tragedy if good and excellent things are lost or downgraded.
Safety of all patients is my top priority. We do not have enough high-dependency beds. We are well down the European list, which is headed by Germany and France. We have many critically ill patients. There is a gulf between intensive care and the general wards. There is a dark cloud hanging over England, which must save £20 billion when the NHS has increasing lists of patients who need treatment and medication. With commissioning being done by clinicians who might have self-interests, perhaps I may ask the Minister if there are enough safeguards in the Bill. If patients become suspicious of their doctors and trust is lost, that will be a tragic disaster. There should be integrated healthcare, and patient and public involvement to help with commissioning. Many members of the public who have paid their taxes and national insurance feel that the National Health Service is there for them when they need it.
Many people, including professionals, think that healthcare assistants working in hospitals and care homes are registered. They are surprised when they hear that they are not. Many members of the public were horrified and dismayed when they learnt about the callousness and cruelty to patients over a long period at the Mid-Staffordshire NHS Foundation Trust, when the system within the hospital let them down; and likewise when they saw the "Panorama" programme about the care home, Winterbourne View. This sort of behaviour to patients just cannot go on.
It is welcome that the Government have recognised that unregulated workers supporting healthcare professionals represent a risk to patient safety that needs to be addressed through regulation. I strongly believe that only a mandatory regulatory model will be sufficiently robust to safeguard these workers who
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Care assistants are often dressed up in uniforms that make them indistinguishable from nurses. When the national nursing research unit at King's College, London carried out a review of models of regulation of support workers, it found that for the two types of healthcare support workers-healthcare assistants and assistant practitioners-there are no consistent UK-wide training standards. Healthcare assistant courses can range from an hour-long induction to NVQ level 3. Assistant practitioners undertake more complex tasks than healthcare assistants, but again there is no training consistency across the UK. The report demonstrates that both often undertake tasks for which they are not trained. The lack of regulation means that employment as a support worker may be obtained by people who have been dismissed from a previous healthcare post for misconduct, or who have been struck off the register as a nurse or a midwife. I will be moving or supporting amendments to try to help rectify this unsatisfactory situation.
I am sure that nobody would disagree with the importance of the patient voice in the reforms-no decision about me without me. Can the Minister, the noble Earl, Lord Howe, who is so hard-working and committed to high-quality healthcare, assure me that specialist care for patients who need it will not be affected during this period of upheaval in the NHS? The cuts are already causing concerns in various directions. Some of the expert advisers within the Department of Health have retired and have not been replaced. One is the microbiologist who advises on infection control. With the increase of drug resistance to various infections such as E. coli and tuberculosis, perhaps I may ask a question. There are many specialties of illness, disease and infection. Will the commissioners have advisers so that they will understand what they are commissioning? I hope that the Minister will have a positive answer.
With the increase in HIV/AIDS and other sexually transmitted diseases, what will the Government do to ensure that stigmatising views of HIV and of sexual health more broadly do not affect decisions about local public health services? Can the Government confirm how the NHS Commissioning Board will be held to account for the quality of its own commissioning, and by whom? I ask this in particular in relation to HIV treatment and care, and healthcare in prisons and other places of detention. Will the Government allow for a national tariff covering sexual health services to be applied to local authorities as part of the mandate for Public Health England? Will the Government specifically allow the pre-existing tariff for GUM and sexual reproductive health to be used? There is fear that the service might become fragmented.
How is the patient voice to be heard? It is important for special groups such as Diabetes UK, and patients' groups such as the Spinal Injuries Association, the Patients Association and hundreds more, to speak out and be heard. The Government are setting up HealthWatch. It would have been helpful if Governments had built on community health councils, but this was not to be. Health forums were set up and then closed down. Then came LINks, which few people have heard
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The lessons should be learnt from Mid Staffordshire NHS Foundation Trust and the numerous care homes that have become places of oppression and agony for the residents. HealthWatch cannot be both champion of the public and poodle of the local authority. It is essential that primary and secondary health work is done in co-operation, and that pharmacists are involved. They are concerned that currently in the legislation provision for clinical commissioning groups to obtain appropriate advice is too vague. I hope that your Lordships will be able to do what the House of Lords is good at, which is to improve this mammoth Bill for the good of the NHS and of those who serve in it and who use it.
Baroness Cumberlege: My Lords, I declare an interest as executive director of Cumberlege Connections, which is a training organisation. I am also a fellow of three royal colleges and have associations with a number of health charities.
Those are not my words but those of a great leader of the medical profession-the remarkable Archie Cochrane, when he gave the Rock Carling lecture at the Nuffield Trust in 1971, 40 years ago. Forty years ago he could see the sense in putting GPs in the driving seat. But I know that there are many GPs who would be back-seat drivers rather than take on the,
I can really understand why. It is a great responsibility. It takes courage. It is very demanding and many of them feel that it is not their vocation. They came into medicine to treat, cure and heal. Fair enough. But we are not asking every GP to step up to the plate-only those who want or feel able to.
After the report on medical professionalism commissioned by the Royal College of Physicians was published, I was invited to a number of roadshows across the UK, sponsored by the King's Fund, to explain the thinking of the working party I had chaired. On one such occasion in Bristol the hall was full and we invited feedback from the audience. A very distinguished and respected hospital consultant said: "I remember the Griffiths reforms in the 1980s. Roy Griffiths recommended the introduction of general management and we the medical profession said, 'Right, you can have your managers, they can manage, but we will go away and stick to our clinical work'. What fools we were!".
We are now giving clinicians another chance-not to be day-to-day managers, not to become expert finance directors poring over endless spreadsheets, but to lead, shape and organise the services that they know matter to patients. That makes a lot of sense. We know that 95 per cent of healthcare problems are dealt with by GPs and their practice teams; more than 15 per cent of the entire population see a GP in any two-week period; and 75 per cent of patients want to consult a GP they know and trust. It seems sensible that those who are so trusted by their service users should be designing services and commissioning them. Currently the PCTs do that.
Since the threat of abolition there has been a great wave of nostalgia for the good old PCTs. Never before have they been so loved and wanted. I recently spent two days in Torbay and if only all PCTs were as good as Torbay the case for change would be hard to make. But sadly that is not the situation. Too many PCTs have been criticised for their inefficiency, lack of understanding of clinical issues and inability to commission quality across the board.
People move house in order to get the education they think best for their children. Parents know all about "pester power"-from a very young age children are deeply competitive. They want the very best: the best trainers, the best scooter, the best track suit. It is part of human nature-we are competitive animals. For those of us who know the NHS well, we will choose the best: the best hospital, the best GP, the best clinic for ourselves and our families. For me, raising standards means removing the worst and installing the best. If people want to call that competition-fine. I call it something to strive for.
If Assura Medical is judged, after a fair and open process, to run, manage and deliver a better service of higher quality than the NHS, I cannot understand why the noble Baroness, Lady Jay, should be so concerned, particularly when we know that the Brunswick research shows that patients are not especially worried about who provides the service, so long as it is of a very high standard and free at the point of use.
According to the CQC, 96 per cent of NHS patients using independent facilities for elective surgery are satisfied, but only 79 per cent of those using NHS facilities are. Commenting on the seminal four-year study by the University of York into competition in the NHS, Julian Le Grand, professor of social policy at the LSE and policy adviser to the then Prime Minister, Tony Blair, told the Financial Times yesterday:
"This is a very important result. It shows that one of the most frequent criticisms of patient choice and hospital competition in the NHS-that it would disadvantage the less well-off-is quite misplaced".
The NHS is of itself competitive. When dealing with the pharmaceutical industry, it negotiates for the best deals, moving to generic medicines when it is to its advantage. And yet here we have people within the NHS who are being highly protective when it comes to service provision. They will resist any suggestion that another organisation outside of the NHS should provide a service, even if it is of a higher quality, more efficient, innovative, and giving the taxpayer better value for money. This is simply inconsistent.
The basis of democracy is competition. There is competition for seats in another place, and competition for party leaderships is so fierce that brother competes against brother. The best win, losers are driven out. Why are these principles attacked by the vested interests within the NHS? Is it to hide bad practice from scrutiny? Is it barefaced protection of inefficiency and the worst manifestation of trade unionism? We, the people, demand open government. The NHS should not demand a closed shop-a cosy nest on a rotten bough.
I accept that this Bill is not universally loved, but it does bring the NHS into the real world. There is room for scrutiny and improvement, which as always your Lordships in Committee will undertake with wisdom, skill and, in this case, fortitude. I will be voting against the amendments proposed by the two noble Lords in this debate for the cogent reasons outlined by my noble friend Lord Howe.
Lord Clinton-Davis: With apologies to Ecclesiastes, may I say that this debate has been a time when many invaluable ideas have been put forward, and when one has learnt so much; and this process will continue. But at the end of the day-or rather tomorrow-I will unhesitatingly vote against this destructive Bill and support both amendments, if need be.
The National Health Service, established more than 60 years ago, proved to be one of the most enduring of many enduring accomplishments of the 1945 Labour Government. It is cherished by most of our population and envied by many outside Britain. Even the present Government pay lip service to it.
Our people are overwhelmingly opposed to the dismemberment of their National Health Service. From its beginnings, the Tories tried to wreck it, with no apology and no admission that they were wrong then, as they are now. Just seven years ago, a Tory spokesman, Oliver Letwin, let the cat out of the bag. He declared that the National Health Service would disappear within five years of the Tories coming to power. Is this not what this Bill means in the long term?
I do not contend that the NHS is without flaws. These were recognised by the previous Government. But the essential remedies, it seems, have been sidelined. Instead, this Government are allowing our comprehensive health service to wither on the vine. What I argue is that the NHS, despite the strains placed upon it by immense technical advance, is better-far better-than anything which might be put into its place.
Private health companies continue to pour huge sums of money into Conservative coffers. Why? What do they hope to get out of it? When the Prime Minister and others claim that these so-called reforms are designed to improve the health service, they are disbelieved by senior doctors and others employed in and dedicated to the NHS. For "improve" they should substitute "fragment".
The Government talk of widespread consultation about their programme but in fact turn a deaf ear to any serious criticisms of their plans and potential deleterious effects on patients. Consultants and others remain unconvinced by the Government's proposals to allow the private sector to work within the National Health Service. They consider that costs will spiral, and the founding principle of the NHS, which has served millions of people so well for so many years, will be irrevocably damaged.
The House of Commons, to its shame, has endorsed this Bill. The Lib Dems-with four honourable exceptions -have reneged on their previous commitments. What will they do tomorrow? Will they follow the example of the noble Baroness, Lady Williams? I do not know.
I was somewhat surprised that, when addressing the Independent Healthcare Forum, the noble Earl, Lord Howe-for whom personally I have enormous respect-declared that the private sector would be presented with "huge opportunities". Opportunities for what? For whom? At whose expense?
Lord Rodgers of Quarry Bank: My Lords, on the occasion of a debate in the House on 16 December last, I said that I had been agnostic about the merits of the July 2010 Liberating the NHS White Paper and nor had I been persuaded since. Ten months later, I have moved on, but I am still uneasy about the Bill. That is the way I shall remain, long after the legislation is passed and when the policy is finally implemented. Only time will show fully the outcome of the Bill and the balance of advantage. There will certainly be rough edges and mistakes, and lessons will have to be learnt. The NHS is an immensely complex and living institution and we cannot know the extent of change for the better.
There have been legitimate and strong differences about the health service ever since it was established in 1948. Two years later, NHS costs and the decisions to charge for teeth and spectacles divided the Attlee Cabinet and damaged the Government. Wide differences on this Bill will remain, including over the role and extent of the private market within the public sector. I am impressed that the country has already been covered by the shadow clinical commissioning groups. There are now 250 of them. Some are small groupings but others-like the London Borough of Camden, Oxfordshire and now Sheffield-are large and, in effect,
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However, the picture is patchy and there are also dissident and unhappy GPs. They say that they are clinical experts and do not wish to become experienced commissioners, and are not interested and competent in administration. It is not clear what happens when a shadow CCG fails to meet the statutory requirement. On the face of it, the Secretary of State wants CCGs to get on with it but it could end in a confused picture by 2013.
In the July White Paper, it was said that the new Commissioning Board would be a "lean and expert organisation". Sir David's board may be expert but it will certainly not be lean. I make no complaint, as it seems to me that Sir David will have to take a grip on problems arising from failures by the CCGs. There could be tension between letting go and retaining control at the board, and we should be aware of the limits of localism.
In the debate of 16 December, I referred to the ending of the primary care trusts. I drew attention to a success story in PCTs reaching agreement about having fewer and more sophisticated stroke units in London hospitals. In contrast, there had been an all-party outcry against the possibility of closing the A&E departments in the Whittington Hospital-near to my home-and elsewhere. The closure of Chase Farm A&E has recently made news and is an object lesson of short-term politics and pointless delay. The role of CCGs in respect of closures, and whether they will have a constructive role in those decisions, is far from clear.
The chief executive of the NHS Confederation reminded us that the health service is facing £20 billion of efficiency savings by 2015-a huge sum in a very short time. Moving services and closing complete hospitals may be essential while raising standards for the benefit of the patients. It could be said that these priorities and tasks in saving the NHS should have been treated ahead of the Bill. There is deep concern about whether the NHS can deliver greater efficiency and quality while overhauling the NHS structures in the Bill.
In successive Governments since Gladstone, the Treasury has thrown up its hands in horror at the possibility of hypothecated taxation in a major area of policy. However, it may now be right to consider hypothecated taxation for the NHS. This would make NHS expenditure more transparent, showing the public-the taxpayer-the awkward choices when the demand for services is at above the rate of inflation due to rising expectations, an ageing population and increased technological costs.
Meanwhile, we have the Second Reading today and tomorrow in the knowledge of much still to be done in scrutinising the Bill in the hope of agreed amendments that will lead to further improvements and relieve some of the anxieties. However, I cannot support the amendments in the names of the noble Lords, Lord Rea and Lord Owen. Since the publication of the July 2010 White Paper, there has been a deluge of consultation papers and memoranda. Following the White Paper,
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In due course, the Bill was published and reached the Commons for Second Reading. Again, there was another flood of paper prior to the beginning of parliamentary scrutiny. At the same time, my noble friend Lady Williams of Crosby took up the cudgels on key controversial aspects of the Bill and the Liberal Democrats made the running for amendments. After that, the NHS Future Forum, led by Professor Field, was devised and during what was called a "pause", there was a further set of documents independent of the Secretary of State and the department.
I will not tell the story of the White Paper and the Bill any further, as noble Lords are very familiar with the whole saga. However, I will mention the report of the Constitution Committee. As the noble Baroness, Lady Jay-the chairman of the committee-said this morning, the committee has expressed its concern that the Bill might dilute the Government's constitutional responsibilities with regard to the NHS. Despite today's disappointing government response, I hope Ministers will think again.
By lunchtime tomorrow, there will have been over 90 speeches advocating many shades of opinion. I am a lay man in a debate dominated by medical experts. I have heard speeches critical of the Bill and others as uneasy as I personally remain. However, I find no advantage in another Select Committee. We shall give thorough scrutiny to the Bill in Committee and on Report; it will be the end of a long, perhaps unique, process of argument and examination. The House is now able to make fully informed decisions. Whether we like them or not, we should not duck or delay them further.
Baroness Murphy: My Lords, we are not alone. All over the world, advanced healthcare systems are trying to tackle the quality of care and safety, raise productivity and shift the care from acute hospitals into primary and community settings-whether it is surgical, medical or mental health services. We have well rehearsed today the reasons for that and the imperative of finding a sustainable way forward for the 21st century that meets the aspirations of Bevan and the founders of the NHS. This is a most remarkable institution, but we need to improve on it to meet what patients need and want now and over these next challenging years. I support this Bill as a well reasoned way forward and as a sensible step which builds on the international and local evidence.
It is time for me to declare my interests as a lifelong employee and honorary employee as a doctor, clinical academic and NHS manager. I am proud to say to the noble Baroness, Lady Cumberlege, that I was one of the original Roy Griffiths managers. If you like, I got on that horse quite early. I then chaired a university
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Seldom have so many health policy folk fought so many pre-Bill skirmishes over what in the end have proved to be rather modest changes intended to preserve and improve the NHS based on the principles of the NHS constitution, and rarely have I received so much misinformed lobbying about a Bill. I hear that the Bill heralds the end of the NHS as we know it; I read that armies of evil capitalists from the United States and the Middle East are geared up to zoom into the UK like the hordes of Genghis Khan to hoover up our favourite hospitals and services. It is twaddle. In fact, this Bill contains no privatisation at all, it does not transfer any assets to the independent sector and, if we build on the contribution of the independent sector of 1 to 2 per cent per annum, we shall be doing quite well. We have been building on the expansion of existing policies that have been in place and developing slowly over the past 20 years and introducing a new level playing field for providers from all sectors.
As another noble Lord said, this is a vast improvement on favouring the independent sector treatment centres. I quite understand why that had to be done in the early days, but this puts everybody on a favourable, equal footing. It will sharpen NHS commissioners to get the quality of care improved and, crucially, will improve productivity, which has fallen quite catastrophically as investment has risen in the past decade. This Bill improves the contribution of clinicians to the planning and management of services and shifts a hospital system chained to central diktat towards a regulated emancipation to manage their own affairs. In my view, the most important aspect of this Bill is the introduction of the independent regulatory framework for providers, with the tools to promote a sharpening of competition and co-operation that will promote the kind of integrated care across primary community and specialist services that we all want.
Those of us who were at the meeting last night heard Sir David Nicholson repeat what the NHS Confederation has constantly stressed: that any delay will be profoundly depressing to the service, which now wants a clear steer and direction of travel. We have had two years of delay already. Almost all the features of this Bill are familiar to us: clinical commissioning; foundation trusts; a regulatory system; competition and collaboration between qualified providers; and patient choice. They have all gone before, so the new Bill builds on what has been learnt, especially by ensuring that competition is based on quality not price. There seems to be a widespread misunderstanding that we are basing these new proposals around price. That is absolutely not the case, and I would not support this Bill if it did.
Some people talk nostalgically about the demise of PCTs and SHAs, but the demise is in an orderly fashion, and as a former chair of a strategic health authority, I can only say "Hurrah". In fact, clinical commissioning groups are what primary care trusts were supposed to be in the first place. For those who can recall primary care groups, those were also what clinical commissioning groups were meant to be. The
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I cannot be the only person who thinks that it was a stroke of genius to appoint Sir David Nicholson as the new CEO of the Commissioning Board, because that will ensure that the transition arrangements are far less worrying for the service. We should be very relieved that he is there to support the new clinical commissioning edifice, including the regional offices and the different ways of commissioning at different levels to support the cancer and stroke care networks-all the precious things that we want to hang on to.
Many people have mentioned the change of wording relating to the Secretary of State's responsibilities. That is not, by the way, something that is ever raised in the service, where there do not seem to be any doubts that the Secretary of State will still be very much in charge. I worked out that the Secretary of State last managed services directly in 1989, when the special hospital services transferred out of the Department of Health into the new Special Hospitals Service Authority. I do not think that there have been any directly managed healthcare services since then; they have been provided through agencies. Therefore, the description of what the Secretary of State does has been poorly worded. We now need an accurate description of what we think he is going to do. He will not lose political accountability, and he will have specific responsibilities for the health of the public. Is that not what we want the Secretary of State to have? I am sure that we can find some wording to reflect what he will really be doing-it may not be quite right in the Bill. I read the Constitution Committee's report with much interest. It is fascinating. If we are to debate it, let us do so on the Floor of the House-we have constitutional experts in this House who are a delight to listen to-and see whether we can get this matter right with amendment, explanation or whatever.
Public health started with local authorities and it is returning home. The Secretary of State has very clear responsibilities, and I think that Public Health England, which will provide the support to public health specialists in the localities, is probably as good a solution as we have had since 1974. Therefore, again, I support that.
The development of Monitor to become the main economic regulator is also welcome. Safeguards put in place following the listening exercises are now very extensive-some might say too constraining. Monitor is to have regard to a whole list of things and I wonder whether we might be able to moderate that slightly. Other regulators have shown that there are too many responsibilities at the moment, and we need to find a way forward. However, I particularly welcome the way in which the tariffs are being developed, with new
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There has been much angst in some quarters about the abolition of the private patients cap. I understand why and I am very sympathetic to the unions' concerns. No one wants to divert NHS clinicians' and managers' energies and preoccupations into private care, however much cash it brings in. However, the cap has proved to be technically extraordinarily difficult to get right, highly disadvantageous to mental health services and a real barrier to some of our great teaching hospitals becoming foundation trusts because some patients are recruited from abroad-Great Ormond Street is a good example. We have to think very carefully about how we go forward in discussions on that.
Finally, I have one major concern. How are we ever to get services reconfigured or units and hospitals closed? Mid Staffs was not an outlier very far from other hospitals. Perhaps a quarter or so of our DGHs are redundant, and many more services need concentrating on specialist sites if we are to improve quality. I want to ensure that Monitor has the tools to intervene early and the right processes to complete the changes. It is always politically difficult to make the final decisions and most inaction on failed organisations-we have already had quoted the wonderful Chase Farm-is caused by lack of ministerial bottle. In Ontario, the ultimate decision was moved from ministers to an independent organisation and finally people started to get the movement that they needed. We have left the Secretary of State in the same old role, so when people are thinking about constitutional changes, they need to remember that. The failure regime has become exceptionally difficult. Can the Minister reassure me that the system can be made to work and, if it proves impossible, that Ministers will have another strategy up their sleeves?
Just as education Bills do not improve education without improving teachers, so we will not improve healthcare without improving the quality of doctors, nurses, other professionals and the people who deliver care, including the managers. We do not talk enough about that, but for the moment I will support the Bill and will not support the amendments that have been tabled to it.
Lord Warner: My Lords, it is always a pleasure to follow the noble Baroness, Lady Murphy. I detect from her remarks that I may have been forgiven for her old SHA being one of the 18 that I abolished five years ago.
As you walk into Parliament from the Underground, you see a large poster telling the citizenry that they can find out how laws are passed here. Let us hope that this Bill is not used as a case study. The Government's approach has done few favours to the cause of NHS reform, which many of us believe is still needed. The failure to produce a convincing narrative on why change is required on this scale has allowed the utterly predictable voices of reaction and vested interests to drive the agenda of opposition. They have made things worse by failing to show how their legislation will help the
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A key plank of Andrew Lansley's defence has been that he was just continuing the Blair health reforms. That has a slug of truth in it, but he fails to acknowledge that those of us implementing those reforms had a clear mandate to do so in our 2005 manifesto, with which, I say to my colleagues, we won an election.
It is very easy with this Bill and the Government's handling to engage in political point-scoring. However, I suggest that our greater responsibility in this House should be to the current needs of the NHS and how we can best make this Bill more fit for purpose. NHS staff are in a no-man's land between a partially dismantled system and no clear and workable new system in place to which they can transition. This is a bad place to be, given the state of the public finances and the challenges that the NHS faces. Now, the NHS needs the maximum removal of uncertainty and the strategic leadership to take it forward confidently, as so eloquently advocated by my noble friend Lord Darzi. All that scrapping the Bill would do is worsen the chaos. The grown-up thing to do is to improve the Bill as quickly as possible so that the NHS can move forward with greater certainty. From my own inquiries, that is the view of the NHS Confederation, which has provided us all with an excellent briefing.
Of course, this House needs to discharge its functions of scrutinising the Bill, and it needs to do that thoroughly, speedily and with a clear sense of purpose. The guiding principle should be fashioning amendments that make the NHS more likely to be able to deal with the challenges that it faces over the coming years. That will certainly be my approach, drawing on expert help both inside and outside this House.
Neither of the amendments to the Motion of the noble Earl, Lord Howe, helps in this regard. My noble friend's Motion is well intentioned but thoroughly misguided, given the needs of today's NHS, and I cannot support it. Nor will I support the amendment of the noble Lord, Lord Owen.
We should recognise that we have enough evidence of the Bill's strengths and shortcomings, as the noble Lord, Lord Rodgers of Quarry Bank, pointed out to us. We have now to settle down in a Committee of the whole House and work our way through the amendments to improve the Bill. In this regard, I hope we will find the Minister in a listening and negotiating mood. Perhaps he will recall that when I took another rather controversial health Bill through this House, on foundation trusts in 2003, I moved or accepted some 200 amendments. So that is the benchmark for judging the flexibility of the noble Earl opposite.
I shall comment briefly on the Constitution Committee's report. The Secretary of State's responsibility for health service provision has always been a bit of a fiction when it comes to accountability. Clause 1 seems to me a more accurate description of where the Secretary of State's responsibility and accountability are now and where they should remain, although I shall certainly argue in Committee that his powers of mandation in
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I make it clear that I am proud of Labour's improvements to the NHS and the external recognition of them. We have better buildings and equipment, including IT, much needed extra staff, better service access and a huge improvement in the clinical performance on the killer diseases: cancer, coronary heart disease and stroke. But NHS productivity was poor relative to the scale of that investment. Office for National Statistics figures show inputs growing by 60 per cent in real terms between 1997 and 2007 and output barely moving. That is not a good performance. A major programme of service reconfiguration is required quickly. Too many acute hospitals are not good enough for FT status now, let alone in the tougher climate ahead, and the 1960s all-purpose district general hospital is an out-of-date, failing business model. We need change in configuration. We need to give great attention to the part of the Bill that deals with it and to strengthen the ability of decisions to be taken locally, clinically and without too much political interference. We have talked the talk on integration, but the Bill needs to walk the walk, especially on integrating health and social care. We need to remember that social care is in the Bill's title. NHS performance requirements need strengthening so that the public have access to much more useful information. We need to clarify, and simplify, the extremely complex set of arrangements in the Bill for fixing the NHS tariff.
These areas and others such as public health, the patient's voice, social care reform, research, NICE and the NHS Information Centre all need attention, but those are things that we can deal with in Committee.
Perhaps I may say a few words about the vexed question of competition, which is not privatisation, is integrally linked with extending patient choice and is not incompatible with service integration. I end with a quotation from a recent study that was peer-reviewed and appeared in the Economic Journal. The study was undertaken by researchers at the London School of Economics, led by Zack Cooper. They looked at whether hospital competition under Labour saved lives. They stated:
"We find that after the reforms were implemented, mortality fell (i.e. quality improved) for patients living in more competitive markets. Our results suggest that hospital competition can lead to improvements in hospital quality".
I hope that when we get to the nitty-gritty of the Bill on Monitor we will approach the issue of competition a little more dispassionately than in the recent past and will consider the evidence and not just our prejudices.
Baroness Emerton: My Lords, I thank the noble Lord, Lord Warner, for mentioning integration because, as my notes say, the recent Dilnot report findings and the title of this Bill-health and social care-are the chance in a lifetime for us really to grasp this in terms of crossing the boundaries between health and social care, particularly the boundaries with local government which are sometimes difficult to close, which really is necessary for the elderly, frail and infirm.
We have heard a lot this morning and afternoon about the details. There is no doubt that the devil is in the detail. I am quite sure that the House will scrutinise the Bill in the forthcoming weeks and that we will be able to come to a consensus view. I declare an interest as a long retired nurse and a fellow of the Royal College of Nursing. Apart from the noble Baroness, Lady Masham, who has raised the issue of support workers, we have not mentioned nursing much this morning or afternoon. I want to raise three things: the challenge that is currently being faced out there in the field with the Nicholson £20 billion savings, the cost of the new structural recommendations and the effect that they are having.
The Royal College of Nursing is already reporting large reductions in numbers of staff, which are not being replaced by nursing posts, and that specialist nurses are being redeployed from their nursing posts to do other duties. Thus, the patients who require the specialist nurse-particularly in breast cancer, multiple sclerosis and all the others-are suffering the loss of their nurses. Where there is no support available by family or friends, an integrated pathway leads from primary care, secondary care, tertiary care back to secondary care, primary care and social care. It does not favour the experience of an 84 year-old with very little mobility recovering from quite a severe stroke to be discharged on a Friday evening at 6 pm to an empty house, with the only toilet upstairs and nobody to care for her until Monday morning.
The Royal College of Nursing has demonstrated that where costs being driven down becomes an overriding factor and corners are cut at the expense of the quality of service delivery, as sadly demonstrated in the Maidstone, Tunbridge Wells and the Mid Staffordshire foundation trusts, patient outcomes and even safety come into danger. This also affects the culture within the organisation, where fear begins to take over. Incontrovertible research evidence from independent academics across the United Kingdom, the United States and Australia show the relationship between patient outcomes and registered nurse staffing levels. In order to guard against the possibility of further tragedies and failures in the management of correct nursing staff levels upon the wards, the Royal College of Nursing would like to see the Bill amended to include mandated staffing ratios and levels. The national Commissioning Board would specify guidelines and the registered to non-registered ratio would not fall below 55 registered nurses to 35 non-registered, and, on the higher dependency wards, 65 to 35. The local CCGs would also monitor and assess compliance and efficiency. The RCN would also like to see these staffing levels and ratios as set standards to be taken into account by Monitor and the CQC.
I now move to Part 7 of the Bill and Clause 231, which my noble friend Lady Masham has already mentioned. I want to explain in a little more detail what the Nursing and Midwifery Council feels is necessary. The council recognises that the Government have accepted that unregulated workers supporting healthcare professionals represent a risk to public protection that needs to be addressed through regulation. The suggestion of voluntary registers may provide a solution for some healthcare regulators but the NMC believes that voluntary
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Clause 231 gives no indication that a voluntary system will be underpinned by consistent UK-wide standards of training that would assure the public and employers that health support workers have the knowledge and skill they need to practise safely. The NMC believes that a voluntary system would do little to prevent cases of serious abuse and failure by health service workers such as those illustrated earlier this year at Winterbourne View and in the Parliamentary and Health Service Ombudsman report Care and Compassion?. Only mandatory registration can provide the statutory powers that the NMC needs in order to take action against health support workers who pose a risk to the public.
The Royal College of Nursing supports the regulation of healthcare assistants and support workers. I know that many noble Lords do too and that the public would support this. The Bill proposes the abolition of the 10 English SHAs. In so doing, the Government will need to take into account that the SHAs currently host the local supervising authorities' independent organisations responsible for ensuring that the statutory supervision of midwives is undertaken according to Nursing and Midwifery Council standards. We know that there have already been problems with the delivery of midwifery in some areas and the local supervising authorities play an important part in controlling standards. Any changes in the hosting and function of the local supervising authorities may necessitate legislative changes to the Nursing and Midwifery Order 2001 and the Midwives Rules and Standards.
On education and training, in their response to the NHS Future Forum report the Government stated that they will introduce an explicit duty on the Secretary of State to develop a system of professional education and training as part of a comprehensive health service. That will be crucial. However I urge the Government, when drafting the amendment, to consider the need for the Secretary of State to promote multi-professional education and training to ensure that the NHS can continue to develop a high-quality multi-professional workforce to support improved outcomes for patients and service users.
Finally, I thank the Government for the announcement made by the Secretary of State that there would be a chief nursing officer on the national Commissioning Board and a director of nursing at the Department of Health. However, I would like those two posts and the nursing post at CCG-level to be written into the Act, because the nursing and midwifery professions are
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The recognition of authority and accountability is important at service delivery level, as it is at the national board level. Very often, moral parameters get in the way and it becomes blurred. Eighty per cent of care delivered to patients is by nurses, and it is important to the public and patients, as well as the professions, that their leaders are recognised alongside other heads of professions and have equal voice at the table, with direct accountability to the chief executive or designated lead officer.
I therefore ask the Government to consider making the posts mandatory at national and CCG level. I am aware that the Government do not wish to be prescriptive, but that is necessary at this time to give reassurance to the professions, patients and the public that there is at least recognition of the position of nursing within the NHS. It is then up to the professions to ensure that they are worthy of recognition by delivering high quality, compassionate care.
Baroness Kennedy of The Shaws: My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of
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Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.
The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.
Lord Mawhinney: My Lords, as this is a debate, I thank the noble Baroness, Lady Murphy, the noble Lord, Lord Warner, and my noble friend Lady Cumberlege
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I shall focus my remarks rather more. I join others in congratulating my noble friend Lord Howe on the masterful way in which he introduced the debate. On a Bill that is, as we have heard, contentious, he carried the whole House with him. Everybody listened attentively, which reflects the personal standing in which he is held. I thank him. I am sorry that the noble Baroness, Lady Thornton, has just left; I want to congratulate her, too. I hope that the noble Lord, Lord Hunt, will tell her that while I did not agree with everything she said, the tone that she adopted was excellent. I say to her and my noble friend the Minister that if they are able to persuade the House to maintain that tone through what are likely to be very long hours, this place will do a service to the British people.
Turning to the Bill itself, I start by welcoming the emphasis that my noble friend placed on outcomes. Those of us who have served in Richmond House have had the slightly depressing experience of being forced, not least in the other place, to talk about health in terms of beds, buildings and money, as though they were the characteristics that determined the excellence of the health service. They all play their part but nobody would talk about outcomes. If this legislation leads to that cultural and significant change in this country-so that we start talking about outcomes-the work of this House and the Government will long be remembered. What we are concerned about are patient convenience, patients treated and patient outcomes.
Secondly, I welcome the fact that this legislation includes real delegation from the Secretary of State. I say real delegation because we live in a slightly make-believe world, in which SHAs and other bodies claim to have delegated power. I was not sure when I was in the department and am still not sure how real that delegation is. However, now it will be real. I hope that the Government understand that real delegation means legal liability, responsibility and accountability, judicial reviews and all the other aspects that go with a statutory framework. That will be a positive development but we ought not to skip over the likely consequences of this significant change.
I very much welcome commissioning. The Minister commended it and the important role that GPs have in developing healthcare. So did the noble Baroness, Lady Thornton, on behalf of the Opposition. This particular bit of the legislation got off to a slightly inauspicious start when, in the Second Reading speech in the House of Commons, the Secretary of State talked about fundholding having "failed to promote quality". Having told him to his face that that is not my memory and having been encouraged by my noble friend Lady Bottomley in that conversation, my main evidence that putting GPs in charge of fundholding improved quality lies with the honourable and right
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We had a two-tier system because the quality being delivered by fundholding GPs was so much better than that which was being produced by non-fundholding GPs that the difference was stark. If I have a regret about the Major Administration it was that in the summer of 1994, when more than 50 per cent of GPs were already in fundholding, the Prime Minister-how do I put this delicately?-did not see the need to drive the successful programme to a conclusion. Had he done so, by the summer of 1995 all GPs would have been fundholders and we would not be having this debate today.
I understand the need and case for a national Commissioning Board. I am not sure what is going to be the relationship between the national Commissioning Board and the CCGs and the relationship between the CCGs and the individual GPs. I see a lot of opportunity for conflict and I hope that, as we go through Committee, the Minister will be able to clarify those relationships. We do not need a new set of bureaucratic institutions which get in the way of the demonstrable ability of GPs to do what is best for their patients. In the health service, GPs are probably the only people who genuinely personally care for patients.
Can I tell my noble friend how pleased I am that PCTs and SHAs are going? This is long overdue. I read stories about the health service in the media and I do not know whether they are true, but I know what is going on in my old constituency. I am not impressed-and I do not think that a lot of people are-by a PCT that managed to get itself £20 million into debt, and an SHA that did not notice and does not know who was responsible and does not care because it is in the past. So well done for getting rid of them, but you need to do something about them between now and the implementation of this Bill.
A lot of nice things have been said about Sir David Nicholson and the Nicholson challenge. There is one small example. The East of England SHA has decided to amalgamate the Peterborough and Cambridge PCTs. Nobody wants this. In Peterborough it did not consult the primary care trust. It did not consult the Peterborough hospital. It did not consult the Peterborough council. It just did it, Sir Neil McKay tells me, because it would save some money. This is probably a small bit of the Nicholson challenge. When I asked the Government about this in Parliamentary Questions, I was told to go and ask Sir Neil McKay, whose behaviour within the SHA prompted a lot of the questions in the first place.
Baroness Kingsmill: My Lords, as a former deputy chairman of the Competition Commission, I am of course a strong believer in the positive effects of fair competition in most markets. However, we must remember
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I am not impressed by the regulatory elements in the Bill and I am not impressed by Monitor. It seems at the present moment to be a somewhat underpowered regulator. For something as sensitive as the NHS, if competition is to be introduced, we need to be very careful about how we regulate it. We need a remit for the public interest over and above anything else. An overweening public interest requirement must be the first issue that any regulator in this marketplace must consider. A mandate to prevent anticompetitive behaviour is simply not enough. There will always be the means by which anticompetitive behaviour arises without being apparent in clear ways.
It is also important to recognise that regulation has its limits, but a level playing field is important in the first place. At present, it does not appear that there is a level playing field with fair competition. Large health providers will be competing with current NHS providers that will not have the same access to funds and bank financing. This means that there will not be a level playing field or fair competition and it will be much too late to regulate for this afterwards.
It also concerns me-again as a former chair of an NHS trust-that a great number of very unpopular services will have no adequate compensation. I was the chair of Optimum Health Services, which was a community trust. It was the sister trust-the very poor sister-of Guy's and St Thomas'. Our remit was to provide community services in one of the poorest boroughs in London. The sorts of things we were concerned with were chiropody for the elderly and incontinency services. We were forced under the previous round of Conservative changes, with the introduction of the internal market, to figure out ways of reducing the number of incontinency pads provided to our clients from six a day to five a day. That was the kind of decision we were being forced to take. I cannot see very much competition for the provision of services such as those being apparent.
It is all very well for us all to talk about market forces and competition as if somehow that will be the answer to everything. However, I have seen from direct experience that it very rarely is the answer to everything. We do not do a good job of regulating our public services in this country. We have only to look at the railways to see that. We do not do a good job and I cannot see anything in the Bill so far that allays my fears.
I have been in the House only for five years but I have received more letters over this issue than any other one and somehow people seem to have got hold of my personal e-mail as well. I am overwhelmed with e-mails and letters and they all say the same thing. Some of them are emotional pleas along the lines of "Save our NHS" which are perfectly understandable but many of them are from individuals and organisations who are very well informed both about the Bill and the NHS. They have come forward with very powerful arguments as to why this is not appropriate for them. They are strong, well reasoned arguments and I feel we are obliged to take note of them. That is why I support the amendment of the noble Lord, Lord Owen. It would be entirely appropriate for us to have a Select Committee where people could come forward and give proper evidence, have it heard in public and televised if necessary so that a full and clear debate about these issues could be had-not simply rushed through with the inadequate scrutiny we have had both in the other place and here. We are all trying our best but quite frankly we just have not had the time. This is a Bill that could fundamentally change one of the pillars of our society and I do not think we have had enough time to look at it. The very modest and sensible suggestion made by the noble Lord, Lord Owen, is one we should all support.
There are other elements of the Bill that concern me greatly. I have some anxieties about the lack of close attention being paid to the problems of conflict of interest. I am very concerned about the possibility of GPs having a financial interest in the providers they may be commissioning. In Australia and New Zealand-I am a New Zealander-that is not allowed. It is expressly forbidden-you cannot have a financial interest in a body you commission. That is a very important thing that seems to be completely missing in the Bill.
We should also recognise-this is something that those who have worked in the NHS will realise-that it is more change. It takes ages and ages for these sort of changes to filter through and actually take place. It is costly, upsetting, damaging and unless you are absolutely certain that the outcomes are going to be improved it should not be embarked on lightly. I have grave anxieties that we are all going too far, too fast.
Lord Willis of Knaresborough: My Lords, I first declare an interest as the chair of the Association of Medical Research Charities. Judging by the number and passion of the communications that I and other Members have received you could be forgiven for believing this Bill was drafted in Hades by the most malevolent lawyers urged on by Ministers hell-bent on destroying the whole of the National Health Service. It simply is not that at all. Many of the same arguments were deployed against the Darzi health reforms of the previous Government-in fact many of the demons now being prayed in aid by the noble Baroness, Lady Kennedy, and others were Labour creations. The fact they were does not mean they were wrong or ill conceived, and the same can be said for much of the current Bill. It is our job to ensure that we scrutinise it fully and we are only just starting that process.
However, then as now, it was the failure to communicate what the reforms were trying to achieve that was at the heart of the discontent, not the motives to improve our health service. It is the confusion and complexity of these reforms that my noble friend must address if he is to convince the House that benign evolution rather than malevolent dogma lies at the heart of this Bill. However, evolution must not imply a lack of urgency or boldness. We can discuss organising commissioning groups in whatever configuration we like but, unless we can deliver to our clinicians the fruits of the most productive health and medical research base in the world, they will lack the tools that they need to truly deliver 21st-century health and social care.
Put simply, if patients are to be the new focus, as the Minister rightly says, they must be the beneficiaries of the work of our research community. In 1975, Milstein and Kohler at the MRC lab in Cambridge developed monoclonal antibodies, able to target individual proteins in the body. Following clinical trials using the NHS database, the technology was made available for therapeutic use and today monoclonal antibodies account for one-third of all new treatments, including ground-breaking cancer therapies such as Herceptin and Rituxan. Closer to home, few in your Lordships' House will not live longer and healthier as a result of the work of the MRC scientists and the British Heart Foundation, whose large-scale study using NHS patients revealed the relationship between cholesterol and heart disease. Today the wide-scale prescription of inexpensive statins not only reduces the risk of cardiovascular disease for millions but substantially reduces costs for the NHS.
Whether it is the use of induced pluripotent stem cells to find a cure for Parkinson's disease or stem cells to regenerate bone and cartilage in arthritic patients, translating research into clinical practice faster is what will really make a difference to patients, whoever they are and wherever they come from in our NHS. How right the noble Lord, Lord Darzi, was when he said in his excellent speech this morning that "healthcare resides at the edge of science". Yet this Bill is woefully weak on scientific research and the use of the NHS database. True, we now have Clause 5, which places a duty on the Secretary of State to promote research. A parallel duty to promote research is placed on the NHS Commissioning Board and the clinical commissioning groups-but this is merely window-dressing, without real substance.
The UK's universities and hospitals, vibrant medical science industries, strong health research charities and a unified healthcare system have all contributed to our status as a world leader in health research. Recent surveys by MORI for my organisation have shown that 72 per cent of patients are willing to join clinical trials and 80 per cent would consider allowing researchers to access their medical records. But efforts to do so are seriously undermined by an overly complex regulatory and governance environment. It takes an average of 621 days to recruit the first patient to a cancer trial, according to CRUK, largely because the regulatory environment has evolved in a piecemeal manner over several years as new regulatory bodies have been introduced. The net effect is a fragmented process characterised by multiple layers of bureaucracy,
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Most importantly, there is absolutely no evidence that these measures have enhanced the safety or well-being of patients or protected the public. Quite the opposite-duplication in obtaining permissions from NHS trusts and other regulators simply creates confusion and unnecessary delays. As a result of this "one size fits all" approach, there has been a fall in the UK's global share of patients in clinical trials and an increase in the time and cost of navigating the UK's complex research approval processes. That flies in the face of the idea that we get better outcomes for our patients.
In short, the current situation is stifling research, driving medical science overseas and seriously disadvantaging the very UK patients whose lot we in this House want improved. This Bill could and should deal with these issues by translating into statute the recommendations of the Academy of Medical Sciences. At the centre of its proposals was the creation of a new single research regulator to oversee and manage the regulation and governance of all health research; to deliver on opportunities to reduce complexity, costs, timeliness and inefficiency; and to build confidence in the conduct and value of health research. What is frustrating is that the Government are so supportive of that approach, but there is no sense of urgency to actually deliver. The promise of a Bill at some future date is simply not acceptable unless the Minister can put on record, when he winds up tomorrow, that it will be in the next Queen's Speech.
Setting up a health research authority as a special health authority is welcome but, apart from finding a home for the Medical Ethics Service, it answers few of the fundamental questions raised by the Academy of Medical Sciences. Equally, plans to improve the NHS R&D permissions process by making future funding conditional on NHS trusts meeting new approval timelines is very welcome, but how autonomous trusts will be persuaded to fast-track approvals is far from clear. What if the new commissioning groups say, "Research is not our priority"? How will the Secretary of State, without those powers, deal with exactly that? During Committee, I hope that amendments will come forward to consider setting up a new authority, though I recognise that unpicking our existing governance framework in order to streamline it will require a phased approach, the transition of several functions, and therefore co-ordination between a number of bodies. It will also mean dealing with the fall-out from the Public Bodies Bill, which seems to have been forgotten, and dismantling organisations such as the Human Tissue Authority and the Human Fertilisation and Embryology Authority. However, the academy has created a clear vision so that all those involved in undertaking research are clear on the end-point we are aiming for, and what is expected of them during the transition.
My noble friend has said that he wants to listen and that he wants to make necessary improvements to this Bill. He can become a hero in the medical community. He can become a god among patients, if he listens and takes our advice-and that is probably the best advice that he is going to get today.
Of course, all sides of this House would support such an aim. We can all agree that reforms of the NHS on some key issues are needed. When in government, my party started the current programme of reform to improve quality and productivity in line with the increased investment we made in the NHS.
Yet the changes to the NHS proposed in this Bill present us with a very different reality. Judging by my postbag, these changes have signally failed to engage the support of those in primary care, and have created huge anxieties among the people of this country. The Secretary of State has said that he wants,
Eminent clinicians and other medical professionals in their hundreds have shared with us their belief that the Bill as it stands will do irreparable harm to the NHS, to individual patients and to society as a whole.
I share, but do not intend to repeat, the many concerns voiced during this debate. Instead I want to focus on proposals which seem to me to impact particularly on education and training in the NHS. I am deeply anxious that the radical reorganisation proposed by this Bill will undermine the current UK-wide system of high level education, training and research. In particular, I am dismayed that we still do not know what will replace the strategic health authorities, responsible for the bulk of education and training. The SHAs host the postgraduate deaneries, which deliver postgraduate medical education, and which are responsible for the continuing professional development of all doctors and dentists. The intention seems to be that local skills networks of employers will take on many of the workload functions currently undertaken by the SHAs.
I cannot help but think that this is the wrong reform at the wrong time. The highly effective deaneries are able to tailor their workforce planning via local schemes within regional frameworks. I cannot see how the provider skills networks will do this more effectively or efficiently, particularly as there is no requirement for the networks to work with higher education institutions-the UK's centres of scholarship and academic expertise.
Professional leadership in medical education, based on co-operation between the medical royal colleges and deaneries, is currently very strong. Devolving responsibilities to networks of providers would certainly weaken this. I know that the coalition has given a commitment that deaneries will still have oversight of the training of junior doctors pending further changes, but the long-term future of these deaneries is still uncertain. The "safe and robust transition" for the education and training system, promised by the coalition following the Future Forum, has still to be made clear. Indeed, the Future Forum said explicitly that education and training needs to be service sensitive but professionally and academically informed. I also say that I very much
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I believe we could see fewer opportunities for education and training if the number of new providers of NHS services increases, as this Bill invites. There is real danger of conflicts of interest if training shifts to being employer led. Being "service dominated" rather than, as I believe it should be, "service informed" risks stagnation of educational provision and the danger of not addressing future workforce needs. I also fear that local employers would lack the necessary broad overview of medical workforce requirements, particularly given that specialist training can be as much as ten to 15 years following graduation.
The management, planning and oversight of the medical workforce can only be done at national and, more properly, at UK level. Can the Minister, in his response, explain whether there will be an explicit duty on the Secretary of State to retain a national, UK-wide system of high-level education and training? As we are discussing the duties of the Secretary of State, I remind the Government that it is the responsibility of the Secretary of State for Health to make available, in premises provided by him by virtue of the National Health Service Act 1977, as amended by subsequent legislation, such facilities as he considers are reasonably required by any institution in connection with clinical education and research.
That brings me to another area of concern, which is research. I am pleased to follow the noble Lord, Lord Willis, in his spirited advocacy for research. It is vital-for patient care but also for the economy of the UK-that research is not overlooked as we debate this Bill. The structural changes to the NHS proposed in this Bill could, as I see it, be a threat to the UK's important biomedical research industry. We must ensure that every healthcare provider has a duty to train the next generation of doctors and nurses. Having a research culture embedded in the NHS, from the Secretary of State to clinical commissioning groups, is vital if we are to tackle some of the health challenges we face.
At the same time, the NHS's consultant and professorial teaching staff must be incentivised to remain in the UK. The Secretary of State has had a report into the clinical excellence award scheme from the Review Body on Doctors' and Dentists' Remuneration on his desk since early July. Withdrawal of these awards would have a catastrophic effect on clinical academic careers and would immediately threaten the UK's pre-eminence. I hope that the Minister will confirm that the Government do indeed value their research workers and will take the necessary steps to ensure that the UK remains competitive.
I said that I would not repeat the concerns of others, but I wish to add my voice to those calling for further scrutiny of the duties of the Secretary of State. I believe the House must consider seriously the unanimous conclusion of the all-party Constitution Committee. The duty to,
has been placed on the Government since the NHS was established in 1948. For more than 60 years, people have known that the Secretary of State and the elected Government are responsible for defining and providing a comprehensive health service.
The proposed change of wording is not simply a question of being pragmatic about how decisions are made. This is not about a nice distinction between the duty to provide and the duty to secure that services are provided, as the Minister in his opening remarks seemed to suggest. It goes to the heart of who takes responsibility for a national universal health service. I believe passionately that the Secretary of State must retain the duty to provide these services. In this way, ministerial accountability, responsibility and legal accountability are maintained.
Therefore, I support the amendment to the Motion that would refer that section of the Bill to a specially convened all-party Select Committee. This remains one of the most contentious aspects of this very controversial Bill. It is essential that we take the time to get it right.
The Earl of Sandwich: My Lords, I start with a health warning: prescribed drugs can kill-a message which I recommend that all GPs pin up in their surgeries forthwith. The Minister already knows why I am saying this and why I have entered this debate today, and I will try not to repeat what I have said in this House previously. I will explain later how my intervention fits into the Bill and may lead me to put down amendments. I apologise to the Minister and to the House that, because of minor surgery, I will not be able to attend the wind-up speeches tomorrow.
Just over a year ago, as vice-chair of the All-Party Group on Involuntary Tranquilliser Addictions, I put the case for a vulnerable group in society which I feel has been virtually ignored by the health service. In most cases, these people-including a member of my own family- have been left in their homes in intolerable pain. These non-patients, through no fault of their own, have become victims of addiction to and withdrawal from prescribed drugs, such as benzodiazepines. There are an estimated 1.5 million people at risk, including many whose doctors and psychiatrists connive at overprescription and are then, it seems, incapable of coping with its ill effects. It is a scandal that has been known about since the 1960s. What are the Government doing about it?
To be fair, the Ministers responsible-Ann Milton and the noble Earl, Lord Howe-have both given me personal encouragement by way of letters and meetings during the past year. I sincerely believe they would like to make some headway. Earlier this year, the Department of Health published two reports by the National Treatment Agency and the National Addiction Centre, but these reports take us no nearer to policy-making. In reviewing the evidence, they were unable to identify the size of the problem or to separate legal users of prescribed medicines from illegal substance misusers. Apparently, the number of prescriptions is available but the number of patients-which is held on the GPs' databases-has been left unanalysed. So what benefit has there been for the patients from these reports? There are none that I can see. They are not a threat to society, so the suspicion must be that they are therefore lower in the order of priorities than illegal drug addicts, who are the only beneficiaries of the Government's drug strategy and, of course, of public money. Yet the pain of
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I also believe there is a gap in understanding between the department and its related health services, and this is relevant to the wider debate about tiers of authority. I give one example. My family and I have tried to put together research on the extent to which limited services for benzodiazepine patients exist in places like Oldham, Bristol, Cardiff, Belfast, Newcastle and the London Borough of Camden. I noticed that the Department of Health included Wandsworth in its list, so I telephoned the number it gave me. I was subsequently given three more telephone numbers and was finally advised by the PCT to contact the addiction centre in Roehampton, which advertised the service. One visit was enough to prove that the service did not actually exist. The psychologist involved admitted that it was a gap, and that they would have to take advice on setting up such a service.
Can this situation be a one-off? I suspect not: it is clear that other addiction centres do not have the necessary expertise. They have not had to deal with, nor been trained in, benzodiazepines except as part of a cocktail of illegal drugs. They will have experts in hard drug addiction and substance misuse, who either turn away occasional prescribed-drug patients or give them inappropriate and dangerous cold-turkey treatment, as happened in our case. The specialised services that exist are mainly independent of the NHS and are largely staffed by volunteers who have suffered withdrawal themselves and who, through that experience, have become the experts. A few work with their local PCTs or are funded by them and are properly recognised as the best practice in their area, but most counties in the UK simply do not have these services.
What is the expertise? In the case of addiction, the most important thing is gradual withdrawal with careful tapering and psychological support. The expert manual on tapering was written by Professor Ashton of the University of Newcastle. Patients need places to meet addiction workers-ideally in specialised clinics, existing multipurpose centres or church halls-and they need help with transport. Counselling by telephone or e-mail is important. It is not ideal, but helplines and the sharing of experience online enormously help those who spend long hours alone in their rooms in pain. Alternative therapies are available through the NHS, but these are not always appropriate in connection with prescribed-drug addiction. Families need professional support as well.
This is where the Bill comes in. At a time of economic cutbacks, we should be paying much more attention to these voluntary services, which provide real value for money. This Government evidently want to increase the role of the private sector, and that includes local voluntary agencies, but how will local authorities and CCGs cope if there is no national plan or funding? The health service created the problem of prescribed-drug addiction, so why can it not find the funding and design best practice to help its victims? Services may be managed by individuals who run their own charities and are not subject to direct management control by the NHS. Not-for-profit organisations are
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I would therefore like the Government to give much more encouragement to the people who are already working on the front line to help the victims of prescribed-drug withdrawal. These services, I can testify, are of a high standard and should go straight on to the list of qualified providers. It is time for the DoH to recognise them and organisations like them throughout the health service and give them support.
Baroness Gibson of Market Rasen: My Lords, in the 11 years since I joined your Lordships' House, I have never received as much correspondence on one piece of legislation as this Bill has generated. I have had hundreds of letters, e-mails and telephone calls about the Bill from individuals and organisations. Some have asked, indeed begged, me to oppose the Bill as a whole, others have picked out large chunks or particular clauses of the Bill, and only one e-mail has asked me to support the Bill in its entirety. If I had ever had any doubts about the love of the British people for the NHS before, I would have none now. The NHS is not only dear to our hearts but a fundamental part of our nation. I do not have the expertise about the NHS which many others in the debate have, but I respect and admire it and those who work in it. I have only a few matters to comment upon, about which I have some knowledge.
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