Editor's blog Tuesday 1 February 2011: Commons second reading of Health and Social Care Bill
You'll already know that the second reading of the Health and Social Care Bill passed last night.
The brilliant folks at Hansard have the transcript online now.
Some key extracts follow below; first, a few thoughts.
1. New and recent intake Conservative and Lib Dem MPs have a distinct animus against PCTs. This is probably as a result of never having had very much to do with them. Will they like GP consortia any better? Consortia will have the same job PCTs did - that of rationing care. And MPs will be much, much less able to pull democratic accountability rank - because consortia will be very local bodies, finely tuned into the population via local Health Watch and Health and Wellbeing Boards. And hassling the Secretary of State will in the future not help MPs.
2. If the Kings Fund's iridescent chief economist Professor John Appleby copyrighted his name, he could be sending quite a few royalty demands this morning.
3. There were some very good speeches from Stephen Dorrell, Sarah Woolaston, Nadine Dorries (to my surprise), Hugh Bayley, Malcolm Wicks, Kevin Barron, Grahame Morris, David Miliband - and a much better end to his main speech from John Healey, which brought quiet to the Chamber.
4. The London stroke services reorganisation was raised early, and points to a crucial issue over reconfigurations. NHS London had planned and agreed the changes prior to the change of government; SOS Lansley sent them back because they were not 'bottom-up' and failed his infamously flaky four tests. Back they came after some fairly flaky 'consultation', and what do you know? They were the same as the original NHS London plans.
The issue applies to long-ducked closures or changes in many areas. And the politics of changing or closing services are hard, hard work. With which the Opposition will make hay - as Oppositions do. PCTs are already shedding staff and clustering. Until this Bill passes, service reconfiguration requires public involvement, engagement and consultation. There may not be too many PCT managers left who want to take those bullets or that grief.
A few do - Lib Dem Andrew George of St Ives warned SOS Lansley that "in Cornwall the primary care trust has engaged in the transfer of community hospitals and services without adequate public consultation and at breakneck speed? If 'no decision about me, without me' is to apply to service design and patient involvement, is he prepared to intervene to ensure that the public are involved in such important decisions?"
But most are not.
So shutting things that need shutting is in limbo.
5. Andrew Lansley's been well-coached on the Care UK donation issue - he correctly told the House that "I did not receive money directly from a private health company for my office while in opposition".
Indeed not: as the Telegraph story showed, the money was donated by the wife of Care UK's chair John Nash and channelled to Mr Lansley's office via Conservative Party Central HQ.
The Secretary of State for Health (Mr Andrew Lansley): I beg to move, That the Bill be now read a Second time.
The purpose of the Bill can be expressed in one sentence-to improve the health of the people of this country and the health of the poorest fastest. While the previous Government increased funding for the national health service to the European average, they did not act similarly to increase the quality of care. We spent more, but others spent better. In important areas, the NHS performs poorly compared with other countries. An expert study found that out of 19 OECD countries that were investigated, the UK had the fourth-worst death rate from conditions that are considered amenable to health care. If NHS outcomes were as good as the EU15 average, we would save 5,000 lives from cancer and 4,000 lives from stroke every year. We would also prevent 3,000 premature deaths from respiratory disease and 1,000 premature deaths from liver disease every year. This cannot go on: things have to change to protect the NHS and deliver better results for patients.
Mr Kevin Barron (Rother Valley) (Lab): I do not dispute what the Secretary of State says about European comparators, but what does he say to Professor John Appleby, who said last Friday that all those markers, some of which are not direct comparisons, are getting nearer to European targets? Professor Appleby suggested that the disruption that is going to take place in the health service will not help us to do that.
Mr Lansley: I would say two things to Professor John Appleby. First, the latest data published in EUROCARE-4, which I know the right hon. Gentleman will have seen, are clear about the gap between cancer survival rates in this country and others, and in recent years that gap has not diminished as it should have. He can read in last week's Lancet an authoritative study of cancer survival rates in this country and a number of others demonstrating that the gap remains very wide and that we have to close it. Secondly, the King's Fund supports the aims of the Bill and Professor Appleby, as a representative of the King's Fund, clearly understands, as we do, that if we are to deliver the change that is needed, we need the principles in the Bill.
People trust the NHS, and its values are protected and will remain so-paid for from general taxation, available to all, free at the point of delivery and based on need rather than the ability to pay. However, a system in which everyone is treated the same is not one that treats everyone as they should be treated. Our doctors and nurses often deliver great care, but the system does not engage and empower them as it should.
Geraint Davies (Swansea West) (Lab/Co-op): On the John Appleby point, does the Secretary of State accept that what he actually said was that the rate of deaths from heart disease would be better in Britain than in France by 2012, on current trends, even though France spends 28% more on its health service? Is not that a ringing endorsement of what is happening now rather than a prescription for blowing up the system as the Secretary of State suggests?
Mr Lansley: First, I have just answered the point about John Appleby. It is true in a number of respects, as I have made clear, that although there have often been improvements in the NHS, they have not been what they ought to have been. It was a Labour Prime Minister, back in 2001, who said that we must raise resources for the NHS to the European average, but he did not achieve results that compared with the European average.
Let me give the hon. Gentleman some examples. A recent National Audit Office report showed that as many as 600 lives a year could be saved in England if trauma care were managed more effectively. Too often, the latest interventions, which are routine in other countries, take too long to happen here. John Appleby used heart disease to illustrate his point. Primary PCI- percutaneous coronary intervention-using a balloon and stent as a primary intervention to respond to heart attack was proven to be a better first response years ago. I knew that because cardiologists across the country told me so several years ago. I remember a cardiologist at Charing Cross telling me, "I have a Czech registrar working for me who says that in the Czech Republic PCI as a response to a heart attack is routine, but it hardly ever happens in this country." Since then, it has been better implemented in this country, but that started to happen only when the Department of Health gave permission for its adoption.
The same was true of thrombolysis for stroke. That happened too late in this country, after such changes had taken place in other countries, because health care professionals there were empowered to apply innovation to the best interests of patients earlier.
Nadine Dorries (Mid Bedfordshire) (Con): Does my right hon. Friend agree that, given the disparity in survival rates in trauma care and in many illnesses, including cancer care and heart attacks-citizens in this country are twice as likely to die of a heart attack as those in France-the NHS is in desperate need of modernisation?
Mr Lansley: My hon. Friend is right. We need not only to match European spending, as we do now, but to ensure that we achieve European-level results. It is not just about benchmarking, which we know we must do. We must benchmark ourselves against the best in the world if we are to deliver the best results for patients. We must also constantly make sure that we achieve a modernised health service that delivers the best possible care-sometimes going ahead of what others achieve, and applying innovation more quickly.
In some ways, as we know-for example, in mortality rates from accidents and from self-harm, and in equity of access to health care-the NHS leads the world, but our doctors and nurses are regularly hobbled by a system that treats equality as sufficient, when what we need is both equity and excellence.
Why did spending more not deliver better results? We know why that is- [Interruption.] No, better results should have been achieved. Hon. Members on the Opposition Benches need to realise this, because it has been at the heart of their failure in public service reform over the past decade: the Office for National Statistics said a few weeks ago that productivity in the NHS fell in every one of the past 10 years. It fell by 1.4% a year in hospital services.
Despite a huge amount of money rightly invested in the NHS, taxpayers and patients were not getting the service that they should have had. Billions of pounds have also been wasted on an ever-growing bureaucracy, taking money away from the front line and away from patient care. The number of managers doubled under Labour. I give way to the Chair of the Public Accounts Committee.
Margaret Hodge: I thank the right hon. Gentleman. He is right to draw attention to the fact that productivity has fallen in the past 10 years, but should he not consider whether it is wise in those circumstances to distract people from driving up productivity and achieving savings by the unnecessary institution of reform? That is just taking people away from the thing that they should be concentrating on.
Mr Lansley: The right hon. Lady should understand, as I will go on to explain, that we are not distracting the NHS from the need to improve services for patients. We are enabling the NHS to improve services for patients. In her role on the Public Accounts Committee, she should understand that right across the public services, one of the consequences of dealing with the deficit is that we will have to reduce the costs of bureaucracy and administration.
We will do that in the NHS as much as anywhere else, but we will not do it in the way that the Labour party pressed us to do, which was to cut the NHS budget-[Hon. Members: "What?"] Yes, Opposition Members did exactly that. We will increase the NHS budget. As we set out in the spending review, we will increase the NHS budget
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by £10.7 billion over the life of this Parliament-investment that Labour opposed-and we are determined to get far more for British taxpayers' money.
Angie Bray (Ealing Central and Acton) (Con): My right hon. Friend will be aware that there has recently been an excellent reorganisation of stroke treatment in London, with a number of hospitals earmarked as emergency centres, all of which, crucially, are within 30 minutes of every Londoner. Once patients have been through the emergency procedures and are stabilised, they are returned to local stroke centres, which are also earmarked as part of the whole programme. Can he reassure me that that kind of regional organisation of hospitals, which has delivered good results, will not suffer through some of the proposed reforms?
Mr Speaker: Order. I remind Members that interventions should be short. There are 57 Members seeking to speak in the debate, so interventions must be pithy.
Mr Lansley: Thank you, Mr Speaker. I can give my hon. Friend the Member for Ealing Central and Acton (Angie Bray) precisely that reassurance. I was with NHS London at the beginning of last week, and it is clear that GP commissioning groups are coming together with providers to develop those kinds of commissioning plans, going beyond trauma and stroke care, which has already happened in London, to look, for example, at the integration of diabetes care between primary care and hospital services.
Under the Bill, patients will come first and will be involved in every decision about when, where, by whom, and even how, they are treated-"there must be no decision about me, without me." The 2002 Wanless report called for patient engagement, but that did not happen. Now it will. Because patients cannot be empowered without transparent information, an information revolution will give them more detailed information than ever before, showing them and their doctors the consultants who deliver the best care, giving them control over their own care records and enabling everyone to access the care they need at the right place and at the right time. Patients and their doctors and nurses will be able to see clearly which provider of health care offers the best outcomes and to make their decisions accordingly.
The coalition agreement states: "We will strengthen the power of GPs as patients' expert guides through the health system by enabling them to commission care on their behalf."
Our manifesto stated that we would strengthen the power of GPs, "putting them in charge of commissioning local health services."
I have just quoted from the coalition agreement and our manifesto, so hon. Members have heard both.
Through the outcomes framework, which we published in December, we will stop the top-down, politically motivated targets that have led to real quality being sidelined. We will ensure that we focus on the outcomes that really matter and back them up for the first time with quality standards that are designed to drive up outcomes in all areas of care. Those standards have not been dreamt up in Whitehall, but are being developed by health professionals themselves. Similarly, doctors and other health professionals will not be told by us how to deliver those standards. The standards will indicate clearly what is expected, but it will be up to clinicians to decide how to achieve them. At every step, clinical leadership-that of doctors, nurses and other health professionals-will be right at the forefront. It will be an NHS organised from the bottom up, not from the top down.
The shift in power away from politicians and bureaucrats will be dramatic. The legislation none the less builds on what has gone before. It is not a revolution, but as the shadow Secretary of State said just a fortnight ago:
"The general aims of reform are sound-greater role for clinicians in commissioning care, more involvement of patients, less bureaucracy and greater priority on improving health outcomes-and are common ground between patients, health professions and political parties."
Emma Reynolds (Wolverhampton North East) (Lab): The right hon. Gentleman quoted the National Audit Office earlier. Does he agree with the statement in its report that his revolution in and upheaval of the NHS risk undermining the quality initiative-the so-called QIPP programme-that the previous Government introduced?
Mr Lansley: No, far from it-actually, quite the contrary. It is only by virtue of our ability to engage front-line clinicians more strongly in the management and design of care that we will deliver those quality, innovation, productivity and prevention ambitions; and it is only if we cut bureaucracy and the costs of bureaucracy that we will be able to get those resources on to the front line more effectively. I made it very clear, and the shadow Secretary of State endorsed the view, that there is consensus about the purposes of reform, but if Labour now voted against the Bill, although we do not know whether it will, it would abandon that consensus and, indeed, its own policies when in government.
Mr Jim Cunningham (Coventry South) (Lab): Can the right hon. Gentleman say how many jobs will go in front-line services and how many hospital closures there will be as a result of his policies?
Mr Lansley: I just wish that the hon. Gentleman would look at the latest published data. Since the election, we have reduced the number of managers in the health service by almost 4,000 and increased the number of doctors. For the first time, there are more than 100,000 doctors in the NHS, and we are increasing the number of health visitors, after years of their numbers being reduced under the previous Government. He should get his facts right before he starts flinging accusations about.
The Labour party, when in government, pioneered patient choice; Labour said, "We must have patient choice." I remember John Reid, when he was a Member, saying that the articulate and the well-off negotiated their way through the health service, and that he wanted to give choice to everybody in the health service. He was right. The social attitudes survey in 2009 found that more than 95% of people felt that they should have more choice, but that fewer than half of patients actually experienced it. The Labour party started down the road of extending choice; we will complete that journey.
Andrew George (St Ives) (LD): On patient choice in health service design, is the Secretary of State aware that in Cornwall the primary care trust has engaged in the transfer of community hospitals and services without adequate public consultation and at breakneck speed? If "no decision about me, without me" is to apply to service design and patient involvement, is he prepared to intervene to ensure that the public are involved in such important decisions?
Mr Lansley: I am grateful to my hon. Friend for that point. I have not previously been asked to comment on the matter, nor have I received information about it, but from my visits to Cornwall I entirely endorse his view about the importance of community hospitals in accessing services. He will see that, in the Bill, a specific duty is placed on the commissioning board and each commissioning consortium to reduce inequalities in access to health care. He will see also that, through the Bill, we will strengthen accountability where major service change takes place, because it will require not only the agreement of the commissioning consortium, representing as it were the professional view, but the endorsement of the health and wellbeing board, which includes direct, local, democratic accountability. Points have been made about what was in manifestos, but the Liberal Democrat manifesto was very clear about the need for democratic accountability in health service commissioning-and so there will be.
Let me return to the point, because the previous Government also went down the route of practice-based commissioning. It was their policy, but, as the shadow Health Minister, the hon. Member for Leicester West (Liz Kendall) said, many GPs felt that "they didn't always get the power, responsibility and resources they might have wanted."
Well, now they will, and we will give it to them.
On our definition of quality, Opposition Members say "quality matters". It does, and it was under the Labour Government that Ara Darzi pioneered the thought that quality must be at the heart and an organising principle of the health service. It is we now who are going to make that happen. We are publishing quality standards. We are putting into this legislation a duty to improve quality that extends to all the organisations that commission and provide NHS services.
Mr Ronnie Campbell: Will there be public accountability for the private companies that will come in and do the commissioning for the doctors? I can see their people getting top salaries-the executive getting £200,000 and the financial officer getting £250,000. That is the sort of thing that we are trying to stop. What will happen when these companies run things for doctors?
Mr Lansley: The accountability in the NHS will be for the quality of the service being provided. The hon. Gentleman may not have agreed with the last Labour Government on this, and perhaps many in the Labour party are now changing their view on what was pursued by that Government, but it was that Government who introduced and encouraged a policy of "any willing provider". In 2003, Alan Milburn said: "If I can get a private-sector hospital to treat an NHS patient, then for me the person remains an NHS patient."
Everybody in the NHS who provides NHS services will be accountable through the- [Interruption.] The money will follow. The Chair of the Public Accounts Committee is here. Where public money goes, accountability for its use will follow.
On the point of allowing the independent sector to be a provider to the NHS, I should say that it was the right hon. Member for Leigh (Andy Burnham), the shadow Secretary of State's predecessor, who said that "the private sector puts its capacity into the NHS for the benefit of NHS patients, which I think most people in this country would celebrate."-[ Official Report, 15 May 2007; Vol. 460, c. 250WH.]
Well, Labour Members are not celebrating it now; they have reverted to type
Mr Baron: The Government's increased focus on improving outcomes is long overdue and very welcome, but will the Secretary of State address the issue of cancer networks and the concern that some of the expertise may be lost because of the funding gap between the end of funding for the cancer networks themselves and GP commissioning fully taking effect? Can the Government do anything to bridge that gap so that we allow GP consortia to be better informed in making decisions about what services to commission?
Mr Lansley: My hon. Friend rightly takes a close interest in these matters. When I was with him and other colleagues at the Britain against cancer conference, I made it clear-and he made it equally clear-that the cancer networks funding is guaranteed during the course of 2011-12. There is not a gap, because from April 2012 onwards the NHS commissioning board will take up its responsibilities. There will then be decisions by the commissioning board about how it will structure that.
Let me come back to what the last Labour Government did. They introduced the concept of payment by results. Unfortunately, however, payment tended to be by activity and not by results. We will now make it payment by results and really make that happen.
To complete the picture, I should say that throughout the Bill there are elements of policy that we are taking forward, such as foundation trusts. The Bill follows the brainchild of Alan Milburn and Tony Blair back in 2002. In 2005, the Labour Government said that every NHS trust should become a foundation trust by December 2008. That just did not happen. Again, it will be our task to make modernisation in the NHS consistent and comprehensive.
Mr David Lammy (Tottenham) (Lab): Will the Secretary of State say how many GP contractors he estimates will be private companies? Will he also make it clear to the House that none of the private medical providers that funded his office in opposition will gain from the change?
Mr Lansley: There are two points to make. First, we have made no estimate of the extent to which GP-led commissioning consortia will contract with independent sector providers, so I cannot give the right hon. Gentleman such an estimate. Secondly, I did not receive money directly from a private health company for my office while in opposition. So there we are.
Labour's reforms were piecemeal and incoherent. Under the previous Conservative Government, the internal market and fundholding of the early 1990s failed to promote quality and risked conflicts of interest among GPs. We have learned from those mistakes and from the failings of a Labour Government over the past 13 years. This Bill is different. It views the NHS as a whole service, every bit of it geared towards meeting patients' needs. This Government understand that the best health care comes from the close partnership between patients and their clinicians. Every part of the NHS, every incentive, every structure and every decision must support and strengthen that relationship.
First, we will place the individual needs of each patient above all else, encouraging, wherever possible, a personalised approach to health care, tailoring services to have the greatest individual, and greatest overall, impact. Secondly, decisions made in the consulting room, in local service design, in commissioning, and in the services any particular provider offers, will be local decisions-real autonomy and real devolution of power.
Thirdly, there will be relentless focus on quality, embedded within a new legal duty. Fourthly, there will be a diverse and vibrant social market for health care. We will encourage NHS staff to set up social enterprises and foundation trusts, and we will encourage new capacity in delivering services through social enterprises, charities, private companies, and, indeed, NHS providers.
We want clinicians and their patients to lead the NHS, but they cannot do this while they sit under a vast hierarchy of regional and local organisations, all reporting to Whitehall. Everyone agrees that top-down command and control gets in the way of clinicians doing their job, so we need to dismantle the structures that sustain that interference; that is why we will abolish primary care trusts and strategic health authorities. There are many excellent people working in those organisations. Many will move to be with the new general practice-led commissioning consortia, to local authorities and to the NHS commissioning board. Some will want to set up their own new social enterprises. But even the best people cannot deliver the NHS that patients need if things stay as they are, so we will also introduce direct local democratic accountability. Councillor-led health and wellbeing boards will oversee and work with local NHS consortia, working to bring together the NHS, social care and public health services, and bringing a strategic coherence to the health and well-being of local communities.
Mr Blunkett: On bottom-up decision making at a local level, will the Secretary of State give a guarantee to the House that if the GPs now coming together in consortia decide that they wish to employ the expertise residing in the current primary care trust, he and the future health board will not intervene to stop them doing that? Will he also guarantee that he will not insist on redundancies that cost a fortune and preclude that expertise being available to the existing local consortia, with private enterprises then employing them to do the job that they were doing in the first place?
Mr Lansley: Let me make two points to the right hon. Gentleman. First, in the impact assessment that we published with the Bill on 19 January, we set out very clearly our estimates-they are no more than estimates since they will have to be decided by the general practice commissioning consortia and local authorities-that between 50% and 70% of the staff in primary care trusts would be employed in the successor organisations.
Secondly, the idea that somehow general practice-led commissioning consortia would engage the private sector where that has not happened up until now is, I am afraid, completely contradicted by the facts. Under the Labour Government, in the two years leading up to the election, there was an 80% increase in the use of management consultants, while at the same time the number of administrators and managers in those same organisations was rising dramatically. We arrived at the point where there were 50,000 administrators in primary care trusts, and they were still spending nearly £300 million a year on top for management consultancy. That all has to change.
One thing that Labour abjectly failed to do was to empower patients with a real voice in the health service. Through this Bill we will establish local healthwatch organisations that will represent the patient's voice in the design of local services and help individual patients, especially the most vulnerable, to make the most of the choices available to them and to help them when things go wrong. Sitting within the Care Quality Commission, the national healthwatch organisation, too, will act as the eyes and ears of the quality regulator, and work to give the local organisations real teeth in their dealings with their local NHS-something that was completely, abjectly destroyed by the Labour Government when they abolished community health councils. Indeed, I know that families of those treated at the Mid Staffordshire hospitals welcome the additional powers for patients to have a voice.
Clive Efford: The right hon. Gentleman will know that the Bill introduces European competition law into the national health service, and removes the existing protection once and for all. His Government have just taken the decision to put billions of pounds into stopping Irish banks failing. If a local hospital fails under the new market arrangements, will he step in and save it?
Mr Lansley: Time does not permit me to explain the extraordinary ignorance of that series of points. First, the Bill sets out that the regulator will have a responsibility to establish a failure regime. In 2003, when the predecessors of those currently on the Labour Front Bench took the health legislation through the House, they said that they would introduce a failure regime, to be implemented by Monitor, in legislation. They never did so. At the moment, there is therefore no proper failure regime.
Secondly, European competition law-indeed, competition law-applies in this country. A body was established in the national health service under the previous Labour Government called the co-operation and competition panel, the express purpose of which was to apply competition rules in the NHS. To that extent, all the Bill will do is to ensure that the rules that already apply are applied fairly, consistently and transparently across all providers.
Jeremy Lefroy: The Secretary of State referred to the Mid Staffordshire NHS Foundation Trust, into which an inquiry is taking place. What lessons from the various investigations have been applied in the Bill to address the concerns that have been raised?
Mr Lansley: I am grateful to my hon. Friend for that question. In addition to the measures on healthwatch and patient voice, we are strengthening the responsibilities of commissioners. As I suspect he knows from his local knowledge, general practitioners knew in many cases that the services at Stafford hospital were not meeting the quality of care that they ought to have met. However, there was no transparency in the outcomes, and there was no responsibility collectively among general practices and local health professionals to intervene. There was no mechanism that enabled or incentivised them to do so. We are going to change that. When Sir Robert Francis's report is published in due course, I hope that the Bill, by strengthening patient voice, commissioning and the regulatory structure, will give the opportunity for whatever recommendations he makes to be implemented rapidly.
I will explain further what the Bill will do. Local authorities, with a ring-fenced budget, will bring public health to the front and centre of public policy. This is not just about the NHS, but about improving the health of the whole population. That is why we are putting local authorities at the heart of it. The health of the general public is as much about the environment, the economy, housing and transport as what happens in the NHS. Health and wellbeing boards will make the link between health and social care, which have too often been in silos. We understand how intertwined those things are and how they must work together.
The unions, of course, are against this modernisation of our public services. I suspect that they are the "forces of conservatism" that, more than a decade ago, the former Prime Minister told us he had to fight against. They oppose the principles of our plans, or so they say, but do they have an alternative? No. That contrasts completely with the reaction of general practitioners and health care professionals in GP pathfinders.
General practitioners and health care professionals in GP pathfinders are, in contrast to the unions, enthusiastic about what we are trying to achieve. For example, Dr Paul Zollinger-Read, a general practitioner and the chief executive of NHS Cambridgeshire, said recently: "In our area, the GPs got together and focused on quality of care. They looked at diabetic care, for example, and services in this area improved. That means fewer diabetics will need to go to hospital in an emergency, there will be fewer amputations and less heart and kidney disease."
Far from GPs being reluctant at the thought of taking on new responsibilities, applications to be pathfinder consortia were over-subscribed.
There are now 141 pathfinders, covering more than 28 million patients. More than half the population are already benefiting from the clinical leadership of their local health professionals. I have met some of the pioneers, such as in Redbridge, where they are pioneering bringing ophthalmology and dermatology services out into the community, and in Bexley, where they have pioneered better access to cardiology services for their patients. [Interruption.] Opposition Members say that they were doing that, but my whole point is that we are turning the exceptional cases in which GPs have had such opportunities in the past into the opportunity for all GPs across the country to do so. The Opposition might like to talk to the new chair of the clinical cabinet in Bexley, one Dr Howard Stoate, whom they will recall as a Member of the House before the election.
It is not only GPs who are anxious to get on with it. We are already working with 25 early implementer health and wellbeing boards that want to start bringing benefits to their communities. By April, we expect to be working with up to half of all local authorities, and the Bill will create that framework. Whereas the previous Government often talked a good game, we will put our ambitions and the new roles into law. The Bill explicitly defines roles and responsibilities that were previously at the discretion of Ministers. Until now, legislation on the NHS has more or less said, "The NHS is whatever the Secretary of State chooses to make it at any given moment." That was why, in the past, reorganisations took place on a practically annual basis under the Labour Government, without there ever being any consistency or coherence to them. I intend to be the first Secretary of State in the history of the NHS who, rather than grabbing more power or holding on to it, will give it away.
As well as devolving decision making, the Bill will transfer power back to Parliament and strengthen the accountability and transparency of the NHS. It will protect the NHS constitution, ensuring that the rights in it are reflected within NHS commissioning and regulation. It contains a number of new duties, including a duty on the Secretary of State, the NHS commissioning board and each commissioning consortium to seek continuous improvement in the quality of services, and to seek to reduce inequalities in access and health outcomes.
The Bill contains a duty of autonomy, so that politicians allow providers and commissioners to provide the best care as they see fit, minimising burdens wherever possible. There is a duty on Monitor to protect and promote the interests of patients, through competition where appropriate and through regulation where necessary. The role of local authorities will increase greatly, including not only the scrutinising of local health services but a duty to promote integrated working between the NHS, social care services and public health services.
As I have said, in 2003 Labour promised a proper regime in the event of the failure of any provider of NHS care. They did not provide that; this Bill will. Should a provider fail, there will be a transparent process for maintaining designated services, to ensure continuity of services for patients.
Monitor will be empowered to set up a "risk pool", to which providers will pay a levy that will meet the costs of maintaining key services. There will also be a clear and transparent process for setting the NHS tariff for different services. The National Institute for Health and Clinical Excellence will develop quality standards, give advice and make recommendations on the clinical effectiveness of medicines and treatment. As the shadow Secretary of State said a fortnight ago, the Bill is "consistent, coherent and comprehensive". It will put patients first and improve health outcomes.
The Bill will change structures, abolish bureaucracy and inject added competition, but those are only the means to a much greater end. As large and complex as it is, there is one simple objective behind the Bill-better care for patients, measured not by political targets but by real results for patients. It is about gearing the entire system towards supporting the relationship between doctor and patient-a "meeting of experts", as Tuckett would have called it, with the patient being an expert on themselves and the clinician being an expert on their clinical management and condition. It is about bringing the two together based on trust, transparency and the best available treatment from the best available provider.
Previous changes have tinkered with one piece of the NHS or another, when what was needed was comprehensive modernisation to create an NHS fit for the demands of the 21st century. That is precisely what this Health and Social Care Bill will deliver. What we see from the Labour party is nothing but opposition for its own sake-opposition to the modernisation that the NHS needs-and most of it is inconsistent with Labour's own manifesto. It is clear that Labour opposes not only our investment in the NHS and our cuts in NHS bureaucracy but our modernisation of the NHS, which it pursued while in government.
The House knows my passion for the NHS, my respect for those who work in it and my ambition for it to be the best health care service in the world. This Bill, and the modernisation of which the Bill is just a part, are about that passion for the NHS and for securing its future. I commend the Bill to the House.
John Healey (Wentworth and Dearne) (Lab): The Health Secretary is a man who is struggling to sell his plans. The more people learn about them, the less they like them. The more those in the NHS see, the more worried they become and the less they find to support. Only one in four of the public back him in wanting profit-making companies to be given free access to the NHS. Most GPs neither like nor want these changes, and three out of four doctors do not believe that they will improve services to patients.
Today, for the second week running, the Prime Minister is talking about the NHS changes. He is like a football club chairman stepping in to back a beleaguered manager because everyone else is losing faith in the manager's judgment. Mind you, the Prime Minister does not always help the Health Secretary, because his words do not ring true with people. Last week, the Prime Minister called the NHS "second rate". People know that it can be better, but they are proud of the NHS. They have seen big improvements during the last Labour decade, and they know that waiting lists are at their lowest ever and that patient satisfaction is at its highest ever. Those facts are backed up by international comparisons from the Commonwealth Fund, which said last year that Britain's NHS is one of the very best in the world, and second to none on best value for money.
Nick Boles (Grantham and Stamford) (Con): The Labour Government introduced foundation hospitals, private sector provision in the NHS, patient choice and payment by results-four things on which we are now building. They also introduced GP commissioning through pathfinders. Which elements of the Blair reforms to the health service is the right hon. Gentleman not repudiating today?
John Healey: It is true that we encouraged many of the GP commissioning models that the Health Secretary now champions, but that process was always within a planned and managed system, and it was never implemented at the expense of other clinicians or patients being in charge. We used private providers when they could add something to the NHS and help it to raise its game, and when they could add capacity so that we could clear waiting lists. Of course there is a role for them in the future, but that is not the question at the heart of the Bill. I will come back to the hon. Gentleman's question later, however. People saw big improvements in the NHS under Labour, but they now realise that many of those gains might be at risk as a result of the decisions that this Government are taking.
David Miliband (South Shields) (Lab): Does my right hon. Friend agree that the most significant change in the Bill was not mentioned by the Secretary of State? It is that the Bill introduces price competition into a market that, up to now, has allowed competition only on quality. The London School of Economics, citing academic evidence, states clearly that "most international evidence suggests that, whereas hospital competition with fixed prices can improve quality, simultaneous price and quality competition can actually make things worse".
John Healey: Characteristically, my right hon. Friend is absolutely right. The Government will talk about some changes, but not about others. The changes are like an iceberg, with big, substantial, ideological changes hidden from public sight.
Mr Lansley: The edifice of an argument from the right hon. Member for South Shields (David Miliband), which is repeated by others, is based on one fact: in December 2009, the operating framework said that commissioners in the NHS could set a maximum price and not just a fixed price. That was December 2009. The right hon. Gentleman and the shadow Health Secretary were in the Government who put that measure into the operating framework. This Government did not put it in; the previous one did.
John Healey: The point made by right hon. Friend the Member for South Shields is based on page 42 onwards of the Health Secretary's impact assessment of the Bill, which mentions a premium for private providers of £14 per £100. The Bill allows the system to pay a premium and a bung to private sector providers.
Mr Stephen Dorrell (Charnwood) (Con): Will the right hon. Gentleman now answer the question put to him by my right hon. Friend the Health Secretary? Does he agree or disagree with the maximum price tariff principle that was set out in December 2009 by the previous Labour Health Secretary?
John Healey: We operated an NHS with a set tariff, not a maximum tariff. In government, we operated an NHS in which price could not be the factor that drove decisions about what services patients received and by whom they were provided. My right hon. Friend the Member for South Shields is absolutely right to point out that the Bill will introduce price competition and the flexing of the price so that there is no longer a set tariff for treatments and patients but a maximum price that can be undercut by providers coming into the field. The Government will not talk about that.
The Prime Minister is not helping the Health Secretary, because the changes the Bill makes were not in his election manifesto, not on his election posters and not in his election speeches. I have the Conservative manifesto here. There is no mention of axing all limits on NHS hospitals treating private patients, so that NHS patients lose out; no talk or mention of undercutting on price, so that established NHS services are hit as new private companies cherry-pick easier patients and services; no mention of guaranteeing only selective hospital services, so that others can be closed and lost to local people without public consultation; and no mention of putting a new market regulator at the heart of the NHS with the principal job of promoting and enforcing competition. There is no mention in the Conservative manifesto of the biggest reorganisation of the NHS since it was set up more than 60 years ago. They did not tell people about their plans before the election and they promised not to introduce such measures in the coalition agreement after the election. There is no mandate from the election or the coalition agreement for this fundamental and far-reaching reorganisation. That is not a debating point, but a point of democratic principle.
Gordon Birtwistle (Burnley) (LD): I do not remember in the 2005 Labour party manifesto the "Meeting Patients' Needs" programme that closed the A and E unit and the children's ward in Burnley. Do not start getting on to us about what we are and are not closing. The right hon. Gentleman closed those things. Does he agree that what he did was a disgrace to the people of Burnley?
John Healey: May I urge the hon. Gentleman to look very closely at the Bill and beyond what he hears the Health Secretary say when he talks about it? I urge him instead to look at how local hospitals could be undercut by private health companies, and at how GPs could be forced to put out work to those companies. That will undermine local hospitals such as the one in Burnley and lead to hospital closures driven not by proper planning and the development of better services in the community, but by hospitals being driven to the point of bankruptcy and closure.
Dan Byles (North Warwickshire) (Con): The right hon. Gentleman does not seem to understand how the health service operated under his Labour Government. My constituents in Warwickshire have been suffering because NHS Warwickshire, under the rules we inherited from his Government, set up a fixed-price, below-tariff contract with one of the trusts in its area that has led to patients being drained from the George Eliot hospital trust in my area and the area of my hon. Friend the Member for Nuneaton (Mr Jones) to Warwick. It was Labour's rules that allowed it to undercut the hospital in my constituency.
John Healey: If the hon. Gentleman was worried about the past, he should be a good deal more worried about the future, and, a bit like the Health Secretary, he should spend a lot less time talking about the Labour Government and what we did to the health service and more time talking about the plans and big changes to come.
For the first time in the NHS we are facing, first, the potential for profit at the point of commissioning and, secondly, commissioning-in other words, decisions about rationing as well as referral-being made at the individual patient level, not at the collective area level, and we are looking at them being made by bodies and individuals who are not publicly accountable, including to the House.
Mr Lammy: My right hon. Friend is right to press the case about private providers. Is he surprised that the Secretary of State, in response to my question earlier, did not confirm to the House that the wife of John Nash, the chairman of Care UK, funded his office in November 2009 to the tune of £21,000? Does he think that the Secretary of State should put that on the record?
John Healey: I am surprised that the Health Secretary was asked a direct question and did not answer. I would simply encourage my right hon. Friend to keep asking the questions that he feels are important for the future.
The truth about what is happening in the health service now is that patients are starting to see the signs of strain and services being cut, and that is not what they expected when they heard the Prime Minister, before the election and afterwards, promising to protect the NHS.
Andrew Bridgen (North West Leicestershire) (Con): I thank the right hon. Gentleman for giving way. In my first two weeks as an MP, I paid a visit to the local PCT in Leicester, and in a meeting with the chief executive I asked how the PCT would cope with the immediate 35% cuts in management imposed by the coalition Government. The answer truly shocked me: I was told, "It will be no problem at all, because we have already increased our management by 50% in the past year." Will the right hon. Gentleman accept that under the previous Government's watch, the PCTs became the bloated bureaucracies that now need reforming?
John Healey: The problem for PCTs, and the managers and staff who work in them, is that they are being asked to do several things at the same time: to make unprecedented efficiencies at a time when the NHS is being put through its tightest financial squeeze in history; to axe its own jobs; and to guide the reorganisation and ensure that it can take place. That is a tough challenge for anyone. I am sure that the hon. Gentleman will keep on his local PCT's case.
Andrew George: I am grateful to the shadow Secretary of State for giving way. I would accept his criticisms more openly-I think-were he prepared to acknowledge that the previous Labour Government set up independent treatment centres and rigged the market to hand over 15% of all elective operations in an area such as mine to an independent company that they more or less set up themselves, and which undermined the local acute trust and services with changes that patients had not asked for. That was forced on the PCT and not something for which it asked. It was a rigged market. Would he like to apologise to the House for the practices of the previous Labour Government?
John Healey: I am more interested in what we will be facing in future. I am more interested in the claim by the Health Secretary that there will not be, as he describes it, a rigged market in future, but a level playing field for all providers. However, my hon. Friend- [ Interruption. ] Well, we will see. The hon. Gentleman is a member of the Select Committee on Health, and he follows such matters closely. I urge him to read page 42 onwards of the impact assessment, because there he will see the preparations for being able to pay for the sort of thing that he criticises in the health service.
As the hon. Gentleman gives me this opportunity, let me say to him and his Lib Dem colleagues that what we are facing is clearly Conservative health policy, not coalition health policy, and certainly not Lib Dem health policy. The main evidence of any influence of Lib Dem ideas on health policy in the coalition agreement was the commitment to "ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust".
The Bill abolishes PCTs. The Lib Dem policy priority before the election was to ensure that local people had more control over their health services. The Bill places sweeping powers in the hands of a new national quango-the national commissioning board-and a new national economic regulator, which is charged with enforcing competition, to open up all parts of the NHS to private health companies. The Lib Dems' principal concern was to strengthen local and public accountability of health services, but the Bill seriously restricts openness, scrutiny and accountability to both the public and Parliament. It will lead to an NHS in which "commercial in confidence" is stamped on many of the most important decisions that are taken. I therefore say to the hon. Gentleman and his Lib Dem colleagues: this is not your policy, but it is being done in your name.
The policy is not Liberal Democrat policy, but it is being done in their name, and the public will hold the Liberal Democrats responsible if they allow the Tories to do this to our NHS.
Jeremy Corbyn (Islington North) (Lab): Is my right hon. Friend aware that, in the rush to establish a GP commissioning system, PCTs are being merged, and that large numbers of highly skilled staff are disappearing quickly, as is the ability of PCTs to administer anything, and all this before the Bill has even received a Second Reading? Does he not think that the Secretary of State is culpable in the rapid disintegration and disorganisation of local NHS facilities all over the country?
John Healey: That is one of the things that worries experts and those in the health service the most. It is also one of the things that the right hon. Member for Charnwood (Mr Dorrell) and his Health Committee were most concerned about. [ Interruption. ] The right hon. Gentleman is nodding. "Disruptive" was one term that the Committee used for the changes.
Mr Dennis Skinner (Bolsover) (Lab): Why on earth should the health service be changed? We had 13 years. We dragged the health service from the depths of degradation and hoisted it to the pinnacles of achievement. There was £33 billion in 1997; we increased that to £110 billion. All those miners in my constituency and that of my right hon. Friend who wanted those knees or hips replaced-they have all been done, after waiting not for five years, but for a few months. That is what I call achievement, and that is what the people in Bolsover and elsewhere know. That is why the health service was safe in our hands and why, they assume, this one on the Government Front Bench is now going to privatise it.
John Healey: Well, my hon. Friend is right in this respect: people will come to see clearly that they cannot trust the Tories with the NHS; they will come to see clearly what these changes really mean for their services; and they will come to see clearly what the future of the NHS holds.
My serious concern is that this Government have told only half the story from the start. The Health Secretary and the Prime Minister are happy to talk about GP commissioning and happy to talk about cutting management-the organisational changes-but they downplay or deny the deep ideological changes at the heart of these plans. The Health Secretary mentioned the new economic regulator, Monitor, in just one line in a speech lasting more than 40 minutes. The Prime Minister said last week in his speech on public services that these reforms "are not about theory or ideology".
The Prime Minister writes in The Times today, just as the Health Secretary did last week, both of them producing 700 words about their health plans, yet they made not a single mention of competition.
We will explain and expose the truth throughout this debate and the Bill's passage through Parliament because these changes will break up the NHS; they will open up all areas of the NHS to price-cutting competition from private health companies; and they will take away from all parts of the NHS the requirement for proper openness, scrutiny and accountability to the public and to Parliament.
These Government changes are driving free market political ideology into the heart of the NHS, and that is why doctors are now saying: "As it stands, the UK Government's new Bill spells the end of the NHS."The public are being told that the reorganisation is "patient centred", but patients are being sold a false promise on the NHS. The changes in the Bill come in only in 2013, but patients are already seeing the consequences of the Government's handling of the health service. The Government have scrapped Labour's waiting time targets, which were, of course, the patients' guarantee of being seen and treated promptly. They are breaking the Prime Minister's promise of a real increase in NHS funding, so Scotland is being short-changed next year by £70 million and Wales is being short-changed next year by £40 million. England, if we take out the double counting of cash to be spent on social care rather than on NHS services, faces a shortfall next year of £1.2 billion on the Prime Minister's promise.
With this Bill, the Government are now breaking their promise to stop top-down internal reorganisations and they are putting extra unnecessary pressure on the NHS. Patients are starting to see waiting times rise; they are starting to see discharges from hospital delayed; they are starting to see wards mothballed and staff posts cut. That is not what people expected when the Prime Minister promised to protect the NHS. The Prime Minister's most personal pledge to the public is becoming his biggest broken promise.
This is ideological. It is about driving politics into the heart of the NHS, and in some respects breaking what has been a 60-year consensus. Parties on all sides have tried to make decisions about the best interests of patients and better services, and not about their own political ideologies. That has changed today, with this Bill.
The public are being told that this reorganisation is patient-centred, but most patients' GPs will not, in practice, be doing what the Government claim they will be doing. GPs spend an average of only about eight minutes with each patient. If they continue as family doctors, the commissioning will not be done by them; it will be done in their name by the managers in the primary care trust who carry out that function now, or by private health companies that are already hard-selling their services to GP consortia. Those consortia are being sold a false promise as well. Because expanded open-ended choice of treatment means funding unused capacity in the system, it is highly unlikely to happen at a time when NHS finances are under pressure.
Despite the boast about putting patients at the heart of everything that the NHS does, there is no place for patients on the bodies that will make the most important decisions on the NHS. There is no place for them on GP consortia, no place for them on the national commissioning board, and no place for them on the regulator, Monitor.
Mr Baron: The right hon. Gentleman talks of broken promises. What does he say to cancer patients who regularly see our cancer survival rates in the lower divisions of the international cancer league, despite 13 years of a Labour Government?
John Healey: The hon. Gentleman has already heard some of my hon. Friends mention the analysis of Dr John Appleby, published in the British Medical Journal online last week. He took to task those who had made the sweeping assertion that somehow Britain's health service lags behind those of the rest of Europe. It is an argument that the Prime Minister advances. It is an argument for change, he says, because we are still a long way from European standards of care.
Let me read something to the House. We have been told that "if you have heart surgery in England, you now have a greater chance of survival than almost any other European country - over the last five years, death rates have halved and are now 25 per cent lower than the European average." Those are not my words, or even those of Dr John Appleby. They are the words of the Health Secretary, published on ConservativeHome last week.
The Prime Minister argues that this is somehow an evolution and not a revolution. The Bill, however, is more than three times as long as the legislation that set up the NHS in 1948. The NHS chief executive told the Select Committee on Health:
"The scale of change is enormous-beyond anything that anybody from the public or private sector has witnessed".
The Health Secretary argues that the Bill is somehow an extension of Labour policies. That is wrong, and it disguises again the fundamental changes to the NHS in the Government's plan. Make no mistake, Mr Deputy Speaker: this is a revolution, not an evolution.
Jesse Norman (Hereford and South Herefordshire) (Con): I note that the right hon. Gentleman failed to answer the question about the rate of increase in the number of managers. When I last checked, the NHS had 1.3 million employees, of whom almost exactly half were administrators and half were on the front line. Is he really willing to defend such an extraordinary level of overstaffing in management?
John Healey: Oh dear, the hon. Gentleman really has to get a better briefing from his Whips than that.
Clive Efford: Will my right hon. Friend confirm that in order to shoehorn private enterprise into the NHS, the regulations are being written to add a 14% premium into the tariff for private sector companies that will be tendering for work?
John Healey: My hon. Friend may be right. I have not seen the regulations, but that is certainly in the impact assessment, so he is on to an important point.
The Government Members and the Health Secretary have spent a long time talking about Labour's plans, policies and record, but the debate at the heart of this Bill is not about whether competition, choice or the private sector has a part to play in the NHS-they have and they do. The debate at the heart of this Bill is about whether full-blown competition, based on price and ruled by competition law, is the right basis for our NHS. That is why Labour Members oppose this Bill. We want the NHS run on the basis of what is best for patients, not what is best for the market. We want the NHS to be driven by the ethos of public service, not by the economics of forced competition. We will defend to the end a health service that is there for all, fair for all and free to all who need it when they need it.
If the stated aims for the reform were all the Government wanted-we have heard the Health Secretary say that he wants a greater role for doctors in commissioning, more involvement of patients, less bureaucracy and greater priority put on to improving health outcomes-he should do what the GPs say: turn the primary care trust boards over to doctors and patients, so that they can run this and do the job. But there is no correlation between the aims that the Health Secretary sets out and the actions he is taking. There is no connection between his aims and his actions. He is pursuing his actions because his aims are not sufficient. His actions would not achieve the full-scale switch to forced market competition, which is the true purpose of the changes.
Meanwhile, the biggest challenges and changes for the NHS will be made harder, not easier, by the reorganisation. Such challenges include making £20 billion of efficiency savings and improving patient services; ensuring better integration of social care and health care, of primary care and hospital care, and of public health and community health; and providing more services in closer reach of patients in the community rather than in hospital. But the Government will not listen to the warnings from the NHS experts, the NHS professional bodies, patient groups or even the Select Committee on Health.
The more that NHS staff see of the changes and the consequences of this Government's handling of the NHS, the more concerned they are about the changes and the more they are starting to see the NHS go backwards. But the Government will not listen to these warnings that are coming from all sides. They are in denial about the risks: the risk that patients will see services get worse, not better; the risk that up to £3 billion will be wasted on internal reorganisation; the risk that innovation and improvements in care that come from greater collaboration will be blocked by the Office of Fair Trading, competition courts and the new market regulator; and the risk that the Bill will create the monster of a full-blown market in health care which GPs will not control and nor will Ministers or Parliament.
If patients have been sold a false prospectus, that is true of GPs too. GPs are being told that they will call the shots on deciding who provides care for their patients, but they are being set up by the Government. They are likely to find their hands tied by Monitor and the Office of Fair Trading and by the courts enforcing competition law. They are likely to find their decisions challenged by private companies if they do not accept "any willing provider", especially one that offers to undercut on price. The chair of the Royal College of General Practitioners recently issued a warning to her colleagues. She said: "I understood these reforms were about putting GPs at the centre of planning healthcare for their patients, not about making sweeping cuts, which will include shutting hospitals, making enormous redundancies, closing services".
Because the reorganisation will force doctors to make rationing decisions as well as referral decisions for their patients, they will make treatment decisions with one eye on their patient and the other on their budget and their consortium's bottom line.
The Government say they are devolving power to front-line services, putting clinicians in control, making the NHS more accountable and improving the integration and quality of services, but in the Bill they are making the forces of competition and centralisation far stronger than those of devolution, democratic accountability or the development of quality in patient services. We will explain and expose the gap between what Ministers are saying and what they are doing in every debate at every stage of this legislation.
Patients and staff are already seeing signs of strain in the NHS. They are starting to ask, "What on earth are the Government doing with the NHS? Why don't they listen to the warnings? Why is the Prime Minister breaking the very personal promise he made to protect the NHS?" The Bill puts competition first and patients second. That is why we will oppose the Bill tonight and expose this truth in the months ahead. These are the wrong reforms for the wrong reasons at the wrong time.
Mr Stephen Dorrell (Charnwood) (Con): I rise to support the Bill. The shadow Secretary of State started by saying that my right hon. Friend the Secretary of State struggled to explain his reasons for introducing the Bill, but I think that the shadow Secretary of State struggled to explain why he opposes it. He struggled from the moment that my hon. Friend the Member for Grantham and Stamford (Nick Boles) intervened to draw his attention to the fact that the Bill represents an evolution of policy that has been consistently developed by every Secretary of State since 1990, with a single exception in the form of the right hon. Member for Holborn and St Pancras (Frank Dobson), who sits on the Labour Back Benches. The question that the shadow Secretary of State has to answer is this. Which of the key themes does the right hon. Gentleman oppose? Is it the practice-based commissioning or the "any willing provider" model? Is it the introduction of private sector expertise into commissioning, which was first articulated in the world class commissioning programme, or is it the principle of the maximum tariff? Let me help him by quoting from the operating framework of 2009, to which my right hon. Friend the Secretary of State referred. It states:
"After 2010/11, we shall move to a position where national tariffs represent the maximum price payable to a commissioner, as opposed to the mandated price for a particular activity."
With which of those four key policies does the right hon. Gentleman disagree?
John Healey: The right hon. Gentleman started by saying that the policies are an evolution. If that is the case, why did he say: "I thought we were looking to develop existing institutions rather than starting again, and that appeared to be confirmed in the coalition agreement." The right hon. Gentleman, who is nodding, went on: "Then in July that approach was changed. That came as a surprise."
Mr Dorrell: Indeed it did. I offered the right hon. Gentleman four consistent themes of policy. He accurately quoted my comments about a specific element of bureaucracy. One of the questions that the Select Committee addressed was why, since all these broad themes are so broadly supported, we went down the road of replacing the PCTs with the consortia. That is a question that the Select Committee said in its report had not been adequately explained, but that is a relatively minor question of bureaucratic presentation when compared with the broad themes of policy that were articulated in the debate by my hon. Friend the Member for Grantham and Stamford. Which of these key policies does Labour now wish to dissent from?
Hugh Bayley: I wonder whether the Select Committee agrees that private contractors, where they are engaged, should be required to publish the same information about cost, quality and outcomes as NHS providers, to ensure a level playing field and real, true comparison.
Mr Dorrell: I have been here long enough not to presume to speak on behalf of a Select Committee on a question that the Select Committee has not addressed, but I think there would be broad support across the House for the principle that where the private sector provides a service to a public sector commissioner, the private sector provider should be accountable to that commissioner on precisely the same terms as the public sector provider. As my hon. Friend the Member for St Ives (Andrew George) mentioned in his intervention on the shadow Health Secretary, one of the problems about the independent sector treatment centre programme was exactly the point that the hon. Gentleman makes-the accountability expected of a private sector provider was different from the accountability expected of a public sector provider.
Therefore, I agree with the hon. Gentleman and hope that he can persuade his right hon. and hon. Friends on the Front Bench to endorse the principle of common accountability for public and private sector providers providing a service to a public sector commissioner. I see my right hon. and hon. Friends on the Government Front Bench endorsing the principle. I hope that I am not misrepresenting the way that they are reacting to the hon. Gentleman's question.
This is a consistent set of themes. Why is it consistent? I want to move the debate on. The House of Commons loves debating structures in the national health service. The inference from what I have said so far might be that that means it is all business as usual-that what has gone on, with the exception of the period when the right hon. Member for Holborn and St Pancras was in charge, is a seamless development of policy since 1990.
However, the truth is that during the lifetime of this Parliament the national health service faces a genuinely unprecedented challenge, first articulated not by my right hon. Friend the Secretary of State in the present Government, but by the chief executive of the health service before the general election in May 2009, when he drew attention to the fact that demand for health care should be expected to continue to rise at roughly 4% per annum, as it has done throughout the recent history of the national health service. However, because of the budget deficit situation, we will not see the health budget continue to rise to absorb that rise in demand, in the way it has done over the past decade.
Therefore, during the lifetime of this Parliament, we will have to see, in the national health service, a 4% efficiency gain four years running-something that not merely our health care system, but no other health care system in the world, has ever delivered. The Select Committee has referred to that as the Nicholson challenge, reflecting the fact that it was first articulated by the chief executive and endorsed by the previous Government. Again, this is a case of a shared agenda across the House of Commons.
Given the Budget deficit, the only way we can continue to meet the demand for high-quality health care, which we all want to see, is by delivering an unprecedented efficiency gain in the NHS for four years running. That is why I support the Bill. I support it because to my mind it is inconceivable that we can deliver such an efficiency gain without delivering more effectively than we have done yet on the ideas, which have been endorsed over the past 20 years, about greater clinical engagement in NHS commissioning, which I have been talking about. Commissioning cannot be successful if it is something that is done to doctors by managers; it must engage the whole clinical community. We must address the democratic deficit, because we cannot bring change on the scale that we need to deliver the efficiency gain without engaging local communities.
Finally, the NHS must also be a national service that is accountable through the commissioning consortia, the commissioning board and the Secretary of State to this House, because it is ultimately the taxpayers who pay for it. Those are the principles that were set out by the Health Committee, and it is those that we will seek to review as the Bill goes through Parliament.
Mr Kevin Barron (Rother Valley) (Lab): I shall move on quickly. We had seven hours and 45 minutes to debate the Bill, but the first hour and 15 minutes was taken up by Front Benchers. Given that the Government have not found time to debate the White Paper that they published in July, we should probably have had two days' debate on a Bill as important as this. As the shadow Secretary of State said, it is far larger than the 1948 Bill that established the national health service.
I find it difficult to find any justification for such a major reorganisation of our NHS. We have had a decade of major investment and we have seen improving services and major satisfaction ratings given by patients. In November 2009, the then Leader of the Opposition, now Prime Minister, said that "with the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS."
He was supported by the now Secretary of State for Health, who said as shadow Secretary of State in July 2007 that the NHS needed no more top-down reorganisation. Indeed, even after the general election, the coalition agreement stated: "We will stop the top-down reorganisations of the NHS that have got in the way of patient care."
It went on to spell out the continuing role of PCTs in some detail, pledging, "We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust...The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level".
A few months later, we have this potential chaos thrown on to the national health service. Once again, people are looking at the NHS and trying to change its culture by reorganising it.
We have had 30 years of Governments of different political persuasions trying to change the culture of the national health service by reorganisation. Every time, there have been years-long delays in implementation, performance has been affected in a negative way and there have been costs-particularly on this occasion, when the NHS is being instructed to make efficiency savings.
I agree with the report on commissioning just published by the Health Committee. I am not too sure whether the Chair agrees with it himself; the right hon. Member for Charnwood (Mr Dorrell) spoke earlier. The report states: "The Coalition Programme anticipated an evolution of existing institutions; the White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy has yet been sufficiently explained given the costs and uncertainties generated by the process."
The last 30 years should tell the House and the Government exactly that.
In my borough, the PCT-as was; it still is, although it is now Rotherham NHS-will become the GP commissioning consortium. Let us not get away from that. The idea that getting rid of the strategic health authorities or anything else is going to save massive amounts of money is palpable nonsense.
Does anybody think that top-down meddling is going to end because of this reorganisation? If the local GP consortium does not offer provision as it should, the national commissioning board will tell it what to do. If that is not top-down, I do not know what is. Those will be the people responsible for whether local residents, particularly those who need specialised commissioning, are going to get the services or not. The idea that those people are going to be responsible for NHS dentistry in my constituency is nonsense. There has now been a move away from midwifery, and that was going to be commissioned nationally. The changes are nonsense; they have been ill thought out.
Mr Stuart: The Chair of the Health Committee also set out the central challenge, which was recognised by the previous Government: to make major savings, year on year, for the next four years, at a time when budgets will not be able to increase-or at least not by much. How does the right hon. Gentleman think that that issue could best be addressed? Suggesting, as he did at the beginning, that we could just carry on as we were would not be sustainable.
Mr Barron: I am not saying that savings should not be made. Indeed, the Select Committee in the last Parliament took evidence from the chief executive of the NHS on that particular point. The case that I make is about the type of reorganisation. Not only has nobody in the public sector ever been able to get 4% a year in savings, but nobody in the private sector has, in the time scale being predicted now. [ Interruption. ] The Secretary of State says that that is rubbish-it is not rubbish at all. He should go and talk to his advisers about what happens in the real world, as opposed to the world that has appeared since July last year.
I would like to say something in defence of managers. This Government have been bashing managers in the NHS every week they have been in office, and did so for many months before they got there. How do they think we got waiting lists for things such as new knee and hip joints down from years to months, and even weeks, in areas such as mine? I will tell them. It was not done by taking the surgeons out of theatres to do the administration, but by putting people in to do the administration so that the surgeons could spend more time in theatres seeing more patients. That is the real truth. The management -bashing that has been taking place of people inside the NHS might be popular on the ground, but let me say this to the Government: if they take those managers out and we go back to the waiting lists and waiting times of five or six years ago, they will see where popularity lies.
The King's Fund, which the Secretary of State mentioned, supports some parts of the Bill. Indeed, I support a lot of its aims, but I do not support the reorganisation and upheaval that it will create inside the NHS. That is why I will vote against it. The King's Fund says: "The Bill abolishes the Health Protection Agency, places a duty on the Secretary of State to promote public health, and transfers responsibility for public health to local authorities."
I agree with that. However, the Bill does not give me any confidence that GP consortia will have responsibility for the health of the population they cover.
Anybody looking at the history of public health in this country should recognise that we cannot run it on the basis of just handing it over to local government. The issues are far wider than that. The Secretary of State shakes his head, but people should look at the answers to questions that I got a week or so ago about what has happened to smoking cessation since this Government took over. Rates of smoking cessation have plummeted because of the advertising and promotion that is permitted. About 50% of health inequalities are created by smoking. The Government have taken their foot off the accelerator on the main thing that we should be doing to address public health inequalities, and they will suffer at the polls because of it.
David Miliband (South Shields) (Lab): It is a pleasure to follow the hon. Member for Central Suffolk and North Ipswich (Dr Poulter). I congratulate him on his important and interesting speech, and I wish to pick up his challenge. The choice is not between no reform and reform; it is between good reform and bad reform. I believe that the proposals in front of us represent not a curate's egg, with some good reforms and some bad, but a set of poison pills for the NHS.
The first poison pill is the massive upheaval that the Bill proposes at the time of an unprecedented efficiency drive. The right hon. Member for Charnwood (Mr Dorrell) said that it was precisely because of the efficiency drive that we should have massive upheaval, but he must know that all the evidence from reorganisations throughout the years is that projected savings are double the out-turn, and projected costs turn out to be half the actual level. When the Prime Minister says that there is a £300 million difference between the costs and the savings-£1.7 billion of savings and £1.4 billion of costs-he is actually treating us to a reorganisation that will end up costing money and causing redundancy costs at a time when hospitals and GPs are trying to get the job done.
The Minister of State, Department of Health (Mr Simon Burns): May I correct the right hon. Gentleman before he goes too far down that path? The impact assessment suggests that the one-off cost will be £1.4 billion, and that the savings from that investment over the life of this Parliament will be £5 billion. By the end of the decade, the saving will be £13.6 billion, which is £1.7 billion a year after 2013-14.
David Miliband: I am happy to wager the hon. Gentleman that the costs will turn out to be more like double those estimated and the savings more like half.
The Bill is myopic, or "deluded", to use the word of the British Medical Journal, in three key areas, which I wish to mention. First, it assumes that all GPs are ready now to take on hard budgets in the commissioning framework. It took the previous Tory Government six years to get 56% to be GP fundholders. Secondly, it will deepen the divide between primary and secondary care. The hon. Member for Central Suffolk and North Ipswich raised that matter, which is vital. We all know that in our constituencies, collaboration between primary and secondary care is key, especially for chronic conditions. The Bill will make the divide worse, because collaboration will be deemed anti-competitive.
Thirdly, the Bill has absolutely nothing to say about quality control of GPs. In fact, it will remove the local drivers for improvement that I have seen in my constituency. The hon. Member for Basildon and Billericay (Mr Baron) mentioned cancer survival rates, and the Appleby research shows that we in this country have made more progress over the past 30 years than any other country in Europe, and will overtake France in 2012. It also shows that the extent to which we are behind can be explained by late diagnosis in the first year of cancer, which is the responsibility of GPs. They should focus on improving their cancer treatment, not commissioning care.
All the matters that I have mentioned are to service a vision of health care as a regulated industry. The Secretary of State has engaged in a ding-dong about which operating framework is more important-the 2009 or the 2010 one. Two points, though, have not been contested. The first is that in 2011-12, for the first time, there will be competition according to price-page 54 of the operating framework says that. The second is that the academic evidence is absolutely clear that price competition results in lower prices, yes, but also in lower quality.
The hon. Member for St Ives (Andrew George)asked the Secretary of State, "What about my community hospitals?", but of course the Secretary of State does not want to make decisions about community hospitals. His predecessor but six, eight or 10, Nye Bevan, said that he wanted a bedpan falling in Tredegar to be heard in the corridors of Whitehall. The Secretary of State does not want to hear bedpans falling; he wants to say that it is GPs who should be making decisions, or the commissioning board, or, in the ultimate irony that my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) pointed out, the European Court of Justice under European competition law. He pointed out the irony of the Lisbon treaty being critical, but at this very time the House is passing a Europe Bill that calls for referendums when any power is transferred to the EU, including on matters as puny as the appointments system for the Court of Auditors, never mind on a vital part of NHS provision.
Frank Dobson (Holborn and St Pancras) (Lab): Does my right hon. Friend agree that the hon. Member for St Ives (Andrew George) is perhaps being a little ungrateful? He might have mentioned that the NHS wanted to close all his community hospitals in Cornwall, and that the dreaded centralist top-down Dobson stopped it.
David Miliband: The benefits of memory are useful in politics, and perhaps my right hon. Friend's intervention will help the hon. Member for St Ives to decide how to vote in the Lobby tonight.
Many people have asked why the Government are making these proposals at such breakneck speed. Surely it is not to solve a political problem on health. After all, the Conservative party spent the whole of the last Parliament doing everything possible to avoid any policy on health that might hint at radical change. That paid off, because in the last prime ministerial debates before the general election, not a single question on health was put to any of the party leaders. It would be massively in the interests of my party and all Labour Members if the next general election were dominated by debates on the health service. On that basis, we should be urging the Government to plough ahead and make the next general election a referendum on health. Frankly, however, the cost would be far too high, and the consequences would be far too great for the national health service.
The truth is that a radical Secretary of State would do something that too few of his predecessors have been willing to do-namely, to say, "On my watch, there will be no reorganisation of the national health service." Such a Secretary of State would dedicate himself to implementing the reforms that are working today. It is not the case that the only choice is between no reform at all and the reforms now being offered. According to health experts, there is more reform going on in the English health service now than in other health system in Europe. Our Scottish and Welsh friends might benefit from some of the changes that are taking place in England, because those changes have made the English health service a fast-improving one in Europe.
There is always room for improvement in the national health service to strengthen commissioning, to link health authorities and local government, to get people out of hospitals and to align with social care. The Dilnot commission has just been appointed to review the funding of social care, but it will not report until July. At exactly the time when we are looking at the localisation of health provision, the Government have appointed someone to look at the nationalisation of social care provision and its funding. This is not a Health and Social Care Bill; it is a health without social care Bill.
"The real choice is not between stability and change, but between reforms that are well executed and deliver results for patients and reforms that are poorly planned and risk undermining the NHS".
Those are not my words but those of the chief executive of the King's Fund. The Hippocratic oath says that we should "Do no harm". The Bill fails that test. It aims at irrevocable change and threatens real harm, and that is the reason to oppose it in the Lobby tonight
Grahame M. Morris (Easington) (Lab): One thing is clear: from whatever perspective we consider the reforms in the Bill-whether from that of Charnwood or Holborn and St Pancras-there is a serious and worrying lack of evidence base for the Government's proposals. These are proposals identified by the King's Fund as without doubt "the biggest shake up of the NHS since it was established".
While the Health Secretary was the Conservative party's shadow health spokesman-from June 2004 until he took office in May last year-he was coy about his real intentions towards the NHS, as indicated by my right hon. Friend the Member for South Shields (David Miliband). When the Government published the Bill, six major health unions and professional bodies wrote in a letter to The Times: "There is clear evidence that price competition in healthcare is damaging. Furthermore the sheer scale of the ambitious and costly reform programme, and the pace of change, while at the same time being expected to make £20 billion of savings, is extremely risky and potentially disastrous."
Labour Members welcome greater clinical involvement in commissioning, but GPs are not the sole font of knowledge in best practice and other areas. According to evidence given to the Select Committee on Health, specialists in secondary care and the nursing and other professions could add their expertise to the commissioning process.
The shake-up of the NHS goes far beyond simply involving clinicians in spending decisions. GP commissioning is a red herring. We were told by the Secretary of State that these reforms are needed because productivity has fallen since Labour's increased investment. However, after 18 years of mismanagement and under-investment under the Conservative party, it was obvious that on a crude measurement of productivity-inputs versus outputs-there was going to be a decline in supposed productivity, because obviously money had to be directed towards clearing up the mess left by the previous Tory government, to building new hospitals, accident and emergency units and maternity units, and to reducing waiting lists, which in many areas of the country were 18 months and longer.
The Secretary of State raised the satisfaction survey. Indeed, in December 2010, the National Centre for Social Research released its most recent report on British social attitudes. It found that public satisfaction with the NHS was at an all-time high, whereas in 1997, when Labour came to power, only 34% of people surveyed were satisfied with the NHS-the lowest level since the survey began in 1983. By 2009, satisfaction had nearly doubled to two thirds-to 64%. Given that most health unions, professional bodies, think tanks and the public did not call for such reforms, where did the Secretary of State's motivation come from? These are not patient-led reforms; they are private health care-led reforms.
There are concerns about the removal of the tariff floor and the introduction of price competition into the service. That is radical and revolutionary; it is not evolutionary. Rather than open-market health care, the British Medical Association and others are calling for a "cooperative and coordinated environment where patients are guaranteed the most clinically appropriate and cost-effective care. Price competition and a fully open market will make this impossible."
Clause 63 allows the Secretary of State to impose requirements on consortia to promote competition between providers, and clause 64 makes it possible for Monitor to investigate any complaint of anti-competitive behaviour made against commissioners by any interested party. That might be a third party or an overseas private health care company, and would make it far more difficult for GPs to ensure that their patient services are integrated, inclusive and carried out in partnership. The Bill also forces trusts to achieve foundation status within three years and will lead to more important priorities, such as safe patient care, being compromised. Furthermore, the abolition of the private patient income cap set out in clause 150, removing the limit on the amount of income foundation trusts can earn from private operations and private health care, will create a two-tier health system. Foundation trusts forced into the market without protection will face financial pressures to turn a profit, and NHS patients will risk being pushed to the back of the queue.
To my mind, and according to evidence submitted to the Health Committee by the Royal College of Nursing in which it identified 27,000 nursing posts that will go, these reforms will result in tens of thousands of job losses and undermine national terms and conditions for NHS staff. The scrapping of targets has left the NHS open to a dangerous postcode lottery. The duty to tackle health inequalities is one of the few remaining powers to be held by the Secretary of State, but he will have nothing to back it up.
There is also no protection for the taxpayer from exorbitant and excessive behaviour by the consortia, an issue raised by my hon. Friend the Member for Blyth Valley (Mr Campbell). It is possible that we will see banker-style bonuses and the import of private sector pay into health care. [ Interruption. ] The Minister moans from a sedentary position, but there is nothing in the Bill to prevent that from happening. The Bill will also leave us, as Members of Parliament, with no voice in the NHS. This Tory-led Government seem to be trying to de-risk this political hot potato, which the Conservatives have never been able to manage properly. However, if Ministers think that the British public will allow them to wash their hands of the NHS without any comeback at the next general election, they should prepare to be shocked.
I would like to say one more thing in the time left-now that the hon. Member for St Ives (Andrew George) is back in his place and given what the hon. Member for Burnley (Gordon Birtwistle) said-about the combined impact assessment. I have received a letter from a GP saying that the practical significance of the Bill will be such that the many MPs who campaigned to save their local hospitals cannot vote for it in all honesty, knowing that in so doing they will be voting for a measure that is purposefully and expressly designed to prevent them from having any say and which will potentially lead to the very outcomes that they so vociferously campaigned against.
Nadine Dorries (Mid Bedfordshire) (Con): I rise to support a Bill that I believe is perhaps one of the most exciting, if controversial, Bills to have been put before Parliament in the 62 years since the NHS was established. It is a fact that a resident in this country today is twice as likely to die from a heart attack as a resident in France. In this country, we also fail to reach European averages for stroke care. In fact, 4,000 stroke victims a year lose their lives because our NHS is not up to European standards in stroke care. If we delivered trauma care slightly differently, we could also save 600 more lives a year, but we do not. Those figures alone show that it is now time, 62 years since it was established, for the NHS to be modernised.
In those 62 years, drug research and development have advanced hugely. Medical technologies have advanced in a way that could not even have been imagined 62 years ago. As a result of the internet and the information now available, patients expect and demand to have a say in how their condition is managed. They want more information and they want to discuss their care with their GPs. The Bill will put the patient right at the heart of the NHS, and that is why I so passionately support it. The central tenet of the Bill is: "No decision about me without me". It will ensure that, for the first time, each and every patient can almost become their own lobbyist, sitting in front of their GP and discussing their condition and treatment in an open way, where they have information and the GP will have to engage with them. That does not happen today, and certainly not in hospitals.
I would like to give an example-something that I heard about this weekend from a patient-that clearly epitomises why the patient has become invisible in the NHS today. That patient was in hospital at the weekend when a doctor walked up to him, lifted his arm, took blood, put his arm back down and walked away without saying a single word to him.
That patient was in hospital when the doctor walked up, took blood and put his arm back down without even a word of acknowledgment. A nurse then came and put his tray of food at the end of the bed. The patient was attached to a heart monitor and a drip, and could not reach the food. The patient was distressed, vulnerable and in pain, yet he was invisible to the health care professionals who were treating him. He was invisible because what is important in today's NHS is the process-the management, not the patient. The humanity of the patient has almost been lost, and there is no way to put it back into the NHS other than to tip the understanding of who is important in the NHS on its head. The Bill does that in a way that has never been done before and which is now needed.
When nurses sat their medical exams 62 years ago, when the NHS was first established, the answer to each question had to begin and end with the words: "Reassure the patient". It did not matter what someone said in the answer; if they did not emphasise the fact that the patient had to be reassured, they failed. That has gone. That demonstrates exactly how the patient has become invisible in today's NHS.
I support the Bill because I support GPs working in consortia. A common myth-an urban myth-that we have heard in the few weeks leading up to this debate, and which has been thrown at us from the Opposition Benches, is that GPs are simply not up to the task of becoming business managers. The truth is that they already are business managers, because they all manage their own businesses. They will not be working as individuals or in individual practices; they will be working as part of a consortium, which is quite different from the impression given by the Opposition. Right now, 141 pathfinder consortia are demonstrating that they are ready and able to take on commissioning, and that they endorse patient involvement in the decision-making process. As a result of the "any willing provider" provisions, there will be a genuinely wider choice of care options available to the GP and the patient.
I would like to rebut the argument that the private sector will come in and undercut the NHS. That is complete nonsense. There will be no undercutting of the NHS whatever. Services will be- [ Interruption. ] I can only say that Opposition Members have not read the Bill, because there will be a tariff. Charities and the private sector will be able to provide services, but with a tariff. I shall give an example. If a patient requires a surgical procedure, which they discuss with their GP, and the local hospital has no bed available for six weeks, two months or however long, but if the local private hospital can provide a bed the next morning at the same price, are the Opposition really saying that an ideological obstruction should be put in the way of that patient being admitted to that private bed for that procedure the following day? If that patient were in pain, why should they not be admitted into that bed if it were available? That is how the market will be opened up by GPs, to the benefit of patients.
We recently heard from my right hon. Friend the Prime Minister about an extra £60 million that will be available to fund the latest bowel cancer screening technology, with wider deployment of the flexible sigmoidoscope. That does not need to be provided in secondary care in a hospital; it could be provided in the GP practice under the "any willing provider" provisions, perhaps via charities with specialised trained technicians. The Bill will ensure a new approach to providing services to the patient. "Any willing provider" will give patients the choice that they have not had for 62 years, empowering them to make decisions over that choice and opening up health care that patients in this country have not had, certainly for the past 15 years. With new technologies coming on stream and new ways of delivering care, both in the patient's home and in the GP practice, that has to be welcomed. The Bill has to be welcomed, and Government Members will vote for it because the most important person in the Bill is the patient. That is why I support it wholeheartedly
Hugh Bayley (York Central) (Lab): The Government White Paper said some sensible things: it promised to increase NHS spending in real terms, to improve patient choice, to devolve decision making, to reduce management costs and to hold doctors to account for their clinical outcomes. Indeed, the objectives are very similar to many of those of the former Labour Government. The problem, however, is that the Bill will undermine many of those good aspirations.
Health spending is, as we know, falling because the amount by which the Government increased the NHS budget is lower than the rate of inflation. [Interruption.] For my health authority, it is 0.3% lower than the rate of inflation. Patient choice will remain limited to where GPs choose to commission services. Centralising many services under the NHS commissioning board-a new layer of bureaucracy-means that NHS dentistry, community pharmacy, optometry services, regional and sub-regional specialties and, indeed, some more complicated local services will be commissioned at national level by that board rather than at local level by a primary care trust, as in the past, or by a commissioning consortium in future.
I am sure that the Government will try to reduce NHS management costs. Every Government since the creation of the NHS have sought to do so, but this Government need to explain how creating 500 or 600 commissioning consortia-each with the skills to commission services-will cost less than the 150 PCTs that currently do the job. They are likely to lose economies of scale and the decisions taken could well lead to the fragmentation of some services such as dermatology or pathology. Such services are currently commissioned by a PCT for the whole PCT area, but in future could be commissioned in three or four different ways by different consortia. Small, less well resourced GP commissioning consortia will, I believe, be less effective than PCTs and strategic health authorities in controlling the costs of powerful hospital foundation trusts.
The Government are right to stress the importance of measuring clinical effectiveness and outcomes, but that makes it extraordinary that they have put primary care in the driving seat. We know a lot about the work of hospital doctors from the hospital episode statistics, but there are no national data on GP consultation rates or the thresholds they employ before they intervene with treatment or on GP outcomes, yet GPs are being put in charge of demanding this from everybody else.
Running through the Bill is the idea that transparency and accountability will drive up performance, so here are some questions to the Minister, which I hope he will address in his concluding speech. The Bill is designed to reduce health inequalities, yet there are enormous inequalities in GP services. Some GPs are very good; others less so. There are differences in their prescribing and referral rates, so how are the Government going to measure GPs' clinical performance? How will a GP commissioning consortium hold erring GP practices to account? What sanctions will be employed?
How will patients hold their GPs to account for their commissioning decisions? We are, of course, familiar with GPs being sued for bad clinical decisions, which is why they take out medical insurance and have to pay increasingly more for it each year. Will patients sue their GPs for bad commissioning decisions? How will the consortia hold hospitals to account?
How much will the GP commissioning consortia receive in management allowance per patient, because the Government's success in making administrative savings will depend on that? What sanctions will be imposed on a GP commissioning consortium to ensure that it commissions effectively and uses a good evidence base for its decisions?
The Government tell us that PCT deficits will be written off before the consortia take over, but what help will the commissioning consortia get in areas such as mine where there has been a difficult structural deficit-brought into balance by the previous Labour Government, but out of balance once again under the new Administration-to stop them falling into deficit? What will happen if they do go into deficit? Will their budgets and the services they provide to patients be cut as a result?
Mr Dorrell: The hon. Gentleman is making a thoughtful speech and asking, if I may say so, some very good questions, with all of which I agree. There is an implication behind his speech, however, which is that if all those questions can be answered, as I hope and believe they can, he will support the Government's policy. Is that implication correct?
Hugh Bayley: If I were convinced that they could be answered, I would indeed support the Government, but unfortunately I am far from convinced that it is the case.
Let us take another issue. The Government are providing a lesser increase in funding to the NHS this year, which amounts to a cut in real terms when the rate of inflation is taken into account. They think they will get away with this because the NHS staff wage bill is being frozen for a two-year period. What thought have they given to the wage bounce that will inevitably come in two years' time? There will be enormous wage pressure on the NHS budget; are the Government intending to increase it significantly at that time?
Mr Dorrell: I am anxious to provide the hon. Gentleman with extra minutes so that he can tell us whether he approves, in principle, of the idea of practice-based commissioning, which was originally introduced by the previous Government?
Hugh Bayley: I certainly do not agree with the way in which it is being introduced. The right hon. Gentleman will probably know that before the last election, I made a proposal to strip out one level of NHS bureaucracy-the PCT level-and do commissioning where it was needed at the SHA level. That would have achieved administrative savings. Instead of that, however, the Government have decided to replace 150 bureaucracies-PCTs as commissioning bodies-with some 500 or 600 bureaucracies the GP commissioning consortia. I do not think that that will achieve administrative savings. With the NHS budget so tightly squeezed by the current Government, if more money is taken away to meet the costs of bureaucracy, less money will be available for treating patients. That is the crux of the issue.
I believe that those are some very serious questions, which the Government need to answer if they going to convince the public of their plans. There is an intellectual incoherence in many of their proposals. They have not looked either at how some of their goals-on patient choice, for instance-might conflict with other goals such as increasing efficiency. Will a doctor be able to insist that patients have the most efficient treatment even if they do not choose that option themselves? Would it not make sense to pilot these changes before imposing them, untried and untested, on the NHS
Malcolm Wicks (Croydon North) (Lab): The status quo in British health care is certainly no serious option. Improving the NHS is, of course, a continuing challenge, not least because of the ageing of our population, rising medical costs in many sectors and rising public expectations, which are sometimes fuelled by information on the internet. If one adds to that the new public health agenda and the need to bring health and social care into better alignment, one can see the scale of the challenge. However, that is not to say that a top-down reorganisation is the answer.
I want to ask Ministers some specific questions about how the Bill will impact on some of the values and underlying principles of the NHS. The first is the principle that the health service should be based on need, not income or wealth, which is perhaps the essence of the NHS. How do the proposals relating to private patients in hospitals relate to that ethical principle? The proposal is to remove any limit on the use of NHS beds and staff to treat privately paying patients. Unless the Government somehow envisage surplus hospital resources, spare staff and empty beds-a far-fetched proposition-will not more private patients create longer waiting times for NHS patients and/or poorer care? What is the Minister's judgment on that?
My second question concerns the profit motive, which jars, at least for many of us, with the principle of patient care. Will Ministers confirm that private companies might in practice commission on behalf of GPs, possibly including US companies, while other companies will be awarded contracts? Have I understood that correctly? What is to stop companies competing on price for relatively straightforward procedures, perhaps initially cherry-picking as a loss-leader while leaving NHS hospitals with, frankly, the more difficult medical territories? What proportion of the NHS budget might effectively be in private hands? Of the £80 billion annual expenditure that we hear about, what sums might end up as profits for private shareholders? Ministers must have some idea of the answers to those questions, so I would be pleased to hear their answers or guesstimates.
Margaret Hodge: Does my right hon. Friend agree that there is another issue with privatisation? If a private, BUPA-run, hospital that provides health care gets into financial difficulties and is forced to close, does it not behove the commissioning body-the publicly run commissioning body-to take over the failing private hospital to ensure that the designated services are available to local people? Is that not an outrageous way of using public money?
Malcolm Wicks: Certainly, I can see that the commissioners might feel that someone had to look after the patients, and the financial implications of that pose another question for Ministers.
Given that the Bill allows for the new commissioning board to make payments to a commissioning consortium if performance is good, what happens exactly to that payment? Who benefits from it? Does it go to improved patient care, which is fine, or to bonuses for those working in the consortiums-the GP practices?
My third set of questions concerns accountability and parliamentary oversight. In this brave new world of competition, profits and privatisation, with the fearsome economic regulator, where does the NHS buck stop? Is the Secretary of State still responsible? Is he or she still accountable to this Parliament? If not, who is? If my Croydon constituent has to wait too long for surgery, are Ministers accountable? Can I ask questions? Will I get answers? If constituents cannot access mental health services, can MPs still expect Ministers to intervene and to act? Are they accountable? Will Parliament and public still be able to access the information, the data, the monitoring and the evaluative statistics to comment on performance? Is the publication and integrity of health statistics guaranteed by the legislation?
A further question concerns the relationship between patients and GPs. The Secretary of State and his colleagues wax lyrical about how decisions will now be taken by GPs and patients, and I remember that refrain during the general election, but what exactly does that mean for patients? How will those decisions be taken by patients as well as by GPs? How will patients be involved in commissioning? Will they be part of the commissioning body?
Moreover, will GP commissioners meet in public, like primary care trusts? If not, why not? Where is the accountability? If a patient wishes to complain about services, to whom do they complain-to their own GP, who does the commissioning? Where is the patient's complaint procedure in all that?
This Bill- [ Interruption. ] There is no point in the Minister just whispering at me. We have a winding-up procedure, whereby serious questions can be answered- I would hope-rather seriously by the Minister. [ Interruption. ] She has not wound me up so far.
The Bill is somewhere between a relapse into market ideology and an untried, untested leap in the dark. For the national health service, it is a fearful time. As we have heard, the Government wish to cut public expenditure, yet they are embarking on this top-down reorganisation that no responsible body seems to welcome.
The Bill will also be shown to be a fearful leap in the dark for the Conservative party, just when in recent years it has been making some headway in convincing the British public that the national health service might be safe with it. It is a fearful step for the Conservatives, and they will learn that in the coming years.
Margaret Hodge (Barking) (Lab): I speak both as Chair of the Public Accounts Committee and as the MP for Barking. As PAC Chair, my concerns have not been allayed by the evidence sessions that we have held on these issues. I do not want to be saying in three years' time, "I told you so." I urge the Government to think again before they introduce changes that have not been thought through properly, that are incredibly risky, and that could result in long-term damage.
There has been insufficient focus on the risks of the changes. The NHS chief executive said in evidence that
"the risk is higher. If you try and reorganise, the risk becomes higher. I think we'd be kidding you to say that it wasn't".
Making Monitor an economic regulator forces it to concentrate on competition, not quality. Its purpose will be to drive down costs, not drive up health outcomes. If the spotlight is on price, the risk is that patients will lose out. The NHS chief executive agreed in his evidence that lowering tariff prices could endanger patients. Opening the health market to any willing provider will undermine the viability of many NHS foundation hospital trusts, which face immovable fixed costs, such as their private finance initiative costs. Again, that risk has not been assessed properly.
The Government appear to be driven by an ideological mission. The NHS needs pragmatism, not dogma. I fear that there is no firm grip on the costs of reform. The NHS already faces the unprecedented challenge of finding £20 billion of savings and its record is poor. Over the past decade, despite assurances to the Treasury, NHS productivity declined, with hospital productivity declining by 1.4% annually. The NHS should therefore concentrate its efforts on the enormous financial challenge, and should not be diverted by an unprecedented organisational challenge. Quality and productivity, not reorganisation and privatisation, should be the priorities.
As I understand it, Ministers have set aside £1.7 billion to finance their reforms, but as my hon. Friend says, if the costs of redundancy are higher than planned, or if people carry on attending A and E rather than seeing their GP, the costs of reform will spiral and front-line services will have to be cut. I am not convinced that Ministers have transition costs properly under control.
Nor has anybody sorted out to our satisfaction the issue of accountability for public money. For instance, foundation trusts are supposed to be directly accountable to Parliament. With 167 trusts accountable to the PAC and the House, if there is financial failure or poor quality of care, will that accountability be good enough? In the past, Monitor could sack the board of a trust, but under the Bill it will lose that power. How can we hold the permanent secretary to account when there is a plethora of new quangos or new responsibilities for quangos? We have to know where the buck stops. I seek Ministers' reassurances tonight that there will be clear, practical accountability that enables Parliament to hold the Executive to account.
The Government do not have effective plans to deal with failures, and there will be failures-hospitals bankrupt, GP commissioning consortia overspending. Ministers must explain how they will deal with failure, so that local services will be maintained even when trusts and consortia collapse. So far, officials have been unable to provide us with the confidence that we need to feel that the Government have got a grip.
That matter is of particular importance to my constituents. For years, our NHS trust has been in terrible trouble, and last week it was named and shamed by the Audit Commission for systematic failure on its finances. It has failed to balance its books for years, and it has a projected deficit of £29 million this year. The quality of care has deteriorated, too. In the week of the general election, 99% of people at our King George A and E and 92% at Queen's hospital were treated within four hours. By 2 January this year, that had dropped to 83% at King George and just over 61% at Queen's. More than 1,000 people were forced to wait for more than four hours, ambulances were queuing around the block and all but the most urgent cases were turned away. In one case, a patient died because she was sent home.
That hospital trust is not fit to become a foundation trust. Despite a stream of new chairs and chief executives, the underlying problems persist. Now, the only answer that NHS London has is to try yet again to close the A and E at King George. That is health vandalism at its worst, with patients' needs sacrificed at the altar of financial cuts.
What would happen to my constituents under the proposed NHS reforms? King George A and E would go, forcing my neediest and poorest constituents to spend hours on three buses to get to a hospital. Queen's hospital would become unviable, and what then? Where is the local hospital ready to meet local needs? Who would want to consider merging with a hospital trust struggling with an impossible financial burden, and even if anyone did, would they ensure that our services remained local? The current health care reforms should put the patient at the heart of the NHS, but it does not feel like that is happening in Barking. I urge the Government to think again before they act to damage the health care of the people who need it most, the people I represent here in Parliament.
Dr Sarah Wollaston (Totnes) (Con): It is easy to see why politicians continuously want to fix the NHS. The perspective from the green Benches is very different from the perspective one gets as a GP-I say that having worked in the health service for 24 years. My surgeries and postbag, and I am sure those of other Members, are full of stories of delays, frustrations and sometimes really poor practice. The trouble is that not enough people write to their MP to tell them how sensitively or compassionately they have been treated, or how the NHS saved their life. They do feel those things, however, and they do appreciate the NHS. That is why they are understandably wary of any changes, proposed by whatever Government.
Here are the things in the Bill that I welcome. I really welcome clinical leadership. We should be in no doubt about this: there is clear evidence that commissioning works best when there is clinical leadership backed up by excellent management. The Bill will go some way to pushing us towards true clinical leadership in all parts of the NHS.
The provisions will also result in an information revolution. That will involve information about not only whether someone's treatment worked but what the experience was like-a kind of TripAdvisor for the NHS. We all know that, with information, daylight is the best disinfectant. If people know that their performance is going to be compared with that of others, that is likely to drive up performance in the NHS.
The provisions will allow for that early scan that can make all the difference in an early diagnosis of cancer. When GPs can commission very good early diagnostics much more quickly, we will see a difference. The changes will also give GPs much greater flexibility to respond to their own area. In Devon, for example, community hospitals are really important, but they might not be so important in inner cities. The provisions should also give better choice to services such as mental health, and bring in opportunities for the voluntary sector. I recently met a group of carers for patients suffering from mental health difficulties, and they told me that they wanted better access to talking therapies. Rather than the support that has traditionally been supplied to them, they want better access to other kinds of support. I also really welcome putting public health back where it belongs, with local authorities.
Our spending now matches the European average, and I genuinely congratulate the Labour party on that, but I am afraid that that has also been a wasted opportunity. It is unforgivable that so much of that money was squandered, and that we have seen flat-line productivity. For that level of spending, patients should be able to expect the kind of services that people receive in France or Germany. I am sure that we have all heard instances of people coming back from a holiday on the continent with a minor condition, having had a scan and treatment within a week. We should be able to deliver that here. Health care workers should not have to spend three weeks chasing down a patient's results. I am sure that we have all heard instances of that, as well.
The challenge is to improve aspects of the NHS, to look at the detail, to listen to patients and professionals and to ensure that we get this right. In Torbay, they have been getting it right for some time. It has been part of a national pilot of integrated care. Baywide, a not-for-profit company of local GPs, commissions health and social care from a pooled budget.
We have heard some terrible slurs about GPs profiteering and lining their own pockets. I am absolutely confident that that is not what we are going to see.
Torbay has been highly successful because it has pooled budgets and it can design integrated care. That saves lives and money. No one should be in any doubt that improving the quality of care, and thereby the quality of life, for those with complex, long-term conditions is the key to improving health care and cutting costs.
Andrew George: My hon. Friend talks about the role of GPs in cutting costs. I would be interested to hear whether, from her experience, she believes that the introduction of price competition-in which a maximum tariff would be set, below which there could be competition -will be helpful, or does she believe, as many authorities and other bodies do, that it is likely to put quality at risk?
Dr Wollaston: I am very confident, because I have discussed that question with the Secretary of State, who has assured me that the reforms are about competition not on price, but on quality. All doctors know that if they get it right the first time, they provide not only better care, but better value care.
GPs and PCTs throughout Devon are rolling up their sleeves and getting on with the job in hand, but to deliver the undoubted benefits of integrated care, they need to be able to work closely with colleagues in hospital, as well as with people in the community, to design those logical pathways. As I just mentioned, the Secretary of State has reassured me on the question of price versus quality competition, but it would help to spell out explicitly in the Bill that that will be protected. Professionals are understandably scared, and I hope the Minister will make the position absolutely clear in his winding-up speech.
Commissioners will not feel liberated if they are liberated from the Secretary of State but shackled to Monitor. Fundamental to the outcome of the reforms will be the powers of Monitor. I should like those powers to be carefully constrained in the Bill, so that it does not take on an unintended role. Focusing on quality and not on cost would help to bring all the professionals back into thinking that this is a positive step forward, because that remains a concern.
In the limited time I have left, I should like to ask the Secretary of State to consider how we will monitor the quality of primary care. Who will be responsible for performers' lists, audit, and identifying poorly performing doctors? As I understand it, all GP contracts will be held with the NHS commissioning board. What powers will GPs within consortia have to deal with those whom they feel are underperforming if they have no control over their contracts? What will be done about the ongoing, disgraceful situation regarding doctors from the EU with poor English skills, over whom we have few powers to protect patients until there has been a problem?
Professionals are also concerned about the make-up of consortia. Will they have the flexibility to include consultants and other specialists ... ('time is up')
Mr Geoffrey Robinson (Coventry North West) (Lab): I am pleased to follow the hon. Member for Totnes (Dr Wollaston), who speaks with a great deal of experience in such matters. The House will share her aspirations for the positive involvement of GPs in commissioning, for the improvement in the provision of secondary care by involving primary care, and for the organisation of primary care. Those aspirations may be shared, but the Government's hopes, and the evidence on which they are based, of carrying out this huge reorganisation and achieving its alleged aims are flimsy indeed.
In the history of Government-led reorganisations-it little matters whether they are bottom-up or top-down-this reorganisation is massive. The former Health Secretary, the right hon. Member for Charnwood (Mr Dorrell), referred to the view of the NHS chief executive. He said that the Nicholson challenge is to carry out successfully such a huge, large-scale reorganisation in the time proposed-the two challenges that need to be pulled off. I think I quote Nicholson accurately when I say that the first challenge is to do in four years something so massive that it can be seen from the moon-together with the great wall of China-and that that would be unbelievable. The second challenge-the other inherent part of the two-part challenge-is that that has to be done while achieving a 4% reduction in costs over four successive years; and
"To pull of either of these challenges would therefore be breathtaking; to believe that you could manage both of them at once is deluded."
I do not know why David Nicholson is still in his position. I do not know how the chief executive of the national health service can think that the Government must be deluded to put forward a proposal such as the one that the Secretary of State has proposed and remain in his place, but he clearly does not believe it. I do not want to cast any aspersions on the Secretary of State's mental health, although I note that the editorial of the last edition of the British Medical Journal read:
"What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad."
Government collective responsibility obviously applies.
It is difficult to understand why the Secretary of State is going down this route, because there is no evidence that these sorts of reorganisations-top-down, bottom-up-in the health service or anywhere else bring the benefits, cost reductions and performance improvements expected of them. If any Government Members wants to correct that, I will willingly give way, even in the limited time available. However, there simply is no evidence for it. Indeed, the National Audit Office, in looking at nine reorganisations carried out in the last five years of the Labour Government, found no evidence at all. They all cost far more, and the benefits, so far as they could be identified, were much less.
Similarly, it is pretty obvious that the something like 15 structural reorganisations, particularly in primary and secondary care in the health service, were not successful either. We only have to read through them. Kieran Walshe has described the bewildering array of forms and structures put in place to run primary care and commission secondary care- [Interruption.] I see that anybody who does not agree with the Secretary of State is dismissed automatically-that is a sign of hubris and is not a good approach. A similar approach was taken towards Professor Appleby, who was dismissed as someone of no importance. Yet these are people who are looking at the facts-Appleby looked at improvements in the health service. The conclusion is that "there have been family practitioner committees, health authorities, GP fundholders, total purchasing consortiums, GP multifunds, primary care groups, primary care trusts, and external commissioning support agencies."
I freely admit that a lot of those came from the Labour Government. However, I cannot imagine why the Government refuse to learn from our mistakes. That applies also to one of the most serious developments in this whole proposed reorganisation relating to the introduction of price competition. It is feeble of the Government Front-Bench team to say, "Well, your Government intended to do it, so we are going to do it." They spend hours every day criticising everything the Labour Government did. This is one thing they did not do-apparently they intended to do it-but suddenly it is so welcome that the Government insist on doing it. The fact is, however, that it will happen.
We have a huge change but with no evidence that it will bring any good; we have the fact that the NHS has to make savings that nobody believes will be achieved; and we have the fact that we are opening it up to competition. The position of the consortia becomes very questionable, as does the position of the NHS commissioning board itself. Other Members have raised these points. What sanctions have been provided for? To whom will the consortia report? Is the Secretary of State abdicating any responsibility for their performance? It is not clear from the legislation, as far as I can see-there are 61,000 words of it-what the Government's role will be in the control, functioning and performance of these new boards.
Derek Twigg (Halton) (Lab): This has been a fascinating debate with some interesting and excellent speeches. Some 17 Labour Members and a similar number on the Government Benches have given a variety of speeches, some showing great knowledge and some not so much. I particularly congratulate my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) on her excellent maiden speech, in which she demonstrated her great knowledge of the health service and her background in it. I am sure that she will make many more such speeches and be a great success in this House.
I would like to thank the NHS staff for all the work they do every day in our health service. That includes those at PCTs; one might sometimes think that they were ogres, given how PCTs are described by some Government Members. They work very hard, and they, too, have to deliver the changes that will take place as a result of this Bill.
The Secretary of State is pushing ahead with the Bill despite criticism from all sides. Patient groups, professional bodies and health experts have attacked the plans as high cost, high risk, a danger to the commissioning of key health services, and a distraction from the need to find efficiencies. The heads of the British Medical Association, the Royal College of Nursing, the Royal College of Midwives and the Chartered Society of Physiotherapy, as well as union leaders, have described the reforms as extremely risky and potentially disastrous. The more they see, the more they become concerned. The clear message that we have been getting is that the proposals have come at the wrong time, they are ill conceived, and a lack of attention has been paid to stakeholders' concerns.
The Secretary of State has ignored the massive improvements that took place under the Labour Government. One would think that he was talking about a different health service, because we had record numbers of doctors and nurses and record low waiting times. I wonder whether the Minister will confirm, as the Prime Minister and the Secretary of State have not done so, that there will be no increase in waiting times during the life of this Parliament. There have been record levels of patient satisfaction, with 71% agreeing that Britain's national health service is one of the best in the world-the highest figure on record. That is also evidenced by the satisfaction levels recently recorded across user groups, with, for instance, 91% of GPs and 90% of out-patients satisfied. The argument that the NHS is in crisis and is not dealing with patients' concerns does not stand up. It is important to look at some of the other improvements that have taken place. In June 2010, 90% of admitted patients and 98% of non-admitted patients were being seen within 18 weeks. The coalition has scrapped the targets that delivered those improvements to patient care.
Several Members referred to international comparisons. Let me take the example of the Commonwealth Fund, which ranked the UK first for efficiency and effective care in a study of seven top health care systems. In its 2010 international survey, it found that 92% of people were confident that they would receive the most effective treatment when sick-the No. 1 figure among comparable nations.
A lot has been said about cancer mortality. From 1997 to 2008, cancer mortality rates in all regions of England decreased by between 17.5% and 23%. Even more pronounced improvements have been observed in mortality from circulatory diseases: between 1995-97 and 2006-08, the mortality rate for England fell by 47%.
There are many uncertainties and unanswered questions about the Bill. There are concerns about who will be involved in commissioning and whether it will include other clinicians such as hospital doctors, physios and, importantly, nurses. How do nurses fit into the structural regime? In an article in today's edition of The Times, the Prime Minister says:
"Nurses too will continue to play a vital role. GP consortia will have a statutory duty to work with nurses and other healthcare professionals, ensuring they have a real voice in shaping better care for patients".
The Royal College of Nursing says that it was interested to see this, because it does not believe that the Bill goes far enough for it to be possible to claim that that is a statutory duty. Perhaps the Minister will respond to that, too. The only provision that the RCN believes relates to that matter is new section 14O in clause 22, which states that commissioning consortia must obtain appropriate advice. It does not believe that the Bill goes far enough in ensuring that commissioning consortia have relevant multi-disciplinary expertise to commission appropriate care.
I should like to turn to Monitor and competition-an aspect that has not been much mentioned. An ideological commitment to competition on price and to a massively increased role for the private sector is at the heart of the Conservatives' proposals, despite their attempts to hide it. On 17 January, in a 700-word article in The Times, the Secretary of State did not mention the word "competition" once, but the Government have had to reveal where the true thrust of this legislation lies. Of course, he did not mention it much in his speech today, either. The Prime Minister told the House that "what we want is a level playing field for other organisations to come into the NHS."-[ Official Report, 19 January 2011; Vol. 521, c. 831.]
When we appeared together on "Newsnight" a couple of weeks ago, the Minister of State, Department of Health, the hon. Member for Chelmsford (Mr Burns) said: "It is going to be a genuine market. It is going to be genuine competition."
The Government have hidden the great bulk of the ideological market and competition changes from public view. There is the introduction of competition on price. Monitor will have the power to direct consortia to put the provision of services out to tender, irrespective of what the GP consortia say. The Minister wants to deny that, but it is what we read in the Bill. Monitor will be driving this, not the GP consortia. Government Members should be reading that part very carefully. NHS resources, such as beds and staff, will be used without limit to treat private patients as the cap on private patients in hospitals is lifted. That means that private patients may jump the queue while NHS patients are waiting for treatment. Services or whole hospitals may be forced to close as the most profitable patients are cherry-picked by private providers.
I turn to the Liberal Democrats. The hon. Members for Burnley (Gordon Birtwistle) and for Manchester, Withington (Mr Leech) suggested that the Bill will protect hospitals and wards from closure. I am afraid that it will not. They need to read the Bill again. Monitor will be driving a lot of this, and they need to be clear about what the Bill actually does. They should join the hon. Member for St Ives (Andrew George), who is taking the interesting stance of not voting for the Bill tonight. He understands it better than other Government Members.
Concerns over fragmentation and obstacles to integrated working have been raised by numerous bodies in the health service and by those who work in the health service. The Commonwealth Fund states that the UK has the best co-ordination between health care providers and professionals, with the lowest percentage of patients having experienced co-ordination problems in their care. Only 10% of patients have received conflicting information. The more privatised, competition-driven systems in Australia and the US experience greater co-ordination problems.
The King's Fund brief for this debate states "The Bill signals a significant shift towards a more competitive market for health care. While we support increased competition in areas where it demonstrates benefits to patients, the Bill appears to move towards promoting competition at the expense of collaboration and integration."
That is from one of the most respected think-tanks.
One cannot underestimate the huge powers that will be given to Monitor. It will expose the NHS to a rigorous competition regime, with services going out to tender. The explanatory notes state that Monitor will become the "economic regulator for all NHS-funded health services", with the power to "do anything it needs to in order to exercise its functions."
In other words, the NHS will become like a utility.
Of course, the Government are full of broken promises. The Prime Minister said that there would be real-terms increases in NHS spending, but there are not. He said that there would be no cuts, but there are. He said that there would be no top-down reorganisations, but we have a top-down reorganisation. David Nicholson said that
"no one could come up with a scale of change like the one we are embarking on at the moment. Someone said to me 'it is the only change management system you can actually see from space'-it is that large."
This is a massive change. There are other issues, such as the cuts in staff that are taking place and the vacancies that are not being filled. We are being told about that by people who work in the health service. That is the true nature of the health service under the Conservatives and the coalition.
We are in favour of improving the quality of care, driving up standards, greater clinical involvement and giving a greater say to patients. We are therefore not anti-reform, but we are against this reckless, top-down reorganisation with a cost of £3 billion, which was hidden away during the general election campaign. It is reckless, it is not in our best interests and many believe that it will be the end of the NHS as we know it.
The Minister of State, Department of Health (Mr Simon Burns): When NHS funding has reached the European average, but the outcomes for care have not; when doctors are seeking to improve the quality of care but are hindered by politically imposed targets; and when the defence of bureaucracy is put above front-line services, we know that something has gone very wrong. That is why the coalition Government will act, act now and act with determination to improve and modernise our national health service. The Bill will create an NHS that puts patients first, that frees clinicians to deliver the best and most innovative care they can, and that focuses on what matters most to patients-health outcomes.
This has been an interesting debate, although at times, sadly, not a well informed one. I begin, however, by congratulating the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) on her fluent debut speech in the Chamber. I wish her every success in her future contributions, although I warn her that she will not get such a quiet ride next time around. I also congratulate my right hon. Friend the Member for Charnwood (Mr Dorrell) on an interesting and incisive speech, and my hon. Friends the Members for Boston and Skegness (Mark Simmonds) and for Central Suffolk and North Ipswich (Dr Poulter). The latter has great experience, having worked in the NHS.
I wish also to congratulate a number of my other hon. Friends on interesting contributions, including my hon. Friends the Members for Mid Bedfordshire (Nadine Dorries), for Basildon and Billericay (Mr Baron)-we will certainly write to him with answers to his questions-for Winchester (Mr Brine) and for Loughborough (Nicky Morgan).
It is always a delight to listen to the Member who, I suspect, is probably best described as the old Labour dinosaur, the right hon. Member for Holborn and St Pancras (Frank Dobson). I also enjoyed the elegant contribution of the right hon. Member for South Shields (David Miliband). Having listened to his fluent speech, all that I can say is, what a difference opposition makes. It is interesting that what he supported as part of a Labour Government in power he now seems to have abandoned in opposition. The hon. Member for York Central (Hugh Bayley) asked a number of intricate questions, and given the time that I have, I promise that I will write to him with answers to all of them.
Hon. Members might find it helpful if I debunk a few of the myths that have sprung up about our plans to modernise the NHS. The first, and perhaps the most insidious, is that they were kept secret and hidden from the electorate. Quite frankly, that is palpable nonsense. In June 2007, my right hon. Friends the Secretary of State and the Prime Minister, when in opposition, published the Conservative party's white paper, "NHS Autonomy and Accountability". It laid out our clear intentions, which we reiterated on pages 45 and 46 of our election manifesto. We said, as a commitment to the British people, that we would "give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers."
We stated that we would "strengthen the power of GPs...by...putting them in charge of commissioning local health services" and "set NHS providers free to innovate by ensuring that they become autonomous Foundation Trusts".
We also stated that we would create an independent NHS board. It is quite ludicrous to suggest that we did not tell the British people our plans both before and during the election campaign.
A second myth is that our plans to modernise the NHS are revolutionary. In fact they are evolutionary and an extension of the policies of previous Administrations, notably the Blair and Brown Governments. That is particularly true of the move towards the "any willing provider" principle and patient choice. In 2003, when the Labour Health Secretary Alan Milburn moved to introduce a plurality of providers and patient choice, he argued that "the NHS cannot be run forever like a 1940s-style nationalised industry".
He was right. The NHS needs the constant drive of improvements to raise standards and improve outcomes.
More recently-perhaps Opposition Members would like to listen to this-in 2007, the Labour Prime Minister, the right hon. Member for Kirkcaldy and Cowdenbeath (Mr Brown), gave evidence to the Liaison Committee. He stated:
"We have been asking in people from the private sector to review what we can do to give them a better chance to compete for contracts...so the independent sector increases its role, will continue to increase its role and, in a wider and broader range of areas, will have a bigger role in the years to come."
He said: "The test at the end of the day is not private versus public, it is value for money, and it is not dogmatic to support one against the other."
In 2008, he said: "We will continue to open up acute care with...choice of hospitals trusts across private and public sectors in England...including more than 150 private sector hospitals working as part of the NHS and at NHS cost and standards of quality. We will use all mechanisms available to us to improve our NHS-public, private and voluntary providers can all play their part".
This Government have also been falsely accused of wanting somehow to privatise the NHS. Privatisation is defined as making people pay for their health care. That is not going to happen under this Government. This Government are totally committed to the values of the NHS: paid for through general taxation; free at the point of need; and always based on clinical need and never on a person's ability to pay.
Others have erroneously claimed that any involvement of the private sector will undermine the public sector ethos. That is a rather surprising view, considering that it was the last Labour Government who embraced the private sector. I shall quote Dr Howard Stoate, who was recently elected chair of Bexley's shadow GP consortium. Opposition Members will remember that, until the last election, he was the Labour Member of Parliament for Dartford. In a recent article in The Guardian, he said: "We have found the idea that services can be offered by any willing provider can actually strengthen the ethos of the NHS rather than weaken it."
Dr Stoate went on to say that, in his experience, GPs "reveal overwhelming enthusiasm for the chance to help shape services for the patients they see daily...Far from miring GPs in bureaucracy...GP commissioning can free them to operate more effectively."
This Government have one simple objective for the NHS. That is that it should give patients health outcomes that are consistently among the very best in the world, including higher survival rates, greater clinical effectiveness and safer care for patients. Excellence cannot be delivered by having Ministers bark orders down the chain of command. It is done by encouraging innovation and creativity, and by putting the interests of patients ahead of the system and of tomorrow's headlines.
We will free local clinicians to use their expertise to shape local services. We will free patients to choose the best possible care for their specific needs. We will bring a culture of openness and transparency to the health service, and we will allow any willing provider to compete to provide the best patient care. These plans are consistent, coherent and comprehensive, and they will deliver care that is free at the point of use for all. They will build on the best of what has gone before.
Some say that the reorganisation of the national health service will cost £3 billion, but that is factually incorrect. The impact assessment shows that there will be a one-off cost of £1.4 billion. It also demonstrates how the changes will pay for themselves by 2012-13, saving £5.2 billion by the end of this Parliament. They will continue to save £1.7 billion in every year after that, up to the end of the decade. Every penny of those savings-the equivalent of 40,000 extra nurses, or 17,000 extra doctors or 11,000 extra consultants every year-will be completely and totally reinvested in front-line services, not wasted on back-office costs.
As society evolves, so too must the NHS. The Bill will deliver a modern NHS fit for the 21st century. It is the natural progression of the original vision to deliver the finest health care for all our citizens, remaining true to the founding principles set out by Nye Bevan.