I beg to move,
That this House believes that the Government is pursuing a reform agenda in health that represents an ideological gamble with successful services and has failed to honour the pledges made in the Coalition Agreement to provide real-terms increases each year to health funding; further believes that the Government is failing to honour its pledge in the Coalition Agreement by forcing the NHS in England through a high-cost, high-risk internal reorganisation as set out in the health White Paper; is concerned that the combination of a real cut to funding for NHS healthcare and the £3 billion reorganisation planned by the Secretary of State for Health will put the NHS under great pressure and that services to patients will suffer; supports the aims of increasing clinician involvement and improving patient care, but is concerned that the Government’s plans will lead to a less consistent, reliable and responsive health service for patients which is also more inefficient, secretive and fragmented; and calls on the Secretary of State for Health to listen to the warnings from patients’ groups, health professionals and NHS experts and to rethink and put the White Paper reforms on hold, so that in this period of financial constraint the efforts of all in the NHS can be dedicated to improving patient care and making sound efficiency savings that are reused for frontline NHS services.
The motion is set in similar terms to the motion standing in the name of my right hon. Friend the Member for Leigh (Andy Burnham), the shadow Education Secretary, which we will debate a little later. That is because in both health and education we are seeing many of the same broken funding promises, much of the same free market ideology, many of the same problems of big changes forced through without considering or caring about the consequences, and many of the same risks that the poorest and most vulnerable will lose out and that comprehensive, consistent public services will be broken up. Beyond the spending cuts, we are starting to see the pattern of what public service reform means in Tory terms.
The Prime Minister told Britain before the election:
“We are the only party committed to protecting NHS spending.”
In his coalition agreement with the Deputy Prime Minister, he went further, saying:
“We will guarantee that health spending increases in real terms in each year of…Parliament”.
The Government whom the Prime Minister leads are now breaking the promises that he made to the British people. The Secretary of State has been caught out double-counting £1 billion in the spending review as both money for the NHS and money to paper over the cracks in social care. Let me quote from a Library research paper, which confirms:
“Including the (social care) funding is critical to the description of the settlement as a ‘real terms increase’; without it, funding for the NHS falls by £500 million—0.54% in real terms.”
There we have it—the facts in the figures. There is no real-terms rise in NHS funding, but a real-terms cut over this Parliament by this Government—[Interruption.]
The Secretary of State says “Nonsense” from a sedentary position. If he wants to deny the figures in the Green Book, deny the report in the Library research paper, and take issue with the Nuffield Trust, who all say the same, he should do so. He should by all means take credit for funding social care, but he should not double-count the credit by including it for both NHS funding and social care funding.
I do indeed deny that. It is very simple. The total NHS budget will rise in real terms. Resource funding will rise by 1.3% in real terms over four years. Even if the money to be transferred to local authorities were taken out, that is an increase in resource funding for the NHS in real terms.
The right hon. Gentleman must consider that if a health service buys rehabilitation for patients returning home after being in hospital so that they do not need another emergency hospital admission, or puts telehealth in someone’s home so that their independence at home is maintained, that is health spending. It is the normal approach of the NHS to providing preventive services.
There is a good case for more funding in social care, but the truth is, as Age UK says, that in this Parliament it will be cut by an average of 7% in real terms. Social care may help the health service, but if money is spent on social care, it is not spent on NHS services, and it cannot be double-counted as NHS funding. When that is taken into account, and when the Secretary of State stops fiddling the figures, we see that the country and the NHS will get a real-terms cut, not a real-terms rise during this Parliament.
My right hon. Friend the shadow Chancellor said in response to the Chancellor’s spending review:
“We support moves to ring-fence the”
“budget”.—[Official Report, 20 October 2010; Vol. 516, c. 968.]
People saw Labour’s big investment in the NHS bring big improvements—50,000 extra doctors, 98,000 more nurses, deaths from cancer and heart disease at an all-time recorded low, the number of patients waiting more than six months for operations in hospital down from more than 250,000 in 1997 to just 28 in February this year, and more than nine in 10 patients rating their experience of hospital care as good, very good or excellent.
We still have a lot further to go. There have been big improvements in international comparisons, but we must go further. It beggars belief that the Government have decided not to press ahead with plans to give patients a guarantee of, for example, receiving test results within one week, especially as hon. Members on both sides of the House recognise the importance of early diagnosis for cancer, and the cancer specialist, Mike Richards, said that this contribution to early diagnosis could save 10,000 lives a year.
Instead of building on those great gains, I fear that the NHS will again go backwards under this Tory-led Government. It is already showing signs of strain. The number of patients waiting more than 13 weeks for diagnostic tests has trebled since last year, 27,000 front-line staff jobs are being cut, and two thirds of maternity wards are so short-staffed that the Royal College of Midwives says that mothers and babies cannot be properly cared for.
This is not what people expected when they heard the Prime Minister say that he would protect NHS funding. In fairness, a proper, long-term perspective is needed on NHS financing. Year-on-year funding just below or even 0.1% above inflation is way short of the 4% average increase that the NHS has had over its 60 years. During the last Labour decade, it averaged 7% in real terms.
There are, and have been for many years, built-in pressures on the NHS: the cost of staff, drugs and equipment rises by about 1.5% above general inflation, and the demands of our growing and ageing population adds £1 billion to the bill each year just to deliver the same services.
It is interesting that the right hon. Gentleman omitted from his list any mention of the escalating costs of administration in the NHS. Does he agree with us that what is really important is to reduce the cost of administration?
The hon. Lady is right, and there is plenty of scope to do that. We recognised that, and we had plans to take out many of the managerial costs. I will come to that later, but it is hard to understand how creating three or even four times as many GP consortiums doing the same job as primary care trusts is likely to reduce rather than increase bureaucracy in the NHS. My right hon. Friend the Member for Leigh says that in Wigan there is one PCT, but it is set to have six GP consortiums. The same job will be done six times over in the same area. How is that a cut, or an improvement in the bureaucratic overheads and costs of the NHS?
In the spending review, the NHS is set for the biggest efficiency squeeze ever. On 12 October, the NHS chief executive, David Nicholson, told the Health Committee:
“It is huge. You don’t need me to tell you that it has never been done before in the NHS context and we don’t think, when you look at health systems across the world, that anyone has quite done it on this scale before.”
Money is tight, and something must happen, but that can be done by building on Labour’s big improvements in the NHS over the last decade. It will be tough, but I will back the Government, as long as all savings are reused for better front-line services to patients.
Before the right hon. Gentleman continues, may I remind him that the “it” that Sir David Nicholson was talking about was the achievement of between £15 billion and £20 billion of efficiency savings, which is a substantial improvement in productivity that is expected over the next four years? That is in complete contrast with a Labour Government who had declining productivity over the whole of the last decade. The efficiency savings of £15 billion to £20 billion that Sir David was talking about were set out by the last Labour Government in late 2009. We are continuing with that, but we will make it happen, and Labour did not.
I have read David Nicholson’s transcripts, and he was indeed talking about £15 billion to £20 billion of efficiency savings, which were not achieved, as the Secretary of State said, but planned. That is a big test for the NHS, and it will be more difficult because of his plans for reorganisation, which I will come to.
As I was at the evidence session, I can confirm that Sir David Nicholson was clearly talking about the challenging £15 billion to £20 billion savings, which I would have thought the whole House approved of and agreed should be achieved. But the right hon. Gentleman was right to say that Sir David was also talking about their being achieved in the context of the proposed changes in the White Paper.
Of course Sir David was talking about the two together, because the Select Committee was understandably probing both matters. In the quote that I gave, he was talking about the significant efficiency savings required of the health service at this time of an unprecedented financial squeeze. Many would say that that is the toughest financial test in the NHS’s history.
The right hon. Gentleman is right to say that Sir David was talking about the £15 billion to £20 billion efficiency challenge, and as my right hon. Friend the Secretary of State said, that programme has its roots in the time of the last Government. Will the right hon. Gentleman confirm that his party still supports the QIPP challenge—quality, improvement, productivity, prevention—that was first articulated when his right hon. Friend the Member for Leigh (Andy Burnham) was Secretary of State?
If the right hon. Gentleman reads the official record, he will see I have just said that I will back plans to get the efficiency savings out of the NHS. They are needed and they have to happen, and I will back them as long as all the savings are reused for front-line services to patients.
Faced with the toughest test in its history, the least NHS patients and staff can expect is that the Government keep their funding promise. At this time of all times, the last thing the NHS needs is a big internal reorganisation. The Prime Minister ruled out such a reorganisation before the election, saying:
“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”.
The right hon. Gentleman, now the Secretary of State, ruled it out, saying that the NHS
“needs no more top-down reorganisations”.
The coalition agreement was clear and reassuring on this point. In it, the Prime Minister and the Deputy Prime Minister pledged:
“We will stop the top-down reorganisations of the NHS that have got in the way of patient care”.
That was before the Secretary of State’s White Paper plans, which the head of the King’s Fund has called
“the biggest organisational upheaval in the health service, probably since its inception”.
Promise made in May, broken in July. Promise made by the Prime Minister, broken by the Secretary of State.
There is a story doing the rounds in the media of a journalist being briefed by No. 10, early on the morning of the publication of the White Paper, and told
“there’s nothing much new in it.”
When did the Secretary of State tell the Prime Minister that he was breaking his promise? When did he tell the Prime Minister that he was not only breaking the Government’s promise but forcing the NHS through the biggest reorganisation in its history, with a £3 billion bill attached, at a time when all efforts should be dedicated to achieving sound efficiencies and improving care for patients? This is high cost and high risk; it is untested and unnecessary.
The Public Accounts Committee has identified that improving integration and co-ordination of services for the 580,000 people who suffer from rheumatoid arthritis would deliver efficiency savings on the annual £560 million bill faced by the NHS each year for this care. The National Rheumatoid Arthritis Society believes, however, that the new commissioning responsibilities outlined in the White Paper
“risk increasing fragmentation in services”
and reducing savings overall. Does my right hon. Friend agree?
In a way it does not matter whether I agree; it matters much more that the National Rheumatoid Arthritis Society and many other patients groups are deeply concerned about this.
It is not just patients groups but professional bodies and NHS experts who are worried. Even the GPs are not convinced, and they are meant to be the winners in all this. They are meant to be the ones planning, buying and managing the rest of the NHS’s services. A King’s Fund survey carried out last month found that fewer than one in four GPs believe that the plans will improve patient care, and only one in five believe that the NHS will be able to maintain the focus on efficiency at the same time.
In my constituency, we have been holding one-to-one dialogues with GPs, particularly about the White Paper, and I can tell the right hon. Gentleman with total confidence that well over 65% of the GPs I have met—it is only 65% because I have not managed to meet all of them—have endorsed the removal of the PCTs, from which they felt remote and disjointed and from which they felt they were getting poor value for money.
If two thirds of the GPs the hon. Gentleman met are in favour, one third are obviously not convinced, but they will be forced to do this anyway. That is part of the problem, and I will come to that in a moment.
It is no wonder that the head of the NHS Confederation, the body that is there for those who run the NHS, told the Health Committee last month that
“there is a very, very significant risk associated with the project”.
Even the Secretary of State’s right-wing supporters in the Civitas think-tank tell him that he is wrong. They have said:
“The NHS is facing the most difficult…time in its history. Now is not the time for ripping up internal structures yet again on scant evidence”.
I have been listening to the right hon. Gentleman with great interest. I know his moderate views on many things, but he misrepresented what my hon. Friend the Member for Enfield North (Nick de Bois) said about the numbers of GPs. Now that targets and top-down management—the centrepiece of the last Labour Government’s policies—are being discarded even by those on the right hon. Gentleman’s own Front Bench, does he not agree that giving significant freedoms to front-line professionals is a better way forward?
Yes, of course; we had been doing that for some years before the election and we had plans to do it after the election, but the fact is that we did not win the election, and the Secretary of State is in power now. He is making the decisions and he is the one who is entrusted with the future of our NHS. He is the one who needs to answer to the House for his plans.
The problem with broken promises is worse than I have already suggested. The coalition agreement promised:
“The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs.”
The Secretary of State’s plans will do precisely the opposite. He is abolishing the PCTs, not building on the best of what they do.
There is a great deal of talk about reducing bureaucracy and administration, but PCT staff work on issues such as NHS treatment for people with learning disabilities. Ministers have talked about that role continuing, but will those staff not be really worried about their futures now? They will be looking around, and if they see another job, they are not going to wait two years; they are going to jump now, and the PCTs will lose that expertise. It will drain away and the PCTs will be unable to carry out all those important residual functions.
This is precisely why those who understand the health service, including those who run it, say that it is going to be so hard, at a time when the NHS has never faced such a tough financial challenge, to see through the biggest reorganisation in its history at breakneck speed.
Whether on funding, reorganisation or the role of the PCTs, the Secretary of State is doing precisely the opposite of what was set out in the coalition agreement. He is running a rogue Department with a freelance policy franchise, in isolation from his Government colleagues. He claimed on the “Today” programme yesterday that he had been saying all this for four years before the election. So when did he tell people, and when did he tell the Prime Minister, that GPs will be given £80 billion of taxpayers’ money—twice the budget of the Ministry of Defence—to spend? When did he tell people that, in place of 150 primary care trusts, there could be up to three times as many GP consortiums doing the same job? When did he tell people that GP consortiums will make decisions in secret and file accounts to the Government only at the end of the year?
When did the Secretary of State tell people, and the Prime Minister, that nurses, hospital consultants, midwives, physiotherapists and other NHS professionals will all be cut out of care commissioning decisions completely? And when did he tell the Prime Minister that hospitals will be allowed to go bust before being broken up, if a buyer can be found for them? When did he tell people that NHS patients will wait longer, while hospitals profit from no limit on their use of NHS beds and NHS staff for private patients? When did he tell people that lowest price will beat best care, because GPs will be forced to use any willing provider? When did he tell people that essential NHS services will be protected only by a competition regulator, similar to those for gas, water and electricity? And when did he say that he was creating a national health service that opens the door for big private health care companies to move in?
I am grateful to the right hon. Gentleman, who is generous in giving way. It is never an ideal thing to quote yourself, but let me risk doing so:
“We have been clear about the need for improvement in the NHS: responsive to patient choice; where budgets are in the hands of GPs; where hospitals are set free; where professionals are released from targets and bureaucracy; where the independent sector has a right to supply to the NHS; where competition delivers efficiency; and where patients have the assurance that NHS standards of care are based on the founding principle of the NHS—free at the point of use and not based on the ability to pay.”
I said that in a letter to The Daily Telegraph on 10 March 2006—four years ago.
The real question is why the right hon. Gentleman, if he had these plans, did not tell the Prime Minister and the Deputy Prime Minister when they were writing the coalition agreement what he wanted to do on funding, on reorganisation and on the role of primary care trusts. Why did he allow his Government to make these pledges to the British public in May and then break their promises two months later in the White Paper? Whatever the boss of Tribal health care says about the private health care companies, he described the White Paper as
“the denationalisation of healthcare services”.
He went on to say that
“this white paper could result in the biggest transfer of employment out of the public sector since the significant reforms seen in the 1980s.”
This is not what people expected when they heard the Prime Minister tell the Conservative conference last month that the NHS would be protected.
It is incontrovertible that the White Paper contradicts the coalition agreement in respect of top-down reorganisation, but I think we would accept the right hon. Gentleman’s criticisms of top-down manipulation of local services a great deal more if he were prepared to accept that the previous Government failed in their attempt to reorganise through independent treatment centres or alternative providers of medical services which were massively expensive and did not necessarily provide better services on the ground. Will the right hon. Gentleman at least acknowledge that the previous Government failed in that regard?
The treatment centres, which the hon. Gentleman mentions, helped contribute to bringing waiting times down to 18 weeks and helped to say to the British public, “Whatever treatment you need in hospital, you will not have to wait more than 18 weeks for it.” That was a consistent universal promise that we were able to make to patients as a guarantee for the future. That has now been ripped up, and we can see the result as waiting times and waiting lists lengthen. As I said at the start of my speech, my fear is that during this period of Tory leadership, we will see the NHS going backwards.
As for the hon. Member for St Ives (Andrew George), I understand his problem. He is a Liberal Democrat and I have to say that this health policy bears very little of the Liberal Democrat imprint. The one part of the Liberal health manifesto that they managed to get into the coalition agreement was this:
“We will ensure there is a stronger voice for patients locally through… elected individuals on the boards of their local primary care trust”.
Within two months, of course, that was not even worth the coalition agreement paper it was written on.
Does my right hon. Friend agree that there is something else that the Government are not telling us—namely, the huge cost of getting rid of primary care trusts and strategic health authorities in respect of redundancy and getting out of broken contracts? Does he, like me, speculate that many of the people affected will end up working for GP consortiums or private health care firms—a huge cost to the public purse that delivers not one iota of front-line care?
Quite so. Estimates of the cost of the reorganisation are up to £3 billion, but we have not had any cost announcements from this Government, who will not tell us how much is going to be spent on reorganisation rather than on patient care. At a time when finances are tight, this is precisely the wrong prescription for the NHS over the next few years.
It is no wonder that GPs have grave doubts—they trained as family doctors, not as accountants or procurement managers, and they are committed to treating patients, not doing deals over contracts. However, they will be forced to commission services, whether they like it or not; they will make rationing decisions, not just referral decisions for their patients; and they will have to take on the deficits or inbuilt funding shortfalls in their PCT areas. GPs spend an average of eight or nine minutes with each patient. If they plan, negotiate, manage and monitor commissioning contracts in future, they will have no time left to see patients. If they continue to be family doctors, commissioning will be done for them, not by them; it will be done in their name by many of the same PCT managers who presently do the job or by commercial companies that have already started hard-selling their services to GPs. The other day I picked up “The Essential Guide to GP Commissioning” helpfully published by United Health—one of the biggest US-based health care companies in the world.
Does the right hon. Gentleman realise that not all GPs will have to be involved with commissioning? Does he welcome the efforts of the Royal College of General Practitioners to introduce real clinical leadership and tuition for those GPs interested in taking up commissioning, helping them to provide this service?
The GP fundholding experiment took place in a completely different context—within an NHS that still had an area-based plan and still had bodies accountable through the Secretary of State to Parliament. In the end, however, it did not work and we stopped it.
Will the right hon. Gentleman accept that there is some kind of ideological disagreement going on in his own mind, given that the last Labour Government did exactly the same thing to head teachers by bringing alternative providers into schools and giving them control over budgets and what services to deliver? Our proposals for GPs are exactly the same—aiming to put in charge the professionals who deliver services and have contact with the people who use them.
I thought the hon. Gentleman was in his place at the start of the debate. In that case, he will have heard me say that one reason for having an Opposition day debate on both health and education is that we see many of the same ideological fingerprints over the plans for education and for health. These are Tory ideological fingerprints, and I hope that this will become clearer as the debate progresses.
Let us make no mistake: if these changes go ahead, patients will rightly question whether GPs’ decisions are about the best treatment for them or about the best interest of the GP budget and consortium business. The public will find “commercial in confidence” stamped over many of the most important decisions taken about our NHS services. Members of Parliament wanting to hold Ministers to account in future when hospitals go bust, there are no contracted services for constituents or there is a serious failure in the system will be told, “It’s nothing to do with me”.
Was the right hon. Gentleman perfectly happy about the situation under the last Government? When anyone complained in this Chamber about anything happening in their local health economy, they were told rather piously by a Minister that it was a matter for local decision making by a quango that was completely unelected and beyond their control. In what sense were the PCTs in any sense accountable?
Part of the problem is that there is so little detail in the White Paper that we simply cannot see how the bodies taking big decisions about taxpayers’ money will be accountable to the public. I lost count of the number of times during the last Government when Health Ministers came to this House and to Westminster Hall and had meetings with Members in order to respond to and sort out the problems that their constituents were experiencing with NHS services.
What the Secretary of State says he wants from the White Paper plan is to put patients first, to improve health care outcomes, to cut bureaucracy and to improve efficiency. These are “motherhood and apple pie” aims. We can support his aims, but we cannot support the action he is taking or the breakneck speed with which he is forcing these changes on the NHS. He wants shadow GP consortiums to be in place by April, and he will remove primary care trusts entirely two years after that. What he is doing is rushed and reckless. Almost every respondent to the White Paper has warned of the risks and said, “Slow down.”
Is my right hon. Friend aware that yesterday the Health Committee was told by health service organisations that some London PCTs would close by March 2011? Is anything happening in that regard? We know that there was a suggestion that PCTs would close in 2012, but we heard for the first time yesterday that they might close in 2011.
I am very concerned if those plans are being speeded up rather than slowed down, because that would be entirely contrary to the view that has been consistently expressed by patients groups, experts in the NHS and professional bodies in response to the consultation on the White Paper. “Too far, too fast,” says the King’s Fund. According to the NHS Confederation:
“It will be exceptionally difficult to deliver major structural change and make £20 billion of efficiency savings at the same time.”
The Alzheimer’s Society says:
“The pace of structural change has the potential to undermine the progress made in services for people with dementia and their families, unless handled carefully”.
Almost every other group representing patients says the same. Even the chief executive of the NHS has written to the Secretary of State saying:
“Implementing the White Paper will require us to strike the right balance between developing early momentum for change and allowing enough time to properly test the new arrangements. Getting this balance right will be critical to maintaining quality and safety”.
I know that the right hon. Gentleman does not have a policy of his own, but the motion seems to be saying, “It’s all become a bit difficult, so let’s just put it off.” Until when exactly does he propose to put these changes off? Will they be made in the current Parliament, in the next Parliament, or 10 years down the line?
The hon. Gentleman is new to the House, but he and his party are in government now. One of the frustrations for me and for other Labour Members is that his party is making the decisions, and is responsible for the future of the health service. Our plans would be different, but this is what the Government are planning.
The Secretary of State has received the responses that I have quoted. He has been advised to listen, to slow down, and not to risk the future of the NHS in his consultation. However, he is not listening. I hope that the Prime Minister is listening, for the sake of the NHS, its patients and staff, and for the sake of us all.
Here is a “thought for the day” for the Prime Minister. The Tories worked hard to be trusted by the public with the NHS before the election. The Government’s reckless big-bang reorganisation at a time of tough financial pressures in the NHS will wreck their reputation, but that is the Prime Minister’s problem. My problem is that he is set to wreck the great NHS gains made for patients over the last decade, and to wreck the founding principle of our NHS: that it should be available equally to all, free at the point of need, and properly funded through general taxation. We on the Labour side of the House will not allow him to do that.
I commend the motion to the House.
Order. Some 15 Members are seeking to participate in the debate. Mr Speaker has therefore decided that there will be a seven-minute time limit on speeches after the Secretary of State has spoken. I remind Members that they do not have to speak for as long as seven minutes; seven minutes is the maximum. If they bear that in mind and are considerate to other Members, it may be possible for everyone to contribute.
I will ask the House to reject the motion.
As I listened to the speech of the right hon. Member for Wentworth and Dearne (John Healey) I was very disappointed, because it seemed to be all about primary care trusts rather than about patients, all about managers rather than about doctors and nurses, and all about processes rather than about outcomes. It was completely the opposite of what the White Paper sets out to do, which is to give patients control of health care and allow more shared decision making for patients.
The White Paper is all about focusing on improving health care outcomes, and about empowering the doctors and nurses who work in the health service and recognising the contribution that they make. I am really disappointed that the Opposition motion does not recognise fully, as it should, the role that should be played by patients and staff in the NHS. I advise the right hon. Gentleman, when he tables motions such as this, always to think more about the staff of the NHS and the patients whom they look after, and less about the managers and the processes.
I will give way to the right hon. Gentleman if he wishes, but let me tell him this. Fighting a campaign called “Save the primary care trusts” will cut no ice with the people of this country. Fighting a campaign to save our NHS is what we did in the last Parliament; we did it successfully, and now that we are in government, saving the NHS is exactly what we are going to do.
If the Secretary of State—who, I concede, has a six-and-a-half-year head start on me in this job—really cared about NHS patients, really cared about NHS staff and really cared about NHS services, he would not be putting the NHS through the biggest reorganisation in its history, especially at this time. As I said earlier, it is patients groups and bodies representing NHS staff who are saying, “Slow down—think again.” I urge the Secretary of State to do that today, and to rethink.
The right hon. Gentleman has just taken to heart the old saying that the job of the Opposition is to oppose. That is all he is doing: he is simply opposing. Nothing in his motion states positively what should be done, whether that is supporting NHS staff or listening to patients and giving them the shared decision making opportunity that is so essential. While opposing the reforms that we in the coalition Government are introducing, he seems to have ignored the simple fact that those reforms, in truth, represent the coherent consistent working out, in practice, of policies that were initiated, but never properly implemented, by the Government of whom he was a member. They are not revolutionary, as he has called them.
As the right hon. Member for Wentworth and Dearne (John Healey) said earlier, the seventh point in the coalition agreement begins with the words:
“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 remainder of the PCT’s board will be appointed by the relevant local authority or authorities”.
Was the Secretary of State consulted before those words were included in the agreement? If he was, what changed his mind between the drawing up of the agreement and the White Paper?
The answer to the first question is yes. The answer to the second question is that we in the coalition Government collectively took the sensible view that form must follow function. If we arrived at a point at which people were being elected to primary care trusts which themselves no longer had a substantive role to play, because public health was rightly being transferred to local authorities—
We did know that at the time. [Interruption.] I will not engage in a conversation with the hon. Lady when she is intervening from a sedentary position. I am replying to my hon. Friend the Member for St Ives (Andrew George).
If we arrived at that point—a point at which GP-led commissioning consortiums were rightly leading on the commissioning of health care services—we would then find ourselves suggesting the election of people to a body that did not exercise any substantive responsibilities.
We therefore made a collective decision not to implement the policy in that way. The principle that we were pursuing was the strengthening of local democratic legitimacy in relation to health care—and, for that matter, social care—and that is exactly what we are going to do. We are going to do it through the health and well-being boards, and through the local authorities that are directly responsible for the provision of health improvement plans in their areas, engaging directly with local GP consortiums in the strategic commissioning functions and increasingly integrating health and social care.
Let me return to the point that I was making to the right hon. Member for Wentworth and Dearne. He ought to recognise, but does not seem to understand, that when I was announcing our intentions in 2006, the Government of whom he was a member were saying that these were the reforms that they wished to pursue. Tony Blair made a speech in June 2006 in which he said that NHS reform should be based on patient choice, independent sector providers, general practice-led commissioning and foundation trusts, yet the right hon. Gentleman’s motion today has left all that out. All those things that the Labour Government once supported, he, in opposition, now opposes.
The right hon. Gentleman’s motion is notable for what it has left out: it has left out the call for patient information and choice; it has left out any reference to the need for improving health outcomes; and it has left out a recognition, which the House should always reiterate, of the commitment of health and social care staff to the patients they care for. Particularly tellingly, it has also left out any indication of whether Labour supports or opposes our health service spending plans.
The right hon. Member for Leigh (Andy Burnham) has left the Chamber, but before the spending review he said to us, “Don’t protect the NHS budget; cut the NHS budget and transfer it to social care.” We did not do that; we did not do what the Labour party suggested. Instead, we have both protected the NHS budget and supported social care.
Before the election, the Labour Administration said, “Cut NHS capital budgets by 50%,” but the real-terms reduction in NHS capital budgets will be just 17%. They said, “Protect the primary care trust budgets but cut central budgets; cut research and development in the NHS; cut education and training,” but we are not doing that. We are protecting the resource funding for the NHS, and it will increase in real terms.
The Secretary of State talks about protecting social care, but he must be aware that at the same time cuts of 28% are being made to local council budgets, of which social services and social care account for the largest component. Even before the comprehensive spending review, six or seven councils were already saying their situation was moving from moderate to substantial, and for one council that has now risen from substantial to critical—and that is before the Government implement their cuts of 28%. There is no such protection in place, therefore. Instead, this radical NHS reorganisation is happening at the same time as those huge council budget cuts, and next year will be terrible. My right hon. Friend the Member for Leigh (Andy Burnham) was right to protect social care, as well as in the other things that he did with the NHS.
The hon. Lady is simply completely wrong. Local government budgets are not being cut by the figure she cites. The formula grant from central Government is having to be cut because of the debt we inherited from Labour, although she, like the rest of her party, is in denial about that, but that does not mean a cut—
No; I am addressing the point that the hon. Lady made. That cut in formula grant does not mean a corresponding cut in council tax, so that revenue is available to local authorities. In addition, the NHS is going to support social care activity in the ways I have described, such as through telehealth, re-ablement and equipment adaptations. We are transferring the learning disability transfer grant and other adult social care grants collectively representing £2.7 billion a year from the NHS to local authority funding, without reductions in those grants. I am afraid the hon. Lady is just simply wrong, therefore.
I congratulate my right hon. Friend on his determination to improve our national health service, and on the initiatives that he is proposing. However, does he agree that in enabling the NHS and social care services to work more closely together, it is vital to have integrated cost-effective services, and make sure that the patients get the best out of the system?
My hon. Friend is absolutely right. The Minister of State, Department of Health, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), and I are very impressed that the local NHS and local authorities are, sometimes for the first time, sitting down together and discussing how they can use their resources. Even this year we managed to save £70 million from the budget that we inherited from the Labour party. That money can be invested in re-ablement, and in bringing local authorities and the NHS together to improve the service to people who are going home.
I want to make a little progress first.
The Opposition motion reveals that they have no alternative vision. The Labour party today is empty of ideas, confused and incoherent. It did not have anything to offer the country at the general election, and it has nothing to offer today. I will deal with each of the points made by the right hon. Member for Wentworth and Dearne, but first I want to say something about what we are doing through the White Paper, and why we are doing it.
We should be proud of the fundamental values of the NHS: that it is free at the point of use, and that it is based on need and not on the ability to pay. Nothing that we do will ever undermine those principles; that is the coalition Government’s commitment. However, our pride in these values is no excuse for complacency. The demands facing the NHS over the coming decades are many: an increasing and ageing population; continued advances in medicine and technology; and rising expectations on the part of patients and the public. That is why, as we maintain equity in access to services, we will also pursue excellence in health care. We will do so because despite the great improvements in the NHS in the past—such as in cardiac surgery and cardiology, and, more recently, in stroke care and many cancer services—we have much more still to do.
Outcomes for patients in this country are too often poor in comparison with outcomes in other countries: someone in this country is twice as likely to die from a heart attack as someone in France; survival rates for cervical, colorectal and breast cancers in this country are among the worst in the OECD; and premature mortality rates from respiratory disease are worse than the EU-15 average. Simply putting more money into the system has not worked, which is why reform is needed.
I am grateful to the Secretary of State for giving way. He has argued the need for greater localism and for local health services to be more accountable to local people. However, pulmonary hypertension is one condition in which significant advances have been made in recent years. It affects a number of my constituents but it is a rare condition, and has to be managed not locally but on a country-wide—indeed, often a Wales and England and Scotland-wide—basis. How can the Secretary of State make sure that, with the pressure towards local services, proper account is also taken of conditions on which action can be delivered only on a national basis?
For England, the White Paper sets out very clearly that specialised commissioning, whether currently regional or national, will be undertaken through the NHS commissioning board, rather than by individual commissioning consortiums.
The point about the reform process is that if we change nothing, nothing will change. The Labour party is the party of no change: it is the party of stasis, inertia and inactivity. Labour says, “Do nothing, put the reforms on hold”—whatever that means. Our aim is a simple one. We cannot stand still. If we carry on as we are, resources will, as over the last decade, be consumed without delivering the improved outcomes for patients that are so essential. Delivering improved outcomes for patients is our objective, and the White Paper gives us a clear and consistent vision for achieving that, based on three guiding principles.
The Secretary of State was discussing the disappointing cancer survival rates. A National Cancer Intelligence Network survey was conducted earlier this week, and I was shocked to learn that it found that one in four cancers were diagnosed only when a patient was rushed to hospital experiencing symptoms. Does the Secretary of State think ring-fencing the public health budget and co-ordinating it better with local authorities will enable us to make a swifter impact in respect of the preventive aspects of cancer management, in order to reduce that figure?
Yes, I feel that it should. When the NHS last came under financial pressure in 2005-06, public health budgets were cut and public health staff were lost, but we are determined to address the worrying situation that my hon. Friend described. That is why we are committed to the implementation of a cancer signs and symptoms campaign. It will be launched in the new year, and its purpose is precisely to ensure that we tackle the lack of awareness of cancer symptoms, so that people will present to their GP earlier and we can bring them to diagnosis sooner.
The right hon. Gentleman said that he wanted to improve treatment. How does he think the treatment of sick children at Great Ormond Street hospital will be improved if it has to do without the £16 million that his Government are currently threatening to take away?
I explained to the right hon. Gentleman at Health questions just a fortnight ago that we are in discussions with the specialist children’s hospitals. They are very clear that they are engaging constructively with the Department, with the intention that the payments through the tariff should accurately reflect the costs incurred in providing specialist services. That is the current situation, and no decision has yet been made.
I was talking about the principles of the White Paper.
In a moment; the right hon. Gentleman must allow me to make some progress.
I was talking about the principles of the White Paper. They are very clear. First, patients should be at the heart of the new national service, with a simple principle of “No decision about me without me” transforming the relationship between citizen and service.
Secondly, we will focus on outcomes, not processes. We will focus on outcomes that capture the entirety of patient care, and quality standards and indicators that genuinely reflect what a high-quality service should actually deliver. We will orientate the NHS towards focusing on what really matters to patients, not narrow processes. Thirdly, we will empower clinicians, freeing them from bureaucracy and centralised top-down controls, so that change is genuinely driven from the grass roots, rather than driven, top-down, from above.
The right hon. Gentleman’s speech did not appear to recognise that central principle at all when he talked about people in the NHS Confederation and the managers who run the NHS. Clinicians are already the people who actually do the commissioning: general practitioners make the referrals and write the prescriptions, and consultants in hospitals make referrals from one consultant to another. In effect, cost and commissioning in the NHS is already controlled by clinicians, but they are divorced from the processes of combining the management of patient care with the management of resources. Whether in this country or in others around the world, it is perfectly clear that that divide is what breaks health care systems. What makes health care systems more effective is bringing together the management of patient care with the management of commissioning and resources on behalf of patients.
I wanted to intervene to discuss what my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) said about Great Ormond Street hospital. I have the official record of what was said at Health questions, to which the Secretary of State referred. He said that the proposal would have
“the overall effect of reducing Great Ormond Street’s total income by less than 2%.”—[Official Report, 2 November 2010; Vol. 517, c. 754.]
How does he reconcile that with the trust’s figures, which say that the reduction will not be less than 2%, but will be more than 5.5%? Would he like, therefore, to correct the official record now? Will he also publish the figures so that this House and Members who represent these areas can make up their own minds about whether those big stealth cuts to the hospitals that treat many of our most critically ill kids are a good idea?
No, I will not do those things, because what I said was accurate. The specialist children’s hospitals and ourselves are engaged in a constructive process of discussion about the future of the tariff for those hospitals and the top-up. Until a proposal is made there is no purpose in informing the House. We will inform the House as soon as we are in a position to say what the tariff for next year looks like.
I totally commend the Government for their focus on cancer reform and improving outcomes. I accept that this is in the melting pot at the moment, but does my right hon. Friend agree that it is important that the one-year and five-year cancer survival rate figures are presented not as a league table but as a performance table, to ensure that all primary care trusts and GP consortiums are tasked with improving performance, irrespective of how they compare with others?
Yes, my hon. Friend makes a good point. What we are looking for is not a league table at all, as health care should not be regarded in that way; we are looking for proper benchmarking to take place. We are going to benchmark this country’s performance against that of the best health care systems around the world—the Labour party never did that—and we are going to ensure that there is a culture of continuous improvement in the NHS in respect of both the one-year and the five-year cancer survival rates, which my hon. Friend rightly mentioned.
The reforms that I was talking about are not a radical departure from the past. The principles of the White Paper should be what the NHS has always been about, but it has been distracted too often by the bureaucratic processes that the Labour party was always supporting. Let me make it clear that many of the things that we are doing were championed by former Labour Ministers. When John Reid was Health Secretary he championed patient choice, and we know why. His view was, rightly, that in the NHS, in a bureaucratic system, the articulate middle classes get access to the best health care, and it is only through institutionalising and embedding patient choice—shared decision making for every patient—that we will ensure that the most disadvantaged in society get the right access to health care.
As for GP-led commissioning, the Labour party was supposed to have introduced practice-based commissioning.
Not only is it my choice, but it is a necessity. As you said earlier, Madam Deputy Speaker, 15 Members wish to speak in the debate, and they will be allowed only seven minutes. I shall therefore take less time than the shadow Secretary of State did.
The Labour Administration pursued practice-based commissioning. Labour Members now make up numbers about how many GP-led commissioning consortiums there will be, but under practice-based commissioning there are 909 practice-based commissioning consortiums. The Labour Government did not give them any power, but they established them and they all have costs associated with them; there are 152 primary care trusts. Bureaucracy and cost in the system is legion, and we have to take it out; we have to reduce the number of people.
Under the Labour Administration the number of managers and senior managers in the NHS doubled. Where was the corresponding improvement in outcomes? The number of nurses increased by only 27%. That shows the kind of distorted priorities that were at the heart of the previous Government. They said that all NHS trusts should be foundation trusts by December 2008, but they simply did not bring that about; we are going to make it happen. They set up the idea of a right to request for staff in PCTs in provider services to become social enterprises, but we are the ones who are now bringing that about. Yesterday, I was able to announce 32 more social enterprises in the NHS, where staff are taking responsibility and ownership of the service that they provide, representing 15,000 additional staff and more than £500 million of revenue. If the Labour party is now against all the reforms that used to be part of the process of delivering greater empowerment of staff and patients in the NHS, what is it in favour of? I simply cannot find out the answer to that question any more.
What does represent a radical departure from the past is the fact that we are pressing ahead with the reforms with purpose and pace. I make no apology for the fact that we are going to achieve the changes required in the NHS more rapidly than anything that the Labour party did in the past—because not to do so would prejudice the opportunity to deliver resources to the front line, choice for patients and clinical responsibility for leaders across the NHS.
On at least two occasions in the House since the general election, the right hon. Gentleman has cited the Health Committee report on commissioning that was published in March, and used my name, as that Committee’s then Chair, to suggest that the report supports his changes in commissioning in the White Paper. Will he confirm that it does not do that? Where is the evidence that the change in commissioning will save any money?
What is very clear from the Health Committee’s report before the election is that, as the right hon. Gentleman knows, it criticised in strong terms the weaknesses of PCT commissioning, and that position has only been reinforced since then. One such example is out-of-hours services, for which PCTs were supposed to be the commissioners but did not properly scrutinise the services being tendered, and did not monitor the contracts or the quality of the contracts. PCTs have too often been responsible for simple cost and volume commissioning. What we are concerned with, because we shall engage clinical leadership in the commissioning of services through the NHS, is being engaged in commissioning for quality. Patients will be able to exercise choice based on real information that tells them about the quality of the services being provided, not the cost and volume—
I have already given way to the right hon. Gentleman, and I am now going to conclude rapidly.
Contrary to what the right hon. Member for Wentworth and Dearne said, we have heard organisations from right across the NHS supporting the principles of the White Paper. The British Medical Association says that it
“strongly supports greater clinical involvement in the design and management”
of the health service.
The Royal College of Nursing said:
“The principles on which the proposed reforms are based—placing patients at the heart of the NHS, focusing on clinical outcomes and empowering health professionals—are both welcome and supported by the RCN.”
The King’s Fund said that it
“strongly supports the aims of the White Paper”.
The National Association of Primary Care described the White Paper as
“a unique opportunity to raise the bar in the commissioning and delivery of care for patients.”
The chairman of the NHS Alliance said that it provides
“a unique opportunity for frontline GPs... to make a real difference to the health of their patients”
The Foundation Trust Network said:
“the vision for the NHS articulated in the White Paper is the right one—putting patients and carers at the centre”.
The right hon. Member for Wentworth and Dearne made a number of specific points. He said that the reforms were an ideological gamble. Well, if they are, they are based on an ideology once shared by the Labour party; and if there is an ideology, it is the belief that patients and clinicians in the health service know best. That is not a gamble at all; it is a certainty.
The right hon. Gentleman talked about reorganisation, but he did not say that the number of managers in primary care trusts rose all the way through to last year in the face of the impending crisis in finances over which the Labour Government presided. He did not tell us that last year primary care trusts spent £261 million on consultancy—an 80% increase in such expenditure in two years.
The right hon. Gentleman gave us the benefit of some of his figures—some of his dodgy numbers—so let me give him a real number. Our decisions to cut the cost of management and administration in the NHS will release £1.9 billion of savings a year by 2014-15. That money will be reinvested directly to support front-line care, so there will be not only a real increase in the resources available to the NHS, but a real change and increase in the resources that get to the front line, because we are cutting the costs of administration and back offices.
Let me make this clear—
Against all the advice from the Opposition, we protected the NHS budget in the spending review. It was a brave decision for a Government to take in such circumstances, but it underlined our commitment as a coalition to the NHS. It was a decision that went contrary to the advice and recommendations of the Opposition. For the right hon. Member for Wentworth and Dearne to try to attack the Government over “cuts”—he used that word—in the present circumstances is pure opportunism.
The right hon. Gentleman will not say whether he backs our NHS budget. He talked about what the shadow Chancellor is supposed to have said, but it was the shadow Chancellor who specifically said that he did not support our proposals to increase the NHS budget. Does the right hon. Member for Wentworth and Dearne support our cancer drugs fund or not? He did not say. Does he back our integration of health and social care and the resources that we will use through the NHS to support social care and local authorities? He has not said.
The right hon. Gentleman has not said whether the Opposition oppose or support our commitment to the NHS. How could he? The Leader of the Opposition said before the spending review that he would publish his alternative proposals, but he never did so. The Opposition were promised it, but it did not happen. Without a plan for the economy and for public services, the right hon. Member for Wentworth and Dearne can say nothing about the NHS.
Our commitment to the NHS is clear. We have made tough choices on public spending so that we can protect the NHS and ensure that the sick do not pay for Labour’s debt crisis—
I gave way to the right hon. Gentleman before.
The big gamble is not pressing ahead with reform; the gamble now would be to carry on as the last Government did, failing to implement the reforms that are necessary and desirable—and supported—across the service. The spending review and the White Paper give the health service a clear, practical, evidence-based framework for sustained improvement in the future. We will not go back to the days of top-down Whitehall micromanagement and bureaucracy. We will free the NHS to improve outcomes for all patients and to meet our vision of ensuring that health outcomes for the people of this country are among the best in the world. I urge the House to reject the Labour party’s motion.
I want to focus on one specific part of the Government’s plans, which has already been mentioned by a couple of my hon. Friends and by the former Secretary of State for Health, my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson). It is the funding of our children’s hospitals.
I am fortunate enough to have at the heart of my constituency Sheffield children’s hospital, which is a centre of excellence for the region and for the country. It offers pioneering services in trauma and orthopaedics, it is a regional centre for the whole of the north of England for burns injuries and the principal treatment centre for South Yorkshire for childhood cancers, and its metabolic bone service is accessed from across the UK. It does a superb job treating some of our most critically ill children and I want to use one example to bring to light the importance of its work.
A young girl was left unconscious on the streets of Derbyshire with devastating brain injuries after being hit by a car. She was 13 years old. She was transferred to the hospital’s intensive care unit, where a scan revealed the full extent of her head injuries. She was seen to have diffuse axonal injury, one of the most devastating types of traumatic brain injury and, as the Secretary of State will know, a major cause of long-term unconsciousness. She was moved to the children’s hospital’s neurosciences unit, which has specialist equipment to support her rehabilitation and expert consultant neurosurgeons—these are crucial points. Her mother said:
“The doctors and nurses were wonderful and really did go above the call of duty to provide the very best care and treatment. The ward manager was like a second mum to her. The team cared for her like a member of their own family. She is now back at home, relearning simple things such as walking and talking. There is a long road ahead, but if it was not for the Children’s Hospital she wouldn’t be here.”
Such cases involve staff from many disciplines and services to ensure that the patient makes the best recovery possible. Neurosciences are one of the trust’s flagship services, treating children who have suffered brain injuries or who have other brain conditions, spinal cord conditions, diseases such as meningitis or conditions such as epilepsy. The intensive care unit is part of the hospital’s state-of-the-art critical care facility for children and is situated alongside high-dependency and neonatal surgical units, meaning that all the critical care services are in close proximity.
Such services come at a cost, however, and I have always understood that that is why we have had a top-up tariff to pay for the extra staff and the additional support needed to provide that specialist care to very young patients. We now understand that the Government plan—they might be in discussions, but we understand that this is the plan—to cut the tariff to less than a third of its current value.
I certainly would. To cut the tariff from 78 to 25% is the most outrageous proposal on health care to have come from this Government.
When questioned on this issue—this is extraordinary—a spokeswoman from the Department of Health said, very casually,
“less than 10 hospitals are likely to be affected significantly by these changes and the tariff is not their only source of income.”
We are talking about 10 of the leading hospitals that care for our children. Let us be clear: the Sheffield Children’s NHS Foundation Trust has estimated that the change could cut its budget by as much as £4.9 million. That is a reduction of almost 10% in its total funding. It has said that that
“would have a serious impact on the hospital finances and ability to deliver some services.”
I am very pleased that the hon. Gentleman has an excellent hospital in his constituency. Will he advise me why the Labour party set in train the closure of Burnley’s children’s ward when it was in power, leaving an area of Burnley, Pendle and Rossendale and more than 250,000 people without a children’s ward, never mind a children’s hospital?
I can certainly talk at length about the enormous investment that we made in our hospitals and health services and about the tremendous difference that that made to patients and to reducing the waiting lists that we inherited in 1997. However, I want to make the point about the impact on Sheffield children’s hospital. As the hospital said, the change will have a serious impact on its ability to deliver services that provide critical interventions for those whom we should be protecting most—our children. If the Government are prepared to attack these budgets in such a way, what will the commitment to guarantee health spending increases in real terms in each year of this Parliament be other than another broken promise?
In the brief time available, I do not want to follow the hon. Member for Sheffield Central (Paul Blomfield) in a detailed discussion of children’s hospitals, but I congratulate him on the first part of his speech, because he reminded us of what we are here to talk about—the delivery of high-quality care to patients, often in circumstances of extreme distress to them and their families.
I welcome the fact that the debate is taking place, but it is important for us not to imply that there is a choice to be made by politicians in 2010 about whether the health service faces the need for fundamental reform. The truth is that the health service, by which I mean the pattern of delivery of health care to patients, needs fundamental reform, as has been acknowledged since at least 2009. The shadow Secretary of State was good enough to confirm in his contribution that he recognises the need for that fundamental reform, which was set out by Sir David Nicholson in the £15 billion to £20 billion efficiency challenge. The purpose of the Nicholson challenge is to reconcile continuing rises in demand for health care, which we must assume will continue their long-term trends, with the inevitable fact that health budgets are more constrained, and will be more constrained in the years ahead, than during the period of the Labour Government. That was recognised before the general election, which is why the Nicholson challenge was articulated.
But does the right hon. Gentleman agree that instead of taking such a big gamble with the NHS at this stage, it would be better to pilot some of the initiatives and changes to see whether they actually deliver better health outcomes?
I shall come to the White Paper later, but I want to focus on what I regard as the key, unavoidable reforms that have to be delivered during this Parliament. I do not think the hon. Lady will find them controversial. They are the continued development of improvements in the delivery of primary care; the priority need to address unnecessary admissions to hospital, which have been identified by the National Audit Office as running at 30% of non-emergency hospital admissions; the need to address the requirement the health service faces to use its most expensive resource, clinicians’ time, more effectively; the need to improve links between social care and health-care, because if they do not work effectively there is no way we can deliver the aspirations we all share for high quality care delivered by the national health service; and the need to deliver better patient, user and local community involvement in the design and delivery of health care.
All those things are the challenges the health service faces over the lifetime of this Parliament. They are not a matter of political choice; they were articulated by Sir David Nicholson during the previous Government. They were endorsed by the previous Secretary of State and this afternoon they have been endorsed again by the shadow Secretary of State. It is simplest to summarise them by describing them in total as the need to deliver a 4% efficiency gain through the entire national health service system for four years running.
A few weeks ago, when Sir David Nicholson was before the Health Committee, which I have the privilege to chair, we asked him to set that challenge in context and he described it—as the shadow Secretary of State was right to say—as the most substantial challenge not just anywhere in the public service, but anywhere in the economy. The challenge has no precedent in any advanced health care system in the world. The challenge is huge: a 4% efficiency gain throughout the NHS, four years running. We are looking to deliver a wholly unprecedented efficiency gain. Against that background, what is the importance of the White Paper?
I ask the House to consider for a moment the counterfactual. Is it possible to deliver that kind of efficiency gain in the health service without effective empowered commissioning driving change? If effective empowered commissioners will not do it, who on earth will? Secondly, is it possible to imagine effective empowered commissioning that does not engage the clinical community in the process more effectively than we have yet done?
If there is a requirement for more clinical involvement—for GPs to be more involved in commissioning—why do the Government not simply put GPs on the boards of primary care trusts? That would be a simpler, easier solution and would not cost as much. Is it not the case that the Government would rather open up commissioning to the private sector? Is that not the reality of their proposals?
I cannot summarise the Government’s proposals in the White Paper in three minutes, but one of their key drivers is to deliver far greater clinical engagement in the commissioning process than was achieved in the lifetime of the previous Government, in my time as Secretary of State or at any time in the 20-year history of health service commissioning. We want to achieve a step change in the engagement of the clinical community in the commissioning process. As long as commissioning is something that is done to clinicians by managers, it will fail. It has to engage the clinical community on both sides of the argument. That, as I understand the Secretary of State’s White Paper, is one of his core objectives, and if it is, it has my full-hearted support.
In advancing that idea, does the right hon. Gentleman accept that the power to commission is being given to clinicians only in primary care, and that clinicians who work in a hospital setting are not being empowered or involved in the commissioning process at all?
The hon. Gentleman is a fellow member of the Select Committee and I know from our discussions that the principle of clinical engagement in commissioning is broadly supported in the Committee. It is fair to say that none of us would support the view—I suspect the Secretary of State would not either—that clinical engagement means only GP engagement. We should see the GP as the catalyst for broader clinical engagement in the commissioning process if we are to deliver our objectives.
To deliver the Nicholson challenge, we must have strong commissioning, with clinical engagement, and we have to remove unnecessary processes that do not add value. We cannot afford to waste money on them. We must have greater local accountability for the commissioning process in order to embrace public support for change on this unprecedented scale.
I have only 40 seconds left for my speech, so if my hon. Friend will forgive me I should like to conclude.
My key message is that as we look at the lifetime of this Parliament, I do not see the White Paper as the linchpin of reform, but as a key tool in the delivery of the reforms that are neatly encapsulated in what I have described as the Nicholson challenge.
I often comment that when I became an MP I did not get two items that would have made life so much easier—tarot cards and a crystal ball. In considering the coalition Government’s health policy, they would be essential tools for the job, because before the general election, the statements of the Leader of the Opposition—now the Prime Minister—gave us the impression of a future for the NHS that was completely different from the one we now face. He said:
“We are the only party committed to protecting NHS spending…I’ll cut the deficit, not the NHS.”
He spoke about a period of organisational stability in the NHS. Those were broken promise No. 1 and broken promise No. 2. Instead, we are faced with a vision from the Secretary of State which could set us back 20 years. I say so not as political rhetoric, but from 30 years’ direct involvement in the NHS, including 10 years as chair of a hospital.
The press seems to share that pessimistic view—“extraordinary gamble,” “cocktail of instability,” “accident waiting to happen”—hardly a ringing endorsement of the Government’s health policy. For me, it is a recipe for disaster: one part reduced financial resources, two parts structural reform and three parts break-neck speed—
Absolutely. I am sure the Secretary of State will give due cognisance to the comments being made, especially about putting resources right there on the front line, delivering for the very people who are paying the wages.
In his evidence to the Select Committee on 20 July, the Health Secretary set out five aims of the White Paper, and he went through them here today. I shall review some of those in the light of the dribbles of information that we have received, and see how they stand up. The first aim was creating a patient-led NHS. Let us start with the Secretary of State’s glib catch-phrase, “No decision about me without me”—
Does the hon. Lady agree that when it comes to prevention and early diagnosis of diseases, the GP and what happens at the clinic and the surgery is critical? Money can be saved in the long term. Perhaps that is what the Government should be doing—making sure that money is there on the front line, in the GP surgeries and in the clinics.
Nobody could disagree with that.
The NHS will be one where the area and street where people live will determine whether they have access to certain drug treatment, because of the weakening of NICE and a shift back to value-based pricing, placing drug companies back in control, and a return to postcode prescribing—an NHS where people may or may not get certain operations. Already in my area, across Lancashire, primary care trusts are reviewing funding for 70 procedures, so if patients require an endoscopic procedure for their knee or back, or a hysterectomy, those may no longer be available.
How far people travel to their hospital depends on whether they have a hospital close by that offers the treatment that they need. On 26 October at the Select Committee, various witnesses gave evidence that hospital closures will be necessary to release moneys back into the wider health service. How many patients would agree that such a state of affairs is part of a patient-led NHS? Not many, I bet.
Improving health care outcomes was the Secretary of State’s second aim. It seems highly unlikely, given that the ability to deliver improved outcomes is reliant on front-line services and the availability of the staff to deliver them. The Royal College of Nursing expects to lose 27,000 front-line jobs. That is the equivalent of losing nine Alder Hey children’s hospitals. The work of the RCN suggests that under the guise of 45% management cuts, the NHS will lose health care assistants, nurses and medical staff—front-line cuts by stealth.
All this must be set in the context of what was said to be the lowest financial settlement since the 1950s, reputed to be 0.1%—as we heard today, that is already disputed—together with massive pressure on NHS budgets from increased VAT costs—[Interruption.]—redundancy payments, budget short-falls and hospitals having tariffs frozen—[Interruption.]
It would help if I could hear the right hon. Gentleman, but never mind.
The difficulties are topped up with increasing demand for services, an ageing population, an increase in the number of people with complex illnesses and the rising cost of treatment. That is all very worrying.
At the Select Committee the Secretary of State spoke about increasing autonomy and accountability in the NHS. I have raised that with him on a number of occasions and I tried to intervene today. It is a further example of the two health policies of the Administration, one mythological and the other the reality. Perpetuating the myth, the Secretary of State said at the Select Committee that
“the conclusion that we reached was that we could achieve democratic accountability more effectively by creating a stronger strategic relationship between the general practice-led consortia and the local authority.”
We might imagine that that meant patients and elected representatives at the heart of decision-making, and that the consortiums would operate with councillors on the board, who would be able to vote, but no. Scrutiny will come from well-being boards, which means that patients and councillors will not be there offering their opinions and able to vote. Well-being boards, like the current NHS overview and scrutiny arrangements, may as well not exist because they will be nothing more than a focus group.
I said at the Select Committee that those arrangements were nothing short of throwing snowballs at a moving truck—they would make little or no difference. The Government are giving a budget of more than £80 billion to GPs who just want to practise medicine and not get involved in the experiment.
We need to get more GPs to do that, and I think that is what the Secretary of State is trying to say.
The Government plan no testing or pilots, just a big bang, using consortiums as a shield to deflect criticism from them, rather as they currently use the Liberal Democrats.
The fourth aim was promoting public health. Everybody agrees that prevention is key to easing the cost burdens further down the health pathway, so if we were serious, we would be doing more about promoting public health. Simply allocating 4% of the NHS budget and giving it to cash-strapped local authorities does not seem the best and most effective way of promoting public health. We await more detail, although that might be as difficult to follow as the Department of Health’s £1 billion allocation to social care.
That brings me to the fifth aim of the White Paper. Following the publication yesterday of “A Vision for Adult Social Care” by the Department, the foreword gives us a sense of where we are heading with the Government’s policy. Under the third value, responsibility, it states:
“Social care is not solely the responsibility of the state. Communities and wider civil society must be set free to run innovative local schemes and build local networks of support.”
I wonder whether that is code for “We’ve got no real money to invest. Local authorities are not going to be able to meet the demand. Oh well, you’d better get on with it yourself.”
It is no use the document quoting Frederick Seebohm from 1968, as that might not reflect the world of today. As an ideal, it is great, but not every family and every individual can offer the help and support that are required. There are incredible strains on hard-working families and individuals trying to make ends meet while struggling to provide care for ill and elderly relatives—
I support the Opposition’s motion in one respect: their call on the Secretary of State
“to listen to the warnings from patients’ groups, health professionals and NHS experts”.
I want to address particularly the issues affecting those in integrated health care. I speak as the chair of the integrated health care group—the old complementary medicine group—and as someone who has the honour of serving under my right hon. Friend the Member for Charnwood (Mr Dorrell) on the Health Committee. I wish to look at the regulation of herbal medicine, the possibility of complementary medicine leading to cost reductions in the health service and the choice of services.
As my right hon. Friend the Secretary of State knows, we will have a problem next year with the implementation of the traditional herbal medicines directive, about which many colleagues have been approached by constituents. From April, practitioners will no longer be regulated under section 68 of the Health Act 2009, so my first plea to my right hon. Friend is to come up with a solution to this problem ahead of time—ahead of Christmas, I hope. Otherwise, from April, practitioners will be unable to prescribe the herbs they have been prescribing under the section 68 derogation. The best course of action is the Health Professions Council, because that is the only body—
Order. I should remind the hon. Gentleman that we are not discussing the directive, amendments to the directive or herbal medicine. We are discussing the reorganisation of the health service, to which he needs to direct his points to make them relevant to the motion.
Thank you, Madam Deputy Speaker. What I am talking about is relevant to cost savings, choice and the use of existing practitioners. I hope that my right hon. Friend will deal with that issue; otherwise it will cause him major problems next year. I will now move on.
The other, related problem is that, under this arrangement, unless my right hon. Friend acts, we will lose many available products from the shelves, which will affect health service costs and what practitioners can do. Yesterday, I went to Brussels to discuss the issue as it affects health service, which we are discussing, and related cost savings. I spoke to Elena Antonescu, a Member of the European Parliament, who advised me that if the health service is to continue with traditional Chinese and Ayurvedic medicines, the Secretary of State will have to lobby Members of the European Parliament to go to the Commission to produce a report that they first proposed in 2008.
I am most grateful to you, Madam Deputy Speaker, for your help. I have made my point about Europe having to be involved.
I also want to comment on the points made by my hon. Friend the Member for Basildon and Billericay (Mr Baron) and others about cancer care. Cancer patients can be much helped by integrated health care practitioners. I could cite many different hospitals, but I shall mention just one—Royal Surrey County hospital, which is a national health care award-winning hospital. It includes St Luke’s cancer centre, which offers a wide range of complementary therapies in support of the health service. I want to see such choice widened. If herbal and nutritional medicines are used, that will reduce the costs of the health service referred to in the motion. Many institutions abroad, such as Australia’s National Institute of Complementary Medicine, have shown Governments the way and enabled them to restructure services and provide cost savings.
With those remarks, I very much hope that my right hon. Friend the Secretary of State looks with care at what I have said about these benefits.
I am delighted to have an opportunity to say a few words in this debate.
Labour’s investment in health care over the past 13 years has produced huge strides. When we think about the position in 1997, with long waiting lists and hospitals in desperate need of refurbishment, we realise that we have come a very long way. I am disappointed that the new coalition Government, instead of deciding to build on the very successful investment over the past 13 years, are now engaged in an ideological approach to the NHS to bring in the private sector and to destroy a lot of the very good work that has been done.
I pay tribute to all NHS staff, clinical, non-clinical and administrative, who do their best and work very hard for patients. One of the most upsetting things I have heard since May is Government Front Benchers’ denigration of our NHS managers and administrators. That is very wrong.
My main starting point is to look at whether the coalition’s proposals will improve the health of my constituents in Hull. I do not think they will. I am absolutely appalled that the Government are to spend £3 billion on reorganisation when there is such a tight financial settlement for the NHS. Their focus should be on ensuring that patient care is maintained over the next few years, not on reorganisation.
Hull has a very good primary care trust. I pay tribute to the excellent and innovative work of Chris Long, the chief executive, and of Wendy Richardson, the jointly appointed director of public health with the local authority. As a spearhead PCT, Hull received additional money under the previous Government. It introduced projects such as the health trainers who have done so much in working with communities that have high levels of health inequality, for which different ways of working must be adopted. It has also done work on domestic violence and worked with its perpetrators.
The reason I am such a fan of Hull PCT is that, unfortunately, we have a Liberal Democrat-controlled council that does not seem to have any focus on its responsibilities for public health. The previous Labour council introduced free healthy school meals in all the city’s primary and special schools, rather than wait for an evaluation after three years of the pilot project, but the Lib Dems came in and scrapped it. The project was trying to do something about the high levels of obesity and poor performance in schools—to get to our youngsters early to ensure that they eat well. When that Lib Dem council is given the agenda for public health, I do not have much faith in it taking it seriously.
Hon. Members will recall the introduction of the free swimming initiative in the previous Parliament, which got our young people active through swimming and engaged our councils. Of course, Lib Dem-controlled Hull city council said, no, it was not going to get involved, and at the same time it put up the costs to our youngsters of attending sports clubs in the city. I am therefore very sceptical about the proposed public health agenda being taken on by Lib Dem local authorities.
My hon. Friend will know about the health needs in Newham, where the incidence of TB is rising and the rate of HIV is very high. The people who have helped me and my constituents most in managing these health needs have been the people at the PCT, who have been very responsive to my requests and requirements. Has she found the same in Hull?
Absolutely. Although not all PCTs have operated as we would like, there is good practice throughout the country. We should focus on that and see what we can learn.
I am concerned about the coalition Government’s approach to public health, because the junk food industry seems to be helping them to make policy, as some of our national media have reported in the past few days.
Absolutely. My hon. Friend campaigned long and hard for families, especially low-income families, in a previous occupation. The health in pregnancy grant is going and the Sure Start grant will now be paid only for the first pregnancy, so we are starting to see what the Government really think about improving people’s health, especially that of women.
Of course, we must not forget that during the election campaign in May the Liberal Democrats made it very clear that they thought NHS funding should not be ring-fenced. The right hon. Member for Twickenham (Vince Cable) said that the NHS should not be treated as a sacred cow. Again, we see the Liberal Democrats being the more regressive part of the coalition.
I wish now to concentrate on GP commissioning, because there are major issues on which we need to focus. Many specialist groups, particularly the muscular dystrophy group in Yorkshire, have been in touch with me to say that they are concerned that local GPs will not understand their health needs. I have talked to patients in the local hospital and other people receiving health care locally, who are anxious about their particular needs being met.
For me, a bigger issue is the performance of GPs. PCTs have been particularly successful in holding to account GPs who do not perform as well as they should, and I am particularly concerned about who is going to hold the ring. Who will deal with GPs who do not meet the needs of their communities?
A number of hon. Members have mentioned the bureaucracy in the new system of GP consortiums. I believe that there will be more administrators, and I say to the Secretary of State that, if we are to focus on health outcomes, bureaucrats will be needed to put together information and statistics and we will not, therefore, see the massive reduction in backroom staff that the Secretary of State expects.
A lack of accountability at local and national level is a major problem. The new national board—the largest quango that we have ever seen—is being created, but to whom will it be accountable? It is not acceptable for the Secretary of State and his Ministers to come to the House and say, “That is for the national board”, or “That is for local decision making.” We need control over what happens to our NHS. As I asked in my intervention on the right hon. Member for Charnwood (Mr Dorrell), why cannot we have some pilot projects? If the change is to be so great, let us pilot it, see what happens and take a considered approach. Let us have some evidence to back up the White Paper.
I do not believe that any of the Government’s proposals will improve the health care of the people I represent. Of course we believe that clinical involvement is important, and of course doctors and other health care professionals should be involved. My hon. Friend the Member for Rochdale (Simon Danczuk) made the point that we should use the PCT structure to provide more clinical information and advice—we can have that involvement without throwing out the whole structure.
The Government must also consider other health care professionals, such as pharmacists. There are pharmacists on the high street in my constituency who really contribute to the health care of my constituents. People such as Mr Hall on Beverley road and Cath Boury on Newland avenue do face-to-face work to encourage people to give up smoking or reduce their weight. If we want to get clinicians involved, let us get all the clinical practitioners involved.
I finish with the “any willing provider” model in the White Paper. The Labour Government made it clear that the NHS was the provider of choice. That was exactly the right thing to do, because it recognised the important role the NHS has played over the past 60 years. It has staff with specialism and dedication, but the idea of “any willing provider” is just code for the private sector, is it not? The attitude is, “Let’s just roll it out and have the private sector run our NHS.” Most people in this country, particularly those who vote for the Liberal Democrats—I point to their Benches in saying this—will be shocked to know that their MPs are standing up for the private sector. It is disgraceful, and I hope very much that the White Paper will be amended to state that the Government support the NHS as the main provider of choice, rather than going down the road of the private sector and the Americanisation of the NHS.
The Government’s refresh of the cancer strategy, announced within two months of their taking office, and their commitment to the cancer drugs fund, clearly illustrate their commitment to improving cancer services in this country. As chairman of the all-party group on cancer, I very much welcome that.
May I suggest that the Government’s focus on outcomes is long overdue? Cancer survival rates in this country have been improving steadily for the past 30 years, but it remains scandalous that the UK is still floundering in the lower divisions of the international cancer league. Part of the problem is that for too long, the NHS has been focused on process-based targets. We need greater focus on outcomes to put the spotlight on just how well the NHS treats patients, not just on how quickly they are seen. That focus will be very important to patients, and particularly to cancer patients.
Last year, our all-party group set up an inquiry, which reported at the end of the year, on cancer inequalities. The evidence clearly showed that patients who survive one year stand as much chance of reaching the five-year point as cancer patients in other countries. However, where this country lets itself down is that our figures are poor compared with other countries when it comes to the one-year survival rates. That suggests that the NHS is as good as, if not better than, any other health service when it comes to treating cancer once it is detected, but falls down badly in detecting the cancer in the first place. That was why the all-party group’s report recommended the introduction of a one-year cancer survival rate measure, to encourage earlier diagnosis. Late diagnosis makes for poor one-year figures, hence our recommendations. I was therefore delighted that the Government picked up on that point and introduced one-year cancer survival rates as well as five-year survival rates in the White Paper.
I am following the hon. Gentleman’s excellent speech with care, and I totally agree with what he has said so far, especially about early diagnosis. In poorer areas, early diagnosis does not occur so often, for myriad reasons. In his view, what is set out in the reorganisation White Paper that will make early detection of cancer easier in areas such as mine?
The answer to the hon. Lady’s question was supplied by my right hon. Friend the Secretary of State in answer to my question earlier. The one and five-year cancer survival rate figures will be published and presented, although how that will happen is in the melting pot. I very much welcome the work of the Office for National Statistics, the National Cancer Intelligence Network and the London School of Hygiene and Tropical Medicine. Whatever form the figures take, they will be in a performance table, not a league table, to ensure that all PCTs and then GP consortiums are tasked with improving performance, irrespective of how they compare with others. That will obviously include PCTs in deprived areas across the country.
I suggest to my right hon. Friend the Secretary of State that the focus on outcomes must include patient experience measures and longer-term quality of life measures, such as whether patients are able to return to work. That, too, is very important from the point of view of cancer patients.
As an aside, I suggest that there is a question mark about process-based targets such as waiting times in general. To return to the point made by the hon. Member for West Ham (Lyn Brown), the real problem when it comes to late diagnosis is not whether it takes one, two or four weeks for a patient to see a cancer specialist. It is how long it takes for the suspicion to be raised that cancer exists in that patient in the first place. Perhaps we should incentivise GPs to detect cancer earlier.
I absolutely appreciate the expertise that the hon. Gentleman brings to the debate, but I should like to ask his views on the issue of anxiety while waiting for an appointment. Whatever the physical outcomes of early treatment, there is a peace of mind issue for patients who are anxious to see their doctor as quickly as possible.
I accept what the hon. Lady says, and I hope that the focus on outcomes will include matters such as patient experience surveys, which will incorporate that very point. It is an integral part of a patient’s experience, and it should be picked up when we start focusing on outcomes.
I return to GPs being incentivised to detect cancers earlier. In that vein, I very much support Cancer Research UK’s campaign to encourage greater access for GPs to diagnostic testing. That will be terribly important when it comes to detecting cancers earlier.
Moving on to GP commissioning of cancer services, there is no doubt in my mind that there is room for improvement in this area, and it would be naïve of Members to believe otherwise. There is often frequent confusion between the roles of strategic health authorities, cancer networks, PCTs and hospital trusts. The priorities of the cancer reform strategy are often not aligned with those of the PCTs.
I should like to play devil’s advocate and suggest to the Secretary of State that we need to tread carefully in dealing with the challenges ahead. The Secretary of State will be aware that GPs see only about eight new cancer cases a year, and that cancer is a set of 200-plus diseases with often complex care pathways. The GPs are often involved in the early and late stages of that care pathway, but the complex bit in the middle is often conducted by clinicians in hospitals.
Challenges lie ahead. We need to ensure that the responsibilities of the NHS commissioning board, the PCTs and the GP consortiums are clearly defined to avoid fragmentation of treatment across the cancer pathway. The reforms must help and not hinder the close working relationship between primary and secondary care doctors. The role of cancer networks in supporting GP consortiums needs to be clarified before those networks are broken up and their expertise is lost.
Furthermore, we must consider whether we need to redistribute the financial incentives to encourage more focus on the earlier and late stages of the care pathway. In other words, we must ensure that reward matches responsibility. Should a qualities and outcomes framework be realigned so that early diagnosis, survival and people dying in their place of choice are included?
In the last minute left to me I shall mention the cancer drugs fund. I have raised the issue with the Secretary of State before. There appears to be early evidence of disparity of access. When it comes to the cancer drugs fund, access should always be clinician-led. In some regions, approaches can be made to the PCT, and in others they are made to the cancer network, which, in turn, has access to the fund. Elsewhere, GPs are forming panels. May I suggest that best practice from the interim drugs fund is applied uniformly before the main drugs fund kicks off next spring? We do not want to add to cancer inequalities when it comes to access to treatment and drugs.
In the past, rarer cancers have had a very raw deal. I know that the Secretary of State is conscious of that and will ensure that those who suffer from rarer cancers will be treated much more fairly than in the past.
There is not time for the Secretary of State to answer all my questions now, but I hope that he will address them when he speaks at the Britain Against Cancer conference on 14 December, and I look forward to hearing what he has to say.
In short, the refocusing on outcomes is the greatest innovation and benefit to patients since the NHS began. However, that must not be undermined by the problems with GP commissioning.
Thank you, Madam Deputy Speaker, for giving me the opportunity to speak in this debate. I want to take up a few of the points made by the Secretary of State. First, he talked as if the previous Labour Government had done nothing for the NHS and had shown no concern about how people were treated. It is worth reminding the House what Labour inherited in 1997 after a number of years of Conservative mismanagement. We used to have waiting lists of more than two years. Now, waiting lists are down to less than six months. A record number of nurses, doctors and porters have come into the hospital system. Many hospitals have been built and many others have been refurbished. Therefore, we will not listen to the Government telling us that we did nothing or that we did not take care of the NHS. We spent more than £80 billion on the NHS, which benefited many people. The Government state that they will protect the NHS and will not reduce the funding. That is just not correct. They talk about billions of pounds going into the NHS, but the money will actually go to the social care fund, which does not directly benefit people in hospitals. In real terms, there will be a 17.5% cut over four years. There is a decrease in the budget and services will be affected.
My hon. Friend must have noticed the chuntering taking place on the Government Front Bench. The same happened during the speeches of a number of other Opposition Members. Does she not think that that is really poor form, especially when the Secretary of State did not seem able to take interventions when it was his turn?
We are told by the Government that the reorganisation is not ideologically driven, but is somehow a way of maximising efficiency and making the systems better. At a time when we are being told that there is not enough money, commentators and experts are saying that this reorganisation will cost at least £3 billion. We are not talking about a small amount of money; we are talking about £3 billion.
In my constituency of Wigan, despite the extreme and visible progress that we have made in the past 13 years of Labour Government, there are still significant health inequalities. In fact 129 per 100,000 people in my constituency die of coronary heart disease, compared to 90 nationally. I know that my hon. Friend shares my concerns, but does she agree that, at a time when we should be addressing those health inequalities and continuing to invest in the NHS, it is an absolute scandal that we are spending the amount of money that she suggests?
I entirely agree with my hon. Friend. She and I have almost adjoining constituencies, and many of the issues and problems of her constituents are very similar to those in my area. When we were in power, £345 million was set aside for disabled children, for respite and all-night breaks. All of those children will now suffer because the White Paper makes no mention of funding for disabled children after March 2011. Yet, we have £3 billion to pay for reorganisation. On 2 November 2009, the Prime Minister, then Leader of the Opposition, told the Royal College of Pathologists that under the Conservatives, there would be no more restructuring of the NHS.
On 20 May, the coalition Government said:
“We will stop the top-down reorganisations of the NHS that got in the way of patient care.”
What are they doing? They are carrying out exactly that reorganisation. If the Government want to make some real improvements to the NHS, the principle of “no decision about me without me” should be considered. The Health Secretary should reconsider the NHS reorganisation and try to think of a better way to use that money for patients.
My hon. Friend says that the reorganisation is ideologically driven. Is not it the case that when one intends to spend up to £3 billion, one needs an evidence base and proof that that spending—whatever it is on—will be money well spent? As my hon. Friend the Member for Kingston upon Hull North (Diana Johnson) said, there have been no trial programmes or pathfinders. The money could be spent without a shred of evidence that it will make one bit of difference.
I agree. I was about to discuss the impact of the reforms, with GP consortiums replacing PCTs. We know that there will be huge differences in the arrangements for health care in different areas. With the formation of up to 500 GP consortiums, all free to set their own priorities, a highly visible two-tier service will develop. Patients will be forced to move GPs or be reallocated to another area to get the care that they need.
The financial success of each consortium will also affect the service that patients receive. It will influence the type of care provided and how long it lasts. Some patients who need hospital treatment will inevitably be told by their GP, “Sorry, you’ll have to wait until next year.” Evidence has shown that making providers compete for patients and providing more choice to patients has done little to improve quality. Most people who are offered a choice of hospitals opt for their local provider. Choice may be important, but for patients, it comes below the quality, speed and accessibility of care.
The proposals do not make it clear whether the patients of the commissioning GP do the choosing. However, the GPs’ new contract will have a powerful incentive to hit commissioning targets. How, therefore, do patients know whether they are being prescribed the best or just the cheapest treatment going?
Again, there is no evidence to show that the restructuring would reduce the bureaucratic load. Hospitals alone will have at least three times the number of commissioners with whom to communicate and contract. Five hundred GP consortiums, each with its own set-up and administrative costs, will replace the current 150 PCTs. Huge differences in the arrangements for health care will emerge between areas. A postcode lottery will develop.
Does my hon. Friend agree that the description of a consortium of GPs—a loose affinity of people with whom they get on rather than a geographical boundary—and the loss of co-terminosity will affect patients? Indeed, it will not simply be a postcode lottery, but, across the board, a matter of whom a patient is registered with.
I thank my hon. Friend for that intervention. Some years ago, when that sort of process was introduced in the legal system, with solicitors able to apply for franchises, the big firms benefited and the smaller, local firms went bust. A similar thing will happen. Some GPs, who run small surgeries in the heart of a community, will not be able to form consortiums. What happens to them? Does it mean that people in parts of Kearsley in my constituency will have to travel seven miles to go to a big GP consortium rather than being able to walk down the street and speak to their GPs, as they currently do?
The reform means that private patients will have a chance to pay for faster care in the NHS. Now that the restriction on the income that can be made from private patients is being lifted, cash-strapped hospitals will find it difficult to resist that income stream. Patients could routinely be offered that route to faster treatment. Thus wealthier people can queue jump, while NHS patients will linger on a lengthening waiting list.
I know that the Secretary of State—
I shall be brief as I know that many hon. Members wish to speak. I am pleased to speak in the debate as someone who is about to see rather a lot of our national health service. My wife and I are due literally any day now—some may say tomorrow—to have our second child at the Royal Hampshire county hospital in Winchester, so all, including my Whips, will forgive me if I miss the Adjournment debate tonight.
Perhaps I am a little biased, but the Royal Hampshire in my constituency is in many ways the sort of institution that I see as the cornerstone of our national health service. It is a classic district general hospital, with a full service, and maternity and A and E departments at its heart. Elderly care services are first rate and infection rates are among the lowest in the NHS. We have a neonatal baby care unit, for which many similar sized institutions would give their right arm, and a bustling out-patients unit. Of course, the hospital would like to do more, but it sits at the heart of the community in Winchester and the surrounding areas because it is continually strengthened by the fact that the people who work there—the nurses, the midwives, the consultants and the cleaners—live in and around the city of Winchester. Of course, the NHS is more than its physical hospital buildings, but I view the Government’s equity and excellence White Paper in the context of institutions such as the Royal Hampshire and the locally connected NHS services that cluster around it.
My local NHS trust will undergo many changes in the coming years as it prepares, with its partners, to make the gear change to foundation status. That is absolutely right in my view to liberate our NHS. As I have often said to my trust and to the people I represent, I am not hung up on the name at the top of the wage slip for individual employees of the NHS in Winchester or anywhere else; I am merely concerned about the services that the NHS in Winchester offers the people I represent. I suspect that no hon. Member would disagree with that.
Equally, I am concerned about protecting the services in the financial context in which we find ourselves and the enormous national debts under which we labour. I am proud that my right hon. Friend the Prime Minister put the NHS at the heart of his programme for government. He must have been watching closely because I did the same in Winchester. I am especially proud to be elected as a new member of the new Government, who made the political choice—it is a choice; we did not have to do it—to protect health spending in the recently announced spending round. I know that Labour Members do not believe that and that at every turn they will try to rubbish it, as we have seen from part of the motion’s wording today. I guess that part of me, were I in their position, would do the same. It must really rankle. There is a new coalition Government, led by a Conservative Prime Minister, who are pledged to protect the NHS and put it at their heart. I am proud of that.
Does the hon. Gentleman think that the terrible cuts that our local authorities will face in adult social care and other core services will absorb the ring-fenced money for health simply because they will not be able to provide in future the sort of services that they currently provide?
No, there is absolutely no reason for them to do that. My right hon. Friend the Secretary of State for Communities and Local Government will make an announcement on council funding, but the Secretary of State for Health has already announced in the comprehensive spending review that the Government have allocated moneys for social care.
I know that the Labour party will try to rubbish our proposals, and that is their choice. My point is this: the people I represent do not care much about how the NHS is structured, but they care a great deal about ensuring that their NHS is there when they need it. They pays their money, and they expect the NHS to be there when they need it, free at the point of use. That is the cornerstone of what we are proposing.
I am very happy to defend outcome-focused, GP-led commissioning for my constituents. Every health care system in the world worthy of the name has the GP-patient relationship at its heart, and our proposals for GP consortiums seek to strengthen that for the sake of all the people we represent. Why on earth would we propose anything different? GP consortiums are an enormous opportunity for the NHS, and the perfect way to further the “no decision about me without me” agenda that is so important. I do not think that that is glib, as an Opposition Member said earlier. It is about rejecting the “Like it or lump it—this is the service you’re going to get” view that we have heard for far too long in our health service.
I would like to state on the record that the expression is glib when it is uttered by a Secretary of State who does not back it up, who does not place patients at the centre, who will not have patients or their elected representatives serving on consortiums and who makes grand statements that are baseless and meaningless.
I am sorry I gave way; I expected something else. I do not think for one minute that it is glib. We are not suggesting that every single patient will be involved in every single element of their care, but how could anybody disagree with “no decision about me without me”?
GP consortiums are an opportunity for the health service finally to realise one of its original aims—the sophisticated management and prevention of illness through the intelligent use of the patient list. That is still a largely untapped resource in our national health service.
GPs I speak to are up for their new role in commissioning for their patients. Of course they have questions—it would be strange if they did not—but they are not calling, as the Opposition’s motion is, for us to ditch our plans because things have got difficult and they have a fear of change. The Opposition cannot have it both ways. They support our plans for more GP involvement in patient care, but call plans for GP consortiums inefficient and secretive.
I see my job as a Member of Parliament as being an important link in helping GPs to answer some of those questions about consortiums that are coming down the line. I know that my right hon. Friend the Secretary of State has met groups of GPs in other areas of the country, and I ask him today to check his inbox because an invitation from me is coming his way.
As we know, following the establishment of GP consortiums, primary care trusts will no longer have NHS commissioning functions. It would be nonsense to create GP consortiums and keep two other tiers of management commissioning alongside them. Investment in the NHS has not been matched by reform. Yes, we will protect NHS investment, but our reform agenda builds on the best of the reform process over the previous 20 years. An Opposition Member said that we reject everything that went on under the previous Government, but of course we do not. We have made that very clear. These proposals build on Labour Government measures such as practice-based commissioning and NHS foundation trusts, and rightly so.
I sometimes hear it said—I heard it put to my right hon. Friend the Secretary of State yesterday morning on the “Today” programme—that the Government’s health policy was a bit of a surprise to everybody. I do not know why that would be. I mentioned earlier that the Health Secretary visited the Royal Hampshire county hospital. That was in May 2008, and he discussed the policy with people there then. He will remember the visit.
No, I want to finish my remarks. My right hon. Friend will remember discussing with those professionals his ideas, which were published. He referred to those ideas in 2006, and they eventually made it through to our manifesto and the coalition agreement. They certainly should not have been a surprise to anyone who was watching.
I know that my colleagues will all be speaking to their PCTs and strategic health authorities, as am I. I have had a positive dialogue with NHS Hampshire in the months since I was elected, and I pay tribute to its chief executive who takes the responsible view that her job is to ensure that the NHS in Hampshire has what she calls a safe landing and a smooth transition to GP consortiums.
On public health and local accountability, as we know, a key part of the coalition plans for health involve the transfer of public health to local authorities, who will employ a director of public health. I know that these directors will be responsible for health improvement using a ring-fenced public health budget according to the needs of the local population, and I warmly welcome the move. However, I sound a note of caution about local authorities leading in public health. I urge Ministers, perhaps through partnership-working with the Local Government Association, to ensure that councillors are taken into every single step of the process and that sufficient training is given. I know that the cult of the amateur has held sway in many parts of our public service, but this is one area in which we need to support locally elected representatives as much as possible.
As co-chair of the all-party group on breast cancer, it would be remiss of me not to mention the very real concerns that we have about access to specialist nurses in the NHS, which traditionally have been an easy target for cuts. That must not happen under the new arrangements. It would be a false economy for any GP consortium to do that.
The coalition plans for health reform are not a gamble; nor are they ideological. They are about recognising that we live in the shadow of appalling national debts, and we remember where they came from. Protecting the front line, pushing power down to the local level and dealing with the national debt crisis are what “Equity and excellence” is all about, and that is why I will not be supporting the motion.
Let me begin by wishing the hon. Member for Winchester (Mr Brine) and his partner well for the pending new arrival. I am sure that they will receive an excellent service in their local NHS hospital, and that the whole House wishes them the very best.
I should like to use this opportunity to raise a few of the concerns that have been brought to my attention by people in my constituency. Many do not fully understand how the new proposals will work to deliver the outcomes we hope for, and I hope that the Minister can answer for them this afternoon. Essentially, people are anxious that where they live and who they are will begin to determine the level and quality of their care.
I am sure we all agree that consistency and guarantees of standards must be an integral part of the operation model that the Government seek to introduce. That is especially important in relation to health outcomes for the poorest and most vulnerable. There is a high level of health inequalities in my constituency. The people who live in the poorest wards suffer much worse health outcomes than those in the better-off wards in the south of the borough of Trafford. The local authority was quite slow to recognise that, so how will health inequalities receive strategic attention in the proposed new structures?
What will be the role of the public health director, who will be placed within the local authority? I am keen to know how that public health role in the local authority will devolve and relate to those at the sharp end in all health settings—those who provide front-line care. I hope that the Minister can fully explain that in his winding-up speech so that my constituents can be clear about it.
My constituents and I are concerned about how the wider drivers of health inequalities—income, education, employment and so on—will be addressed in the new structure, particularly when so many national policies seem to be taking us in the opposite direction, as my hon. Friend the Member for Kingston upon Hull North (Diana Johnson) pointed out earlier.
Does my hon. Friend agree that as well as the vast inequalities in life expectancy, the lingering issue of care for those who live longer and longer with chronic illnesses needs to be addressed? Those people are suffering now. Does she agree that it is an absolute disgrace that the Government have decided to tinker with the structures rather than put in urgent investment to help those people, including people in my constituency of Wigan?
Labour Members want to know whether the money spent on the restructuring of front-line care in our communities is the best use of that money. As the Health Secretary himself pointed out, we continue to have poor health outcomes and standards compared with our European neighbours, so why does it make sense to put more money into reorganisation and less directly into front-line care? I look forward to hearing what the Minister says about that.
The second issue that I want to address involves patient voice. That, too, has been raised in my constituency. A particular concern of mine is to ensure that the poorest and most vulnerable are heard. I am concerned about the lack of voice of those who do not have the sharp elbows and the articulacy to speak up for themselves to secure the best for themselves and their families. We know that that is the fate of many in our poorer communities, and especially of those with mental health problems.
I have been told a number of times in my constituency, including by GPs, that GPs are not particularly expert in, or equipped to deal with, mental health needs. How will those patients’ needs be identified, recognised and responded to in the new structure? What help will be available to enable patients to articulate such needs? There is uncertainty in my constituency on the future structure. How will patient voice, choice and opinion feed in to the new model?
The Trafford patient LINk—local involvement network—service is uncertain about its future role and status. I very much hope that Ministers will be able to give us more information about how we will get a clear opportunity for advocacy, so that every patient’s voice can be properly heard, and for proper support for patients who are perhaps less able to articulate their needs and secure services for themselves.
I am concerned also because I know—not just from my constituency, but from my long experience of supporting and working with vulnerable families—that different values pertain among different doctors and practitioners. I am particularly concerned, for example, for the young woman who may present herself to a GP who does not feel it appropriate to offer her advice on contraception or abortion. How can those minimum standards be protected, so that everybody—wherever they live, whoever their doctor is and whatever the structure is—knows that they will be guaranteed the care that they need.
Thirdly, I would like to raise with Ministers the issues that have been raised with me by health practitioners and professionals—and which have been highlighted in this afternoon’s debate—relating to GPs’ ability and willingness to take on the management aspects of their commissioning role. Many GPs have said to me—perhaps the Minister will be able to reassure them this afternoon—that what they see tanking towards them is a heavy burden of management, albeit without the additional resource with which to manage it. Many GPs have said to me that they have not really had the training—they lack the expertise—to be health managers as well as good-quality health practitioners and providers of front-line health care. I am interested to know whether Ministers have plans for training GPs and developing those skills and abilities in GP practices, or whether, as many of us on the Opposition Benches fear, the proposal will in fact be used as an opportunity to privatise that management function. If that is the case—this is not an ideological point, but an efficiency point—I shall be keen to know what financial model Ministers expect to operate if a substantial amount or even a proportion of the money that would otherwise be held in GP practices will go to fund the profits of private providers.
Those are the issues being raised with me in my constituency. They are issues that I am afraid I do not feel equipped to answer, because I do not fully understand how the new structures will work well in practice and, in particular, how they will work well for the poorest.
In concluding, I would like to highlight a point that has been made by a number of my hon. Friends this afternoon. The injection of extra uncertainty and disruption into our national health service at this time is further—and considerably—stretching our capacity to deliver excellent front-line care. I would urge Ministers to listen to the many GPs who have said to me—and who I am sure are saying to them—that what is proposed represents an element of change and disruption that they cannot yet see the benefits of. What they can see is that there is considerable uncertainty in the way that they are now working. There is certainly concern in my primary care trust. I hope that Ministers can offer some reassurance on that point, because at the moment there is considerable instability, and that cannot be good for any patient outcomes.
This is a period of great challenge for the national health service, and it would be whoever was in government. However, Government Members accused us of not having a care for staff and patients. In fact, it is precisely because we are concerned about staff and patients that we are using this debate to point to all that is problematic—and potentially even disastrous—about the Secretary of State’s proposed NHS reorganisation.
In exploring the gap between what those in government said while in opposition and what they are saying now, we can do no better than refer to a speech that the present Prime Minister gave to the King’s Fund in 2006, in which he set out the five key components of his approach to the NHS—components that, to my knowledge, he has not altered. His first component was that he wanted to guarantee the NHS the money that it needs. Who believes that now? Certainly not the Institute for Fiscal Studies, which has noted that not since the 1950s—from April 1951 to March 1956, to be precise—has there been such a small increase in NHS funding; and not the chief executive of the Royal College of Nursing, who said:
“A huge range of services and jobs are earmarked for cuts against this urban myth that the NHS is being protected. The evidence is quite clear…this is simply not the case”.
Hon. Members, who, as the weeks turn to months, will see the cuts in their own constituencies, will not believe it either.
My hon. Friend the Member for Sheffield Central (Paul Blomfield) talked about what is happening to children’s hospitals. What has not been factored in is the cost of reorganisation, which experts have said will be £3 billion. Ministers have said that their estimate is £1.7 billion, but when asked about the number of redundancies they cannot answer. We know that the cost—
No, I must get on.
The cost of redundancies, when they are factored in, will be hundreds of thousands of pounds. We believe that the figure of £1.7 billion will be overshot, and bring greater financial pressure on the NHS.
The second point that the Prime Minister made in 2006 was that he wanted to end the damage caused by pointless and disruptive reorganisation of the NHS. He said:
“We will not mess around with existing local and regional structures”.
So the Secretary of State’s big idea for the NHS was a pointless and disruptive reorganisation.
What do the people who work in the NHS think about that? The Royal College of General Practitioners says:
“our members are not convinced that the scale of the changes proposed is justifiable, especially in the context of cost reductions”.
The British Medical Association
“questions whether a less disruptive, more cost-effective process could have achieved the aims of reducing bureaucracy”.
The Royal College of Midwives says that it is
“very disappointed that despite pre-election promises to end…top-down reorganisation…the White Paper focuses far more on structures than it does on care delivery.”
The reorganisation is high-cost, high-risk and contrary to everything that was said by those who are now Ministers in the run-up to the election. They have accused us of being confused and incoherent, but it is their reorganisation that is confused and incoherent. Every professional body echoes that thought.
The Prime Minister said that he wanted to
“work with the grain of the Government’s reforms…So we will go further in increasing the power and independence of GPs and PCTs”.
He has gone so far that he has left GPs behind, and only one in four believe that the reorganisation will improve patient care. As for PCTs, contrary to the Government’s promises when in Opposition, they have abolished them.
What was the Prime Minister’s fourth point about his main driving aims for the NHS? He said that he wanted to
“take the politics out of the management of the NHS”.
There could not be a more political reorganisation. It is driven by ideology and a belief in free market ideology. As the chair of the BMA, Hamish Meldrum, said:
“If the Government is truly committed to reducing waste and inefficiency, their proposals for NHS reform should focus less on competition and more on a co-operative approach on delivering health care.”
Finally in his 2006 speech the Prime Minister said that his main commitment on the NHS was
“fair funding to the NHS…We will end political meddling…removing the scope for fiddling”.
We will see how much the scope for fiddling is removed when money is moved from the NHS budget to local authorities for social care.
My hon. Friends the Members for West Lancashire (Rosie Cooper), for Kingston upon Hull North (Diana Johnson) and for Bolton South East (Yasmin Qureshi) all expanded on what is problematic about the reorganisation. The Secretary of State began by posing as the friend of patients and those who work in the NHS. I will not take lectures from him on that. My mother came to this country as a pupil nurse from Jamaica in the 1950s. She was part of that generation of West Indian women who helped to build the national health service. Government Members cannot talk to us about the people who work in the NHS. As for patients, are Ministers listening to the patient groups—people who represent children, people who represent the elderly, and people who represent those with mental health problems—about their concern about what the reorganisation will mean for them?
This reorganisation is ill thought out and, at a time of tremendous financial stress in the national health service, ill timed. We believe that Government Members have been lulled into a false sense of security about what is to come. They believe that although students might be marching and the Church might be in uproar, the NHS is safe. I put it to them that, as the weeks turn to months and we move through the winter, and as we begin to see winter bed pressures, the consequences of this ill-thought-out, unnecessary, top-down reorganisation will reverberate not only in this Chamber but in the surgeries of Government Members and of all Members of this House. I am proud to support the motion.
This has been a revealing debate. Labour has come to the House today to make the case for the status quo—the case for standing still. Labour is here defending a failed status quo. We have heard Labour Members presenting to the House a number of extraordinary claims and grotesque caricatures of the Government’s plans. They want to defend a failed status quo in which the NHS has been spending at European levels but has been so tied up in red tape that it has not delivered European levels of quality health care.
For 13 years, Labour tested to destruction the idea that the NHS was best run from Whitehall. The record speaks for itself. My hon. Friend the Member for Basildon and Billericay (Mr Baron) talked about cancer survival rates, and it is nothing short of a scandal that cancer survival rates in this country lag so far behind the best in Europe. If the status quo is right, as Labour Members seem to be arguing, why are a staggering 23% of cancer patients diagnosed only when they turn up as emergencies? Why is that an acceptable outcome?
No, I said that the Opposition had failed and that they were defending a failed status quo. Let me give the House an example of a failed status quo. If the NHS were performing at the level of the best in Europe, 10,000 more lives could be saved every year. This is what our focus on outcomes is all about. It is what patient-reported outcomes are all about, too.
We all agree that elderly patients should be treated with dignity and compassion, yet for far too many, that is not what happens in practice. Just last week, a report on patient deaths found that 61% of older people received “inadequate” care in their final days. After 13 years of a Labour Government, the NHS is in the bottom third in Europe in dealing with dementia—way behind Ireland, Spain and Portugal.
As the Minister will know, the independent public inquiry into Stafford hospital is taking place in my constituency at the moment, and the matters that he has just mentioned are highly relevant to that. Will he give the House an undertaking that the evidence given to that inquiry will inform the debate on the forthcoming Bill?
We will, of course, follow the inquiry closely and ensure that we learn lessons from it. We would not have set up the inquiry if we did not intend to learn lessons.
Labour’s legacy is a demoralised and disempowered work force. Reforms have been half implemented, and billions of pounds have been wasted on a flawed NHS IT programme. This Government are clear that the NHS can be so much better than it is today—spending better and doing better both for patients and for the taxpayer. It is this Government’s purpose to liberate the NHS so that it can deliver health care that is among the best in the world, to learn the lessons of Labour’s top-down target-driven approach to health care, to reverse the obsessive focus on process that has stifled innovation and created dependency in the system, and to move away once and for all from a culture that measures success by ticking boxes, hitting the target but missing the point.
Labour talked about reforming the NHS and making it more patient centred, but its reforms were half-hearted, lacking coherence and a clear purpose. Reforms such as the introduction of foundation trusts, practice-based commissioning groups and patient choice, which promised so much, did not deliver under Labour.
I am grateful to the right hon. Gentleman for raising that issue, as I was coming on to deal with the comments of the hon. Member for Sheffield Central (Paul Blomfield). We are all here to say, rightly, that we want the best from our NHS—dedication from our staff of professionals and creativity from front-line staff. Both the right hon. Member for Holborn and St Pancras (Frank Dobson) and the hon. Member for Sheffield Central talked about that, but I remind the right hon. Gentleman that the review of top-up tariffs started under Labour. [Hon. Members: “So what?”] Yes, it was in the NHS operating framework under Labour. We will complete that review and we are engaged constructively with the foundation trusts, but I think the right hon. Gentleman should have a conversation with his own Front-Bench team before he attacks the Government Front-Bench team.
Our proposals build on reforms such as practice-based commissioning, patient choice, foundation trusts, tariffs and social enterprise, and they hold true to the founding principles of the NHS—that it is free at the point of delivery, and not based on ability to pay.
Freeing front-line staff from the tyranny of process targets is another issue. The hon. Member for Winchester (Mr Brine) was right to talk about the need to build on the knowledge of general practices and help them to shape services to fit local need and deliver quality outcomes.
The hon. Member for Stretford and Urmston (Kate Green) talked about health inequalities and how they had widened in her constituency under Labour. That is why the Government are forging new relationships between the NHS and local government, making common cause on public health so that we can see it not only as a matter of medical health but as part of a far wider attack on the determinants of ill health in the first place. That makes local government entirely the right place to start.
We must ensure that collaboration takes place. The right hon. Member for Charnwood (Mr Dorrell) talked about collaboration between health and social care becoming the norm rather than the exception, as it is today. We need to increase local accountability for health care decision making. Yes, we also need to empower patients and provide more choice and more control. Through HealthWatch, a champion for patients and service users, we should make sure that the seldom heard, too, are heard in decision making.
My hon. Friend rightly makes much of the need to stop the top-down reorganisations of the past and to emphasise the importance of having patient-centred structures. In that light, if a local area preferred to graft in clinical engagement in the management of the existing PCT and greater patient involvement in the structure, would he accept that as an alternative to the sort of top-down reorganisation that the Government currently propose?
It will be very much up to the consortiums to decide how to configure their governance. What we have said is that this is about the devolution of power. My hon. Friend was not against the devolution of power to the devolved Administrations in Scotland and Wales, yet this is about the same thing—shifting power away from this Front Bench and Whitehall and putting it back into the hands of patients and clinicians. Those clinicians will be engaged in commissioning, as we need them to be.
Much has been made of accountability. Under Labour, the NHS lacked it. The hon. Member for Kingston upon Hull North (Diana Johnson) really should reflect more on what was done under Labour, because there was a huge democratic deficit. We will have greater transparency and, through our new council health and well-being boards, genuine democratic accountability.
In the Labour motion before us today, it is wrongly claimed that the NHS has not been protected and that promises have been broken. The hon. Member for Hackney North and Stoke Newington (Ms Abbott) referred to the 1950s, but I would refer her to the 1970s, when Labour was busily cutting back—
No. The hon. Gentleman arrived very late and was not in his place for much of the debate.
We heard a breathtaking attack from Labour Members who argued against ring-fencing. Indeed, just a few weeks ago, we heard the right hon. Member for Leigh (Andy Burnham) say:
“It is irresponsible to increase NHS spending in real terms within the overall financial envelope”.
That was, and is, Labour’s view—cuts to the NHS. That is not the coalition’s view. That is why the NHS will get real-terms growth. Yes, it is a tough settlement; yes, there needs to be scope for increased productivity; and yes, management costs in the system need to be reduced. The Government, however, are determined to ensure that we reform the national health service, deliver the clinical engagement and deliver the change that will make the service better for our public. I urge the House to reject the motion.