[Relevant document: The Third Report of the Health Committee, Commissioning, HC 513]
I beg to move, That the Bill be now read a Second time.
The purpose of the Bill can be expressed in one sentence—to improve the health of the people of this country and the health of the poorest fastest. While the previous Government increased funding for the national health service to the European average, they did not act similarly to increase the quality of care. We spent more, but others spent better. In important areas, the NHS performs poorly compared with other countries. An expert study found that out of 19 OECD countries that were investigated, the UK had the fourth-worst death rate from conditions that are considered amenable to health care. If NHS outcomes were as good as the EU15 average, we would save 5,000 lives from cancer and 4,000 lives from stroke every year. We would also prevent 3,000 premature deaths from respiratory disease and 1,000 premature deaths from liver disease every year. This cannot go on: things have to change to protect the NHS and deliver better results for patients.
I do not dispute what the Secretary of State says about European comparators, but what does he say to Professor John Appleby, who said last Friday that all those markers, some of which are not direct comparisons, are getting nearer to European targets? Professor Appleby suggested that the disruption that is going to take place in the health service will not help us to do that.
I would say two things to Professor John Appleby. First, the latest data published in EUROCARE-4, which I know the right hon. Gentleman will have seen, are clear about the gap between cancer survival rates in this country and others, and in recent years that gap has not diminished as it should have. He can read in last week’s Lancet an authoritative study of cancer survival rates in this country and a number of others demonstrating that the gap remains very wide and that we have to close it. Secondly, the King’s Fund supports the aims of the Bill and Professor Appleby, as a representative of the King’s Fund, clearly understands, as we do, that if we are to deliver the change that is needed, we need the principles in the Bill.
People trust the NHS, and its values are protected and will remain so—paid for from general taxation, available to all, free at the point of delivery and based on need rather than the ability to pay. However, a system in which everyone is treated the same is not one that treats everyone as they should be treated. Our doctors and nurses often deliver great care, but the system does not engage and empower them as it should.
On the John Appleby point, does the Secretary of State accept that what he actually said was that the rate of deaths from heart disease would be better in Britain than in France by 2012, on current trends, even though France spends 28% more on its health service? Is not that a ringing endorsement of what is happening now rather than a prescription for blowing up the system as the Secretary of State suggests?
First, I have just answered the point about John Appleby. It is true in a number of respects, as I have made clear, that although there have often been improvements in the NHS, they have not been what they ought to have been. It was a Labour Prime Minister, back in 2001, who said that we must raise resources for the NHS to the European average, but he did not achieve results that compared with the European average.
Let me give the hon. Gentleman some examples. A recent National Audit Office report showed that as many as 600 lives a year could be saved in England if trauma care were managed more effectively. Too often, the latest interventions, which are routine in other countries, take too long to happen here. John Appleby used heart disease to illustrate his point. Primary PCI— percutaneous coronary intervention—using a balloon and stent as a primary intervention to respond to heart attack was proven to be a better first response years ago. I knew that because cardiologists across the country told me so several years ago. I remember a cardiologist at Charing Cross telling me, “I have a Czech registrar working for me who says that in the Czech Republic PCI as a response to a heart attack is routine, but it hardly ever happens in this country.” Since then, it has been better implemented in this country, but that started to happen only when the Department of Health gave permission for its adoption.
The same was true of thrombolysis for stroke. That happened too late in this country, after such changes had taken place in other countries, because health care professionals there were empowered to apply innovation to the best interests of patients earlier.
Does my right hon. Friend agree that, given the disparity in survival rates in trauma care and in many illnesses, including cancer care and heart attacks—citizens in this country are twice as likely to die of a heart attack as those in France—the NHS is in desperate need of modernisation?
My hon. Friend is right. We need not only to match European spending, as we do now, but to ensure that we achieve European-level results. It is not just about benchmarking, which we know we must do. We must benchmark ourselves against the best in the world if we are to deliver the best results for patients. We must also constantly make sure that we achieve a modernised health service that delivers the best possible care—sometimes going ahead of what others achieve, and applying innovation more quickly.
In some ways, as we know—for example, in mortality rates from accidents and from self-harm, and in equity of access to health care—the NHS leads the world, but our doctors and nurses are regularly hobbled by a system that treats equality as sufficient, when what we need is both equity and excellence.
With his knowledge of European matters, the right hon. Gentleman knows that we are in the later stages of the collective approval through the European Union of the European cross-border health directive, which allows precisely that and makes it clear that the same criteria are applied to patients seeking health care in other countries as would apply were they to seek it through the NHS in this country.
In a moment. I have just answered one question.
Why did spending more not deliver better results? We know why that is—[Interruption.] No, better results should have been achieved. Opposition Members need to realise this, because it has been at the heart of their failure in public service reform over the past decade: the Office for National Statistics said a few weeks ago that productivity in the NHS fell in every one of the past 10 years. It fell by 1.4% a year in hospital services.
Despite a huge amount of money rightly invested in the NHS, taxpayers and patients were not getting the service that they should have had. Billions of pounds have also been wasted on an ever-growing bureaucracy, taking money away from the front line and away from patient care. The number of managers doubled under Labour. I give way to the Chair of the Public Accounts Committee.
I thank the right hon. Gentleman. He is right to draw attention to the fact that productivity has fallen in the past 10 years, but should he not consider whether it is wise in those circumstances to distract people from driving up productivity and achieving savings by the unnecessary institution of reform? That is just taking people away from the thing that they should be concentrating on.
The right hon. Lady should understand, as I will go on to explain, that we are not distracting the NHS from the need to improve services for patients. We are enabling the NHS to improve services for patients. In her role on the Public Accounts Committee, she should understand that right across the public services, one of the consequences of dealing with the deficit is that we will have to reduce the costs of bureaucracy and administration.
We will do that in the NHS as much as anywhere else, but we will not do it in the way that the Labour party pressed us to do, which was to cut the NHS budget—[Hon. Members: “What?”] Yes, Opposition Members did exactly that. We will increase the NHS budget. As we set out in the spending review, we will increase the NHS budget by £10.7 billion over the life of this Parliament—investment that Labour opposed—and we are determined to get far more for British taxpayers’ money.
My right hon. Friend will be aware that there has recently been an excellent reorganisation of stroke treatment in London, with a number of hospitals earmarked as emergency centres, all of which, crucially, are within 30 minutes of every Londoner. Once patients have been through the emergency procedures and are stabilised, they are returned to local stroke centres, which are also earmarked as part of the whole programme. Can he reassure me that that kind of regional organisation of hospitals, which has delivered good results, will not suffer through some of the proposed reforms?
Thank you, Mr Speaker. I can give my hon. Friend the Member for Ealing Central and Acton (Angie Bray) precisely that reassurance. I was with NHS London at the beginning of last week, and it is clear that GP commissioning groups are coming together with providers to develop those kinds of commissioning plans, going beyond trauma and stroke care, which has already happened in London, to look, for example, at the integration of diabetes care between primary care and hospital services.
Under the Bill, patients will come first and will be involved in every decision about when, where, by whom, and even how, they are treated—“there must be no decision about me, without me.” The 2002 Wanless report called for patient engagement, but that did not happen. Now it will. Because patients cannot be empowered without transparent information, an information revolution will give them more detailed information than ever before, showing them and their doctors the consultants who deliver the best care, giving them control over their own care records and enabling everyone to access the care they need at the right place and at the right time. Patients and their doctors and nurses will be able to see clearly which health care provider offers the best outcomes and to make their decisions accordingly.
May I assure my right hon. Friend that this is not being greeted by local GPs in my constituency as some disruptive revolution, but as a logical extension of all the debate and development in the NHS over the past 20 years or more on giving patients more power and GPs more control over the allocation of resources?
I agree with my hon. Friend. In effect, that gives the lie to what the hon. Member for Wrexham (Ian Lucas) suggested. The coalition agreement states:
“We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.”
Our manifesto stated that we would strengthen the power of GPs,
“putting them in charge of commissioning local health services.”
I am sorry, but 57 Members wish to speak, as you have rightly told us, Mr Speaker. I will give way as often as I can, but more than one intervention from each Member is excessive. [Interruption.] I have just quoted from the coalition agreement and our manifesto, so hon. Members have heard both.
Through the outcomes framework, which we published in December, we will stop the top-down, politically motivated targets that have led to real quality being sidelined. We will ensure that we focus on the outcomes that really matter and back them up for the first time with quality standards that are designed to drive up outcomes in all areas of care. Those standards have not been dreamt up in Whitehall, but are being developed by health professionals themselves. Similarly, doctors and other health professionals will not be told by us how to deliver those standards. The standards will indicate clearly what is expected, but it will be up to clinicians to decide how to achieve them. At every step, clinical leadership—that of doctors, nurses and other health professionals—will be right at the forefront. It will be an NHS organised from the bottom up, not from the top down.
The shift in power away from politicians and bureaucrats will be dramatic. The legislation none the less builds on what has gone before. It is not a revolution, but as the shadow Secretary of State said just a fortnight ago:
“The general aims of reform are sound—greater role for clinicians in commissioning care, more involvement of patients, less bureaucracy and greater priority on improving health outcomes—and are common ground between patients, health professions and political parties.”
The right hon. Gentleman quoted the National Audit Office earlier. Does he agree with the statement in its report that his revolution in and upheaval of the NHS risk undermining the quality initiative—the so-called QIPP programme—that the previous Government introduced?
No, far from it—actually, quite the contrary. It is only by virtue of our ability to engage front-line clinicians more strongly in the management and design of care that we will deliver those quality, innovation, productivity and prevention ambitions; and it is only if we cut bureaucracy and the costs of bureaucracy that we will be able to get those resources on to the front line more effectively. I made it very clear, and the shadow Secretary of State endorsed the view, that there is consensus about the purposes of reform, but if Labour now voted against the Bill, although we do not know whether it will, it would abandon that consensus and, indeed, its own policies when in government.
I just wish that the hon. Gentleman would look at the latest published data. Since the election, we have reduced the number of managers in the health service by almost 4,000 and increased the number of doctors. For the first time, there are more than 100,000 doctors in the NHS, and we are increasing the number of health visitors, after years of their numbers being reduced under the previous Government. He should get his facts right before he starts flinging accusations about.
No. I am going to make some progress.
The Labour party, when in government, pioneered patient choice; Labour said, “We must have patient choice.” I remember John Reid, when he was a Member, saying that the articulate and the well-off negotiated their way through the health service, and that he wanted to give choice to everybody in the health service. He was right. The social attitudes survey in 2009 found that more than 95% of people felt that they should have more choice, but that fewer than half of patients actually experienced it. The Labour party started down the road of extending choice; we will complete that journey.
On patient choice in health service design, is the Secretary of State aware that in Cornwall the primary care trust has engaged in the transfer of community hospitals and services without adequate public consultation and at breakneck speed? If “no decision about me, without me” is to apply to service design and patient involvement, is he prepared to intervene to ensure that the public are involved in such important decisions?
I am grateful to my hon. Friend for that point. I have not previously been asked to comment on the matter, nor have I received information about it, but from my visits to Cornwall I entirely endorse his view about the importance of community hospitals in accessing services. He will see that, in the Bill, a specific duty is placed on the commissioning board and each commissioning consortium to reduce inequalities in access to health care. He will see also that, through the Bill, we will strengthen accountability where major service change takes place, because it will require not only the agreement of the commissioning consortium, representing as it were the professional view, but the endorsement of the health and wellbeing board, which includes direct, local, democratic accountability. Points have been made about what was in manifestos, but the Liberal Democrat manifesto was very clear about the need for democratic accountability in health service commissioning—and so there will be.
Let me return to the point, because the previous Government also went down the route of practice-based commissioning. It was their policy, but, as the shadow Health Minister, the hon. Member for Leicester West (Liz Kendall) said, many GPs felt that
“they didn’t always get the power, responsibility and resources they might have wanted.”
Well, now they will, and we will give it to them.
On our definition of quality, Opposition Members say “quality matters”. It does, and it was under the Labour Government that Ara Darzi pioneered the thought that quality must be at the heart and an organising principle of the health service. It is we now who are going to make that happen. We are publishing quality standards. We are putting into this legislation a duty to improve quality that extends to all the organisations that commission and provide NHS services.
Will there be public accountability for the private companies that will come in and do the commissioning for the doctors? I can see their people getting top salaries—the executive getting £200,000 and the financial officer getting £250,000. That is the sort of thing that we are trying to stop. What will happen when these companies run things for doctors?
The accountability in the NHS will be for the quality of the service being provided. The hon. Gentleman may not have agreed with the last Labour Government on this, and perhaps many in the Labour party are now changing their view on what was pursued by that Government, but it was that Government who introduced and encouraged a policy of “any willing provider”. In 2003, Alan Milburn said:
“If I can get a private-sector hospital to treat an NHS patient, then for me the person remains an NHS patient.”
Everybody in the NHS who provides NHS services will be accountable through the—[Interruption.] The money will follow. The Chair of the Public Accounts Committee is here. Where public money goes, accountability for its use will follow.
Let me complete this point, then I will give way to my hon. Friend the Member for Basildon and Billericay (Mr Baron). On the point of allowing the independent sector to be a provider to the NHS, I should say that it was the right hon. Member for Leigh (Andy Burnham), the shadow Secretary of State’s predecessor, who said that
“the private sector puts its capacity into the NHS for the benefit of NHS patients, which I think most people in this country would celebrate.”—[Official Report, 15 May 2007; Vol. 460, c. 250WH.]
Well, Labour Members are not celebrating it now; they have reverted to type.
The Government’s increased focus on improving outcomes is long overdue and very welcome, but will the Secretary of State address the issue of cancer networks and the concern that some of the expertise may be lost because of the funding gap between the end of funding for the cancer networks themselves and GP commissioning fully taking effect? Can the Government do anything to bridge that gap so that we allow GP consortia to be better informed in making decisions about what services to commission?
My hon. Friend rightly takes a close interest in these matters. When I was with him and other colleagues at the Britain against cancer conference, I made it clear—and he made it equally clear—that the cancer networks funding is guaranteed during the course of 2011-12. There is not a gap, because from April 2012 onwards the NHS commissioning board will take up its responsibilities. There will then be decisions by the commissioning board about how it will structure that.
Let me come back to what the last Labour Government did. They introduced the concept of payment by results. Unfortunately, however, payment tended to be by activity and not by results. We will now make it payment by results and really make that happen.
To complete the picture, I should say that throughout the Bill there are elements of policy that we are taking forward, such as foundation trusts. The Bill follows the brainchild of Alan Milburn and Tony Blair back in 2002. In 2005, the Labour Government said that every NHS trust should become a foundation trust by December 2008. That just did not happen. Again, it will be our task to make modernisation in the NHS consistent and comprehensive.
Will the Secretary of State say how many GP contractors he estimates will be private companies? Will he also make it clear to the House that none of the private medical providers that funded his office in opposition will gain from the change?
There are two points to make. First, we have made no estimate of the extent to which GP-led commissioning consortia will contract with independent sector providers, so I cannot give the right hon. Gentleman such an estimate. Secondly, I did not receive money directly from a private health company for my office while in opposition. So there we are.
Labour’s reforms were piecemeal and incoherent. Under the previous Conservative Government, the internal market and fundholding of the early 1990s failed to promote quality and risked conflicts of interest among GPs. We have learned from those mistakes and from the failings of a Labour Government over the past 13 years. This Bill is different. It views the NHS as a whole service, every bit of it geared towards meeting patients’ needs. This Government understand that the best health care comes from the close partnership between patients and their clinicians. Every part of the NHS, every incentive, every structure and every decision must support and strengthen that relationship.
First, we will place the individual needs of each patient above all else, encouraging, wherever possible, a personalised approach to health care, tailoring services to have the greatest individual, and greatest overall, impact. Secondly, decisions made in the consulting room, in local service design, in commissioning, and in the services any particular provider offers, will be local decisions—real autonomy and real devolution of power.
Will the Secretary of State give way?
In a moment. [Interruption.] The right hon. Gentleman’s Front Benchers have been asking me to explain what the Bill does, and I am doing that.
Thirdly, there will be relentless focus on quality, embedded within a new legal duty. Fourthly, there will be a diverse and vibrant social market for health care. We will encourage NHS staff to set up social enterprises and foundation trusts, and we will encourage new capacity in delivering services through social enterprises, charities, private companies, and, indeed, NHS providers.
We want clinicians and their patients to lead the NHS, but they cannot do this while they sit under a vast hierarchy of regional and local organisations, all reporting to Whitehall. Everyone agrees that top-down command and control gets in the way of clinicians doing their job, so we need to dismantle the structures that sustain that interference; that is why we will abolish primary care trusts and strategic health authorities. There are many excellent people working in those organisations. Many will move to be with the new general practice-led commissioning consortia, to local authorities and to the NHS commissioning board. Some will want to set up their own new social enterprises. But even the best people cannot deliver the NHS that patients need if things stay as they are, so we will also introduce direct local democratic accountability. Councillor-led health and wellbeing boards will oversee and work with local NHS consortia, working to bring together the NHS, social care and public health services, and bringing a strategic coherence to the health and well-being of local communities.
On bottom-up decision making at a local level, will the Secretary of State give a guarantee to the House that if the GPs now coming together in consortia decide that they wish to employ the expertise residing in the current primary care trust, he and the future health board will not intervene to stop them doing that? Will he also guarantee that he will not insist on redundancies that cost a fortune and preclude that expertise being available to the existing local consortia, with private enterprises then employing them to do the job that they were doing in the first place?
Let me make two points to the right hon. Gentleman. First, in the impact assessment that we published with the Bill on 19 January, we set out very clearly our estimates—they are no more than estimates since they will have to be decided by the general practice commissioning consortia and local authorities—that between 50% and 70% of the staff in primary care trusts would be employed in the successor organisations.
Secondly, the idea that somehow general practice-led commissioning consortia would engage the private sector where that has not happened up until now is, I am afraid, completely contradicted by the facts. Under the Labour Government, in the two years leading up to the election, there was an 80% increase in the use of management consultants, while at the same time the number of administrators and managers in those same organisations was rising dramatically. We arrived at the point where there were 50,000 administrators in primary care trusts, and they were still spending nearly £300 million a year on top for management consultancy. That all has to change.
One thing that Labour abjectly failed to do was to empower patients with a real voice in the health service. Through this Bill we will establish local healthwatch organisations that will represent the patient’s voice in the design of local services and help individual patients, especially the most vulnerable, to make the most of the choices available to them and to help them when things go wrong. Sitting within the Care Quality Commission, the national healthwatch organisation, too, will act as the eyes and ears of the quality regulator, and work to give the local organisations real teeth in their dealings with their local NHS—something that was completely, abjectly destroyed by the Labour Government when they abolished community health councils. Indeed, I know that families of those treated at the Mid Staffordshire hospitals welcome the additional powers for patients to have a voice.
The right hon. Gentleman will know that the Bill introduces European competition law into the national health service, and removes the existing protection once and for all. His Government have just taken the decision to put billions of pounds into stopping Irish banks failing. If a local hospital fails under the new market arrangements, will he step in and save it?
Time does not permit me to explain the extraordinary ignorance of that series of points. First, the Bill sets out that the regulator will have a responsibility to establish a failure regime. In 2003, when the predecessors of those currently on the Labour Front Bench took the health legislation through the House, they said that they would introduce a failure regime, to be implemented by Monitor, in legislation. They never did so. At the moment, there is therefore no proper failure regime.
Secondly, European competition law—indeed, competition law—applies in this country. A body was established in the national health service under the previous Labour Government called the co-operation and competition panel, the express purpose of which was to apply competition rules in the NHS. To that extent, all the Bill will do is to ensure that the rules that already apply are applied fairly, consistently and transparently across all providers.
I am grateful to my hon. Friend for that question. In addition to the measures on healthwatch and patient voice, we are strengthening the responsibilities of commissioners. As I suspect he knows from his local knowledge, general practitioners knew in many cases that the services at Stafford hospital were not meeting the quality of care that they ought to have met. However, there was no transparency in the outcomes, and there was no responsibility collectively among general practices and local health professionals to intervene. There was no mechanism that enabled or incentivised them to do so. We are going to change that. When Sir Robert Francis’s report is published in due course, I hope that the Bill, by strengthening patient voice, commissioning and the regulatory structure, will give the opportunity for whatever recommendations he makes to be implemented rapidly.
I apologise, but I have taken longer than I had intended, and 57 Members are waiting to speak.
I will explain further what the Bill will do. Local authorities, with a ring-fenced budget, will bring public health to the front and centre of public policy. This is not just about the NHS, but about improving the health of the whole population. That is why we are putting local authorities at the heart of it. The health of the general public is as much about the environment, the economy, housing and transport as what happens in the NHS. Health and wellbeing boards will make the link between health and social care, which have too often been in silos. We understand how intertwined those things are and how they must work together.
No, not at the moment.
The unions, of course, are against this modernisation of our public services. I suspect that they are the “forces of conservatism” that, more than a decade ago, the former Prime Minister told us he had to fight against. They oppose the principles of our plans, or so they say, but do they have an alternative? No. That contrasts completely with the reaction of general practitioners and health care professionals in GP pathfinders.
I have given way to the right hon. Gentleman before.
General practitioners and health care professionals in GP pathfinders are, in contrast to the unions, enthusiastic about what we are trying to achieve. For example, Dr Paul Zollinger-Read, a general practitioner and the chief executive of NHS Cambridgeshire, said recently:
“In our area, the GPs got together and focused on quality of care. They looked at diabetic care, for example, and services in this area improved. That means fewer diabetics will need to go to hospital in an emergency, there will be fewer amputations and less heart and kidney disease.”
Far from GPs being reluctant at the thought of taking on new responsibilities, applications to be pathfinder consortia were over-subscribed.
No, not at the moment. Sorry.
There are now 141 pathfinders, covering more than 28 million patients. More than half the population are already benefiting from the clinical leadership of their local health professionals. I have met some of the pioneers, such as in Redbridge, where they are pioneering bringing ophthalmology and dermatology services out into the community, and in Bexley, where they have pioneered better access to cardiology services for their patients. [Interruption.] Opposition Members say that they were doing that, but my whole point is that we are turning the exceptional cases in which GPs have had such opportunities in the past into the opportunity for all GPs across the country to do so. The Opposition might like to talk to the new chair of the clinical cabinet in Bexley, one Dr Howard Stoate, whom they will recall as a Member of the House before the election.
It is not only GPs who are anxious to get on with it. We are already working with 25 early implementer health and wellbeing boards that want to start bringing benefits to their communities. By April, we expect to be working with up to half of all local authorities, and the Bill will create that framework. Whereas the previous Government often talked a good game, we will put our ambitions and the new roles into law. The Bill explicitly defines roles and responsibilities that were previously at the discretion of Ministers. Until now, legislation on the NHS has more or less said, “The NHS is whatever the Secretary of State chooses to make it at any given moment.” That was why, in the past, reorganisations took place on a practically annual basis under the Labour Government, without there ever being any consistency or coherence to them. I intend to be the first Secretary of State in the history of the NHS who, rather than grabbing more power or holding on to it, will give it away.
As well as devolving decision making, the Bill will transfer power back to Parliament and strengthen the accountability and transparency of the NHS. It will protect the NHS constitution, ensuring that the rights in it are reflected within NHS commissioning and regulation. It contains a number of new duties, including a duty on the Secretary of State, the NHS commissioning board and each commissioning consortium to seek continuous improvement in the quality of services, and to seek to reduce inequalities in access and health outcomes.
The Bill contains a duty of autonomy, so that politicians allow providers and commissioners to provide the best care as they see fit, minimising burdens wherever possible. There is a duty on Monitor to protect and promote the interests of patients, through competition where appropriate and through regulation where necessary. The role of local authorities will increase greatly, including not only the scrutinising of local health services but a duty to promote integrated working between the NHS, social care services and public health services.
As I have said, in 2003 Labour promised a proper regime in the event of the failure of any provider of NHS care. They did not provide that; this Bill will. Should a provider fail, there will be a transparent process for maintaining designated services, to ensure continuity of services for patients.
Monitor will be empowered to set up a “risk pool”, to which providers will pay a levy that will meet the costs of maintaining key services. There will also be a clear and transparent process for setting the NHS tariff for different services. The National Institute for Health and Clinical Excellence will develop quality standards, give advice and make recommendations on the clinical effectiveness of medicines and treatment. As the shadow Secretary of State said a fortnight ago, the Bill is “consistent, coherent and comprehensive”. It will put patients first and improve health outcomes.
I must conclude and allow other Members to contribute to the debate.
The Bill will change structures, abolish bureaucracy and inject added competition, but those are only the means to a much greater end. As large and complex as it is, there is one simple objective behind the Bill—better care for patients, measured not by political targets but by real results for patients. It is about gearing the entire system towards supporting the relationship between doctor and patient—a “meeting of experts”, as Tuckett would have called it, with the patient being an expert on themselves and the clinician being an expert on their clinical management and condition. It is about bringing the two together based on trust, transparency and the best available treatment from the best available provider.
Previous changes have tinkered with one piece of the NHS or another, when what was needed was comprehensive modernisation to create an NHS fit for the demands of the 21st century. That is precisely what this Health and Social Care Bill will deliver. What we see from the Labour party is nothing but opposition for its own sake—opposition to the modernisation that the NHS needs—and most of it is inconsistent with Labour’s own manifesto. It is clear that Labour opposes not only our investment in the NHS and our cuts in NHS bureaucracy but our modernisation of the NHS, which it pursued while in government.
The House knows my passion for the NHS, my respect for those who work in it and my ambition for it to be the best health care service in the world. This Bill, and the modernisation of which the Bill is just a part, are about that passion for the NHS and for securing its future. I commend the Bill to the House.
The Health Secretary is a man who is struggling to sell his plans. The more people learn about them, the less they like them. The more those in the NHS see, the more worried they become and the less they find to support. Only one in four of the public back him in wanting profit-making companies to be given free access to the NHS. Most GPs neither like nor want these changes, and three out of four doctors do not believe that they will improve services to patients.
Today, for the second week running, the Prime Minister is talking about the NHS changes. He is like a football club chairman stepping in to back a beleaguered manager because everyone else is losing faith in the manager’s judgment. Mind you, the Prime Minister does not always help the Health Secretary, because his words do not ring true with people. Last week, the Prime Minister called the NHS “second rate”. People know that it can be better, but they are proud of the NHS. They have seen big improvements during the last Labour decade, and they know that waiting lists are at their lowest ever and that patient satisfaction is at its highest ever. Those facts are backed up by international comparisons from the Commonwealth Fund, which said last year that Britain’s NHS is one of the very best in the world, and second to none on best value for money.
The Labour Government introduced foundation hospitals, private sector provision in the NHS, patient choice and payment by results—four things on which we are now building. They also introduced GP commissioning through pathfinders. Which elements of the Blair reforms to the health service is the right hon. Gentleman not repudiating today?
It is true that we encouraged many of the GP commissioning models that the Health Secretary now champions, but that process was always within a planned and managed system, and it was never implemented at the expense of other clinicians or patients being in charge. We used private providers when they could add something to the NHS and help it to raise its game, and when they could add capacity so that we could clear waiting lists. Of course there is a role for them in the future, but that is not the question at the heart of the Bill. I will come back to the hon. Gentleman’s question later, however. People saw big improvements in the NHS under Labour, but they now realise that many of those gains might be at risk as a result of the decisions that this Government are taking.
Does my right hon. Friend agree that the most significant change in the Bill was not mentioned by the Secretary of State? It is that the Bill introduces price competition into a market that, up to now, has allowed competition only on quality. The London School of Economics, citing academic evidence, states clearly that
“most international evidence suggests that, whereas hospital competition with fixed prices can improve quality, simultaneous price and quality competition can actually make things worse”.
I shall answer my right hon. Friend the Member for South Shields (David Miliband), then I will give way.
My right hon. Friend is absolutely right. The Government will talk about some changes, but not about others. The changes are like an iceberg, with big, substantial, ideological changes hidden from public sight.
The edifice of an argument from the right hon. Member for South Shields (David Miliband), which is repeated by others, is based on one fact: in December 2009, the operating framework said that commissioners in the NHS could set a maximum price and not just a fixed price. That was December 2009. The right hon. Gentleman and the shadow Health Secretary were in the Government who put that measure into the operating framework. This Government did not put it in; the previous one did.
The point made by my right hon. Friend the Member for South Shields is based on page 42 onwards of the Health Secretary’s impact assessment of the Bill, which mentions a premium for private providers of £14 per £100. The Bill allows the system to pay a premium and a bung to private sector providers.
Will the right hon. Gentleman now answer the question put to him by my right hon. Friend the Health Secretary? Does he agree or disagree with the maximum price tariff principle that was set out in December 2009 by the previous Labour Health Secretary?
We operated an NHS with a set tariff, not a maximum tariff. In government, we operated an NHS in which price could not be the factor that drove decisions about what services patients received and by whom they were provided. My right hon. Friend the Member for South Shields is absolutely right to point out that the Bill will introduce price competition and the flexing of the price so that there is no longer a set tariff for treatments and patients but a maximum price that can be undercut by providers coming into the field. The Government will not talk about that.
The Prime Minister is not helping the Health Secretary, because the changes the Bill makes were not in his election manifesto, not on his election posters and not in his election speeches. I have the Conservative manifesto here. There is no mention of axing all limits on NHS hospitals treating private patients, so that NHS patients lose out; no talk or mention of undercutting on price, so that established NHS services are hit as new private companies cherry-pick easier patients and services; no mention of guaranteeing only selective hospital services, so that others can be closed and lost to local people without public consultation; and no mention of putting a new market regulator at the heart of the NHS with the principal job of promoting and enforcing competition. There is no mention in the Conservative manifesto of the biggest reorganisation of the NHS since it was set up more than 60 years ago. They did not tell people about their plans before the election and they promised not to introduce such measures in the coalition agreement after the election. There is no mandate from the election or the coalition agreement for this fundamental and far-reaching reorganisation. That is not a debating point, but a point of democratic principle.
I do not remember in the 2005 Labour party manifesto the “Meeting Patients’ Needs” programme that closed the A and E unit and the children’s ward in Burnley. Do not start getting on to us about what we are and are not closing. The right hon. Gentleman closed those things. Does he agree that what he did was a disgrace to the people of Burnley?
May I urge the hon. Gentleman to look very closely at the Bill and beyond what he hears the Health Secretary say when he talks about it? I urge him instead to look at how local hospitals could be undercut by private health companies, and at how GPs could be forced to put out work to those companies. That will undermine local hospitals such as the one in Burnley and lead to hospital closures driven not by proper planning and the development of better services in the community, but by hospitals being driven to the point of bankruptcy and closure.
The right hon. Gentleman does not seem to understand how the health service operated under his Labour Government. My constituents in Warwickshire have been suffering because NHS Warwickshire, under the rules we inherited from his Government, set up a fixed-price, below-tariff contract with one of the trusts in its area that has led to patients being drained from the George Eliot hospital trust in my area and the area of my hon. Friend the Member for Nuneaton (Mr Jones) to Warwick. It was Labour’s rules that allowed it to undercut the hospital in my constituency.
If the hon. Gentleman was worried about the past, he should be a good deal more worried about the future, and, a bit like the Health Secretary, he should spend a lot less time talking about the Labour Government and what we did to the health service and more time talking about the plans and big changes to come.
Does my right hon. Friend accept that the core difficulty with the Bill is that it is not about patient choice but about a movement towards general practitioner choice and GP consortia choice? They want to maximise not medical outcomes but profitability. That is what this is about, and the reason is the same as what was said about flexible pricing.
My hon. Friend is right. For the first time in the NHS we are facing, first, the potential for profit at the point of commissioning and, secondly, commissioning—in other words, decisions about rationing as well as referral—being made at the individual patient level, not at the collective area level, and we are looking at them being made by bodies and individuals who are not publicly accountable, including to the House.
My right hon. Friend is right to press the case about private providers. Is he surprised that the Secretary of State, in response to my question earlier, did not confirm to the House that the wife of John Nash, the chairman of Care UK, funded his office in November 2009 to the tune of £21,000? Does he think that the Secretary of State should put that on the record?
Mr Nash’s wife also bankrolled my opponent at the last election—for all the good it did him. However, something else was not in the Tory party manifesto, and that was cuts in the health service. I have in my hand a letter from the chief executive of my primary care trust that simply states that
“healthcare in North West London will face a £1bn shortfall in funding by 2014/15, given these upward pressures.”
Is that not something else that the Tory party did not tell the truth about, and something on which it is not following the Labour Government?
My hon. Friend won his seat at the last election because he helped to expose the truth about the Conservative plans for housing—a truth that it denied but which has now come true. He is absolutely right. The truth about what is happening in the health service now is that patients are starting to see the signs of strain and services being cut, and that is not what they expected when they heard the Prime Minister, before the election and afterwards, promising to protect the NHS.
I thank the right hon. Gentleman for giving way. In my first two weeks as an MP, I paid a visit to the local PCT in Leicester, and in a meeting with the chief executive I asked how the PCT would cope with the immediate 35% cuts in management imposed by the coalition Government. The answer truly shocked me: I was told, “It will be no problem at all, because we have already increased our management by 50% in the past year.” Will the right hon. Gentleman accept that under the previous Government’s watch, the PCTs became the bloated bureaucracies that now need reforming?
The problem for PCTs, and the managers and staff who work in them, is that they are being asked to do several things at the same time: to make unprecedented efficiencies at a time when the NHS is being put through its tightest financial squeeze in history; to axe its own jobs; and to guide the reorganisation and ensure that it can take place. That is a tough challenge for anyone. I am sure that the hon. Gentleman will keep on his local PCT’s case.
I am grateful to the shadow Secretary of State for giving way. I would accept his criticisms more openly—I think—were he prepared to acknowledge that the previous Labour Government set up independent treatment centres and rigged the market to hand over 15% of all elective operations in an area such as mine to an independent company that they more or less set up themselves, and which undermined the local acute trust and services with changes that patients had not asked for. That was forced on the PCT and not something for which it asked. It was a rigged market. Would he like to apologise to the House for the practices of the previous Labour Government?
I am more interested in what we will be facing in future. I am more interested in the claim by the Health Secretary that there will not be, as he describes it, a rigged market in future, but a level playing field for all providers. However, my hon. Friend—[Interruption.] Well, we will see. The hon. Gentleman is a member of the Select Committee on Health, and he follows such matters closely. I urge him to read page 42 onwards of the impact assessment, because there he will see the preparations for being able to pay for the sort of thing that he criticises in the health service.
As the hon. Gentleman gives me this opportunity, let me say to him and his Lib Dem colleagues that what we are facing is clearly Conservative health policy, not coalition health policy, and certainly not Lib Dem health policy. The main evidence of any influence of Lib Dem ideas on health policy in the coalition agreement was the commitment to
“ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust”.
The Bill abolishes PCTs. The Lib Dem policy priority before the election was to ensure that local people had more control over their health services. The Bill places sweeping powers in the hands of a new national quango—the national commissioning board—and a new national economic regulator, which is charged with enforcing competition, to open up all parts of the NHS to private health companies. The Lib Dems’ principal concern was to strengthen local and public accountability of health services, but the Bill seriously restricts openness, scrutiny and accountability to both the public and Parliament. It will lead to an NHS in which “commercial in confidence” is stamped on many of the most important decisions that are taken. I therefore say to the hon. Gentleman and his Lib Dem colleagues: this is not your policy, but it is being done in your name. The public will hold you—
Order. I know that this debate is attracting a lot of emotion and generating a lot of heat, but will Members please try to speak through the Chair? I have been accused by both sides of doing many things in this debate, and I have not done any of them.
I accept that correction, Mr Deputy Speaker. Let me put it in these terms. The policy is not Liberal Democrat policy, but it is being done in their name, and the public will hold the Liberal Democrats responsible if they allow the Tories to do this to our NHS.
Is my right hon. Friend aware that, in the rush to establish a GP commissioning system, PCTs are being merged, and that large numbers of highly skilled staff are disappearing quickly, as is the ability of PCTs to administer anything, and all this before the Bill has even received a Second Reading? Does he not think that the Secretary of State is culpable in the rapid disintegration and disorganisation of local NHS facilities all over the country?
That is one of the things that worries experts and those in the health service the most. It is also one of the things that the right hon. Member for Charnwood (Mr Dorrell) and his Health Committee were most concerned about. [Interruption.] The right hon. Gentleman is nodding. “Disruptive” was one term that the Committee used for the changes.
Why on earth should the health service be changed? We had 13 years. We dragged the health service from the depths of degradation and hoisted it to the pinnacles of achievement. There was £33 billion in 1997; we increased that to £110 billion. All those miners in my constituency and that of my right hon. Friend who wanted those knees or hips replaced—they have all been done, after waiting not for five years, but for a few months. That is what I call achievement, and that is what the people in Bolsover and elsewhere know. That is why the health service was safe in our hands and why, they assume, this one on the Government Front Bench is now going to privatise it.
Well, my hon. Friend is right in this respect: people will come to see clearly that they cannot trust the Tories with the NHS; they will come to see clearly what these changes really mean for their services; and they will come to see clearly what the future of the NHS holds.
I cannot follow the previous contribution, but the right hon. Gentleman has mentioned democratic accountability, so will he accept that in 10 years of Labour government, nothing was done about democratic accountability in the NHS? We simply had rule by quangos.
No, I do not accept that, but I will tell the hon. Gentleman that the measures in this Bill will undermine many of his principal concerns and policy priorities about opening up the NHS to the public and to Parliament. I hope that he will take a close look at what the Health Secretary really plans.
I hope that my right hon. Friend will agree that the NHS is supposed to be about people and their health, so does he also agree that putting different parts of the health service in competition with one another will lead to fragmented and disjointed pathways of care and undermine innovation and the sharing of best practice, as well as increasing administrative and other costs with public funding being wasted on transaction costs?
My hon. Friend is right—and the chief executive of the Patients Association, Katherine Murphy has said just that. Many patient groups are making the same arguments and issuing the same warnings.
My serious concern is that this Government have told only half the story from the start. The Health Secretary and the Prime Minister are happy to talk about GP commissioning and happy to talk about cutting management—the organisational changes—but they downplay or deny the deep ideological changes at the heart of these plans. The Health Secretary mentioned the new economic regulator, Monitor, in just one line in a speech lasting more than 40 minutes. The Prime Minister said last week in his speech on public services that these reforms
“are not about theory or ideology”.
The Prime Minister writes in The Times today, just as the Health Secretary did last week, both of them producing 700 words about their health plans, yet they made not a single mention of competition.
We will explain and expose the truth throughout this debate and the Bill’s passage through Parliament because these changes will break up the NHS; they will open up all areas of the NHS to price-cutting competition from private health companies; and they will take away from all parts of the NHS the requirement for proper openness, scrutiny and accountability to the public and to Parliament. These Government changes are driving free market political ideology into the heart of the NHS, and that is why doctors are now saying:
“As it stands, the UK Government’s new Bill spells the end of the NHS.”
The public are being told that the reorganisation is “patient centred”, but patients are being sold a false promise on the NHS. The changes in the Bill come in only in 2013, but patients are already seeing the consequences of the Government’s handling of the health service. The Government have scrapped Labour’s waiting time targets, which were, of course, the patients’ guarantee of being seen and treated promptly. They are breaking the Prime Minister’s promise of a real increase in NHS funding, so Scotland is being short-changed next year by £70 million and Wales is being short-changed next year by £40 million. England, if we take out the double counting of cash to be spent on social care rather than on NHS services, faces a shortfall next year of £1.2 billion on the Prime Minister’s promise.
With this Bill, the Government are now breaking their promise to stop top-down internal reorganisations and they are putting extra unnecessary pressure on the NHS. Patients are starting to see waiting times rise; they are starting to see discharges from hospital delayed; they are starting to see wards mothballed and staff posts cut. That is not what people expected when the Prime Minister promised to protect the NHS. The Prime Minister’s most personal pledge to the public is becoming his biggest broken promise.
Will the right hon. Gentleman try to understand—[Interruption.] Perhaps he will. Members suggest that this is ideological. I do not see how it is ideological not to repeat the gross error of 2008-09 when, under the right hon. Gentleman’s watch, managers were recruited at five times the rate of nurses working on the front line—which is not ideological either, and does not serve patients.
This is ideological. It is about driving politics into the heart of the NHS, and in some respects breaking what has been a 60-year consensus. Parties on all sides have tried to make decisions about the best interests of patients and better services, and not about their own political ideologies. That has changed today, with this Bill.
I want to make a bit of progress before I give way again.
The public are being told that this reorganisation is patient-centred, but most patients’ GPs will not, in practice, be doing what the Government claim they will be doing. GPs spend an average of only about eight minutes with each patient. If they continue as family doctors, the commissioning will not be done by them; it will be done in their name by the managers in the primary care trust who carry out that function now, or by private health companies that are already hard-selling their services to GP consortia. Those consortia are being sold a false promise as well. Because expanded open-ended choice of treatment means funding unused capacity in the system, it is highly unlikely to happen at a time when NHS finances are under pressure.
Despite the boast about putting patients at the heart of everything that the NHS does, there is no place for patients on the bodies that will make the most important decisions on the NHS. There is no place for them on GP consortia, no place for them on the national commissioning board, and no place for them on the regulator, Monitor.
The hon. Gentleman has already heard some of my hon. Friends mention the analysis of Dr John Appleby, published in the British Medical Journal online last week. He took to task those who had made the sweeping assertion that somehow Britain’s health service lags behind those of the rest of Europe. It is an argument that the Prime Minister advances. It is an argument for change, he says, because we are still a long way from European standards of care.
Let me read something to the House. We have been told that
“if you have heart surgery in England, you now have a greater chance of survival than almost any other European country – over the last five years, death rates have halved and are now 25 per cent lower than the European average.”
Those are not my words, or even those of Dr John Appleby. They are the words of the Health Secretary, published on ConservativeHome last week.
The Prime Minister argues that this is somehow an evolution and not a revolution. The Bill, however, is more than three times as long as the legislation that set up the NHS in 1948. The NHS chief executive told the Select Committee on Health:
“The scale of change is enormous—beyond anything that anybody from the public or private sector has witnessed”.
The Health Secretary argues that the Bill is somehow an extension of Labour policies. That is wrong, and it disguises again the fundamental changes to the NHS in the Government’s plan. Make no mistake, Mr Deputy Speaker: this is a revolution, not an evolution.
I note that the right hon. Gentleman failed to answer the question about the rate of increase in the number of managers. When I last checked, the NHS had 1.3 million employees, of whom almost exactly half were administrators and half were on the front line. Is he really willing to defend such an extraordinary level of overstaffing in management?
My hon. Friend may be right. I have not seen the regulations, but that is certainly in the impact assessment, so he is on to an important point.
Government Members and the Health Secretary have spent a long time talking about Labour’s plans, policies and record, but the debate at the heart of this Bill is not about whether competition, choice or the private sector has a part to play in the NHS—they have and they do. The debate at the heart of this Bill is about whether full-blown competition, based on price and ruled by competition law, is the right basis for our NHS. That is why Labour Members oppose this Bill. We want the NHS run on the basis of what is best for patients, not what is best for the market. We want the NHS to be driven by the ethos of public service, not by the economics of forced competition. We will defend to the end a health service that is there for all, fair for all and free to all who need it when they need it.
If the stated aims for the reform were all the Government wanted—we have heard the Health Secretary say that he wants a greater role for doctors in commissioning, more involvement of patients, less bureaucracy and greater priority put on to improving health outcomes—he should do what the GPs say: turn the primary care trust boards over to doctors and patients, so that they can run this and do the job. But there is no correlation between the aims that the Health Secretary sets out and the actions he is taking. There is no connection between his aims and his actions. He is pursuing his actions because his aims are not sufficient. His actions would not achieve the full-scale switch to forced market competition, which is the true purpose of the changes.
Meanwhile, the biggest challenges and changes for the NHS will be made harder, not easier, by the reorganisation. Such challenges include making £20 billion of efficiency savings and improving patient services; ensuring better integration of social care and health care, of primary care and hospital care, and of public health and community health; and providing more services in closer reach of patients in the community rather than in hospital. But the Government will not listen to the warnings from the NHS experts, the NHS professional bodies, patient groups or even the Select Committee on Health.
In a disparaging comment earlier, the Secretary of State said that the voices of concern were the voices of the trade unions. They are led by people who were health professionals and they represent 1.3 million professionals. Surely somebody in this place should listen to what they say and not to Government Members, who have a biased reason for doing this.
My hon. Friend is right. The more that NHS staff see of the changes and the consequences of this Government’s handling of the NHS, the more concerned they are about the changes and the more they are starting to see the NHS go backwards. But the Government will not listen to these warnings that are coming from all sides. They are in denial about the risks: the risk that patients will see services get worse, not better; the risk that up to £3 billion will be wasted on internal reorganisation; the risk that innovation and improvements in care that come from greater collaboration will be blocked by the Office of Fair Trading, competition courts and the new market regulator; and the risk that the Bill will create the monster of a full-blown market in health care which GPs will not control and nor will Ministers or Parliament.
If patients have been sold a false prospectus, that is true of GPs too. GPs are being told that they will call the shots on deciding who provides care for their patients, but they are being set up by the Government. They are likely to find their hands tied by Monitor and the Office of Fair Trading and by the courts enforcing competition law. They are likely to find their decisions challenged by private companies if they do not accept “any willing provider”, especially one that offers to undercut on price. The chair of the Royal College of General Practitioners recently issued a warning to her colleagues. She said:
“I understood these reforms were about putting GPs at the centre of planning healthcare for their patients, not about making sweeping cuts, which will include shutting hospitals, making enormous redundancies, closing services”.
Because the reorganisation will force doctors to make rationing decisions as well as referral decisions for their patients, they will make treatment decisions with one eye on their patient and the other on their budget and their consortium’s bottom line.
The Government say they are devolving power to front-line services, putting clinicians in control, making the NHS more accountable and improving the integration and quality of services, but in the Bill they are making the forces of competition and centralisation far stronger than those of devolution, democratic accountability or the development of quality in patient services. We will explain and expose the gap between what Ministers are saying and what they are doing in every debate at every stage of this legislation.
Patients and staff are already seeing signs of strain in the NHS. They are starting to ask, “What on earth are the Government doing with the NHS? Why don’t they listen to the warnings? Why is the Prime Minister breaking the very personal promise he made to protect the NHS?” The Bill puts competition first and patients second. That is why we will oppose the Bill tonight and expose this truth in the months ahead. These are the wrong reforms for the wrong reasons at the wrong time.
Order. Because of the popularity of this debate, a six-minute limit on speeches has been introduced, with the usual injury time on two interventions. It is up to you whether you take the full six minutes and whether you take interventions, but, clearly, the more interventions there are and the longer you speak, the fewer people will get in.
I rise to support the Bill. The shadow Secretary of State started by saying that my right hon. Friend the Secretary of State struggled to explain his reasons for introducing the Bill, but I think that the shadow Secretary of State struggled to explain why he opposes it. He struggled from the moment that my hon. Friend the Member for Grantham and Stamford (Nick Boles) intervened to draw his attention to the fact that the Bill represents an evolution of policy that has been consistently developed by every Secretary of State since 1990, with a single exception in the form of the right hon. Member for Holborn and St Pancras (Frank Dobson), who sits on the Labour Back Benches. The question that the shadow Secretary of State has to answer is this.
Let me pose the question and I shall be delighted to give way. Which of the key themes does the right hon. Gentleman oppose? Is it the practice-based commissioning or the “any willing provider” model? Is it the introduction of private sector expertise into commissioning, which was first articulated in the world class commissioning programme, or is it the principle of the maximum tariff? Let me help him by quoting from the operating framework of 2009, to which my right hon. Friend the Secretary of State referred. It states:
“After 2010/11, we shall move to a position where national tariffs represent the maximum price payable to a commissioner, as opposed to the mandated price for a particular activity.”
With which of those four key policies does the right hon. Gentleman disagree?
The right hon. Gentleman started by saying that the policies are an evolution. If that is the case, why did he say:
“I thought we were looking to develop existing institutions rather than starting again, and that appeared to be confirmed in the coalition agreement.”
Indeed it did. I offered the right hon. Gentleman four consistent themes of policy. He accurately quoted my comments about a specific element of bureaucracy. One of the questions that the Select Committee addressed was why, since all these broad themes are so broadly supported, we went down the road of replacing the PCTs with the consortia. That is a question that the Select Committee said in its report had not been adequately explained, but that is a relatively minor question of bureaucratic presentation when compared with the broad themes of policy that were articulated in the debate by my hon. Friend the Member for Grantham and Stamford. Which of these key policies does Labour now wish to dissent from?
I wonder whether the Select Committee agrees that private contractors, where they are engaged, should be required to publish the same information about cost, quality and outcomes as NHS providers, to ensure a level playing field and real, true comparison.
I have been here long enough not to presume to speak on behalf of a Select Committee on a question that the Select Committee has not addressed, but I think there would be broad support across the House for the principle that where the private sector provides a service to a public sector commissioner, the private sector provider should be accountable to that commissioner on precisely the same terms as the public sector provider. As my hon. Friend the Member for St Ives (Andrew George) mentioned in his intervention on the shadow Health Secretary, one of the problems about the independent sector treatment centre programme was exactly the point that the hon. Gentleman makes—the accountability expected of a private sector provider was different from the accountability expected of a public sector provider.
Therefore, I agree with the hon. Gentleman and hope that he can persuade his right hon. and hon. Friends on the Front Bench to endorse the principle of common accountability for public and private sector providers providing a service to a public sector commissioner. I see my right hon. and hon. Friends on the Government Front Bench endorsing the principle. I hope that I am not misrepresenting the way that they are reacting to the hon. Gentleman’s question.
This is a consistent set of themes. Why is it consistent? I want to move the debate on. The House of Commons loves debating structures in the national health service. The inference from what I have said so far might be that that means it is all business as usual—that what has gone on, with the exception of the period when the right hon. Member for Holborn and St Pancras was in charge, is a seamless development of policy since 1990.
However, the truth is that during the lifetime of this Parliament the national health service faces a genuinely unprecedented challenge, first articulated not by my right hon. Friend the Secretary of State in the present Government, but by the chief executive of the health service before the general election in May 2009, when he drew attention to the fact that demand for health care should be expected to continue to rise at roughly 4% per annum, as it has done throughout the recent history of the national health service. However, because of the budget deficit, we will not see the health budget continue to rise to absorb that rise in demand, in the way it has over the past decade.
Therefore, during the lifetime of this Parliament, we will have to see, in the national health service, a 4% efficiency gain four years running—something that not merely our health care system, but no other health care system in the world, has ever delivered. The Select Committee has referred to that as the Nicholson challenge, reflecting the fact that it was first articulated by the chief executive and endorsed by the previous Government. Again, this is a case of a shared agenda across the House of Commons.
Given the Budget deficit, the only way we can continue to meet the demand for high-quality health care, which we all want to see, is by delivering an unprecedented efficiency gain in the NHS for four years running. That is why I support the Bill. I support it because to my mind it is inconceivable that we can deliver such an efficiency gain without delivering more effectively than we have done yet on the ideas, which have been endorsed over the past 20 years, about greater clinical engagement in NHS commissioning, which I have been talking about. Commissioning cannot be successful if it is something that is done to doctors by managers; it must engage the whole clinical community. We must address the democratic deficit, because we cannot bring change on the scale that we need to deliver the efficiency gain without engaging local communities.
Finally, the NHS must also be a national service that is accountable through the commissioning consortia, the commissioning board and the Secretary of State to this House, because it is ultimately the taxpayers who pay for it. Those are the principles that were set out by the Health Committee, and it is those that we will seek to review as the Bill goes through Parliament.
I make no apologies for the policies that were pursued while I was Secretary of State for Health, because I set about implementing every item in Labour’s election manifesto. I know that implementing promises in election manifestos has gone out of fashion on the Government Benches, but it has not gone out of fashion with me. Before I became Health Secretary, while I was Health Secretary and since, most doctors, nurses, midwives and others in the health service have said above all, “For God’s sake, leave us alone, stop diverting our attention into reorganisation and let us get on with the job of looking after patients and raising standards of treatment and care.” Presumably, that was why the Conservative manifesto and the coalition programme both stated:
“We will stop the top-down reorganisations of the NHS”.
They claim that their proposed reforms are not top-down, but I cannot think of anything more top-down than an Act of Parliament set out in 353 pages and 61,344 words, and yet it is still a broken promise.
The NHS, as we all know, is doing better than ever before: waiting lists have come down dramatically; waiting times have been massively reduced; and survival rates are dramatically improving. Most people, in most places, and most of the time, are getting a very good deal from the health service, which is why it is more popular than ever before.
No, I do not have time.
Those improvements have come about not as a result of any structural changes, but because the Labour Government put into the NHS more money than ever before, built more new hospitals than ever before, put in more new equipment and, above all, recruited record numbers of doctors and nurses. We also put more emphasis on standards and on trying to ensure that we spread best practice right across the health service.
I accept that we need more clinician involvement in decision making, but we do not need to go to GP commissioning to bring that about. All we need do is get more of them on primary care trusts with more influence there. Why is it just confined to GPs? There is no reference to greater involvement of hospital specialists and there is nothing in the 61,000-odd words about giving hospital doctors a bigger say, and they have some expertise in these matters. Many GPs, as we know, do not support the proposals, and many of them want to get on with just being doctors.
One great deception that is being promoted is saying to patients, “You and your GP will decide where you will get treated.” That is simply not true. Unless the consortium of which the GP is a compulsory member has a contract with a particular hospital, the patient will not be able to go there from their GP.
The NHS is essentially a co-operative organisation in principle and in practice, and now it will be forced to compete: every part of the health service competing with the other parts and the private sector on price. It is rather remarkable, considering all the Eurosceptics on the Government Benches, that the Government are going to force our NHS to comply with European competition rules set out in the Lisbon treaty—the Lisbon treaty that the Tories voted against. Who is most likely to benefit from those rules? The answer is American health corporations, almost all of which have been indicted in the United States for defrauding US taxpayers, doctors, patients and, sometimes, all three. I asked the Secretary of State whether he would rule out any of those outfits obtaining contracts, and I am afraid his answer was, “I can’t say.”
The next question is, how will we know what is going on? How will we and local TV, radio and newspapers know what is being decided? In the Bill, there is no serious obligation for hardly any of the decision-making bodies to hold their meetings in public; there is no obligation on declaration of interests; and there is no obligation on consultation. If anyone says, “Well, freedom of information will cope,” we know what the answer will be, “Commercial confidentiality; you can’t have it.” If we are to have a competitive system, almost everything will be commercial and, therefore, almost everything will be confidential.
These proposals will divert people in the NHS from their job of looking after people. The Government are privatising the NHS, they are fragmenting the NHS, they will cost us a fortune and do little or no good for anybody.
I shall support the Bill, because it will mean an end to the disruption and devastation of local hospital services owing to overpaid, faceless bureaucrats in palatial offices many miles from people’s local hospitals deciding that a particular service is no longer needed or is better off elsewhere. The Bill’s local democratic legitimacy policy strives to ensure that decisions on serious hospital reconfigurations never again ride roughshod over the wishes of the local community.
When I asked the Secretary of State who would make the decision if the consortium and the health and wellbeing board disagreed on the reconfiguration of hospitals, he said the reconfiguration panel as it exists today—no difference.
I am pleased that the reconfiguration board is now studying a decision that the previous Government made to close my local hospital’s children’s ward. The Secretary of State is due to rule on that shortly.
A prime example of the authoritarian nature of primary care trusts can be seen in my constituency. Without proper consultation, we have seen our accident and emergency department closed and our children’s ward transferred to Blackburn. My constituency is seriously deprived, and the decisions made by managers in Manchester have had a disastrous effect on the health and well-being of thousands of my constituents, many being seriously ill children. The proposals before us will ensure that, for the first time, commissioners and all providers of NHS-funded services have to consult the local authority on the proposed substantial reconfiguration of designated services. In my eyes, that can only be a good thing.
I want to bring to the House’s notice a young man called Logan Cockroft, who lives in my constituency. He has cerebral palsy, and he cannot speak or walk. The only thing that Logan can do is smile. His parents live near Burnley general hospital; they moved there because of Logan’s illness. He made many visits to the hospital because of his illness, the nurses knew him, and he was happy to go there. Logan seemed intent on smothering himself with a pillow, so the nurses at Burnley hospital kept a close eye on him and put him close to the nurses’ station. The family were happy with the treatment that Logan received. Unfortunately, under their meeting patient needs programmes, the previous Government closed down our children’s ward. Logan now has to go to Blackburn. The nurses on the children’s ward in Blackburn do not know Logan. They do not know about Logan’s problems.
The service was removed by the hon. Lady’s Government, so I do not need to worry too much about private services.
As I said, Logan has those problems. When he is in Blackburn, his parents are extremely concerned about the care that he is receiving—not because the care is poor, but because staff there are seriously stretched. An attempt has been made to put the children’s ward in Burnley into the children’s ward in Blackburn, which was already overloaded, and the staff cannot manage. That cannot be right and it would not have happened if the PCT had contacted the people of Burnley, who have signed a 25,000-name petition against the move. Almost every GP is against the move, and the people of Burnley are unanimously against it. The move would not have happened under the new system that we are setting up.
The bureaucrats in Manchester tell me that the reconfiguration is not about money but about what is best for Burnley. I tell them that their unfounded interference will result in deaths. Nobody in my constituency wanted the A and E or children’s wards to close; they were a valued service. The Bill will strengthen democratic involvement by ensuring that the full council decides on whether to refer proposals to the NHS commissioning board or the Secretary of State. The people of Burnley had no say at all in what happened to our children’s ward. The Bill will strengthen the important function of scrutiny and recognise the new enhanced leadership of local authorities in health and social care.
It is about time—[Interruption.] I have been here only six months; if Labour Members cannot win, they start arguing, don’t they? But they never stand up and say anything fruitful.
It is about time that measures were put in place to strengthen the role of local authorities and the involvement of democratically elected representatives. That is how there will be representation. We will have somebody to listen to us who has been democratically elected. I have met no one in Burnley who found anybody in the primary care trust or the palatial offices of the strategic health authority in Manchester to speak to about the closure of the children’s ward. Now the people’s voices will be heard.
I am particularly pleased that the Government recognise that district councils have an important role to play in shaping our local hospitals. I hope that the proposed health and wellbeing boards take into account the recommendations of local hospitals and listen to patients. I trust GPs in Burnley to make the right call about our hospital. I only wish that these measures had been in place before the previous Administration reduced services at Burnley general hospital to the point of non-existence.
I welcome these radical changes. Local democratic legitimacy in decision making about our hospitals is desperately needed. It is time that we gave power back to the people.
I shall move on quickly. We had seven hours and 45 minutes to debate the Bill, but the first hour and 15 minutes was taken up by Front Benchers. Given that the Government have not found time to debate the White Paper that they published in July, we should probably have had two days’ debate on a Bill as important as this. As the shadow Secretary of State said, it is far larger than the 1948 Bill that established the national health service.
I find it difficult to find any justification for such a major reorganisation of our NHS. We have had a decade of major investment and we have seen improving services and major satisfaction ratings given by patients. In November 2009, the then Leader of the Opposition, now Prime Minister, said that
“with the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS.”
He was supported by the now Secretary of State for Health, who said as shadow Secretary of State in July 2007 that the NHS needed no more top-down reorganisation. Indeed, even after the general election, the coalition agreement stated:
“We will stop the top-down reorganisations of the NHS that have got in the way of patient care.”
It went on to spell out the continuing role of PCTs in some detail, pledging:
“We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust…The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level”.
A few months later, we have this potential chaos thrown on to the national health service. Once again, people are looking at the NHS and trying to change its culture by reorganising it.
We have had 30 years of Governments of different political persuasions trying to change the culture of the national health service by reorganisation. Every time, there have been years-long delays in implementation, performance has been affected in a negative way and there have been costs—particularly on this occasion, when the NHS is being instructed to make efficiency savings.
I agree with the report on commissioning just published by the Health Committee. I am not too sure whether the Chair agrees with it himself; the right hon. Member for Charnwood (Mr Dorrell) spoke earlier. The report states:
“The Coalition Programme anticipated an evolution of existing institutions; the White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy has yet been sufficiently explained given the costs and uncertainties generated by the process.”
The last 30 years should tell the House and the Government exactly that.
That is an interesting comment, but the Bill does not represent that. In my borough, the PCT—as was; it still is, although it is now Rotherham NHS—will become the GP commissioning consortium. Let us not get away from that. The idea that getting rid of the strategic health authorities or anything else is going to save massive amounts of money is palpable nonsense.
Does anybody think that top-down meddling is going to end because of this reorganisation? If the local GP consortium does not offer provision as it should, the national commissioning board will tell it what to do. If that is not top-down, I do not know what is. Those will be the people responsible for whether local residents, particularly those who need specialised commissioning, are going to get the services or not. The idea that those people are going to be responsible for NHS dentistry in my constituency is nonsense. There has now been a move away from midwifery, and that was going to be commissioned nationally. The changes are nonsense; they have been ill thought out.
The Chair of the Health Committee also set out the central challenge, which was recognised by the previous Government: to make major savings, year on year, for the next four years, at a time when budgets will not be able to increase—or at least not by much. How does the right hon. Gentleman think that that issue could best be addressed? Suggesting, as he did at the beginning, that we could just carry on as we were would not be sustainable.
I am not saying that savings should not be made. Indeed, the Select Committee in the last Parliament took evidence from the chief executive of the NHS on that particular point. The case that I make is about the type of reorganisation. Not only has nobody in the public sector ever been able to get 4% a year in savings, but nobody in the private sector has, in the time scale being predicted now. [Interruption.] The Secretary of State says that that is rubbish—it is not rubbish at all. He should go and talk to his advisers about what happens in the real world, as opposed to the world that has appeared since July last year.
I would like to say something in defence of managers. This Government have been bashing managers in the NHS every week they have been in office, and did so for many months before they got there. How do they think we got waiting lists for things such as new knee and hip joints down from years to months, and even weeks, in areas such as mine? I will tell them. It was not done by taking the surgeons out of theatres to do the administration, but by putting people in to do the administration so that the surgeons could spend more time in theatres seeing more patients. That is the real truth. The management -bashing that has been taking place of people inside the NHS might be popular on the ground, but let me say this to the Government: if they take those managers out and we go back to the waiting lists and waiting times of five or six years ago, they will see where popularity lies.
No, I will not; I have given way twice. The hon. Gentleman can make his own speech.
The King’s Fund, which the Secretary of State mentioned, supports some parts of the Bill. Indeed, I support a lot of its aims, but I do not support the reorganisation and upheaval that it will create inside the NHS. That is why I will vote against it. The King’s Fund says:
“The Bill abolishes the Health Protection Agency, places a duty on the Secretary of State to promote public health, and transfers responsibility for public health to local authorities.”
I agree with that. However, the Bill does not give me any confidence that GP consortia will have responsibility for the health of the population they cover.
Anybody looking at the history of public health in this country should recognise that we cannot run it on the basis of just handing it over to local government. The issues are far wider than that. The Secretary of State shakes his head, but people should look at the answers to questions that I got a week or so ago about what has happened to smoking cessation since this Government took over. Rates of smoking cessation have plummeted because of the advertising and promotion that is permitted. About 50% of health inequalities are created by smoking. The Government have taken their foot off the accelerator on the main thing that we should be doing to address public health inequalities, and they will suffer at the polls because of it.
It is always a pleasure to follow the right hon. Member for Rother Valley (Mr Barron). Although I did not agree with much of his speech, I strongly agree with his last point about the importance of keeping the foot on the accelerator to try to narrow health inequalities. That is right at the top of the priorities of Health Ministers. This is a very important and complex Bill. We all want to see high-quality care and value for the taxpayer in the provision of health care. I think it is fair to say that there has never been a better-informed, more knowledgeable and better-prepared incoming Secretary of State than we have at the moment.
The opening speeches by my right hon. Friend and by the shadow Secretary of State stood in stark contrast to one another. I feel rather sorry for the shadow Secretary of State. He is clearly an intelligent man, but he is cornered by the supplicatory role that his leader is playing to the trade union movement. I am sure that the shadow Secretary of State agrees with the Government’s introduction of independent treatment centres. I am sure that he also agrees with the previous Government’s introduction of the independent sector into provision and into commissioning, “any willing provider”, practice-based commissioning, payment by results—although it was payment by activity then—and national tariff ceilings within quality standard frameworks. However, he could not say so because he is cornered.
Listening to some Labour Members, one would think that there were no improvements to be made—that the national health service was a utopian structure prior to the last general election. Let me point to 10 things that I sketched out this morning: too much money spent on administration and bureaucracy and not enough on front-line patient care; too little patient-centric information to inform decision making; too little innovation; too little clinical input into decision making; too much inertia and hostility to reform, as we have seen today; too much process-driven target culture distorting clinical decision making; falling productivity; poor outcomes across a range of clinical indicators; too often, weak commissioning of servicing; and widening health inequalities in the past 10 years, in addition to the scandals that occurred in Staffordshire and Kent. That is hardly a situation that makes the status quo desirable.
My hon. Friend is absolutely right. I remember him fighting tirelessly and vociferously to try to prevent those in the health service and the then Health Secretary from allowing that to happen.
Another thing that Labour Members have to understand is that we must move the NHS towards being a service that is centred on the patient, not one where the patient revolves around the system. To enable that to happen, we must measure and improve outcomes on a continuing basis, and we must do it with patient-centric information that will enhance patient choice, not only about the choice of the provider and the location of their treatment, but about the treatment that they receive for their ailment. This Bill deals with all the failings that were present when the Labour party was in charge.
There are three or four areas where the detail still needs to be discussed, and I want to make some suggestions. There must be an opportunity for integrated care and for improved patient pathways. I would very much like acute clinicians, pharmacists and others who deliver patient care to be involved in GP consortia and the commissioning process. Some of the more forward-thinking consortia are already involving acute clinicians, and this needs to be implemented across the board. We need to find a non-prescriptive architecture to enable consortia to work together to collaborate where appropriate, not only in the all-important area of cancer, as appropriately highlighted by my hon. Friend the Member for Basildon and Billericay (Mr Baron), but in acute stroke services. This has been done successfully, and it must continue to be done.
Performance management is absolutely critical. The Bill seems to make no specific mention of out-of-hours care. My right hon. Friend the Secretary of State will remember only too clearly the terrible case of Mr Gray, who was killed by Dr Ubani, the out-of-hours doctor who flew in from Germany and prescribed him the wrong dose of a drug. That was a performance management failure. The SHA failed to monitor the PCT, which was failing to monitor the provider. We must ensure that GPs are involved in driving improvements in out-of-hours care as well as in-hours care.
We need to look at GPs’ contracts. It is rather perplexing that a PMS—personal medical services—contract could be held by a national commissioning board. Who will be in charge of revalidation, training and performance lists? We must move GPs’ quality and outcomes framework towards one that is outcome-based rather than process-based.
Like my hon. Friend, I will support the Bill. Does he hope, as I do, that the Government will look very carefully at any conflicts of interest? As we rightly give the power down to clinicians, we need to ensure that they always take decisions in the interests of the patient and not for their own financial gain.
I entirely agree with my hon. Friend. My understanding is that the NHS commissioning board will have a significant monitoring role to ensure that GPs commission services not automatically from themselves but from providers who provide the best outcomes for the patients they are trying to look after.
I would like to make one final point to the ministerial team. Information is the key that will drive improvements in the NHS, and that information must be comparable, easily accessible and easily understandable in order to inform patients’ decision making processes. It should not just be on the internet. We should not just wait for patients to access information—we have to find ways of taking it to them, particularly those living in socio-economically deprived areas.
The Bill is a significant step in the right direction. It preserves the best of the national health service—equality of access—while creating opportunities to improve the provision of health care in the UK, so that it can become among the best in the world, rather than lag behind. Excellence for all should be the goal.
It is a pleasure to follow the hon. Member for Boston and Skegness (Mark Simmonds). Although I do not agree with much of what he said—I certainly do not agree with his rationale for supporting the Bill—he made a few genuine points that, in the calmer atmosphere of a Committee, could be looked at in detail.
I agree with the hon. Gentleman that the difference between the two Front Benches could hardly be starker. This is about the view of what the national health service should be. I am not disappointed for one moment that the view of the Labour party is different from that of the Conservative party and its followers from the Liberal camp. Much has been made of that great event on 5 July 1948, when the national health service came into being. Of course, at the time, it was ferociously opposed by the Conservative party. At the beginning, it was also opposed by large parts, although not all, of the medical profession.
I will not give way, for one good reason: I might get injury time for it, but others would lose out.
The medical profession has changed its view, as has the Conservative party. The Conservative party has changed its view largely because the NHS and the principles that underpin it resound so clearly with the British people. This has been a difficulty for the Conservative party over the years.
I have seen a few Conservative party reorganisations of the health service. Thirty-five years ago, I was appointed to the Lambeth, Southwark and Lewisham area health authority, which included such hospitals as our local one over the river, St Thomas’s, Guy’s, King’s College and Lewisham. The AHAs were set up as a consequence of the Heath Government’s reforms in the early ’70s. They were abolished, but not before Lord Jenkin suspended the Lambeth, Southwark and Lewisham AHA for refusing to accept the cuts in the budgets that the then Government were trying to inflict.
The Tories reorganised the health service again and brought in district health authorities. I served on Lewisham and North Southwark district health authority for some time, until in 1990 I was thrown off for having the temerity to be a local councillor. I am sure that there are others around the Chamber who suffered similarly. Who engineered that amazing transformation? It was none other than the current Secretary of State for Justice. I think that he just sacked anybody who was not on his Christmas card list, quite frankly, because nothing in that reform of the health service did anything to improve its accountability or performance. It did hand over the health service, more than ever, to central control and direction, which, we are asked to believe, the Conservative party today decries so readily.
The Conservative party, of course, contains members who believe—and who go on foreign broadcasting stations to announce—that the national health service is a 60-year-old mistake. That is what was said by an MEP who was advising Republicans in the United States to oppose the Obama reforms. He was slapped down quite quickly, unsurprisingly. It is the great embarrassment of the Conservative party that it cannot reconcile its atavistic feelings towards the health service and belief in the free market with the feelings of the vast majority of the British people.
In recent years, as my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) pointed out, waiting times for most specialisms have come down almost to the point where they are no longer a consideration. I will tell the House briefly about the experience I had towards the end of 2009. I suffered chest pains of various kinds. I went to A and E at Lewisham hospital on 28 July. I was referred to the chest pain clinic at the same hospital the following week. I went for an angiogram at King’s College hospital two weeks after that, where the consultant advised me that I needed bypass surgery. I asked how long it would take—I did not mean the operation, obviously, but the wait. He said, “When can you come in?” I could not make the first date that I was offered, so I had to put it back. My experience was repeated millions of times across this country when the Labour party had stewardship of the NHS. It is that relationship that is so critically under attack.
The NHS is about patients—of course it is. Everybody knows that patients come first and that it must be patient-centred. Those things are meaningless clichés. Patient care and patient choice matter, but what matters more is patient trust. Patients must trust that any therapy, drug or treatment that is suggested by their clinicians and medical advisers is what is best for them—not what is cheapest or what has been contracted for. It is that critical, basic relationship in the national health service that is most under threat from this Bill and that Government.
I, too, rise to speak in favour of the Bill. There is a clear divide in the House between the Labour party, which stands by and defends NHS bureaucracy, box-ticking and putting bureaucracy in front of patients, and the Secretary of State and the coalition Government who genuinely want to deliver reforms that will benefit patients. As the Bill says, the people who are best placed to be the advocates of patients are doctors and other health care professionals. Such people are much better placed to be the advocates for their patients than the faceless bureaucrats who have made so many bad decisions, and who have put tick-boxes and targets in front of patient care.
A key issue in this debate was articulated by my right hon. Friend the Member for Charnwood (Mr Dorrell), who said that the NHS, whoever were in government, would face unprecedented strains and problems. One such problem is the ageing population. It is great that people live many years longer, but people consume the majority of their health care in the later years of their lives. Unless we reform the NHS, make it more patient-centred, and cut out the bureaucracy and put the money to better use on the front line, we will not be able to properly look after those older patients.
I agree that the issue of ageing patients is a fundamental challenge. Does my hon. Friend agree that domiciliary care, which is currently delivered through local authorities and primary care trusts, is a vital service that maintains many people’s health for the longer term and often prevents unnecessary stays in hospital? Does he agree that appropriate steps should be taken by the Government in the Bill to ensure access to high-quality domiciliary care for all?
My hon. Friend represents Eastbourne, which has a large elderly population. He is right to make that point. Under the Bill, health and wellbeing boards will be set up, which will deliver a proper partnership between GPs, hospitals and local councils. That will allow, for the first time, properly joined-up thinking about how we deliver social services care that is joined up with NHS care for older people. I am delighted that the Government will put in almost £1 billion to support that initiative, which can only be a good thing.
The second challenge facing the NHS, which my right hon. Member for Charnwood also mentioned, is that we are having to get more and more out of a limited resource, because people expect more and more from their health care, regardless of their age. People want, quite rightly, to be given the latest cancer drugs. They want to ensure that they have top-quality care and access to information that delivers that care. The problem with the bureaucracy that has been in place is that, far too often, it has taken too long to deliver higher quality care and a greater choice in treatment for patients. When we know that a cancer drug works, it should be available as soon as possible. It should not have to go through a process of two, three or four years of bureaucracy to be made available, and the Bill will help to change that. For those reasons, the Bill’s reforms to the NHS will provide an excellent framework in which to deliver better ways of spending limited resources and looking after our ever-ageing population.
A lot of health care professionals will be saying, as I did earlier, that far too often, medicine and health care have been reduced to a tick-box exercise, with targets and top-down bureaucracy getting in the way of patient care. Under the A and E targets delivered by the previous Government, equal priority was given to treating a patient with a broken toe as someone with potentially life-threatening chest pain. That cannot possibly be right. Putting doctors, nurses and other health care professionals in charge of making health care decisions will mean that clinical priorities and better patient care can be delivered.
Has the hon. Gentleman made any assessment of the reduction in the number of managers, consultants and other bureaucrats that will be caused by moving from 152 primary care trusts to potentially 500 or 1,000 GP commissioning groups?
The Opposition need to take on board the fact that the cost of running PCTs has gone up by about £1 billion a year since they were first put in place. The cost of bureaucracy and management in the NHS is unsustainable, and most of the money that we are putting into the NHS is going on salaries and bureaucracy rather than on front-line patient care. It is surely a good thing to remove the middle strand of bureaucracy—PCTs, strategic health authorities and other quangos that cost a lot of money but do not deliver front-line patient care. That will help deliver more money to the front line and to patients, and Members on both sides of the House should support such an initiative.
I shall elaborate on the point about how PCTs have been a great source of wasted money. In my part of the world in Suffolk, they have spent millions of pounds each year on external consultants to tell them how they should be doing the job that they should have been doing in the first place. There has also been a total disconnect between primary and secondary care and a breakdown in the relationship between them. For example, as the Secretary of State alluded to earlier, hospitals have wanted to put in place outreach clinics for mental health, dermatology and rheumatology, but too often, as in my area, they have been told that the PCT will not allow them to do that.
Hospitals have said that they value and need community hospitals, because they provide an excellent place for step-up and step-down care and for rehabilitation after an acute hospital stay, but PCTs have closed down community hospitals such as Hartismere hospital in my community. We know that that is not a good thing. Far too often, PCTs have been a barrier to joined-up thinking in the NHS between the primary care sector and hospitals.
No, I have taken two interventions and I will not take any more.
The Bill will allow health care to become more localised. Some of our constituencies have urban needs and some have rural needs, and allowing GPs to set up localised consortia that are more responsive to the needs of local communities will enable them to recognise those health care needs. For example, the area of my hon. Friend the Member for Eastbourne (Stephen Lloyd) has an ageing population, so the GP consortia and health and wellbeing boards will rightly focus on looking after the older population. In areas of the country such as our some of our inner cities, including parts of Bradford and Manchester where there are huge health care inequalities, the Bill will provide a real opportunity for the health and wellbeing boards and local GPs to tailor their services much more effectively to tackling local problems. For instance, they may face problems such as heart disease, diabetes and obesity more acutely than other areas.
The Bill is a good thing. It will bring to the NHS framework and the national care standards a much more focused, much less bureaucratic and much more patient-centred approach, which will be much more responsive to the needs of local communities. I am proud to speak in favour of it.
It is a pleasure to follow the hon. Member for Central Suffolk and North Ipswich (Dr Poulter). I congratulate him on his important and interesting speech, and I wish to pick up his challenge. The choice is not between no reform and reform; it is between good reform and bad reform. I believe that the proposals in front of us represent not a curate’s egg, with some good reforms and some bad, but a set of poison pills for the NHS.
The first poison pill is the massive upheaval that the Bill proposes at the time of an unprecedented efficiency drive. The right hon. Member for Charnwood (Mr Dorrell) said that it was precisely because of the efficiency drive that we should have massive upheaval, but he must know that all the evidence from reorganisations throughout the years is that projected savings are double the out-turn, and projected costs turn out to be half the actual level. When the Prime Minister says that there is a £300 million difference between the costs and the savings—£1.7 billion of savings and £1.4 billion of costs—he is actually treating us to a reorganisation that will end up costing money and causing redundancy costs at a time when hospitals and GPs are trying to get the job done.
May I correct the right hon. Gentleman before he goes too far down that path? The impact assessment suggests that the one-off cost will be £1.4 billion, and that the savings from that investment over the life of this Parliament will be £5 billion. By the end of the decade, the saving will be £13.6 billion, which is £1.7 billion a year after 2013-14.
I am happy to wager the hon. Gentleman that the costs will turn out to be more like double those estimated and the savings more like half.
The Bill is myopic, or “deluded”, to use the word of the British Medical Journal, in three key areas, which I wish to mention. First, it assumes that all GPs are ready now to take on hard budgets in the commissioning framework. It took the previous Tory Government six years to get 56% to be GP fundholders. Secondly, it will deepen the divide between primary and secondary care. The hon. Member for Central Suffolk and North Ipswich raised that matter, which is vital. We all know that in our constituencies, collaboration between primary and secondary care is key, especially for chronic conditions. The Bill will make the divide worse, because collaboration will be deemed anti-competitive.
Thirdly, the Bill has absolutely nothing to say about quality control of GPs. In fact, it will remove the local drivers for improvement that I have seen in my constituency. The hon. Member for Basildon and Billericay (Mr Baron) mentioned cancer survival rates, and the Appleby research shows that we in this country have made more progress over the past 30 years than any other country in Europe, and will overtake France in 2012. It also shows that the extent to which we are behind can be explained by late diagnosis in the first year of cancer, which is the responsibility of GPs. They should focus on improving their cancer treatment, not commissioning care.
No, I have given way once and I want to make some progress. If I have time, I will come back to the hon. Gentleman.
All the matters that I have mentioned are to service a vision of health care as a regulated industry. The Secretary of State has engaged in a ding-dong about which operating framework is more important—the 2009 or the 2010 one. Two points, though, have not been contested. The first is that in 2011-12, for the first time, there will be competition according to price—page 54 of the operating framework says that. The second is that the academic evidence is absolutely clear that price competition results in lower prices, yes, but also in lower quality.
The hon. Member for St Ives (Andrew George) asked the Secretary of State, “What about my community hospitals?”, but of course the Secretary of State does not want to make decisions about community hospitals. His predecessor but six, eight or 10, Nye Bevan, said that he wanted a bedpan falling in Tredegar to be heard in the corridors of Whitehall. The Secretary of State does not want to hear bedpans falling; he wants to say that it is GPs who should be making decisions, or the commissioning board, or, in the ultimate irony that my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) pointed out, the European Court of Justice under European competition law. He pointed out the irony of the Lisbon treaty being critical, but at this very time the House is passing a Europe Bill that calls for referendums when any power is transferred to the EU, including on matters as puny as the appointments system for the Court of Auditors, never mind on a vital part of NHS provision.
Does my right hon. Friend agree that the hon. Member for St Ives (Andrew George) is perhaps being a little ungrateful? He might have mentioned that the NHS wanted to close all his community hospitals in Cornwall, and that the dreaded centralist top-down Dobson stopped it.
The benefits of memory are useful in politics, and perhaps my right hon. Friend’s intervention will help the hon. Member for St Ives to decide how to vote in the Lobby tonight.
Many people have asked why the Government are making these proposals at such breakneck speed. Surely it is not to solve a political problem on health. After all, the Conservative party spent the whole of the last Parliament doing everything possible to avoid any policy on health that might hint at radical change. That paid off, because in the last prime ministerial debates before the general election, not a single question on health was put to any of the party leaders. It would be massively in the interests of my party and all Labour Members if the next general election were dominated by debates on the health service. On that basis, we should be urging the Government to plough ahead and make the next general election a referendum on health. Frankly, however, the cost would be far too high, and the consequences would be far too great for the national health service.
The truth is that a radical Secretary of State would do something that too few of his predecessors have been willing to do—namely, to say, “On my watch, there will be no reorganisation of the national health service.” Such a Secretary of State would dedicate himself to implementing the reforms that are working today. It is not the case that the only choice is between no reform at all and the reforms now being offered. According to health experts, there is more reform going on in the English health service now than in other health system in Europe. Our Scottish and Welsh friends might benefit from some of the changes that are taking place in England, because those changes have made the English health service a fast-improving one in Europe.
There is always room for improvement in the national health service to strengthen commissioning, to link health authorities and local government, to get people out of hospitals and to align with social care. The Dilnot commission has just been appointed to review the funding of social care, but it will not report until July. At exactly the time when we are looking at the localisation of health provision, the Government have appointed someone to look at the nationalisation of social care provision and its funding. This is not a Health and Social Care Bill; it is a health without social care Bill.
“The real choice is not between stability and change, but between reforms that are well executed and deliver results for patients and reforms that are poorly planned and risk undermining the NHS”.
Those are not my words but those of the chief executive of the King’s Fund. The Hippocratic oath says that we should “Do no harm”. The Bill fails that test. It aims at irrevocable change and threatens real harm, and that is the reason to oppose it in the Lobby tonight.
It is a great pleasure to follow the right hon. Member for South Shields (David Miliband). I am delighted to be able to speak in support of the Bill, because I believe that it responds to some of the issues that have been affecting my constituency for the past dozen or so years. I want to focus on two elements of it in the relatively limited time available to me.
The first concerns the influence of GPs. Like many hon. Members, I hold constituency surgeries, and barely a week goes by without one of my constituents coming to me with an issue about the national health service. Few of my constituents understand the inner machinations of the NHS, but the vast majority of their complaints are directed towards hospitals and treatments, and the way in which treatment is commissioned. For those with some knowledge of how the system works, it is clear that the problems lie with one of the three organisations that serve Worcestershire—the acute hospitals trust, the primary care trust and the mental health partnership—and the way in which they interface with each other. However, what my constituents never complain about is their GP—[Hon. Members: “What?”] Well, they do not. Most of the problems lie in the fact that the chain of delivery of services is too complicated. For a GP to commission services for their patient, their wishes must cross not one but two organisational interfaces, at the very least. That does not make any sense. Anyone designing a complex system tries to instil the highest possible level of simplicity so that opportunities for mistakes are kept at a minimum.
My local GPs, far from fearing change, have welcomed and embraced the new proposals set out in the White Paper. When I met them last September, they had already formed a shadow consortium serving my constituents. They are enthusiastic to take on the responsibilities of commissioning, and they were disappointed not to have been chosen as one of the initial pathfinder consortia. That has now been remedied with the second tranche, with the Wyre Forest consortium being chosen to act as pathfinder.
It is in the second aspect of the Bill that I have a specific interest. Hon. Members will be acutely aware of the issues surrounding Kidderminster hospital and the changes that affected it in the early years of the previous Government. What started as a removal of blue-light services from our hospital ended up as a downscaling from district general hospital to a mere treatment centre with a minor injuries unit, although I must say that the treatment centre is now well liked locally.
At the time, there was huge protest at this outrage. Public opinion was dead against the downscaling, with local residents marching in force against it, a human chain being formed around the hospital to protect it and finally, and most dramatically, an extraordinary result in the 2001 general election when the people of Wyre Forest demonstrated their anger in the strongest way possible by voting at the ballot box to save Kidderminster hospital. But still they were not listened to, and the hospital was downscaled.
Shortly after I was selected as the candidate in Wyre Forest in January 2004, I arranged the first of many visits from the then shadow Secretary of State for Health, now the Secretary of State. I wanted him to come to Kidderminster to hear at first hand how angry local residents were at not being listened to. He came on many occasions and listened to the staff, to patient groups, to doctors and to nurses. Indeed, he has come so often that he is now on first name terms with the two matrons at Kidderminster. [Hon. Members: “Ooh!”] He is a very popular fellow, I can tell you. He has also been to other hospitals facing closure and downscaling, and he seems to have listened to them as well, because the second key element in this Bill is the proposal for local health and wellbeing boards and the local democracy that they will bring.
I am grateful to the right hon. Gentleman for bringing that up. If my predecessor were that upset about the proposals, it would have been good of him to get in touch with his Member of Parliament and voice his concerns to me directly. He has not done that. He is, however, a man for whom I have a great deal of respect, and his views are worth listening to, although I would not necessarily agree with him on this point.
When I look at the Bill, I ask myself a fundamental question. If these provisions had been in place after 1997, would Kidderminster hospital have been downscaled? I am confident that it would not.
These proposals clearly have the full and enthusiastic support of my local GPs, who are willing, ready and able to take on these new responsibilities. I and they believe that the Bill will result in a more responsive NHS that listens to local people in delivering local solutions to local problems. Finally, I can say to my constituents in Wyre Forest, who are still angry because they thought that they were ignored for a decade, that they are being listened to, that it was the Conservative Opposition who listened to their plight, and that it is their anger at being ignored and the response to that anger that lie at the heart of the Bill.
Thank you for calling me to make my maiden speech in this debate today, Mr Speaker. I am deeply honoured to have been elected as the Member of Parliament for Oldham East and Saddleworth in the recent by-election—the first woman MP for Oldham. The circumstances for the by-election were indeed unusual, and it is only right to mention that many constituents and colleagues from across the House have remarked on my predecessor Phil Woolas’s intellect, his incredible attention to detail and the kindness he showed to them. [Hon. Members: “Hear, hear.”]
My constituency is a beautiful place with a remarkable history. For example, it was not only where the Independent Labour party was born and where Winston Churchill started his political career, but where the suffragette Annie Kenney originated from. Oldham’s first parliamentary representatives were of course the radicals William Cobbett and John Fielden, and I intend to be equally radical in my own way.
As beautiful and as varied as my constituency is, what I care most about are the remarkable people. During the by-election, I met thousands of constituents from all walks of life, some of whom supported me and some of whom did not. Regardless of their political affiliation, however, they were invariably polite. Of course, there were one or two who chased me down their garden paths, but, fair dos, it was Christmas day! [Laughter.] Their tolerance and decency reflect something very special about our society: a social conscience that values fairness, treating people as they would like to be treated, while recognising that different people have different needs and merits. As we know, both intuitively and from research, fairer societies do better, and are better for everyone. Of course, all political parties have claimed that they are the party of fairness, but I think most people will agree that action speaks louder than words.
I promised the people of Oldham East and Saddleworth that I would stand up for them and fight against unfairness. I believe—there is increasing evidence to support this—that the Government’s policies are deeply unfair and, contrary to their assertions, unwarranted. As history has shown, Governments set the tone for the culture of a society. The tone being set by this Government threatens the country’s sense of fair play and social justice.
I asked to deliver my maiden speech on Second Reading of the Health and Social Care Bill because, as some people will know, my professional background is in health. I am passionate about the NHS. For me, it not only plans and provides our health services, but reflects the very values of our society.
In ’97, the NHS was on its knees. Staff were leaving in droves, and the level of spending on health was one of the lowest in Europe. Labour more than trebled investment in the NHS, enabling us to recruit more doctors and nurses and to improve access to care. Gone are the days when people waited two years or more for a hip replacement or to have their cataracts removed.
The shift to improving health, preventing illness and providing care closer to home has made real, positive differences to the nation’s health. The Bill threatens not just those developments, but the very future of the NHS. I have expressed my concerns in the past about the marketisation of our NHS, but the Bill is in another league—it is about the total privatisation of our NHS. Some fear that all that will be left will be the name.
Where is the mandate for that from the British people? We can all sign up to the Bill’s objectives, but there is no evidence to support the idea that the proposals will deliver better health outcomes. The reforms are based on the notion that increasing competition drives down costs and improves quality. However, the overwhelming evidence from the UK, the US and elsewhere, is that that is not how competition works in health care.
I have heard some Government Members ask, “What does it matter who provides our health care as long as it is free at the point of need?” I say to them that that does matter. I have seen how the decisions about which patients those providers treat are based on whether they are profitable or not; they are not based on clinical need.
The reforms will affect the choice of medicines prescribed, and what type of treatments are provided and what kind of patients are prioritised. Certainly, that will not mean those with complex conditions. Unprofitable patients can expect short shrift from this evolved NHS. At my surgery last week, one of my constituents, who is in remission from leukaemia, came to see me because she fears that the drugs that she has been prescribed will be unavailable under the new reforms. What am I going to tell her?
Abolishing primary care trusts as part of the costly NHS reorganisation is yet another broken promise from this Government. Putting £80 billion of the NHS budget into the hands of a few GPs who enjoy managing a business might sound liberating, but in my experience, the vast majority of GPs want only to care as well as they can for their patients. In reality, the commissioning of health services will also be done by private health care companies, and there are significant conflicts of interests when those companies are both commissioners and providers of care.
The impact on equitable access to health care is another real issue. The Bill does not require GP consortia to work together, which leaves the possibility of neighbouring consortia taking different decisions about services, giving rise to a new postcode lottery. By forcing those GP consortia to put all services out to competitive tender, the Bill encourages any willing provider to cherry-pick profitable slices of NHS services. The introduction of price competition for the first time is a disastrous step, with the potential to undermine the quality of patient care.
In public health, which is my field, I have little confidence that the move of the public health service to local authorities will lead to health gain. That depends on an independent and well-resourced public health work force. The Bill also fails to define what will be covered by the ring-fenced budget that is given to local authorities. Thank you again, Mr Speaker, for calling me.
Before I begin my remarks on the Bill, may I say how well the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) made her maiden speech? I suspect that we disagree quite fundamentally on the future of the NHS, but one thing that is true of her and of all right hon. and hon. Members is that we want the very best health care for our constituents; we just disagree on the path that we take to get there.
A fortnight ago, I was privileged to speak on Second Reading of the Localism Bill. The hon. Lady spoke of the desire to be radical, but the Localism Bill is a radical measure that proposes to give power over the future of communities back to the people. The Health and Social Care Bill is very much in concert with the Localism Bill—and legislation on policing that is yet to be introduced—in giving authority, choice and power over the important services that people receive back to them.
Right hon. and hon. Members know that when we engage our electorates, they always—rightly and understandably—express certain priorities such as the future of our communities and law and order. Consistently, people are concerned about the future of health care. Health care is one of those great levellers. It matters not what one’s background is: we are all equally adversely affected when we do not have the right sort of health care available locally. The measures outlined in the Bill go a long way to giving back to people control over that most important public service, on which all of us and our families without exception rely.
I have spoken on many occasions to local GPs in my constituency. They are enthusiastic about their GP consortium pathfinder status. Already, they are brimming with ideas on how they can improve the patient experience in my constituency, which is broadly to be welcomed. Indeed, I have been heartened by the fact that many of my local GPs are enthusiastic about the democratic accountability that the Bill allows. My local GP pathfinder consortium wishes to be a health and wellbeing partnership pilot, working with Crawley borough council—the immediate local authority—and West Sussex county council.
I had the pleasure of working at my hon. Friend’s local hospital at Crawley. When I was there, I saw the downgrading of that hospital by the PCT—it lost more and more services. What discussions has he had with his local GPs on how they will improve and enhance services at the local community hospital and generally?
My hon. Friend is indeed legendary at Crawley hospital, and it is great to take part in this debate with him. Unlike him, I do not have a health background. My wife used to work in the NHS, but my background is as a local elected representative of my community and as a patient, and as someone whose family has had experience of the NHS.
I am afraid that I shared the bitter experience of many in Crawley during the 13 years in which the Labour party was in government. On 1 May 1997, when Labour took office, Crawley had an A and E department and a maternity unit. I am sorry to say that in 2001, Crawley hospital lost the maternity unit. At the time of a rather joyous occasion for my family, it was saddening that my children could not be born in our local hospital.
I dispute that reading of the Bill. Maternity was taken away from my local community in 2001 and is now 10 miles up the road, in another county, and accessible only by single-carriageway roads, which is at best inconvenient, and at worst dangerous for patients.
The sorry tale goes on. In 2005, under Labour, Crawley hospital lost its A and E unit to East Surrey hospital—10 miles up the road, in another county—which has been seriously detrimental to my constituents, and something that they and I very much regret.
I was struck by many of the comments of my hon. Friend the Member for Wyre Forest (Mark Garnier), because he mentioned things very similar to our experiences in Crawley—and listening to other right hon. and hon. Members, there seem to have been similar experiences across the country as well. I can speak only from my local experience, but there was an eerie resonance in the sort of downgrading of services under the Labour Government.
Does the hon. Gentleman accept that what his community, like other communities, will face is a local monopoly—the GP consortia—that will focus on the most profitable lines of treatment, rather than on the best treatment? Surely this is not the right direction.
I do not see how multiple providers is a definition of a monopoly. However, I must make progress in the short time left to me.
My constituents are pleased that for the first time in many years health decisions will be made in Crawley, rather than, as has happened up until now, on the south coast, in east Surrey or up in Whitehall, and that more decisions will be made by local people.
I am sorry, but I have not got enough time.
I will support the measures in the Bill, as should all right hon. and hon. Members. However, I would like briefly to ask for clarification on two points from those on the Treasury Bench. First, hospices are greatly valued in our local area—on Friday, I was privileged to visit the Chestnut Tree House children’s hospital, which serves my constituency—so some clarity over future support for hospices would be greatly appreciated. Secondly, I would also like an assurance that the merry-go-round of failing managers in our acute sector will be addressed. I regret to say that on new year’s eve, at East Surrey hospital—the acute hospital for my constituency— 14 ambulances were queuing to get into accident and emergency. That is not good enough. It is another area of the sector that needs to be reformed.
Forgive me, Mr Speaker, because in the seven seconds I have left, I would like to report that there is well-being in Crawley today, because they are due to play at Old Trafford in about three weeks’ time.
One thing is clear: from whatever perspective we consider the reforms in the Bill—whether from that of Charnwood or Holborn and St Pancras—there is a serious and worrying lack of evidence base for the Government’s proposals. These are proposals identified by the King’s Fund as without doubt
“the biggest shake up of the NHS since it was established”.
While the Health Secretary was the Conservative party’s shadow health spokesman—from June 2004 until he took office in May last year—he was coy about his real intentions towards the NHS, as indicated by my right hon. Friend the Member for South Shields (David Miliband). When the Government published the Bill, six major health unions and professional bodies wrote in a letter to The Times:
“There is clear evidence that price competition in healthcare is damaging. Furthermore the sheer scale of the ambitious and costly reform programme, and the pace of change, while at the same time being expected to make £20 billion of savings, is extremely risky and potentially disastrous.”
Labour Members welcome greater clinical involvement in commissioning, but GPs are not the sole font of knowledge in best practice and other areas.
Does my hon. Friend agree that in any one year some GPs will deal only with one or two patients with, in particular, a neurological condition? GPs might not be in the best position, therefore, to be the providers and commissioners of such services.
I agree completely with my hon. Friend’s point. According to evidence given to the Select Committee on Health, specialists in secondary care and the nursing and other professions could add their expertise to the commissioning process.
The shake-up of the NHS goes far beyond simply involving clinicians in spending decisions. GP commissioning is a red herring. We were told by the Secretary of State that these reforms are needed because productivity has fallen since Labour’s increased investment. However, after 18 years of mismanagement and under-investment under the Conservative party, it was obvious that on a crude measurement of productivity—inputs versus outputs—there was going to be a decline in supposed productivity, because obviously money had to be directed towards clearing up the mess left by the previous Tory government, to building new hospitals, accident and emergency units and maternity units, and to reducing waiting lists, which in many areas of the country were 18 months and longer.
The Secretary of State raised the satisfaction survey. Indeed, in December 2010, the National Centre for Social Research released its most recent report on British social attitudes. It found that public satisfaction with the NHS was at an all-time high, whereas in 1997, when Labour came to power, only 34% of people surveyed were satisfied with the NHS—the lowest level since the survey began in 1983. By 2009, satisfaction had nearly doubled to two thirds—to 64%. Given that most health unions, professional bodies, think tanks and the public did not call for such reforms, where did the Secretary of State’s motivation come from? These are not patient-led reforms; they are private health care-led reforms.
Does my hon. Friend share my concerns that these plans will lead to high and low-tariff services, and cherry-picking, and that services such as child and adolescent mental health services, children’s health services and adult mental health services will lose out?
I agree with the concerns expressed by my hon. Friend. There are concerns about the removal of the tariff floor and the introduction of price competition into the service. That is radical and revolutionary; it is not evolutionary. Rather than open-market health care, the British Medical Association and others are calling for a
“cooperative and coordinated environment where patients are guaranteed the most clinically appropriate and cost-effective care. Price competition and a fully open market will make this impossible.”
Clause 63 allows the Secretary of State to impose requirements on consortia to promote competition between providers, and clause 64 makes it possible for Monitor to investigate any complaint of anti-competitive behaviour made against commissioners by any interested party. That might be a third party or an overseas private health care company, and would make it far more difficult for GPs to ensure that their patient services are integrated, inclusive and carried out in partnership. The Bill also forces trusts to achieve foundation status within three years and will lead to more important priorities, such as safe patient care, being compromised. Furthermore, the abolition of the private patient income cap set out in clause 150, removing the limit on the amount of income foundation trusts can earn from private operations and private health care, will create a two-tier health system. Foundation trusts forced into the market without protection will face financial pressures to turn a profit, and NHS patients will risk being pushed to the back of the queue.
To my mind, and according to evidence submitted to the Health Committee by the Royal College of Nursing in which it identified 27,000 nursing posts that will go, these reforms will result in tens of thousands of job losses and undermine national terms and conditions for NHS staff. The scrapping of targets has left the NHS open to a dangerous postcode lottery. The duty to tackle health inequalities is one of the few remaining powers to be held by the Secretary of State, but he will have nothing to back it up.
There is also no protection for the taxpayer from exorbitant and excessive behaviour by the consortia, an issue raised by my hon. Friend the Member for Blyth Valley (Mr Campbell). It is possible that we will see banker-style bonuses and the import of private sector pay into health care. [Interruption.] The Minister moans from a sedentary position, but there is nothing in the Bill to prevent that from happening. The Bill will also leave us, as Members of Parliament, with no voice in the NHS. This Tory-led Government seem to be trying to de-risk this political hot potato, which the Conservatives have never been able to manage properly. However, if Ministers think that the British public will allow them to wash their hands of the NHS without any comeback at the next general election, they should prepare to be shocked.
I would like to say one more thing in the time left—now that the hon. Member for St Ives (Andrew George) is back in his place and given what the hon. Member for Burnley (Gordon Birtwistle) said—about the combined impact assessment. I have received a letter from a GP saying that the practical significance of the Bill will be such that the many MPs who campaigned to save their local hospitals cannot vote for it in all honesty, knowing that in so doing they will be voting for a measure that is purposefully and expressly designed to prevent them from having any say and which will potentially lead to the very outcomes that they so vociferously campaigned against.
I rise to support a Bill that I believe is perhaps one of the most exciting, if controversial, Bills to have been put before Parliament in the 62 years since the NHS was established. It is a fact that a resident in this country today is twice as likely to die from a heart attack as a resident in France. In this country, we also fail to reach European averages for stroke care. In fact, 4,000 stroke victims a year lose their lives because our NHS is not up to European standards in stroke care. If we delivered trauma care slightly differently, we could also save 600 more lives a year, but we do not. Those figures alone show that it is now time, 62 years since it was established, for the NHS to be modernised.
In those 62 years, drug research and development have advanced hugely. Medical technologies have advanced in a way that could not even have been imagined 62 years ago. As a result of the internet and the information now available, patients expect and demand to have a say in how their condition is managed. They want more information and they want to discuss their care with their GPs. The Bill will put the patient right at the heart of the NHS, and that is why I so passionately support it. The central tenet of the Bill is: “No decision about me without me”. It will ensure that, for the first time, each and every patient can almost become their own lobbyist, sitting in front of their GP and discussing their condition and treatment in an open way, where they have information and the GP will have to engage with them. That does not happen today, and certainly not in hospitals.
I would like to give an example—something that I heard about this weekend from a patient—that clearly epitomises why the patient has become invisible in the NHS today. That patient was in hospital at the weekend when a doctor walked up to him, lifted his arm, took blood, put his arm back down and walked away without saying a single word to him.
It strikes me that despite what the hon. Lady is saying about the patient becoming the heart of the NHS, it will instead be the GP who becomes the heart of the NHS. Is she suggesting that the GP will be in the hospital with that patient to hold their hand at every stage of their treatment?
I wish that that had been a more sensible question, because then I would have been delighted to give the hon. Lady an answer.
That patient was in hospital when the doctor walked up, took blood and put his arm back down without even a word of acknowledgment. A nurse then came and put his tray of food at the end of the bed. The patient was attached to a heart monitor and a drip, and could not reach the food. The patient was distressed, vulnerable and in pain, yet he was invisible to the health care professionals who were treating him. He was invisible because what is important in today’s NHS is the process—the management, not the patient. The humanity of the patient has almost been lost, and there is no way to put it back into the NHS other than to tip the understanding of who is important in the NHS on its head. The Bill does that in a way that has never been done before and which is now needed.
One of the concerns that I have come across is from health professionals who would be delighted to see red tape removed. I have spoken to directors of nursing who spend more time on red tape than they do with their patients, and they are deeply frustrated. Does my hon. Friend agree?
Absolutely, and the Bill will address that, in as much as care will be more easily accessed by the GP and the patient, in a much more streamlined process.
When nurses sat their medical exams 62 years ago, when the NHS was first established, the answer to each question had to begin and end with the words: “Reassure the patient”. It did not matter what someone said in the answer; if they did not emphasise the fact that the patient had to be reassured, they failed. That has gone. That demonstrates exactly how the patient has become invisible in today’s NHS.
I support the Bill because I support GPs working in consortia. A common myth—an urban myth—that we have heard in the few weeks leading up to this debate, and which has been thrown at us from the Opposition Benches, is that GPs are simply not up to the task of becoming business managers. The truth is that they already are business managers, because they all manage their own businesses. They will not be working as individuals or in individual practices; they will be working as part of a consortium, which is quite different from the impression given by the Opposition. Right now, 141 pathfinder consortia are demonstrating that they are ready and able to take on commissioning, and that they endorse patient involvement in the decision-making process. As a result of the “any willing provider” provisions, there will be a genuinely wider choice of care options available to the GP and the patient.
I would like to rebut the argument that the private sector will come in and undercut the NHS. That is complete nonsense. There will be no undercutting of the NHS whatever. Services will be—[Interruption.] I can only say that Opposition Members have not read the Bill, because there will be a tariff. Charities and the private sector will be able to provide services, but with a tariff. I shall give an example. If a patient requires a surgical procedure, which they discuss with their GP, and the local hospital has no bed available for six weeks, two months or however long, but if the local private hospital can provide a bed the next morning at the same price, are the Opposition really saying that an ideological obstruction should be put in the way of that patient being admitted to that private bed for that procedure the following day?
I cannot, because I have given way twice and I have no more time.
If that patient were in pain, why should they not be admitted into that bed if it were available? That is how the market will be opened up by GPs, to the benefit of patients.
We recently heard from my right hon. Friend the Prime Minister about an extra £60 million that will be available to fund the latest bowel cancer screening technology, with wider deployment of the flexible sigmoidoscope. That does not need to be provided in secondary care in a hospital; it could be provided in the GP practice under the “any willing provider” provisions, perhaps via charities with specialised trained technicians. The Bill will ensure a new approach to providing services to the patient. “Any willing provider” will give patients the choice that they have not had for 62 years, empowering them to make decisions over that choice and opening up health care that patients in this country have not had, certainly for the past 15 years. With new technologies coming on stream and new ways of delivering care, both in the patient’s home and in the GP practice, that has to be welcomed. The Bill has to be welcomed, and Government Members will vote for it because the most important person in the Bill is the patient. That is why I support it wholeheartedly.
The Government White Paper said some sensible things: it promised to increase NHS spending in real terms, to improve patient choice, to devolve decision making, to reduce management costs and to hold doctors to account for their clinical outcomes. Indeed, the objectives are very similar to many of those of the former Labour Government. The problem, however, is that the Bill will undermine many of those good aspirations.
Health spending is, as we know, falling because the amount by which the Government increased the NHS budget is lower than the rate of inflation. [Interruption.] For my health authority, it is 0.3% lower than the rate of inflation. Patient choice will remain limited to where GPs choose to commission services. Centralising many services under the NHS commissioning board—a new layer of bureaucracy—means that NHS dentistry, community pharmacy, optometry services, regional and sub-regional specialties and, indeed, some more complicated local services will be commissioned at national level by that board rather than at local level by a primary care trust, as in the past, or by a commissioning consortium in future.
I am sure that the Government will try to reduce NHS management costs. Every Government since the creation of the NHS have sought to do so, but this Government need to explain how creating 500 or 600 commissioning consortia—each with the skills to commission services—will cost less than the 150 PCTs that currently do the job. They are likely to lose economies of scale and the decisions taken could well lead to the fragmentation of some services such as dermatology or pathology. Such services are currently commissioned by a PCT for the whole PCT area, but in future could be commissioned in three or four different ways by different consortia. Small, less well resourced GP commissioning consortia will, I believe, be less effective than PCTs and strategic health authorities in controlling the costs of powerful hospital foundation trusts.
The Government are right to stress the importance of measuring clinical effectiveness and outcomes, but that makes it extraordinary that they have put primary care in the driving seat. We know a lot about the work of hospital doctors from the hospital episode statistics, but there are no national data on GP consultation rates or the thresholds they employ before they intervene with treatment or on GP outcomes, yet GPs are being put in charge of demanding this from everybody else.
Running through the Bill is the idea that transparency and accountability will drive up performance, so here are some questions to the Minister, which I hope he will address in his concluding speech. The Bill is designed to reduce health inequalities, yet there are enormous inequalities in GP services. Some GPs are very good; others less so. There are differences in their prescribing and referral rates, so how are the Government going to measure GPs’ clinical performance? How will a GP commissioning consortium hold erring GP practices to account? What sanctions will be employed?
How will patients hold their GPs to account for their commissioning decisions? We are, of course, familiar with GPs being sued for bad clinical decisions, which is why they take out medical insurance and have to pay increasingly more for it each year. Will patients sue their GPs for bad commissioning decisions? How will the consortia hold hospitals to account?
How much will the GP commissioning consortia receive in management allowance per patient, because the Government’s success in making administrative savings will depend on that? What sanctions will be imposed on a GP commissioning consortium to ensure that it commissions effectively and uses a good evidence base for its decisions?
The Government tell us that PCT deficits will be written off before the consortia take over, but what help will the commissioning consortia get in areas such as mine where there has been a difficult structural deficit—brought into balance by the previous Labour Government, but out of balance once again under the new Administration—to stop them falling into deficit? What will happen if they do go into deficit? Will their budgets and the services they provide to patients be cut as a result?
The hon. Gentleman is making a thoughtful speech and asking, if I may say so, some very good questions, with all of which I agree. There is an implication behind his speech, however, which is that if all those questions can be answered, as I hope and believe they can, he will support the Government’s policy. Is that implication correct?
If I were convinced that they could be answered, I would indeed support the Government, but unfortunately I am far from convinced that it is the case.
Let us take another issue. The Government are providing a lesser increase in funding to the NHS this year, which amounts to a cut in real terms when the rate of inflation is taken into account. They think they will get away with this because the NHS staff wage bill is being frozen for a two-year period. What thought have they given to the wage bounce that will inevitably come in two years’ time? There will be enormous wage pressure on the NHS budget; are the Government intending to increase it significantly at that time?
I certainly do not agree with the way in which it is being introduced. The right hon. Gentleman will probably know that before the last election, I made a proposal to strip out one level of NHS bureaucracy—the PCT level—and do commissioning where it was needed at the SHA level. That would have achieved administrative: savings. Instead of that, however, the Government have decided to replace 150 bureaucracies—PCTs as commissioning bodies—with some 500 or 600 bureaucracies: the GP commissioning consortia. I do not think that that will achieve administrative savings. With the NHS budget so tightly squeezed by the current Government, if more money is taken away to meet the costs of bureaucracy, less money will be available for treating patients. That is the crux of the issue.
I believe that those are some very serious questions, which the Government need to answer if they going to convince the public of their plans. There is an intellectual incoherence in many of their proposals. They have not looked either at how some of their goals—on patient choice, for instance—might conflict with other goals such as increasing efficiency. Will a doctor be able to insist that patients have the most efficient treatment even if they do not choose that option themselves? Would it not make sense to pilot these changes before imposing them, untried and untested, on the NHS?
Thank you, Madam Deputy Speaker, for calling me to speak in this most important debate. The scope of the Bill is far reaching and other Members have covered many aspects in their contributions, so I want to focus on one area—that of the future governance of the NHS.
The Secretary of State has identified a powerful and simple concept that resonates with people across the country—that “No decisions taken about me should be taken without me.” While this concept is usually applied to the individual relationship between the patient and clinician, I believe it is just as applicable to the communities that the NHS serves in any particular area.
As we have seen from campaigns across the country, people do not want decisions about the health and care services available to them in their community to be taken without the opportunity to get involved in the decision: “No decisions about us without us.” Over the last few years, I have seen the lack of openness, the lack of transparency, the lack of consultation and the consequent fear and suspicion that that brings.
I realise that not everyone will want to become involved in local decision-making and that many are happy to leave it to others, but I believe that we are right to enable more resilient and empowered communities to shape their own futures. Giving more power to the people is as important in the context of decisions about health and well-being as it is in the context of decisions about planning, homes and the environment.
The Bill is nothing short of a revolution in terms of the devolution of decision-making power to people in their communities, accountability, and the governance of health and care services. First, it links two crucial services. For too long the separation of those services, and the silo mentality governing the care delivered by local authorities and health services commissioned by primary care trusts, have prevented care pathways from being developed effectively in a way that works for the patient, which has often closed off the vital role played by families, carers and volunteers in supporting people. There cannot be a Member in the House who has not had personal experience of that, or shared the experiences of elderly constituents who have been bundled around the system, described as bed-blockers and made to feel a burden.
Of course, in some parts of the country health and care services have been integrated, but they are in the minority. The Bill, and the money that the Government are making available to help fund the integration, will enable all parts of the country to develop the high-quality, joined-up services that are currently available only to a few.
I agree with much that my hon. Friend is saying about integration and the need to work with the community, and I applaud many of the changes made by the Bill. For years we have all talked of using pharmacists in a smarter way. Does not the Bill provide an opportunity for much more integration of community pharmacy with the consortia, and for the Government to support the consortia in that endeavour?
As someone who represents a rural area of Cornwall where GPs’ delivery of pharmaceutical services is vital, I think that that is an extremely good idea.
Secondly, the new responsibilities of Monitor and the Care Quality Commission will make possible independent regulation of both quality and safety of care and value for money. I have observed the problems that have occurred in recent years when managers have evaluated their own compliance with standards. Good decisions can be made only with sound evidence. The powers of the National Institute for Health and Clinical Excellence and the Information Centre will be enshrined in legislation for the first time, and their independence from Government will thus be guaranteed.
Thirdly, the Bill creates a new role for local authorities in public health. Directors of public health, jointly appointed by Public Health England and local authorities, will play a leading role in the discharging of authorities’ public health functions. Arguably, it was the initiatives of local authorities in past centuries—such as the introduction of fresh water, drains, sewage management and the controlling of vermin—that led to some of the most significant improvements in life expectancy.
I entirely agree with my hon. Friend, who has anticipated a point that I was about to make.
The returning of more responsibility to local authorities—along with the considerable social determinants of health for which they are already responsible, such as the availability of good-quality housing and the regulation of places of work, environmental health and leisure services—has the potential to improve health outcomes, and to close the ever-widening gaps in health equalities in this country.
The Bill will ensure that every upper-tier authority establishes a health and wellbeing board consisting of the director of public health, GP consortia, children’s services, adult services, care providers from all sectors, and local health watch organisations. Such boards should provide local leadership and a strategic framework for the co-ordination of health improvement and the addressing of health inequalities in their areas. The joint strategic needs assessment will be integral to the process, and will influence the commissioning of services. The local health and wellbeing boards will, in effect, hold the ring when it comes to the health and care services provided in their communities. Local authorities will maintain and extend their role as scrutineers of all services, whether they are commissioned locally or nationally and whether they involve health or social care. They will also be able to commission complaints and advocacy services from any provider, rather than just from the local or national health watch.
The Local Government Association has warmly welcomed the proposed changes. The best local authorities have good experience of working with public, private and not-for-profit organisations as well as the charity sector in delivering integrated care. They are used to planning person-centred and personalised care.
I believe that—along with the changes that the Secretary of State has already made to the operating framework of the NHS in relation to the reconfiguration of services—the Bill, when effectively implemented in communities across the country, will lead to greater openness, greater accountability, and greater confidence for all those working in health and care, as well as for the ordinary people up and down the land who have lost so much confidence in the way in which decisions are made. These changes will take time, but I am confident that within the next four years, when we ask the people of this country, “Do you feel that decisions are being taken about you and with you?”, many more people will say “Yes” than would do so if asked that question today. That is a result that I shall be proud to have played my part in achieving.
As we have already heard today, the public love the NHS. and they are right to do so. Of course it is not universally perfect; of course there are times when it does need reform; but it is still something of which we are right to be proud, and we should not be proud of it just from a moral standpoint.
As economists of many different political persuasions have shown, a centrally funded NHS is a far more efficient way of providing a system of health care than the imperfect market of a system of health insurance. We need only look to America, where, until the recent reforms, more than half all personal bankruptcies were caused by people who were unable to meet their medical bills, to recognise how decent and effective our system of health care really is.
That brings me to the main point that I want to make. In my view, these proposals do not represent an evolution in the NHS reforms of the last Government. The principal goal of the Bill—to transfer commissioning from PCTs to GPs—is, in fact, a dangerous gamble with one of the country’s most-prized institutions. Bringing GPs closer to decision-making did not require the wholesale dissolution of PCTs and the transfer of their responsibility to GPs. When the Government promised no further top-down reorganisation, they should have meant it, because this reorganisation is ill judged and ill advised, as is spending the £3 billion that it will cost. However, now that they have embarked on this revolution, they should be aware of what has come about as a result of it.
Throughout the country, there is a pressure cooker of discontent in the primary care sector as PCTs struggle to balance their budgets and hand over what, on paper, will appear to be their stable financial footing. In order to do that, many have already implemented restrictions on procedures, described in the jargon as “procedures of limited clinical value”. I assure Ministers that they are not of limited value to people who are suffering and in need of care. In a number of areas, PCTs have asked GPs to suspend all but urgent referrals to secondary care. This prompts us to ask what kind of health service GPs will be inheriting. Patients are suffering now as a result of the actions of this Secretary of State.
I also fear that the commissioning of specialised services will create a real gap. For all the faults that some may ascribe to them, PCTs ensured equity for those who, if commissioning had been done on a smaller scale, would have struggled to have had their voices heard. There is a real question of scope here. Many GPs simply do not have sufficient sight of some types of work to commission effectively. The provision of mental health services is a particular concern. As ever with this Government, it seems that the most vulnerable will be most at risk.
If GPs really are better placed to commission services on behalf of patients, why were there shortages of flu vaccines this winter? GPs were responsible for ordering those vital supplies. They had the medical records of the people in their areas; they had the information that they needed in order to make effective provision. In my area it was the local PCT that remedied the situation, but who will be there to do that in future? GPs already have to balance financial and medical considerations. Have they really proved that they can do so effectively?
Finally, we must look at what exactly GPs will be expected to do and how they will go about doing it. In all the contracts they award, someone will have to monitor financial and clinical governance. That requires expertise, which GPs will have to buy in. Who will evaluate the tenders for services and deal with contractual issues? That will require yet more expertise to be brought in. Once we consider all that PCTs do across a wide geographical area, we see that GP consortia doing the same thing over a smaller area will result in an army of consultants, private companies and ex-PCT staff being contracted in by the consortia. We will, in effect, have the expense of PCTs as they work on the same things as now, but without the accountability and economies of scale currently enjoyed. Alternatively, GP consortia might achieve these economies of scale, but they will do so by ceasing to be the community-based practices with which we are all familiar. They will become faceless corporate entities, where doctors will be salaried members of staff with no connection to a specific practice or locality. That might be the Government’s intention, but it is not an evolutionary change to the NHS.
I do not wish to be entirely negative, because there are parts of the Bill—these do not deal with changes to commissioning—that I have to be more positive about. I welcome the ongoing commitment to patient choice, as I have never believed those who say that the public do not want to choose which NHS facilities they wish to use. As with other public services, the NHS must reflect the autonomy people now expect to be able to exercise over their own lives. I also welcome a stronger role for local government in scrutinising health outcomes in their area, provided that that is a real power, not a symbolic one, entailing the ability to force changes when outcomes are not good enough.
However, those are small consolations when we consider a Bill that risks the very future of the NHS as we know it. This is a poor Bill, which has been rushed out without scrutiny and which lacks a democratic mandate. It is not so much a hand grenade thrown into the national health service, as a commercial demolition designed to break the NHS as we know it in order to serve a set of interests which are—
I am not going to give way. Other hon. Members wish to get involved in this debate and it is a disgrace that we have only one day to discuss this.
This Bill will break the NHS to serve a set of interests that are not those of NHS patients, not those of NHS staff and not those of my constituents. It is for those reasons that I shall vote against it today.
I rise to support the Bill, because I support the two big ideas behind it. The first of those is the increased focus on outcomes, which is long overdue and very welcome. For those who suggest that there is no need to improve the NHS or to worry about the issue of outcomes, I shall just highlight this country’s relatively poor cancer survival rates—as some hon. Members will know, I have a particular interest in cancer. Improvements have been made over the years, but those improvements go back over 30-odd years and other countries have improved, too. This country still flounders in the lower divisions of the international cancer league tables, and that situation has to be wrong.
The all-party group on cancer focused on that issue in 2009, finding that patients who reached the one-year survival mark in this country stand as much chance of getting to the five-year survival point as patients in other countries, but that our one-year survival rates are very poor indeed compared with those of other countries. That tends to suggest that the NHS is as good as others, if not better, at treating cancer once it is detected, but very poor at detecting cancer in the first place.
Part of the problem is in the area of early diagnosis, which is why we recommended focusing on one-year survival rates. We suggested introducing an outcomes benchmark that focuses the NHS on the one-year survival rate, because late diagnosis makes for poor one-year survival figures. If we can get the NHS focused on that, many patients will benefit. Therefore, we are delighted to see that both one-year and five-year benchmarks have been introduced in the outcomes framework for 2011-12. We very much welcome that, but I believe I am right in saying that the 2011-12 outcomes framework covers only colorectal, lung and breast cancer. We have lots of data for other cancers, such as prostate cancer, and I urge the Government to think seriously about extending the cancer types covered in the 2012-13 outcomes framework. The risk is that if we do not do so and we include just a narrow range at a national level, that will make for a lack of priority at the GP level.
As for GP commissioning, bringing commissioning decisions closer to the patient has to be a good idea; patients have got to benefit from that. Some people say, “GPs see only about eight new patients a year. What could they possibly know about commissioning cancer services?” I would turn that around by asking how many cancer patients the chief executives of primary care trusts see. They are commissioning cancer services at the moment. That point needs to be discussed.
Given the hon. Gentleman’s interest in cancer, I am sure that he will know that the point is that the cancer networks often aid commissioners at all levels in providing this care and they are dissolving before our eyes right now as a result of these changes. GPs will not have the experience to commission care in respect of rare tumour types.
I agree with the general gist of what the hon. Gentleman is saying, but I would not say that the cancer networks are dissolving. I have raised this important point many times in the House—perhaps he was not in the House when I intervened on the Secretary of State—and what I would again ask my Front-Bench team about is the funding gap. I understand that the funding for the cancer networks ends in 2012 and there is a gap until the GP commissioning takes full effect. The answer given to me from the Dispatch Box today was that the national commissioning board will be up and running by 2012. The problem with that answer is that the national commissioning board will give guidance but the arrangements for the people who will actually make the commissioning decisions, the GPs at the front line, will not be truly effective until 2013 at the earliest—that will probably happen in 2014.
The worry is that in that gap a lot of expertise could be lost to the cancer community as a lot of expertise within those cancer networks decides to walk out of the door. I again ask the Government whether there is any way in which we could bridge that gap in order to ensure that GPs are better able to make informed decisions about the commissioning of cancer networks, because those networks contain an awful lot of expertise that we would not wish to lose.
I am fated to ask that question of the Minister of State, Department of Health, my hon. Friend the Member for Chelmsford (Mr Burns) again, as we are fated to discuss the issue. I appreciate that cancer is not his specialty, but I would like to get an answer on that point. There is a difference between the national commissioning board taking responsibility for guidance and the GP consortia actually taking responsibility for the commissioning. That point has to be addressed carefully, because various cancer charities have already reported that some 50% of the staff of cancer networks are thinking of leaving or have been told that they will be leaving within the next 12 to 18 months as part of a cost-cutting exercise. We need to address the point sooner rather than later.
In the remaining minute allowed me, may I quickly discuss eye health? I am wearing my hat as co-chair of the all-party group on eye health and visual impairment. I welcome the clauses that place primary ophthalmic services with the national commissioning board, which is likely to devolve enhanced optometry services to GP commissioners. That is the right decision and those working within the medical profession welcome it. However, I suggest two areas where we need to establish a national system. The first relates to glaucoma referrals under the NICE guidelines and the second relates to community-based acute services—in other words, those managing red eye and minor eye problems. The Secretary of State visited the school of optometry in Cardiff and, apparently, he liked what he saw. Can we ensure that those national guidelines are in touch, because otherwise we get a fragmented service and patients may suffer as a result?
In conclusion, I welcome this Bill, which could be transformational, particularly with its focus on outcomes. The Government will therefore have my support in the Chamber tonight.
This is a very dark day for the future of our national health service, particularly for those who have spent most of their political lives campaigning for and supporting the NHS. Some of us remember what 18 years of Conservative government did—the hospital closures and continually increasing waiting times that patients had to endure. One of the first cases that came through my door when I was newly elected to Parliament was that of someone who had been waiting 18 months for open-heart surgery. His wife came on his behalf, pleading for something to be done. I am pleased to say that he was treated under a Labour Government and that he is still alive today.
In contrast, this is a good day for those who have always hated the national health service. I remember a former Tory MP, Matthew Parris, who became a journalist, going on TV at around the time of the 1997 election and being asked, “What is it about the Conservatives and the NHS?” He replied, “It is quite clear—they hate it.” They hate the idea that they pay taxes and that the “undeserving poor” get equal treatment in the NHS, and they do not accept that people should be treated according to clinical need. That is why they continually chip away at the NHS. I do not blame the Tories, because they are just doing what Tories always do to the