§ Order for Second Reading read.
§ Mr. Deputy Speaker (Sir Alan Haselhurst)
MR. Speaker has selected the amendment in the name of the Leader of the Opposition. I also remind the House that there is a 10-minute limit on speeches by Back-Bench Members.
§ The Secretary of State for Health (Mr. Alan Milburn)
I beg to move, That the Bill be now read a Second time.
The Bill implements commitments in the national health service plan that was published in our manifesto for the general election. That election presented people with a fundamental choice. For many, it came down to a choice between short-term tax cuts and investment in public services. I am thankful that the British public chose the latter. It was the right choice for Britain, and a choice that the Labour party made.
Some claim that getting patients to pay privately for health care is the only answer to the problems in the national health service. However, Labour Members believe unequivocally that the NHS is the fairest and most efficient way of providing health care for our people. It is based on the right principles of care according to people's need, not the size of their wallets.
Those were the right principles when the NHS was created and they remain the right principles now. It is not NHS principles that need to change but NHS practices. That is what the Bill seeks to address. People today grow up in a consumer society. Services, whether public or private, succeed or fail according to their ability to match modern expectations of service delivery. People exercise more choices in their lives than at any point in history. Many can afford to walk away from public services that do not command their confidence.
Our task as a nation surely must be to make the NHS a service of first choice, not last resort. We in the Government recognise that we cannot build a one-nation Britain on two-tier health care. There is, as we know, a long way to go to give patients the flexible, convenient, high-quality services that they expect. Patients wait too long for treatment. There are staff shortages, dilapidated buildings and outdated equipment.
In their amendment, the Conservative Opposition crow about failings in the NHS. They know a lot about failings in the NHS because they were responsible for many of the present failings. They complain about doctor shortages, but they cut the number of doctors in training. They complain about nursing shortages, but they cut the number of nurses in training. They complain about bed shortages in hospitals, but they cut the number of beds by 40,000. They complain about the state of NHS hospitals, but they were spending less capital at the end of their last Parliament than at the beginning.
Only a fool—and the hon. Member for Oxford, West and Abingdon (Dr. Harris)—would believe that decades of neglect in the NHS can be reversed in a few years of investment. [Interruption.] The hon. Gentleman is good on those figures, and he will get better over time.
199 The NHS plan that we published last year is not for one year or for two years, but for 10 years. We need a decade of investment to follow decades of decline. The years of health care on the cheap are at an end. The NHS is growing at twice the rate that it grew at under the Conservatives. Under the Labour Government, it is the fastest growing health care system of any major country in Europe.
§ Mr. Andrew Hunter (Basingstoke)
The Secretary of State refers to increasing expenditure. Does he recall that when he visited Basingstoke during the general election, according to the local media, he reported additional funding for cardiac treatment? The local media have tried to get news on that extra funding from his private office, but have not received a reply.
§ Mr. Milburn
I will try to be responsive to the local media in Basingstoke. I hope that they are as responsible as the national media on matters relating to the health service. If the hon. Gentleman has specific questions about investment in Basingstoke, in cardiac care or otherwise, I am happy to look into them. If he writes to me, I will gladly write back to him.
Staff, who do such a brilliant job in the NHS, are increasing in number at record rates. There are 6,000 more nurses and 1,300 more doctors in just one year, and there are 20,000 more nurses and 10,000 more doctors to come. The cuts in nurse training and general practitioner training that took place in the 1990s have been reversed. Applications for medical schools, and the number of medical schools, are up for the first time in years. Applications for nursing degrees are up by more than 80 per cent. I can report to the House that the latest figures show that the number of nurses returning to the NHS is well in excess of 9,000.
This year, 1,000 GP surgeries are being improved. Thousands of new intermediate care beds and places have been established. The biggest hospital building programme in NHS history is under way. This year, for the first time in 30 years, the number of beds in NHS hospitals is rising rather than falling.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I am grateful to the Secretary of State for interrupting his flow of statistics. The news about nurses coming back to the health service is welcome. Has he any data on how many nurses are still leaving? Was his figure a net figure or a flow one way?
§ Mr. Milburn
I reported the number of nurses who left the health service and have now returned. In terms of the number of nurses overall—the number recruited minus the number who have left—I am happy to report that there are 17,000 more working in the NHS than when the Government came to office.
The number of people waiting more than 12 months for a hospital operation is down 13 per cent. in just a year. That is still too long, but we are moving in the right direction. Cancer patients are being seen by a hospital specialist within two weeks when they used to have to wait months. There are 3,000 more heart operations, over 150 more chest pain clinics and 17 per cent. More 200 cardiologists. Prescription of cholesterol-lowering drugs is up by over a third in just a year. We are spending more than £250 million in this financial year alone on new drugs for conditions such as cancer, heart disease, dementia and arthritis. None of that progress would have been possible without the investment made by this Labour Government.
No one should fall for the fallacy that, unless every problem in the NHS is solved by yesterday, no problems are being solved today. The programme that we outlined in the NHS plan is well on course to be delivered, but, as we recognise, investment alone will not do the trick. Delivering improvements in care to patients depends on fundamental reform of how that care is organised and provided. Here, too, there is progress.
For the first time, there is a sensible relationship between the public and private sectors to expand the care available to NHS patients. For the first time, there are clear national standards and the ability to implement them. For the first time, there are real incentives to reward good performance and to deal with poor performance. For the first time, I am pleased to say, we are finally getting health and social care working together rather than against one another.
Those reforms are based on one fundamental insight: although the values of the NHS are right for this century, its structures owe too much to the last. Services are too slow. Staff are run off their feet. The NHS is too bureaucratic and too monolithic. In my view, public confidence demands a fundamental change not just in the level of investment, but in the culture of the whole health service, to put patients' needs first in the hospitals and surgeries just as we seek to put parents and pupils' needs first in the schools.
Throughout the past two decades of organisational change in the NHS—there has been a lot of change during those years—the essential post-war structure of top-down control remained largely intact. The result was that, too often, Governments of all political persuasions defended the interests of the NHS as a service provider when they should have focused on the interests of patients as service users.
It is right, of course, that there should be national accountability for the workings of our country's health care system. For the sake of fairness, clear national standards should be applied not just in parts of the country, but across the whole country. It is right, too, that the Government should allocate resources to ensure that NHS cash genuinely meets the greatest health care needs. Beyond that, the old top-down model of the 1940s can no longer be expected to deliver health care in the 21st century.
Vesting control at the centre has diminished control where it counts—in local communities where local health services interact with local people. Our aim must be a more pluralist, decentralised health service that is capable of overcoming bureaucratic inertia and encouraging genuine innovation.
That is what the Bill will help to achieve. It has its origins in the White Paper that we published in December 1997, and the resulting Health Act 1999 abolished the Conservatives internal market, which was fragmented, bureaucratic, divisive and disruptive. While it promised that the money would follow the patient, the patient followed the contract. That market damaged equity and failed to promote patient choice.
201 It was right to end that failed internal market. In its place, there are primary care groups and trusts, which put front-line staff in charge of front-line services. The NHS plan, which we published last year, set out our proposals for further devolution. Since then, the important Kennedy inquiry has reported on the tragedies at Bristol royal infirmary. The Kennedy report called for further reforms to move the centre of gravity in favour of a more responsive, patient-centred NHS.
The three big measures in the Bill aim to achieve just that: first, by devolving more resources to front-line services; secondly, by giving local patients more power in their local health service; and thirdly, by strengthening independent regulation of those services. It might help if I deal with each measure in turn.
§ Mr. Steve Webb (Northavon)
A frequently expressed truism is that we should focus less on the national health service and more on public health itself and the prevention of illness. Would the Secretary of State consider establishing a people's health survey, rather like the labour force survey, which would be conducted continuously? Every month or every quarter, we would be given information not about how many operations were being performed, but about how healthy people were. That might focus our attention on whether we could keep people healthier, rather than on whether we could ensure that more operations were carried out.
§ Mr. Milburn
I do not know about the specifics, but the hon. Gentleman's general point is important. For too long the debate, in this country at least, has been more about health inputs and structures than about health outcomes.
When we produced the coronary heart disease blueprint a year or so ago, one of the most striking figures that emerged—which, as the blueprint was drawn up by clinicians, had some force—related to the time which people wait for heart operations. Reducing the maximum wait to three months would save approximately 600 lives a year. We need desperately to do that because too many people are waiting for too long. Moreover, taking some simple steps in primary care—prescribing statins, aspirin and so forth, and doing so more effectively—could save 1,800 lives a year.
We need to strike a balance between prevention and treatment. Sometimes the debate, certainly in the NHS itself, suggests that one must be chosen above the other. It is rather like the debate about primary and secondary care. If it came to choosing between the two, we might as well all give up and go home now. We need good primary care services, and good secondary care services. Even more, we need good preventive services.
The hon. Gentleman's point about reporting is interesting. As he knows, we have set ambitious targets to try to ensure that the number of deaths from, in particular, coronary heart disease and cancer is reduced, and we shall want to report to both the public and the House on a pretty regular basis.
§ Mr. David Heath (Somerton and Frome)
I thank the Secretary of State for his thoughtful reply to my hon. Friend the Member for Northavon (Mr. Webb). May I test him further on primary care? As he knows, the ability to recruit and retain general practitioners is now a real issue.
202 He has told us that more people are entering GP training, but is he as concerned as I am about the number who are leaving general practice in their 50s, never to return? We are losing experienced practitioners.
Is there anything in the Bill—or can the Secretary of State do anything—to keep GPs aged 50 and over in practice? That is needed in Somerset, but also, I suspect, throughout the country.
§ Mr. Milburn
I cannot promise the hon. Gentleman an equally thoughtful reply, but I shall try.
I am less pessimistic than the hon. Gentleman about the number of retiring GPs. Data from the NHS pensions agency suggest that early retirements are and will remain more or less static in terms of the age at which people are retiring. I think that the average retirement age is about 62; if I am wrong, I will write to the hon. Gentleman.
As the hon. Gentleman probably knows, we have been working on the issue, partly because of concerns that have been expressed. We submitted some evidence to the Doctors and Dentists Remuneration Review Body as part of our evidence on pay this year. I am relatively satisfied that the number of entrants and the number of retirements are not out of sync; what we must do, however—as I think I have said in the House before—is achieve a better balance in a doctor's career.
Rather bizarrely in my view, we are getting doctors into practice and working them hard throughout their lives, but working them harder as they approach retirement than at the beginning of their careers. In most walks of life that does not happen. As we expand the capacity of the NHS, we need to view doctors' careers—and, indeed, other careers—in what could be described in a much more fragmented way. We should get them to work hard and give a big service commitment during the early part of their careers, but towards the end of their careers we should harness their commitment and expertise for the benefit of the next generation of doctors. Those issues will need to be dealt with during the discussions and negotiations that are taking place now on the GP contract.
On the first main measure—devolution—when we came to office GP fundholders controlled about 15 per cent. of the NHS budget. Today, primary care groups and primary care trusts control over 50 per cent. The Bill will give doctors and nurses in PCTs the power that they need to match local services to the needs of the local communities that they serve. The Bill paves the way for PCTs to control up to 75 per cent. of the total health service budget. As Ian Bogle of the British Medical Association has rightly said, this isa dramatic move away from centralised health authority controlwhichshould bring decision making closer to the patient.Far from increasing bureaucracy, it will cut it. By the end of March next year, the changes we have already made by ending the internal market will have taken £1 billion from NHS administration and invested it in patient care.
With this Bill we can go further still. It will abolish health authorities as they currently exist. The NHS regional offices will go, too. As our manifesto promised, to reinforce the actions that we need to take to improve recruitment and retention, not just of doctors and nurses but of other staff, we will use the £100 million that we save to improve child care for working parents in the 203 NHS. Improving services relies on staff having greater involvement and a greater say. In the way it is organised, the NHS needs to give control to front-line services where patients and professionals interact.
That brings me to the second major measure in the Bill. A health service designed around the needs of patients must give more power to patients. The present structures for giving patients a voice in the NHS lack teeth and are out of date. Community health councils were a bold innovation more than quarter of a century ago. Many have done a good job, but who in this House, still less in the service itself, believes that public expectations, either as citizens or consumers, remain unchanged from the 1970s?
§ Mr. David Hinchliffe (Wakefield)
Does my right hon. Friend accept that on the Labour Benches and, I think, elsewhere, there is a feeling that the Government have yet to present a coherent case for the abolition of the CHCs? It is as though they have been found guilty and sentenced to death, and we have yet to hear the case for the prosecution. Can he give us some concrete arguments as to why the CHCs need to be abolished and why the system proposed in the Bill will be better?
§ Mr. Milburn
If my hon. Friend insists, I will try to do precisely that.
Just as reform is needed elsewhere in the NHS, reform of the CHCs is needed too. As the Kennedy report, which I am sure my hon. Friend and others have read, made clear:the public should be on the inside rather than represented by some body on the outside.The Bill seeks to deal with the failings identified in the Kennedy report. Independent patients forums will be established in every trust and every primary care trust. A new commission for patient and public involvement in health will co-ordinate the work of patients forums, promote the involvement of the public in NHS decision making and represent patients and the public nationally.
§ Mr. Milburn
May I go just one stage further?
I know that in this House and in the other place there have been concerns about the replacement of community health councils. As hon. Members are aware, there is much interest outside the House, too, evidenced by the more than 1,000 responses we received to our recent consultations on the proposals.
§ Mr. Milburn
It does say it here because it is a speech that I wrote earlier, believe it or not. I thought that that is what I was here to do. The hon. Gentleman sits there and makes benign and stupid comments.
The Bill strengthens the patients' voice inside the NHS. The CHCs had no role in primary care; patients forums will have that role. The CHCs were refused the right to inspect GPs' premises; patients forums will have that right. The CHCs were partly appointed by the Secretary 204 of State for Health; patients forums will all be appointed independently of both the Secretary of State and indeed the NHS. The CHCs had no formal rights of representation within NHS organisations; patients forums will elect, as of right, one of their members to sit on every trust board. This is about not diminishing patients' rights in the health service, but increasing patients' rights in the health service.
§ Helen Jones
Does my right hon. Friend accept that if we are to strengthen the voice of communities and patients in the health service, we have actively to seek to involve people from communities that are currently under-represented in the NHS's decision-making process? Will he give us an assurance that the commission will actively seek the involvement of people from deprived communities not only on advisory bodies, but in the NHS's decision-making process?
§ Mr. Milburn
I very much agree with my hon. Friend. One of the functions that we shall be locating with the new commission is to ensure that, so far as is possible, we have better representation in the national health service of the patient and the public voice. I think that we are all aware that wherever appointments are made in the NHS or in other public services, in some senses, although there is an independent appointments system, those who come up for appointment tend to be self-selecting. We need to get a better balance, to ensure that precisely the type of people whom the national health service serves are themselves serving in decision-making capacities in the health service.
Unless we improve the NHS's governance and make it more representative of the local communities that it serves, we shall never reach the position at which local services are responding to the needs of local communities. By giving the commission the tangible function of broadening the scope of representation in former NHS structures, it will be able to perform a very important function in democratising the NHS and the way in which it is run locally.
§ Dr. Liam Fox (Woodspring)
Perhaps the Secretary of State can answer a question that was not satisfactorily answered in Committee. When the CHCs are abolished, what will happen to all the information, including confidential patient information, that they hold? Who owns that information and where will it go?
§ Mr. Milburn
The hon. Gentleman is chuntering away—[Interruption.] I am glad that he has apologised.
We shall have to get right the transition from the old structure to the new one in relation to staff who are currently employed in the CHCs. Many of them will have a new function and a new job within the new structures. The hon. Gentleman has made an important point on the available information. It would be tragic if we lost the wealth of information that is available on individual patient problems and on more general problems in the 205 local health service. We have to find a way of transporting that information into the new structures. There will be a formal transition process to do precisely that.
§ Clive Efford (Eltham)
Does my right hon. Friend accept that community health councils have said all along that they recognise the need to change and become more responsive and more representative locally of the broader health service? As for the point on local accountability and local representation, the concern is precisely that patient health forums are self-selecting. We can choose to appoint to a forum the last person to get off the bus outside the local hospital, but unless that person has some expertise he or she cannot effectively represent the local community. We need that expertise. As I understand it, the CHCs will be abolished when the Bill is enacted, assuming that it is. Can my right hon. Friend say whether, before the Bill receives Royal Assent, the transitional advisory committee will reach some conclusions on the CHCs and their expertise?
§ Mr. Milburn
The transitional advisory committee is currently working on precisely the issues that the hon. Member for Woodspring (Dr. Fox) and my hon. Friend have raised. I pay tribute to the work of the very many CHC staff and to local community representatives who have served on local CHCs and done a very good job of work. It is important not to lose that body of expertise and knowledge.
The first point that my hon. Friend the Member for Eltham (Clive Efford) made is very important. We need to ensure that the patients forums are not only representative of the local community but can express expertise on behalf of that local community. Consequently, as a result of consultation that we have been conducting in recent weeks, the Bill's proposals are different from those that we put out to consultation. We have now lodged with the national Commission for Patient and Public Involvement in Health the duty of appointing patient forum representatives, precisely to ensure that the commission, as an independent patient organisation, can feel satisfied that the people being appointed locally are up to doing the job on behalf of the local communities that they serve. I hope that my hon. Friend will take some comfort from that change.
The third main measure in the Bill is the strengthening of independent regulation. As the Kennedy report highlights all too clearly, for almost 50 years there was confusion at the heart of the NHS about where regulatory responsibilities began and ended. Indeed, it is only in the past few years that national standards have been put in place in the NHS alongside the means to implement them. The system of professional self-regulation has been changing too, and I pay tribute in particular to the leadership of the medical profession for responding to public concerns about a perceived lack of accountability and transparency in the old arrangements. The Bill builds on those changes.
The Bill takes its cue from the Kennedy report in introducing a new Council for the Regulation of Health Care Professionals to which all of the individual professional regulators will become accountable. It will have a majority of lay people and people appointed from the NHS. The council will be independent of the Government and it will, instead, report to Parliament.
206 The Bill will also strengthen the role of the Commission for Health Improvement. It will give the commission a new function of carrying out inspections of the quality of local health services. Where it identifies significant failings in the way services are being run, the commission will report and recommend any special measures that might need to be taken. Its independence will be strengthened too, not least by being required to make an annual report to Parliament on the quality of NHS services. From next year it will be the CHI, through the new Office for Information on Health Care Performance—called for in the Kennedy report—rather than the Department of Health that will be responsible for assessing the clinical and organisational performance of each part of the NHS.
Together, those changes will provide a powerful incentive for local health services to raise standards. What motivates people working in the NHS is the desire to improve the care they provide to patients. Just as we are tackling the postcode lottery in prescribing, so the Bill addresses the postcode lottery in performance. Just as we have made appointments to NHS boards independent, so we are now making independent the assessment of NHS performance. A strengthened NHS independent regulator will leave the Department of Health to concentrate on what it should properly do in an accountable public service—provide resources, set standards and hold the overall system to account.
The Bill marks a decisive shift in the centre of gravity in the NHS. It moves towards regulation that is the hands of independent regulators rather than Ministers or the health service. It moves towards resources that are in the hands of front-line staff and towards power that is in the hands of patients. It is opposed, as I see from the amendments tabled by the Conservatives and the Liberal Democrats, every step of the way by the two main Opposition parties. They are two sides of the same coin. The Tories have their hostility to investment; the Liberal Democrats have their hostility to reform.
The Conservatives, who for two decades did so much to damage the NHS then, have the nerve to talk of an NHS crisis now. They scaled up bureaucracy and scaled down investment. They had the wrong policies then, but they have no policies now. Just as the Conservatives would starve the NHS of investment, the Liberal Democrats would starve it of reform. The hon. Member for Oxford, West and Abingdon makes policy by ducking every difficult issue, avoiding every harsh decision and appeasing every lobby group. Theirs is a policy of oppositionalism and opportunism.
Only the Labour party and this Government have the will to make the necessary investment and the necessary reforms to improve the health service. The Bill is about decentralisation and decreasing bureaucracy. It is about increasing the power of the patient and decreasing the power of Whitehall. It represents the biggest devolution of power in the history of the NHS. It will provide the basis for a health service rebuilt and renewed; a health service with its principles strengthened and its performance improved; and a health service capable of meeting the expectations of the people that it serves. I commend the Bill to the House.
§ Dr. Liam Fox (Woodspring)
I beg to move, To leave out from 'That' to the end of the Question, and to add instead thereof:'this House declines to give a Second Reading to the National Health Service Reform and Health Care Professions Bill because it is irrelevant in the face of a worsening health care crisis; will lead to increased bureaucracy; increases political interference by augmenting the role of the Secretary of State; fails to deal with the downward spiral of morale afflicting health professionals; imposes unnecessary structural change which will further detract from patient care; and abolishes the community health councils, which have served the interests of patients and communities.'I shall begin by apologising to the House through you, Mr. Deputy Speaker, as I have apologised already to Mr. Speaker and to the Secretary of State, for the fact that I am unable to present for the winding-up speeches later this evening.
Many charges can be made against the Bill, the most serious being that it is irrelevant to the crisis currently facing the NHS. It is a centralising Bill that pretends to he decentralising. It is highly bureaucratic, it is being rushed in far too quickly and it diverts activity and money away from patient care. Its provisions are unclear and confusing and it does nothing to increase patient choice.
To understand how irrelevant the Bill is, we need only take a quick look at what is happening in the NHS. Despite all the promises made by the Prime Minister and his Ministers at two general elections, patients in Labour's NHS are waiting longer in accident and emergency departments and to see their GPs. They are also waiting longer for their hospital operations.
Only last week, a poll commissioned by the BBC showed that six out of 10 people questioned thought that Labour had made no difference to the NHS, while 62 per cent. were not confident that the Government would improve the service in the next four years. Moreover, 27 per cent. of those questioned believed that the standard of care was getting worse.
It is little wonder that people should respond in that way: the recent Audit Commission report showed that, although investment had increased and the number of doctors had risen faster than the rise in patient numbers, patients were still waiting longer to be seen, or to be admitted to hospital from casualty. Fortunately, Ministers' blushes were spared, because the Audit Commission did not delve into the murkier aspects of modern casualty management. For example, it did not investigate the way in which targets for trolley waits are being reached by keeping some patients waiting in ambulances rather than in casualty departments. That tactic allows hospitals to pick up one of the Secretary of State's precious stars.
In the NHS today, patients wait longer for treatment. After a bit of a mix-up as they tried to work out whether the figures had risen or fallen, Ministers had to admit a couple of weeks ago that the number of patients waiting more than 12 months for in-patient treatment in English health authorities has risen by 63 per cent. since March 1997. That is the proud boast of the Government's record.
Much of the difficulty arises from the number of beds in our hospitals that are blocked because patients cannot be discharged somewhere else. In Buckinghamshire, 17 per cent. of beds are officially blocked. The figures for Hillingdon and Birmingham are 18 per cent and 15 per cent., respectively. Goodness knows what the real figures 208 are, given that what we have are subjected to the mathematical ethnic cleansing of the spin doctors in the Department of Health.
Why has the problem arisen? In September, Laing and Buisson published the 2001 market survey "Care of Elderly People". It revealed that, by April 2001, there were an estimated 525,900 places in residential settings for the long-stay care of elderly and physically disabled people across all sectors.
That should be of interest to the Minister of State, the hon. Member for Redditch (Jacqui Smith), who the other day said that the Opposition's figures were wrong. The estimate in the survey represents a fall of 49,700 places since the peak level. That is why so many beds are blocked. There is no point in Ministers talking about the record of the previous Government. This is a disaster entirely of their making: during the passage through the House of the Bill that became the Care Standards Act 2000, they were warned about what would happen, given the Government's approach to local government funding. They would not listen, but every Opposition prediction has come about—the blocked beds, the increased waits for operations, and the delays in accident and emergency departments.
The list of failure goes on. Today's Daily Express talks about huge NHS waste and, in the latest chapter of Labour's internal war, even the Chancellor of the Exchequer's men have described the Secretary of State as useless.
What is the Government's response? It is the one thing that nobody working in the profession suggested—wholesale reorganisation yet again. The respected health academics Kieran Walshe and Judith Smith have voiced concerns, saying that the NHS does not need fundamental reform. They point out that the opening paragraph of the Secretary of State's White Paper "Shifting the Balance" states thateverything possible should be done to minimise disruption if the NHS is to remain focused on the delivery of the NHS Plan.The document goes on to outline a reorganisation that will affect virtually every NHS organisation. Walshe and Smith believe—and they are not alone—that the reorganisation will lead to the NHS plan being delayed for at least 18 months as tens of thousands of people change their jobs, their job titles, their organisations—or all three.
The Government have changed their tune. I wonder who said:The last thing the NHS needs is a programme of wholesale reform … The imposition of further change and upheaval could not be justified in terms of cost alone and more importantly, it would be confusing for the public and grossly unfair on doctors, nurses and other NHS staff.The Secretary of State need not worry—it was not him. It was his predecessor, the right hon. Member for Holborn and St. Pancras (Mr. Dobson), who will no doubt be trekking into the Lobby to support the very thing he said should never happen.
In the true Orwellian double-think so beloved by new Labour, the Bill is described as decentralising. It is nothing of the sort. It contains 58 powers for the Secretary of State for Health, either gained, retained or enhanced. I wonder whether Labour Back Benchers actually understand what is involved when the Secretary of State determines the level of allocation for every primary care trust in the country. I ask them to consider the trouble 209 that arises over the local government financial allocation. Multiplying that by as big a number as they can gives an idea of what their postbags will look like. Very decentralising.
This supposedly decentralising Bill will set up the strategic health authorities, each one of which will have its own chief executive. Let us guess who will be appointing the chief executives—the head of the civil service at the Department of Health, who also happens to be the head of the NHS executive. So the personal appointments will lie, very neatly, in the Secretary of State's office. How very decentralising.
The Bill will appoint a council to oversee the regulatory bodies. However, there will always be a majority of one, appointed by—guess who?—the Secretary of State. Calling this a decentralising Bill is a fantasy.
§ Mr. Patrick Hall (Bedford)
Will the hon. Gentleman explain how the considerable shift of devolution of resources to primary care trusts is a centralising move?
§ Dr. Fox
The measure is decentralising only if people have the freedom to do what they like with the money. If the Secretary of State sets the budget and the criteria to be used for performance targets and can withdraw money if people do things that he does not like, that is not decentralising. That may be how new Labour's lexicon defines decentralising, but the rest of us think it a dangerously centralising move.
Not only is the Bill dangerously centralising, but it breaks specific promises to both Houses about the pace and nature of the development of health care. On 25 February 1999, Baroness Hayman told the House of Lords:It is important to say at the start that it is no part of the Government's agenda to impose primary care trusts on the service … We want measured change, progression to trust status, driven locally, based on local views. That is why the Secretary of State will be able to establish a trust only after local consultation."—[Official Report. House of Lords, 25 February 1999; Vol. 597, c 1268.]Even more explicitly, the former Minister of State for Health, the right hon. Member for Southampton, Itchen (Mr. Denham), told the Standing Committee considering the Health Bill on 27 April 1999:it is not part of our agenda to impose PCTs on the national health service … Full and proper consultation must therefore always occur before a PCT is established, and due consideration should be given to the views of a full range of local stakeholders."—[Official Report. Standing Committee A, 27 April 1999; c. 228–29.]Nothing could be further from what is proposed. Given the breathtaking effrontery with which Ministers have broken their specific promises on the subject in the past, how can we believe anything they say now?
The Bill will do nothing to stop the flow of centralised direction and instructions. It will strengthen the hand of the Secretary of State to interfere at local level. The Secretary of State will allocate the money to the PCTs so that he can determine what they will do. He can withhold money; he can set resource limits as well as cash limits; he sets performance rewards. It is micromanagement of policy, and it is folly.
Is the current system ready for this deluge of change? The remaining 130-odd PCGs will be rushed into becoming PCTs whether they want to or not—so much for the GP freedom that was promised. Some existing 210 PCTs and PCGs are being rushed into mergers, whether they want to or not, and all the PCTs will be given extra responsibilities, notably commissioning, whether or not they want it or are prepared for it.
The Government have financially supported the tracking survey carried out by the National Primary Care Research and Development Centre in collaboration with the King's Fund. The survey suggests that there are many doubts as to the ability to absorb the pace of reform. Professor David Wilkin, the project director, said that the pace of change was being dictated by Government timetables rather than by aprocess of learning and building on experience".He also pointed out thatit is not merely a question of resources to sort out this issue … what is needed are managers with the right skills and experience coming through the system. Managers from trusts and health authorities can be taken on, but we are dealing with primary care and they don't necessarily have the skills needed".The survey pointed out that the average number of managerial, financial and administrative staff employed by PCGs was 6.8, compared with an average for PCTs of 15.8. That is a serious discrepancy. Equally worrying is the fact that one in seven PCGs or PCTs still has no financial director.
According to the report, the situation relating to information management and technology was perhaps of more concern. It stated:Information to support core functions of PCG/Ts is inadequate and shows little sign of improving. PCG/Ts have made some progress in formulating development plans … and increasingwhat the report callsconnectivity, but shortages of skilled staff and resources make it doubtful whether they will achieve key national targets.Of greater worry to the authors of the report, to the BMA and many others is whether the changes in the Bill will divert activity and resources away from front-line patient care. Three quarters of the chief executives questioned believed that the reorganisation would delay the delivery of the national plan and a quarter thought that the delay would be severe.
Will the measure save money or cost money? The Secretary of State claims that £100 million will be saved by the reorganisation. We have all heard that before in the House—from one side or the other. Hands up all those who think that any reorganisation of the NHS has ever saved money! No one who has ever been involved in running the NHS would think that. No one in the NHS thinks that there will be a net saving; indeed, there may be increased costs.
For clarification, I turned to the Government's estimate of public sector financial effects. Line 1, paragraph 184 states:None of the provisions in this Bill will entail significantly increased public spending".Then I noticed that the arrangements for patient and public involvement will necessitate "some" increase in expenditure, that the new functions of the Commission for Health Improvement, or CHI, will result in "some" increase in expenditure and manpower, and that the creation of the Council for the Regulation of Health Care Professionals will have "a small financial cost". So costs are up by "some" amounts, although the Secretary of State 211 does not know—or will not say—by how much. Perhaps it is no wonder that the Chancellor is having doubts about him.
How are those costs to be offset? There will be unspecified "reductions in bureaucracy" and "significant savings in management", but no "decreases in manpower" and, best of all, asignificant increase in volunteer input … is forecast to bring about a reduction in costs".The secret of the plan is unveiled: the WRVS to the rescue. Will the Secretary of State make a commitment now that not a penny will be diverted from front-line patient care while these changes are being implemented? That is what people on the front line want to know.
There is also concern, not least in the BMA comments, that PCTs will inherit health authority deficits and the revenue consequences of capital schemes. As that is of extreme importance, will the Secretary of State now say clearly to the House that PCTs will be given a fair chance by starting with a clean slate? In other words, will he say that they will inherit no health authority deficits or revenue consequences of capital schemes?
It is clear that we are not being given that assurance, so the worry of the BMA and others is very real. Will the Secretary of State give an undertaking that the criteria he uses to allocate budgets to individual PCTs will be published, so that the process is as transparent as possible? We look forward to the winding-up speech. Perhaps when some of the pieces of paper arrive from the civil servants, we shall receive answers to those questions.
Everything will be more confusing in Wales, where the plans are even less clear than those for England. Will 22 commissioning bodies mirroring the local authority be set up or not? How much bureaucracy will be entailed and will the result be territorial disputes on the border—all to the detriment of patient care?
Other aspects will cause concern, not least—as has already been mentioned—the Government's continued malevolence towards the community health councils, whose only crime seems to have been having the audacity to criticise the Government's handling of the NHS. Far too many questions remain unanswered about the new structures and the transition phases.
The Secretary of State was unable to answer one of the most basic questions: who owns the information? CHCs throughout the country keep large amounts of confidential patient information. It would be quite wrong for that information, which contains many patients' complaints about trusts, to go to the trusts, so who owns the information? Someone in the Government must know where the ownership of that information lies, yet neither during the passage of the Health and Social Care Act 2001, nor apparently during that of this Bill can the Government answer a simple technical, but fundamental question.
We find the same lack of detail in the relationship between the new inspection bodies. Given the time required to prepare for any inspection, the BMA asks how such activities will be co-ordinated to ensure that even more time is not diverted from patient care. Indeed, why have the Government not taken the opportunity provided by the Bill to streamline regulation, by creating a single regulatory body covering the private sector as well as the public sector?
212 Given the Secretary of State's enthusiasm for his concordat and having NHS patients treated in private hospitals, I should have thought it made great sense to create a single regulatory body to ensure that patients are looked after in exactly the same way, irrespective of where the state pays for their treatment. Perhaps the Government will want to rethink that; or perhaps tomorrow's Unison cinema advertising campaign might have something to do with the Secretary of State's new bashfulness.
Perhaps the most depressing thing about this Bill is that it will do absolutely nothing to increase choice for patients. Only this week, data have been published that show an unacceptable level of variation in the quality of care delivered by the NHS. With Labour's abolition of GP fundholding and extra-contractual referrals, which allowed doctors far greater freedom and choice as to where their patients could be treated and by whom, the net effect has been to inform patients that they may live in health ghettos, but that the Government are depriving them of the means to escape to where cure and survival rates are better. It is Labour's role, as the anti-choice party, that damns it most in the health debate.
This Bill is irrelevant to the current NHS crisis. It is hugely centralising, bureaucratic, rushed and wasteful. It will divert time and resources from patient care, and it will offer no choice to patients who have already seen their choice restricted under this Government. It is best summed up in the comments of some of the chief executives quoted in the Government's own report. The first said:This is the most ill-conceived, poorly thought through set of changes in decades. Is the plan to torpedo the implementation of the NHS plan?Another said:These reforms are a gamble. They may or may not work. Either way, they will inevitably result in more structural changes within the next five years. The government should not implement such risky and costly changes without much clearer analysis and assessment.But perhaps the greatest insight came from one who said:This is my sixth reorganisation in a 30-year career in the NHS. I have always responded positively to change previously. However, these proposals are a recipe for disaster, a blend of lack of insight, ineptitude and disregard for staff at all levels.That is the story of the Secretary of State, his Bill and this Government.
§ Mr. David Hinchliffe (Wakefield)
I hope that my approach to the Bill will be a little more balanced than that shown in the previous contribution. I try to offer constructive criticism, and I hope that what I say today will be taken as constructive criticism. The Bill has many positive aspects, but the fact that I have only 10 minutes in which to speak does not leave me a great deal of time to expand on them, so I shall concentrate on the issues about which I have some concern. I hope that some of those issues will be addressed during the Bill's consideration.
The Secretary of State has talked about the way in which the Government are finally, as he put it, getting health and social care to work together. I wish I were as optimistic as he is. Frankly, looking at my own backyard, which he knows reasonably well, things are as bad as 213 ever. Two weeks ago, I saw the figures on delayed discharges, which are very worrying. Although my right hon. Friend disagrees with my solution, he knows what it is. Perhaps we could engage in a dialogue during the Bill's passage through Parliament.
One of my concerns about the Bill is that it is too narrowly focused on health. Some of the structures proposed fail to take account of the crucial relationship with social care. I shall come to that in more detail shortly.
The Bill also accepts uncritically one of the central historical weaknesses of the NHS—its lack of democracy and lack of engagement and involvement with the people whom it serves. The Bill says that it seeks to involve the patients and the public in the NHS, but it will not let them run it. We should consider how we can ensure that we have a democratically elected health service that means that those who use the service are in the driving seat in a way that they have not been since the service was created in 1946. Another key problem relating to that is the lack of personal ownership of the health service by its users. That is why some people do not take care of the service that they use or regularly fail to turn up for appointments.
We hear much about joined-up government and I believe that the Government are, in some respects, genuinely trying to join up thinking. However, the Bill fails to relate to the growing debate in areas such as mine on the need for regional government. The new strategic health authorities provide an opportunity to draw together important policy strands in radical new ways and I genuinely welcome their introduction. As the Secretary of State is well aware, clear problems have arisen as a result of the lack of a strategic overview at a regional level. Local reconfigurations have suited one area but affected another, and no one has considered the big picture.
When the Secretary of State attended the Select Committee on Health the other week, I raised my concern about public health strategies. We need to ensure that the new regional bodies have a clear role in addressing health inequalities. I worry that the public health agenda is sliding slightly as a result of the changes that are taking place. I hope that I will be reassured on that point as the Bill goes through Parliament.
I welcome the new bodies, but they miss an opportunity in that they will not draw together strategic planning on health and social care. They will not be linked to democratic regional structures that could combine regeneration with public health and social care.
I welcome the proposal for joint working with the Prison Service, because there are two prisons in my area. I also welcome the proposal for the Council for the Regulation of Health Care Professionals but, as I have said before, why does it not regulate health and social care professionals? We have recently legislated on social care and, as we consider joint working and moving people closer together, it might be appropriate to include social care professionals in that umbrella organisation. I broadly support the proposals for strengthening the Commission for Health Improvement because it has made an important contribution to addressing quality issues.
On patient involvement, the Government have failed completely to produce a coherent argument to convince me and others of the need for the abolition of the community health councils. I am not a great fan of the 214 CHCs; they leave a great deal to be desired. However, the Government have not convinced me that the proposals on offer in this or the previous Bill will be any better.
I pay tribute to the Under-Secretary, my hon. Friend the Member for Salford (Ms Blears). Over the past few weeks and months, she has worked extremely hard to try to come up with a coherent alternative. I praise the fact that she has been prepared to listen to people and to talk to them, but she has been landed with an impossible brief. I feel sorry because she has had to try to come up with a solution that will lead to the abolition of the CHCs.
I have considered the proposals in the Bill and I find them baffling. I honestly do not understand them. One of the key points is that the system should be easily understood, but the complexity of the proposals needs to be reconsidered so that the patient—the man or woman in the street—knows where to go and who does what. I have looked at the proposals and, frankly, do not understand who is going to do what. I look forward to hearing the Minister's response because that might explain to me—perhaps I am on the simple side—what the Government are getting at. I have tried desperately hard to understand what they are doing but, so far, they have not come up with any solutions.
I understand the role of the Commission for Patient and Public Involvement in Health and that local networks will support and co-ordinate patients forums, commission independent complaints advocacy and help community groups. We will also have outreach teams working from local premises and standing lay reference panels to guide the local work programme. The local networks will be the glue to bind other elements together. Frankly, if the system was not fractured we would not need glue. I am concerned, as I was about the previous proposals, that we should not have dislocated structures; we should, instead, have united structures.
What is missing is a function similar to that of the patients council to draw local separate elements together in a coherent way. The proposals are too narrowly focused. They fail to enable a collective organisation of members of a patients forum to develop an overall picture of the local health economy. Only last week, the Health Committee took evidence from Central Manchester CHC on the overall impact on its health economy of the local private finance initiative scheme. I do not understand how that bigger picture can be reflected in the new structures because they are not glued together as the CHCs are. I accept that the CHCs do not deal with primary care issues, but they could do, as the Secretary of State is aware. It would be easy for them to deal with those sectors that they have not been allowed to address. We need to modernise the CHC structure. I have no problem with getting rid of the CHCs, but I want a coherent alternative, which does not seem to be available at present.
I am also worried that the approach to the independent complaints advocacy service will be inconsistent. I am not aware where that important service will be located. I see that it will be related to the new body, but it might be situated in different parts of the local health structure across the country. We need consistency. I recall talking to the Secretary of State about my belief that the advocacy role should be placed within patients councils if we get rid of the CHCs. There should be one common place for advocacy so that people, wherever they are, know which body will offer them that advice, but that is not the case 215 at the moment. From my experience of dealing with complaints and difficulties in the health service, I realise that that is a major problem with the Bill.
Overall, the Bill has many positive aspects and the correct steps have been taken. I hope that some of the points that I have raised will be considered in Committee so that I will understand fully on Report that the Government are offering something that is better than the present system.
§ Dr. Evan Harris (Oxford, West and Abingdon)
There is an old joke about a man who goes to see his doctor complaining that his brother thinks that he is a chicken. The doctor says, "Why don't you turn him in? He is clearly crazy", and the man says, "I would, but I need the eggs." The Secretary of State is that man and the Bill is his chicken. I suspect that he genuinely believes that he will deliver the NHS plan with a Bill that distracts the attention of people who work in the service while failing to give a sensible allocation of the resources—not just in funding terms, but in staffing and time terms—to deliver the plan. The fact that he has already left the Chamber suggests that he does not want to hear the diagnosis. He is all too willing to make claims about other people's unwillingness to accept reform, but unwilling himself to hear the diagnosis of his own failure.
The Bill is the emperor's new clothes. It reflects a desire to be seen to be active in making changes to the structure while the NHS continues to fail to deliver what patients deserve. That has been the story of this Labour Administration and the preceding one. There has been a lot of talk about radical reform and the abolition of the internal market. Indeed, the Secretary of State boasted about that in his opening remarks. The internal market separated commissioning from provision. That separation still exists, and it is right that it has not been abolished.
The market was described as the money following the patient, but as the Secretary of State said, that never happened—the patient simply followed the contract. In their previous reforms, the Government simply renamed contracts as service agreements, and now the patient follows the service agreement. The only instance in which money followed the patient was in extra-contractual referrals, and those were abolished in favour of out-of-area treatments, in which money does follow the patient, but two years late and too late to make life easy for those who plan specialised treatments.
We have a Government who are proud of claiming to reform when they are failing to reform at all. They talked about ending the two-tier system, claiming that there was a terrible gap between provision for patients of GP non-fundholders and provision for patients of GP fundholders, when in fact the major inequity is now between people who can afford to go private for treatment that is not available on the NHS or is available only after a long wait, and those who cannot. The effects of that two-tier system have got worse under this Government.
The Government seem to want to inflict on the health service reform for its own sake. Liberal Democrat Members are very keen to see reform when a case is made for it, but reform for its own sake is simply sabotage, and that we will not support. If there were evidence that these 216 reforms were based on a master plan, which had widespread support, they would have more credence. We have yet to see the Government's response to the Kennedy report, so we do not know whether the reforms that it suggests, which have the full support of Liberal Democrats, will be implemented in full. That would be a sensible place to start with NHS reform.
The Government fail to take responsibility for their own mistakes. They have been very keen on blaming the last Government, although they now realise that they themselves were the last Government, so they talk about the Government before last. However, it was a Labour Government who raised expectations by claiming that they would save the NHS in 14 days, or at least within four years.
§ Dr. Harris
Indeed, perhaps the stakes are being raised all the time.
The Government could not meet those expectations, and they should not have claimed to be able to do so. There is significant support among Liberal Democrats for the Government's view that the failures in manpower planning by Conservative Governments between 10 and 15 years ago led to the current shortage of specialists and other medical manpower. The cuts in the number of nursing school places was also a major mistake by the Conservatives from which we are still recovering.
The Government would have more credibility on that score if, on corning into power, when the problem was obvious, they had acted to increase medical school numbers. Instead, they waited until 1999 to start a seven-year rolling programme of increase. Similarly, they were slow to increase nursing school numbers. That is because, while rejecting Tory policy, they accepted, at least for the first two or three years, Tory spending plans. The two decisions are inconsistent, and the Government are now living with the results of their failure. They have raised expectations without delivering funding. Now the funding is being made available. We believe that it is inadequate, but compared with previous years the amounts are significant. However, that money is being wasted on the funding of agency nurses. My hon. Friend the Member for Sutton and Cheam (Mr. Burstow) has showed that in London the expenditure on agency nurses has shot up.
The Government are paying the price of their failure to deliver joined-up health and social services care, as we can see in the effects of delayed discharges, which deny resources to people trying to get health service treatment while putting people who seek to leave acute hospitals at risk of infection and of a failure to get the rehabilitation that they need. We now have a crazy system in which elderly people have to queue up to get into hospital and then are not allowed out when they have been treated. As the hon. Member for Wakefield (Mr. Hinchliffe) said, the Bill is notable for the absence of any measure to provide extra joint working between health and social services. There is no recognition that year-on-year increases in social services funding have fallen way behind increases in health funding despite the fact that social services face the same demographic pressures and staffing cost pressures.
217 Liberal Democrats have explained, in our reasoned amendment, why we cannot support the Bill on Second Reading. It fails to address the major issues in the health service, and it causes problems in the provision of public health services instead of solving them. As the hon. Member for Woodspring (Dr. Fox) said, it is a centralising measure but it pretends to be otherwise. As the hon. Member for Wakefield said, the Bill fails to deliver the patient and public involvement that is desired by stakeholders in the health service, by the country and by Members in this House and the House of Lords.
§ Mr. Jon Owen Jones (Cardiff, Central)
The hon. Gentleman has just told the House that Liberal Democrat Members intend to vote against the Bill on Second Reading. What will that do to the partnership agreement in the Welsh Assembly, because the clauses that deal with Wales are promoted by his party in Wales and will fall if the Bill falls?
§ Dr. Harris
We hope to be able to amend those parts of the Bill that we do not support. I will go on to explain which parts we support. The prevalent idea among Labour Members that one can hitch a measure that is supported to a measure to slaughter the first born, and expect Opposition Members to support it as blindly as Labour Back Benchers do, shows their lack of a grip on reality. Our opposition is constructive.
§ Dr. Harris
It would not be fair to him to allow the hon. Gentleman to intervene again, but I can tell him that my hon. Friend the Member for Brecon and Radnorshire (Mr. Williams) is hoping to catch the Speaker's eye so that he can talk about the proposals that relate to Wales.
I want to concentrate on the Bill's impact on the delivery of public health. The hon. Member for Wakefield expressed his regret, which I share, that public health has fallen so far down the Government's agenda. The Secretary of State, who sadly is no longer in the Chamber, tantalisingly pointed out that the prescription and provision of statins, cholesterol-lowering drugs, can save even more lives per year than the faster delivery of heart operations in the acute sector. However, he did not say that even more lives would be saved by NHS provision of smoking cessation advice to far more people than now receive it under the Government's scheme. That shows how public health has slipped down the Government's agenda.
The United Kingdom Public Health Association expressed concerns about how the abolition of health authorities would affect public health practitioners and about the clarity of the proposed structure. The hon. Member for Woodspring read extensively from the excellent House of Commons Library briefing, so I shall do the same. The UKPHA said:Above all, we regret most profoundly the effect of the 'planning blight' now affecting public health specialists and practitioners at all levels, but particularly at senior level. While welcoming the strong presence of public health at all levels in the new structure, we remain concerned that the respective roles and contributions of public health leaders at primary care trust, strategic health authority and regional levels need to be clarified as a matter of urgency. The risk otherwise is that scarce public resources will not be utilised effectively and confusion will arise between the various levels and their core responsibilities.218 The function of public health is critical to effective and cost-effective commissioning. There is a fear that good, experienced people will have had enough of continual change and will leave the front-line services. Sadly, some have left those services in my county of Oxfordshire, and I know that the story is repeated elsewhere.
The Government must answer the charge of control freakery. The desire to control all commissioning decisions in the health service is a serious problem for a Government who claim that they are decentralising. We have already heard concerns about the provisions of clause 8, especially the proposed new subsection 3 of the National Health Service Act 1977, which will reward certain primary care trusts for what can only be described as political obedience. The last thing that patients need is commissioning based on political obedience rather than their interests, including the better delivery of health care.
§ Mr. Kevan Jones (North Durham)
The hon. Gentleman has now spoken for 12 minutes. He said that his party would vote against the Bill; can he tell us what the alternatives are?
§ Dr. Harris
I am certainly going to come on to that. It is for the Government to come up with sensible reforms, but I shall certainly explain to the hon. Gentleman which aspects of the Bill I support and what we would like to see in it. As I said, the idea of reform for its own sake is effectively sabotage; the health service does not need something that cannot be supported by those working at the coal face. No constituent, who has sent me a letter expressing concern about the failure of the health service to deliver, has begged me to reform NHS structures still more. We need an amnesty on health service reform. Sometimes undertaking no reform is better than reform for its own sake, which is equivalent to sabotage. It diverts people from trying to deliver outcomes that we all want, including the Government, by asking those individuals to reapply for their jobs in some other structure.
The Government have talked about their wish for decentralisation, but it is clear that they are not decentralising power which, in the health service, is founded on the ability to take decisions about which services to commission, the shape of service provision and which new treatments to provide. That implies that there is sufficient growth funding to allow local discretion, where the power is allegedly devolved, to make funded changes. Health authorities throughout the country have made it clear that that growth money is already spoken for in must-dos and diktats that have been issued centrally. The Government cannot claim to decentralise power when, in fact, they are centralising it. They are centralising praise by making announcements of new money centrally, but are seeking to decentralise blame, because they know that otherwise they will be held to account for failing to deliver.
The Secretary of State said that he wants to be judged on tipping the balance from central interference, as he called it, to a more patient-centred approach, and specified three measures to achieve that: improved regulation, measures to change—or, he would argue, improve—public involvement, and the devolution of power locally. We award the Government only one out of three; we support the greater independence of the Commission for Health Improvement and, in principle, the setting up of a council to regulate health professions. However, 219 they cannot have our support for two of the three proposals because of their failure to deliver a more patient-centred approach involving the public and patients, and their refusal to decentralise genuine power. That is why we shall oppose the Bill tonight.
The Government have said that their changes will deliver £100 million-worth of savings in the context of £1 billion-worth of savings from management changes. Will the Minister allow the Audit Commission to check whether those savings have been, or will ever be, delivered? The creation of more commissioning groups, following the abolition of health authorities and the creation of strategic health authorities and more primary care trusts will lead to more bureaucracy and tiers of management in the health service.
We have some concerns about the new Council for the Regulation of Health Care Professionals. However, it is clear that best practice in each profession ought to be spread to the other professions. There is no reason why the regulation of doctors' practices should be wholly different from the regulation of the practices of nurses and professions allied to medicine. There is no doubt that practices in some areas are better than in others. If the new council has a co-ordinating role in inviting other councils to modernise and update their procedures, as has begun to take place under the order-making powers in the Health Act 1999, we welcome that.
The Government must be clear about whether there will be extensive powers to direct councils to do the bidding of the new body, given that its make-up does not amount to professional self-regulation to which, in Standing Committee recently, the Minister said the Government were committed. If we do not have professional self-regulation by dint of not having a professional majority on the new council which can issue directions to the uni-professional councils and the Council for Professions Allied to Medicine to do certain things, that may be a retrograde step. The Government must clarify the extent of those powers. It is welcome that a majority of members on the new council are not professionals. However, the Secretary of State finessed the fact that most of that majority will probably be appointed by him, so will not be independently appointed. The Government need to explain why that is not indirect political regulation of the health professions.
Finally, we have an open mind about which structures will deliver public and patient involvement. We have set tests for that involvement and want to make sure that the structures that the Government are imposing in the Bill will deliver the capabilities that they specify.
§ Andy Burnham (Leigh)
A moment ago, the hon. Gentleman told my hon. Friend the Member for North Durham (Mr. Jones) that he would deal with his party's alternative proposals for the NHS. Will he now enlighten the House on what they are and how he proposes to pay for them?
§ Dr. Harris
I should be delighted to do so, but I am keen to stick mainly to the Bill. However, I direct the hon. Gentleman to the manifesto that we produced at the last election, which made it clear that we would provide significant extra money, funded by fair taxation, which is 220 the only taxation—the hon. Gentleman is probably proud of this—that the Labour party has committed itself not to raise. There will be stealth taxes, regressive taxes and rises in council tax to try to repair the damage to social services, but there will be no resources, funded through fair taxation, which are required, for example, to abolish charges for personal care and nursing care for elderly people.
Such proposals have gained widespread support, not only from the electorate, but from people who are interested in a health service that is free at the point of delivery and stands for equity, quality and access. I will send the hon. Gentleman details of our proposals if he is desperate, but I suggest that he takes the time to read our manifesto. I suggest that he takes the time properly to scrutinise his own Government, as their proposals on public and patient involvement are worse than those that they previously introduced in the House.
We have an open mind about the exact structures needed for such involvement. We have the same questions as the hon. Member for Wakefield about why community health councils cannot be reformed, as the councils themselves wish. They do not have the power to reform themselves, so the Government should not sweep away parts of the CHCs that are working well, but should give them the power to get involved in primary care, to provide the relevant structures so that their members are independently appointed and to enable them to enjoy formal representation on the boards of local bodies. At some point, the hon. Member for Leigh (Andy Burnham) should scrutinise his own Front-Benchers.
Having said that, I welcome the fact that the Government are prepared to change the position that they set out in their consultation paper. It is wrong for political parties to oppose something, then criticise Governments who appear to listen for making a U-turn. I do not wish to criticise the Minister or the Secretary of State for moving back from the position in their consultation paper, but the Bill's proposals still do not pass the tests of accessibility, accountability, effectiveness, independence and integration. There is no accessibility, as the hon. Member for Wakefield said, because it is not clear to which body members of the public and patients can turn, whether for independent advocacy or for scrutiny of what is going on in the health service.
That is why we believe that there is a role for a body such as a co-ordinated patients council, whether it is called a patients council or a reformed community health council, in providing the cohesiveness and integration that are required. It is not clear how patients forums will be accountable to those who appoint them. We need a wider body at a local or sub-regional level to provide that accountability to the representative groups, including local government, that have stakes in the delivery of health care. It is not clear that the Government's proposals will be effective, as it is not clear whether they will involve a professional secretariat and the experience that it would bring to bear.
On all those tests, the current proposals fail. We look forward to the Government making suggestions, preferably in Committee here, but perhaps in later stages of the Bill's passage in this place or the House of Lords, that meet the tests of effectiveness, accountability, accessibility, independence and integration. We will consider such proposals with an open mind.
221 In conclusion, it is clear that the Government do not have a coherent plan. They are desperate to avoid getting the blame for their failure to deliver in this Parliament because of their failure to allow the health service space to choose its priorities within the all too limited funds that they have so far allocated. We can see a willingness to decentralise only blame and to centralise praise, and to shift not the balance of power, but the blame.
§ Mr. Win Griffiths (Bridgend)
I rise to praise virtually unreservedly the proposals for improving health in Wales and the structural changes that go with that which are contained in the Bill.
The proposals have their root in the thinking that was initiated immediately after the Labour party's victory in 1997 and that has been developed consistently since then. Our purpose in Wales was to create an NHS in which all parts and all people worked together to provide quality care and effective services for patients. Apart from co-operation across the NHS in Wales, we also took the decision to develop at NHS trust level an integrated service combining, in the main, acute, community and mental health services. The Velindre trust, specialising in cancer care, and the Wales Ambulance trust were the only two of the 16 trusts not to contain at least two of those sectors, and 11 of the other 14 contained all three.
In considering the development of a positive agenda for health in Wales that went beyond treatment issues, we established a framework to develop partnerships between the NHS and local government. Hence, 22 local health groups were created to establish the principle of co-terminosity: matching NHS trusts and local councils to facilitate partnership and joint working, especially between the health service and social services.
Those principles and foundations for action were laid in the first 14 months of the Labour Government and they have been built on consistently since by successive Secretaries of State—my right hon. Friends the Members for Cardiff, South and Penarth (Alun Michael) and for Torfaen (Mr. Murphy)—and Welsh Office Health Ministers—my hon. Friends the Members for Cardiff, Central (Mr. Jones) and for Delyn (Mr. Hanson). The mantle in the National Assembly for Wales was taken up by Jane Hutt, Assembly Member for Vale of Glamorgan and Minister for Health and Social Services in Wales.
Accordingly, I welcome virtually all that has come out of the consultation on structural change in the NHS in Wales. I submitted a contribution to the Assembly and many, although not all, of my concerns have been tackled. The Welsh clauses in the Bill give the Assembly very substantial and wide-ranging powers to abolish health authorities, create local health boards and strengthen strategic guidance and oversight of the NHS in Wales. That will enable the development of a strong and creative partnership between the NHS and local government, which, in addition to tackling treatment problems at local and trust level, will develop a programme for health improvement. I share Jane Hutt's belief that it is essential to maintain the principle of co-terminosity of health and local government structures to deliver a better health service for people in Wales. I differ, however, on the absolute need for that co-terminosity to be determined by the number of county and county borough councils in Wales, an issue to which I shall return in my concluding remarks.
222 I welcome the strengthening of the NHS Wales directorate with the creation of a primary care directorate and lead directors for mental health and children's health. The importance of the latter initiative cannot be overemphasised. I look forward to the establishment of new medical committees based on the old district medical committees, but now including secondary as well as primary care staff, to develop policy and tackle health problems in Wales. The creation of a clearly delineated public health service in the Wales centre for health that is accountable to the chief medical officer and operates at local health board level will provide a new focus for high standards in public health services for personal health and well-being, which are of fundamental importance. The hon. Member for Oxford, West and Abingdon (Dr. Harris) might just have mentioned that in his diatribe on that particular subject.
I look forward to the strengthening of the role of the Specialised Health Services Commission for Wales in commissioning tertiary and highly specialised acute services that could not easily be developed in any one trust or by one local health board acting alone, and in providing guidance and oversight in those sectors. I am pleased that, as a result of the consultation, the proposals to create three so-called health economies containing local health board consortiums and disintegrate compulsorily the recently integrated trusts by removing community health and intermediate care services have been dropped. I am pleased that the latter proposal will proceed only if trusts volunteer for it.
Before concluding on the linchpin issue of the role and number of local health boards, I want to pay tribute to the way in which the role of nurses has been recognised, albeit belatedly, on the local health boards and at other levels of the NHS in Wales. The Royal College of Nursing in Wales has responded very positively to consultation on structural change, although, like me, it has one remaining significant concern about the appropriate number of local health boards.
As a general rule, the best way to achieve co-terminosity and maintain the match of national health service trusts and local councils is to base local health boards on trust areas. The boards will be stronger for that, as well as better able to employ high-quality staff and get able board members who are fully capable of working with the trusts to provide improved health care and develop positive health strategies.
Given that the Bill does not specify the number of local health boards or state that each local health authority must have one, and as the National Assembly for Wales is still developing its plans for the final nature of local health boards with the demise of the five health authorities, I shall not rehearse in detail all my arguments about why I think that the arrangement should, as a general rule, relate to the trusts rather than to the local authorities. However, I look forward to continuing dialogue with the Assembly on the most appropriate number of local health boards to maintain the principle of matching trusts with local councils and develop a health service that will serve the people of Wales well.
§ Mrs. Marion Roe (Broxbourne)
Like most community health councils, the four CHCs in Hertfordshire recognised that certain changes were necessary to improve public and 223 patient involvement in health care. They have been working closely with local NHS organisations to try to put into practice some of the proposals to put patients at the centre of the national health service. To that end, they are engaged in setting up shadow patients forums in each local NHS trust, bringing together complaints staff from each CHC to create an embryonic independent complaints advocacy service, and working closely with the county council and other local authorities on the overview and scrutiny functions.
None the less, although the East Herts community health council, which covers my constituency, views the Bill's public and patient involvement proposals as an improvement on previous health measures, it has several serious anxieties, which I shall outline.
The proposal for a Commission for Patient and Public Involvement in Health, with local offices to support and integrate the work of patients forums, commission the independent complaints advocacy service and encourage the transmission of patient and public views to local authority overview and security committees, goes some way to answering the criticism that the proposed system will fragment the current arrangement whereby the CHCs act as a one-stop shop for all those functions. However, it means that the number of members, accountability and staffing of the commission are of the utmost importance.
The Bill makes none of those matters clear. The criteria for appointment to the commission, its size and to whom members are accountable are unclear.
§ Angela Watkinson (Upminster)
What confidence does my hon. Friend have that anyone who is not a Labour supporter will be appointed to the new bodies?
§ Mrs. Roe
That is why such serious anxieties exist in my constituency. Nothing states from where members will be drawn. In view of the composition of other health authorities and bodies, people are worried about the balance of membership.
I received a copy of the latest document, "Involving Patients and the Public in Healthcare: Response to the Listening Exercise" this morning. Although it gives some idea of the proposed make-up of the commission by suggesting a system of nominations from the lay panels of the commission's local networks—a new proposal that is not in the Bill—and national patients organisations, the criteria for appointment, number of members and accountability remain unstated. The amount and source of the commission's funding is also unknown.
The composition, appointment and accountability of members of patients forums, which are proposed to take over the CHCs' role of reviewing and monitoring NHS services, arouse similar anxiety. Although the functions and responsibilities of patients forums are given in detail, including an extension of inspection rights to cover primary care—the CHCs have requested such rights for many years—the Bill is largely silent about their accountability, size, make-up and membership criteria.
It is suggested that the independent NHS Appointments Commission will make the appointments. However, that is a national body, whereas patients forums are essentially local organisations that need to reflect local interests.
224 The explanatory notes state that membership will be drawn from patients, carers and organisations in the voluntary sector that represent patients. Although the response to the listening exercise suggests that the criteria for membershipwill need to be open and clear",and clarifies to some extent how the commission will operate locally, specific proposals on accountability, numbers and the required staff do not appear in the Bill. To make forums truly representative, the concerns of ordinary taxpayers, who have a right as citizens to express their views about health services, need a place.
The way in which the proposed procedure in the response to the listening exercise will ensure fair and balanced representation, including that of disadvantaged members of society, deserves greater clarification. Given that there are likely to be 600 or 700 forums, attracting enough people to serve on them remains a challenge.
The Bill is silent about staffing, including the level of professional advice as well as administrative provision, its adequacy for the tasks assigned to the forums and funding details.
A further anxiety is that the public's right to have contentious matters, such as the closure or reconfiguration of NHS facilities and services, referred to the Secretary of State—the CHCs currently exercise that right on behalf of the public—will be obscured by its transfer to overview and scrutiny committees.
The proposed abolition of the CHCs means that the current position will be superseded. Although the response to the listening exercise states:powers of referral will be no less than the current powers held by CHCs",that was not stated clearly in the Health and Social Care Act 2001 and is too important not to be enshrined in legislation. I seek an assurance from the Minister that the rights of the public will be expanded rather than simply maintained or even diminished.
Another anxiety is the form that any transition will take, if the Bill is approved. The CHC members and staff have been in limbo for almost 18 months. Demoralisation and uncertainty has meant that many CHCs throughout the country have lost valuable members and staff. Replacement has become extremely difficult.
My local CHC has been fortunate in maintaining its momentum by trying to deal with patient and public involvement positively, with the encouragement of the local NHS trust and health authority. That encouragement should be undertaken nationally by the Government, especially the Department of Health, and regionally. The CHCs need formal and practical encouragement, including adequate resourcing, to move to any new system.
The proposals in the response to the listening exercise try to deal with that and should be welcomed as far as they go, but they are too late for many staff and members. The Government must ensure that the valuable experience, knowledge and expertise of CHC members and staff do not continue to haemorrhage to the detriment of the NHS, but are retained for its benefit and, more important, for that of all those who use its services.
As my hon. Friend the Member for Woodspring (Dr. Fox) said, the Bill does nothing to solve the genuine problems of the NHS. Replacing the CHCs with a plethora of alternative bodies with far less independence does not constitute progress.
§ Mr. Frank Field (Birkenhead)
I want to make a general point and a specific point, and I shall be as brief as possible. Today, we are debating the last of our nationalised industries, and many hon. Members wish to catch your eye, Madam Deputy Speaker. During my time in the House, the abolition of our nationalised industries has often been cheered by Members of at least one party. However, it is noticeable that when we debate the national health service, almost no Member criticises it. It is the one part of our post-war settlement that is held in such regard by the public that politicians reform it at huge personal and political risk. The fine picture painted by my right hon. Friend the Secretary of State at the end of his speech will be endorsed by the House and the entire country.
It is noticeable that the hon. Member for Macclesfield (Mr. Winterton) is in his seat for the debate. It is probably fair to say that he was one of the first Members to enter the Lobby when the House denationalised most of the nationalised industries, but there was no stronger champion of the NHS than he during the Tory Governments of the late 1970s and the 1980s and 1990s. In that way, he has accurately reflected the view in the country.
When the Secretary of State painted that broad canvas depicting his vision of the NHS at the end of a 10-year period, and spoke about how he hoped for the support necessary to turn that nationalised industry from a producers co-op into a consumer industry, it was noticeable how limited his first steps were in that direction. We need only think about how we behave as consumers in every other activity of our lives, and contrast that with how we have to behave as consumers in the NHS, to realise the lengths to which we must go to ensure that our last and only respected nationalised industry is successfully reformed. That is my general point.
My specific point relates to part 2 of the Bill. The ideas that I put before the House, and to which I may return in Committee and certainly on Report, relate to the regulation of the medical professions. I make a plea to the House to stand back and look at what we have been doing on regulation for the past 20 years. We have been denationalising ourselves and handing our functions to quangos outside the House, which are hardly responsible to the House. They lay an annual report before the House, but we all know that that is not accountability to the House. We have not recognised that the process of regulation should apply to an equally urgent issue on the Government's agenda—the modernisation of the House of Commons.
One of the problems that we face when we debate modernisation of the House is that some people have a hidden agenda, and view modernisation of the House of Commons as a means of defeating the Government. Of course, the Government must be sensitive to the views in this place, but if we are to hold the Government accountable at election times, Governments must, generally speaking, get their measures through, otherwise they will say, "We would have liked to do all that, but the rebels on the Back Benches prevented us from doing so."
Our role is not to take back the regulatory powers that we have given—the four huge ones to the public utilities now in the private sector, or to the Financial Services Authority or the Food Standards Agency. However, we should at least make those bodies responsible to the House 226 of Commons or to both Houses through a joint Select Committee, which would have the time and some of the expertise not to perform the function of regulation, but to hold the regulators accountable to Parliament and thus to the people.
The Council for the Regulation of Health Care Professionals, which has a co-ordinating function, should have been established by the part of the Bill dealing with quality. If we, as consumers, are concerned about the professional standards of the growing medical profession that will affect us and our constituents, we should see it as part of the regulatory function and also part of our function to support those professions as they try to push up the quality of care and the standards to which they conduct their proceedings in the NHS and, as has been argued, in the private sector.
Those are not simply my ideas—they have been developed with Sir Donald Irvine who, as is well known, is the radical president of the General Medical Council. I hope that we may return to the idea on another occasion and not only debate more fully the effective reform of the NHS, but take the reform of Parliament out of the cul de sac where it has been for so long and give it a new track down which it could go towards success.
The first of my two points, then, is that the views expressed by my right hon. Friend the Secretary of State in his concluding remarks are shared by the entire House. Our job soon will be to improve the Bill so that it will achieve the objectives that he set before us and the country. Secondly, I have made a plea for us to link, in Committee and on Report, the raising of standards of care and professional standards of conduct in the health service to the reform of Parliament.
Perhaps with this measure we will cease to denationalise ourselves and hand our functions to quangos, and welcome the existence of new quangos but make them accountable to us. In that way, the new Council for the Regulation of Health Care Professionals will be able to carry out its functions more effectively, and many more Back Benchers will find a useful role in the House of Commons.
§ Mr. Stephen Dorrell (Charnwood)
The comments that I shall make follow on neatly from the first of the two points made by the right hon. Member for Birkenhead (Mr. Field). The question that I put to the House is simple: why is the Bill creating so little interest among those who share the broad vision with which the Secretary of State concluded his speech and which the right hon. Member for Birkenhead endorsed?
No Member can doubt that health policy is an issue of concern to the great majority of voters. The Secretary of State's claim for his Bill was certainly not understated. He said that it represented the most fundamental reform of the health service since its foundation more than 50 years ago. If we are dealing with a subject of intense political interest, and the Secretary of State claims that his Bill is the most fundamental reform of the service for more than 50 years, why is there a deafening silence outside the House in the public reaction to the proposals he claims are so radical?
Any dispassionate observer looking at the comments on health politics would recognise that there is the occasional dutiful editorial, usually the second or third editorial in the broadsheets on a quiet news day. Even the 227 Health Service Journal has found it impossible to limber itself up to care about the Bill. That is true whether the views expressed are in favour of the Bill or against it. The speeches we have heard so far have not roused passion for or against the Bill. Why is it that a Bill which focuses on an issue of major political import, and which the Secretary of State believes is a major radical reforming Bill, arouses almost no interest in the health service or outside it?
The answer is simple—the voters understand something which they fear the politicians do not, namely, that the problems of health care delivery in a modern society will not be solved by further administrative reform of the NHS. God knows, we tried it over 30 years. Sir Keith Joseph invented district health authorities, area health authorities and regional health authorities; Patrick Jenkin abolished area health authorities; Norman Fowler introduced general managers; my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) introduced trusts and fundholders; my right hon. Friend the Member for South-West Surrey (Virginia Bottomley) reorganised social care; and I played a modest part in the process by abolishing family health services authorities. The Secretary of State is reinventing district and regional health authorities. That is an abridged version of the process of administrative reform to which we have subjected the NHS over the past 30 years.
None of those reforms, whether sponsored by my right hon. Friends or by Labour Members, was as bad as people feared, but none delivered the results claimed for them when they were advocated. The voters do not care about the Bill because they know that reforms, as they are introduced and sponsored by the politicians, will not deliver what is claimed for them. People already understand that simple bureaucratic change will not deliver the social policy objectives that we all have for health care.
The Secretary of State identified in his opening remarks the right staring point for genuine reform of the health service, which is not yet another administrative change. He correctly said that, if we are to deliver our social policy objectives on health, we must understand how to deliver a health system that responds to the needs of consumers who have grown used in the rest of society to a different model for the delivery of services that are important to them. They have grown used to a world in which institutions must be customer, client and consumer responsive, and which faces in a way that the NHS has never yet learned.
The Secretary of State was right to emphasise in his NHS plan the importance of considering service delivery from the patient's perspective, but we cannot really be thinking about health care and social care delivery from the service user's perspective when the anomalous distinction between them still remains at the heart of our delivery system. That was pointed out by the hon. Member for Wakefield (Mr. Hinchliffe), with whom I do not always agree on health service issues.
I understand the bureaucratic distinctions that people draw, but in over four years as a Health Minister I never met a single 80-year-old who understood the difference between health care and social care, except to the extent that people understood jolly well whether those had to be paid for. That is the only difference for the service 228 recipient, and it is the bigger problem of health care delivery caught in microcosm. How to deliver a health care and social care system that responds to patient wishes and grows in response to them, and how to pay for that, lie at the heart of genuine NHS reform. The voters are well aware of that and they think that the political class is in denial.
The Bill is a good example of the political class being in denial and its central message is that the health service will continue as before, although the bureaucracy will change. That has been the NHS message for 30 years. There is a disconnection because the voters know that, sooner rather than later, the model we have sought to deliver must be addressed more fundamentally. They agree with the Secretary of State, as I do, that the social policy objective must be to deliver health care on the basis of clinical need without regard to the patient's ability to pay, but they know, although the right hon. Gentleman is not willing to acknowledge it, that the service is not responsive enough and that it will not become so through such bureaucratic change.
The Secretary of State, like me before him and like all previous Secretaries of State, denies that people go private because they think that their capacity to pay will deliver better health care. All Secretaries of State know, as the World Health Organisation pointed out earlier this year, that other countries have found ways to harness the patient's willingness to pay with the social policy objective of equity of access. They also know that the NHS is underfunded and that the Chancellor or the Prime Minister saying that they can solve that problem through the tax system is the equivalent of the tooth fairy.
We in the House are in danger of being disconnected from our voters because we are in denial about truths that they recognise while we are unwilling to do so. Until we address those issues head on, we shall not earn their trust or respect.
§ Siobhain McDonagh (Mitcham and Morden)
I shall make a general contribution to the debate. I welcome the Government's continuing commitment to reforming the national health service to make it more efficient and more responsive to the needs of its users. The NHS remains a proud achievement of the 1945 Labour Government—perhaps the Administration with whom this ambitious Labour Government identify most closely.
The very existence of the NHS is one reason for my joining the Labour party 25 years ago. I am proud to be here to witness its reform and renewal as an organisation that is equipped for the challenges of modern health care and modern management and striving for equality of health care across our country. I hope that, in 50 years, our successors in the House will be describing the NHS, with equal enthusiasm and an equally protective instinct, as one of the best public services that this country has to offer.
However, that is not to say that any of us, least of all the Secretary of State, is blind to the problems that the NHS has faced for much of its existence. My constituents in Mitcham and Morden have recently had to bear the worry and stigma of their local hospital trust, Epsom and St. Helier, being criticised by the Commission for Health Improvement over the quality of services it provides.
Those failings are being addressed, but for a long time they were not news to people in St. Helier, Ravensbury or lower Morden, who tried endlessly to explain the 229 problems but who were endlessly ignored. I know that my constituents will welcome the Government's reforms, provided that they have a tangible and visible effect on their hospital and give them a stake in the way it is run.
Members on both sides of the House know NHS hospitals at first hand or through the experience of elderly parents, children or friends. We all know that hospitals need to be improved and that a variety of causes hold that back. I remember when the unions were blamed for the ills of the NHS, but these days the public-private partnership has begun to be used as a catch-all scapegoat for whatever problems it faces.
Both those points of view have more to do with dogma than reality. Dogma never delivered a baby, found a cure for cancer, provided a modern hearing aid or helped people to rebuild their lives after the devastation of a stroke. We must stop considering the NHS through the prism of the past and, as modernisers and pragmatists, must work to a better NHS for everyone—all the people who have a right to decent public health care and who are not concerned about who builds the hospital, as long as someone gets on and builds it.
The people of this country expect us to crack on with building hospitals, operate existing ones to the highest standards possible and, where appropriate, reopen defunct cottage hospitals across the country as intermediate care facilities to provide step-down beds and ease the colossal pressure on larger acute hospitals.
for example, I would like the Wilson, which was once a very fine cottage hospital serving the community in Mitcham, to reopen. For some years, it has been used as offices by Merton, Sutton and Wandsworth health authority, so where there were once beds there are now desks and filing cabinets. Equidistant between St. Helier and St. George's hospitals, the Wilson could ease the pressure on the acute beds in both. People would strongly support opening a large number of such dormant facilities to ease the pressure on acute hospitals and care for the elderly.
In recent decades, the NHS has been hamstrung by a lack of resources and a lack of vision for its future, particularly in the bleak, bleak Tory years when it seemed to many that people were being forced to accept a poor, chaotic health service although, as patients and as taxpayers, they had every right to expect much better. We faced a mountainous task in May 1997, and four and a half years later we are still on the lower slopes.
A right hon. Friend of mine once said that we had 24 hours in which to save the NHS. Sometimes, when I receive letters from constituents who have had an appalling time in hospital, who have waited upwards of 12 months to see a consultant, or who must put up with ill-fitting temporary analogue hearing aids when their lives could be transformed by digital aids, I feel that 25 years might be nearer the mark.
The long struggle that we all face, in government or not, is the struggle to restore the diminished confidence in the health service, modernise its delivery to our people, and reform its structure so that it can offer a much more patient-focused service. We must invest heavily in hospitals throughout the country, so that everyone has access to health care they can trust at the time when they need it.
I was pleased to read the ambitious proposals in the document "Shifting the Balance of Power within the NHS—Securing Delivery". I am glad to note that they 230 have been translated into effective legislation in the Bill. I welcome the creation of a national patients organisation and an overarching professional regulatory body, both of which will ensure greater protection of the rights and dignity of patients. It is entirely right for the people, whether they are patients or not, to have a voice—I hope it will be a loud voice—in decision making in the NHS.
Provided that they are adequately resourced and listened to, I also welcome the proposals for patients forums. I am glad to learn of the role they will play in gathering and reporting on the views of patients and carers about the services of trusts, giving patients and carers advice and information about those services and monitoring their operation. I am also pleased that there has been a far greater acknowledgement than ever before of the selfless role played by carers in delivering health care. That role has been ignored for too long.
In the context of regulation, I welcome the creation of more independence for the Commission for Health Improvement. Strong and effective links with other key bodies, including the Commission for Patient and Public Involvement in Health and the national patient safety agency, will be essential to ensuring a thorough and co-ordinated approach to monitoring and regulation. The case for inspection and regulation is strong. In the 20 months of its existence the CHI has published reviews of more than 50 trusts, and a further 50 reports will come before April. That will mean that more than 70 per cent. of acute hospitals have been reviewed.
The CHI has shown that it will be brutally honest when it identifies unacceptable patient care, as it has at St Helier hospital which serves people in my constituency. It has, however, been full of praise for hospitals that are succeeding—for instance, the North Tees and the Royal Devon and Exeter hospitals.
Patients know that such extremes exist in the health service. Sadly, they are to be found in every public service. It is important that the CHI reflects the reality experienced by patients; it is also important that it can say when an ailing hospital has turned the corner. I very much hope that that will be possible in my constituency. We are talking about a fundamental first stage in the rebuilding of public confidence in the services on offer there.
In the NHS, there are signs of improvement as a result of the CHI's work. The better trusts are putting their houses in order before its visits, and patient care is better as a consequence. But what of trusts that are dragging their heels, or simply have not the capacity to improve? At present, a CHI report is followed by an action plan written by the trust and overseen by the NHS regional office. That is all very well, but the CHI has no role in revisiting the trust for four years. When it finds quality to be unacceptable or there is a failure in management, it must be able to visit again much sooner, and must be able to require the trust concerned to take remedial action before its next visit. Those are the special measures of which the Bill speaks, and I think they are entirely justified if we want a more accountable, patient-focused NHS.
The CHI has shown itself to be equal to the task it has been given. The wider remit conferred by the Bill constitutes a recognition of that, but the Bill also gives the CHI the teeth it needs to deal with the difficult minority of hospitals that are failing patients to such an extent that they need further action and support in order to improve their care.
231 Moves towards a patient-focused NHS and the tackling of health inequalities are entirely laudable, and many of my constituents would say it was about time such things happened. It is clear to me, however, that further reform will be needed in terms of patients' dealings with their GPs. I believe we have a duty to provide measures ensuring that patients cannot be removed from their GPs' lists without reasonable cause, and that they have the right to a fair and open explanation of a GP's reasons for taking any such action. I also feel that the current system of health charges should be revised to ensure that no patients are prevented from obtaining essential health care. That must be a fundamental plank in the eradication of health inequality.
I support the Bill's aims, and hope it will enable the Government to make significant progress in their mission of NHS investment and reform. I know that significant progress is what the people of Mitcham and Morden want, whether they are visiting their GPs or their local hospitals.
§ Sir George Young (North-West Hampshire)
I wish I shared the optimism of the hon. Member for Mitcham and Morden (Siobhain McDonagh).
The Bill's origin lies in last year's White Paper, "The NHS Plan: A plan for investment, A plan for reform". At the time, the Secretary of State said:The NHS can address the need to reform itself—from top to toe—to meet the challenges of rising patient expectations.Reform from top to toe has been happening ever since, and the Bill is part of that.
I want to follow the line of argument developed by my right hon. Friend the Member for Charnwood (Mr. Dorrell). I want to ask whether the current wave of reform is genuinely meeting those challenges of rising patient expectations, to ask whether the reform is based on a cool analysis of the problems on the ground, and—if I find it is not—to suggest that it may be an unwelcome distraction.
Out there in the real world, the NHS's back is against the wall. Last month, the Basingstoke Gazette said:Hospital faces drastic cuts. Worried health chiefs are to write to MPs about a cash crisis which is forcing them to plan closures of 40 hospital beds and make cuts in services amounting to millions of pounds.As for the new resources that Ministers keep telling us about, the paper commented:The Directors said the new money coming into the health service has been 'badged' for specific services and swallowed up in pay awards and targetsand went on to say that the trust involved planned to deal with bed blocking and then close the beds.
Much as we all love our local newspaper, we do not necessarily believe every word that it prints. Looking behind it and consulting the NHS's own publications, however, will show us that the paper is right. A week or two ago, my health authority published "Improving Performance in North and Mid-Hampshire", which sits uneasily with what we have heard from the Minister this afternoon. The first page tells us:This means that there is currently an underlying deficit of £7.5 million in the NHS in North and Mid-Hampshire. Consequently, we face a major challenge if we are to secure health services fit for the 21st century within the resources available locally.232 We are told that the deficit is unsustainable and thatsome changes will affect how services are delivered to patients.I think we can all crack the code, and deduce that that means a reduction in services.
If we dig a little deeper and look at individual trusts, we see the problems that confront them. According to the recently published annual report of Winchester and Eastleigh trust,despite the size of these savings"—savings already made—the economy is likely to remain in deficit and further savings will be required if the Government's ambitious targets embodied in the NHS plan and the full cost of pay and price rises are to be met.According to the minutes of the last meeting of North Hampshire Hospitals NHS trust:By August 31st, the Trust was overspent by £1.2 million…The Trust would still be unable to break-even at the year-end and was looking at a considerable deficit. Further proposals would be brought back to the Board next month on measures to help decrease the deficit, following discussion with the PCT and the Regional Office".Against that background, my constituents find it impossible to reconcile the rhetoric of Ministers with what is actually happening in Hampshire. Of course, that is having an impact on the quality of the service they receive. The Secretary of State mentioned cancer services. I have a letter dated 4 September from Mrs. H, who wrote:I have just been told that the lymph node that was removed three weeks ago was malignant.She needed immediate radiotherapy to deal with that. On 11 October, five weeks later, she received a letter from Southampton general hospital:Your specialist has made arrangements for you to have a course of radiotherapy. At the moment, we have a long wait list…please accept our apologies for any anxiety…as a result of this situation.Of course there is anxiety and, after further correspondence, treatment will start this Thursday, 10 weeks after she was told that she needed it. She wrote to me a few days ago:I am still not happy about having to wait so long for treatment on my cancer".I have asked for the radiotherapy waiting times at Southampton general hospital to see if that was unusual. The maximum acceptable waiting time according to the guidelines for radiotherapy after a mastectomy is 28 days. Not one case at Southampton was dealt with in that time: the average wait is 78 days—three times the maximum.
Like other colleagues, I pursue such matters with the health authority to ensure that it knows what is going on. I am told by the chief executive:I am satisfied that the Trust are making all endeavours to provide a service that attempts to treat patients within good practice guidelines, having regard to the constraints of available equipment and specialist staff.I want to come back to those constraints because they are at the root of the problems in Hampshire.
Our hospitals have the stars, the beacons and all the trophies that validate competence in today's NHS. What we do not have is the cash, so I ask whether the problems that I have outlined are likely to be put right by a further round of administrative reform, or do the causes of the problem lie elsewhere? Will further reform make life more difficult?
The problems in my constituency—it is not unique—can be simply stated: pay awards and other costs are in excess of the inflation uplift given by the Government; 233 the formula for allocating resources is wrong, which is why nearly all the authorities around London are in deficit; NHS staff cannot afford to live in Hampshire and other parts of the south-east, so there are recruitment and retention problems and excessive use of agency staff, which leads to budgetary problems; and there are severe problems of "delayed transfers of care", or bed blocking, which means that hospitals have to treat more people than they should.
Against that background, one must ask whether the Bill will help. Clause 1 sets up the new strategic health authorities—major turbulence. I was sent the document relevant to my constituency. It was entitled "Modernising the NHS: Shifting the Balance of Power in the South East", a grandiose title with geopolitical overtones, but it really means that four health authorities in Hampshire and the Isle of Wight are knocked into one. The first paragraph tells us that NHS reform willaddress the issues that really affect the patientsbut once we have read it, we realise that it does not. It is a thin document with 12 lines on the financial implications on page 21. There are no details of any costs or savings, simply an aspiration that any savings would be earmarked for reinvestment in front-line services. Presumably, the obverse is true: any costs will have to come out of front-line services.
Clauses 2 and 3 propose major reform for PCTs. I am not against that, but it is worth pointing out that those are fragile and untested bodies. On their slender shoulders will pass responsibility for managing large services, employing staff and negotiating with the trusts, and then they will have to do all the stuff in the NHS plan: modernise the service, involve patients and the public, lead on partnership with local authorities and liaise with the independent sector. I am not convinced that they are adequately resourced to take on all those roles. I want an assurance from the Minister that they will not inherit all the deficits from their predecessors.
Clauses 8 and 9 are about money. Every year, there is a huge redistribution of resources in the NHS—it is a larger sum of money than the revenue support grant—but with minimum debate and minimum accountability. On that allocation formula rests the quality of service that our constituents get. It is the so-called York formula.
The local government finance settlement is £36 billion year. There is an open and transparent system of distribution, and a debate about it each year. The spend on the NHS in the UK is £59.1 billion—a far larger sum—but the distribution system is not open, accountable or debated. On those obscure foundations rests the quality of service that our constituents get.
As has been said, under the new regime the money will go direct from the Department to primary care trusts. There will be less room for error. At the moment, it goes to the area and there is viring between the various trusts in order to ensure that there is no problem. There will be no room for manoeuvre under the new regime and a premium on right information.
§ Sir George Young
I am afraid that I am against the clock. My hon. Friend will know that with the rate support grant there is all sorts of controversy, but if the 234 Government do not get that right, the council tax can act as a buffer. There is no such buffer when it comes to that particular formula.
The independent panel set up by the Minister last year made it absolutely clear that the formula was wrong for Hampshire:We heard no evidence to support such a large reduction on the national needs 'norm' … Denying the area full funding will not make the population any less … health conscious.I end with a helpful suggestion. How do we take the pressure off the NHS, while adhering to its principles? If we hold the view that money is part of the problem, how can we get the percentage of GDP up without upsetting the Chancellor of the Exchequer? I think that one should introduce what I would call NHS at work—an employment-based health insurance scheme complementary to the NHS—
§ 7.6 pm
§ Mr. Paul Truswell (Pudsey)
I wish to concentrate on the patient representation elements of the Bill. I hate to say it but, unlike my very good and hon. Friend the Member for Wakefield (Mr. Hinchliffe), I more or less understand them.
I have both a dream and a nightmare about the Bill's proposals. In the dream, everything falls into place and it represents a radical extension of patients' voices in the NHS. In the nightmare there is fragmentation and confusion. I sincerely hope that the reality much more closely resembles the dream than the nightmare.
In various guises, I have worked with and in CHCs for almost 24 years; I think that they were established in 1974, so I have been involved with them for most of their lifetime. I personally have a positive view of the role that their members and officers have played over the years. I am not, however, a fully paid up member of the CHC preservation society, although I am keen to conserve the very good things that the CHCs have achieved and the lessons that they have taught us. I believe that a model based on the CHC would have been valid for the Bill, but the Government have taken a different tack, which I hope is ultimately vindicated.
The Association of Community Health Councils for England and Wales has said in a briefing:The Bill replaces a system of proven efficacy that is easily understood and accessed by the public with a highly complex and fragmented structure.Despite that assertion, in my experience, the CHCs have to some extent remained one of the NHS's best kept secrets. It is a secret that I regularly find myself having to divulge to constituents who contact me for advice about complaints. I believe that ACHCEW is right, however, to voice concerns about a complex and fragmented structure. Without careful introduction and proper resourcing, its fears are plausible.
On Second Reading of the Health and Social Care Bill, I expressed concerns about the overall lack of co-ordination between PALS—the patient advice and liaison service—the independent advocacy service, patients forums and the overview and scrutiny committees. The need for that role has been recognised in 235 the Bill. It will be fulfilled, it is hoped, by the local networks of the Commission for Patient and Public Involvement in Health—quite a mouthful. Those local networks have been described elsewhere by the Under—Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), as the glue that will unite the various disparate strands of the new structure.
As my hon. Friend the Member for Wakefield said, whether glue and bureaucracy really go together only time will tell, but what we really need at this juncture is a clearer exposition of how the commission's local networks will be resourced and how they will operate. They should, ideally, provide a servicing role to patients forums not unlike that currently performed by CHC staff in support of CHC members. They should provide independent policy, legal, research and administrative support. It is worrying that the explanatory notes relating to subsection (2)(d) refer only to the local commission providing "administrative support". I hope that that is a shorthand way of describing all the support that I have listed above, but if it is not, that will be a real deficiency in the system. That support will have to come at a cost, and I believe that that cost will be much greater than the current cost of CHCs. If that cost is not met, however, the system will be much the worse off.
In Leeds, the local commission will have to service seven patient forums. Additionally, it will have to discharge its outreach function of increasing public participation and its co-ordination and monitoring role between the various pillars of the new system. If we add to local costs the cost of setting up PALS and the independent advocacy service, we are talking about a significant sum. It would be helpful if Ministers could at some stage quantify and cost the proposals and provide a commitment that the Government will provide the resources to make them work effectively. I believe that, to discharge its function effectively, the commission should be much more localised than it is intended the strategic health authorities will be. I should think that it must have a base within a city the size of Leeds.
I also wonder whether the commission's local network will provide support to patient forum members who are elected to a trust board. Those individuals will have to carry a substantial burden. It is therefore crucial that nominees to trust boards have effective independent support and advice. If they do not, I fear that they will simply be co-opted into the collective corral of the NHS board on which they serve. It is also unclear whether the nominees will perform the function of delegates from the patient forum with all that that might imply. I certainly seek clarification from the Minister on that point.
As has been said, some welcome action is being taken to increase the forums' powers beyond those of the CHC. However, I re-iterate the comment that those powers could quite easily have been added to those of CHCs. The CHCs have, for example, asked for many years for their remit to be extended to primary care, a request on which the Bill obviously delivers. We should also extend visiting rights to private sector facilities, and there should be provision—which has been called for for many years—for unannounced visits so that forum members, on behalf of patients, can see facilities, warts and all.
236 The hon. Member for Broxbourne (Mrs. Roe) mentioned the power currently vested in CHCs to refer unacceptable proposals to the Secretary of State. I hope that that power will continue regardless of the body in which it is vested; otherwise health bodies will continue to treat consultation as a cynical exercise and the patient's voice with some contempt.
In order to promote wider membership, we should introduce measures for patient forum members that are similar to those enjoyed by local authority members, including a statutory right to time off. An alternative to that would be some form of remuneration, particularly as some forum members will be paid non-executive directors of trusts. We should also consider proposals such as a loss of earnings provision.
Forum members must be appointed for a sufficient period to allow them to learn the ropes and make an effective contribution. Currently, CHC members are appointed for four years and, as I understand it, can serve two terms. Such an arrangement has much to recommend it to ensure continuity.
I certainly welcome the commission's overarching local and national remit, which seems to be an effective way of killing two birds with one stone. I am less enamoured, however, with suggestions that the Secretary of State should appoint the commission chairman and chief executive. Surely, for the sake of independence being seen to be done, other arrangements can be found.
I welcome the recognition in the NHS plan and in the Bill of the importance of advocacy services, which will complement existing services in places such as Leeds where they are provided very effectively by the voluntary sector. It would be interesting to have the Minister's views on how the services envisaged in the Bill will fit in with the advocacy services that are already being provided in places such as Leeds. I am also pleased that the distinction between advocacy and advice has been recognised in the renaming of PALS by use of the word "advice" rather than "advocacy".
A focus on advocacy is long overdue. In the mid-1980s, Leeds city council established an advocacy service. The health service viewed it with great suspicion and found the term advocacy to be adversarial, threatening and intrusive. I believe, however, that if such services had been more widely available, some of the scandals that have occupied the time of this place over the years might have been averted and that the necessary corrective action might have been taken much earlier.
I have grave reservations about the transitional arrangements between abolition of CHCs and the new structure coming into place. As has been said, the transition needs to be achieved in a manner that does not entail patient representation and the patient voice being left in limbo. It is also essential that the many good and effective CHC staff—most of whom we know and respect in this place—are not lost to the system. They have the experience and expertise to make the new structure work.
I genuinely believe that the Bill could represent one of the most ambitious, exciting and radical steps taken by the NHS in its history. Conversely, it could fulfil the fears of ACHCEW. I hope that my right hon. and hon. Friends will succeed in making it the first possibility. However, they will do that only if they combine a genuine commitment to extending patient involvement with the funding that is necessary to make the structure work properly.
§ Mr. Roger Gale (North Thanet)
I shall concentrate on part 2 of the Bill, which has received almost no attention at all in this debate and I believe is a time-bomb that is ticking away and could explode and blow the health professions to pieces.
On 13 November, the Minister of State, Department of Health, the right hon. Member for Barrow and Furness (Mr. Hutton), wrote a letter to hon. Members headed, "Modernising Regulation in the National Health Service". He started by saying:We shall shortly be laying before Parliament two Orders under section 60 of the Health Act 1999. These will provide for the setting up of new modern regulatory bodies to deal with professional standards and discipline for three quarters of a million key healthcare professionals covering nurses, midwives and allied health professionals.These bundles of fun that I am holding are the two statutory instruments—on the health professions and on nurses and midwives—that were mentioned in the letter. They will not be debated on the Floor of the House, but will creep through as statutory instruments. They are also the documents referred to in paragraphs (g) and (h) of clause 23(3). In an explanatory note to the documents, the Minister of State said:There has been very strong support, across the board, for this once-in-a-generation opportunity to modernise the current systems that are widely acknowledged to be outdated and inflexible.I do not know where the widespread support comes from, but I do know that the health visitors in my constituency, who serve my constituents, are desperately worried. Despite assurances from the Minister of State and others in the Department, health visitors simply do not trust the undertakings being given by the Government that standards will be maintained, that their professional prestige will be maintained, and that the demand for high standards and qualifications will be maintained. They cannot for the life of them understand—and neither can I, on their behalf—why the proposed nursing and midwifery council does not include in its title the health visitors whom Ministers say that they so much admire.
This morning, one health visitor told me that she believes that the proposals will sound the death-knell of a part of the health care professions that is already finding it desperately difficult to recruit. I know from my own experience in my own constituency just how short-staffed they are. I should have thought that the Minister of State would want at the very least to promote their cause and help them to recruit to that vital part of the health service, rather than effectively to snub them, remove them from the title of that council which the Government are determined to create, and leave them wondering whether they have a future at all.
The other proposed council is for the health professions, to cover among others chiropodists and podiatrists. Jill Yeo, one of my constituents and a health professional, wrote to me thathaving read the draft copy of the legislation, I and fellow non-state-registered Chiropodists … have … concerns for our professions, livelihoods, and for patient choice and standards of care.She continues:We welcome the proposals for the state sector and public sector Chiropodists/Podiatrists to work more closely together. There is a great demand for qualified Chiropodists to work within the NHS. Any discrimination of either sector will put added pressure on the 238 already overstretched NHS Chiropodists, with detriment to patient care … The non-state-registered sector represents more than half of our profession, yet we seem to have been overlooked in the proposed draft legislation. There are more than eight thousand of us currently practising in Great Britain … The new legislation if implemented could prevent us from using the title of Chiropodist/Podiatrist meaning the loss of our livelihoods, the majority of us being experienced professionals who are thought very highly of by our patients.She also points out:It has taken me two years to become a Chiropodist. I funded the course myself and the training included an eight-hour written examination as well as practical hands on experience to enable me to qualify. I am working hard to establish my business, and already have very satisfied patients of all ages who are grateful for the quality care I give them. My colleagues … have extensive private practices with at least 20 years combined Chiropody expertise and knowledge behind them. It would be such a waste if all of this were to change, and at a cost to the patient and possibly the NHS.It is not so long ago—well, it is, but time passes quickly when one is having fun—since the Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), introduced in Westminster Hall a debate on the failings of the General Osteopathic Council and the weaknesses in the Osteopaths Act 1993. In fact, it was 13 months ago. I do not know whether the hon. Lady has changed her tune since her move to the Front Bench, but at that time she was desperately concerned that the 1993 Act was not working, despite its fine intentions. It had, far from uniting the osteopaths' profession, divided it to the point where we now have a General Osteopathic Council, which is recognised by some, and a pirate democratic osteopaths council alongside it. Almost 50 per cent. of osteopaths were not satisfied with the way in which the GOC was set up.
We have had the debate on osteopaths and another Minister of State has held an inquiry—it was a whitewash—into the workings of the GOC, but we are about to make all the same mistakes again, having learned nothing from that experience. I find that desperately sad. Ministers should consider the two orders properly, recognise the value of those true professionals to the health service and change their minds.
It was said earlier that the Government have succeeded in making the elderly wait to get into hospital beds and wait to get out of those beds. In Kent, that is absolutely true. The right hon. Member for Holborn and St. Pancras (Mr. Dobson), when he was Secretary of State for Health, took a wildly unpopular but courageous decision on the reorganisation of health care in east Kent. I was, and still am, not very popular for backing it either. The right hon. Gentleman recognised that it is necessary, in a modern health service, to determine when and how services will be delivered, and that may mean some unpopular changes. However, that plan is being completely undermined by the Government's attitude to the health service.
When my hon. Friend the Member for Woodspring (Dr. Fox) opened the debate for the Opposition, he said that we had lost tens of thousands of residential and nursing home beds. That is true, and it is especially true in Kent. Thousands of those beds have gone and, as a result, hundreds of patients are blocking the beds in our acute hospitals. The Bill will do nothing to enhance cottage hospital care, to create minor injuries units, to get patients out of the beds that they are blocking or to solve the problems that many of our constituents face in desperation day after day. It has been said that the Bill is 239 the equivalent of rearranging the deck chairs on the Titanic. It is more like moving the chairs on the deck of a submarine, with the Secretary of State being hellbent on making it dive.
§ Helen Jones (Warrington, North)
Unlike some hon. Members who have spoken tonight, I believe that the Bill marks a major step forward for the NHS. It will move us away from an NHS that has been directed from the top down and in which decision making was often remote and bureaucratic, and allow us to create a health service that empowers its front-line staff, responds to patients' needs and enables us to create real partnerships with communities to tackle some of the health problems that face us. While the NHS has transformed the lives of many people, has an excellent staff and delivers miracles every day, it is still largely a service that was designed for the 1940s. If it is to deliver what we need in this century, it has to be a service that uses the expertise of staff who are now much more highly trained than before, and that can deal with patients who know much more about the health choices available to them and who demand, rightly, much more flexible care.
The key provisions in the Bill, which give the lead in providing health services to primary care trusts, will give us a real opportunity to achieve those aims, but Members of Parliament can only set out the framework. Delivery will be achieved only if those people involved in primary care trusts are really keen on listening to staff who are at the sharp end of the health service. I do not mean merely fulfilling the statutory obligations about who serves on trust boards, but really listening not only to GPs, but to district nurses, midwives and health visitors who know far more about the health needs of their communities, and the social needs underlying them, than many of the staff further removed.
I have spent time in my constituency with health visitors and with GPs delivering personal medical services pilots. I have sat in their clinics and gone out with them on their rounds. I know that they have the vision and energy to change the NHS for the good of the people they serve and they have to be allowed to do it, but so too do the communities that our primary care trusts will serve. We need to involve them if we are deliver the key objective of ending inequalities in health. I make no apology for returning to that theme, because it is a key issue in my constituency and in many others like it.
The areas that I represent in the north of Warrington have much greater health care needs than the more affluent areas in the south of the town. They have higher rates of coronary heart disease and long-term illness and much higher mortality rates. But not only do they get fewer resources than their health needs would suggest, they are under-represented at all levels of decision making—sometimes they are not represented at all—in the NHS. The primary care trusts must ensure that that changes, and the Commission for Patient and Public Involvement in Health, which the Bill will set up, will play a key role in bringing that about. It will need to ensure that such communities are represented not only on advisory bodies but in the real decision-making process of the NHS. It will need actively to seek out people to 240 become involved, because the problem is not that those communities do not have people capable of making the decisions.
I know many people in my constituency who run local organisations, manage budgets and know a great deal about the area. It is patronising nonsense to suggest that they are not capable of becoming involved in the NHS. They know far more about strategic partnerships and joined-up working than many people who pronounce on such issues. Those involved in the community can tell us whether there is no point sending patients to a clinic because there is no bus to get them there, or if there is no point treating them for stress because that stress is caused by poor housing or crime and vandalism in the area. They do not need lectures about social exclusion, because they understand that. They need to be included, and the bodies that the Bill will set up must ensure that that happens.
The Bill is about putting patients at the heart of the NHS and two of its features will be important in achieving that. One is the setting up of the independent advocacy service, because most people—in my experience as a constituency MP and as a solicitor who dealt with clinical negligence cases—want their cases dealt with on the spot. As my hon. Friend the Member for Wakefield (Mr. Hinchliffe) said, it will be crucial to ensure that the service is easily accessible, and that it is seen to be independent. I hope that the Minister of State, Department of Health, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), will comment on how the service is to be managed outside the trusts in which it works, so that we can see that independence in fact.
I welcome too those parts of the Bill that allow the Commission for Health Improvement to refer cases in which it considers that patients' safety or welfare is at risk and which have not been tackled. Many of the tragedies that have occurred in the NHS would not have occurred if that provision had existed. The truth about many of those cases is not that people did not know what was happening, but that too many did know and did nothing.
In respect of the protection of patients, I turn now to the matter of regulation. The Council for the Regulation of Health Care Professionals, which the Bill will set up, together with the provisions of the Health Act 1999, will allow us to regulate other health professions much more easily than hitherto. When the Bill is enacted, I hope that the civil service will have run out of excuses for not regulating some of the people currently working in the health service who have not been regulated so far. I refer specifically to operating department practitioners and health care assistants. It is a nonsense that people who deal with controlled drugs and perform intimate services for patients do not come under any form of regulation. That nonsense must be ended.
Finally, I welcome the provisions on the prison health service. They have not been mentioned so far in the debate, and we know that there are no votes in providing good health care for prisoners. However, the prison medical services have long been a disgrace to a civilised society. The arrangements established by the Bill for joint working and pooled funding will go a long way to solving that problem.
Prisons have many serious health care problems. They involve the mental health of prisoners, their greater propensity for suicide and the spread of addiction in prisons. However, we have not been able to attract as 241 many good staff as are needed to work in prisons. There are serious shortages of nurses and psychiatrists, and especially of registered mental nurses.
In part, that has happened because there has been no adequate career path for staff working in the prison medical service. The Bill will allow staff to share best practice and update their skills. It will also provide great support for prison medical service staff in the ethical dilemmas and difficult decisions that they have to face every day. In addition, the arrangements in the Bill will facilitate the transfer of patients when that becomes necessary.
In the prison medical service and many other sectors, the Bill offers a real opportunity to transform the health service. It is not about bureaucratic measures: it is about creating a health service fit for the 21st century. I hope that those working in the health service will take the opportunity to build on the foundations that we are laying down tonight. I commend the Bill to the House.
§ Dr. Richard Taylor (Wyre Forest)
I am grateful for the opportunity to speak in this important debate. I agree with the Secretary of State that NHS practices must change, but I have a problem with the nature and timing of the proposed changes. Some of them are right, but I do not think that now is the right time for such extensive changes.
That is largely because of the crises that exist in the NHS at the moment. The Secretary of State was wise to admit that delays for coronary artery bypass surgery amounted to one specific crisis. Despite the changes that have been made, 216 patients in the west midlands have been waiting more than 12 months for an operation. When one of my constituents was told that he was on the critical list and that he would have to wait six to nine months for his operation, he decided to mortgage his house and get private treatment.
All hon. Members will know from their postbags of the trolley waits that patients still endure. I received a letter only today from the relatives of an 80-year-old woman who waited 11 hours. She was not an unexpected emergency, because the hospital had been warned beforehand about her case.
I quote from a letter written by an orthopaedic surgeon to one of the major national dailies, in which he expressed his concern. He wrote aboutthe widespread despair and disillusionment amongst NHS consultants",who, he said, were very aware ofthe increasing pressures and financial constraintsunder which they found themselvestrying to provide some sort of civilised service to our patients.The surgeon added:Sadly, the truth is that the situation at the front line continues to deteriorate.A time of crisis is not the right time to thrust ahead with major changes that risk disruption. I therefore plead for delay. Of the three primary care groups in my county of Worcestershire, one is already a primary care trust. It is probably about ready to take on the new responsibilities. The other two are still primary care groups, and are not ready.
242 In south Birmingham, 60 per cent. of GPs have voted against the change because they are not ready for it. A report in the local newspaper states that theyfear the shake-up is being pushed through too quickly and will cause administrative chaos".They believe:the money spent on the reforms would be better spent on health care.If primary care trusts are not ready, there is no reason to rush through with the strategic health authorities. I strongly agree with the hon. Member for Wakefield (Mr. Hinchliffe) that community health councils have performed a very useful task. I should much prefer to see them strengthened than removed.
The CHCs enjoyed relatively democratic input. A number of their members were elected councillors, and although some were appointed by the Department of Health, others represented local charities. They were therefore true representatives of local people.
What is the real reason for the abolition of the CHCs? The Secretary of State did not answer that question from the hon. Member for Wakefield. I wonder whether the reason is that CHCs had one tooth: they could refer controversial decisions to the Secretary of State.
If, by chance, my plea for some delay were heard, the question of how to resolve the current crisis would remain, and my approach would probably be considered revolutionary. I believe that now is the time, not for devolution, but for instruction about where the extra money is to be spent.
There have been examples of managers and consultants falling out, with consultants saying that the service is badly managed, and managers trying to blame the consultants. I believe that in many parts of country, health service managers do not perform their duty to the best possible degree, as they should. Given that money is so scarce, is not this the time for direction in the way that it is spent?
Money should be targeted. I fully support the £300 million that has been given to social services. It will be a great help, but will we be given a breakdown of how it will be spent? Although £300 million sounds a vast amount, analysis shows that my county's social services will receive £713,000. That will provide less than one extra place in a care home per week.
I have another suggestion for the way in which money should be targeted. NHS surgeons in my constituency are idle at times because there are not enough staff or beds to enable the operations on their lists to be carried out. That is one occasion when the private sector can be used as an expedient where there is spare capacity. More money should be made available for that.
If the reforms were delayed, more money would be available. No one has yet said how much this will cost and how much it will save. A week or two ago, an advertisement for a chief executive post for one of the new bodies in the Health Service Journal proclaimed that the salary would be £70,000. Considering how many new bodies with chief executives there will be, I cannot believe that if these measures were delayed for a short time, there would not be some extra money.
243 I conclude with a quote from an article by the president of the Royal College of Physicians in Hospital Doctor a few weeks ago, in which he wrote:We all want to practise medicine for the greatest benefit of the sick and we must indeed be accountable. But let us be sensible about the rate of change and the balance between political correctness and what is actually attainable.Modernisation needs time.
§ Mr. Patrick Hall (Bedford)
Given my role as chair of the all-party group on community health councils, I will confine my remarks to those parts of the Bill dealing with patient and public involvement in the national health service and the abolition of community health councils in England.
Much has already been said about this process. It began in July 2000 with the publication of the national health service plan, which was followed by an Adjournment debate on the future of the CHCs one year ago and the incomplete progress, before the election, of the measure that became the Health and Social Care Act 2001. It is widely accepted that the process was burdened from the start by the lack of prior consultation on the future of the CHCs and the emerging picture of a replacement system that was complex and unclear. I believe that we have moved on from that painful experience.
The new proposals, especially as described in the recently published Government response to the listening exercise last September—which I have looked at—reveal that progress has been made. That welcome situation is due, at least in part, to the excellent work done, following the election, on re-engaging with community health councils. It is right to acknowledge the constructive role played by the Under-Secretary, my hon. Friend the Member for Salford (Ms Blears), who has understood that the new and better system we all want will not even begin to function without the involvement and good will of CHC members and staff.
There is evidence in the Government's response that they have been listening to people. For example, there is the sensible acceptance that patient advocacy and liaison services should be called patient advisory and liaison services. Also important is the Government's recognition of concerns about independence, accountability, integration and support, especially at local level. That said, the picture painted by the Bill does not enlighten us enough. The full picture will emerge as a result of some of the provisions of the Health and Social Care Act 2001, yet to be implemented, along with the provisions of this Bill and, in the main part, regulation and guidance that has not yet been prepared.
Legitimate concerns about the detail will not be addressed by the Bill. The Government's response is reassuring because it contains a lot of detail and paints a credible and coherent picture. However, the Bill does no more than provide a framework. I suggest that during the Bill's Committee stage, draft regulations be prepared so that the detail necessary to understand and support the Bill's framework can be considered. Such an approach was successfully adopted during the consideration of the Local Government Act 2000.
I have a few further points to make in the time remaining to me. The Commission for Patient and Public Involvement in Health is, as has been said, a bit of a 244 mouthful. I note from the Government's response document that the title is described as shorter than the one originally proposed. However, I welcome the creation of the commission nationally to co-ordinate, monitor, promote best practice and support local networks. The Government describe it as a statutory and independent body, accountable to a national lay group.
I understand that the Secretary of State wishes to appoint the chair of the commission and approve the appointment of a chief executive. That does not, in my view, sit comfortably with the intention that the commission be fully independent. Therefore, I ask my right hon. Friend to think again about that.
On the commission's local operation, the Government propose local commission networks working in every primary care trust area through local outreach teams based in local premises. Having looked at the Government's response document, I believe that the essential functions of integration, co-ordination, informing and supporting patients forums, PALS and local authority overview and scrutiny committees—which my hon. Friend the Member for Wakefield (Mr. Hinchliffe) proposed the patients council should undertake—are retained. In addition, there is the interesting and radical suggestion that the networks will also promote and support local people in engaging in proposals affecting their health. That is radical, because such activity might not always be welcomed by the NHS management and boards. It is essential to have such a provision if we are to develop a national health service that is patient-centred.
I commend actions that are likely to generate informed and measured responses by the public and their elected representatives to health care proposals and changes in their area. However, to carry out those tasks, the local commission networks will need to be properly resourced. That will not come cheap.
The shop front—the one-stop shop—has not been mentioned in the debate so far. Community health councils in many parts of the country already provide them. Although I am ready to admit that not too many citizens have made use of them, the presence of a shop front is important, especially if we are looking ahead to an improved system. They should be retained. I am not convinced that that will necessarily be part of the future system. I think that the Government will argue that PALS should provide the point of contact, where and when needed, to patients and their families and that it will link to the independent advisory services for those who wish to pursue a formal complaint. However, the public are not supposed to be served by PALS except in so far as they become patients. The way in which PALS operates at primary care and community health level will clearly not be as obvious as a reception facility in an acute hospital.
The patients forum monitoring each trust will not be a shop front. The commission network could operate from a base that does not need to be visible. I wonder where and how the public are to be made aware of the new system so that they can become involved. That is important if it is to work. I acknowledge that the shop front is not a necessary condition for the whole thing to operate, but it seems a sensible ingredient.
One of the concerns that was much aired earlier this year related to the role of the patients forum member on the trust board—not as an observer, but as a full, remunerated non-executive director. The scope for 245 conflicts of interest and loyalty is obvious, and at least that possibility is acknowledged by the Government. It seems that the election of such a person by a patients forum is not now compulsory—it can happen as and when a vacancy on the trust board naturally arises. That will, of course, lead to patchy coverage across the country. That situation needs to be thought through a little more.
More thought is also needed about the acknowledgement in the Government's response document that more work is required on how to support non-executive directors who find themselves in a conflict between their forum and the board. What does such support mean and who will provide it? That is a serious question about which we do not have any detail, because the regulations or guidance have not yet been produced.
Finally, the Government rightly emphasise the importance of the strategic partnerships, drawing together the experience of local networks, joint overview and scrutiny committees, the strategic health authority and joint bodies of patients forums attached to primary care trusts. However, where will the acute trust patients forums figure in that arrangement? Surely they have key information and an important role to perform. Exclusion from the strategic health authority level of integration seems potentially counter-productive. I look forward to those matters being addressed.
§ Mr. Roger Williams (Brecon and Radnorshire)
Liberal Democrat Members have no problems with distinctiveness and devolutions, so although we have grave reservations about some of the Bill's content, we have no difficulty in supporting the clauses that will give the Welsh Assembly powers to enhance, improve and modernise the NHS in Wales. Of course, the Assembly has not yet finalised those structures; much debate and discussion will take place before it does so.
The formation of local health boards will take the delivery of health out of the hands of distant bureaucrats and will let local doctors, medical professionals, lay people and democratically elected councillors take the lead in delivering appropriate services for the area in which they live and work. Accountability will be re-established.
The local health groups have delivered well and will form the basis for the local health boards. The hon. Member for Cardiff, Central (Mr. Jones) was uncertain about the number of health boards that should be established. We were grateful to him for his work on the last reorganisation of the NHS for the people of Powys. Coterminosity for local health boards and local authorities will help to ensure that the NHS and social services work together better in Wales and that delayed discharge from hospital will be eliminated as far as is possible. Elected councillors on health boards will also make a contribution to that process.
I especially welcome the proposals to set up a unique health board for Powys through the amalgamation of the primary health care trust and the local health group, given the particular requirements of the rural area. All in all, emphasis on primary health care will bode well for the health of the people of the nation of Wales, which has come out in a bad light in almost every survey.
Above all, I welcome the powers to abolish the five health authorities—they have been a dead hand on the NHS and have formed an unwanted layer of bureaucracy 246 in Wales. They will be replaced by a much slimmer body that can take on a full national role in commissioning specialist tertiary care, and can guide and facilitate the commissioning of secondary care from the most appropriate provider. That is why I welcome the provisions granting the Assembly power to create a special health authority that will be able to commission tertiary care, as well as care for the mentally ill and for children.
I am pleased that community health councils will remain in Wales. I am sure that the Assembly will use its powers to ensure that they operate more effectively. It is sometimes said that they have only one tooth—to refer proposed changes back to the Secretary of State or to the Assembly for reconsideration. However, that is an important power and the CHCs exercise it with a degree of discretion.
I welcome the provisions in the Bill that will give the Assembly powers to make the NHS in Wales more effective and more accountable.
§ Joan Ryan (Enfield, North)
I am pleased to speak on Second Reading of a Bill that I strongly support. The Bill is not an isolated instrument, but a key component of the 10-year programme of reform specified in the NHS plan. It cements the much needed and overdue foundations of reform that have been carefully laid during the past four years.
The Bill is essential if we are to have a modern and responsive national health service. Its underlying principle is to make the needs of the patient and the concerns of the public absolutely central to both policy and practice.
The crux of the reform is the reorientation of the functions and resources of statutory bodies—most crucially, providing primary care trusts with the main revenue allocation. That revenue will anchor PCTs as the cornerstone of the NHS, through their ability to commission health care as well as to provide it. For many, many years—going back to the Black report—it has been received wisdom that unless we do something about shifting resources to primary care, we shall never tackle the fundamental inequalities that exist in health, especially in relation to social deprivation issues that are key drivers of those inequalities.
It is important that we are extending the limited range of health care services that primary care trusts secure at present to include responsibility for all family health services that are currently provided by health authorities. The patient's first point of contact is thereby significantly enhanced, indirectly empowering the patient.
Allocating revenue directly to PCTs enables resources to be more accurately matched to the needs of local people and their communities, and thus facilitates more effective delivery. The purchasing power of PCTs shifts greater decision making to front-line staff—the best rehearsed in patients' needs and the best equipped to deliver health care. They are thus being given the mechanisms to deliver that care. I have direct evidence of that in my constituency and health authority area. Enfield, North is now part of the Enfield primary care trust; it is up and running and has a devolved budget. It is an absolute joy to read some of the documents issued by the trust and to see some of its practice.
247 The primary care investment plan and health improvement action plan say many things. One document notes that the proportion of the resident population from black and ethnic minority groups ranges from 4 per cent. in Town ward to 23 per cent. in Ponders End. It gives a range of deprivation scores.
Those documents really take account of the picture in my local area. They are produced by people who not only know the wards, but work in them. They know the people who live in the wards and they know their needs. That is so important when we are considering the allocation of resources to tackle the health inequalities and the health care needs in our local areas.
Furthermore, the documents refer to partnership—working together and not reinventing the wheel. Partnership working is the absolute cornerstone of such reforms, and it will make the reforms work locally.
The one thing that GPs, other health care practitioners, the PCT and local people tell me is that they welcome these reforms. They do think that they will work; they are excited about them. There is local passion for the reforms, contrary to what the right hon. Member for Charnwood (Mr. Dorrell) said, but the cry is, "Please give us the chance to make them work. We need 10 years for them to deliver in the way that they can." Yes, we shall see gains before 10 years are up, but we want to evaluate, monitor and refine them. There is a belief that the reforms are necessary and that they will deliver.
I should like to say a word about my health authority. In the past 18 months, it has already undergone a merger—it was Enfield and Haringey, and it has become Barnet, Enfield and Haringey. In many ways, it is a trailblazer for what is about to happen under the reform of health authorities into strategic health authorities. I pay tribute to all those in my health authority who have seen through one merger and are now embarking on another. They have worked very hard to make that merger work, and some of them have been devolved to the PCTs. They know that the system will work—it is working for them now. However, they very much welcome the document "Shifting the Balance of Power—Human Resources Framework". That has not been mentioned in this debate.
I met those involved in the local Unison branch, which originally represented three health authorities, then two and now one. A lot of people are involved, and they call the document "St. Bop", so they have some fondness for it. They say that it is important because it is all about partnership working and about empowering and valuing staff. There is a recognition that the NHS cannot be changed without having the staff on board. That document has given them a sense of security, and two of the biggest dangers in any merger are the loss of security experienced by staff and, therefore, the loss of morale, which prevents reform from being driven forward and being effective.
The view of those in my Unison branch is that the human resource framework has given them great encouragement, and they very much welcome it, as well as partnership working. Health unions at national level worked on that document, and it has now come down to our local level. Exactly that kind of partnership, in all aspects of the reform, underpins the Bill and the reforms. That partnership will make the reforms work locally.
248 I want to say a word about the plans for patient and public involvement and to give an example from my own casework. In 1998, Mrs. Eileen Webster—one of my constituents—tragically died of cancer. She would have died whatever had happened in hospital. However, she was the victim of a catalogue of serious errors that made her death more difficult than it might have been, especially for her daughter and her husband to deal with. They launched a campaign, Action for Eileen, but they are still involved in the complaints procedure three years on.
Whatever the outcome of that procedure, it can never change the fact that the closest relative of Lisa MacMurdie and her father, Mr. Webster, whom they loved and cared about, died in what they feel were more painful circumstances than necessary, with a lack of dignity and a lack of information. PALS in the hospital could make a vital difference, when that difference is needed. I am glad that they have carried on with their complaint for three years, because people get the health service that they demand, but it is for us to create the framework in which to ensure that people can make those demands in a meaningful and effective way, so that they get the treatment they need when they need it, not three years on when it is far too late.
It is very important that we give power to people on the inside of the NHS, not on the outside, so that they do not have to go to their Member of Parliament or CHC long after the event. That is no use; it does not help people, and I want to stop such things happening to others. I welcome the reforms; they will make a significant difference to health care delivery, to eradicating health inequalities and to ensuring that the people who use our health service feel that it is their health service, so I commend the Bill to the House.
§ 8.5 pm
§ Dr. Andrew Murrison (Westbury)
This Bill is all about shifting the balance of power. It will be successful—it will, without doubt, shift the balance of power from patients and people towards the Secretary of State for Health. It will do so by the direct accrual of powers to the Secretary of State and by injecting confusion and cross-accountability at working level throughout the service. Confusion and complexity are the hallmarks of this Bill.
An indication of the lack of thought that the Government have given to the Bill in their haste to get it through Parliament was given earlier in the Secretary of State's inability to respond to a simple question on the custody of CHC records.
In a similar vein, I was alarmed to find in response to my recent parliamentary question that the Secretary of State did not know where he intends to put the public health function after the abolition of health authorities. No one seems to know whether it would rest with SHAs or PCTs. Even more startling in these troubled times was the revelation that no one seemed to know where consultants in communicable disease control would sit in the new order. Those are the building blocks of health care delivery, and the fact that they are not yet in place supports the assertions of many independent observers that the Bill is woefully immature.
We learn that the CHI will be given statutory powers to enter all premises that are remotely involved with health, including GPs' surgeries and voluntary organisations. 249 Several organisations in my constituency will view that as unwarranted centralist busybody interference in their serious business of doing the best for people. They will undoubtedly view it as yet another strand of interference that will prevent them from getting the job done and, frankly, as another reason to throw in the towel.
The British Medical Association has expressed its concerns about the opportunity costs introduced by the burgeoning cult of inspections and audits. There is now a real risk that they will start to detract from patient care, as we spend all our time inspecting one another and disappear in an enormous regulatory paper chase. That concern also featured in the Kennedy report on the deaths following the tragedies at the Bristol royal infirmary.
The NHS is crying out for a period of stability. Perpetual change involves cost not just in monetary terms but in human terms and in the ability of professional and lay people to understand, get to grips with and learn how to use NHS institutions and structures. The CHCs are a classic example. Just as the general public were getting used to them, the Government of the day closed them down and replaced them with a bewildering array of patients forums, the charmingly acronymed PALS and the tongue-twisting Commission for Patient and Public Involvement in Health. There will thus be no building on the undoubted successes of CHCs as independent watchdogs.
Instead of watchdogs, we will have lots of poodles—a fragmented and highly confusing network of poodles. In fact, there will be very many more than at present, and we are having some difficulty in encouraging people to volunteer for the ones that already exist. There will be no independent support from officials, except those described as outreach workers, belonging to the aforementioned tongue-twisting commission. The future does not look bright for patients forums.
Furthermore, we understand that patients forums will be constructed by the NHS Appointments Commission—more cronies, more members of the chattering classes. This worrying cult of complicity will be fuelled by the inclusion of a patients forum member on trust boards. The move is sinister, given the prevailing doctrine of collective responsibility, because it is surely not wise to allow patient advocates to be tarred with the decision making of the trust under scrutiny. Observer status would surely be more appropriate.
The very sensible suggestion of the NHS Alliance that patients forums—if we must have them—should be confined to PCTs surely makes eminent sense. That would be commensurate with the central position of the commissioning bodies and would dispel any confusion that patients might have as they grapple with the multi-tiers of the national health service.
The Bill suggests that community health councils in England will be abolished immediately. In effect, that means that patients will be deprived of an effective watchdog for an indeterminate period unless patients forums emerge from this process fully booted and spurred. However, experience from the early days of the CHCs suggests that that is rather unlikely.
The Government consider that something must be done about health in prisons—too right. However, what we have in the Bill is a soft-focus entreaty for the NHS and the prison medical services to cosy up to one another. It stops well short of the proposals made by Conservative 250 Members before the election that the two services should merge. There is nothing here that is likely to deliver improved health outcomes, and particularly improved mental health outcomes, for the population in this country that arguably has one of the greatest needs—those detained at Her Majesty's pleasure.
However, the Bill is not all bad. I welcome the Government's proposal for an Office for Information on Health Care Performance within the Commission for Health Improvement. Several right hon. and hon. Members attended a presentation yesterday at which the imaginative DrFoster software for identifying health status by constituency was unveiled. Although the potential for manipulation will be clear to party politicians, the transparency that is possible from the responsible presentation of data is to be warmly welcomed.
Like many members of my profession who pay increasingly large sums for the privilege of being regulated, I have no great fondness for the General Medical Council. However, tragedies such as those at Alder Hey and Bristol should not encourage the Government to ride roughshod over a system of regulation that has in general worked well over many years. I am afraid that they appear to be doing just that.
My over-riding concern is the Government's abject failure to understand that the improvements in patient outcomes that we so desperately need derive from networks of health professionals doing the very best that they can day in, day out, unfettered by the dead hand of oppressive over-regulation and overweening bureaucracy.
§ Denzil Davies (Llanelli)
I will address my brief remarks to the specific parts of the Bill that deal with Wales. Health is a devolved responsibility and the National Assembly for Wales does not have the power to introduce primary legislation, so we have to legislate in the Bill to enable the Assembly to fill in the details by subordinate legislation.
I do not share the enthusiasm of the hon. Member for Brecon and Radnorshire (Mr. Williams) or my hon. Friend the Member for Bridgend (Mr. Griffiths) for the proposals in the Bill. There have been consultation papers and there has been considerable controversy about the proposals in newspapers and on the television in Wales. I recently received a paper from the National Assembly and the NHS directorate headed "Improving Health in Wales—Structural Change in the NHS in Wales" and it sets out the proposals for which authorisation is being asked.
We learn from that paper that the bureaucratic and administrative changes in Wales will start from 1 April 2003. Unfortunately, when I read the paper, it became quite clear that, if the proposals are put into effect, Wales will have from that date the most bureaucratic health service in western Europe.
The Bill provides for the establishment of 22 local health boards. They are to be statutory bodies, with all the bureaucratic paraphernalia and expense that that implies. We have 15 hospital trusts and three regional assemblies—a kind of sub-assembly of the National Assembly—will be established. If my mathematics are correct, that takes us to 40 bodies. Because there will be so many bodies, there must be some co-ordination between them and partnerships will have to do that. 251 Therefore, some people believe that there will be a further 12 partnerships engaged in co-ordination. That means that 52 bodies will be involved.
I am describing devolution and not the central system in Wales. My right hon. Friend the Secretary of State talked about the devolution of power, but those 52 bodies will be at the lower level. On top of them, we will have the Assembly with its Committees and the administration and bureaucracy that it inherited from the old Welsh Office. All that in a small country of 3 million people where most of the people do not use the health service more than once or twice in their lifetimes.
I am glad to assure the House that the health boards will be inclusive. Inclusiveness will mean that the membership of the boards at the county level will read like a who's who of the health bureaucracy in an area. Skilled and scarce professionals, such as doctors, nurses, midwives and physiotherapists, will have to give up their valuable time to sit on meeting after meeting and committee after committee.
The committees' working day will end at 4 o'clock and the working week on Friday. None of them will meet in the evening and they will certainly not meet on Saturday morning, because that in the jargon of the new political bureaucracy is known as "quality time". Because so many people will be represented on the committees, decisions will take a long time to reach and, very often, they will be based on the lowest common denominator. In all these structural changes, there will be winners and losers. I have no doubt that, in this case, the winners will be the local health bureaucracies.
For the provisions to come into force by 1 April 2003, there must be implementation. I have a splendid paper that sets out the structure and the steps necessary for implementation. If the House will bear with me, I shall briefly refer to a few of the steps that are mentioned. However, the language of the paper and the structure that it sets up for implementation tell us much about the bureaucratic cast of mind of the new political bureaucratic class that oversees and puts through these bureaucratic changes.
The paper describes the implementation plan, and 12 bodies will be created to carry it out. We start with something called a "national steering group" whichoversees the process of implementation".That is fair enough, but we then have an implementation group thatoversees the management of the implementation".I am not sure what the difference between management and "the process of implementation" entails; I do not understand the bureaucracy and the jargon well enough.
In addition to the implementation group, there will be nine task and finish groups. Apparently, they will "scope" the implementation. These days, I understand reasonably well the jargon of the new political bureaucratic class. I understand the terms "dynamism", "renewal", "partnership" and even "stakeholders" and "inclusiveness", but the verb "to scope" is not one that I have heard before. Perhaps because I learned English as a second language, it is not part of my vocabulary. However, the nine task and finish groups will scope the implementation.
So we start with a process that is followed by the management and then the scoping of the implementation. At the end of the day, when the 12 groups have sat down 252 and done their work, we have 52 bodies plus the Committees of the National Assembly and its bureaucracy to control and administer the health service for a small nation of 3 million people.
I came into the House a long time ago in 1970. In those days, we had the Welsh Board of Health, which sat in Cardiff, and a few local management committees looked after a collection of local hospitals. The bureaucracy was light, but those were happy days. My constituents did not have to wait up to two weeks to see a general practitioner or a year or more to see a consultant. They certainly did not have operations cancelled five or six times, which has sometimes happened after they have been pushed into the operating theatre. Since then, however, the bureaucracy has increased.
The right hon. Member for Charnwood (Mr. Dorrell) talked about the changes. Indeed, the internal market caused a massive increase in the bureaucracy of the NHS. My right hon. Friend the Secretary of State tried to tell us again that my party has abolished the internal market. I am not convinced of that, but there is no point in arguing about it now because we are changing some of that bureaucracy, although in Wales it might be made considerably worse. The winners will be the bureaucrats and I am afraid that the losers may well be the patients or the customers, or whatever we call them these days.
The House knows that Wales has a democratically elected National Assembly. Its Committees and the Administration, working together with local hospital trusts, should find it fairly easy to administer and control the health service in Wales. Those who drew up the proposals in the paper should tear them up and start again. Frankly, there is little support for them in Wales. I am surprised that two hon. Members from Welsh constituencies spoke so enthusiastically about the proposals. Perhaps they, like the political bureaucratic class, are in denial. My constituents understand the situation well and they do not like it. They do not want the bureaucracy. They see it as creating problems for them.
The proposals will not be changed, though. We will get the 22 statutory local health boards, adding up to a total of 52 bodies. Despite the warm words—I know these, too—of accountability, democracy and consultation, the new political bureaucracy is extremely inflexible, extremely insensitive and often extremely arrogant. The proposals for Wales will do little to improve the delivery—the word that we have to use today—of health and medical services in my constituency. That is why I will not support them.
§ Sandra Gidley (Romsey)
Tempting though it is to indulge in political football, I will concentrate on aspects of the Bill that deserve the greatest attention in Committee. I should declare an interest: I am a member of the Royal Pharmaceutical Society and the Bill will have an impact on my profession, although I might not have time to get to that.
It has been highlighted that one problem that the NHS has had to face in recent years is the culture of continued reorganisation. The right hon. Member for Charnwood (Mr. Dorrell) put it well. He listed the reorganisations under the previous Government, and it is surprising that the Conservatives have the nerve to criticise another change. Unfortunately, I have yet to see a patient who is better off as a result of the reorganisations.
253 I find the proposed changes baffling. For example, in recent years we have moved towards regional structures, which Liberal Democrats support, but the Bill moves us sharply into reverse gear. There is no clear justification for the number—28, 30 or whatever—of strategic health authorities. I am puzzled why the Government were not radical by simply basing the strategic health authorities wholly on the regions, thus making it far easier to co-ordinate policy and liaise with other Departments.
I have some queries on primary care trusts. Many of my local GPs are excited about what PCTs might offer. They see them as a chance to think creatively and purchase care imaginatively and believe that they will be able to fine-tune decisions so that their patients benefit on a locality basis. However, that is providing they are left free to act. Initiative after initiative, although well meaning, has meant that there is a huge amount of central direction. I am not convinced that that will go away when we have PCTs. The Government will still set targets. Some local doctors have a shock coming because their hands will be tied in a way that they have not anticipated. They will have the money, but they will not be as free to spend it as they would like.
Hon. Members have commented on the fact that many PCTs are concerned that they will start with a deficit because those deficits currently owed by health authorities will be reallocated rather than written off. I seek some reassurance that PCTs will start with a clean balance sheet.
The British Medical Association also believes that PCTs hold great promise but, like the Secretary of State, I can also quote Ian Bogle, who said thatthey will require sufficient resources to allow all the local budgets to operate properly".The right hon. Member for North-West Hampshire (Sir G. Young) mentioned the York formula. If 100 per cent. is the standard allocation, he did not say why it is that Winchester and Eastleigh Healthcare NHS trust, which our constituents share, has an allocation of money equivalent to 83 per cent. I cannot remember what the highest allocation is, but it is around 120 per cent. There is a huge difference between the best and the worst funded health authorities. I want to be reassured that primary care trusts will not be penalised in the same way. Just because an area looks affluent on paper, it does not mean that there are not real health problems. The health problems may be different, and we need to reduce the inequalities.
Primary care trusts will also have to fund a variety of services. They will have to contribute towards child protection services and some did not realise that they will have to contribute towards emergency ambulance and patient transport services. The latter has come as news to some PCTs locally and, I suspect, elsewhere. Concerns have been raised that they will all be locked into an unseemly haggling process at a time when everybody's energy should be directed at delivering a top quality ambulance service. That is a particular concern for Hampshire.
Another problem is the lack of pharmaceutical input in primary care trusts. There is no direct requirement for that, which is short-sighted because problems with ineffective prescribing will not readily be tackled.
Hon. Members have raised public health concerns, and the Minister gave a welcome response to the suggestion by my hon. Friend the Member for Northavon (Mr. Webb) 254 that health should be monitored. Public health doctors would have a vital role to play in that. It is good that every primary care trust will have a director of public health at board level, but that person does not have to be medically qualified, and it would be useful if that important provision were tightened up.
On community health councils, I had to smile when I was sorting through my post because I found a letter from the Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), which, in reference to a consultation process, says:I am pleased to say that many CHCs were among those who responded.Perhaps she is so delighted that she will want to keep them—I live in hope. The CHCs have three roles: supporting individual patients and complainants, monitoring local hospital and community services and providing a citizens' perspective on service changes. The Secretary of State gave the House a litany of things that they cannot do and things that will be possible within the new structures. He forgot to mention that much of that is in his power, and it would have been very easy to change the existing structure instead of creating a lot of confusion.
Much attention has been paid, rightly, to making sure that patients have an independent voice. On the face of it, there is a strong patient focus in the Bill. I understand the fears that patient advocacy and liaison services and patients forums seem very in-house, but the NHS culture is changing very slowly, and there is a growing recognition that it is in the interests of both hospital and patient to learn lessons from complaints and treat them constructively. Some trusts have taken that on board.
Less attention has been paid to the CHC function of overseeing service reconfigurations, such as the proposed closure of a small maternity unit. Currently the CHC has a statutory right of referral over such decisions; it can take them away from the local health authority and refer them to the Secretary of State. It is not clear in the Bill whether that responsibility will be fully taken over by the local authority overview and scrutiny committees.
To muddy the waters a little further, the Government are in the process of setting up an "independent review panel". The chair has just been appointed, without interview, by the Secretary of State. That action alone calls into question the panel's independence, and other questions about it remain unanswered. No one seems to know what its remit is, to whom it is ultimately responsible or even how it affects the Secretary of State's responsibility to Parliament. More importantly, what power does the average person in the street have to hold anyone to account on matters of local reconfiguration?
As there appears to be so much fudge and fog, would it not be prudent to delay the abolition of the CHCs until the new structures are fully functioning? Several aspects require clarification. For example, how will the people on patients forums be chosen? Many people have wide-ranging experience of primary care, and it would be relatively easy to provide a balanced overview. With secondary care, things become more problematic, as different departments of a hospital suffer from different problems. How will a balanced representative body be structured? There seems to be little guidance on that, and we run the risk of people coming in with a lot of baggage, for want of a better word.
Patients forums could be compared to the citizens panels operated by many local authorities, which have found it useful to change the membership every few years 255 because the citizens involved generally become very close to the council and perhaps understand it too well. If patients forums are to be at all effective, we need to consider training their members, in much the same way that school governors have been trained in the past. The health service is extremely complex and bureaucratic, and patient representatives need to be helped to be effective.
If effectiveness is the aim, which is not clear, where is the funding for that training? Who will pay for it all? The whole issue of funding has, to a certain extent, been glossed over. There appears to be little acknowledgement that local authority overview and scrutiny committees will require training and funding, and that work is difficult on an already constrained budget—
§ Dr. Howard Stoate (Dartford)
One of the things that I most enjoy about such debates is the fact that Opposition Members are often candid enough and, in some cases, ill-advised enough to tell us what they really think. We have had a great deal of information from them about all that is wrong with the health service, but we have heard extremely little about how it could be put right and how the Government could be helped to improve matters.
We heard from the right hon. Member for North-West Hampshire (Sir G. Young), who seemed to be calling for a workplace stealth tax to fund the NHS. After many years of being a Minister, the right hon. Member for Charnwood (Mr. Dorrell) seemed to be saying that the NHS was no longer sustainable as a wholly tax-based system. The hon. Member for Wyre Forest (Dr. Taylor) seemed to be calling for a Stalinist approach to spending, as he did not think that managers could make such decisions for themselves and needed to be told how to spend their money.
The hon. Member for Westbury (Dr. Murrison) seemed to be against the idea of increased inspection and accountability in the health service. All I can say is that he should tell that to the relatives of the patients at Alder Hey and Bristol and the patients of Shipman and Ledward. Without more accountability, we cannot expect the public to have sufficient faith in the health service, let alone expect improvements.
I have the privilege of being the only practising doctor in the House, so it is a great honour to speak tonight. As part of my duties, I meet many health professionals from all parts of the health service.
§ Dr. Stoate
I have little time, but shall try to give way later if I can.
I try to meet as many health professionals as possible. Although many people whom I meet are not necessarily Government supporters, they all seem to concede that the Government are committed to improving the NHS, putting more money into the system and want greater accountability and better outcomes. GP lists are getting smaller and practices are better resourced than ever before. There are more practice nurses and support staff.
256 There is even evidence of falling GP consultation rates; certainly they are doing much less out-of-hours work than ever before. Yet the point is made time and again that GPs feel incredibly pressurised. Morale in some parts of the NHS is quite low. People tell me that the money is going in, but it is not improving things as they would wish. Clearly, there are concerns about morale, improving standards and where the money is going.
What is the problem and how has it come about? How can the Government address it and how can the Bill begin to deal with it? Many important issues have been raised tonight. There are deep structural problems in the NHS, and shortages of doctors, nurses and hospital beds. The Secretary of State laid out in great detail the reasons for that and explained what we are trying to do about it. Certainly, obvious factors need to be taken into consideration.
Society is changing and people are demanding more than they did before. We live in a culture in which people expect much quicker access to services. They are much more likely to call services to account if they do not get what they want, and demand greater access to them. Doctors are losing their position in society. They are slightly more popular than politicians but, nevertheless, they seem to be losing some of their status, which causes them stress and difficulty. Patients who were previously grateful to receive almost any service from doctors are now far more critical and likely to call them to account. One problem is that, while doctors are not necessarily working longer hours than they used to or seeing more patients, their decisions are being called into question far more, which obviously puts a great deal of pressure on them. They now have to account for almost everything that they do and sometimes they have to face the consequences of their actions.
Complaints are certainly rising a great deal. That does not have anything to do with poor practice; it is much more to do with the fact that patients are more likely to complain and call services to account, which causes great difficulties. The Government are therefore in a dilemma because they are responsible for spending vast sums of the public's money. A lot of money is going into the NHS; previously, not so much was going in. But the Government, of course, expect to get something out. If they are putting all that money in on behalf of the public, they have the right, on behalf of the public, to expect better outcomes; that is only reasonable.
Doctors, on the other hand, take the view that they are in the driver's seat and have to produce the extra services. Doctors are onside. Naturally, they want to see patients more efficiently and quickly, improvements in health care, access to the best drugs, treatments and referrals, and the shortest waiting times possible. Nevertheless, they are under great pressure to deliver. They must fulfil the Government's aspirations by delivering. We have already heard that they are under pressure and that there is a shortage of them. They are justifiably upset that they are expected to produce yet more.
Patients are always in a hurry; they want changes to happen quickly. They know that the Government have been in office for more than four years and rightly ask, "Where are the big changes you promised?" It is difficult to explain to someone suffering from a painful hip that it is impossible to train nurses and doctors and build 257 hospitals in the time scale that they want. It is natural that people are frustrated and want things to happen more quickly.
There is obviously a conflict and tension between the Government, who want to improve the NHS as quickly as possible and put the resources in; doctors, who would like to deliver more, but are finding it difficult; and patients, who are impatient because they pay taxes and want improved treatments. How are we to make progress? There are three ways forward: to increase supply, to limit demand and to change the way in which the service is provided.
The Government are committed to increasing supply. That will happen, but it will take time. Limiting demand is more interesting; many health systems around the world have found ways of doing that by making patients pay for services through co-payment, part-payments or insurance-based schemes—patients put their hand in their pocket and pay out. Many in the medical profession and outside have said that if they charge patients for services, they will use them more appropriately. I disagree with that view. If we were to make patients pay for services, they would use them less, but that does not necessarily mean that they would use them more appropriately. My big worry is that introducing charges into the health service as a way of limiting demand would have a very negative and detrimental effect. I would be very resistant to such proposals. I know that the idea has been discussed and called for, but I am very much against it. If we were to introduce an insurance-based system—
§ Dr. Stoate
We are discussing ways of reforming the health service. I am simply exploring ways in which we might provide a health service that is suitable for the 21st century. In a Second Reading debate, it is perfectly reasonable to range around the subject. If you, Mr. Deputy Speaker, do not stop me, I feel happy to continue with my line of reasoning.
I do not think that the type of system to which I have just referred is the answer. However, my third solution—changing the way in which we use the health service—is a much more fruitful way forward. The thrust of my argument is that we should make much more efficient use of other health professionals, especially pharmacists, who have enormous expertise and knowledge and could be used far more effectively than in the past. They can provide shop-front services without an appointment and supply a wide range of other services to patients. They are very good at health promotion and they can liaise with GPs and manage patients' medicines and repeat prescribing. Indeed, they can manage in an extremely effective and efficient manner many of the functions that are currently undertaken by GPs. I would like to see much more use of pharmacists. They are available in every high street and are used very widely by the public. With a bit more co-ordination and careful interchange in the exchange of information, we could make good progress in that area.
We can also do much more in primary care and general practice itself. We are not making the most efficient use of primary care resources. As I said, the number of practice nurses has increased, but there is room for another class of health care assistants. One can call them 258 assistants, workers or whatever else, but there is room for somebody who has a lower level of training, but can nevertheless undertake many of the basic functions carried out in practices, such as taking blood pressures, ensuring that patients are up to date with immunisation, giving general health advice, leaflets, advice on smoking and diet, and so on. A very large number of functions could be carried out by a lower grade of health care professional in practices. That would take much of the pressure away from general practice.
There have been one or two instances around the country in which health care collaboratives have been used in that way. The national primary care development team has led the way in pilot studies throughout the country in which a significant improvement has been shown. A 20 per cent. reduction in face-to-face consultation was achieved by getting GPs to do follow-ups on the phone, and a 50 per cent. reduction by introducing telephone triage for same-day appointments. A number of things can be done in primary care to make the most efficient and effective use of resources.
I want a much more wide-ranging debate about the use of resources in the health service to arise from the Government's proposals. Resources can be used much more efficiently, which would benefit everybody.
§ Mr. Nicholas Winterton (Macclesfield)
I am very pleased indeed to follow the hon. Member for Dartford (Dr. Stoate), not only because he is a practising general practitioner, but because he speaks a great deal of sense, as he is practically involved at the grass roots of the delivery of health care in this country. I congratulate him on his contribution to the debate.
We have heard some splendid speeches. The right hon. Member for Llanelli (Denzil Davies) spoke with great authority and principle. He is well regarded in this House as a man of independent views and opinions and the House should heed some of what he said. He highlighted the bureaucracy that he believed would result from the Bill. The hon. Member for Romsey (Sandra Gidley) likewise spoke with considerable authority as a pharmacist and I respect very much of what she said. I think that the Secretary of State presented forcefully and transparently the case for the Bill from the Government's viewpoint, and I congratulate him on that. My hon. Friend the Member for Woodspring (Dr. Fox), speaking from the viewpoint of the Conservative and Unionist party, put down markers on what we would seek to do and explained where we believe that faults and problems will result from the Bill.
I fervently believe that all Governments try to do their best for the health service and the health care of the people of this country. There are differences over methods of provision, but I believe that all political parties treat the health service and the health care of our people as a priority.
The contribution of the right hon. Member for Birkenhead (Mr. Field) was impressive not only because his remarks were succinct and brief, but because he speaks from the head as well as the heart. I had the pleasure of serving with him on the Select Committee on Social Services in the 1980s.
My right hon. Friend the Member for Charnwood (Mr. Dorrell) made a stimulating contribution. He apologised for the actions of successive Governments in 259 reforming the health service. He mentioned the number of times that reform had been introduced, as if it could produce the health service that the people of this country expected and provide the health care that they wanted.
The Secretary of State suggested that the Bill was ground breaking. I believe that the health service needs reform like it needs a hole in the head. It needs a period of stability and a Government who are dedicated to improving health care. As the Minister knows, when the health service was set up after the last war, with cross-party support, expectations of it were dramatically different from those of today. The cost of what people want and expect from the health service today has dramatically increased.
I am totally committed to the principle of the health service, which the right hon. Member for Birkenhead mentioned, but I have gradually come to believe that the provision and funding of health care must be tackled differently. For example, the right hon. Member for Llanelli mentioned the huge bureaucracy that would result from the Bill. It is a pity that we are putting more resources into those who administer the health service than into providing health care.
When I first became a Member of Parliament, there was a Macclesfield health board under an administrator. He had the minimum number of staff, but I got quicker responses to any matter that I raised on behalf of a constituent then than I have received since. We went from Macclesfield health board to Cheshire health authority. Different configurations of the health authority followed until we reached today's version, which is the South Cheshire health authority.
I am deeply worried about the Bill's effect on the provision of health care. It could lead to conflict between primary care trusts and acute hospital trusts. I hope that the Minister will respond to that point. The primary care trust will try to do a great deal, much of which is already undertaken by the acute hospital trusts—the East Cheshire NHS trust in my constituency. Conflict will ensue.
The Minister knows of my interest in mental health. I have had the privilege and honour of coming to see him about such matters on a number of occasions over the past four-plus years. I am deeply concerned that mental health services will be taken away from East Cheshire NHS trust—which is an all-purpose trust and highly successful, with the minimum of bureaucracy—and put into a separate trust, the Cheshire and Wirral specialist trust. That could be extremely damaging. At present, there is a partnership between community, mental health and acute services in Macclesfield, which provides a high quality of health care for the people whom I represent.
I am also concerned about bed blocking in my area. Co-ordination is needed between social services and the health services. In my constituency, we are losing huge numbers of beds in residential and nursing homes and creating bed blocking in the health service, which causes difficulties for the through-put of patients in my hospital. How can we solve that? I am not sure that the Bill directs any particular proposals at the problem, but it is an important issue.
I am all for partnerships between trusts and centres of excellence. My own hospital trust, the East Cheshire NHS trust, excellent in every way, has splendid partnerships 260 with hospitals in central and southern Manchester. They are centres of excellence and deal with matters that my acute district general hospital cannot deal with. How will that be affected by the Bill?
We live in difficult times. The health service must change. The funding of the health service must change, or people's expectations will not be met. As the Minister knows, I have strongly opposed my own party in the past. I believe that the people of this country are ready for dramatic changes in the way in which the health service is funded. Putting aside party politics, I hope that the Minister and the Labour Government will take the opportunity to explore ways in which the health service can meet the growing expectations so that it will provide medical operations and treatments that were never envisaged when the health service was founded in the years after the war.
I put down a marker. I am concerned that the strategic health authority for my area will not do as good a job as the health authority, which was impartial and allocated funds in accordance with need. I am deeply concerned that mental health services, which have been dealt with so effectively in Macclesfield will be undermined—
§ Mr. Jon Owen Jones (Cardiff, Central)
I should have liked to follow on from the interesting comments of the hon. Member for Macclesfield (Mr. Winterton), but if he will forgive me, time is short and I must make my own points.
We are, in effect, debating two Bills. There are a number of Welsh clauses in the Bill, and this will be the first occasion on which the House will debate matters arising from the Welsh Assembly which are truly matters of some controversy. In the debate so far we have heard just two and a half speeches about the Welsh issues, and no comment on them from the Front Bench.
The debate is an opportunity to test whether the present constitutional settlement for Wales provides a means for adequate scrutiny of new Bills. The Welsh Assembly does not have primary legislation powers, but if Parliament simply acts as a rubber stamp for Welsh matters brought to the House, we should dispense with the charade and move towards giving the Welsh Assembly primary legislation powers.
An example of the problems that arise was provided by the spokesman for the Liberal Democrats today. The Liberal Democrats do not seem to understand the settlement or the relevant parliamentary procedures. The Liberal Democrat spokesperson was criticised by my hon. Friends for not discussing his own policies and merely finding fault with those before the House, but, in effect, some of those are Liberal Democrat policies. At least the Liberal Democrats share ownership, because they are in coalition in the Welsh Assembly, yet their spokesperson said that they intend to vote against Second Reading. He argued that that does not mean that they are against the Welsh clauses, but I have news for him: voting down Second Reading means that the Welsh clauses fall. Perhaps he thinks that it does not matter how Liberal Democrats vote.
§ Mr. Jones
The Liberal Democrats have probably got used to the idea, but theirs is a typically irresponsible 261 attitude. If Members believe clauses to be important, they must vote for Second Reading. They cannot get away from that.
Interestingly, Plaid Cymru Members have made no contribution to the debate today, but they have contributed in the Welsh Assembly. Their leader, Ieuan Wyn Jones, said today that my hon. Friend the Member for Bridgend (Mr. Griffiths) and I would tear the Welsh clauses to shreds. I do not know whether he anticipated what my right hon. Friend the Member for Llanelli (Denzil Davies) had to say, but I have no intention of tearing the proposals to shreds. That is not to say that I have no reservations.
The Welsh clauses aim to set up a primary care-led health care structure that will enable local commissioning of health care, enhance co-operation between local government and the health services and, in particular, help to ensure joined-up strategies between social care and health care. They aim to foster a local environment that is responsive to local needs and responsible in its commissioning of cost-effective care to meet those needs.
Although I have no difficulty with signing up to all those objectives, I have reservations that seem to be shared by many people in health care in Wales. The consultation process achieved results that are mixed to say the least and a research paper in the Library refers to a survey carried out by the NHS Confederation in Wales which found that 69 per cent. of managers believe that 22 new boards will be difficult to sustain, that 87 per cent. think that accountability will be less clear and that 81 per cent. think that the NHS will find it difficult to manage or understand the structure put before it.
No Member of the House has seen details of the consultation document, and the document itself and those details arrived in the Library only this morning—a single copy 500 pages long. There is no summary and no analysis, and I would be interested to hear whether Ministers have read it.
My researcher spent hours undertaking analysis and hon. Members will benefit from hearing some of it, although I apologise for the fact that we were able to take only a 10 per cent. random sample to try to find out what the consultation said. Of the random sample, 21 per cent. expressed concern about how the restructuring will affect recruitment and retention, 42 per cent. expressed concern about how partnerships and consortiums between local health boards will work, 56 per cent. said that local health boards are too small to work effectively and 61 per cent. said that specialist medical practitioners and managers will splinter because of the smallness of local health boards.
My views largely reflect those responses. The boards may well be too small. How will we restrict the bureaucracy that will probably increase as we move from five to 22 commission authorities? However, my main worry—I hope that Front Benchers are listening—is that the list of 353 respondents to the consultation exercise did not include the name of a single Member of Parliament. I thought that odd, as I had been assured by my hon. Friend the Member for Bridgend that he had responded and I knew damn well that I had done so. Somehow, MPs' responses had been airbrushed from the consultation document. I do not know the reason for that. Perhaps we shall hear it in one of the winding-up speeches. Let me say honestly to the Government, however, that if they believe that the present constitutional arrangements 262 involving primary legislation powers resting here should remain, they have a duty to make that system work and to ensure that MPs are consulted about such powers.
My final point is the most important. How do we ensure that, during this period of upheaval, we do not deflect resources and concentration from the important task of improving service delivery? I shall put it simply—my constituents, and those of other hon. Members, will not care too much about the structure; what they will care about is whether the changes will make any difference to the time for which the Mrs. Davieses, the Mrs. Joneses and the Mrs. Williamses—and the Mr. Williamses—must wait for operations. If they will make a difference, will they increase or reduce the waiting time? That is what we need to be told.
§ 9.2 pm
§ Mr. Paul Burstow (Sutton and Cheam)
The hon. Member for Cardiff, Central (Mr. Jones) suggested that piggy-backing Welsh clauses in a predominantly English Bill made it possible to suborn those on these Benches into supporting a measure that we have rejected in every other respect. I do not accept, and I do not believe my colleagues accept, that devolution means that colleagues in Wales can fetter us any more than we fetter them in terms of the exercise of their discretion and responsibilities in the Welsh Assembly. We will vote against Second Reading because we feel that our disagreement with the principle of the Bill justifies our doing so.
The Secretary of State's speech featured an exceedingly long preamble, followed by a relatively short discussion of the Bill. That, I think, underlined the lack of real substance. This is not a major, ground-breaking piece of legislation that will change the NHS fundamentally. The right hon. Member for Charnwood (Mr. Dorrell) conjured up a picture of a merry-go-round of reorganisation in the service from which he had finally dismounted, admitting that it was not doing any good in terms of delivery to our communities. Unfortunately, the current Secretary of State has climbed on to the merry-go-round, and is taking us on a few more circuits. That, more than anything else, is cause for concern.
I have spoken to health care professionals, and they have been struck by a sense of deja vu. The elements within organisations now being created in England can be given various labels—regional health authority, district health authority and so on. Perhaps they will re-emerge in due course, when there is yet another reorganisation.
I want to say something about the CHI and CHC proposals. I am glad that the CHI proposals will involve greater independence for the organisation: that will do much to build confidence in the good work that it is already doing. There is, however, the issue of its reach being extended into the private and voluntary sectors, and a consequent overlap with the work of the National Care Standards Commission. I hope that that will be discussed in detail in Committee, if the Bill reaches that stage, because Ministers should think about how such an overlap can be avoided and, indeed, consider the possibility of establishing a single agency to regulate and inspect care in all settings, not just the health service.
The House debated community health councils at great length during the passage of the Health and Social Care Bill earlier this year. The Secretary of State says that the 263 CHCs lack teeth, but as we know it is up to the Secretary of State to exercise his responsibilities to give them teeth. He says that they do not have a responsibility in terms of primary care. Why not? It is because he has not given them that responsibility. He says that they do not have a role in inspecting GPs—that is because the Government have chosen not to give them such a role. It has no formal representation in NHS organisations. Again, the Secretary of State has it within his means—he has the legislation before the House—to deal with those issues.
Therefore, why not go down the reform path? It is a path that Liberal Democrats would have liked the Government to explore. We urged them to do so in the previous Parliament; sadly, they did not. As a consequence, they served up in the previous Parliament a dog's breakfast of legislation. There was no consultation and a lack of clarity. There was not even an organisation chart spelling out how the proposals would work.
What we have before us tonight perhaps goes a little further. We have had some consultation. We even have an organisation chart that gives some idea of how the different elements will hang together. In a way, we now have a dog's breakfast where we are told how to go about eating it. I hope that in responding to the debate the Minister can at least give us some information on how much it will cost, and how many staff will be put into place to facilitate the work of the new bodies. Work to analyse the costs of the plethora of new bodies that will replace community health councils suggests that significant sums of money will be needed. The hon. Member for Pudsey (Mr. Truswell) and my hon. Friend the Member for Romsey (Sandra Gidley) have alluded to that.
Community health councils currently spend about £22 million per annum. Next year, that is likely to rise to about £23 million. The pathfinders for PALS have been given £10 million this year. One analysis suggests that implementation of the proposals in the Health and Social Care Act 2001—PALS, the overview and scrutiny committees, and the independent complaints and advisory services—will put the costs up to about £84 million in 2002–03 and that that will rise to £109 million. This Bill will add still further to the costs: it will result in a bill in 2002–03 of £136 million rising to £227 million.
The explanatory notes to the Bill say that there will be no significant increases in costs, and that there will in fact be a £100 million saving as a result of all the musical chairs that the NHS is to go through. Where will the extra money come from to deliver the extra value that the Government tell us will result from the patient involvement initiatives?
The Liberal Democrats believe that those proposals are not well thought through and that they are incoherent, particularly in respect of patient and community involvement. My hon. Friend the Member for Romsey and, indeed, some Labour Members have identified the lack of independence of the Commission for Patient and Public Involvement in Health. It sits ill that, at the same time that the Government are about to give greater independence to the Commission for Health Improvement, they have not gone as far when it comes to patient involvement. Perhaps during the passage of the Bill the Government will consider that matter further and establish equality between the commissions, so that there 264 is greater confidence that the whole system will deliver greater and genuine patient involvement, with patients having a real say in how taxpayers' money is spent on delivering better health care in their area.
A number of hon. Members have referred to the crisis in our health care system. The Bill goes nowhere near to dealing with that crisis. We have lost capacity in terms of long-term care, we have inadequate investment in prevention and there is inadequate capacity in relation to health care employees and staff. All those issues have been missed completely by the legislation, yet they are absolutely central to our constituents' daily experience and to the health service's problems. Hon. Members have described bed blocking as an issue, but I call it a symptom of the wider problems that I have just described.
I hope that the Government will think further on the comments not only of Opposition Members but of Labour Members, who have been particularly concerned about the patient and public involvement proposals, and that Ministers will come to the Committee with amendments that address those concerns and ensure that we have legislation that truly does empower the patient.
§ Andy Burnham (Leigh)
If NHS staff had the time to read debates in the House of Commons, as I am sure that they do not, I feel sure that they would share my disbelief at the sheer cheek of the Opposition parties reasoned amendments to the Bill. Anyone who had to work in the NHS when the ridiculous internal market was operating will find talk of "unnecessary structural change" and "increased bureaucracy" a bit rich to say the least. I was a researcher for Labour's Front-Bench health team between 1994 and 1997, and I then worked for the NHS Confederation. When I went to work in the health service, I was surprised to discover that the issues on which we campaigned while in opposition were entirely true.
The Conservative's reasoned amendment describes a "worsening health care crisis". I wonder whether any Opposition Member took the time to read the briefing that was prepared for this debate by the NHS Confederation, which states:The NHS is improving. The new money for the NHS is being spent on increased quality of services, more services, new services…redesigning services around patients and making staff's lives more tolerable…Years of under-investment in the NHS"—by which I think they mean the years of the previous, Conservative Government—has meant that the NHS is cheap but it is not the NHS the public want.The Opposition are entirely wrong to refer to unnecessary structural change. If the Bill were really unnecessary, I feel sure that the British Medical Association would have said so. In fact, the BMA says:The Bill allows doctors in both primary and secondary care to mould services so they are relevant to local patient need.I shall focus my remarks on the structural changes which, far from being irrelevant, open up historic opportunities to tackle three deep-seated problems that have bedevilled the NHS since its creation. The first and I believe most important of those is the chance to put renewed energy into the drive to tackle the health inequalities that still scar this country and that, for all its virtues, the NHS has hitherto been unable to end. 265 Although those inequalities are created by factors that are of course outside the health service's control, it is the NHS that has to pick up the pieces.
Primary care trusts offer a more finely tuned mechanism than health authorities to target areas and pockets of health inequality. By changing the flow of funding in the system so that it is from the bottom up, rather than from the top down, there is a real opportunity to reach and tackle the root causes of poor health.
I represent an area with historically high levels of illness and disease which are partly caused by its industrial past. Life expectancy in Leigh and Wigan is 16 per cent. lower than the national average and significantly lower than similarly sized towns such as Woking, Guildford and Winchester. In 2000, twice the proportion of people in Leigh died of trachea, bronchus or lung cancer than died of those diseases in Guildford or Winchester. The proportion of the local population dying from heart attacks was more than double that in Woking.
I know that the Department is reviewing the formula to allocate funding to PCTs, and that it does not need me to say that it is crucial that the formula is got right; I simply plead that the guiding principle for allocating resources is to target it on areas where health need is greatest.
§ Mr. Nigel Evans (Ribble Valley)
The hon. Gentleman and I both represent north-west constituencies, and he will undoubtedly be very interested to know what the CHCs in that area have to say on the issues that he has raised. Has he consulted with anyone in the CHCs in his own area who believe that CHCs should be abolished?
§ Andy Burnham
I am not talking about abolition of CHCs; at the moment, I am talking about resources for primary care trusts. I have spoken widely to people working in the NHS—
§ Andy Burnham
I am not talking about the CHCs, and I shall crack on with my speech, if the hon. Gentleman does not mind.
§ Mr. Deputy Speaker
Order. The hon. Gentleman must not keep interrupting from a sedentary position. He intervened and he has received a response. He must not continue intervening from a sedentary position.
§ Andy Burnham
If the hon. Member for Ribble Valley (Mr. Evans) is less well refreshed the next time he comes in the Chamber, perhaps he will allow hon. Members to get on with their speeches.
I hope that Ministers will also take the opportunity to deal with the NHS's long-standing weakness in taking public opinion seriously. There has been a tendency to disregard public opinion, especially in areas that have had a fierce debate about the reconfiguration of local services. It is when people's concerns are borne out by their experience of the service after the reconfiguration that their trust in the NHS is really undermined. We had a classic example in Leigh. The accident and emergency department was closed in the early 1990s. The claim was that it was being closed to improve the delivery of 266 services to local people, but that was fiercely contested by the Leigh community, and today 99 per cent. would say that they have been proved right. While we cannot turn the clock back on that decision, the proposals in the Bill may help the NHS to be better at listening to and understanding public opinion.
The third opportunity is the chance to break the historical hold that acute hospital services have over the health service and the preoccupation with their needs and services. Primary care trusts should focus on the renewal of the physical fabric of the NHS at primary care level at an early opportunity. That, after all, is where most people have their week-to-week contact with the service. For too long, primary care facilities have been organised and developed in a piecemeal fashion, partly because of the status of primary care professionals as independent contractors. That system has not led to the development of high-quality facilities—in Leigh, we know that more than anyone.
Primary care trusts are well placed to tackle that historical problem and provide the catalyst for better primary care facilities. In Leigh, we have the proposals for the Leigh health park. It is envisaged that it will be a PFI scheme, and I know that the Government are still piloting the LIFT scheme—the local improvement finance trust—for primary care. The provision of primary care facilities is a far less complicated exercise than the commissioning of acute hospitals, but the danger is that time and resources are expended on secondary and tertiary PFI schemes, because of their demands, instead of making quick progress in the primary care sector.
I urge the Government to roll out the LIFT scheme to all areas as quickly as possible, so that from the very beginning primary care trusts will have that option in their efforts to improve local facilities. It could also help to solve the problems of GP recruitment by providing attractive surroundings to work in, without individuals having to take a financial stake.
Some critics have attacked the PFI as a waste of taxpayers' money, but they miss a crucial point. However healthy the economy and public finances, there will always have to be a limit placed on the NHS capital budget. Throughout the history of the NHS, building projects and refurbishments have been prioritised and queues formed. Every town could not have a new hospital or clinic at the same time. People had to be patient—in some cases, heroically so. The old capital funding system may have pleased public sector purists, but it did not give the public modern, well maintained NHS facilities and it has bequeathed an NHS estate to this generation that is simply not up to the job. By contrast, the PFI lifts the limit from NHS capital spending and means that more towns and people can have their new hospitals and clinics now. While the cost to the NHS of PFI projects over their lifetime is disputed, there has to be a value in giving the local population access to a modern health care facility that they might not otherwise have had for 10, 15 or 20 years.
The Government are giving local communities a better NHS and the Bill will take forward that process. It will put power where it belongs, at the bottom of the system, and will throw open historic opportunities to create the modern service that we on this side of the House desperately want to see.
§ Laura Moffatt (Crawley)
On Friday, together with staff from Crawley hospital, I abseiled down the side of the hospital building. We did that to raise cash for Children in Need. However, we had another reason. We wanted to communicate to the people of Crawley that we are not so totally consumed by the health service that we cannot think about anything else. We are able to go and do exciting things, raise cash and enjoy ourselves at the same time. The view that the NHS is on its knees and cannot raise its head above the parapet because it is so bogged down with work is completely untrue, and I want the House to know that.
I shall be brief to ensure that all our colleagues who wish to speak in the debate can do so, and I shall concentrate on the Commission for Health Improvement and its work on quality. That work is crucial, and the Government have ensured that it runs as a thread through all their new legislation. It is essential in the partnership between our communities and the health service, because—let us be under no illusions—the NHS has not been good at talking with people. It has been good at talking at people and telling them what it thinks they need, but the relationship has been lacking. The quality of the relationship should lie in the way the NHS communicates with people as well as in the way it does its job.
I have little doubt that we have a first-class service, but one of my constituents attended an accident and emergency department in my area with an injury that was not major yet he found that he had to wait for four hours. He had been seen by the triage nurse, but no one thought to explain that the people waiting would have to hang on because the department was looking after others who were seriously ill.
We can improve our performance in circumstances such as that. Relationships can be improved by involving local people more, and I have no doubt that the new patient advocacy and liaison service will contribute to that. Its staff will be on site, with the result that matters such as I described can be dealt with in a way that will be of great value.
I turn now to the role of local authorities. My local authority has been invigorated by its new role. It now has a say in what is going on my area, and its role in oversight and scrutiny has made it feel part of the community. The authority believes that it has a mandate that allows it to contribute.
The concern that I share with my local authority is how to ensure that the Commission for Patient and Public Involvement in Health will not usurp local authorities' role. The tremendous health service review that we have just undergone has been a fantastic experience. I could not have said that in the House two years ago. I have no idea what the outcome of the review will be, but the process of getting our community involved is not one that I shall forget. People who marched in the streets and demanded that I be taken from the House and hanged in Whitehall are now saying that the review was good. They felt that they had been asked about what they wanted in their services. I hope that a similar process will be undertaken with the proposals under consideration today.
When we look at our health services, we must talk to our local communities and find the people who are able to contribute and who want to do so. We must go beyond the usual suspects in such matters, who come to the fore 268 and say that they are good at articulating problems. We need to find the people in our communities who want to contribute to the process. They are there, they want to take part and they can have confidence in what we are doing. The review of our hospital services is one of the very good things that the Government have undertaken. They have trusted local people to contribute to the service.
I shall say a brief word about strategic and specialist commissioning, especially in respect of issues that can be difficult. We rightly allow those in the front line in the health service to decide what is to happen, but we must ensure that matters such as HIV remain to the fore. Although they are difficult matters to get to grips with, they must be included in the commissioning strategy. I want to ensure that the Herpes Viruses Association can batter down the door of our PCT just as the Alzheimer's Association can.
The hon. Member for Westbury (Dr. Murrison) is not in his place now, but he talked earlier about the poodles in the community who will say anything to suit the Secretary of State. I have to tell him that in Crawley we do not have poodles; we have Jack Russells.
§ Linda Perham (Ilford, North)
I want to speak first about the clauses in the Bill that deal with patient and public involvement. I declare an interest as a former member of Redbridge CHC, and as the new secretary of the all-party group on community health councils. Indeed, the Under-Secretary of State for Health, my hon Friend the Member for Salford (Ms Blears), was my predecessor in that post.
I am aware of the continuing interest shown by my hon. Friend the Under-Secretary in the effective involvement of the public in the health service. In the short period of consultation on the Government's proposals, she attended regional events and received many representations. I appreciate her response to the views expressed to her, and believe that the Government have made a genuine attempt to accept changes and modifications to the Bill.
I still have concerns about the Bill. I am struck by the lack of detail in it, compared to what was contained in the consultation proposals. Much will be left to regulation, or will be "fleshed out in guidance", as the response to the listening exercise puts it.
My CHC has problems about the complexity and fragmentation of the arrangements of the new bodies. My area, which covers one London borough, will have five patients forums. My CHC also has concerns about imbalances in the system, with most of the CHCs' powers passing to the overview and scrutiny committees and their duties to the patients forums.
I welcome the Commission for Patient and Public Involvement in Health, particularly its responsibility for the setting and monitoring of standards to ensure consistency across the country. That is an issue of concern for many of us who attended meetings with Ministers during the passage of the Health and Social Care Act 2001.
I wonder about the commission's independence and the powers of the Secretary of State, which other right hon. and hon. Members have mentioned. I also share the concerns expressed by my hon. Friends the Members for Wakefield (Mr. Hinchliffe) and for Bedford (Mr. Hall) 269 about how the commission will operate locally. All in all, there are a lot of good intentions but much is left to regulation and guidance.
I welcome the devolution of health service planning and commissioning from health authorities to primary care trusts. That will bring service delivery closer to the local community. It is entirely appropriate that family health provision should be administered at as local a level as practicable instead of at a more remote level, as at present. In my area, the health authority covers two very different London boroughs, with diverse populations and needs.
I am encouraged by my early contact with the chair and chief executive of Redbridge primary care trust. One example of an appropriate and timely response to local need is the calling of a meeting with parents and carers of children with special educational needs to discuss problems relating to the provision of speech and language therapy.
I also welcome the joint working with the Prison Service mentioned by my hon. Friends the Members for Wakefield and for Warrington, North (Helen Jones). Last year, as part of my secondment on the National Council for Voluntary Organisations scheme, I visited the prison health policy unit and Pentonville prison, and discussed social exclusion, drug abuse and the mental health problems of inmates. I am therefore very pleased with those joint working provisions.
Finally, I welcome the extension of the powers and constitution of the Commission for Health Improvement, and am pleased that it will produce an annual report on the quality of NHS services. The commission's recent report on clinical governance at my local hospital, King George, identified a number of areas for praise and concern and has enabled the trust to come up with an action plan to address its shortcomings.
This is a wide-ranging Bill with a raft of important changes which, taken as a whole, should put in place real improvements for the public in the delivery of a truly modern health service for the 21st century. I hope, however, that Ministers will listen and respond positively to the areas of concern raised in the debate.
§ Mr. Simon Burns (West Chelmsford)
Those who have been here throughout the debate will have been struck by two exceptional but very different speeches. The right hon. Member for Birkenhead (Mr. Field) spoke with clarity and thoughtfulness about the problems facing the House with regard to quangos and regulators, and the need for greater control and accountability to Parliament. I think that many Members will have agreed with his comments.
My right hon. Friend the Member for Charnwood (Mr. Dorrell) got it absolutely right when he said that the Bill epitomised the political class in denial. I agree with that sentiment; indeed, having listened to his speech, I think that the Secretary of State seems to be in perpetual denial. Frankly, he seemed to be living in a fantasy world, totally divorced from the reality of what everyone else in the House experiences in their dealings with constituents.
Sadly, in typical new Labour spin, the Secretary of State seeks to assure us that everything is rosy in the national health service. In reality, nothing could be further from the truth. In the past week alone, we have seen the latest figures for the treatment of patients fall by 0.1 per cent. That 270 seriously undermines the Government's target that, by next April, no one should be waiting more than 15 months. As Anthony Harrison of the King's Fund said:The Government is in big trouble and they are just not getting activity up.In addition, the latest figures for the number of people waiting for treatment have risen by 3.5 per cent. It was especially poignant to listen to the speech made by my right hon. Friend the Member for North-West Hampshire (Sir G. Young), who drew to the attention of the House the particular problems with regard to those patients waiting for radiotherapy at Southampton hospital.
To add to those problems, the number of people waiting more than 18 months has risen from two in September of last year to 208 this year. For a Government who have constantly argued that patients should never be on a waiting list for more than 18 months, that massive increase is a disgrace.
§ The Minister of State, Department of Health (Mr. John Hutton)
Will the hon. Gentleman tell the House how many times under the previous Administration that 18-month target was actually met?
§ Mr. Burns
May I explain to the right hon. Gentleman that the previous Prime Minister, John Major, concentrated from 1992 on targeting specific money on bringing down waiting lists to ensure that patients waited for shorter periods? The Minister really must grasp the point that his party has been in power for four and a half years; it is no longer good enough for Labour Members to get up, like parrots, and constantly repeat the refrain about what happened previously. Under the last Conservative Government, waiting lists were targeted for action to bring down waiting times. We brought down the times from more than 30 months to 24 months, towards the 18-month target.
§ Mr. Burns
No, I shall not give way for the moment.
The waiting list to get on a waiting list has continued to rise, as the latest figures show. However, even the Secretary of State could not manage that news properly. We have The Mirror to thank for news of the great e-mail debacle.
When the hospital waiting list figures were being issued, the Department of Health sent out an e-mail that would have tested the nerve of Jo Moore. It trumpeted the apparent fact that waiting lists had fallen by 3,500. Within three hours, embarrassed Department of Health officials had to send out another e-mail, entitled "Statistical Press Release—Corrected Version", to correct the fact that the waiting lists had not fallen at all: they had in fact risen by 3,500.
The Secretary of State is in danger of mistaking activity for action. The nation is crying out for action—action on the problems in health care facing our constituents up and down the country.
271 Flying out to Spain to recruit nurses for our NHS is no panacea for real action. As the Daily Express stated on 17 November—in view of the intervention made by the Minister of State, he should pay special attention to this point:Labour cannot simply blame Tory Governments…It has had four years to address the problems but has only recently woken up to the scale of the crisis…If Mr. Milburn really wants to solve the NHS crisis he must understand exactly why working for it has become such a no go area and start doing something about it.Perhaps more worrying for the Secretary of State is the fact that he is no longer a favourite—if he ever was—of the Chancellor: that brooding colossus at No. 11 who casts his shadow over the Government. We discover that apparently "Gordon thinks that Alan is 'useless' at running the health service", reflecting the Chancellor's view that the extra money that he has given the Secretary of State has not led to better services or results.
Ironically, we do not need the Chancellor to point out what everyone else has known for months; we have only to ask our constituents, who have had to endure endless waiting lists to see a consultant or to be treated, who wait to be seen at accident and emergency departments, who wait on trollies before being admitted to beds, or who have to wait to leave hospital to stop bed blocking. The situation is totally unacceptable. This Government's achievement—no Opposition Member would be proud of achieving it—is that new Labour is putting people on a waiting list to leave hospital, as well as putting them on a waiting list to go into hospital.
The Secretary of State has described the Bill as a great, decentralising initiative. Frankly, only this Secretary of State could reach such a conclusion. There are nine schedules and 40 clauses, 23 of which give the Secretary of State order-making powers—22 of them by the negative procedure. In toto, there are 58 opportunities for the Secretary of State to issue orders—58 ways in which the Secretary of State's powers can be gained, retained or enhanced, as my hon. Friend the Member for Woodspring (Dr. Fox) said.
Sadly, most of the Ministers were not here to listen to the excellent speech made by the right hon. Member for Llanelli (Denzil Davies). I am sorry to do this to the right hon. Gentleman, but his speech was very good, and even this Secretary of State might actually learn something if he reads the report of it tomorrow. The right hon. Gentleman explained in great detail just what a bureaucratic nightmare the Bill will produce in Wales and the shambles that it will cause to health care in the Principality.
As my hon. Friend the Member for Westbury (Dr. Murrison) said, the Bill will concentrate powers on the Secretary of State, and the less rubbish we hear from Ministers about its being a great decentralising measure the better.
A quarter of the Bill deals with probably the most far-reaching reforms to the NHS since 1974, if not before, with the replacement of the health authorities with strategic health authorities and the enhancement of the role of PCTs in the delivery of health care. However, my hon. Friend the Member for Macclesfield (Mr. Winterton) certainly does know what he is talking about, given his experience as a previous Chairman of the Select Committee on Health, and he said that the health service needs reform like it needs a hole in the head.
272 I am afraid that my hon. Friend is absolutely right, as is the hon. Member for Wyre Forest (Dr. Taylor) who, with his great experience of working in the health service all his life, said that changes are not needed because there is a crisis in the NHS and that the changes that have been made in past years need to bed down and to be made to work.
I cannot understand why the Government are in such a rush to engineer these reforms, and I question whether the structures that will be put in place are ready to work, without the whole edifice collapsing in confusion and disaster. The rush to change that the Government are pursuing reminds me of the old adage, "Reform in haste, repent at leisure". For example, the BMA has cautioned that the PCTs, where they exist, are relatively new organisations and that the demands that will rest on them may well be beyond their existing capabilities.
The BMA highlights the fact that existing PCTs already have difficulties in recruiting clinical staff and that those problems will be exacerbated. It is also concerned that the timetable for PCTs to be up and running is far too ambitious, especially as there are still approximately 100 PCGs, many of which have not even started to prepare for PCT status. Similarly, other contributors to the debate have quoted academics who said that the Bill would be rushed through given the Government's current timetable. Conservative Members share those concerns, because the Government are rushing headlong into the reforms.
In the Committee that considered the Bill that created the PCTs, the former Minister of State at the Department of Health, the right hon. Member for Southampton, Itchen (Mr. Denham), said thatit is important to emphasise that we"—that is the Government—do not intend a headlong rush to be made into PCTs and that it is not part of our agenda to impose PCTs on the national health service."—[Official Report, Standing Committee A, 27 April 1999; c. 252–3.]The Government have performed a complete U-turn and there are severe concerns in the health profession that the Bill is being rushed through. A recent survey in the Health Service Journal shows that 46 per cent of chief executives in NHS organisations thought that PCTs would be unable to cope with enlarged responsibilities and that 33 per cent. thought that the time scale and the scale of the changes were unrealistic and dangerous. One chief executive has called the reforms "a recipe for disaster" and another has described them asthe most ill conceived, poorly thought out set of changes in decades.Sadly, at this stage, the Government will not listen to or tolerate any criticism regardless of the potential damage that they inflict on the NHS. I assure the Minister that we shall consider that proposal carefully in Committee.
The Bill reintroduces the measures to abolish the community health councils that the Government were unable to get through in the last Parliament. A host of Members on both sides of the House have spoken out against the measure. The knowledge of health of the hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Select Committee on Health, is so great that one does not ignore his advice without being stupid. He is still root and branch against the Government's proposal.
273 My hon. Friend the Members for Broxbourne (Mrs. Roe) and my hon. the Members for Macclesfield are both former Chairmen of the Health Select Committee. They are totally opposed to the Government's plans as is the hon. Member for Pudsey (Mr. Truswell), a member of the governing party.
§ Mr. Burns
The hon. Member for Pudsey expressed concerns about the abolition of the CHCs, as did the hon. Member for Wyre Forest.
What I and the people who contribute so much hard work to the success of the CHCs cannot understand is the decision to abolish a tried-and-tested system that people understand. They know that the CHCs are independent bodies that represent them in their complaints against the health service and about the provision of health care. It is foolish to abolish them for the sake of it and to come up with a system that no one understands and that no one believes will be independent.
People think that the Government are simply acting out of spite because CHCs have had the audacity to have had considerable success in highlighting the failures of the Government's delivery of health care. If the Government really thought that there needed to be improvements in patient representation, why did they not reform those aspects of CHCs with which they are not happy to make them even more effective?
The Bill is a fig-leaf of a policy for the problems facing the NHS. It is irrelevant to the problems facing all our constituents, with waiting list delays, postcode lottery provision of health care and a policy run more by spin and by reaction to adverse media coverage than according to a rational and realistic approach to facing up to the challenges caused by the inexorable rise in the need for more patient care.
while the Chancellor expresses anger and exasperation at the Health Secretary's failures, morale among staff plummets and our constituents become more and more disillusioned with the Government's performance. The Health Secretary fiddles around as a lackey to No. 10, tampering at the edges rather than addressing the real problems facing real patients in the real world. It is for that failure that I urge my hon. Friends to join me in the No Lobby to vote against a Bill that is irrelevant to the task of improving the health care of this nation.
§ The Minister of State, Department of Health (Mr. John Hutton)
We have had a good debate. Some 26 Members contributed to it and we heard some excellent speeches. In that regard, I agree with the hon. Member for West Chelmsford (Mr. Burns). We had the benefit of hearing from a former Secretary of State for Health, the right hon. Member for Charnwood (Mr. Dorrell). We also heard from hon. Members who have worked in, and dedicated their lives to, the NHS, including the hon. Members for Westbury (Dr. Murrison) and for Romsey (Sandra Gidley) and my hon. Friends the Members for Dartford (Dr. Stoate) and for Crawley (Laura Moffatt). We are all the better for hearing what they had to say.
The debate started with the hon. Member for Woodspring (Dr. Fox) speaking for 20 minutes, and none of us was any the wiser about the Tory remedy for the 274 NHS. I will return to that theme when I have had a chance to reflect and comment on what the right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) has said about the NHS. I am sure that my hon. Friends would like to hear his views on it. The hon. Member for Woodspring, whom I hold in high regard, said that he looked forward to hearing my response to the debate. Unfortunately, he is not here to hear it, so I shall have to send him a copy of the video, which he can enjoy at his leisure.
As always, my hon. Friend the Member for Wakefield (Mr. Hinchliffe) made a good speech on this subject. There are issues on which we disagree, and I am sure that he is aware of them. He was wrong to say that we have ignored social care issues. He will be aware, as will other hon. Members, of the provisions that we introduced in the Health Act 1999 and the Health and Social Care Act 2001. The right hon. Member for North-West Hampshire (Sir G. Young) served on the Committee that considered the latter Act and addressed many of the concerns about the need for health and social care services to work closely together. The emphasis in the Bill on primary care trusts will strengthen the NHS's links to social care. My hon. Friend will know that the Government's arrangements for PCTs make a point of ensuring that there are close connections between them and local authorities, which provide social services.
Some hon. Members, including the hon. Member for Westbury and my hon. Friend the Member for Wakefield, expressed concern about how the public health function will end up as a result of the reforms. The Bill will strengthen it by pushing it closer to the front line in primary care trusts. Each PCT will have a director of public health. There will be a strong overview of that and close links to the chief medical officer.
My hon. Friends the Members for Wakefield, for Pudsey (Mr. Truswell), for Ilford, North (Linda Perham) and for Bedford (Mr. Hall) were worried about patient and public involvement. We look forward to considering sensible proposals that they might have on how we can strengthen that aspect of the Bill. We look forward to dealing with the detail in Committee.
I tried hard to take a note of the speech of the hon. Member for Oxford, West and Abingdon (Dr. Harris), but it was difficult. He said much about the need for more doctors in the NHS, so I made an effort to check what he said in the Liberal Democrat manifesto for the 2001 general election. I was surprised to find that his party promised 4,600 extra doctors. That is not enough. It is not what the Government are committed to securing. He chided us about a number of things and made a lot of noise, but none of it made much sense, and much was simply inaccurate. I remain in the dark about whether he favours abolition or maintenance of community health councils. Perhaps we will hear from him on that in Committee.
I am glad that we have support for the clauses that relate to Wales. I am happy to acknowledge that my hon. Friend the Member for Bridgend (Mr. Griffiths) played an important part in developing those important reforms.
The hon. Member for Broxbourne (Mrs. Roe) spoke well about the work being done by her community health councils and the positive way in which they are looking to the future. We look forward to working with her and 275 others to see how we can strengthen the role of patients forums and the new Commission for Public and Patient Involvement in Health.
My right hon. Friend the Member for Birkenhead (Mr. Field) expressed his concerns about the proposal to establish the Council for the Regulation of Health Care Professionals. We shall consider any sensible proposals to improve those clauses and, in particular, the accountability arrangements to which he drew attention.
The right hon. Member for Charnwood made a very good speech and, as always, I enjoyed listening to him. He said that he felt that there was no outside interest in the Bill. Obviously, he has not spoken to the British Medical Association, the Royal College of Nursing, the NHS Alliance or the NHS Confederation, which have expressed close interest in the Bill and strong support for many of its important aspects. Like most Labour Members, I am fascinated to hear former Tory Health Secretaries pose a series of questions about how we could successfully reform the NHS. The questions that the right hon. Gentleman asked today were obviously those that he failed to answer during his period of office, and I am sure that he would have the good grace to acknowledge that, but a bit of soul searching never did anyone any harm.
My hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) spoke about her personal support for the NHS, which I know will be echoed in most parts of the House. She accurately described the Bill as effective, and I made a note of that expression because I am sure that it will amply qualify her to serve on the Standing Committee.
Most of the remarks of the right hon. Member for North-West Hampshire, who takes a close interest in these issues, were directed not at the Bill but at the financial problems experienced by his local NHS organisation. He talked particularly about the problem of deficits in his local health service, and I simply say that the accumulated deficit in the NHS is now substantially lower than it was when we came to office in 1997, although I acknowledge that there are local problems that we need to tackle.
The hon. Member for North Thanet (Mr. Gale) spoke about issues related to the regulation of health care professionals rather than those that are directly relevant to the Bill. He made several points about health visitors and chiropodists. The Standing Committee that is to discuss those orders will meet next week, and I am sure that we can thrash out some of the issues then.
My hon. Friend the Member for Warrington, North (Helen Jones) spoke about the important need to identify the interests of front-line staff and to consult them. PCTs will be able to do that, which is why their role in the Bill is so important.
I am sorry that I did not catch the contribution of the hon. Member for Wyre Forest (Dr. Taylor). I understand that he is against decentralisation and very much in favour of central direction, which is a peculiar position for him, of all people, to take on these issues.
My hon. Friend the Member for Bedford identified concerns about patient and public involvement. The Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), and I look forward to working with him to discuss those issues.
276 I was disappointed by the tone of the hon. Member for Westbury and his comments on reform. He seemed to be against effective regulation and inspection, particularly in primary care, and he was largely against any wider role for patients in the NHS. I am sure that he will take the opportunity to explain that to his constituents in due course. My hon. Friend the Member for Dartford talked much common sense, as he always does on these issues.
The hon. Member for Macclesfield (Mr. Winterton) made a typically gracious speech to which I listened with close interest. He expressed his nostalgia for the Macclesfield health board. I am sure that its passing is still mourned in Macclesfield and that the subject comes up regularly in his surgeries, although I am glad that I am not present for any of those conversations. He also talked about the NHS being set up with cross-party support. It is my recollection that the Conservatives voted against the establishment of the NHS, but perhaps he and I can reflect on that in the weeks ahead.
The hon. Gentleman made one important point, saying that he thought that there could be conflict between PCTs, acute trusts and other NHS trusts. I do not believe that such conflict will arise, and the role of the strategic health authorities will be very important in ensuring that it does not. There is a huge commonality of interest in ensuring that local health services are improved and, as the commissioning body, the PCT will play a central role in that.
The hon. Member for Sutton and Cheam (Mr. Burstow) made one of his typical NHS speeches; to my knowledge, he has made the same one at least half a dozen times. He made the case for no change in the NHS and preserving the status quo; that is the Liberals for you. He expressed a novel constitutional principle in that he hoped that the Bill would reach Committee, but wanted it to be rejected on Second Reading. I do not think that there is any way of doing that, but one never knows.
I have spent a long time trying to respond to points that hon. Members made in our debate, and in the few minutes remaining to me I wish to make some comments about the Bill and its importance. First, it will make the NHS less bureaucratic and more flexible. Under our proposals in clauses 1 to 10, the centre of gravity, as my right hon. Friend the Secretary of State said, will shift from Whitehall to local doctors and nurses. Local communities will have more involvement in, and say over, their local services. Most importantly, more resources will go directly to the front line, giving local staff the freedom to innovate and to develop and improve local services. I believe, as I hope that all my hon. Friends do, that those are essential reforms if the service is to meet the challenges that lie ahead.
Secondly, under the proposals that we are asking the House to endorse tonight, the balance of power in the NHS will shift decisively in favour of the patient. If public services are to command public confidence, they have to give greater control and more choice to the people who use them—[Interruption.]
§ Mr. Speaker
Order. There is far too much conversation in the Chamber. The Minister is addressing the House.
§ Mr. Hutton
I am doing my best, Mr. Speaker.
Those important reforms will take the NHS substantially further forward. We are not only devolving power to the front line, but devolving the assessment of how that power is exercised to an independent body—the Commission for Health Improvement. Those sensible reforms involve trusting doctors and nurses, keeping the public better informed and strengthening quality standards.
A lot of time today has been spent on the Government's record on the NHS. I simply point out to many Opposition Members who have called for more resources for the NHS that we are making unprecedented investment in it. That expenditure has been called into question by the Opposition, but it was never matched by them in their 18 years of power between 1979 and 1997. We are making good the chronic underinvestment of the Tory years, securing twice the rate of growth that the Tories managed during 18 years in office.
I want to return to what the right hon. Member for Charnwood said. He has obviously studied what the Leader of the Opposition has said about the NHS. The Leader of the Opposition recently described his plans to introduce vouchers for operations that can be topped up by wealthy patients who want to use private hospitals.
§ Mr. Hutton
He did. I will send the hon. Gentleman quotes from the Leader of the Opposition in The Sunday Telegraph to look at.
The Leader of the Opposition said:In the private sector operations will cost more, so the patient will have to top up with their own money or use some insurance scheme.In September, the right hon. Member for Charnwood was right to describe those proposals as "absurd." He said that they would create a two—tier NHS; he should know, as he presided over one for many years as a Tory Health Secretary. The Tories have learned nothing from their recent encounters with the electorate.
Does the Minister think that we should have a race to see whether my hon. Friends on the Front Bench can get a health policy more quickly than him?
§ Mr. Hutton
I would be happy to take part in that race because it would be some time before the Opposition produced any coherent programmes.
So we have the same old Tories, not a new political force in Britain with new ideas for the new century, but the same old collection of Tory prejudice and narrow-mindedness. I urge my hon. Friends to support the Bill in the Lobby tonight.
§ Question put, That the amendment be made:—
§ The House divided: Ayes 192, Noes 320.281
|Division No. 67]||9.59 pm|
|Ainsworth, Peter (E Surrey)||Baldry, Tony|
|Allan, Richard||Barker, Gregory|
|Amess, David||Barrett, John|
|Ancram, Rt Hon Michael||Beggs, Roy|
|Arbuthnot, Rt Hon James||Beith, Rt: Hon A J|
|Bacon, Richard||Bellingham, Henry|
|Bercow, John||Horam, John|
|Beresford, Sir Paul||Howard, Rt Hon Michael|
|Blunt, Crispin||Howarth, Gerald (Aldershot)|
|Boswell, Tim||Hughes, Simon (Southwark N)|
|Bottomley, Peter (Worthing W)||Hunter, Andrew|
|Bottomley, Rt Hon Virginia||Jack, Rt Hon Michael|
|Brady, Graham||Jackson, Robert (Wantage)|
|Brake, Tom||Jenkin, Bernard|
|Brazier, Julian||Johnson, Boris (Henley)|
|Breed, Colin||Kennedy, Rt Hon Charles (Ross Skye & Inverness W)|
|Browning, Mrs Angela||Key, Robert|
|Bruce, Malcolm||Kirkbride, Miss Julie|
|Burns, Simon||Knight, Rt Hon Greg (E Yorkshire)|
|Burstow, Paul||Laing, Mrs Eleanor|
|Burt, Alistair||Lamb, Norman|
|Butterfill, John||Lansley, Andrew|
|Cable, Dr Vincent||Laws, David|
|Carton, Mrs Patsy||Leigh, Edward|
|Cameron, David||Letwin, Oliver|
|Campbell, Rt Hon Menzies (NE Fife)||Liddell-Grainger, Ian|
|Carmichael, Alistair||Lilley, Rt Hon Peter|
|Cash, William||Loughton, Tim|
|Chapman, Sir Sydney (Chipping Barnet)||Luff, Peter|
|McIntosh, Miss Anne|
|Chidgey, David||MacKay, Rt Hon Andrew|
|Chope, Christopher||Maclean, Rt Hon David|
|Clarke, Rt Hon Kenneth (Rushcliffe)||McLoughlin, Patrick|
|Clifton-Brown, Geoffrey||Mawhinney, Rt Hon Sir Brian|
|Collins, Tim||May, Mrs Theresa|
|Conway, Derek||Mercer, Patrick|
|Cotter, Brian||Mitchell, Andrew (Sutton Goldfield)|
|Cran, James||Moore, Michael|
|Davey, Edward (Kingston)||Moss, Malcolm|
|Davies, Quentin (Grantham)||Murrison, Dr Andrew|
|Davis, Rt Hon David (Haltemprice)||Norman, Archie|
|Djanogly, Jonathan||Oaten, Mark|
|Dorrell, Rt Hon Stephen||O'Brien, Stephen (Eddisbury)|
|Doughty, Sue||Öpik, Lembit|
|Duncan, Alan (Rutland & Melton)||Osborne, George (Tatton)|
|Duncan Smith, Rt Hon Iain||Ottaway, Richard|
|Evans, Nigel||Page, Richard|
|Fabricant, Michael||Paice, James|
|Fallon, Michael||Paterson, Owen|
|Field, Mark (Cities of London)||Pickles, Eric|
|Flight, Howard||Prisk, Mark|
|Forth, Rt Hon Eric||Pugh, Dr John|
|Foster, Don (Bath)||Randall, John|
|Francois, Mark||Redwood, Rt Hon John|
|Gale, Roger||Reid, Alan (Argyll & Bute)|
|Garnier, Edward||Rendel, David|
|George, Andrew (St Ives)||Robathan, Andrew|
|Gibb, Nick||Robertson, Hugh (Faversham)|
|Gidley, Sandra||Robertson, Laurence (Tewk'b'ry)|
|Goodman, Paul||Robinson, Peter (Belfast E)|
|Gray, James||Roe, Mrs Marion|
|Grayling, Chris||Rosindell, Andrew|
|Green, Damian (Ashford)||Russell, Bob (Colchester)|
|Greenway, John||Sanders, Adrian|
|Grieve, Dominic||Sayeed, Jonathan|
|Gummer, Rt Hon John||Shephard, Rt Hon Mrs Gillian|
|Hammond, Philip||Shepherd, Richard|
|Hancock, Mike||Simmonds, Mark|
|Harris, Dr Evan (Oxford W)||Simpson, Keith (Mid-Norfolk)|
|Harvey, Nick||Smith, Sir Robert (W Ab'd'ns)|
|Hawkins, Nick||Smyth, Rev Martin (Belfast S)|
|Hayes, John||Spelman, Mrs Caroline|
|Heath, David||Spicer, Sir Michael|
|Heathcoat-Amory, Rt Hon David||Spink, Bob|
|Hendry, Charles||Spring, Richard|
|Hermon, Lady||Stanley, Rt Hon Sir John|
|Hoban, Mark||Steen, Anthony|
|Hogg, Rt Hon Douglas||Streeter, Gary|
|Holmes, Paul||Stunell, Andrew|
|Swayne, Desmond||Watkinson, Angela|
|Swire, Hugo||Webb, Steve|
|Syms, Robert||Whittingdale, John|
|Tapsell, Sir Peter||Widdecombe, Rt Hon Miss Ann|
|Taylor, Ian (Esher & Walton)||Wiggin, Bill|
|Taylor, John (Solihull)||Wilkinson, John|
|Taylor, Matthew (Truro)||Willetts, David|
|Taylor, Dr Richard (Wyre F)||Williams, Roger (Brecon)|
|Taylor, Sir Teddy||Willis, Phil|
|Thurso, John||Wilshire, David|
|Tonge, Dr Jenny||Winterton, Mrs Ann (Congleton)|
|Tredinnick, David||Winterton, Nicholas (Macclesfield)|
|Trend, Michael||Young, Rt Hon Sir George|
|Turner, Andrew (Isle of Wight)||Younger-Ross, Richard|
|Tyrie, Andrew||Tellers for the Ayes:|
|Walter, Robert||Mrs. Cheryl Gillan and|
|Waterson, Nigel||Dr. Julian Lewis.|
|Abbott, Ms Diane||Cook, Rt Hon Robin (Livingston)|
|Alexander, Douglas||Corbyn, Jeremy|
|Allen, Graham||Corston, Jean|
|Anderson, Rt Hon Donald (Swansea E)||Cousins, Jim|
|Anderson, Janet (Rossendale)||Crausby, David|
|Armstrong, Rt Hon Ms Hilary||Cryer, Mrs Ann (Keighley)|
|Atherton, Ms Candy||Cummings, John|
|Atkins, Charlotte||Cunningham, Rt Hon Dr Jack (Copeland)|
|Banks, Tony||Cunningham, Jim (Cov'try S)|
|Barron, Kevin||Cunningham, Tony (Workington)|
|Battle, John||Curtis-Thomas, Mrs Claire|
|Bayley, Hugh||Dalyell, Tam|
|Begg, Miss Anne||Davey, Valerie (Bristol W)|
|Bell, Stuart||David, Wayne|
|Benn, Hilary||Davidson, Ian|
|Bennett, Andrew||Davies, Rt Hon Denzil (Llanelli)|
|Benton, Joe||Dawson, Hilton|
|Berry, Roger||Dean, Mrs Janet|
|Best, Harold||Denham, Rt Hon John|
|Betts, Clive||Dhanda, Parmjit|
|Blackman, Liz||Dobbin, Jim|
|Blears, Ms Hazel||Dobson, Rt Hon Frank|
|Blizzard, Bob||Donohoe, Brian H|
|Boateng, Rt Hon Paul||Doran, Frank|
|Borrow, David||Dowd, Jim|
|Bradley, Rt Hon Keith (Withington)||Drew, David|
|Bradley, Peter (The Wrekin)||Dunwoody, Mrs Gwyneth|
|Bradshaw, Ben||Eagle, Angela (Wallasey)|
|Brennan, Kevin||Eagle, Maria (L'pool Garston)|
|Brown, Rt Hon Nicholas (Newcastle E & Wallsend)||Edwards, Huw|
|Ellman, Mrs Louise|
|Brown, Russell (Dumfries)||Ennis, Jeff|
|Bryant, Chris||Etherington, Bill|
|Burden, Richard||Ewing, Annabelle|
|Burgon, Colin||Farrelly, Paul|
|Burnham, Andy||Field, Rt Hon Frank (Birkenhead)|
|Campbell, Alan (Tynemouth)||Fisher, Mark|
|Campbell, Ronnie (Blyth V)||Fitzpatrick, Jim|
|Caplin, Ivor||Fitzsimons, Mrs Lorna|
|Caton, Martin||Flint, Caroline|
|Cawsey, Ian||Flynn, Paul|
|Chaytor, David||Foster, Rt Hon Derek|
|Clapham, Michael||Foster, Michael (Worcester)|
|Clark, Mrs Helen (Peterborough)||Foulkes, George|
|Clark, Dr Lynda (Edinburgh Pentlands)||Galloway, George|
|Clarke, Rt Hon Tom (Coatbridge)||George, Rt Hon Bruce (Walsall S)|
|Clelland, David||Gerrard, Neil|
|Clwyd, Ann||Gibson, Dr Ian|
|Coaker, Vernon||Gilroy, Linda|
|Coffey, Ms Ann||Godsiff, Roger|
|Cohen, Harry||Goggins, Paul|
|Colman, Tony||Griffiths, Jane (Reading E)|
|Connarty, Michael||Griffiths, Win (Bridgend)|
|Grogan, John||Mahmood, Khalid|
|Hall, Mike (Weaver Vale)||Mahon, Mrs Alice|
|Hall, Patrick (Bedford)||Mann, John|
|Hamilton, David (Midlothian)||Marris, Rob|
|Hanson, David||Marsden, Gordon (Blackpool S)|
|Harris, Tom (Glasgow Cathcart)||Marsden, Paul (Shrewsbury)|
|Havard, Dai||Marshall, David (Shettleston)|
|Healey, John||Marshall, Jim (Leicester S)|
|Hepburn, Stephen||Marshall-Andrews, Robert|
|Heppell, John||Martlew, Eric|
|Hesford, Stephen||Meacher, Rt Hon Michael|
|Heyes, David||Meale, Alan|
|Hill, Keith||Merron, Gillian|
|Hinchliffe, David||Michael, Rt Hon Alun|
|Hodge, Margaret||Milburn, Rt Hon Alan|
|Hood, Jimmy||Miliband, David|
|Hope, Phil||Miller, Andrew|
|Hopkins, Kelvin||Mitchell, Austin (Gt Grimsby)|
|Howarth, Rt Hon Alan (Networt E)||Moffatt, Laura|
|Howarth, George (Knowsley N)||Moonie, Dr Lewis|
|Hughes, Beverley (Stretford)||Moran, Margaret|
|Hughes, Kevin (Doncaster N)||Morley, Elliot|
|Humble, Mrs Joan||Morris, Rt Hon Estelle|
|Hurst, Alan||Mullin, Chris|
|Hutton, Rt Hon John||Munn, Ms Meg|
|Iddon, Dr Brian||Murphy, Denis (Wansbeck)|
|Illsley, Eric||Murphy, Jim (Eastwood)|
|Ingram, Rt Hon Adam||Murphy, Rt Hon Paul (Torfaen)|
|Jackson, Glenda (Hampstead)||Naysmith, Dr Doug|
|Jackson, Helen (Hillsborough)||O'Brien, Mike (N Warks)|
|Jamieson, David||O'Hara, Edward|
|Johnson, Alan (Hull W & Hessle)||Olner, Bill|
|Jones, Helen (Warrington N)||O'Neill, Martin|
|Jones, Jon Owen (Cardiff C)||Organ, Diana|
|Jones, Kevan (N Durham)||Osborne, Sandra (Ayr)|
|Jones, Lynne (Salk Oak)||Owen, Albert|
|Jones, Martyn (Clwyd S)||Palmer, Dr Nick|
|Keeble, Ms Sally||Pearson, Ian|
|Keen, Alan (Feltham & Heston)||Perham, Linda|
|Keen, Ann (Brentford & Isleworth)||Picking, Anne|
|Kemp, Fraser||Pickthall, Colin|
|Khabra, Piara S||Pike, Peter|
|Kidney, David||Plaskitt, James|
|Kilfoyle, Peter||Pollard, Kerry|
|Knight, Jim (S Dorset)||Pond, Chris|
|Kumar, Dr Ashok||Pope, Greg|
|Ladyman, Dr Stephen||Powell, Sir Raymond|
|Lawrence, Mrs Jackie||Prentice, Ms Bridget (Lewisham E)|
|Laxton, Bob||Prentice, Gordon (Pendle)|
|Lazarowicz, Mark||Prescott, Rt Hon John|
|Leslie, Christopher||Price, Adam|
|Levitt, Tom||Primarolo, Dawn|
|Lewis, Terry (Worsley)||Prosser, Gwyn|
|Liddell, Rt Hon Mrs Helen||Purchase, Ken|
|Linton, Martin||Purnell, James|
|Lloyd, Tony||Quin, Rt Hon Joyce|
|Llwyd, Elfyn||Quinn, Lawrie|
|Lucas, Ian||Rapson, Syd|
|Luke, Iain||Raynsford, Rt Hon Nick|
|Lyons, John||Reed, Andy (Loughborough)|
|McAvoy, Thomas||Robertson, Angus (Moray)|
|McCabe, Stephen||Robertson, John (Glasgow Anniesland)|
|McCartney, Rt Hon Ian||Roche, Mrs Barbara|
|McDonagh, Siobhain||Ross, Ernie|
|MacDonald, Calum||Roy, Frank|
|McDonnell, John||Ruane, Chris|
|MacDougall, John||Ruddock, Joan|
|McFall, John||Russell, Ms Christine (Chester)|
|McGuire, Mrs Anne||Ryan, Joan|
|McIsaac, Shona||Salmond, Alex|
|McKenna, Rosemary||Sarwar, Mohammad|
|Mackinlay, Andrew||Savidge, Malcolm|
|McNamara, Kevin||Sawford, Phil|
|McNulty, Tony||Sedgemore, Brian|
|McWilliam, John||Shaw, Jonathan|
|Sheerman, Barry||Turner, Dr Desmond (Kemptown)|
|Sheridan, Jim||Turner, Neil (Wigan)|
|Simon, Siôn||Twigg, Derek (Halton)|
|Simpson, Alan (Nottingham S)||Vis, Dr Rudi|
|Skinner, Dennis||Walley, Ms Joan|
|Smith, Rt Hon Chris (Islington S)||Ward, Ms Claire|
|Smith, Geraldine (Morecambe)||Wareing, Robert N|
|Smith, Jacqui (Redditch)||Watson, Tom|
|Smith, Llew (Blaenau Gwent)||Watts, David|
|Soley, Clive||Weir, Michael|
|Spellar, Rt Hon John||White, Brian|
|Squire, Rachel||Whitehead, Dr Alan|
|Starkey, Dr Phyllis||Wicks, Malcolm|
|Steinberg, Gerry||Williams, Rt Hon Alan (Swansea W)|
|Stewart, David (Inverness E)||Williams, Mrs Betty (Conwy)|
|Stewart, Ian (Eccles)||Williams, Hywel (Caernarfon)|
|Stinchcombe, Paul||Wilson, Brian|
|Stoate, Dr Howard||Winnick, David|
|Stringer, Graham||Winterton, Ms Rosie (Doncaster C)|
|Tami, Mark||Wishart, Pete|
|Taylor, Rt Hon Ann (Dewsbury)||Wood, Mike|
|Taylor, Ms Dan (Stockton S)||Woodward, Shaun|
|Taylor, David (NW Leics)||Woolas, Phil|
|Thomas, Gareth (Clwyd W)||Worthington, Tony|
|Thomas, Simon (Ceredigion)||Wray, James|
|Timms, Stephen||Wright, David (Telford)|
|Tipping, Paddy||Wright, Tony (Cannock)|
|Todd, Mark||Wyatt, Derek|
|Trickett, Jon||Tellers for the Noes:|
|Truswell, Paul||Mr. Gerry Sutcliffe and|
|Turner, Dennis (Wolverh'ton SE)||Mr. Nick Ainger.|
§ Question accordingly negatived.
§ Main Question put forthwith, pursuant to Standing Order No. 62 (Amendment on Second or Third Reading):—
§ The House divided: Ayes 310, Noes 200.285
|Division No. 68||[10.15 pm|
|Abbott, Ms Diane||Brennan, Kevin|
|Alexander, Douglas||Brown, Rt Hon Nicholas (Newcastle E & Wallsend)|
|Anderson, Rt Hon Donald (Swansea E)||Brown, Russell (Dumfries)|
|Anderson, Janet (Rossendale)||Burden, Richard|
|Armstrong, Rt Hon Ms Hilary||Burgon, Colin|
|Atherton, Ms Candy||Burnham, Andy|
|Atkins, Charlotte||Campbell, Alan (Tynemouth)|
|Baird, Vera||Campbell, Ronnie (Blyth V)|
|Banks, Tony||Caplin, Ivor|
|Barron, Kevin||Caton, Martin|
|Battle, John||Cawsey, Ian|
|Bayley, Hugh||Chaytor, David|
|Begg, Miss Anne||Clapham, Michael|
|Bell, Stuart||Clark, Mrs Helen (Peterborough)|
|Benn, Hilary||Clark, Dr Lynda (Edinburgh Pentlands)|
|Benton, Joe||Clarke, Rt Hon Tom (Coatbridge)|
|Berry, Roger||Clelland, David|
|Best, Harold||Clwyd, Ann|
|Betts, Clive||Coaker, Vernon|
|Blackman, Liz||Coffey, Ms Ann|
|Blears, Ms Hazel||Colman, Tony|
|Blizzard, Bob||Connarty, Michael|
|Boateng, Rt Hon Paul||Cook, Rt Hon Robin (Livingston)|
|Borrow, David||Corston, Jean|
|Bradley, Rt Hon Keith (Withington)||Cousins, Jim|
|Bradley, Peter (The Wrekin)||Cranston, Ross|
|Bradshaw, Ben||Crausby, David|
|Cryer, Mrs Ann (Keighley)||Jackson, Glenda (Hampstead)|
|Cummings, John||Jackson, Helen (Hillsborough)|
|Cunningham, Rt Hon Dr Jack (Copeland)||Jamieson, David|
|Johnson, Alan (Hull W & Hessle)|
|Cunningham, Jim (Cov'try S)||Jones, Helen (Warrington N)|
|Cunningham, Tony (Workington)||Jones, Jon Owen (Cardiff C)|
|Curtis-Thomas, Mrs Claire||Jones, Kevan (N Durham)|
|Dalyell, Tam||Jones, Lynne (Selly Oak)|
|Davey, Valerie (Bristol W)||Jones, Martyn (Clwyd S)|
|David, Wayne||Keeble, Ms Sally|
|Davidson, Ian||Keen, Alan (Feltham & Heston)|
|Dawson, Hilton||Keen, Ann (Brentford & Isleworth)|
|Dean, Mrs Janet||Kemp, Fraser|
|Denham, Rt Hon John||Khabra, Piara S|
|Dhanda, Parmjit||Kidney, David|
|Dobbin, Jim||Kilfoyle, Peter|
|Dobson, Rt Hon Frank||Knight, Jim (S Dorset)|
|Donohoe, Brian H||Kumar, Dr Ashok|
|Doran, Frank||Ladyman, Dr Stephen|
|Dowd, Jim||Lawrence, Mrs Jackie|
|Drew, David||Laxton, Bob|
|Dunwoody, Mrs Gwyneth||Lazarowicz, Mark|
|Eagle, Angela (Wallasey)||Leslie, Christopher|
|Eagle, Maria (L'pool Garston)||Levitt, Tom|
|Edwards, Huw||Lewis, Terry (Worsley)|
|Ellman, Mrs Louise||Liddell, Rt Hon Mrs Helen|
|Ennis, Jeff||Linton, Martin|
|Etherington, Bill||Lloyd, Tony|
|Farrelly, Paul||Lucas, Ian|
|Fisher, Mark||Lyons, John|
|Fitzpatrick, Jim||McAvoy, Thomas|
|Fitzsimons, Mrs Lorna||McCabe, Stephen|
|Flint, Caroline||McCafferty, Chris|
|Flynn, Paul||McCartney, Rt Hon Ian|
|Foster, Rt Hon Derek||McDonagh, Siobhain|
|Foster, Michael (Worcester)||MacDonald, Calum|
|Foulkes, George||McDonnell, John|
|Galloway, George||MacDougall, John|
|Gardiner, Barry||McFall, John|
|George, Rt Hon Bruce (Walsall S)||McGuire, Mrs Annne|
|Gerrard, Neil||McIsaac, Shona|
|Gibson, Dr Ian||McKenna, Rosemary|
|Gilroy, Linda||Mackinlay, Andrew|
|Godsiff, Roger||McNamara, Kevin|
|Goggins, Paul||McNulty, Tony|
|Griffiths, Jane (Reading E)||McWilliam, John|
|Griffiths, Win (Bridgend)||Mahmood, Khalid|
|Grogan, John||Mahon, Mrs Alice|
|Hall, Mike (Weaver Vale)||Mann, John|
|Hall, Patrick (Bedford)||Marris, Rob|
|Havard, Dai||Marshall, Jim (Leicester S)|
|Healey, John||Marshall-Andrews, Robert|
|Hepburn, Stephen||Martlew, Eric|
|Heppell, John||Meacher, Rt Hon Michael|
|Hesford, Stephen||Meale, Alan|
|Heyes, David||Merron, Gillian|
|Hill, Keith||Michael, Rt Hon Alun|
|Hinchliffe, David||Milburn, Rt Hon Alan|
|Hodge, Margaret||Miliband, David|
|Hood, Jimmy||Miller, Andrew|
|Hope, Phil||Mitchell, Austin (Gt Grimsby)|
|Hopkins, Kelvin||Moffatt, Laura|
|Howarth, Rt Hon Alan (Newport E)||Moonie, Dr Lewis|
|Howarth, George (Knowsley N)||Moran, Margaret|
|Hughes, Beverley (Stretford)||Morley, Elliot|
|Hughes, Kevin (Doncaster N)||Morris, Rt Hon Estelle|
|Humble, Mrs Joan||Mullin, Chris|
|Hurst, Alan||Munn, Ms Meg|
|Hutton, Rt Hon John||Murphy, Denis (Wansbeck)|
|Iddon, Dr Brian||Murphy, Jim (Eastwood)|
|Illsley, Eric||Murphy, Rt Hon Paul (Torfaen)|
|Ingram, Rt Hon Adam||Naysmith, Dr Doug|
|O'Brien, Mike (N Warks)||Soley, Clive|
|O'Hara, Edward||Spellar, Rt Hon John|
|Olner, Bill||Squire, Rachel|
|O'Neill, Martin||Starkey, Dr Phyllis|
|Organ, Diana||Steinberg, Gerry|
|Osborne, Sandra (Ayr)||Stevenson, George|
|Owen, Albert||Stewart, David (Inverness E)|
|Palmer, Dr Nick||Stewart, Ian (Eccles)|
|Pearson, Ian||Stinchcombe, Paul|
|Perham, Linda||Stoate, Dr Howard|
|Picking, Anne||Stringer, Graham|
|Pickthall, Colin||Tami, Mark|
|Pike, Peter||Taylor, Rt Hon Ann (Dewsbury)|
|Plaskitt, James||Taylor, Ms Dari (Stockton S)|
|Pollard, Kerry||Taylor, David (NW Leics)|
|Pond, Chris||Thomas, Gareth (Clwyd W)|
|Pope, Greg||Timms, Stephen|
|Powell, Sir Raymond||Tipping, Paddy|
|Prentice, Ms Bridget (Lewisham E)||Todd, Mark|
|Prentice, Gordon (Pendle)||Touhig, Don|
|Prescott, Rt Hon John||Trickett, Jon|
|Primarolo, Dawn||Truswell, Paul|
|Prosser, Gwyn||Turner, Dennis (Wolverh'ton SE)|
|Purchase, Ken||Turner, Dr Desmond (Kemptown)|
|Purnell, James||Turner, Neil (Wigan)|
|Quin, Rt Hon Joyce||Twigg, Derek (Halton)|
|Quinn, Lawrie||Vis, Dr Rudi|
|Rapson, Syd||Walley, Ms Joan|
|Raynsford, Rt Hon Nick||Ward, Ms Claire|
|Reed, Andy (Loughborough)||Wareing, Robert N|
|Robertson, John (Glasgow Anniesland)||Watson, Tom|
|Roche, Mrs Barbara||White, Brian|
|Ross, Ernie||Whitehead, Dr Alan|
|Roy, Frank||Wicks, Malcolm|
|Ruane, Chris||Williams, Rt Hon Alan (Swansea W)|
|Russell, Ms Christine (Chester)||Williams, Mrs Betty (Conwy)|
|Ryan, Joan||Wilson, Brian|
|Sarwar, Mohammad||Winnick, David|
|Savidge, Malcolm||Winterton, Ms Rosie (Doncaster C)|
|Sawford, Phil||Wood, Mike|
|Sedgemore, Brian||Woodward, Shaun|
|Shaw, Jonathan||Woolas, Phil|
|Sheerman, Barry||Worthington, Tony|
|Sheridan, Jim||Wray, James|
|Simon, Siôn||Wright, David (Telford)|
|Simpson, Alan (Nottingham S)||Wright, Tony (Cannock)|
|Skinner, Dennis||Wyatt, Derek|
|Smith, Rt Hon Chris (Islington S)|
|Smith, Geraldine (Morecambe)||Tellers for the Ayes:|
|Smith, Jacqui (Redditch)||Mr. Gerry Sutcliffe and|
|Smith, Llew (Blaenau Gwent)||Mr. Nick Ainger.|
|Ainsworth, Peter (E Surrey)||Brooke, Annette|
|Allan, Richard||Browning, Mrs Angela|
|Amess, David||Bruce, Malcolm|
|Ancram, Rt Hon Michael||Burns, Simon|
|Arbuthnot, Rt Hon James||Burstow, Paul|
|Bacon, Richard||Burt, Alistair|
|Baldry, Tony||Butterfill, John|
|Barker, Gregory||Cable, Dr Vincent|
|Barrett, John||Calton, Mrs Patsy|
|Beggs, Roy||Cameron, David|
|Beith, Rt Hon A J||Campbell, Rt Hon Menzies (NE Fife)|
|Bercow, John||Carmichael, Alistair|
|Beresford, Sir Paul||Cash, William|
|Boswell, Tim||Chapman, Sir Sydney (Chipping Barnet)|
|Bottomley, Peter (Worthing W)|
|Bottomley, Rt Hon Virginia||Chidgey, David|
|Brady, Graham||Chope, Christopher|
|Brake, Tom||Clarke, Rt Hon Kenneth (Rushcliffe)|
|Breed, Colin||Clifton-Brown, Geoffrey|
|Collins, Tim||McLoughlin, Patrick|
|Conway, Derek||Malins, Humfrey|
|Cotter, Brian||Maples, John|
|Gran, James||Mawhinney, Rt Hon Sir Brian|
|Davey, Edward (Kingston)||Mercer, Patrick|
|Davies, Quentin (Grantham)||Mitchell, Andrew (Sutton Goldfield)|
|Davis, Rt Hon David (Haltemprice)||Moore, Michael|
|Djanogly, Jonathan||Moss, Malcolm|
|Dorrell, Rt Hon Stephen||Murrison, Dr Andrew|
|Doughty, Sue||Norman, Archie|
|Duncan, Alan (Rutland & Melton)||Oaten, Mark|
|Duncan Smith, Rt Hon Iain||O'Brien, Stephen (Eddisbury)|
|Evans, Nigel||Öpik, Lembit|
|Ewing, Annabelle||Osborne, George (Tatton)|
|Fabricant, Michael||Ottaway, Richard|
|Fallon, Michael||Page, Richard|
|Field, Mark (Cities of London)||Paice, James|
|Flight, Howard||Paterson, Owen|
|Forth, Rt Hon Eric||Pickles, Eric|
|Foster, Don (Bath)||Price, Adam|
|Francois, Mark||Prisk, Mark|
|Gale, Roger||Pugh, Dr John|
|Garnier, Edward||Randall, John|
|George, Andrew (St Ives)||Redwood, Rt Hon John|
|Gibb, Nick||Reid, Alan (Argyll & Bute)|
|Gidley, Sandra||Rendel, David|
|Goodman, Paul||Robathan, Andrew|
|Gray, James||Robertson, Angus (Moray)|
|Grayling, Chris||Robertson, Hugh (Faversham)|
|Green, Damian (Ashford)||Robertson, Laurence (Tewk'b'ry)|
|Green, Matthew (Ludlow)||Robinson, Peter (Belfast E)|
|Greenway, John||Roe, Mrs Marion|
|Grieve, Dominic||Rosindell, Andrew|
|Gummer, Rt Hon John||Russell, Bob (Colchester)|
|Hammond, Philip||Salmond, Alex|
|Hancock, Mike||Sanders, Adrian|
|Harris, Dr Evan (Oxford W)||Sayeed, Jonathan|
|Harvey, Nick||Shephard, Rt Hon Mrs Gillian|
|Hawkins, Nick||Shepherd, Richard|
|Hayes, John||Simmonds, Mark|
|Heath, David||Simpson, Keith (Mid-Norfolk)|
|Heathcoat-Amory, Rt Hon David||Smith, Sir Robert (W Ab'd'ns)|
|Hendry, Charles||Smyth, Rev Martin (Belfast S)|
|Hermon, Lady||Spelman, Mrs Caroline|
|Hoban, Mark||Spicer, Sir Michael|
|Hogg, Rt Hon Douglas||Spink, Bob|
|Holmes, Paul||Spring, Richard|
|Horam, John||Stanley, Rt Hon Sir John|
|Howard, Rt Hon Michael||Steen, Anthony|
|Howarth, Gerald (Aldershot)||Stunell, Andrew|
|Hughes, Simon (Southwark N)||Swayne, Desmond|
|Hunter, Andrew||Swire, Hugo|
|Jack, Rt Hon Michael||Syms, Robert|
|Jackson, Robert (Wantage)||Tapsell, Sir Peter|
|Jenkin, Bernard||Taylor, Ian (Esher & Walton)|
|Johnson, Boris (Henley)||Taylor, John (Solihull)|
|Kennedy, Rt Hon Charles (Ross Skye & Inverness W)||Taylor, Matthew (Truro)|
|Taylor, Dr Richard (Wyre F)|
|Key, Robert||Taylor, Sir Teddy|
|Kirkbride, Miss Julie||Thomas, Simon (Ceredigion)|
|Knight, Rt Hon Greg (E Yorkshire)||Thurso, John|
|Laing, Mrs Eleanor||Tonge, Dr Jenny|
|Lamb, Norman||Tredinnick, David|
|Lansley, Andrew||Trend, Michael|
|Laws, David||Turner, Andrew (Isle of Wight)|
|Leigh, Edward||Tyler, Paul|
|Letwin, Oliver||Tyrie, Andrew|
|Liddell-Grainger, Ian||Walter, Robert|
|Lidington, David||Waterson, Nigel|
|Lilley, Rt Hon Peter||Watkinson, Angela|
|Llwyd, Elfyn||Webb, Steve|
|Loughton, Tim||Weir, Michael|
|Luff, Peter||Whittingdale, John|
|McIntosh, Miss Anne||Widdecombe, Rt Hon Miss Ann|
|MacKay, Rt Hon Andrew||Wiggin, Bill|
|Maclean, Rt Hon David||Wilkinson, John|
|Willetts, David||Wishart, Pete|
|Williams, Hywel (Caernarfon)||Young, Rt Hon Sir George|
|Williams, Roger (Brecon)||Younger-Ross, Richard|
|Wilshire, David||Tellers for the Noes:|
|Winterton, Mrs Ann (Congleton)||Dr. Julian Lewis and|
|Winterton, Nicholas (Macclesfield)||Mrs. Cheryl Gillan.|
§ Question accordingly agreed to.
§ Bill read a Second time.