§ 7.30 p.m.
§ Lord Harris of Haringey
rose to ask Her Majesty's Government what response they have to the issues raised and recommendations made by the Commission on the National Health Service, chaired by Mr Will Hutton, and published as New Life for Health in April 2000.
1445 The noble Lord said: My Lords, perhaps I may, first, say how nice it is to see what I assume to be a select team of noble Lords in your Lordships' House this evening, given the rival attraction of the England versus Portugal match. I am particularly pleased to see that this evening's short debate has attracted two maiden speakers. The noble Lord, Lord Shutt of Greetland, adds to the list of distinguished noble Lords from a local government background, as leader of the Liberal Democrat group on Calderdale Council. I am sure that the noble Baroness, Lady Northover, would have had a much more distinguished local government career had she not had the misfortune to stand against me in the Hornsey Central ward of the London Borough of Haringey some years ago. I am sure that both of tonight's maiden speakers will make many more speeches in this House and, perhaps on future occasions, to rather more listeners.
I shall start by declaring an interest. New Life for Health is the report of an independent commission set up by the Association of Community Health Councils for England and Wales. The decision to set up the commission was taken while I was still employed as director of the association, although that decision was not in fact actioned until after I had left.
It is, of course, an appropriate time to examine the issues of the public interest in the NHS and how best to achieve a full and effective system of accountability. The NHS remains enormously popular. A poll reported in the commission's report found that 63 per cent of people regard the NHS as the most valuable institution in the country, compared with a mere 12 per cent who feel the same about Parliament.
Nevertheless, the NHS is in need of modernisation. As other public services respond to changing expectations of their users, so must the NHS. That is why the Government are so keen to promote new initiatives like NHS Direct and walk-in medical centres. It is crucial also to change the balance between the professional and the patient. Patients should not only be empowered, but should also be full partners in the decision-taking concerning their own care. Yet at present, although the vast majority of patients believe that they should have a lot of power over the treatment that they receive, only one-fifth of them believes that they do so in practice.
No doubt greater flexibility in services to meet patients' needs will be part of the Government's new national plan for the NHS. To ensure this, the Government announced their intention to fund the largest sustained real increases in resources to the NHS ever—at the end of the five-year period, we will have seen a one-third increase in the funding of the service in real terms after allowing for inflation. No one should underestimate the impact that this will have, particularly if it is accompanied by a greater emphasis on clinical outcomes, disease prevention and a reduction in inequalities in health status.
However, I rather suspect that the NHS may still remain a rather paternalistic structure, doing what is deemed to be best for people rather than listening to what they want and responding accordingly. A 1446 national plan does not suggest that we shall be moving towards a decentralised locally-accountable model of health provisions. Indeed, the centralist versus the localist debate has been present throughout the history of the NHS, but centralism has always won in the past. So much so that Nye Bevan promised that the sound of a dropped bedpan would echo all the way to the Secretary of State and that, in practice, Ministers would be accountable for all within the service.
New Life for Health identifies a series of weaknesses in the accountability structure of the present NHS, most of which will be familiar to your Lordships; for example, the commission's report talks of the limited powers of the health service ombudsman, the weakness of community health councils as the local patients' watchdogs and the failings of the NHS complaints procedure—long-winded, confusing and, apparently, biased against the interests of those with legitimate grievances. It also mentions the issues surrounding appointed boards at local level answerable to the region or to Quarry House, not to the local community, and so on.
New Life for Health also makes a series of proposals to remedy this democratic deficit. These are, inter alia: that the NHS should have a written constitution (a sort of mission statement dressed up as a Bill of rights), including clear commitments to openness and to equal opportunities and incorporating the central elements of a patients' charter; that the NHS itself should become a public corporation, operating at arm's length from Ministers with an independent board—a sort of super-quango, and even then perhaps not a quasi-autonomous non-governmental organisation but a totally autonomous non-government organisation; in fact, a "tango".
The report also proposes that there should be a new system of democratic accountability at local and regional levels, perhaps involving direct elections to the relevant bodies; that CHCs should be strengthened; that complaints should be dealt with by independent review panels; that parliamentary scrutiny should be strengthened, as should the powers of the NHS ombudsman; and that there should be greater lay representation on the Care Standards Commission, the General Medical Council and other bodies.
While I broadly welcome and support these proposals, I believe that there is some logical inconsistency here. It is difficult to reconcile a public corporation structure with greater democracy and accountability. Parliamentary scrutiny of Ministers may not be as rigorous and as searching as it might be, but it is better than nothing. An autonomous public corporation would, in practice, be subject to only the most limited accountability. Unless its boards were directly elected—a New Life for Health does not suggest such a step—it is difficult to see how the structure would be more accountable than the present arrangement. Moreover, the locally and regionally elected structure that the report proposes would have to operate within a framework laid down by an unelected and unaccountable public corporation. That does not seem like a happy arrangement to me.
1447 Nevertheless, this inconsistency is not a reason for the Government to dismiss New Life for Health and its recommendations. However, I fear that I can guess the response that we shall hear from my noble friend the Minister at the end of the debate. I can almost hear him now: "This is an interesting report. A welcome contribution to the national debate about the future of one of our great institutions", and so on. "It raises big issues, important issues and even fundamental issues", et cetera. "It is, however, unreasonable to prejudge the outcome of the consultation; specific responses will have to await the publication of the National Plan. The Government are grateful to the commission for its work", and so on—and everything would perhaps be lodged neatly in the long grass. It is possible that I misjudge my noble friend and his officials. I certainly hope so.
If this debate is to be considered as an early part of the consultation on the national plan, perhaps I may conclude by making some practical suggestions for inclusion in that plan. I am assuming that the plan's main burden will be to make the NHS more responsive to the needs of individual service users; and that will be welcome. However, the issues raised in New Life for Health about the democratic deficit within the NHS must also be addressed. Accordingly, the national plan should set out a very clear statement of what the citizen should be able to expect from the NHS and what redress there will be if those expectations are not met. In essence, this will be the constitution for the NHS called for by New Life for Health. If the redress arrangements are sturdy enough, they will remove some of the trend towards litigation that we currently see.
There should also be a commitment to strengthen the patient voice—stronger and better resourced CHCs, acting as effective advocates for the interests of individual patients and for the needs of their local communities. There should be a dominant lay presence in all the key institutions of the health service, including—if not especially—those historically dominated by the professions. There should also be a new seamless one-door complaints system, which has as its core an adjudication system for disputes that is independent of the service providers and of the professionals.
As noble Lords will have gathered, I am not convinced of the case for an arm's length public corporation. However, there should be a board overseeing the NHS, one which involves not only Ministers and senior managers but also some independent members appointed on proper Nolan principles. This board should be answerable to Parliament via a strengthened Select Committee of another place and a parallel Select Committee of your Lordships' House.
There should also be a commitment to integrate the NHS regional structures with the nascent regional bodies being set up around the country. In London I believe that the Mayor should be able to appoint a chairman and board for the greater London region of the NHS. For those who think this is a frightening proposal I point out that the Mayor already appoints 1448 the London Development Agency, whereas elsewhere in the country RDAs are appointed by my right honourable friend the Deputy Prime Minister. Therefore, it is possible to have separate institutions directly accountable to a regionally elected structure.
Finally, at local level, those responsible for the NHS should be directly elected. There is provision in the Local Government Bill, currently in another place, for a variety of forms of local governance. One that has so far excited little comment would involve a directly elected mayor and two or three other directly elected executive officials—perhaps the local commissioner for education and for social care services. Why could we not have a locally elected commissioner for health services, directly accountable and directly answerable? Such an arrangement would strengthen the NHS, reinforce links with the public it serves and would at a stroke eliminate that democratic deficit so eloquently identified in New Life for Health. Hook forward to my noble friend's reply.
§ 7.40 p.m.
§ Baroness Northover
My Lords, I cannot say that I have exactly been looking forward to making my maiden speech. But the kindness that has been shown to me from all quarters of this House has reassured me that perhaps I shall survive.
I have been struck by the extraordinary courtesy shown in the debates in your Lordships' House. The staff, too, have been outstanding. I have no idea how they do it, but they seemed to know me before I even reached the door. They gently lead me back from some corridor's dead end; they steer me where I should be going. Your Lordships may soon see me sneaking in my three young children because I live in hope that if at least a little of such courtesy and kindness rubs off on them, life at home would be quite transformed.
I used to teach 20th century history of medicine at University College London. I am therefore especially grateful for the chance to speak in this debate today. I should like to thank the noble Lord, Lord Harris of Haringey, for this opportunity. As he knows, I have followed his career with great interest for many years, for I am a resident of Haringey, where he was leader of the council.
It is also a privilege to speak in the same debate as the Minister, the noble Lord, Lord Hunt of Kings Heath. Many years ago I was appointed as a member of Camden and Islington Family Practitioner Committee. I attended a training weekend at which the noble Lord, in his role as chair of the National Association of Health Authorities, took a leading part. I admit that I was most impressed by him. I thought that he was someone who should go far. Little did I realise how far that would be! The noble Lord, Lord Harris, was, of course, the chair of the Association of Community Health Councils. We must congratulate the association for commissioning this study, itself chaired by another formidable Haringey resident, Will Hutton. The report begins:The NHS is Britain's greatest and most prized national institution".1449 I could not agree more. But for the chance of history, the NHS would not have come into being at all. Those at home in the Second World War looked to a brighter future which included freedom from the fear of destitution when ill. Then morale boosting propaganda encouraged similar expectations among the troops. But, just as importantly, the voluntary hospitals, so often in financial difficulties prior to the war, came during it to rely upon the state. Many young and ambitious doctors began to climb the medical tree not through appointments at home but in the state-rewarded army medical service. These unique circumstances brought about the NHS. If we allow it to crumble, we shall not reinvent it.
So I welcome the report's assumption that there can and should be a comprehensive healthcare system. It is not a matter of how best to take a scalpel to it. The report points out that the NHS is cost effective by continental or American standards. And yet, as we all know, the NHS has serious problems. The NHS took on all the patterns of pre-war years—over provision here, no provision there. It has never been universally comprehensive. Throughout its 50-year history a major task has been simply to try to even out these problems. Change has been difficult, especially because it has not been lubricated by sufficient funds. Decisions are made in secret; patients often feel excluded, ill informed, powerless. The staff know only too well how debilitating constant, ill directed change and vague threats can be.
Will Hutton and his team argue for a written constitution for the NHS to make more explicit what the NHS stands for and what each citizen is entitled to. They also recommend that the NHS should be at arm's length from governments, incorporated perhaps like the BBC.
Neither of these proposals by themselves will solve the long-term problems of an underfunded service. Who will make best use of that constitution? Probably not those receiving the poorest care. The BBC may have greater freedom than the NHS to develop its own strategy, but it has scarcely been protected against the vagaries of under-resourcing.
Assessment, audit and evidence-based medicine are some of the tools for the future improvement of the service. But that too means adequate resourcing. The establishment of the National Institute for Clinical Excellence is welcome, but it will not make a difference if there is not sufficient investment in it. As yet it has reported only on one drug, Relenza.
If the National Health Service is to remain a much loved public service, it must tackle the problems of indifferent standards, lack of transparency and inequalities of access. It must see rising expectations as a positive not a negative challenge. I welcome the commission and its report, with its imaginative proposals for the future of the NHS. But in the end such changes would be to no avail unless the NHS is adequately funded.
1450 I thank noble Lords for their kindness and patience in listening to me today. I look forward very much to participating in other debates on health and the NHS in the weeks and months to come. I am sure that there will be a great deal that we shall wish to discuss.
§ 7.47 p.m.
§ Baroness Massey of Darwen
My Lords, first, I congratulate the noble Baroness, Lady Northover, on her maiden speech. It is not long since I delivered my maiden speech. I assure the noble Baroness that it seems like a long time ago, such is the rapid assimilation into your Lordships' House. I realise that the noble Baroness will have much to offer from her wealth of experience and that her stimulating speech was just a taste of things to come.
The noble Baroness has had a distinguished career, having been a researcher, academic, negotiator, politician, parliamentary candidate and a member of a myriad of organisations. She is currently chair of the Women's Liberal Democrats. She has also found the time to have three children. I am told by a reliable source on the Liberal Democrat Benches that she once presided over a conference debate when she was eight and a half months pregnant. The topic was population explosion! She must also have a keen sense of irony!
I thank my noble friend Lord Harris of Haringey for tabling and introducing this debate in his customary vigorous fashion. I admit some surprise that this report has not been so widely publicised as I would have expected. It certainly deserves, in the words of the report itself, a "healthy public debate" of longer duration than our allotted time this evening.
I read New Life for Health on a plane returning from work in a central Asian country, part of the former Soviet Union. In comparison with the problems of that country, with its health and other services crumbling, the problems of the NHS seem light indeed. However, as the report points out, we have high expectations of the NHS and a growing tendency to complain and speak up if we feel that we are not being well served.
The report states:A gap has opened up both between what the NHS is able to deliver and the expectations and needs of its users, and between its original principles and current practice".This is strong criticism. The report rightly focuses on accountability and on developing structures appropriate to individuals and to communities. My noble friend Lord Harris discussed that issue.
There is much to say, and much has been said. I want to confine my remarks and questions today to the issue of inequalities in health, an issue to which the report referred at several points. The earlier report Saving Lives: Our Healthier Nation also emphasised the inequalities following the Acheson inquiry of 1998.
Inequality in health exists due to several factors: standards, policy, priorities and so on. All this is well known and fairly obvious. Florence Nightingale's Notes on Nursing recognised that,the same names may be seen constantly recurring on workhouse books for generations…death and disease are like the workhouse: they take from the same family, the same house or the same conditions".1451 Things have improved, but we can still predict morbidity and mortality to a certain extent. They relate to inequality.
It is clear that no single agency such as health can improve people's lives without collaboration with a whole range of other agencies, both statutory and voluntary. Individual lifestyle also counts, and the greater emphasis in recent years on prevention of illness is to be welcomed.
I want to highlight some of my concerns about the inequalities mentioned in the report. In doing so I shall refer to the health improvement programmes set up in consequence of the White Paper The New NHS: Modern and Dependable. Following a Royal Society of Medicine symposium held in 1998 to consider the implementation of these programmes, a report was produced. One chapter considers learning from experience in the NHS, termed "the good, the bad and the ugly". The "good" includes a free and comprehensive service; the "bad" includes the NHS as an illness service rather than as a service working in partnership to tackle wider health determinants; the "ugly"—this is where I return to my theme of inequalities —relates to the wide variations in health, healthcare and clinical standards.
It seems to me that the eradication of inequality in health requires stated government commitment and determination, which we have. The previous internal market, with its lack of consideration for equity, has been dismantled, but there are still problems with allocation of resources and budgets within the NHS. There are problems with assessing needs and performance; national data need to be supplemented by local data. I understand, for example, that information according to ethnic group on waiting lists is not available nationally. This seems to me to be inverse racism. We need to know about issues specific to particular groups in order to plan and monitor interventions. We need to involve these groups in planning.
Delivering equity in health demands good relationships between partners at a local level. Accountability is all very well, but local government has problems with getting people to stand for election, getting representative samples of candidates and getting people to vote. Changing structures is not enough; this is about changing mindsets—and that can take a long time. It is essential that primary care groups and trusts have good representation from a variety of ethnic backgrounds and from diversity in society. It is essential that the voluntary sector, with its expertise on specific groups and issues, is involved.
An improved Patient's Charter is suggested in the report, together with an effective complaints procedure and greater participation in decision making. I suggest that for some individuals and groups, support and advocacy from community health councils or civil society organisations will be essential for this to work. Community health councils are key institutions; they have a wealth of experience in research and advocacy for vulnerable groups such as the elderly, those with disability, children, and ethnic minorities. They are well linked to local communities.
1452 In conclusion, I feel that the report raises many issues of importance for one of our publicly recognised great institutions. I look forward to the Minister's comments on the following issues: needs assessment; structures and policy; training; advocacy; support; and in particular on how all this relates to equity in health, so that, in the words of the report, equity does not remain,subordinate to the desire to promote a narrow concept of efficiency".
§ 7.54 p.m.
§ Lord Shutt of Greetland
My Lords, it seems that at the start of a maiden speech the traditions of this House are such that one has to do certain things—that is, to give some idea of first impressions and to give a little insight into the speaker.
As to first impressions, a series of hurdles from a visit to Garter, to the introduction, to today. It then gets more and more serious. The warm welcome from all sides of your Lordships' House—as was mentioned by the noble Baroness, Lady Northover—is quite incredible; the clear possibility that there can be fundamental disagreements in a spirit of personal friendship; the kindness and support given by the talented, interested and enthusiastic staff of the House is something which comes so clearly to the new Member. The insights in regard to me will no doubt evolve over the next few minutes, not least in the matter of declaration of interests.
Before proceeding I must also pay tribute to my family, who have been such a source of strength to me over the years: to my 95 year-old mother, Ruth, who is keenly interested in what is going on from afar; to Margaret, my wife of 35 years standing this very day; and to my children, Christine, Richard and Andrew.
Moving to the document before us, New Life for Health was commissioned by the Association of Community Health Councils in England and Wales. But the commission itself saw fit to commission an opinion poll and sought funding from the Joseph Rowntree Reform Trust Limited. I now declare an interest as a director of that non-charitable grant-making trust. In so doing I should say that that association over the past 25 years—and membership of its sister trust, the Joseph Rowntree Charitable Trust—has given me a tremendous personal interest and insight into many constitutional and democratic issues. Joseph Rowntree's generosity in 1904 has been good for democracy.
Like many other maiden speakers I feel a certain trepidation about today—even more so when the subject is health. It is not a subject that I have made my own; it is one that I have rather shied away from. But I do not shy away from democracy.
The report contains the words, "This popular institution". Within its 132 pages the book refers to the whole panoply of the National Health Service—the trusts, the committees, the groups and so on; there is barely a wasted page. It suggests several substantial reforms that one might call "root and branch". In principle, it contains ideas to which I am naturally 1453 attracted—such as issues of greater accountability, the regional dimension and, indeed, proportional representation.
But three issues stand out. In line with the noble Lord, Lord Harris of Haringey, I query the creation of the NHS as a public corporation. I query, for example, the very important decisions that the Government have made to increase resources by 6.1 per cent per year over four years. Would this have happened had it been an independent public corporation? Would there have been the clout for that to happen? I am not certain about that. Indeed, when the Human Rights Act comes into effect and when eventually the Freedom of Information Bill becomes law, they will have a fundamental effect.
The second issue relates to the consumer, normally referred to as the patient. On page 28 of the book it states:No longer can doctors, clinicians, health managers and politicians decide what they consider to be the public interest in health behind closed doors with only nominal consultation, and expect their decisions to remain unchallenged".That is true. But the representatives who are the challengers will face an increasingly difficult task ahead. There is a suggestion about holding specific health authority elections. Are there sufficient people who would be prepared to stand for public election to these posts? Not only do we have problems with turnout in, for example, local government elections, but we also have problems in persuading people to stand for election. It seems to me that a greater awareness of citizenship and a sense of civic duty will be needed if those ideas are to come to pass. I declare a further interest as the treasurer for the Institute for Citizenship.
Thirdly, we come to elected bodies. My final declaration of interest is that I am still an elected member of the Calderdale Metropolitan Borough Council representing the ward of Greetland and Stainland. I have fought 15 elections. It would be interesting to know, in this unelected House, how many elections the 700 or so Members have contested.
Can we sustain local government elections and local health authority elections? Can we stand that specific tier? In my view, local government has been debilitated year on year over very many years. Powers have been in decline, whether through Acts of Parliament or transfer of resources such as SRBs—single regeneration budgets. Even over the past few years we have seen the plethora of partnerships that are now taking away resources from local authorities and the accountability of the members.
As far as the new local government is concerned, the jury is still out. However, one feature which I believe may do well in that new local government is the formation of the new scrutiny committees. The community health councils could well be strengthened on that model.
In conclusion, structures in a complex undertaking must be understandable and accessible to the people; namely, consumers who are patients, and their relatives, at their most vulnerable time.
1454 New Life for Health is a valuable contribution to this debate in your Lordships' House. I trust that the Minister, the noble Lord, Lord Hunt of Kings Heath, will say, in his final remarks, that "This work is not in vain".
§ 8.2 p.m.
§ The Lord Bishop of Birmingham
My Lords, I know that I speak for your Lordships' House as a whole in congratulating the noble Lord, Lord Shutt of Greetland, both on his 35th wedding anniversary and on his notable and most interesting maiden speech. The noble Lord comes to this House with a wealth of experience in local democracy, in local government and in public service in Yorkshire.
He also brings the particular perspectives which come from his membership of the Society of Friends, a body which makes a contribution to the good health of our society out of all proportion to the size of its membership. We look forward to hearing from the noble Lord again, not least on issues of democracy and accountability, about which he has spoken today.
At the centre of Will Hutton's report are the issues of accountability and ownership. At the local as well as at the national level, how are communities to be enabled to feel a sense of ownership and therefore of responsibility for the services they use? In speaking about one episode in the history of the health service in Birmingham, I must declare an interest; indeed, an interest in more than one sense of the word. I am a non-executive director of the University Hospital Birmingham NHS Trust.
For at least 20 years, health planning in Birmingham was deadlocked. Everyone knew that radical changes were needed, but no one could agree on what ought to be done and all the structures for consultation were dysfunctional. Sectional interests were pitted against one another. In the city there were no fewer than five district health authorities. The regional health authority had lost the confidence of local government. The local press whipped up campaigns to save this or that institution, to which people were understandably, if often short-sightedly, attached. The result was gridlock with decaying buildings, wasted resources, mounting deficits with increasing dangers of clinical risk and all going nowhere.
Change came at last two years ago. The Birmingham Health Authority, after yet again setting out its stall for change in a consultative document, set up an independent commission to take evidence and to make recommendations in response to its proposals. That commission was admirably chaired by the noble Lord, Lord Hunt of Kings Heath, before he held his ministerial responsibilities with the Department of Health. The membership was drawn from the three main political parties, from the various religious and ethnic communities in the city, from academia and from the media.
Under the noble Lord's leadership, the positions of the various interest groups were publicly and vigorously scrutinised, as were the proposals of the 1455 health authority. The outcome was a report which took an independent and comprehensive view of the health needs of the city as a whole. It was a constructive and sanitary change from the usual kind of consultation exercise in which each interest group responds in isolation from all the others. The thing then never adds up.
The commission's report, entitled Simply the Best, was published in the summer of 1998. By using its methods, it succeeded in breaking the log-jam. Furthermore, it helped the community as a whole to take responsibility both for the inherited problems and for finding solutions to which all would be publicly committed. The health authority, the various hospital trusts, the university medical school, the medical profession, the city, the media and the politicians are now working together in a way in which even a few years ago seemed quite impossible.
I have already mentioned the part played by the chairman of that independent commission. However, the other person to mention is the former chairman of the Birmingham Health Authority, Mr Bryan Stoten, who had the political wit to see that the only way to make progress was by way of putting consultation into the hands of a manifestly independent and truly representative commission which was free to form its own judgments and make its own recommendations. I commend that exercise as a model of what can be done if people in charge will sometimes have the courage to let go.
§ 8.7 p.m.
§ Lord Clement-Jones
My Lords, perhaps I may begin by congratulating the noble Lord, Lord Harris of Haringey, on initiating this debate on New Life for Health and, indeed, on being originally responsible for commissioning the report itself. Tonight he has introduced the subject very lucidly to the House.
It is a great privilege to be taking part in a debate which includes not just one, but two maiden speeches from the Liberal Democrat Benches. That certainly demonstrates our continuing interest in matters that affect not only health, but also democracy, accountability and transparency. I very much look forward to future contributions in this House from my two noble friends.
The polling undertaken for the report clearly demonstrates that the NHS is still immensely important to the British public. Some 63 per cent of those polled considered the NHS to be the UK's most valuable institution, a percentage far ahead of that for the police service, the BBC or indeed the Royal Family. However, 56 per cent of those polled considered the NHS to be remote and hard to influence. Their diagnosis of the body that constitutes the NHS was very eloquently set out by the commission. Over the years there has been a steady erosion of local discretion. There is massive patronage by the Secretary of State. Today we have a highly centralised NHS. After the 1990 reforms, NHS regional executives are only an arm of the centre. The Health Select Committee argued in autumn last year 1456 that the NHS needs to transform an ethos that is too defensive, inward-looking and locked in a blame culture.
Indeed, there is little accountability in the system, and even less transparency. The existing systems for accountability and complaints are too weak. The current accountability watchdogs, such as community health councils, do not have observer rights to all NHS bodies; they are often poorly trained and their members are on occasion de-motivated; and they have no systematic access to legal advice. The former Secretary of State for Health, Mr Dobson, acknowledged that the current NHS complaints procedures were inadequate. He stated:The present system is really a bit of a shambles … and at the end of it none of the people concerned is satisfied".That very much echoes what the noble Lord, Lord Harris, had to say on the matter. The health ombudsman, for instance, can only make recommendations based on individual cases and cannot enforce any course of action. All in all, the commission rightly concludes that there is no framework of accountability within which complaints can be dealt with.
Generally, the conclusion of the commission and its chairman is that the NHS is the,least accountable of Britain's major institutions,and that as a result,we fear that there is a trust gap opening up between the public and the NHS".That is not surprising, since all power is now increasingly held at the centre of the NHS, whether this is over budgets, including the modernisation fund, or the priorities to be followed by the NHS.
Yet by its very nature, despite the growth of external audit bodies, the centre has not been able to avoid cases such as those of Shipman and Rodney Ledward, or the Bristol case. It is clear that the NHS cannot be effectively controlled from the centre.
The report's central proposal is to improve openness and accountability through a constitution for the NHS, creating operational independence and moving away from day-to-day ministerial control. Under the model proposed by the commission, the NHS would become an independent institution and would be charged with carrying out government policies within the resources allocated. The report rightly cites the huge advantage of being able to debate with government in a "process of open negotiation", with wide consultation and informed public debate. It responds to the fact that we now have a much more questioning culture.
It is debatable whether the new body should take the form of an executive agency—such agencies have not hitherto been noticeably independent—or a body such as the BBC or the Bank of England, with its own accountable boards. The second principal recommendation is that health authorities should be made more democratic and that direct elections to them should be held. However, like my noble friend Lord Shutt of Greetland, I query whether that would be the best way of giving local government 1457 responsibility. I believe that a better model would be to give local government responsibility for a combined health and social services remit. Whatever the precise model—and we clearly need to debate these models—more local democracy will be popular. In a poll carried out by the commission, 75 per cent of those questioned were in favour of elected or partially elected local boards.
Precedents for the constitutional reform of major institutions have already been set by this Government. Both the Bank of England and the Competition Commission have been given more constitutional independence. The advantages are clear: greater transparency around resourced allocation, making it easier to determine where the true problems lie. The Government would be forced to make difficult and potentially unpopular policy decisions about the future direction of the NHS without resorting to "behind closed doors" management. By re-establishing trust and increasing the transparency with which new funds are used, the constitution could well serve to legitimise increased taxation as a means to fund the NHS.
Other reforms are suggested by the commission. All need debate, and many are extremely valuable suggestions. As regards regional government, what a missed opportunity the setting up of the GLA was. I entirely agree with the noble Lord, Lord Harris. Regional government on an elected basis should be responsible for strategic development of the health services in the regions. We need also, as suggested by the commission, to consider getting rid of the contracting approach. That would obviously have major consequences for structures.
The one downside is the question of timing. How much more change can the NHS stand in the short term? Could we really get rid of PCGs at this stage, for instance? Above all, as the noble Lord, Lord Harris, underlined, we need to redress the balance of power in the NHS between patients and managers and professionals. The Government are clearly going the wrong way in combining the job of the NHS chief executive with the role of Permanent Secretary at the Department of Health.
It is not all gloom and doom. We very much welcome devolution to Scotland, Wales and Northern Ireland. There is also the requirement that health authority members should be locally resident. I very much hope, therefore, that the Minister will reassure us that the Government will consider the report seriously and not plunge into further centralisation without being absolutely sure that that is right for the NHS. Indeed, I hope that they will now start to take on board some of the principles and policies advocated by this excellent report and include them in their national plan, which is due to be published in July.
§ 8.15 p.m.
§ Earl Howe
My Lords, following the excellent introduction by the noble Lord, Lord Harris, and after two distinguished maiden speeches, we can say with 1458 more than our usual degree of warmth how grateful we are to the noble Lord for having tabled this Unstarred Question. It is a fascinating and important subject, and one that deserves more time than the cramped confines of the dinner hour to be considered properly. However, whenever I read that a spokesman for the Department of Health has welcomed something or other as a "useful contribution to the debate", I know that an icy blast is likely to follow from the same quarter. It would be surprising if the challenge from Mr Hutton's commission is one that the Government wish to seize with both hands and run with enthusiastically. But I hope at least that the Minister's criticisms, if criticisms he has, will be constructive in character.
This is a report with a great deal of substance. Its starting-point is to seek ways of putting the patient at the heart of the NHS. It sets about this by posing the question of how well the NHS pursues the public interest, not in terms of its clinical outcomes but rather in terms of its responsiveness and accountability to the public. On those counts, the conclusion it reaches is that the NHS falls badly short of the ideal. The governance of the health service is becoming increasingly centralist; and that is watering down and weakening the ability of the patient to obtain redress for a grievance or even to understand the basis for managerial decisions. The system is opaque and seemingly impenetrable. Worse still, it is sometimes obstructive to the interests of natural justice. The central theme of the commission, in other words, is greater empowerment of the patient.
That is a theme that should resonate with all of us. If you were to tell the most experienced graduate of Harvard Business School that his next job was to be the manager of an organisation consisting of 1 million employees, I suspect that he would tell you straight away that it was beyond him. Yet this task is exactly what is currently demanded of the NHS Executive. The difficulty is compounded by the way in which Ministers choose to involve themselves in the minutiae of health service planning. Nye Bevan's prediction of Ministers being answerable for every dropped bedpan is not far from being a reality. The consequence of this centralisation is a weekly avalanche of paper descending on hospital trusts and health authorities in the form of directions, guidance, targets and new requirements.
One hopes that even Ministers are capable of stepping back slightly and acknowledging that somewhere the plot has been lost. That is not to say, any more than does Will Hutton, that the Secretary of State's answerability to Parliament should be done away with or seen as irrelevant. That would be equally absurd. In fact, contrary to Will Hutton, I believe that the Secretary of State should remain answerable to Parliament on the large political issues such as public health policy, standards and quality of care and the budgetary settlement for the health service. But it is 1459 ridiculous to expect government Ministers to micro-manage the NHS. The aim of government should be to devolve decision-making about the allocation of resources to a point as close to patient care as possible and thereby ensure that the data underpinning those decisions are sensitive to local needs.
Of course, there is also a need for strategic co-ordination; and there is a legitimate debate to be had about how that strategic dimension is achieved and about the balance to be struck between local autonomy and direction from above. It is the policy of the Conservative Party to redefine the relationship between politicians and the management of the health service. The risk of imposing too many political priorities on the NHS from Whitehall is that patients are treated as averages rather than individuals. Our view is that clinical priorities, not political interference, should govern the way in which the health service is managed.
The way forward suggested by Will Hutton's commission is that the NHS should become an independent public corporation with its own constitution, fulfilling government policies within its budget, but essentially free from the shackles of the Department of Health. In a week when the Government have announced that the successor to Alan Langlands as NHS Chief Executive is to be the Permanent Secretary of the Department of Health, I cannot imagine that the idea of independence for the NHS has found any favour whatever with Ministers. Indeed, we witness in that decision a still greater politicisation of the NHS than we have been used to, even by the standards of this Government. But the need for greater transparency in the NHS, which Will Hutton rightly identifies, is no less powerful.
The commission's view is that a written constitution for the NHS will solve the accountability deficit at a stroke. I am open-minded about this idea, but I have yet to be convinced by it. It seems to me that a codification of the principles by which the NHS should function may be a useful tool, but it will not of itself deliver the benefits that the commission identifies. I agree with the noble Lord, Lord Harris, that it also appears to remove too much accountability from the Secretary of State.
There is another deeper problem for me, which is that the sort of patient empowerment to which these proposals are meant to lead is a negative kind of empowerment: redress of grievance, more effective processing of complaints, guarantees of rights and so on. Those, in my view, are secondary to the kind of empowerment that really matters for most people, which is the ability to receive the best and most appropriate treatment when they are ill.
The one obvious word missing from the commission's report is "choice". The rigidities introduced into the NHS by the Government's recent reforms have reduced patient choice. This in turn has reduced the incentives for poorly performing hospital trusts to do better. But that is a debate for another occasion. I look forward with more than the usual interest to hearing what the Minister has to say.
§ 8.22 p.m.
§ Lord Hunt of Kings Heath
My Lords, this has been an extremely interesting debate. I start by thanking my noble friend Lord Harris of Haringey for instituting it. He was a very distinguished leader of the Association of Community Health Councils for England and Wales. I applaud the courage that he and the organisation showed in commissioning Will Hutton and his commission to undertake this import ant work.
I also pay tribute to both our maiden speakers, the noble Baroness, Lady Northover, and the noble Lord, Lord Shutt of Greetland, both of whom made extremely effective maiden speeches, drawing on wide experience in the public service. I very much hope that we shall see them again in future debates on the National Health Service.
The report produced by Mr. Hutton and his colleagues is extremely interesting and stimulating, and indeed a good read. My noble friend Lord Harris tried to anticipate what I would say. Only the leader of a local authority could come out with town hall "bureaucratese" like that. We are far more enlightened in the Department of Health. This will not be kicked into the long grass. It is a very important report. The national plan is due to be published within the next four to six weeks. That cannot be described as being kicked into the long grass. Indeed, we have been criticised by many for the speed with which we shall produce the plan.
We recognise the key importance of many of the issues discussed in the report and debated today by noble Lords. Improving patient and public empowerment within the NHS in its broadest sense is at the very heart of what we are seeking to do with the NHS and the national plan. I assure noble Lords that we shall look very seriously at the issues in the report and in our debate tonight—and not simply in relation to the future role of community health councils. The wider issues of patient involvement and accountability are also being considered.
Tonight's debate goes back to the origins of the National Health Service in 1948. My noble friend Lord Harris and the noble Baroness, Lady Northover, made that point clearly. It was in the post-war Labour Government that Morrison argued for the health service to be run by local authorities. Bevan argued that that would produce a patchy, second-rate service, and Bevan won the argument. In a sense, that tension is still at the heart of our debate. I believe it would also be true to say that for much of its 52 years, at least until May 1997, the NHS found that tension a considerable challenge. Certainly, the Government in 2000, as in 1948, believe passionately in equal opportunity for all. That is why we created, and continue to support, a national NHS, where accountability runs upward to the relevant Secretary of State and thence to Parliament.
I believe that such a central line of accountability provides a clear national focus for the service. As a Minister, I certainly feel accountable to this House for the activities of the NHS. Alongside that, when we look at the impact of the Public Accounts Committee 1461 and the role of the National Audit Office, the Audit Commission and the ombudsman, we see that there are endless mechanisms under which that accountability is discharged.
One of the ironies is that, while the 1948 settlement put hundreds of hospitals and other services under one banner, the NHS has never operated according to clear national standards. I agree with the noble Baroness that variations have dogged the NHS since 1948. They were considerably exacerbated by the introduction of the internal market. There is no doubt that there are many unacceptable variations in NHS performance across the country. A recent interim report that the Government published alongside our work on the NHS national plan shows that average waiting times for elective admissions vary between health authorities from two months to over four months; that day case rates for cataract extractions range from under 40 per cent to over 90 per cent; and that emergency hospital readmission rates vary more than tenfold. One of the most striking facts about the health service is that the care and services one receives still depend too much on where one lives.
We have done much to address that matter. The creation of the Commission for Health Improvement and the establishment of the National Institute for Clinical Excellence are designed to remove the situation that we inherited of the "postcode lottery" of wide variations in services. Clearly, there is much more that we have to do. When it is published in July, the national plan will include a commitment to work with doctors, nurses, therapists and managers, and of course with the public, to develop clear national standards so that patients everywhere receive a first-class, consistent service.
It is very much worth making the point that the NHS transcends many of the traditional local barriers and agencies, because the whole point about the NHS is that we are developing, and wish to develop, a seamless approach to services which cuts across primary, secondary, tertiary and highly specialist care. In that context, national accountability is perfectly appropriate.
Both the noble Lord, Lord Clement-Jones, and the noble Earl, Lord Howe, argued against what they described as over-centralisation. The noble Earl talked about increased centralisation and the noble Lord argued for more local democracy. However, in two years, both as a Minister and a Whip, I have had the pleasure of listening to the many contributions of both the noble Earl and the noble Lord. Local decentralisation has not particularly been a theme of what they have put before the House. How many amendments have they put forward in relation to the powers of health authorities and local authorities where the Bill states "may" and they have wanted "shall"?
§ Lord Clement-Jones
My Lords, perhaps I may intervene, having been provoked by the Minister. The noble Lord will remember an amendment we put 1462 forward for merging responsibility for health and social services in the Health Bill. That is a commitment to local democracy.
§ Lord Hunt of Kings Heath
My Lords, as regards the arguments put forward on such Bills, if we were to amend in that way it would so constrain the role of local authorities that they would hardly consider the position democratic. How many times has the noble Lord argued that "guidance" should be statutory guidance? I do not seek to make a political point. I simply seek to show that most of the pressures on Government in relation to the National Health Service are to ensure national consistency and high standards of services. That is what we wish to achieve: national consistency, national standards and a National Health Service. However, within that—I agree with many of the contributions made—we have to allow space at local level for people to innovate and lead change.
While I do not think that we should alter the fundamental principle of central accountability, we understand that as well as modernising the health service we must modernise the decision-making process. We have to open up that decision-making process at national and local level. We have to involve the public in decisions not just about their own care but also about health policy at local level generally. The creation of modernisation action teams as part of the national plan allows us to look specifically at how we can better involve patients and the public.
I agree with my noble friend Lord Harris about the need to avoid paternalism and to listen seriously. The right reverend Prelate the Bishop of Birmingham explained one of the new innovative techniques which can be used in trying to reach consensus at local level about a major change in services. Clearly, we have to do more.
The noble Baroness, Lady Northover, mentioned complaints. We have commissioned an independent evaluation of the complaints procedure. That is now over half way through. It would be premature to begin implementing any changes in advance of the final report of the evaluation team, which we shall consider carefully.
The question of openness was raised. We are committed to openness in the National Health Service. That is why one of the first actions of the Government was an instruction to trust boards to ensure that their meetings were in public. I applaud the activities of CHCs, which have also encouraged a greater degree of openness in the dialogue between themselves and the NHS.
My noble friend Lady Massey raised important points in relation to inequalities in health issues. I believe that Our Healthier Nation, the health improvement programmes, health action zones and the new flexibilities in terms of partnerships between the health service and local government will allow us to address many of these troubling issues.
A study by Ziggi Alexander identified the issue of statistics in relation to the Department of Health. It is a matter we are considering carefully.
1463 The appointment of an NHS chief executive is to ensure that at the centre we have a co-ordinated approach to the way in which we discharge our accountability and manage the National Health Service. Far from creating the centralist impetus that noble Lords fear, it will enable us to get the right leadership at national level which then allows more space for people at the local level to lead change and innovation.
The clock is against me. In relation to community health councils I recognise the extremely important role they have played over 25 years. But there is a widely held belief, not least among the CHCs themselves, that they need to change to bring them up to date with the new, modern NHS. The patient empowerment modernisation action team which is working in relation to the national plan will consider patient empowerment, public involvement and the future role that CHCs might play.
In conclusion, I believe that Will Hutton's report is extremely interesting and stimulating. I can assure the House that it will not be kicked into the long grass. It will he part of the important discussions we are having in relation to empowering the patient and the public. At the end of the day, the Government need to ensure true, equal access to consistent services. I and the Government will continue to argue for the principle of equality and the pursuit of national standards just as passionately as Nye Bevan himself did in 1948.