§ Motion made, and Question proposed, That the sitting be now adjourned.—[Jim Fitzpatrick.]9.42 am
§ Ms Julia Drown (South Swindon)
Thank you, Mr. Cook, and a happy new year to you and everybody. Thank you, in particular, for coming to rescue us today by taking the Chair. It is regrettable that we are starting 13 minutes late. I know that many hon. Members want to speak and so would like the debate to go on for the full one and a half hours. I will take the matter up with Mr. Speaker.
The Government have done much that is good in the NHS. There has been major investment and change such as nurse prescribing, the national service frameworks and the National Institute for Clinical Excellence. In Swindon we have a new hospital and a walk-in centre, and NHS dentistry has returned. Before Christmas a diagnostic and treatment centre on our new hospital site was approved. We would not have seen those improvements under the Tories. There is no question of the Government's commitment to creating an NHS of which we can all be proud. I, as a supporter of the Government's NHS agenda, and a Co-operative party member, am keen to look at the Government's proposals on foundation hospitals. However, I am not convinced that it is the right reform or the right time for reform.
The Government are aware that there are problems with organisational change. They describe the changes already taking place in the NHS as the biggest organisational change since it was set up. When much of that has hardly settled, more reform needs to be considered with great caution. The NHS plan is hugely ambitious; my constituents in Swindon want the maximum waiting time of six months by 2005 for all in-patients to be delivered sooner than that. It will be a massive improvement on what we experienced under the Tories. If the Government believe that more can be done for the NHS, delivering quicker and better treatments should be the priority. Will more organisational change best deliver the improvements in patient care? It is boring to keep existing targets and it may not create news headlines, but is not what is wanted a determination to deliver what patients need?
I want to deal first with some of the Government's reasons for proposing the introduction of foundation hospitals. The first motivation described by Ministers is the need to give incentives to the best trusts; I have dealt with some of them for many years and they have not cried out for incentives. There is no better incentive than delivering the best service possible for patients and spreading good practice elsewhere in the NHS.
The second motivation cited by Ministers is that the creation of foundation hospitals will stop the Tories privatising the NHS. That is a good motivation, but the 2WH Government do not need defensive policies; if the Tories were determined to privatise, although it is true that proposed legislation for foundation trusts would prevent privatisation, they could do so.
§ Mr. Simon Burns (West Chelmsford)
May I say categorically that the Conservative party never has had and does not have any intention whatever of privatising the national health service?
§ Ms Drown
I am pleased to hear the hon. Gentleman say that, but many statements from the Tory party give one severe doubts. However, my point is that if a future Tory Government wanted to do so, we could not stop them pushing through legislation to allow trusts to be privatised. It is not as if they do not have experience of getting unpopular privatisations through the House.
The NHS is all about care services, but not just for the best hospitals. Why did the Government come up with the idea of foundation hospitals just by talking to the best and not consulting the middle and the worst hospitals, MPs, GPs, social services and others?
A third motivation is that Ministers say that everything cannot be run from Whitehall, but that leads to a strange feature of these proposals. If the organisational changes are needed to improve the efficiency of some hospitals to allow initiative and flair to be shown, why are not the same changes being made in all hospitals? The fact that foundation hospitals are proposed initially for three-star hospitals only, brings me to the first major concern, which is that they could be divisive—why only three-star and not zero-star hospitals? If the proposal is to work, it needs to work in all trusts and we cannot expect three-star hospitals always to stay as such. We assume that Nigel Crisp, chief executive of the NHS, is good at his job. From 1993 to 1997 he was chief executive of what is now the Oxford Radcliffe, which one would expect to have been a top performing hospital, but only five years later it is a one-star trust. Good trusts can turn out not to be so good.
Paragraph 4.1 of "A Guide to NHS Foundation Trusts" states that foundation trusts will not be subject to performance management by the Department of Health or strategic health authorities, but will be held to account by the commissioning process. We must ask by what levers; if a hospital is not performing, commissioners can threaten to move patients elsewhere, or actually move them, but that is not necessarily the best solution. Should not the Government allow themselves the ability to step in and support change management in foundation trusts, as they do in others? In some cases, it will be the quickest and most efficient way of turning a trust around. If the Government think that the commissioning process alone is the best way of achieving the changes needed, there is even more reason to say that all trusts should be foundation trusts, not just the three-star ones.
The Government say that hospitals must have a track record to deliver on foundation status. They say that there will be no cap on the number of foundation trusts, but it is not clear whether that means that all trusts will be able at some point to become three-star trusts and therefore foundation trusts, or whether the Government will, in the next round or a future round, allow two-star trusts to become foundation trusts. It would be helpful if that were clarified.
3WH If public involvement helps to deliver faster improvements in patient services, surely it is even more important that the public are involved in zero-star hospitals than in those with three stars. The Government say that they cannot give those freedoms to poorly performing trusts, but ownership and freedoms are different. The one-star trusts could be given ownership, with the promise of freedoms when standards improve. That would be less divisive.
The logic of the Government's argument that not everything can be run from Whitehall is that the giving of more freedoms should apply to all. If enterprising managers and clinicians are prevented from doing good work, that will happen in three-star and zero-star hospitals, and in community services. Would it not be better to pilot for all the giving of freedoms from directives and then to widen those freedoms, rather than giving many freedoms to some? Should there not be help for the many, not the few? In any case, there are well and badly managed departments in all trusts. A simple one-star or three-star rating hides many variations within hospitals. Should not the good parts in all hospitals be rewarded?
Let us consider how the policy fits in with the new patients voice mechanisms. Foundation trusts will not have to set up their own patients forums. That suggests that the Government think that that type of central direction from Whitehall should be avoided, but they introduced that initiative only recently. I remember my hon. Friend the Minister ably defending the new systems at the Dispatch Box. She secured agreement to many of the changes in a way that many others would not have achieved, but if the new ways of involving patients are not necessarily right for all trusts, why was that not said at the time?
One of the freedoms proposed for foundation trusts is the freedom to pay additional rewards on top of national agreements. That could be hugely divisive and is understandably opposed by unions. Will it be reconsidered? The Tories tried to set up local pay to set one hospital against another; this Government cannot want to recreate that.
The Royal College of Nursing points out that such a system is wasteful in terms of bureaucracy, as local trusts have to have hyped-up human resource managers to negotiate individually with trade unions, and staff representatives have to spend time negotiating, rather than caring for patients. I remember the newspaper articles of 1996 saying that specialist nursing and therapeutic staff had to take time away from patients to negotiate pay deals. Recreating that system sounds illogical when a major new national pay agreement has just been announced.
Ministers will say that protections will be built in to ensure that foundation trusts do not undermine the ability of other NHS trusts to meet their obligations to provide NHS services. I take that to mean that the Government do not want foundation trusts to pinch staff from their neighbours, but how strong will the protections be? Will the neighbouring trusts have to sign off any pay differentials from the nationally agreed "Agenda for Change" deals? If the Government are 4WH serious about fairness in pay, should not the neighbouring trusts have the power to do so? I hope that the Minister will say exactly what is intended.
The next freedom for foundation trusts is the freedom to borrow, but from within the overall NHS capital allocation as agreed with the Treasury. The overall capital allocation for the NHS will be divided into two: a foundation pot and a pot for other trusts. However, we know that the Government want foundation trusts to succeed, so a suspicion will be created that such trusts will be given an unfair proportion of NHS capital in a way that does not put clinical needs first. Will there be a safeguard against that, such as an agreement on the allocation by Parliament rather than by Ministers? Given that any private borrowing for foundation trusts is counted against the same capital pot, that could lead to private money replacing NHS capital with no added gain for the NHS.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
Is my hon. Friend aware that in transport we have already seen what happens in exactly those circumstances? If private firms are brought in, they bring with them consultants and enormous overhead costs, and the money goes into totally unnecessary contractual deals, rather than into good services.
§ Ms Drown
I thank my hon. Friend for her intervention. I am well aware of those concerns. It is important to learn lessons from other Departments so that we get the best as government policy is developed. I am sure that Ministers do not intend private capital simply to replace NHS capital, but will the Minister confirm that? If all borrowed capital comes from a fixed NHS pot, how will the Government ensure that that does not enable the Treasury to save on NHS capital?
Paragraph 1.32 of "A Guide to NHS Foundation Trusts" says:Subject to an overall duty to achieve value for money…capital schemes will not be subject to individual project by project approval by the Independent Regulator".If so, how can the Government be sure that foundation trusts collectively will keep within their overall capital limit? What does value for money mean in this context? If a trust could borrow at 20 per cent. for a five-year pay-back scheme, could it take the loan even if it was known that NHS funding would produce a better result for the public purse?
Similar arguments can be made about the freedom to keep surpluses and to dispose of assets, so why should foundation trusts be given more freedom to keep surpluses when clinical need might dictate that other trusts need those surpluses more? What if a local commissioner would prefer a neighbouring trust, rather than the foundation trust, to keep its surplus?
Foundation trusts' freedom to invest is also bureaucratic. It means that finance directors are rewarded for extra responsibilities, but then have to get extra advice on investment. Surely that is not a good use of time? Rather than hundreds of finance staff investing small sums of money throughout the country, it would be better to leave surplus funds with the Chancellor of the Exchequer for him to look after until they were needed. A fundamental problem with creating different rules for different trusts on pay, keeping surpluses and 5WH the ability to invest is that the effect is divisive, impacts on morale throughout the NHS and ultimately sets hospital against hospital.
I hope that the Minister will tell us about the other freedoms that the Government propose to give to the foundation trusts, which will be subject to the same standards and inspections and will still have to supply information centrally so that parliamentary questions can be asked and health committee analysis carried out. They will still have to adopt all the central strategies, such as those on information and sexual health, although the Minister may tell us that that is not the case. What will be the position of foundation trusts on the medical royal college recommendations, which sometimes delay or prevent recruitment for medical posts and seem to be an unnecessary barrier to expanding services? The proposal will be welcome if such a barrier can be removed, but that should be done for all trusts.
Will foundation trusts have to adopt policies such as family-friendly policies and zero tolerance of violence towards staff? Will maternity services have to provide women with the ability to choose where to give birth, and will the collection of maternity data have to be improved? Will the foundation trusts have to adopt catering standards such as providing halal meat, or comply with safety directives such as on the use of disposable instruments? I presume that they will have to follow all the standard directives, so which of the usual policies and directives will foundation trusts be free to vary or ignore? It would help our debates if the Minister clarified what those freedoms will be; answers given today could inform the debate to be held tomorrow on the Floor of the House.
However, the proposals include one major restriction alongside all these freedoms. Unlike many Members on the left, I support the treatment of private patients in NHS facilities. It is clear that in many trusts the treatment of private patients in NHS rather than private hospitals generates significant income for the NHS, which improves NHS care. Restricting the proportion of income from private patients to within existing limits will be a major disincentive for trusts to become foundation hospitals. Specifying a rigid limit on the proportion of private work could create extra problems for some hospitals.
I invite hon. Members to imagine a trust having its NHS income cut because a commissioner is moving work elsewhere. It would have to make a corresponding cut in its private patient income at a point when it is under pressure to cut budgets to make up for the lost NHS income to keep within the limit of private patient income as a proportion of total income. That would put further pressure on its budgets and would require it to create a fair system to decide which consultants have to cut back on which work. What purpose is served by this additional restriction on foundation trusts? This all seems a long way from a pragmatic, undogmatic approach to "public good, private bad". I thought that the Government were committed to pragmatic local decisions in the interests of NHS care.
It is interesting that the Under-Secretary of State for Health is leading the debate today. I suspect that she has been selected to speak about this newly emerging policy because she is one of the most eloquent and persuasive Ministers. However, when the logic of public health is to 6WH pursue community initiatives to stress the importance of primary care facilities and partnerships, where it might be easier to justify foundation status, it is odd that the creation of foundation trusts will start with acute and specialist hospitals. Thus the focus will be on acute care, rather than on the real public health goals of the Government's NHS.
§ Mr. David Drew (Stroud)
I concur with my hon. Friend's remarks about our spokesperson on the Front Bench.
Does my hon. Friend agree that, if we seek mutuality in health care, we will need bottom-up rather than top-down solutions? Many of us would be happier if more effort were made in that area.
§ Ms Drown
I certainly agree with that.
I suspect that the Minister will say that fears about a two-tier service are unfounded, because there are already differing standards across the country, and there is currently a multi-tier service. That is true, but that multi-tier service has not been created in legislation. The Government are rightly trying to achieve consistent, high standards across the NHS. Foundation trust legislation would create two different structures for NHS hospitals, and Ministers have made it clear that one is considered to be better than the other. That raises concerns about unnecessary competition and divisiveness in the NHS.
I spoke earlier about the additional bureaucracy that will be created in pay structures. The reorganisation of the trusts and their commissioners involves extra bureaucracy that must be justified, because the time of civil servants and NHS staff could be better spent on other things, such as ensuring that the NHS plan is delivered for my South Swindon constituents as soon as possible.
Government documents show that extra support will be given to foundation trusts to pay for legal help for commissioners, who will have to arrange different contracts for the foundation trusts. We are spending time on the Floor of the House today and tomorrow debating the issue. Can we justify taking that time away from the delivery of quality services across the country? [Interruption.]
I am concerned that there is a bureaucracy creation machine in the Department of Health, a unit that wants change for change's sake, wants to ensure that there is always work for management consultants, and wants to keep the focus on organisational structures rather than on quality patient care. I know that Ministers care about the latter, but I wonder whether the former is getting the better of them. If so, the change for change's sake unit must be found and culled.
Will the Minister clarify the areas on which the commissioners will be negotiating with foundation trusts? Paragraph 1.34 of "A Guide to NHS Foundation Trusts" states that there will be longer-term, legally binding service agreements. I would like to know what period those agreements will be longer than, and what would happen if the commissioner did not want a longer-term agreement.
Finally, let us examine the response to the Government's proposals. I am sure that a number of trusts will be keen to take up this Government challenge. 7WH I am delighted that 40 per cent. of the three-star trusts are in deprived areas. However, the creation of foundation trust status only for three-star hospitals does not help my constituents in Swindon, whether or not they live in a deprived area. The Government may say that the new freedoms will give us an incentive to improve in Swindon, but we do not need further incentives. Swindon's NHS is full of hard-working individuals who want to improve patient services.
The NHS Confederation, representing the managers' point of view, is concerned that decentralisation for the few could detract from the more important task of decentralisation for all, and that the proposals will move the focus away from acute care. The Labour party reaction is cold. The RCN is hinting, politely, that it is against the proposals, and the British Medical Association has raised many of the concerns that I have discussed today. There appears to be no support for the pay proposals.
I hope that the Minister can answer the questions that I have posed. There is much good in what Labour is doing for the NHS—massive investment, sensible reforms and a willingness to take the tough decisions that are sometimes needed. However, there is a danger that the reforms will be a major distraction from the main work of delivering the NHS plan. It would be easy for the Government to obtain consensus in Parliament and across the NHS on reducing control of the NHS by Whitehall. Why not make the reforms focus on more freedom for all, not just for the few?
§ Mr. Frank Cook (in the Chair)
Order. First, I thank the Committee for treating my embarrassment over the mobile phone with such good humour. Clearly, I had failed to depress the button for the required two seconds: I am sorry. Secondly, the Committee will have noted my entry with a stick. Had I known that we were to debate foundation hospitals, I would have used crutches; my theatrical entrance was not intentional.
On a serious point, we have lost 13 minutes of debating time. Thanks to both Opposition spokesmen, who have agreed to cut their contributions by half, I am able to make an extraordinary rule to extend the debate by five minutes at the end, which could mean problems for subsequent debates. I therefore appeal to all right hon. and hon. Members to restrict comments to what is necessary, to avoid repetition, to make interventions in a sparing fashion and to conduct the debate in the constructive manner in which it has commenced. Only some of the hon. Members present have given me prior knowledge of their intention to contribute. For the moment, I call Mr. Lansley.
§ 10.5 am
§ Mr. Andrew Lansley (South Cambridgeshire)
I am grateful for the opportunity to contribute and I congratulate the hon. Member for South Swindon (Ms Drown) on securing the debate. As suggested by the choice of Opposition debate in the House tomorrow, the subject is timely. We all agree that it is important to debate this crucial subject early in the new year before legislation is introduced.
8WH I represent two hospitals in South Cambridgeshire—Addenbrooke's, twice judged a three-star hospital in the performance ratings, and Papworth, a specialist cardio-thoracic trust. Specialist hospitals have been subject to the performance scheme only once and Papworth was given a three-star rating. The Commission for Health Improvement gave Papworth the highest rating of any hospital and singled out its excellent corporate and clinical governance.
By contrast with the constituents of the hon. Member for South Swindon, mine can see directly where the benefits lie if foundation hospitals, starting from a high base, deliver substantial increases in capacity and higher standards. My purpose is not to ask questions with a view to damning foundation hospitals with faint praise, but to make some points to ensure that foundation hospital policy works in the long as well as the short term.
I agree with the hon. Lady that it is not all about two-tier status. The NHS has different tiers, but the real question is how best to increase capacity and raise standards. Should it be done by moving everyone at the same pace, or should we accept that different hospitals have different attributes and that those with the strongest corporate and clinical governance should be given the first chance to introduce new approaches?
Several hon. Members may have been present at my Westminster Hall debate on nurses' pay two months ago. Taking Addenbrooke's as an example, I know that "Agenda for Change" is much sought after as a means of increasing pay flexibility and offering opportunities to adapt pay to labour market circumstances and the changing needs of the health service. Addenbrooke's wants to implement such a policy as early as possible.
I am not going to dwell on membership and the ownership of foundation hospitals. The issues are complicated. I certainly hope that good hospitals such as Addenbrooke's and Papworth, which already involve patient groups and the local community, will be able to do so more extensively under the new arrangements—but without excessive burdens. Some risks are associated with mutualisation, which could lead to substantial additional burdens.
It seems to me that the key issue is what the freedoms of foundation hospitals mean. Are they real and an end in themselves, or a means to an end? I submit that they are not real, that they should be extended over time and that they are not an end in themselves but a means to an end. We need to be aware of the end and to be able to adapt the whole system of foundation hospitals beyond the initial extension of freedoms from some bureaucratic controls.
I confess that, like the hon. Member for South Swindon, I am not sure how real the freedoms are. The establishment of an independent regulator is a new structure, but one that seems substantially to translate many of the controls that the Secretary of State might exercise over foundation hospitals into a different set of hands. The commission for healthcare audit and inspection, when it is established, will have similar controls. Complying with national clinical and quality standards does not give people in the hospitals that I represent any concern, but it does not necessarily mean bureaucratic reductions as a consequence. The control 9WH of private services is a new control, and I suspect that the freedom to borrow, to which I will return in a moment, is a little more rhetorical than real.
The freedoms are not as great as they should be and could be made greater. I will not make a long series of points about that, but it is important that we do not see the NHS in isolation. We should look beyond it to what our experience tells us about the process of trying to stimulate enterprise in what have hitherto been monopoly services. Although we do not necessarily have to break up organisations to make them compete among themselves, by translating bureaucratic, Government and political control to independent regulation, as we have observed in other industries, we can achieve that aim if the independent regulator—whoever he or she may be—has a clear set of duties that point to stimulating enterprise and allowing freedoms to emerge over time. Experience of other fields of activity demonstrates that if the independent regulator is focused not on compliance but on standards, independent regulation outside political control with predictable, consistent decision taking that is transparent to those who are regulated can offer substantial benefits.
§ Mrs. Dunwoody
Am I to take it that the hon. Gentleman would like to recreate within the NHS the high standard of organisation and service that we find in the railway industry?
§ Mr. Lansley
The hon. Lady does not tempt me to speak about the transport industry; I want to speak about the NHS. My experience is less of transport than of other industries such as energy and telecommunications. My trade and industry background takes me in that direction.
§ Mr. Lansley
I will not go down that route at length, but I can tell the hon. Lady that, in my experience, at different times in different industries the transfer from national ownership with direct control and intervention over matters such as borrowing to independent regulation where free companies are in a position to attract private capital in a more predictable structure of regulation has clearly been of benefit. It has allowed enterprising companies to deliver better services and greater capacity. The telecommunications industry in this country was transformed after 1984 as a consequence of telecommunications regulation as opposed to national ownership. I will not go further down that path.
My point is that the freedoms should be regarded as a starting point. When the Bill is published, the key issue for me will be the independent regulator's duties and whether they are structured in a way that drives towards the stated purposes and allows the independent regulator, if the foundation hospitals create and maintain high standards and improve on them, to progressively reduce bureaucratic compliance requirements. That is the issue, but the change is not an end in itself, as it concerns capacity. It seems to me that the foundation hospital structure is being created around the current necessity to build new capacity, rather than an attempt to create competition in the 10WH NHS. That is fine at the moment. We cannot create competition in a structure where demand substantially exceeds supply in most circumstances.
§ Angela Eagle (Wallasey)
Does the hon. Gentleman then believe that the way forward for the NHS is more competition under a market-style mechanism?
§ Mr. Lansley
All right, I will answer it. In the long run, the way forward for the NHS is to deliver social enterprise. That will happen where enterprising providers are allied to a system directed not by monopoly purchasers, but by patient choice. That does not necessarily mean a market, and it certainly does not mean privatisation. [Laughter.] If the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) will forgive me, I will explain, but briefly because other hon. Members want to speak.
I want NHS funding to be allied to NHS standards of service, which providers will have to meet, and I want patient choice and enterprising providers to be brought together. Developments will need to be handled properly, and much more needs to be clearly set out, but foundation hospitals are developing in a way that will allow providers that get the private sector behind them to add capacity and be more enterprising.
At the same time, however, we still have monopoly purchasers, and we must think harder and more long term about that. If we merely end up with local primary care trusts making five-year agreements with monopoly purchasers in their area, what opportunity will there be to exercise patient choice? What opportunity will enterprising providers have to vary what they provide? Local communities will be told that they own the hospitals, but what opportunity will they have to vary provision?
The issue is how we introduce patient choice into the system. If we introduce it alongside a diversity of providers who have the freedom to take an enterprising and innovative approach, we can create an NHS that not only adds capacity, but improves standards. That relationship between choice on the part of patients and enterprise on the part of providers will deliver higher standards.
§ Mr. Frank Cook (in the Chair)
Order. Five hon. Members are seeking to catch my eye. There are only 28 minutes until I must call the Opposition Front-Bench spokespeople to begin their winding-up speeches. I therefore appeal to every hon. Member to make their remarks concise and pertinent.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
Mr. Cook, I shall be extremely brief. I had intended to go on at considerable length, because foundation hospitals are probably one of the worst ideas that the Government have come up with, and that inspires an articulate response in me.
11WH We should congratulate my hon. Friend the Member for South Swindon (Ms Drown) on setting out, in considerable detail and very concisely, the objections to foundation hospitals. I hope that the Government will think again. My hon. Friend thinks that a unit somewhere in the Department may be eternally looking for change, but I think that the problem is worse than that. Why do the Government persist with this bizarre idea when they are faced with the appalling example of what is happening in the transport industry, where services work only if they are planned in a proper and co-ordinated way? One can only assume that someone somewhere has a quite disastrous commitment to encouraging private medicine in this country. The Government are talking not only about attracting long-term private sector schemes but about planning to put out to tender only to certain foreign companies services that must remain in the NHS.
I want to say just one thing this morning. I originally came into contact with the NHS through my family 30 years ago, when there was a real division between teaching hospitals, specialist hospitals and district general hospitals. The level of care is now infinitely better, and the quality of services is nothing like what we could have envisaged 30 years ago. None the less, we consistently run the service down and say that it is poor and unacceptable. If that is the case, we should not introduce more divisive measures, which is what the creation of foundation hospitals is. We should not divide one group of staff from another by introducing an absurd bureaucracy that makes each hospital fight for the terms, conditions and wages of its staff. We should not suggest that there is somehow a halfway house between private medicine and the national health service, such that foundation hospitals will not be able to earn so much money that they will in effect be fully privatised units.
We should also say strongly that the people of this country do not want large surgical factories, which push them through and out the other side, like so many sausages. People do not want a system in which some hospitals can attract staff, money, investment and support, while the others are allowed to sink into a mire of disillusion and abandonment. Very simply, they want high-quality diagnostic centres that provide high-quality services. People want involvement with their local community, but do not think that that is provided by the old-style, local committees that I remember from my youth, on to which anyone with a title was allowed, whereas anyone who had been locally elected was regarded as a totally unacceptable candidate.
People want a national health service for which new forms of development are considered, but not those that entail division, an absurd bureaucracy, or contract procedures that require management consultants, hangers-on, accountants or anyone who happens to come along. In the transport industry, one can see what that means, in terms of expenditure, inadequacy and poor services for the public. At some point, I shall make a long speech on foundation hospitals, but this morning I am grateful that we are beginning the debate.
I do not know who in the Government is pushing private medicine and relationships with private firms abroad, or who thinks that we have anything to learn 12WH from private, American medical centres, but such people need to be disabused. There are some things that the ordinary member of the Labour party will not accept: such proposals are pretty high up the list.
§ Mr. David Tredinnick (Bosworth)
I congratulate the hon. Member for South Swindon (Ms Drown) on securing the first debate of the new year. It is interesting to have the year rung in, as it were, by mobile telephones, Mr. Cook.
The debate started somewhat tardily. In the spirit of keeping my remarks short, I shall skip most of my speech and start where it says, "I shall return to governance". I intended to say that I supported some of the measures, although we shall have to take a radical look at how services are provided in the new hospitals, if they proceed. In particular, I draw hon. Members' attention to the fact that the Government's guidelines stress that local stakeholders should be givenreal opportunities to influence the overall stewardship of the Trust and its strategic development.One in five people in this country now use complementary and alternative medical—[HON. MEMBERS: "Ah."] Yes, it is predictable that I should raise that subject. I accept that point. If there is to be more local input and less top-down management, it is inevitable that more people on those boards are going to demand such services.
The thrust of my argument is to say to the Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), that it now behoves the Government to develop a strategy that will enable foundation hospitals to deploy more effectively many of the therapies that can not only reduce the bill of the health service but give doctors greater freedom, give patients better services, and build on some of the work that has already been done, not least by the Minister of State, Department of Health, the right hon. Member for Barrow and Furness (Mr. Hutton). He uses complementary medicine himself and has recognised the positive contribution made by such therapies. He—I think it is he, unless it is the Minister—has been instrumental in introducing NICE guidelines for next year and setting up the Sheffield study, which is examining how such therapies work.
Ministers like to wax eloquent, sometimes in response to debates that I have initiated, about the King's Fund project, led by Westminster university, to create a network of primary care trusts that will use complementary therapies based on good governance. What they have not mentioned is that the clinical director of the school of integrated health at Westminster university is Dr. David Peters, a distinguished doctor who is also involved in the Marylebone health centre, which has pioneered an integrated health service and published a book for doctors explaining how to integrate complementary therapies into primary care. That practical guide for health professionals was produced by several distinguished doctors, who considered all aspects of how complementary therapies could be integrated.
Perhaps I shall be able to develop my point further in tomorrow's debate, if I am lucky enough to catch the Speaker's eye. However, the fact that there is now a 13WH working model that can be deployed in new hospitals makes the Minister's task so much easier. I encourage her to look at the work being done at Marylebone health centre and to consider ways of applying it in the new foundation hospitals. On that point, I rest my case.
§ Ms Joan Walley (Stoke-on-Trent, North)
I wish you a healthy new year, Mr. Cook, and want to say how pleased I am that this debate is taking place because it gives us the opportunity to flag up issues of importance to Parliament. I am as disappointed as anyone that we have so little time to give the speeches that many of us have prepared. Westminster Hall is rapidly becoming the place where important issues are raised. The Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), knows my constituency well and understands the health inequalities that we face in north Staffordshire. My hon. Friend the Member for South Swindon (Ms Drown) made an authoritative, courageous and fully informed speech, and I ask my hon. Friend the Minister to consider all the issues that she raised because I suspect that, if the truth be known, what she described is mirrored in constituencies around the country.
I appreciate all that the Government have done to improve health care. If improvements are needed anywhere, they are needed in Stoke-on-Trent, North. There are prospects of a new training centre and a new hospital in my constituency, but there is considerable progress to be made following the years of under-investment by Conservative Governments. How do we take forward the huge improvements that we have already seen? I do not believe that foundation hospitals, in precisely the form that has been put to Parliament, are the way forward. On Sunday, I spoke to a constituent who told me about her five-month wait for a cataract out-patient appointment, followed by a further four-month wait, which meant that she decided to spend virtually all her life savings on having the operation done privately and, even then, had only one cataract operated on.
My priority and that of my constituents is to take forward the agenda for change and modernisation and to ensure that we build on the real commitment of all our NHS workers to improve health care in the secondary sector, in our hospitals, in primary care and in services ancillary to medicine. I understand the point that has been made about complementary therapies. We must look to see how improvements in public health and healthier lifestyles, as well as all the Government's attempts to deal with poverty and inequality, can underpin and reinforce the work that is done in hospitals and in the primary care sector. That is where Ministers' priorities should be, whether they are Treasury or Health Ministers. They should be working with PCT staff to ensure that they know what is needed and can cut through red tape and bureaucracy. Mutual ownership should be introduced locally in the way that my hon. Friend the Member for Stroud (Mr. Drew) mentioned, so that we can make progress. Foundation hospitals are not the way forward. I hope that the debate will comfort my hon. Friend the Minister and strengthen her negotiating position in further discussions within the Government.
14WH I am full of praise for the three years' work that has been done in respect of "Agenda for Change". Many hours have been spent in drawing up a new negotiating position for our national health service workers. Speaking as a member of Unison, I do not want to see that work undone or lack of agreement on it because of the Government's position on foundation hospitals. Will the Minister address the points about pay that were made by my hon. Friend the Member for South Swindon? Have the Government considered the possible consequences of equal value claims? Will we really allow foundation trusts to pay whatever rates they want to? How will that link in with the good work of the three-year "Agenda for Change" process, under which, with a few exceptions, negotiated positions have been reached? I look forward to the Minister's response.
§ Linda Gilroy (Plymouth, Sutton)
I congratulate my hon. Friend the Member for South Swindon (Ms Drown), who has brought her long experience to bear on an issue that is of concern to all of us. She mentioned the huge strengths of the NHS, the public support for those who use or might need to use it, the public service commitment of those who work in it and the value to the public purse of that ethos. She also mentioned weaknesses, such as the inequalities that my hon. Friend the Minister and I have to address in our constituencies. A man from the inner-city part of Plymouth, Sutton is likely to die 10 years earlier than a man from the leafy suburbs. She also mentioned the frustrations of dealing with red tape and bureaucracy.
This morning, as this year's chairman of the Co-operative group of MPs, I want to advance the case for the mutual model and to show how, through foundation hospitals, we can build on the strengths and address the weaknesses of the NHS. There is a saying, "Tell me, I'll forget. Show me, I'll remember. Involve me, and I'll understand." My hon. Friend the Member for Stroud (Mr. Drew) mentioned the importance of a bottom-up approach. Mutual models provide frameworks that allow local people to be involved on a much more meaningful scale than they are now. My hon. Friend the Minister has a clear and broad understanding of the track record, strengths and potential of mutual models through her service on the Co-operative Commission. I congratulate her on her contribution to the Mutuo publication "Making Healthcare Mutual—a publicly funded, locally accountable NHS." I hope that she will forgive me if I particularly recommend to those who are less familiar with the development of 21st century mutual models the contribution of Cliff Mills in the third part of the document.
§ Mrs. Dunwoody
Is my hon. Friend aware that recent history shows us that mutual societies are not in any way sacrosanct and can be destroyed by the activities of others?
§ Linda Gilroy
I understand my hon. Friend's point, which I will address in a moment, but I am talking about new 21st century mutual models.
I am sure that my hon. Friend the Minister will draw fully on her experience of the mutual sector through the Co-operative Commission. Will she address four matters in particular? First, new mutuals need special 15WH skills backed up by advice from established mutual societies who know what works and what does not work as regards governance structures and development, elections, elected member training and mentoring. Secondly, will she consider the application of mutual models to organisations that are not success stories? Mutuals have a strong track record in phoenix rescues of failing organisations—both social and business enterprises. Thirdly, will she consider the application of mutual models and principles to other parts of the health community? By doing that in primary and preventive health care, we can empower individuals to play more effective roles in corporate governance. Fourthly, my hon. Friend the Minister is enthusiastic about expert patient schemes, and I hope that she will draw on one of the richest traditions in mutual principle and experience—that is, education—by linking the NHS academy proposals to the experience of the Co-operative college, which has, for instance, developed NVQ 1, 2 and 3-level distance learning packages for housing management.
I look forward to hearing my hon. Friend's response. Her constituency faces many similar challenges in relation to regeneration and inequalities, and no one is better placed to tackle them through the mutual models that I have described.
§ Mr. David Drew (Stroud)
I shall be brief to allow time for the concluding speeches. I congratulate all hon. Members on their presentation of the case, and I want to add a few points. We should be able to move away from the rather sterile debate on whether we should rely on the traditional NHS model or privatise it, because, as my fellow Co-operator just said, there is a different way.
We have considered trusts and acute hospitals in relation to the potential mutualisation of some aspects of health services.
§ Angela Eagle
Does my hon. Friend agree that the most interesting area for developing such an approach is not acute hospitals but primary care trusts?
§ Mr. Drew
I agree entirely. Some in the Co-operative movement have said that we should have started by considering the application of mutual models to PCTs.
It is possible to see in the Government's document some of the principles of co-operation, including the devolution of power and practical models of public service delivery, which is what all Labour Members should be about. For 13 years, I have been involved in a site in my constituency—Standish hospital, which delivers acute facilities in the county of Gloucestershire. It will close in 2004; I shall not reopen the debate on whether it should close. With colleagues, I have recently worked on a mutual solution by which the site could be taken on by a community land trust to provide a different type of health care—not only for the immediate area but for the whole region. I shall approach the Minister and her colleagues in the Department to discuss specific matters such as alternative and complementary care, which was mentioned by the hon. Member for Bosworth (Mr. Tredinnick), diagnostic and treatment centres, intermediate care, and services for older people with behavioural problems.
16WH When an NHS site becomes available it is analysed and evaluated. More often than not it has no potential use in the NHS, so it is put up for sale. I am challenging that in respect of this site. We would like to look at mutual solutions. I hope that the Government are allowing that to happen, rather than coming up with top-down solutions. Let the community see whether new models could be brought forward within the NHS, because the NHS should be the main provider on a site such as that in my constituency. We should also consider how that could—dare I say it—link with the private sector. That is my plea.
I have already said that our spokesperson is a great Co-operator. The debate is in danger of becoming a graveyard, and I hope that we can move away from that and open up opportunities. That will, however, take time. The NHS is not good at considering alternative solutions—that is its greatest weakness. I am beginning to get some interest from the NHS community, but it has been a devil of a job. Many doors have been shut. If I were not a Member of Parliament, they would have been not only shut but bolted and I would be outside the loop for ever and a day.
We must encourage people in the NHS to think about different ways of delivering the service. I intend to introduce a proposal on that in my constituency. I hope that my hon. Friend will take the opportunity to visit us and listen to what we are trying to do. That might provide a better way forward and it might be better than having what I regard as a rather sterile debate.
§ Mr. Frank Cook (in the Chair)
Order. I shall be looking to the Minister to commence the Government's response at five minutes to the hour and conclude by five minutes past. I therefore expect the Opposition Members who wind up to split the time equally.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I am aware of the time issue. This is the first of two Opposition debates on this subject and we will have the opportunity to speak further tomorrow. [HON. MEMBERS: "No thanks to you."] That is the point. One debate has been initiated by a Labour Member and the other by the Conservative party. As we shall see, a curious feature of the direction of the Government and the Conservative party is that there is very little between them.
The Government should take note that senior Back-Bench opposition to the proposals goes beyond the usual suspects. It is, however, reasonable to say that the hon. Member for South Swindon (Ms Drown), whom I congratulate on securing the debate, is not a usual suspect. The hon. Lady has generally been loyal and she is also an experienced finance director. I know that she is a tough negotiator. I found that out when I was on the opposite side of the table to her during talks on junior doctors' hours. Her expertise is respected in many areas of health, including maternity services. The Government should take note of that.
The Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), is not only eloquent but capable of packing that eloquence into 10 minutes, 17WH which is better than some others. I do not have her ability to do that, but I want to respond to the points that were raised by the hon. Member for South Swindon. I apologise to other hon. Members because I will not have a chance to comment on points that they have made in this excellent debate.
The hon. Lady mentioned the Government's motivation for bringing in these measures. First, they want to use financial incentives to improve the NHS. I agree with the hon. Lady that in that they fundamentally misunderstand the motives of NHS workers. Those people do not do their best so that a trust may be more financially successful; they do their best within their professional competence for patients. It is disappointing, to say the least, that the Government take that view. The second motive is, allegedly, to stop the Tories privatising the NHS. The Government and, in this respect, the hon. Member for South Swindon have missed the point. The private provision of NHS services is not the greatest threat to the NHS. No matter who provides it, the NHS stands for a service that is free at the point of delivery, which is paid for through general taxation and is comprehensive, regardless of the ability to pay.
The issue is not whether there are more private or voluntary sector deliverers, or whether there is increased private commissioning and purchasing in the NHS. I disagree with the hon. Member for South Swindon on pay beds in the NHS. Those are more of a threat because they use vital capacity for people who can afford it, rather than for those who cannot. The Conservative party has suggested previously that patients should be charged.
§ Linda Gilroy
Does the hon. Gentleman agree that people's reservations and opposition to privatisation are based also on profits, which go outside of the NHS?
§ Dr. Harris
No, I cannot give way now. The hon. Member for South Swindon said that foundation hospitals would be able to keep the income from land sales. That seems unfair, given that they may be sitting on land in a way that other hospitals are not. Since they did not inherit the land by dint of being managers of a foundation hospital, the income should be shared more equally.
The hon. Lady said that the Government's other motivation was their desire not to run everything from Whitehall, or at least to give the appearance of not doing so. I believe that it is a matter of appearance. She drew attention to several worries, most of which I share. The measures are divisive. The ridiculous star-rating system is not based on sensible clinical outcomes; it often runs contrary to the more reasonable measures of performance such as the in-depth studies undertaken by the Commission for Health Improvement.
18WH The measures are a way in which to create a league table to enable the Government to allocate blame for failures in the health service to those who are at the bottom of the table. As I know from the excellent five-star hospital in my constituency, failure is due not to poor performance or incompetence but to inadequate capacity, the inability of social services to place people and a shortage of nurses. That is why no-star trusts are found in areas where there is a shortage of staff, which delays discharges.
The hon. Lady said that she was concerned about the absence of performance management. However, she can be reassured because the Government are not letting go; foundation hospitals will still be subject to targets. Commissioners will have to commission according to targets and through the Commission for Health Improvement, which is not independent because it must inspect according to the Government's targets.
As for local pay, the Government are seeking to be all things to all people. At the same time as saying that local pay will be flexible, they say nonsensically that there will be no poaching. We have many worries about the proposals. They are based on continued structural change, not real reform. They concentrate too much on the side of the providers rather than commissioning in respect of democratisation. They are divisive and attempt to devolve blame, not freedom.
§ Mr. Simon Burns (West Chelmsford)
I congratulate the hon. Member for South Swindon (Ms Drown) on initiating this important and timely debate. In many ways, it is the hors d'oeuvre for the main banquet tomorrow. In what was an elegant speech, I congratulate the hon. Lady on the clever way in which she walked the neat tightrope between outright rebellion and seemingly constructive criticism of her Government's actions.
It has been fascinating listening to all the contributions to the debate, but particularly those from Labour Members. The illustrious and formidable hon. Member for Crewe and Nantwich (Mrs. Dunwoody) gave an extremely interesting, robust speech. I hope that she will catch Mr. Speaker's eye tomorrow when she will have a greater opportunity to elaborate her views. With one exception, it was noticeable that no Labour Member seemed to support the Government's action. We must bear it in mind that the hon. Member for Plymouth, Sutton (Linda Gilroy) is a Parliamentary Private Secretary in the office of the Deputy Prime Minister, unless she has recently resigned or been replaced.
§ Linda Gilroy
The hon. Gentleman is right, but I am here today in my capacity as the current chair of the strong parliamentary Co-operative group.
§ Mr. Burns
However much the Government have modernised matters in other ways, I assume that the code of conduct for Parliamentary Private Secretaries is the same as under previous Governments and that they are bound by collective responsibility. One would not expect them to criticise their own Government's policies in a debate, because Parliamentary Private Secretaries are linked into that responsibility, as are Ministers.
19WH The Opposition support the general principle of foundation hospitals and the freeing of hospitals within the NHS. However, we have considerable difficulties with the way in which the Government seek to move that agenda forward. We will have a better opportunity tomorrow to analyse the policy in greater detail. We believe that hospital freedom should be a priority because the most important factor within the NHS is to ensure that it thrives to provide the highest and best quality care for patients. I emphasise, so that there can be no misunderstanding or slurs from the Liberal Democrats, that that care must be free at the point of use for patients. That is what I have always supported and will continue to support in my future political career—if I have one.
I part company with the Government on one issue, however. As the hon. Member for South Swindon rightly said, in the early stages—which tend to be rather long—the Government will restrict the opportunity of foundation hospital status to three-star hospitals. That is a significant and fundamental error. It will create a two-tier health system, regardless of what Ministers within the Department of Health may say.
The Government should have been bold. At the Labour party conference last year, the Prime Minister himself said that the Government were best when at their boldest. They are not being bold: they are being timid, which is a weakness. I suspect the reason for that timidity. We must not forget that foundation hospitals are the brainchild of the Prime Minister. However, as always with this Government, a shadow is cast over No. 10 from the neighbour at No. 11.
We know that the Chancellor of the Exchequer is not at all keen on the Prime Minister's big idea or on the Secretary of State for Health's pursuing it. One gets the impression that the Chancellor would like to emasculate the policy at birth. The policy is in the best interests of the NHS and enhanced patient care, but I urge the Government to extend it from the outset to all hospitals. All should have the opportunity to be foundation hospitals, rather than some getting the fast-track treatment because they have three-star status and the vast majority being excluded. That will create a two-tier system.
Time does not allow me to go into the minutiae, but in December the Government published "A Guide to NHS Foundation Trusts", in an attempt to flesh out details of the Government's proposals in the absence of published legislation. The trouble is, as the hon. Member for South Swindon highlighted in a series of relevant questions, that the document raises more questions than it answers. Statements, proposals and ideas in the document directly conflict with what the Secretary of State said in previous statements when announcing the movement forward on foundation hospitals. Due to the time constraints, I cannot reiterate the concerns, conflicts and outstanding questions that require answers, but the hon. Member for South Swindon did so. I hope that the Minister will use the time that she has available to her to treat the debate with the relevance that it deserves, and that she will answer as many of the hon. Lady's questions as possible rather than simply read out a brief, 20WH as I fear that she will, that tells us how wonderful foundation hospitals—as the Government propose them—will be for our health.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I am delighted to respond to the first debate of the new year, which I congratulate my hon. Friend the Member for South Swindon (Ms Drown) on securing. I have never been referred to as an hors d'oeuvre before, but we shall have several opportunities to discuss these important issues both over the next few weeks and when the legislation comes before the House. I am genuinely pleased that we have started that process. My hon. Friend raised a series of important points, and I shall endeavour to reply to as many as I can. However, I can tell every hon. Member who made a contribution that I shall take on board all points that were made as the debate unfolds and the policy develops.
First, I want to set the context of the changes. We all have to acknowledge that we have had the biggest ever increase in investment in the national health service and that improvements are starting to come through on waiting, getting more staff and equipment and reducing deaths due to cancer and coronary heart disease. All those things in the NHS plan, to which my hon. Friend the Member for South Swindon referred, represent an incredibly ambitious programme for this country's health service. All Labour Members have made it clear that they welcome the investment and the changes that are going on, and recognise the contribution made by NHS staff in delivering the improvements. That is the context in which we are introducing foundation trusts and extending new forms of ownership and social enterprise in the health service generally.
My hon. Friends the Members for Stroud (Mr. Drew) and for Plymouth, Sutton (Linda Gilroy) made the important point that the policy is not limited to the acute sector of the NHS. I hope that it will permeate everything that is done in the NHS during the months and years to come. There should be a broad range of providers, and we should encourage enterprise in local communities so that we can provide services that are more responsive and accessible to patients whom we serve.
We must have reform to go with that massive investment if we are to ensure that we get maximum value from every single extra pound that we put in. If the Government ask the public to pay extra money to fund the NHS, it is our responsibility to ensure that the investment has the maximum impact. The public should see increased capacity and a reduction in waiting times. My hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) said that she had talked to a constituent who had had to wait for a cataract operation. The public's top priority is waiting and, therefore, the challenge that we all face is creating extra capacity and new ways of doing things. We must spread modernisation throughout the system so that patients can move through the system more quickly while still receiving high-quality services. The proposed reforms come from a need to increase capacity and treat patients more quickly.
Until 1997, we did not have the kind of national health service that we are trying to create. We talk glibly about the NHS as if it was a national uniform service. 21WH However, most hon. Members recognise that before 1997 the service was a collection of organisations that functioned differently, as my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) said. Since 1997, we have introduced the National Institute of Clinical Excellence, the Commission for Health Improvement, national service frameworks and the NHS plan. My hon. Friend the Member for South Swindon asked whether this was the right time to go forward with further reforms. I absolutely believe that it is, because a series of national standards is in place for the first time, meaning that people up and down the country know that they are all entitled to the same level of service. We have shifted the balance of power, and have given power to the primary care trusts; that will provide security of long-term commissioning. Those are the foundations that had to be put in place, and it is the right time to proceed apace with faster, more radical and deeper reform.
Foundation trusts give us the chance to have the best of both worlds. They give us national standards together with local community-based ownership. That, as my hon. Friend the Member for Stroud says, is a means of getting away from the sterile, polarised and adversarial arguments either that the existing system is good enough or that it is not and there must be outright privatisation. Things do not have to be that way; we can have national standards with local community ownership. That will unleash creativity and innovation within the service and keep a key local connection not just with communities but with the rest of the NHS.
The new foundation trusts will be under a duty of partnership to work with every other part of the NHS, including primary care, social care, and the public health service. The foundation trusts will not be free-floating entities somewhere up in the ether; they will be connected to the rest of the service. They will also have a duty to exercise their freedoms in a way that does not undermine or damage the rest of the NHS. The foundation trusts will be drawn into the same system, but will have freedom and flexibility to push forward with the modernisation and change that all hon. Members recognise is needed if people are to be treated more quickly and given a higher standard of service.
My hon. Friend the Member for Plymouth, Sutton referred to the models set out in the guide. Those models build on co-operative themes and principles and on mutual traditions. I was a member of the Co-operative Commission for 12 months, during which we explored not just the successes of the Co-operative movement but, crucially, its risks and its failings. We are not going into the project with rose-tinted glasses. We know that mutual models can present difficulties and need special support. If local people are to be involved, there must be a great deal more emphasis on education, training, 22WH citizenship, governance, and working with the Co-operative college. I take all those points on board, and those are issues that we want to pursue.
I want to make two distinctions between our policy approach and that of the Conservative spokesman, the hon. Member for West Chelmsford (Mr. Burns), and the Liberal Democrat spokesman, the hon. Member for Oxford, West and Abingdon (Dr. Harris). The Tories should be open and honest about their view; however, the hon. Member for Woodspring (Dr. Fox) has been a little too honest for his comfort. The hon. Member for South Cambridgeshire (Mr. Lansley) made a reasoned argument, and the hon. Member for West Chelmsford wanted to put on record his personal commitment to a service free at the point of use, but the hon. Member for Woodspring is on record as saying that he wants to raise money—perhaps by means of health insurance—through self-pay.
Hon. Members should be under no illusion; their agreement with the foundation trust principle is about keeping the NHS connected to local communities and within public community ownership. The Tories' agenda is very much about self-pay and making sure that there are a variety of purchasers, and would lead us back to a two-tier system. That is the first distinction.
The hon. Member for Oxford, West and Abingdon seems to want localism and diversity at the expense of all national standards. The policy has to proceed in the context of national standards. People pay for a national health service; they want to know that they can get the same services wherever they are. Diversity and decentralisation must be married with good national standards and a national framework. That is the second distinction between our approach and that of the Opposition.
Concerns about a two-tier system are at the heart of the issue. Our policy on foundation trusts is about being on a journey, not about a destination for a few, leaving behind the rest of the system. The policy is about saying that in time we want everyone to have the freedoms, flexibility, innovation and creativity that the system will set in train. It is absolutely right that we should start with the best performers, because that way we can manage the risk of this very big change—make no mistake, this is a bold policy. It is right to want to manage that risk in an incremental way.
Organisations that are not yet at the level of the best need extra help. We want to be able to concentrate on supporting them in order to bring everyone up to the standards of the best. Our policy is about promoting excellence for everybody, not about setting hospital against hospital. It is about having a duty of partnership, but getting energy, creativity and dynamism into the system, so that we can make a significant change for the people who pay for, use and work for the services, and who, at the end of the day, will be running and owning them too. That is an exciting prospect, and I look forward to the debate continuing.