Health and Social Care Bill

Baroness Murphy Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Murphy]

My Lords, we are not alone. All over the world, advanced healthcare systems are trying to tackle the quality of care and safety, raise productivity and shift the care from acute hospitals into primary and community settings—whether it is surgical, medical or mental health services. We have well rehearsed today the reasons for that and the imperative of finding a sustainable way forward for the 21st century that meets the aspirations of Bevan and the founders of the NHS. This is a most remarkable institution, but we need to improve on it to meet what patients need and want now and over these next challenging years. I support this Bill as a well reasoned way forward and as a sensible step which builds on the international and local evidence.

It is time for me to declare my interests as a lifelong employee and honorary employee as a doctor, clinical academic and NHS manager. I am proud to say to the noble Baroness, Lady Cumberlege, that I was one of the original Roy Griffiths managers. If you like, I got on that horse quite early. I then chaired a university with a medical school, St George’s, and finally, recently I was on the board of Monitor, the NHS foundation trust regulator.

Seldom have so many health policy folk fought so many pre-Bill skirmishes over what in the end have proved to be rather modest changes intended to preserve and improve the NHS based on the principles of the NHS constitution, and rarely have I received so much misinformed lobbying about a Bill. I hear that the Bill heralds the end of the NHS as we know it; I read that armies of evil capitalists from the United States and the Middle East are geared up to zoom into the UK like the hordes of Genghis Khan to hoover up our favourite hospitals and services. It is twaddle. In fact, this Bill contains no privatisation at all, it does not transfer any assets to the independent sector and, if we build on the contribution of the independent sector of 1 to 2 per cent per annum, we shall be doing quite well. We have been building on the expansion of existing policies that have been in place and developing slowly over the past 20 years and introducing a new level playing field for providers from all sectors.

As another noble Lord said, this is a vast improvement on favouring the independent sector treatment centres. I quite understand why that had to be done in the early days, but this puts everybody on a favourable, equal footing. It will sharpen NHS commissioners to get the quality of care improved and, crucially, will improve productivity, which has fallen quite catastrophically as investment has risen in the past decade. This Bill improves the contribution of clinicians to the planning and management of services and shifts a hospital system chained to central diktat towards a regulated emancipation to manage their own affairs. In my view, the most important aspect of this Bill is the introduction of the independent regulatory framework for providers, with the tools to promote a sharpening of competition and co-operation that will promote the kind of integrated care across primary community and specialist services that we all want.

Those of us who were at the meeting last night heard Sir David Nicholson repeat what the NHS Confederation has constantly stressed: that any delay will be profoundly depressing to the service, which now wants a clear steer and direction of travel. We have had two years of delay already. Almost all the features of this Bill are familiar to us: clinical commissioning; foundation trusts; a regulatory system; competition and collaboration between qualified providers; and patient choice. They have all gone before, so the new Bill builds on what has been learnt, especially by ensuring that competition is based on quality not price. There seems to be a widespread misunderstanding that we are basing these new proposals around price. That is absolutely not the case, and I would not support this Bill if it did.

Some people talk nostalgically about the demise of PCTs and SHAs, but the demise is in an orderly fashion, and as a former chair of a strategic health authority, I can only say “Hurrah”. In fact, clinical commissioning groups are what primary care trusts were supposed to be in the first place. For those who can recall primary care groups, those were also what clinical commissioning groups were meant to be. The difference is that we have a national framework to support and empower them that will not be diverted into the provider system. Sir David Nicholson has articulated a wide range of commissioning support arrangements that he intends to implement, and we need a Bill to bring those changes about. I have heard it widely said that they will somehow come about if we all think hard enough and that we do not need a Bill. That is rubbish; we need a proper legislative framework. I shall come on to the constitutional changes that people suspect may be in the air—they are not—but we need responsibilities to be articulated very clearly in legislation.

I cannot be the only person who thinks that it was a stroke of genius to appoint Sir David Nicholson as the new CEO of the Commissioning Board, because that will ensure that the transition arrangements are far less worrying for the service. We should be very relieved that he is there to support the new clinical commissioning edifice, including the regional offices and the different ways of commissioning at different levels to support the cancer and stroke care networks—all the precious things that we want to hang on to.

Many people have mentioned the change of wording relating to the Secretary of State’s responsibilities. That is not, by the way, something that is ever raised in the service, where there do not seem to be any doubts that the Secretary of State will still be very much in charge. I worked out that the Secretary of State last managed services directly in 1989, when the special hospital services transferred out of the Department of Health into the new Special Hospitals Service Authority. I do not think that there have been any directly managed healthcare services since then; they have been provided through agencies. Therefore, the description of what the Secretary of State does has been poorly worded. We now need an accurate description of what we think he is going to do. He will not lose political accountability, and he will have specific responsibilities for the health of the public. Is that not what we want the Secretary of State to have? I am sure that we can find some wording to reflect what he will really be doing—it may not be quite right in the Bill. I read the Constitution Committee’s report with much interest. It is fascinating. If we are to debate it, let us do so on the Floor of the House—we have constitutional experts in this House who are a delight to listen to—and see whether we can get this matter right with amendment, explanation or whatever.

Public health started with local authorities and it is returning home. The Secretary of State has very clear responsibilities, and I think that Public Health England, which will provide the support to public health specialists in the localities, is probably as good a solution as we have had since 1974. Therefore, again, I support that.

The development of Monitor to become the main economic regulator is also welcome. Safeguards put in place following the listening exercises are now very extensive—some might say too constraining. Monitor is to have regard to a whole list of things and I wonder whether we might be able to moderate that slightly. Other regulators have shown that there are too many responsibilities at the moment, and we need to find a way forward. However, I particularly welcome the way in which the tariffs are being developed, with new ways to innovate on the design of services, and the way that the tariffs can be bundled to provide the better vertical integration of services that we want to see.

There has been much angst in some quarters about the abolition of the private patients cap. I understand why and I am very sympathetic to the unions’ concerns. No one wants to divert NHS clinicians’ and managers’ energies and preoccupations into private care, however much cash it brings in. However, the cap has proved to be technically extraordinarily difficult to get right, highly disadvantageous to mental health services and a real barrier to some of our great teaching hospitals becoming foundation trusts because some patients are recruited from abroad—Great Ormond Street is a good example. We have to think very carefully about how we go forward in discussions on that.

Finally, I have one major concern. How are we ever to get services reconfigured or units and hospitals closed? Mid Staffs was not an outlier very far from other hospitals. Perhaps a quarter or so of our DGHs are redundant, and many more services need concentrating on specialist sites if we are to improve quality. I want to ensure that Monitor has the tools to intervene early and the right processes to complete the changes. It is always politically difficult to make the final decisions and most inaction on failed organisations—we have already had quoted the wonderful Chase Farm—is caused by lack of ministerial bottle. In Ontario, the ultimate decision was moved from ministers to an independent organisation and finally people started to get the movement that they needed. We have left the Secretary of State in the same old role, so when people are thinking about constitutional changes, they need to remember that. The failure regime has become exceptionally difficult. Can the Minister reassure me that the system can be made to work and, if it proves impossible, that Ministers will have another strategy up their sleeves?

Just as education Bills do not improve education without improving teachers, so we will not improve healthcare without improving the quality of doctors, nurses, other professionals and the people who deliver care, including the managers. We do not talk enough about that, but for the moment I will support the Bill and will not support the amendments that have been tabled to it.