Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, it is perhaps inevitable that NHS reform is a subject which generates a great deal of heat but, at times, it seems, precious little light. The NHS is a precious institution; it is one that binds us together; one to which most of us have a very strong emotional attachment. Perhaps like close family members, it is something that we feel that we know well and love but have seen warts and all.

I support many of the principles behind the Bill—increased patient involvement and choice, and integration between health and social care—and welcome many of the changes that the Government have made to the Bill as a result of the Future Forum’s work, particularly the strengthened role of the health and well-being boards. The challenges that the NHS faces are immense. I do not need to rehearse them; many noble Lords referred to them, as did the Minister in his most eloquent opening speech. However, I want to draw attention particularly to the challenge of the scale of the health inequalities in this country, which are so often linked to public health issues.

The challenges are daunting and I have no doubt that reform is needed. I have never been one of those who thought that the NHS could simply stand still and deal with these challenges, particularly at a time when it is being asked to find £20 billion of efficiency savings. We need a fundamental change in the way that healthcare is delivered to people. I am not really talking about structures here—it is more about how those really big slugs of expenditure are used and how the decisions get taken, although of course structures influence those decisions.

At present, foundation trusts have a financial incentive to maximise their activity while GP referrals to hospital consultants do not have any impact on their own budgets. These sorts of arrangements can run counter to the efficient use of the totality of the NHS resource, particularly in chronic care cases. We need to move to a world in which community, primary and secondary care providers have a shared interest and incentive in optimising the most effective use of NHS money for the whole population. For me, in essence, this will be the key test of the success of these reforms.

Inevitably, much of the debate has focused on what I call the architecture of the NHS. This will always be complicated, given the NHS’s scale and complexity, and often feels quite incomprehensible to people not involved in the subject on a daily basis—and I include myself in those numbers. I fully understand that something as huge as the NHS needs a proper management and governance structure, but I fear that much of the political debate will feel a long way removed from the reality of people’s everyday lives. Arguments about cherry-picking, marketisation and commissioner/provider splits are important, but they often seem to have very little relevance if your main concern is that you cannot get an appointment with your GP—or, indeed, get on to the GP’s books—are waiting for a hospital referral or for an operation or are worried about the long-term care of a family member leaving hospital who is unable to look after themselves.

What really matters to most people is the quality, timeliness, responsiveness and personalised nature of the care and that it is delivered in a way that treats them with dignity and respect, is compassionate and has human warmth. People do not want to feel as if they are going through an impersonal, one-size-fits-all sausage-machine type of health system. A lot of that has to do with culture and attitudes, workforce training and standards of clinical leadership—often things that you cannot legislate for.

I do not take a doctrinaire stance on matters of structure, but the structures must contain the right incentives to ensure not only efficiency and value for money but equitable access and outcomes. I am comfortable with a mixed economy of providers—indeed, we have had that for a number of years now in the NHS—provided that there is indeed a level playing field. We heard about this earlier in the debate.

One point that perhaps has not been made in the debate is whether there is a level playing field for charities, others in the voluntary sector and NHS providers. At the moment, in a number of respects, including on issues like how VAT is treated, there is not a level playing field. I know that many charities feel at a distinct disadvantage. The voluntary sector makes a hugely valuable contribution to health outcomes, particularly for vulnerable groups and those with some of the most complex needs. I call upon the Minister to outline his plans for ensuring that the playing field that he talked about really is level for the voluntary sector.

I will judge the success of these reforms, and whether all the time and energy expended on them has been well placed, on whether they improve outcomes for the whole population, particularly the most needy and vulnerable, who all too often have been short-changed in the past. Noble Lords will be familiar with the statistics on health inequalities, but they are stark and bear repetition. In London, where I live, men’s life expectancy ranges from 71 years in one ward in Haringey to 88 years in one ward in Kensington and Chelsea—a difference of 17 years. This underlines the absolutely critical need to put more focus on public health interventions. I welcome the establishment of Public Health England and the fact that public health functions at a local level will now sit with local authorities. However, as the Bill progresses, I hope it will be possible to strengthen still further the provisions relating to health inequalities.

Mental health is an area where I still have considerable concerns. I pay tribute to the eloquent remarks of the noble Baroness, Lady Hollins. Too often, NHS services and structures are designed around physical healthcare needs, with mental health then squeezed in as an afterthought. For example, the NHS 18-week waiting time never applied to mental health. The Bill presents an opportunity to put mental health on an equal footing with physical health, but there are worrying signs that history may repeat itself. In a world without targets the system hinges on properly designed outcome indicators, yet proper mental health outcomes have yet to be developed. Tariffs are also key to the system but mental health tariffs are still not up and running. Without those tariffs in place, I fear that commissioners will struggle to allocate appropriate budgets to mental health and will be working in what you might call a different currency from that of the physical health world, which will make integration harder.

There were other things that I should like to have said, including on children’s mental health, but I do not have time to do that. I shall finish by going back to where all of this started—the central underlying principle of “No decision about me without me”. A strong evidence base is building up which shows that outcomes improve where patients are actively involved in decisions about their care and treatment, not least because they are far more likely to stick to their treatment regime. However, the latest data from the national patient survey show that a large number of patients still do not feel that they are involved in those decisions. Indeed, the figures have barely improved since 2002. Research also shows that patients care more about being able to exercise choice in the type of treatment than about being able to choose between providers—that is, which hospital or GP to use. We know that patient involvement is strongly linked to health inequalities. Therefore, I ask the Minister to clarify the Government’s intention in this area, so that increased patient involvement is indeed a key outcome of these reforms.

I look forward to the detailed scrutiny of the Bill in Committee to strengthen and improve it further. That is where we should now proceed without delay.