Health and Social Care Bill

Lord Kakkar Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Phillips of Sudbury]

My Lords, Amendments 24, 30 and 299B are tabled in my name and those of the noble Baroness, Lady Finlay of Llandaff, and the noble Lords, Lord Kakkar and Lord Darzi. I hasten to state the obvious, which is that I am a relative ignoramus as regards the refinements of the delivery of health within a hospital. The other three noble Lords who have added their names to this amendment are by contrast as distinguished a trio of consultants as one could find. I must at once, as requested by the noble Baroness, Lady Finlay, give her apologies to the Committee for her inability to be here. She is well out of London.

Amendments 24 and 30 add to Clause 3 which in turn adds to Section 1 of the National Health Service Act 2006. Clause 3 is headed: “The Secretary of State’s duty as to reducing inequalities” but refers to NHS patients in different parts of England, not to differences between NHS and private patients within a single NHS hospital.

Other parts of the Bill which talk of equality of access and outcomes are similarly limited. Nowhere in this 445-page mammoth is there any clear statement, let alone requirement, as to equality of clinical treatment and healthcare between NHS and private patients within an NHS institution. Amendments 24 and 30 clarify that. Amendment 299B also clarifies that inessential care such as what one might call the hotel services—the quality of the accommodation, drugs prohibited by NICE standards and indeed treatment and care that is not a clinical priority—can still be provided privately on the basis of privilege. Those matters are, as I say, non-essential and we have put in—the four of us whose names are to these two amendments—Amendment 299B to make very clear that we are not seeking to row back on the status quo.

It was Aneurin Bevan during Second Reading on what would become the National Health Service Act 1946 who said:

“If people wish to pay for additional amenities, or something to which they attach value, like privacy in a single ward, we ought to aim at providing such facilities for everyone who wants them”.—[Official Report, Commons, 30/4/1946; col. 57.]

For example the state will provide a certain standard of dentistry free but if a person wants to have his teeth filled with gold the state will not provide that. It is in that vein that Amendment 299B stands in our four names but, and this is a big but, where there are two patients with the same essential clinical health needs—one an NHS patient, another a private patient; one in a public ward, the other in a private ward—the one with the fat wallet can buy priority and buy his way to the top of the queue. That cannot be allowed in our National Health Service. It would be fundamentally against the spirit of the NHS and directly contrary to the ideals on which it was founded.

In a Britain that is becoming more divided in terms of living standards at a rapid rate the maintenance of the ideals of the original NHS for many of us are absolutely integral to our sense of citizenship and sense of comfort in an increasingly differentiated and diverse society. We must not on any account allow under the new regime a—no doubt inadvertent—two-class service to develop in NHS hospitals with regard to essential care. In saying that, I want to make it abundantly clear that neither amendment will touch private institutions that have no NHS connection—they are free to carry on doing what they will, how they will. That is an aspect of freedom in this country on which I would not for a minute seek to trespass.

The dangers are that the privatising and commercialising, as they are fairly called, will, as I say, bring into the NHS a much wider and deeper engagement with the private sector and that could, and I again say inadvertently, develop into a two-class NHS. Let us be clear: the NHS and the private sector march to different drums. The NHS is concerned solely and only with equal free treatment and fair access to any of us who go to its institutions. The private sector, which I do not wish to unduly disparage—which is made up of public companies and many very commercial entities—is none the less first, secondly and thirdly in the business of profit. It is no good saying that doctors and consultants working within the private sector, unless they are sole traders so to speak, will be immune from that commercialisation, the managerialism that goes with it and the pressures that are inevitably engaged when working for a commercial entity.

Amendment 30 strengthens the original ideals of the NHS. Perhaps I may say to my noble friend the Minister what I have said to him previously: I believe that it will cement public support for what is good in this Bill. There is much that is good and I am not for a minute saying that extending the contact with the private sector is wrong. In many respects, it can be good and can bring new resources into the NHS. But that is all at risk unless we put firmly and clearly in the Bill that we will not allow a two-class service of clinical treatment and healthcare within an NHS institution.

I want briefly to refer to the deluge of letters, petitions and the like which everyone in this House has received. In my 14 years here, there have been far more letters on this Bill than any two others put together. My noble friend Lord Razzall mumbles that there were more for hunting. I have to say to him that I do not think there were, but be that as it may. I just mention the Coalition of UK Medical Specialty Societies, which saw the issue that my amendment is designed to address. It wrote:

“Choice must be for patients rather than provider; the provider choosing the simple cases and leaving the unprofitable, more complex cases (elderly, chronic illness, disabled) to fight for remaining funds will disadvantage patients”.

A petition from more than 400 public health doctors and specialists from within the NHS and academe said:

“As public health doctors and specialists”,

we think that the Bill could usher,

“in a significantly heightened degree of commercialisation and marketisation that will … widen health inequalities”.

It is to prevent that widening that this amendment is put down.

Finally, the BMA, which has informally backed this amendment, in one of its key points states:

“Increasing patient choice should not be a higher priority than tackling fair access and health inequalities”.

We all say amen to that. I hope very much that the Government will accept these amendments. It may well be that on Report I will want to bring forward something to make clear that there should be some oversight of the provisions that these amendments seek to entrench, which might be through the monitors. But, for the time being, I hope that the Committee will warm to these amendments and the sentiments behind them. I beg to move.

[Lord Kakkar]

My Lords, I support this group of amendments and in so doing remind your Lordships of my interest as consultant surgeon at University College London Hospitals NHS Foundation Trust, an institution with private healthcare facilities that I would be entitled to use if I ever decided to do so. This group of amendments is very important because it deals with an area of anxiety with regard to potential consequences that will follow removal of the private patient cap. Removing that cap may well provide important opportunities for NHS foundation trusts in the future, opportunities that they may well need to exploit. But in so doing, we need to be certain that access to clinical facilities in NHS institutions for either NHS patients or those in private healthcare facilities in NHS institutions is based purely upon clinical need and that no other factor influences access to those facilities.

I believe that in the majority of circumstances that will always be the case, as it has been to date. But with the important changes in this Bill with regard to the role of potential private practice in NHS institutions, we need to be absolutely certain that any anxieties or opportunities for misunderstanding are dealt with at an early stage. So in bringing forward these amendments at this stage, one hopes that there is an opportunity for the Government to explore how they plan to deal with any potential tensions and what security the current Bill as we consider it, and any potential amendments in the future or well established working practices in the NHS to date, would protect against a situation developing where access to facilities was determined by anything other than absolute clinical priority. For this reason I strongly support the amendments being brought forward at this stage in the hope that the noble Earl might be able to provide some clarity on the approach that Her Majesty’s Government might take in regard to these matters.

[Lord Walton of Detchant]

My Lords, 53 years ago, after seven years in full-time clinical research followed by 18 months as a first assistant in a neurological department with an honorary senior registrar contract, at the age of 35 I was appointed as a consultant in the NHS. But since at the time I had not even reached a salary of £2,000 a year, on being appointed as a consultant I chose to take a maximum part-time contract to do limited private practice, if only for financial reasons. In fact, it was a very interesting experience. I did this only for a few years before I became a full-time academic.

At that time every NHS hospital had a private ward or had the opportunity, as was the case in the regional neurological centre in Newcastle Upon Tyne, such that on my ward of 28 beds I was entitled, if I so wished, to use four single rooms for private patients. The advantage of that arrangement, which was widespread throughout the country, was that the consultants working in that kind of hospital had the right to be geographically whole-time at the hospital. They were not being diverted away to distant private hospitals. They could look after their patients, both private and public, on the same ward and give them equal standards of care. The only real advantage for the private patients was that they had single rooms.

Many years later, along came Barbara Castle, who was the Secretary of State for Health and who later became the much respected Lady Castle. By that time I was a full-time academic with no private practice. I took private patients under my care into hospital, as I had to do if they came from overseas. In order to take advantage of the research facilities in my department, they had to be treated as private patients. However, under pressure from the trade unions, the Government worked through a process of gradually removing private patient beds from NHS hospitals so that, in the end, in the three major hospitals in Newcastle Upon Tyne we had one private bed in each hospital. The result was that, as an academic with major research facilities for the investigation of neuromuscular disease, I had to refuse patients referred to me from the United States, Canada, Australia and elsewhere because there were no private hospitals which could provide the facilities needed for the investigation of these patients, and there were no private beds into which they could be admitted. I look back on the period before that, when there were private beds in NHS hospitals, with great interest. I think that it was an excellent arrangement.

This is why I strongly support the proposal that the cap on private patient beds in NHS hospitals, foundation trusts and so on be removed, but I agree that there should be a restriction so that the opportunity for such beds to be established for private patient care must not be excessive. However, the advantage is that the NHS will gain substantially from the income derived from those private beds. The noble Lord, Lord Phillips, has enunciated the principle that the standards of clinical care for public and private patients in those hospitals should be entirely comparable. The only advantage for private patients would be a better standard of accommodation, as Amendment 299B indicates, which is wholly acceptable. The quality of medical care should be identical. For that reason, I support the principle.

On the other hand, the wording of Amendment 30 is not satisfactory. Although I accept the principle of equal standards of clinical care, the amendment would make it impossible to provide the improved standards of accommodation to which Amendment 299B refers. The principle is important and I would support it in general, but the amendment needs a little adjustment.