Health and Social Care Bill

Lord Rea Excerpts

Wednesday 8th February 2012 Lords Chamber

[Earl Howe]

The noble Lord will know, because the NHS Commissioning Board authority has published its proposals, that the board will be represented sectorally. There will be field forces in all parts of the country. My vision of this, and that of Sir David Nicholson is that in the areas in which the board operates it will take a view across a region and look at how outcomes vary between local authority areas. The board will be very powerfully placed to influence the kinds of inequalities that the noble Lord has spoken of. It is important for noble Lords to understand that the board will not be a collection of people sitting in Leeds. The majority of its staff will be a field force. I hope that that is helpful.

[Lord Rea]

Does the noble Lord accept that to smooth out inequalities costs money? Therefore, the CCG in Tottenham should get more per capita than the CCG in Totteridge. At the moment allocation is made according to an index that takes deprivation into account to some extent, but not enough. How will that be administered under the new system?

[Earl Howe]

The advisory committee for resource allocation which exists at the moment will advise on the allocation of resources according to a very detailed formula. That applies to the NHS and public health. There will be a separate ring-fenced budget that specifically takes account of deprivation. That budget will be held by Public Health England and passed down to local authorities to use at a local level. We are very clear that deprivation and health inequalities must be reflected in terms of the budgets that CCGs and local authorities receive. I hope that I can reassure the noble Lord on that point.

Government Amendments 68, 112 and 144 set out a requirement for the Secretary of State, the board and CCGs to report annually on their work to reduce health inequalities. We had a great deal of helpful and interesting discussion on reducing health inequalities in Committee and as a result of those discussions, we felt that it was important to bring forward three amendments on the reporting requirements. Amendment 144 requires the Secretary of State to include in his annual report an assessment of how effectively he has carried out these duties, meaning that Parliament will hold him to account. I have tabled parallel government Amendments 68 and 112, which require the commissioning board and CCGs to report on how effectively they have fulfilled their inequality duties. We believe that this will ensure that our objectives to reduce health inequalities and improve quality of care are embedded throughout the system from top to bottom. I hope that noble Lords can support those amendments when I move them.

Tobacco

Lord Rea Excerpts

Monday 6th February 2012 Lords Chamber

[Earl Howe]

My noble friend is absolutely right that that is where the problem principally lies: 320,000 young people experiment with smoking or take it up every year. That is a very serious rate of incidence and it must be tackled at every possible level. The tobacco control plan sets out a concerted programme of action to try to do just that.

[Lord Rea]

My Lords, on 11 July this year the noble Earl said to the House,

“we will make sure that we publish details of policy-related meetings between the tobacco industry and government departments and we are currently exploring the most effective and appropriate mechanism for doing that”.—[Official Report, 11/7/11; col. 560.]

Could the noble Earl please say what that mechanism is, and whether it is now being implemented?

Health and Social Care Bill

Lord Rea Excerpts

Tuesday 13th December 2011 Lords Chamber

I am not against competition but I am against financial competition. I appeal to the Minister, even at this very late stage, to do all that he can to preserve the public service ethos and the healthy competition that we already have, and to avoid at all costs the deeply unpleasant results of replacing competition based upon the best possible care of patients with the money motive.

[Lord Rea]

My Lords, I would like to make a very few remarks on competition versus co-operation from a clinical rather than a legal position, as I am baffled by the complex legality of the amendments on Monitor.

As the noble Earl knows, like many others I have always had concerns about the wisdom of introducing market competition into healthcare. Co-operation and collaboration between providers should always be the norm for the benefit of patients and, as the noble Baroness, Lady Meacher, has just said, it is much less costly. However, it is good to know that competition is now to be on quality and not on price. This removes, theoretically at least, the race to the bottom which has been shown to result in worse outcomes in a number of studies, particularly, as other noble Lords have pointed out, in the United States.

Recently there have been three studies in the UK on competition in healthcare, of which that by Zack Cooper and colleagues at the LSE, looking at hospital data covering 400,000 admissions from 2003 to 2008, is the largest and the best known. They claim to show that competition on quality can improve the outcome for patients with a myocardial infarction or coronary thrombosis. Although carefully conducted, and allowing for many variables, the paper has been criticised by statisticians for the elementary but common scientific mistake of equating correlation with causation.

The mortality rate certainly did fall in the hospitals deemed to have been involved in choice and competition. They were deemed to be such because they were close to other comparable hospitals, mostly in urban areas. The researchers were unable to measure competition as such, which of course is a weakness of the study. The mortality rates in these hospitals were compared to those in hospitals outside these areas with more scattered populations who were likely to have less choice and to use only one hospital. However, differences in the mortality rate could have been due to a number of clinical and diagnostic factors, unconnected to competition, which applied more to the urban than the provincial hospitals. For instance, the urban areas were more likely to contain teaching hospitals, which often lead on the introduction of new treatments.

Another report deemed to show that competition is beneficial was commissioned by the Royal College of Surgeons. It showed that outcomes for elective surgery at independent sector treatment centres were better than those for similar procedures carried out in National Health Service hospitals that also offered emergency care. This is not surprising, for several reasons. The patients at the ISTCs were younger and in better general health; they came from more affluent areas; and they were less likely to have co-morbidities. Therefore, the surgeons at the ISTCs had a more straightforward task and by concentrating on a few surgical procedures may have become more skilled in that limited area.

There is nothing to stop National Health Service hospitals setting up dedicated wards and teams to concentrate on routine operations, with doctors working in those sections being protected from being diverted to treat more urgent or seriously ill emergency cases. A number of National Health Service hospitals have done this quite successfully, providing treatments at a lower cost than those commissioned from the private sector. Two years ago ISTCs received some 11 per cent more remuneration than the National Health Service for doing the same work. Of course I am aware that the National Health Service sometimes needs the private sector to clear a backlog. However, this should be temporary, if only for economic reasons. As many other noble Lords said, competition is welcome and necessary within the National Health Service but should be between hospitals, clinicians and other providers vying to be judged the best. In most cases there is only a temporary need to use commercial, competitive providers. I hope that these general remarks have helped the debate.

[Lord Whitty]

My Lords, I will intervene only briefly because most of the points on competition were made very eloquently, in particular by the noble Lords, Lord Clement-Jones and Lord Owen. My amendments would rather more crudely delete references to anti-competitive behaviour. One thing I will draw to the Committee's attention is that the terminology maximises the chances of this going wrong. The earlier version of the Bill referred to “promoting competition”—in other words, encouraging more providers—which was a relatively benign intervention if one believes that that is the way to go. By referring to “preventing anti-competitive behaviour” we are turning Monitor from being an accreditor and promoter of more providers to being the policeman of the nascent market. That will put it in a very vulnerable position.

All competition and sector regulators that have this duty are inevitably faced with appeals, complaints and other interventions by unsuccessful providers or potential providers, which go through a quasi-legal process with the regulator. The Bill provides that if that is not acceptable, the issue may go to the competition authorities, which rely on the general principles of competition and also—as the noble Lord, Lord Owen, eloquently underlined—of procurement law. Therefore, in almost every case of commissioning the allocation of the contract will be opened to appeal on the grounds that it overrides competition. However, as noble Lords said, there are hundreds of thousands of situations where collaboration and integration, vertically and horizontally, and even mergers between providers, would be in the interests of patients. The Minister said that clearly in all cases the interests of patients were the most important issue. Indeed, the very useful document describing Monitor’s role states that the regulations would help ensure that competition is not applied inappropriately, and only ever in the interests of patients. Well, that is what we would all wish to see. I certainly would not wish to deny Monitor the ability to encourage competition, but if there is an appeal against a particular award by a particular commissioning body, Monitor and the higher courts have to be in a position of judging whether or not the award was in the interests of patients. That seems a severe restriction on the ability of Monitor to provide its general services because it will be engaged in all these cases of complaint and appeal.

There are things that would fit in with the Government’s overall philosophy— which in this area I do not happen to share—but that would not open the door to such a multitude of appeals and to the wider application, referred to by other noble Lords, of both general EU and UK competition and procurement law, which would tie large parts of the National Health Service up in knots.

Health and Social Care Bill

Lord Rea Excerpts

Monday 14th November 2011 Lords Chamber

I know that there is a later amendment which proposes that, if there is a member of the executive or a civil servant with public health expertise on the board, the current amendment might not be necessary. I do not agree. I think it is absolutely necessary that the public health specialist on the board is there independently, to give an independent view.

[Lord Rea]

My Lords, I support all those noble Lords who have spoken so far and I agree with everything they have said; there is hardly anything for me to add. I just want to emphasise that a public health specialist will have had special experience and training in dealing with the massive amount of health data that comes into a health authority or, in this case, to the NHS Commissioning Board; it will be a huge amount. Public health specialists are trained in statistics and in epidemiology, and have other skills needed to handle this information and to help the board to make the correct decisions. I would like to emphasise the point made by my noble friend Lord Warner that very often this can be extremely helpful when certain services are deemed no longer appropriate. They may save a lot of money by giving backing to decommissioning and reconfiguring certain services, ensuring that populations are best served with the resources that are available.

[Baroness Jolly]

My Lords, it sounds as though there is a considerable level of agreement on this. I, too, believe that we should have a public health specialist sitting on the board. Members of the faculty have said that if there is not going to be such a specialist on the board by right, there should at least be one where the CMO is not a public health specialist. This Bill has put public health at its core and at every level.

I shall not say any more about the public health appointment but I will talk a little about the involvement of the patient. The patient is also meant to be fundamental to this Bill: “no decision about me without me.” Again, we have the patient involved through local government and the local commissioning groups but not necessarily on the board. I think that whoever is chair of HealthWatch England should have a seat on the board.

What would both of these positions bring to the board? They would bring a level of expertise that nobody else has. I understand the Government’s reluctance to be specific, and I know that lists are problematic. I also know that with these things there is a tendency to request that every man and his dog, or all and sundry, sit around the board table. However, it is a board table and not a representative council, so I would put those two people there for one distinct reason: they add a dimension that the board does not know it misses. Decisions made without them will be made in a vacuum and will be all the poorer for it. Somebody put it to me earlier today—your Lordships will have to excuse me for this—that the board knows what it knows, it knows what it does not know, and it does not know what it does not know.

Health and Social Care Bill

Lord Rea Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Whitty]

My Lords, I apologise to those I informed that I would not be here to move Amendment 59A—I am here and so I will.

Noble Lords will probably appreciate that I have severe misgivings about aspects of the Bill but the amendment attempts to build on parts of the Bill of which I largely approve. The devolution of commissioning is important, but the later provisions in the Bill which associate issues of public health and well-being more clearly with the role of the health and social care system are also important.

When we are talking about configuration in the sense of bureaucratic bodies, it is important to try to build into this a relationship between what are mainly local authority services and those services which will be commissioned by the new commissioning groups. The original form of the commissioning groups in terms of GP commissions has been altered somewhat but there will obviously be quite a number of them. We do not know how many of these commissioning groups are envisaged by the Government. This amendment attempts to say that there ought to be a relationship between commissioning groups and the local authority boundaries within which they operate. It is intended to be a relatively flexible operation, although it would be very sensible in many areas for there to be a total coincidence in coterminous boundaries between commissioning groups and local authorities. In others, there may well be more than one, but I still think some recognition of a relationship with the local authority services is important. It is important not only in the provision of social care and dealing with the developing conditions of individual patients and users, but for environmental health issues, on which I have later amendments. The public health service should ensure that the commissioning authorities recognise the importance of work in the public health area and the need to co-operate with the public health authorities.

It is actually quite difficult to get the National Health Service, at both local and policy level, to take into account in its operational work the need for a public health dimension. There have been some significant improvements in this relationship in recent years, but they need to go further. I am therefore suggesting that, in principle, we should ensure that there is a relationship between the commissioning groups, the public health authorities and public health and well-being committees, and the local authorities that provide social care and public and environmental health services. It is intended to be reasonably flexible. Clearly such coterminosity, if that is a word, would not apply to specialist commissioning groups and, as I have said, I am not suggesting that there should be only a single commissioning group within each local authority area; although there would be advantages in that, it would cut across a lot of what the Government are attempting to do. I think, however, that somewhere in this Bill—not necessarily in the precise terms of this amendment—there needs to be a very clear relationship written in between the public health boundaries and the commissioning boundaries as they are envisaged in the new configuration. I beg to move.

[Lord Rea]

My Lords, following the noble Baroness, Lady Finlay, I raised this issue briefly on the second day of Committee. I felt, however, that the Minister only gave a partial answer. CCGs must have an “area” as set out in their constitution, but there seems to be nothing in the Bill which defines the limit of this area or its basis other than that CCGs will cover the registered practice population of the GPs sitting on the CCG. This will result in very untidy boundaries which will interdigitate with a variable number of other CCGs.

However, proposed new subsection (1A) in Clause 10(3) says that a clinical commissioning group has responsibility for other people resident in its area but not registered with a GP—homeless people, rough sleepers, asylum seekers, et cetera. A geographical boundary for those people is therefore implied. Can the Minister say how this boundary is to be delineated? Will it coincide, as my noble friend has suggested, with the local authority, or with the former PCT—which in fact in 85 per cent of cases will be the same as the local authority boundary—or will it have some other basis? There is a strong case for—sorry about this word again—coterminosity with local authorities. They provide many of the services on which GPs depend. In fact, they are an integral part of primary care, such as social services and community health services, and public health, including maternal and child welfare services. They are especially important as, under the Bill, local authorities will all have their own director of public health. There are a number of services which were formerly provided by PCTs on a geographical basis: for example, ambulance and emergency services, genito-urinary medicine clinics, and drug and alcohol services. These are by no means all the services which CCGs will have to commission or co-operate with. What arrangements will be made for the area that these services will have to provide for?

[Lord Kakkar]

My Lords, Amendment 60 is in my name and that of the noble Lord, Lord Patel. It proposes to deal with the anxieties over real and perceived conflicts of interest that might exist in the functioning of clinical commissioning groups. The amendment proposes that:

“The Secretary of State must publish, and may from time to time revise, a code of conduct for all clinical commissioning groups … The code must, in particular, incorporate the Nolan principles …‘The Nolan principles’ means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life”.

It is important to take the opportunity to explore the issues around potential conflicts of interest and the anxieties that these raise. The reason is very simple. Clinical commissioning groups will be new public bodies. They will have by large measure a large number of primary care practitioners as their membership. Primary care practitioners, GPs, will have responsibility for delivering care and have very special and cherished relationships with their patients in terms of promoting and guarding the interests of their patients. Moving forward, they will have new responsibilities for the commissioning of services. A potential anxiety exists under those circumstances.

For many other statutory bodies in the public sector involved in healthcare, we have dealt with the problem of potential conflicts of interest by ensuring that those organisations and those who serve in those organisations are obliged to conduct themselves in a way consistent with the seven principles of the standards in public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Those seven principles are very powerful indeed.

On 14 April I put a supplementary question to the Minister at Oral Questions about whether clinical commissioning groups would be obliged to follow the Nolan principles. The Minister stated that, since they were going to be public bodies, they would be obliged to do that. As they are new public bodies, many of those that are going to serve in important capacities in clinical commissioning groups will have little experience of public life. Yet they will have very important responsibilities and have to deal with the sensitivities and anxieties of patients, because they will both serve in capacities on clinical commissioning groups and continue to serve as patients’ principal caregivers and primary medical practitioners. We need to find a way of ensuring that those anxieties are overcome.

In many other situations, we have dealt with that through these seven basic principles. Indeed, the Parliamentary Standards Act 2009 was designed to ensure that anxieties over the conduct of Parliament could be dealt with in such a way as to satisfy the public more generally that there was transparency, and that those serving in public life in this Parliament had no doubts about their obligations and responsibilities. The Parliamentary Standards Act 2009 includes a commitment and requirement to adhere to the standards in public life defined in the Nolan principles. I therefore believe it might be an important opportunity to overcome the anxieties that attend the question of potential conflicts of interest in terms of the conduct of clinical commissioning groups for the same approach to be taken with regard to this Bill, and to include a specific reference to the Nolan principles in terms of the conduct of clinical commissioning groups.

Health and Social Care Bill

Lord Rea Excerpts

Wednesday 9th November 2011 Lords Chamber

As has been noted in this debate and at Second Reading, medical research in the UK—through our universities and hospitals, our health research charities and our medical science industries—has been a long-standing success story. Its importance to a world-class National Health Service is not in doubt. Embedding a culture of research and innovation in the new structures of the NHS is one of the key challenges to be met by this Bill, but we have some way to go yet before that is achieved.

[Lord Rea]

My Lords, I have a short question, on a subject mentioned by my noble friend Lord Turnberg and others. The National Institute for Health Research is now directly related to the Department of Health. Is it going to stay there, or is it going to be moved over, as was suggested, to the NHS Commissioning Board? Is the funding going to be assured? I do not think that we are quite sure about these things.

[Baroness Morgan of Drefelin]

My Lords, I was delighted to lend my name in support of these amendments. We have had a tremendous debate, which is a sign that the Committee stage of the Bill is starting to get down to business and focus on some of the nitty-gritty, now that we have moved on from some of the more extremely high-level principles about whether or not we should see Clauses 1 and 4 in the Bill.

I very much support the opening remarks of the noble Lord, Lord Willis. He is chair of the Association of Medical Research Charities. I declare an interest myself as chief executive of a medical research charity, Breast Cancer Campaign. We are members of the noble Lord’s association, and are very grateful to him for the leadership that he gives.

There are very few points I want to add to the debate, as it has already been very comprehensive. In thinking about this, I want to stress how incredibly important it is that we understand the role of research in the NHS as a driver for quality and improving outcomes for patients. Only today at the AMRC AGM, I heard someone describing research as one of the three pillars, alongside service delivery and education, and stressing the role that research plays in driving up quality and outcomes for patients.

We know that this is something that is not lost on the public. We have already heard what importance the public place on research delivery in the NHS—93 per cent of people asked by the AMRC in a MORI poll said that they wanted their local NHS to be encouraged or required to deliver research locally. That is an enormous vote of confidence in research in the NHS.

The public do not just say this in answer to surveys. They vote for research through their wallets, as we have already heard from a number of noble Lords. Medical research charities contribute £1 billion to research in this country. That is an enormous achievement.

The contribution that the NHS makes to medical research worldwide is very special indeed. It is quite simply a no-brainer that research has consistently delivered real progress for patients. I believe it is agreed that the NHS has a special and unique role to play, which is unparalleled in the world. We have already agreed around the House that in this country we punch above our weight, as the noble Lord, Lord Walton, said. As the noble Lord, Lord Turnberg, said very eloquently, we know that the UK generates over 10 per cent of the world’s clinical science and health research outputs and has created nearly a quarter of the world’s top 100 medicines. That is a great achievement. Now that the noble Lord, Lord Darzi, is back in his place, I can remind the House that in the earlier debate he commented on how life expectancy continues to rise, following on from the success of medical research.

As I said at Second Reading, there are many examples where the special nature of the NHS has contributed to progress. I mentioned particularly the million women study, supported by Cancer Research UK in partnership with the NHS, a collaboration that revealed the role of hormone replacement therapy in breast cancer risk—an enormous study, made possible by the NHS. I also talked about a project that my own charity is involved in. It is a real challenge. Noble Lords have already made many points about the difficulty in establishing informatics systems. We are working to establish a tissue bank, to look at breast cancer specifically, and to drive forward the vital role that genomics plays. This is also made possible by the NHS. There are many examples, as I have said.

I welcome this duty. It is the first time we have seen a duty of this nature on the Secretary of State, and it is a very important step forward, but if the duty is going to be meaningful we need to know—so I would like to hear from the Minister—what the Government will see as success in executing that duty. I want to understand what success will look like—what will be the benchmarks that the Secretary of State will use to know whether his duty has been executed successfully.

Will we continue to evaluate the contribution that NHS research makes to GDP? How will the NHS research duty play in to the research assessment exercise that is undertaken in higher education? Could that be used to show how effective partnerships work in the NHS, because it is often those partnerships between NHS trust and academic institutions which are so important? What could Monitor or the Care Quality Commission do to help us understand the contribution that research has made to improving outcomes in various settings? Will we have an impact rating for NHS foundation trusts relating to their promotion of R&D? Will we be considering the number of patients in clinical trials as a measure—that is something that many people are worried about at the moment? Should we be looking at the number of clinical fellows or clinical professors in surgery?

What will success look like for the Secretary of State? I have heard talk that a research tariff is being developed; that has been referred to in correspondence. I would be grateful if the noble Earl could explain whether it is and what the consultation process might be. There has been a suggestion that a diagram or an organigram might help us here when looking at how the funding streams might work. We had a meeting with Dame Sally Davies when that was on the agenda. We have been reassured that funding will work in the same way as in the past. I am not sure whether it can, so I should be grateful if the Minister could reassure us on how that would work and perhaps produce a diagram for us.

Health and Social Care Bill

Lord Rea Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Cumberlege]

My Lords, I should like to ask a few questions about Amendment 10A. I thank the noble Baroness, Lady Finlay, for her introduction, but we do not yet have a precise definition of what she means by area-based populations. All sorts of different services have different catchment areas. At the beginning, the noble Baroness cited family planning services. She said that she felt that perhaps it was a bad example, and I think it probably is because there are so many different services that require different boundaries. I am for coterminosity as far as we can get it, because when I was a regional chairman, I saw that where you had coterminosity between the health service and local government, you could achieve a great deal. That worked well, but when one examined it carefully, it was not so much about the boundaries; it was about the relationships built between different people. That was what made the services work extremely well.

With regard to GP practices, GPs usually want people within their area, especially if they will have to do home visits. I have been in the situation—I am sure that many noble Lords have—where I had an emergency in London but my GP is 52 miles away. That can be coped with; you can still manage that, although it is quite awkward in some respects. My anxiety about allocating patients to different GPs—being neat and tidy and trying to get all the boundaries sorted—is that I do not know what it does for choice. Perhaps the noble Baroness will say something about that. What happens when people want to choose a different GP who is out of their area, which is what we want to do locally but are unable to because the boundaries have been so clearly fixed, I have to say, by the GPs themselves?

[Lord Rea]

My Lords, the noble Baroness, Lady Finlay, has somewhat stolen my thunder because I had meant to say almost exactly what she said, but I was going to mention it when we got to the part of the Bill describing the clinical commissioning groups. Schedule 2, which relates to clinical commissioning groups, states:

“A clinical commissioning group must have a constitution … The constitution must specify”,

the name, the members and the area of the group. That is there. I would like the noble Earl to describe how that area is to be measured and whether it is to be coterminous with existing boundaries, particularly local authority boundaries, for the very reason given by the noble Baroness, Lady Finlay.

[Baroness Tonge]

My Lords, most of the points I wanted to raise have already been raised so I will not repeat them. I congratulate the noble Baroness, Lady Finlay, on her comprehensive overview of her amendments. What concerns me most is those patients who fall through the net of the new general practice commissioning groups. If it is not area-based and there is not a primary care trust responsible for allocating those patients, where will people who do not speak English very well, asylum-seekers, the homeless, mentioned by the noble Baroness, and Travellers go? What about those patients whom I remember well, whom most GP practices did not want on their lists at all and who were rotated around general practices in order that they got medical treatment? What will happen to all those patients? There are many of them and some of them have severe disabilities and some are severely mentally ill. They fall into all sorts of groups. I am extremely concerned that without an area base or a responsibility on a PCT or a commissioning group to deal with patients in a particular geographical area, those patients will suffer hugely.

I want to make one final point. The other service that will suffer hugely is our accident and emergency departments, because if those people do not have GPs, that is where they will go. I was a casualty officer in central London for a whole year, once upon a time, and I virtually ran a general practice there then for patients who were unattached to general practices. That problem will increase, and I hope that the Minister will address that in his comments.

Health and Social Care Bill

Lord Rea Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Rea]

My Lords, I have spent most of my professional life working in the National Health Service. I have also worked in and observed other healthcare systems and have come to value the NHS all the more not only for its universality but for the high quality of its coverage. I admire it also for its economy of working. We spend considerably less on health per head of population than most other countries at a similar stage of economic development.

By and large, the NHS has conformed to the principles laid down in the amendment. Of course, it is far from perfect. Its bureaucracy, as the noble Baroness, Lady Williams, said, is sometimes inflexible. For example, the treatment of whistleblowers is often inappropriate. Internal criticism should be heard and acted upon and not suppressed, but this Bill is not necessary in order to correct that. The amendment is an important reminder to government at both national and local level of what the NHS stands for. Any action by government or individual staff should be taken with these principles firmly in mind.

[Baroness Morgan of Drefelin]

My Lords, there is nothing like suggesting to a House of Lords Committee that we move on to encourage one to stand up and contribute.

The noble Baroness, Lady Thornton, mentioned the debate that took place at the start of the Committee stage of the Apprenticeships, Skills, Children and Learning Bill, now an Act, in 2009. I remember sitting behind the Dispatch Box next to my then noble friend Lord Young listening to the noble Lord, Lord Hunt of Wirral, make a very convincing case for the Opposition on the need to set out a clear definition of apprenticeships and the importance of a well thought through, principled preamble. I remember listening to my noble friend take the Committee through a detailed and well argued explanation of how all those issues were carefully covered throughout the very long Bill. However, both Her Majesty's Opposition and the Liberal Democrats were united in saying that they needed to be stated clearly at the start of the Bill. They won the day and there that statement is in the apprenticeships Act.

When I saw the amendment of the noble Baroness, Lady Thornton, it made me think about all the important legislation of the past, and it led me to the Children Act 1989, which I am sure the Government are still very proud of. An important aspect of that Act is the principle of paramountcy, whereby the interests of the child are paramount in any decisions taken about their health and welfare.

Listening to debates on this Bill, I have felt genuine concern about how we resolve issues around conflict of interest. The relationship between a health professional —a doctor, nurse or physiotherapist, but principally a doctor—and their patient is based on an extremely high level of trust and is one of the cornerstones of our NHS, and I was wondering how the importance of that trust and that relationship could be incorporated in some principles. Have the Minister or the noble Baroness, Lady Thornton, thought about whether it would be appropriate to have a principle under which the needs and interests of the patient should be paramount when decisions are made about them? Obviously, there are a lot of ways of thinking about that from a legal perspective, but it is something that we need to be very concerned about. How is the conflict of interest to be carefully managed where a GP refers a patient to a service that they own and profit from? How can patients—whether as individuals or a population—be absolutely sure of the decisions being made about them, at every level throughout the system, including commissioning? It is very important that we think about the principles underpinning the health service. This is a very important debate.

Health and Social Care Bill

Lord Rea Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Rea]

My Lords, after our marathon debate, I congratulate the noble Earl on his continued clarity and stamina, and the same applies to my noble friends Lady Thornton and Lord Hunt. Time presses, so I shall be very brief, although there are a thousand things that I would like to say in reply to the Minister and to those who have spoken.

I have sensed widespread unease about the Bill among your Lordships, and this alone would be enough to justify my calling for a Division. However, more than that, like all your Lordships I have also heard a tumultuous call from the country not simply to amend the Bill but to reject it entirely. I think that the Bill is virtually unamendable—certainly in the timetable that we have been offered, even if it were extended, and even if the amendment of the noble Lord, Lord Owen, were accepted. Whole swathes of the most senior members of my profession want the Bill to be sent back to the drawing board so that the National Health Service can get back to work without a sword of Damocles hanging over it. How can the Minister expect to get high productivity from a disaffected workforce?

I end by quoting Sir Roger Boyle, the retiring National Director for Heart Disease and Stroke, whose work was praised by my noble friend Lady Andrews yesterday. He says:

“All the improvements in cardiovascular care have come from collaboration and leadership. Where is the evidence that competition between commercial providers makes a blind bit of difference to cost efficiency and quality? The competition I want to see is between clinicians vying with each other over whose service is the best. If you try and improve care by getting United Health to provide the service that would be crazy.

I absolutely think the NHS is the best public service in the world. It is horrific that its future is threatened”.

I ask noble Lords to accept my amendment, which asks the House to decline to give the Bill a Second Reading.

Health and Social Care Bill

Lord Rea Excerpts

Tuesday 11th October 2011 Lords Chamber

Moved by

[Lord Rea]

As an amendment to the Motion that the Bill be now read a second time, to leave out from “that” to the end and insert “this House declines to give the Bill a second reading, in the light of the statement in the Coalition Agreement that ‘we will stop the top-down reorganisations of the NHS that have got in the way of patient care’.”

[Lord Rea]

My Lords, the noble Earl, as always, gave us a carefully crafted and elegant speech, much of which I agreed with. However, I will start by raising one point. In the letter he sent to Peers last week, he repeated verbatim the words in the White Paper that claim that Britain's health record is worse than that of other EU countries, especially France. It appears that he has not read the paper in the British Medical Journal by John Appleby, the chief economist at the King’s Fund, which demonstrates that these claims are false, that Britain's health is improving faster than that of any other country in the EU, and that we will shortly overtake France, whose health expenditure is far greater as a percentage of GDP than ours.

I will explain why I put down my amendment. I did not do this lightly. I realise that it is very unusual for your Lordships' House to oppose a Bill that has passed all its stages in another place. However, the Library tells me that it has happened 13 times since 1970—about once every three years. The Salisbury-Addison convention aims, of course, to ensure the primacy of the House of Commons. The convention that has evolved is that in the House of Lords, a manifesto Bill is accorded a Second Reading and is not subject to wrecking amendments. Over the years, the convention has been discussed at length and in depth. In the case of a coalition Government without a joint manifesto—as we have now—the clearest indicator of the policy to be followed lies in the coalition agreement.

The noble Lord, Lord Strathclyde, said on 20 January in a debate on coalition government secured by the noble Baroness, Lady Symons:

“The Salisbury convention applies to manifesto Bills, but this Government did not contest the election as a single party under a single manifesto. However, the Government … were formed and are sustained on the basis of the confidence of the House of Commons. This confidence has been secured on the basis of a programme set out in the coalition agreement”.—[Official Report, 20/1/11; col. 600.]

That agreement contains the words I included in my amendment. I will repeat them:

“We will stop the top-down reorganisations of the NHS that have got in the way of patient care”.

The agreement contains no words suggesting that this enormous Bill was in the pipeline. Nor was it mentioned in either the Conservative or Liberal Democrat manifestos.

An indication of Conservative policy that reached far more people than the number who read the 110-page manifesto was David Cameron's widely reported statement made to the Royal College of Pathologists in November 2009. He said:

“It’s true, with the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS”.

Instead of having a Bill that was in a manifesto, we have one that was expressly ruled out by the words of David Cameron’s speech, and subsequently by the coalition agreement. So the Salisbury convention, if relevant here, applies in a reverse direction. If we allow the Bill to pass, we will be voting directly against the words of the coalition agreement.

It seems that there was deliberate concealment of what was planned. The Bill—or something like it—must have been in gestation for months if not years before the election. Michael Portillo said, on Andrew Neil’s late-evening politics programme, that it was not put into the Conservative manifesto because it would have lost the election, as the NHS is almost a religion in Britain. That implies that it had to be slipped in by the back door. How patronising that is. It says that we, the Conservatives, know what people need better than they do. In fact, it is possible to trace the development of the ideas behind the Bill in Conservative think tanks dating back more than 20 years.

What is proposed is probably the most far-reaching reorganisation of the NHS ever undertaken. It now has 320 clauses and 22 schedules, in two volumes, with 353 pages. It is longer than the Bill that created the National Health Service in 1946.

The White Paper, Equity and Excellence: Liberating the NHS, which is full of euphemistic phrases that everybody can agree with, did not prepare us for the Bill. Neither the White Paper nor the Bill expressed clearly the underlying intention of the Bill, which many think is to open the door wider—it is already ajar—for the market and the independent sector to play a bigger role in the National Health Service. The process was made possible first by the compulsory tendering of domestic services in the 1980s, followed by the introduction in 1990 of the internal market, which was retained by the Labour Government. They brought in the private sector to provide some clinical services, reduce waiting lists and provide certain other services.

Many have argued, with evidence and from experience, that this could have been done within the National Health Service. Short-term political gain has resulted in us now reaping the whirlwind of greatly increased costs, nowhere more so than in the private finance initiative, referred to by the BMA as “perfidious financial idiocy”. This assessment has now been confirmed by the Public Accounts Committee. Since 1990, the proportion of the National Health Service budget devoted to administrative costs has risen from 5 to 14 per cent, according to the Centre for Health Economics at York University. That is an extra £10 billion a year.

This Bill, despite its stated effects of saving administrative costs, is likely to increase them further. The Government say that the financial difficulties of the NHS are such that the Bill must be enacted quickly. However, there is no evidence that the changes suggested by the Bill will reduce costs—rather the reverse. A recent research review by a team at the London School of Hygiene and Tropical Medicine showed that competition in the health sector, far from improving National Health Service costs and clinical outcomes, had the reverse effect.

Clinicians in the proposed clinical commissioning groups will find that commissioning is a highly complex task. They will need the assistance of experienced administrators, statisticians and public health specialists, as well as competent clerical support. These experts are already being lined up. They are not experienced PCT staff who are available without extra expense, and who are now anxious about their future, as David Nicholson pointed out yesterday. They are mainly from commercial health companies. A freedom of information request revealed a list of 40 organisations, most of them private, which have been invited to bid for contracts to train GP consortia, now clinical commissioning groups. For this role, in London alone, £7 million has been allocated for the initial phase, taken from funds originally allocated for postgraduate education.

It will be argued that changes on the ground are too far down the road to reverse. However, PCTs are still in existence and could be re-established in a leaner and more efficient form, with enhanced clinical membership, perhaps bringing in pathfinder groups. A similar suggestion has just been made by Andy Burnham, our new shadow Health Minister, in a letter to Andrew Lansley. Many of us would like to know the Government’s justification for starting to implement the changes before the Bill has passed through Parliament. An inquiry might find this to be unconstitutional, if not illegal. The noble Baroness, Lady Williams of Crosby, suggested as much in a powerful article in the British Medical Journal this week.

In conclusion, I ask Liberal Democrat and other government Peers who are unhappy with the Bill to seriously consider voting for my amendment, or at least abstaining if a Division is called. The Bill is not in the coalition agreement, and it is always open to coalition parties to disagree on some issues. The coalition will not fall if the Bill is lost. I assure the noble Lord, Lord Owen, and other Peers, that if my amendment is not carried I will certainly vote for his amendment, and I urge all Peers to do so. Of course, I know that I can count on the support of my noble friends.

There are many aspects of the Bill that I have not covered. However, I am sure that others among the many speakers will fill in the gaps. I shall be guided by the course of the debate on whether to divide the House. However, I know that many thousands of people throughout the country—not only health professionals by any means—oppose the Bill and want the House to reject it. The large, peaceful demonstration on Westminster Bridge on Sunday was an example of this. They will be bitterly disappointed with the House if I do not call for a vote, and I will not ignore them.

[Baroness Anelay of St Johns]

My Lords, it may be helpful to the House if at this stage I give some guidance on an advisory speaking time. There are 100 speakers signed up for the whole of the debate, including the Front Bench spokespersons. If Back-Bench contributions were kept hereafter to eight minutes, the House should today be able to rise at about 11.30 pm. For the avoidance of doubt, perhaps I may emphasise that the next speaker is the noble Baroness, Lady Thornton, who is a Front Bench spokesperson for the Opposition. Therefore, my advice is for all speakers subsequent to her.