Health and Social Care Bill

Andrew George Excerpts

Tuesday 20th March 2012 Commons Chamber

[Mr Burns]

The aim of this Bill is to secure a national health service that achieves results that are among the best in the world. Through it, the Government reaffirm their commitment to the values and principles of the NHS: a comprehensive service, available to all, free at the point of use and based on need, not ability to pay. However, we have always been prepared to listen and make changes to improve the Bill, and we have continued to do so in another place. The Lords amendments in this group fall within five main areas.

First, we recognised that concerns had been expressed about the Secretary of State’s accountability for the health service. Although it was never our intention in any way to undermine that responsibility, we have worked with Members of another place and the House of Lords Constitution Committee to agree Lords amendments 2 to 5, 17, 18, 24, 39, 40, 74, 246, 287 and 292. Those amendments put beyond doubt ministerial accountability to Parliament for the health service. In addition, they amend the autonomy duties on the Secretary of State and the NHS Commissioning Board, to make it explicit that the interests of the health service must always take priority. They also amend the intervention powers of the Secretary of State and the board, to clarify that they can intervene if they think a body is significantly failing to exercise its functions consistently with the interests of the health service. Finally, a new provision will make it explicit that the Secretary of State must have regard to the NHS constitution in exercising his functions in relation to the health service.

Although clinical commissioning groups will have autonomy in their individual decisions, Lords amendment 9 clarifies that CCGs must commission services consistently with the discharge by the Secretary of State and the board of their duty to promote a comprehensive health service, and with the objectives and requirements in the board’s mandate.

The Government also tabled amendments in response to the recommendations of the House of Lords Select Committee on Delegated Powers and Regulatory Reform, all of which we have accepted. Amendments 15 and 16 ensure that the requirements set out in the mandate, and any revisions to those requirements, must now be given effect by regulations.

Commissioning will be led by GPs, who know patients best. However, with that responsibility must come accountability. Therefore, further to the amendments made in the House requiring CCGs to have governing bodies, the other place has strengthened requirements in relation to CCGs’ management of conflicts of interest. We recognised how important it is to ensure the highest standards of probity in CCGs and accepted amendments 31, 300, 301 and 302, which were tabled by the noble Baroness Barker, and which require CCGs to make arrangements to ensure that members and employees of CCGs, members of the governing body, and members of their committees and sub-committees, declare their interests in publicly accessible registers.

The amendments also require CCGs to make arrangements for managing conflicts of interest and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes. The board must issue statutory guidance on conflicts of interest, to which CCGs must have regard.

Taken together, those amendments provide certainty that there will be clear and transparent lines of accountability in the reformed NHS. However, I cannot support Opposition amendment (a) to Lords amendment 31. The Bill is clear that CCGs must manage conflicts of interest in a way that secures maximum transparency and probity. In most cases, that would mean that a conflicted individual withdraws from the decision-making process, but that might not always be possible, for instance when a CCG is commissioning for local community-based alternatives to hospital services, and determines that the most effective and appropriate way to secure them is to get them from all local GP providers within its geographic area. In that event, it would not be possible for every GP to withdraw from the decision-making process. We cannot, therefore, agree to a blanket ban.

[Andrew George (St Ives) (LD)]

Will the Minister clarify something in view of what he has just said about the conflict that all members of the board and the CCG will have with regard to decisions on the provision of new services? Does he share my fear that the structure of CCGs results in bodies that will continue to be conflicted? Does that continuing conflict not undermine that important structure within the health service?

[Mr Burns]

I appreciate the hon. Gentleman’s intervention, but I am afraid I do not share that view. I hope that what I shall go on to say will help to give him additional reassurance on that.

There will be additional safeguards in the Bill to ensure that those processes are transparent, including the regulations that Monitor will enforce on procurement practices and its accompanying guidance. In addition, the board must publish guidance for CCGs on their duties in relation to the management of conflicts of interest. Of course, the CCGs' commissioning intentions will have been set out in its commissioning plan, which is subject to consultation with both the public and the health and wellbeing boards.

The second area in which the other place has strengthened the Bill relates to the duties placed on commissioners to ensure a patient-focused NHS. It has always been the Government’s intention to put in place reforms that support the simple principle, “No decision about me without me.” To achieve that, commissioners will for the first time have a duty in relation to patient involvement in decisions. The House strengthened those duties following the listening exercise, and they were further improved by amendments 19, 32 and 33 in the other place, to make it explicit that the duty means promoting the involvement of patients in decisions relating to their own care or treatment.

Another core principle of the White Paper was the need to eliminate discrimination and reduce inequalities in care. The Bill will for the first time in the history of the NHS place specific duties on the Secretary of State and commissioners to have regard to the need to reduce health inequalities.

To reinforce that further, the other place agreed amendments 22, 23, 36, 37, 38 and 60. These ensure that the Secretary of State, the board and CCGs will be better held to account for the exercise of these duties through their annual reports, the board’s business plan and, in the case of CCGs, their commissioning plans and annual performance assessment by the board. However, improvements in quality, outcomes, and reduced inequalities will not happen unless we better integrate services for patients. That is why we placed duties on commissioners, again for the first time, to promote integration in new sections 13M and 14Y, and made clear, following the listening exercise, that competition will not take priority over integration.

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[Liz Kendall]

I am going to finish this point.

The Minister of State, the hon. Member for Sutton and Cheam (Paul Burstow), said that all and any changes to those provisions were “unnecessary”, and denied that there was any lack of effective governance. I would remind Liberal Democrat Members that the Minister argued that putting a board in place or dealing with conflicts of interest would mean that clinical commissioning groups would fail to be “liberated”. Those criticisms were among the many issues that were supposed to be dealt with when the Government embarked on their now infamous “pause” in the Bill’s progress last spring, but they were not. The Government were therefore forced to return to the issue in the other place. However, the amendments before us are still weak, incomplete and ineffective.

The Government say that clinical commissioning groups will have to include in their constitutions how they intend to manage conflicts of interest. However, I am afraid the Government are deluded if they think that the national NHS Commissioning Board will be able adequately to scrutinise whether hundreds of clinical commissioning groups are properly implementing the measures in thousands of contracts, particularly when the board has already taken on so many other huge responsibilities for managing the Government’s new system. Giving Monitor powers to scrutinise clinical commissioning groups is inadequate for the same reason. Saying that Monitor can deem a clinical commissioning group’s contract to be ineffective, if it thinks that conflicts of interest have not been dealt with, will in effect mean closing the stable door once the horse has bolted. Indeed, there could be huge problems on the ground, as a provider may have already started delivering services to NHS patients by the time Monitor takes its decision.

Labour’s Front-Bench team in the other place tabled a comprehensive amendment to deal with conflicts of interest in clinical commissioning groups. It would have ensured a code of conduct for how clinical commissioning groups register, manage and report on conflicts of interests among its members and employees, and imposed a duty on CCG members to abide by the code. The amendment would have ensured that no member of a clinical commissioning group could take part in discussion or decisions concerning any provider of services with which that person had a registrable interest, and allowed the Secretary of State to appoint an adjudicator to investigate complaints about any breaches of the code, with a range of financial and other sanctions available, including the ability to suspend or remove a person from the clinical commissioning group. However, the Government rejected that comprehensive amendment, saying that such sanctions were unnecessary.

The Government have agreed to Lords amendment 31, which at least says that there must be a register of interests for a group, along with its governing body, sub-committee and employees, and that the register must be kept up to date, with information updated within 28 days. That change is welcome, but it does not go anywhere near far enough in ensuring that conflicts of interest are robustly dealt with. That is why our amendment (a) to Lords amendment 31 would ensure that members of a clinical commissioning group would not be able to take part in discussions or decisions about services in which they had declared a registered interest, which is the same format as in local government.

[Andrew George]

Although we welcome Lords amendment 31, which was tabled by my noble Friend Baroness Barker in another place, the hon. Lady’s amendment (a) proposes to go a stage further. I personally welcome that, but did she notice that the Minister, in justifying the Government’s position that it would not practically be applicable, gave the example of a CCG commissioning from all its membership? Does that not fundamentally undermine the argument that clinical commissioning groups cannot be conflicted per se?

[Liz Kendall]

I am simply arguing in amendment (a) that the same robust mechanisms that exist in local government should apply in this case. The hon. Gentleman will have to have a conversation with his own Ministers about what they have said in response.

The potential for conflicts of interest under the Bill is so great, and the amount of public money being spent by clinical commissioning groups so substantial, that the Government should have put in place far tougher provisions to deal with conflicts of interest. The Deputy Prime Minister has failed to guarantee the integrity of clinical commissioning groups, as he claimed in his joint letter with the noble Baroness Williams to Liberal Democrat Members. The integrity of clinical commissioning groups cannot be guaranteed by having only two lay members who will not even be independently appointed, nor can it be guaranteed through guidance for GPs, which the General Medical Council is currently developing. Indeed, I would argue that the GMC’s role should be to ensure professional integrity in the treatment of individual patients, not with regard to organisational misconduct, which would be a complete change in its current role. Nor can the integrity of clinical commissioning groups be guaranteed by national bodies such as the NHS Commissioning Board and Monitor, which will be too distant, too remote and too busy dealing with the fallout from other aspects of the Government’s Bill to be able effectively to address the potential conflicts of interest that clinical commissioning groups will face every day.

This issue might not have received as much public or media attention as other aspects of the Bill, but it will become significant in future, as patients and taxpayers struggle to determine whether their best interests—not the financial interests of GPs—are at the heart of the NHS. Examples of that have already come to light. In October last year, the Haxby practice in York wrote to its patients to say that a range of minor treatments would no longer be available on the NHS, but that they could be carried out privately at a number of clinics, including one owned by the practice itself. Those treatments included the removal of skin tags, at a cost of £56.30, and the treatment of benign tumours at a charge of £243.20.

Dr Richard Vautrey, of the British Medical Association’s GP committee, has rightly said that

“the direction of travel in NHS policy, particularly combined with the financial situation, does increase the risk of conflicts of interest for GPs which is one of the reasons the BMA is so concerned about the Health and Social Care Bill.”

Similarly, the NHS Confederation and the Royal College of General Practitioners have felt forced to issue guidance to GPs on how they should manage conflicts of interest, because they believe that the arrangements will become more complex under the Government’s plans. The Lords amendments before us are not robust enough to deal with this. It is a real concern for GPs that they will be unable to deal with conflicts of interest. That is what they are saying, and they need to be protected. The Government should support our amendment, because that would enable that to happen.

[Andrew George]

I congratulate my noble Friends Baroness Jolly, Baroness Barker, Lord Marks, Baroness Williams, Baroness Tyler and Baroness Northover on putting in a tremendous amount of work during the Bill’s various stages to negotiate and table amendments to advance the arguments that my Liberal Democrat Friends and I have expressed concern about. I have already put on record the fact that, although some of those amendments represent important strides towards making the Bill less bad, the changes still do not satisfy me to the extent that I feel that the Bill should be entitled to go forward from this, the elected House, as a piece of legislation. Unfortunately, that is not an argument that I am going to win, but I wanted to put the point on record.

Lords amendment 31 represents an important step forward, but it will merely provide a sticking plaster in what will be a fundamentally challenging scenario. The clinical commissioning groups represent a crumbling pillar in the edifice of the legislation. The big weakness at the centre of the CCGs is the fact that their members will, collectively and individually, be conflicted in almost all circumstances, and they will be unable to escape from that.

The Minister emphasised that point further when he told the House why he could not accept the amendment tabled by those on the Labour Front Bench. He told us that members of a CCG should not take part in certain discussions and decisions, even though they had declared an interest, because the groups would, on occasion, be commissioning for all their members. In those circumstances, a CCG would be incapable of making a decision because none of its board members or general members could be brought in to help because they would all be conflicted. That demonstrates a fundamental weakness in the legislation. My noble Friend Baroness Barker tabled an excellently drafted amendment to deal with that problem, but she was working within very limited parameters. The amendment would simply provide a sticking plaster for a crumbling edifice that will be unable to hold up this policy. I have a fundamental concern about the way in which the legislation will work in this regard.

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[Dr Poulter]

I rise to speak in support of the Government, and of what the previous Government did for the NHS. When the shadow Secretary of State was Secretary of State for Health—the same was the case with many of his predecessors—there was a consistent policy whereby the private sector should be used where it could add value to patient care in the NHS. That was done very effectively by the previous Government to bring down waiting times for operations, but it was not effective when it was not done in an integrated way. Very often, it was done without regard to post-discharge planning for patients but, as we heard earlier, the renewed focus on integration should help to deal with those problems.

We have some of the very best hospitals not only in this country but in the world, including the Royal Marsden and Moorfields eye hospital, where a relatively high proportion of activity is carried out by the private sector. No one doubts those hospitals’ commitment to their NHS patients or that they still provide those patients with the very high standards of care of which health care systems in other countries are very envious. We are very proud of what those hospitals do, and the Government would like to give other hospitals the same opportunity and freedom to follow their example. The Government believe that it is absolutely appropriate that we should use the private sector where it can enhance value to NHS patients. That is absolutely consistent with the previous Government’s policies, for which many Labour Members campaigned at the last general election. This Government are also committed to those policies.

[Andrew George]

I understand and respect the sincerity of the principle that my hon. Friend is describing, but can he reassure me, particularly given his understanding of the NHS and health systems, that under these proposals it would not be possible for a foundation trust to drive some NHS patients towards the private arm of the activities that they undertake, particularly in the case of procedures that are exactly the same in the private and the public sector?

[Dr Poulter]

My hon. Friend makes a valid point, and he is right to raise it. That happened in the past when, under the previous Government, private sector providers were paid 11% more for the provision of services than NHS providers, which created an incentive for the private sector to be used ahead of NHS services. This Government are committed to ensuring that that does not happen. My hon. Friend the Minister and my right hon. Friend the Minister and Member for Cheltenham—[Interruption.] I mean Chelmsford; I apologise, particularly as I get the train through his constituency on the way home every Thursday night. They have clearly stated that the Bill is about making sure that we use the private sector when it adds value for money. The hospital that uses the private sector the most—the Royal Marsden—does not have a two-tier service for NHS patients and private patients. The involvement of the private sector at that hospital greatly enhances the work of the NHS and the quality of service and care available to its NHS patients because of the increased research that is performed, the high quality of care, and the high standard of clinicians who are attracted to work there. That works well for the private sector and for the NHS.

I agree with the right hon. Member for Bermondsey and Old Southwark (Simon Hughes) that, where possible, we should be using NHS providers. The Royal Marsden, where there is a high potential cap on private sector involvement, does not use the full capacity of that cap, and there is less private sector activity than it could undertake. That is because the Royal Marsden says, in effect, “Yes, the private sector is good, but it is not only about maximising our cap and maximising our profits but taking into account the best interests of our local patients and striking a balance.” That works very well.

[Andrew George]

As I understand it, the majority of the private work at the Royal Marsden is in areas such as research and development that are not in any way similar to the services it provides to NHS patients. I asked my hon. Friend whether he agreed that where the private sector and public sector were providing the self-same services for NHS patients, there was a risk that patients might be driven from the NHS towards the private sector.

[Dr Poulter]

I hope I reassured my hon. Friend with my earlier answer. Yes, he is right that that has happened in the past. However, there is a presumption in the Bill—particularly for rural areas such as Cornwall and in Suffolk, which I represent—that the renewed focus on integrated care that we heard about earlier is the primary focus and purpose of commissioning, over and above the use of any willing provider or private sector providers. That has given me great reassurance regarding our ability to take on and deal with the big demographic challenges of looking after older people better.

I am reassured by what the Minister has said, and I urge Government Members to support the Government.

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[Paul Burstow]

My right hon. Friend is absolutely right. Hard-wired throughout the Bill are requirements on patient and public involvement in clinical commissioning groups and health and wellbeing boards. Local healthwatch will provide a vehicle for delivering much wider engagement. One criticism that has often been levelled at past attempts at public and patient engagement has been the absence of hard-to-reach groups, which are seldom heard from in our health system. As a result, their voices have not helped to shape commissioning decisions. We need to ensure that they do, so that CCGs commission effectively for their whole population. That is a key part of what the Bill provides for.

As the Bill makes its way on to the statute book, Members of all parties will need to look closely at the opportunities for far wider public involvement that will result from how it has been improved. We have listened closely to groups such as the Richmond group, which has been a powerful advocate on behalf of a wide range of patients’ groups. It has talked about the importance of involving patients far more in co-production and commissioning decisions. That is an essential component of how we intend the Bill to be given effect in the months to come.

In tabling our amendments in the House of Lords, we wanted to ensure that local authorities had greater flexibility in the organisational form that local healthwatch takes. Local authorities are best placed to make decisions about the right way to commission a local healthwatch service for their area, but they cannot decide not to have a local healthwatch organisation, and we would not allow them to do that. It is essential that the voice of patients and carers is heard loud and clear in the decision-making processes of our NHS and social care services.

[Andrew George]

I am grateful to my hon. Friend, particularly for his last remark. I know that he will come on to Lords amendment 181, but I could not find anything in the debate in the House of Lords justifying the rationale behind the provisions relating to the establishment of local healthwatch organisations as statutory bodies corporate. I am sure that he is just about to provide that rationale.

[Paul Burstow]

I am grateful to my hon. Friend for the opportunity to do just that. First and foremost, I want to be absolutely clear that local authorities are under a statutory duty to ensure that local healthwatch arrangements are put in place. The Lords amendments do not change that one iota, and they do not in any way weaken the statutory functions conferred upon local healthwatch organisations. Nor do they enable local authorities in some way to limit, restrict or censor what local healthwatch organisations can do. Indeed, we tabled amendments to ensure there are better safeguards in relation to how local authorities carry out their role. The Secretary of State will be able to publish guidance relating to potential conflicts of interest between a local authority and its local healthwatch organisation, to which both sides must have regard. We have provided for HealthWatch England to make recommendations in that respect, but to be absolutely clear, local healthwatch has a statutory basis. All that has changed is that we want to enable local decisions about whether it is a social enterprise, a voluntary organisation or another format.

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“reform fatigue among local activists.”

[Andrew George]

I am listening carefully to the hon. Lady’s arguments about the structure and funding of local healthwatch bodies and HealthWatch England. I ask this question not to be deliberately mischievous, but in view of her comments and criticisms: what is the preferred option of the Labour party for those scrutiny bodies?

[Liz Kendall]

I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords, which set out how we could have a separate independent, body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.

National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK, Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.

Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.

The risk register says that there is a high risk that

“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities

“will not invest in establishing effective relationships with existing LINks and other community organisations”

because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch

“doesn’t work effectively with providers and commissioners. HW is not fully representative.”

It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:

“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”

The cause is identified:

“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”

Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.

Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[Interruption.] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified

“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”

The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.

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[Simon Hughes]

I understand that. I was not pretending that everything could be dealt with in regulations. I said to the hon. Lady, I hope fairly—I am trying to be fair—that I thought she made a good point that the proposal has come late in the day and does not have the support of the people leading the community involvement at the moment, one of whom she cited and whom I have known for many years. I do not think that the Government have yet given a full explanation of why the new proposals are better than the old ones. I understand why they have suggested that there should not be a one-size-fits-all approach, but I hope that in his winding-up speech the Minister will explain, because I think that Ministers have a case to answer.

[Andrew George]

My right hon. Friend will have heard me intervene on my hon. Friend the Minister of State on that issue, seeking the rationale behind the decision to remove the statutory basis for HealthWatch. As I understand it, his response was that there would be a statutory measure to achieve this—healthwatch organisations would be tied in with local authorities. Does my right hon. Friend agree that there is a potential weakness there? If we are seeking to integrate health and social care, a conflict of interest may arise if a body is tied in with the local authority but is also supposed to be scrutinising the activities of that authority.

[Simon Hughes]

I understand that point and share some of those concerns. I hope that the Minister will explain before the end of the debate why the more variegated model will not carry the risks that were alluded to by the hon. Lady when she read from the document earlier and by my hon. Friend.

I want to flag up two other things in relation to accountability, one of which is to do with the decisions made by the commissioning groups. Like many colleagues, I met a group of my local doctors again the other day. They had two areas of concern. First, they had concerns about the Bill. There is a lot of work to be done by Ministers and by all of us to allay concerns about the Bill when it becomes an Act—that is, on the basis of the facts, not the fiction. There is a huge amount of work to do. I do not think that we should underestimate that. Secondly, they have concerns about the system as it is now, before any measures have become law. I hope that Ministers have heard those concerns, some of which are not of this Government’s making but derive from previous legislation.

There is a concern that there is an excessive interest in some places in looking for private work and private contracts. There is a concern that the middle class and well heeled will speak more loudly and influence the commissioners in their interests, rather than in the interests of the poor and the vulnerable. That is a real issue in a constituency such as mine, where a lot of people are on low incomes and in need of a good public health system.

I want to put on the record that, although I understand the argument about getting rid of tiers of management and giving GPs the power to commission, and that is a good thing, it will not be a good thing if the decisions end up being taken not by GPs and the commissioning groups and the people who are meant to be taking them, but by the people they appoint to do the work for them. They may be private sector companies or somebody else. We have to make sure that it is health service professionals who make the decisions, in an open, accountable and transparent way, not people they employ, who may have a big vested interest in capturing more work for their own commercial gain.

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[Mr Deputy Speaker (Mr Nigel Evans)]

I thank the hon. Lady for her point of order. It is in order for the Minister not to be here at this moment in time, and it is up to each Member’s judgment as to what to make of that.

[Andrew George]

It is a pleasure to follow the right hon. Member for Wentworth and Dearne (John Healey), who has taken us round a number of issues, particularly in relation to the public’s ability to scrutinise, through the proposed healthwatch organisations, the effective delivery of commissioning in their areas.

As my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) suggested, there is a desperate need for provision within our procedures whereby important Bills such as this, which have been significantly altered in another place, can be reviewed on Third Reading. Our earlier debate about the still unpublished transitional risk register was, in a sense, a proxy for that lack of a Third Reading debate.

This debate has placed public health and the role of HealthWatch, particularly local healthwatch, in the context of local health services being placed at risk. We have already discussed how clinical commissioning groups may be fundamentally conflicted. In my contribution to that debate, I posed questions about the conflicts that intrinsically exist within those organisations. I believe that HealthWatch should be there to provide scrutiny of those conflicts. Throughout the debates on the Bill, fundamental concerns have been expressed about the fragmentation of local health services. We need a strong and independent-minded local healthwatch in all our areas to be watching for that and looking out for opportunities to maintain the integration of local services.

I fear that one of the effects of such a major reorganisation of the health service nationally and locally will be to make it more difficult to deliver the £20 billion efficiency gain that the previous Government proposed and that the coalition Government intend should be delivered. That issue needs to be considered at national level, with HealthWatch, and at local level. I believe that we need an independent body that is capable of ensuring that efficiency gains are being achieved at local level and that keeps an eye on the commissioning and delivery of local health services.

The Royal College of Nursing has said today that there is a need to look carefully at staffing levels in front-line health services, including in acute hospitals. There is a debate about whether that should be mandatory. That has long been a concern of mine when looking at the delivery of local health services and it is identified by people when they visit hospitals. There are staff-to-patient ratios that, in my view, are barely tenable and barely safe. Qualified nurses are struggling to provide the support and care that patients require, simply because the staffing ratios are inadequate. The same ratios may have been adequate in the past when the throughput of patients and the acute status of patients were lower, but with the current turnaround of patients and their acute status, it is no surprise that the RCN’s survey has identified the need to review staffing levels in our wards.

[The Secretary of State for Health (Mr Andrew Lansley)]

In commenting on the level of nursing staff, will the hon. Gentleman observe that since the election, there has been a 5% improvement in the ratio of nurses to occupied beds in general and acute wards?

[Andrew George]

I am not in a position to doubt that figure. The question is whether the ratio is sufficient to ensure that there is safe staffing in our hospitals now, as the RCN identified after a recent survey. I understand the argument advanced by Ministers that it comes down to the management and the management of paperwork within hospitals, and is not just about staff-to-patient ratios. I do not want to have a debate just about staff -to-patient ratios, but that issue has been raised today and I believe that it resonates with people out there in the country, who can see that nurses in particular are struggling to provide adequate services within their hospitals. Those ratios have an effect on the level of care that nurses can provide, as has been found by a variety of reports. The problem is not down to the callousness of the nurses or untrained care assistants who provide the services—where that exists, it should clearly be rooted out of the service—but to whether staff resources are sufficient to maintain safe services on our hospital wards. I think the RCN is right to raise that issue.

That concern is relevant to ensuring that we have adequate local healthwatch services because it shows that we need independent scrutiny of the health service by a body that is not in the pocket of anyone, including the local authority, but that is able to scrutinise hospitals and speak out about staffing levels in its area. We cannot be dependent on the RCN reporting such matters to the Department and on there being top-down diktats that impose mandatory staffing levels that apply in all circumstances. Rather, there should be a local healthwatch that looks at the guidance and recommendations of the professional bodies and ensures that the services in its local hospitals are adequate to provide safe nursing and hospital care. That is why it is important to ensure that the local healthwatch bodies are, as far as is possible, independent of any external influences, whether from the Department, the NHS Commissioning Board, clinical commissioning groups or the local authority. That is where I shall take my arguments.

[Fiona O'Donnell]

I feel as if I have been here before, in that I agree with some of what Government Members are saying. Will the hon. Gentleman therefore vote with us tonight?

[Andrew George]

I shall sidestep that question at present and return to it later, because I first want to listen to the Minister’s winding-up speech. As I want to ensure that he has adequate time, I shall conclude my remarks as swiftly as possible.

I could, however, initiate a brief yah-boo interlude, such as by saying that the previous Government got rid of community health councils. Many people look back at the era of CHCs as the halcyon days of independent scrutiny of local provision. In creating local healthwatch, we should as far as possible mirror, and learn from, the excellent services provided by the CHCs.

[Liz Kendall]

On 26 October 2006, when the Secretary of State was the shadow Secretary of State, he set out his policies on HealthWatch. He said:

“I envisage it as an independent body with a separate funding stream and the right to decide its own agenda of work.”

Does the hon. Gentleman agree that that has been completely changed under this Bill?

[Andrew George]

Earlier, I asked a question about the rationale behind the last-minute change from having independent bodies to the situation now, under which, as a result of both a proposal we are debating this evening and an amendment tabled in the Lords, we are allowing local authorities to commission community interest companies or others to provide the healthwatch function in their areas. That ties the local healthwatch into the local authority. I believe we should devolve and localise, and empower local communities as far as possible, but this change does not achieve that. Instead, it empowers the local authority. If there is a genuine intention to ensure that we have integrated health and social care, then there is a problem here. If the local authority provides both the social care and the local scrutiny, I fear we may not have effective scrutiny of the work of the local authority in this regard.

Liberal Democrats in the Lords have done excellent work in advancing a large number of amendments to improve the Bill, and I am perplexed that the proposal before us tonight appears, in effect, to backpedal from that progress made in other areas. That is why I hope the Minister will reassure us on the rationale for this proposal, and assure us that the new body will be genuinely independent and genuinely effective. I shall therefore reserve judgment on the question of which way to vote tonight.

[Grahame M. Morris]

Although the HealthWatch issue is important, in the brief time available to me I want to talk about Lords amendments 249 to 283, dealing with the health and social care information centre and patient confidentiality. The amendments raise several issues about who would have access on a mandatory basis to the information provided by the centre as well as changes in the terminology used to refer to the persons who would be able to make such requests. There are important issues here about patient confidentiality and protections to ensure that the right checks and balances are in place. I am sure Ministers will be well aware of the arguments made in Committee about the issue, and I wish to seek some assurances and express some concerns. Perhaps the Minister may be able to address some of them.

One issue that was raised in Committee was the power of the Secretary of State to direct the information centre as he wishes. The Opposition think it is a good thing that the Secretary of State should discharge certain powers, particularly when failures happen, and be held to account for them by the House. Naturally, we support the view that people should have greater access to, and control over, their health and social care needs and the care that they receive. I am sure the whole House can subscribe to that idea. However, the opportunity to access health and social care records has to be tempered by protections for patient confidentiality and, equally importantly, protections to prevent the misuse of information by private bodies.

The Opposition have raised the issues of access to patient information and privatisation, and expressed concerns that sensitive information may find its way to organisations that will use it for commercial reasons. In Committee, my right hon. Friend the Member for Rother Valley (Mr Barron) spoke about the value to patients of anonymised data, which enable them to make relevant choices. It is not a huge leap of faith to imagine that those same data would be commercially valuable to pharmaceutical companies and commercial interests. I am concerned to hear from the Minister that adequate safeguards are in place in the Lords amendments.

Health and Social Care Bill

Andrew George Excerpts

Tuesday 13th March 2012 Commons Chamber

[Andrew George (St Ives) (LD)]

I beg to move an amendment, to leave out from “Bill;” to end and add:

“declines to support the Bill in its current form; and calls for an urgent summit of the Royal Colleges, professional bodies, patients’ organisations and the Government to plan health reforms based on the Coalition Agreement.”

It is a pleasure to follow the hon. Member for Walsall South (Valerie Vaz), a fellow member of the Health Committee, who talks with great knowledge and, from the manner in which she handles herself in the Committee, is clearly very committed. The primary concern of us all in this debate is the future of the NHS; I do not question anyone’s motives as far as that is concerned. That is why I was particularly pleased when the right hon. Member for Leigh (Andy Burnham) opened the debate by reassuring us that we would have a non-tribal, non-partisan debate, and that is also why I feel rather saddened that the debate so quickly degenerated once again into tribalism, which I am sorry to say will seriously undermine our chances of coming forward with a rational solution to the intractable problem of what to do with the Bill.

Although the positions have become further entrenched by the debate, I am concerned about its outcome, because ultimately we will not defeat the Bill. This is not Second Reading, when Members could independently make up their mind on the issue outside the tribal mix. We should debate the matter in a manner that might assist the Government to reflect on where we are. I hope that ultimately they will withdraw the Bill, which is what many of us want them to do. As far as I can see, the Bill cannot be defeated by either House, so the power, and the fate of the Bill with it, lies pretty much entirely in the hands of the Government.

Although I understand that the Secretary of State is obliged to advance the arguments in the way he did today, I am concerned. Therefore, if we are to advance as I propose by withdrawing the Bill and, as set out in the amendment, calling a summit of those who want to take forward a lot of what I think is good in the Bill and in the coalition agreement, I am not sure how that could be achieved on the basis of what we have heard so far. Clare Gerada, the chair of the Royal College of General Practitioners, this morning talked about withdrawing the Bill in order to stabilise the NHS and ensure that we go forward without basing the future of the NHS on ideology, but we of course need to do that while ensuring that everyone is working together.

I agree with the Secretary of State’s approach to the issue, which is that no change is not an option and that change and reform are of course required in the NHS, but I think that it is better that we take this forward on a more consensual basis than the Government have achieved so far.

I already have only a little time left, so let me say something about the Secretary of State himself, because his commitment to the NHS has been questioned in today’s debate. Let me make it clear to my right hon. Friend—in this regard—that, as I said on Second Reading, I believe that he approaches the issue with the very best of intentions, and I would never question the sincerity of his commitment to the NHS over many years, which I highly respect, along with his knowledge of the subject; our disagreement is on the judgment of the legislation. I do not know whether that metaphorical embrace will damage his reputation among his Conservative colleagues, but I hope that it will not.

There are many failings in the current legislation.

[Andy Burnham]

I am listening very carefully to the hon. Gentleman, but may I push him a little? He says that the Bill cannot be defeated, because of parliamentary arithmetic, but what is his take on the points that his right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) made? Is it not the hon. Gentleman’s understanding that the Lib Dem conference withdrew its permission for his peers to vote for the Bill? Does that not therefore take permission away from Liberal Democrat MPs to support it?

[Andrew George]

The right hon. Gentleman is aware that the conference was advisory on the issue. The motion before it actually congratulated our noble Friends in the House of Lords on having achieved significant amendments to the Bill. They have made the Bill less bad but not good enough to make it acceptable to myself—or indeed to many of my colleagues.

The right hon. Gentleman knows very well that Liberal Democrat Ministers and others cannot vote against the Government, so it is not very helpful of him to try to tease out such a situation. The pressure on those who are not so constrained has, however, been lifted.

[Mr David Anderson (Blaydon) (Lab)]

For the purposes of clarification, would the summit that the hon. Gentleman’s amendment puts forward include the trade unions? If not, why not?

[Andrew George]

The summit should be as inclusive as possible—so that there is no sense of it being exclusive. The professional bodies and patient organisations in the amendment would be included as well, so I hope that the hon. Gentleman is reassured on that point.

I congratulate my colleagues in another place on what they have achieved, but underlying that is a concern about the role of the private sector. Serco in Cornwall provides an important out-of-hours service, but there are serious concerns about how the service is being run, and I have raised concerns about that over the past year. The Secretary of State has pointed out that the contract was let under Labour, but even so we can learn lessons from the previous Government’s failings on letting private sector contracts, and there are issues, which I shall take up with the Secretary of State, in that regard.

The purpose of the amendment is to ensure that the debate calms down and becomes less tribal, so that people can speak more freely and the Government can reflect on the fact that the Bill has less support than it did when it started. Support is ebbing away, and opposition to it is increasing even at this stage.

[Mr Adrian Sanders (Torbay) (LD)]

Will my hon. Friend give way?

[Andrew George]

I cannot at this stage. I am sorry about that.

I urge the Government to reflect on this debate and on the opposition in the country, to withdraw the Bill and to allow such a summit to go ahead.

Adult Social Care

Andrew George Excerpts

Thursday 8th March 2012 Commons Chamber

[Barbara Keeley (Worsley and Eccles South) (Lab)]

May I start by congratulating the hon. Member for Truro and Falmouth (Sarah Newton) on leading the debate and on the way in which she has just opened it? It is good to work with her on the all-party group on social care. In debates such as this we work together to ensure that social care receives the focus that it needs to have in the House.

I want to discuss two aspects of the future of social care. The first is the current crisis in care and the need to bring in extra resources to close the funding gap. The second is the recommendations of the Dilnot report, which the hon. Lady has already touched on, which mainly focused on dealing with the catastrophic cost of sustained high-level care and support.

On the funding gap, the Minister told me and the Health Select Committee recently:

“We don’t accept the position that there is a gap. We have closed that gap in the spending review.”

However, Age UK’s “Care in Crisis” report says:

“This year spending on older people’s social care in England has fallen by £500 million and the funding gap is growing. … We project that by 2011-13 the Government would need to spend £1 billion more than this year to stop the situation getting any worse. … The current system is at breaking point.”

Research by Age UK showed that 82% of local authorities now provides care only to those with substantial or critical needs. Fewer than one in five local councils still provide care for those with moderate needs. I have to say I am happy that that includes my own local authority of Salford.

The Economic and Social Research Council centre for population change has looked at the issue of unmet need for social care. It concludes that, regardless of the data source used,

“there is significant unmet need for care among older people.”

For example, 66% of people aged over 65 who need help with bathing were not receiving any support. That figure was based on data from 2008 and since then we have had front-loaded cuts to local authority budgets. I am sure that, although there is no up-to-date estimate, there are greater levels of unmet need than the figure I have given.

The Association of Directors of Adult Social Services has reported £1 billion of cuts to adult social care budgets in 2010-11, with further cuts predicted for next year.

This week many of us were involved when about 1,000 campaigners and 60 organisations lobbied Parliament for the urgent reform of social care and an end to the care crisis. For the first time, thousands more who could not attend Parliament joined the lobby online. A statement from those care and support organisations to MPs and Ministers said:

“Our social care system is broken. It cannot cope with a rapidly ageing population and positive impact of people living longer with illness and disability. Those who use our social care system can no longer tolerate a social care system which leaves many with no support and others with poor quality services. The public are angry that they can face huge care charges and end up losing all their savings or being forced to sell their home.”

One of the 1,000 people who came to Parliament to lobby MPs was a deaf-blind woman from Manchester who got up at 5 am to travel down because she said she was so worried about the future of social care. The Care and Support Alliance said that MPs heard personal experiences from people who need care but are receiving none, disabled people unable to access the support needed to live independently, families paying huge bills for care and carers pushed to breaking point.

I wanted to test the situation in my local area before the debate. Over the past few days I checked with three organisations that support older people and carers in Salford and the neighbouring area in Greater Manchester. This drew a depressing but familiar picture of services worsening, mainly due to budget cuts, but also due to cuts and organisational changes brought about by the NHS reforms. A staff member at Parkinson’s UK in Greater Manchester told me about her clients, people who have worked hard all their lives but are now struggling to pay for services that are essential to them. In some cases she had to apply for grants to help people with Parkinson’s buy a profiling bed or even pay off debts.

The staff member told me about a couple struggling to pay for the care needed by the husband, who has Parkinson’s. To help get him out of bed and dressed costs £22 an hour, and having someone sit with him while his wife does the shopping costs £11 an hour. Another carer of someone with Parkinson’s and dementia had her respite care cut from two weeks a year to one week. She feels that she cannot cope without those two weeks of respite. The staff member also told me that budget cuts mean that people with Parkinson’s can wait for a year for a stair lift, and she knows one man who has to go to bed at 7 pm because later in the evening his mobility gets worse and he cannot manage the stairs.

The staff member also told me that NHS efficiency targets mean that GPs are switching to cheaper brands of drugs for patients with Parkinson’s, but many of these are less effective. One person she told me about was admitted to hospital after becoming ill following a switch to a cheaper, less-effective medicine. The hospital staff had told her to “be firm with her GP” and insist on the more expensive brand. We have to be realistic that that is a difficult thing to do. NHS budget cuts in the local area have meant the loss of the community matron service, a service that was used by Parkinson’s UK staff for many of their clients but has now ended. In Salford—I have raised this point before—the primary care trust ended the pilot of active case management for people with long-term conditions, which was proving popular and effective.

Locally, Age Concern has told me that it has now lost the funding for a “Friends for Life” pilot scheme, which was part of the national dementia strategy. Its dementia support service has a planned income reduction of 40% over three years. It has had to make seven staff redundant and reduce its dementia support. Funding for day centres is being reduced by one fifth and will then be ended owing to the switch to direct payments from individual budgets. We all support personalisation and individual budgets, but not if it is a cover for cuts. I was disturbed to hear of a couple of cases where that is happening. In one case I was told about, a carer who had previously had two hours of respite care was given a budget of £9 and told, “Do what you want with the money.”

Our carers’ centre manager in Salford told me of her own experience of such cuts, this time to the personal budget of a family member she cares for with a learning disability who lives in Sheffield. Following what she described as a “fairly perfunctory” re-assessment that was done solely with the person with the learning disability, with no input from a carer or guardian—that is an important point—the personal budget was cut by £10,000. In that case, the carers’ centre manager was able to lodge a complaint and get legal help from a community care lawyer, but she knows that such an intervention would not be possible for other carers. These examples are what we mean when we talk about a care system in crisis.

However, those are not the worst examples. As I mentioned earlier, we know that some 800,000 older people are left without basic care. They have been described as

“lonely, isolated and at risk”.

Those are the words of 60 experts in social care in their recent letter asking the Government to make social care reform a top priority. We therefore know that the problem of unmet need is getting worse. Much of the additional burden will fall on unpaid family carers, many of whom are already overburdened. Statistics from the NHS Information Centre show that the proportion of carers providing more than 50 hours a week has doubled in the past 10 years. I think that that is the level at which it can be counted as a 24/7 caring job, as was discussed by the hon. Member for Brentford and Isleworth (Mary Macleod).

Many organisations have sent us briefings for this debate. There is a consistent call for a solution to the care crisis. Carers UK calls for the capped costs model that the hon. Member for Truro and Falmouth talked about. It sees a cap on costs as essential. It favours the cap being set at £35,000, which it feels would give carers and families the ability to plan for care arrangements and costs, and provide an opportunity for the development of care insurance products. I agree with that assessment and would caution against setting the cap at a higher level, such as £60,000, which has been discussed in the media. That is the value of some properties in Salford, so it could mean a family losing the entire value of their home, which would be wrong.

Carers UK believes that if families know that costs will be capped, they might be more willing to buy care and support earlier. That would help to promote independence and reduce the pressure on carers, which can result in ill health, giving up work or reducing working hours. It is thought that it will be harder to produce that shift in behaviour and move towards a new market in insurance products without a capped costs model.

Care and Support Alliance members argue for an additional £5 billion to be put aside over the next three years to meet the growing demand for social care. The cases that I have mentioned show that there is a clear need for additional resources to meet the growing demand, address the unmet need and tackle the shortfall in resources that has been growing for some years.

The Dilnot commission was given the task of making recommendations on how to achieve an affordable and sustainable funding system for care and support. Its report confirmed what has been said repeatedly for years: the current system is unfair and unsustainable, and without reform it will deliver ever-poorer outcomes for individuals and families. That includes the 1,000 people we saw here this week. The report also said that the funding of social care is inadequate and that people are not receiving the care and support that they need.

Although we may not have time to discuss this today—I certainly will not—the provision of advice and information is poor and very limited. People struggle to find financial information and advice, and there is little information and advice for carers. Worst of all—perhaps we can understand this—because the system is complex and difficult to understand, most people do not plan for, or even think about, the future care provision that they may need.

There is much consensus around the capped costs model. There is support for setting a cap at £35,000 and, as the hon. Member for Truro and Falmouth mentioned, for setting an asset threshold for means-tested support at £100,000. There are other important aspects, such as the need for national eligibility criteria and the need for local authorities to meet the eligible needs of carers. I think that those points are equally important. What still needs to be discussed, and I am not sure whether we will get into it today, is how to pay for the capped costs model and the additional resources that are needed to close the funding gap.

Care and Support Alliance members believe that there is a public appetite for reform. I think that we must take the debate across the country and ensure that the issues and solutions that I have talked about start to be debated. I have spoken about social care issues for the past seven years and I believe that they are now well understood. The 60 organisations that have lobbied Parliament this week have been lobbying on these issues for many years. The people in those organisations and the people they represent are tired of being consulted on the future of social care. What they want is action.

[Andrew George (St Ives) (LD)]

I congratulate my colleague on the Health Committee on her contribution to the report on social care. Does she agree that underlying the issue of care in crisis is an issue with the work force, who often work on the minimum income, are poorly regarded and are subjected to a lot of unfavourable reporting in the press? Does she think that we take them for granted when we look at the overall sector?

[Barbara Keeley]

Indeed, the work force issues are very important. I will not have time to discuss them today, but perhaps other Members will. The things that we hear about, such as tasks being reduced to one-minute periods and visits being cut down to very short periods, must make it a distressing and difficult job. We also have to recognise that personalisation leads to people working in an isolated way. Whereas before they might have been part of a local authority work force, they are now individually employed by care agencies and may not see anyone else. There are some new issues for us to consider, including the one that the hon. Gentleman mentions.

In 2009, after much consultation, my party brought forward plans to establish a national care service. As my right hon. Friend the shadow Secretary of State knows, Labour’s proposals for funding social care were treated as a political football, and there were some regrettable political attacks on them during the general election. That was unfortunate, and we cannot allow it to continue. I congratulate him on going back into the cross-party talks with great willingness, which must have been difficult knowing what happened to him during the election. We must work to achieve consensus across parties and across the country, because the issues that I have mentioned are becoming more pressing than ever before.

I believe I have found a unique way to link two speeches today, both of which you have heard, Madam Deputy Speaker. I talked earlier about women in sport, and this Sunday I will be running in a 10 km race to raise funds for Age UK’s “Spread the Warmth” campaign, which is aimed at making life better for older people in winter and avoiding needless deaths from the cold.

--- Later in debate ---

[Andrew George]

Will the Minister give way?

[Paul Burstow]

I will in a moment, because I made a point in direct response to my hon. Friend.

In some places, full staffing complements perform badly, while places under considerable staffing pressure perform exceptionally well.

[Andrew George]

rose—

[Paul Burstow]

I will give way to my hon. Friend, who I know works hard on these matters.

[Andrew George]

I am very grateful to the Minister, whom I respect. Poor standards need to be rooted out wherever they exist, whether among the lowest-paid care workers or the highest-paid managers, but does he accept that the care system is based on workers who work antisocial hours, who are often untrained and unsupported, and whose salaries are appallingly low?

[Paul Burstow]

I accept that we have a largely untrained work force—or they are not as trained as they should be. This is the first Government to set down the need for training standards for health care assistants and care assistants. We have signed off the funding to allow Skills for Care and Skills for Health to do that essential work for the first time.

On transparency, we need to know what is happening within caring organisations. Transparency is vital to improving the quality of services on offer and to holding providers and commissioners to account. As is happening already in the NHS, we need more information and data to improve the quality of social care. Without those, how can local authorities, individuals or their families hold providers to account?

That is why we published the adult social care outcomes framework last April, which was developed in partnership with the Association of Directors of Adult Social Services, the Local Government Association and others. I thank all those involved in developing that new tool, which has the potential radically to improve the quality of social care in England. The outcomes framework will enable local authorities to hold providers to account, and in turn enable local people to compare and contrast performance on social care in one part of the country with performance in another, and to hold their councils to account.

In the past, the emphasis has been on patients and people who use services bending to the convenience of service organisations. That must change, and it must do so faster than ever before. By focusing on the individual and integrating services around them, we can begin to break down institutional barriers that for too long have held back the improvements in care that the country needs.

Many people’s lives could be so much better. We are right to celebrate the fact that our population is living longer, and often living longer better, but we can do much more to ensure that we add quality to the extra years that the success of our health and other systems have delivered. That is why the best social care means the difference between a life of dependency and life lived with independence and dignity—the difference between a life endured and a life enjoyed, or a life in which potential is not realised or unlocked and a life in which it is.

Social care is among the most pressing issues facing us today—I believed that when I first came into the House. I hope that, during this Parliament, this Government, working in partnership with others and the Opposition on funding, can reach a consensus that can be delivered, and that we can translate that into sustained action. That is how we can do something that has not been done for 60 years.

We have inherited laws that are out of date, which make it impossible for some people to navigate their way around our social care system. It is time to change. That is why the Government will publish our White Paper and set out our plans for legislation. I look forward to more debates on adult social care as time goes by, but today I look forward to listening to colleagues, and will respond to further questions.

NHS Risk Register

Andrew George Excerpts

Wednesday 22nd February 2012 Commons Chamber

[Mr Lansley]

I have just quoted what the Labour Chair of the Public Accounts Committee said on the basis of advice from the National Audit Office, which is precisely in line with data published by the Office for National Statistics. I think I will rest on that.

I want to make it absolutely clear that I appreciate what NHS staff do and the fact that they are delivering improving outcomes. We published 30 indicators of NHS outcomes just two months ago, and 25 of them showed that performance had been maintained or improved. They had not all gone up, but that is why we are focusing on those outcomes, and not just waiting times. However, the average time for which in-patients waited for treatment was 7.7 weeks in December 2011, down from 8.4 weeks at the last election. For out-patient treatment, the average is down from 4.3 weeks at the election to 3.8 weeks now.

[Andrew George (St Ives) (LD)]

rose—

[Mr Lansley]

I know that my hon. Friend will join me in appreciating the success of the NHS in improving waiting times.

[Andrew George]

I do indeed welcome that news, and I do not question what the Secretary of State says about it. However, I am curious about the fact that on one hand the shadow Secretary of State says that it is all going terribly badly but opposes reform of the NHS, and on the other the Secretary of State says that outcomes have never been better but is pressing on with the Bill. Why is he doing so?

[Mr Lansley]

The curious thing, as I know my hon. Friend will appreciate, is that even the Leader of the Opposition says that reform is needed in the NHS because of the challenges that it faces. Of course we can debate what the nature of the reform should be, but the idea that we can simply stand still and that nothing in the NHS needs to change is not the view of NHS staff, patients, the Labour party or the Government. We therefore have to consider what the nature of that reform needs to be, and I believe in patient choice and empowering doctors and nurses on the front line to deliver care. I believe in cutting bureaucracy and removing whole tiers of management to enable that to happen, and in common with my Liberal Democrat friends and colleagues I believe in strengthening democratic local accountability in the NHS and strengthening public health services through local government operations.

The worst possible thing for me to do would be to say, “We need to reform the NHS because it is doing so badly.” I do not believe that, but I do believe we have to root out poor performance. I was shocked to hear the shadow Secretary of State and the right hon. Member for Exeter (Mr Bradshaw), who has disappeared, talking about Stafford hospital. They were the ones who never appreciated the risk of what was happening there. They know that they went through reorganisations without ever addressing the risk. The dreadful things there happened on their watch, so they might at the very least have come here and apologised. The right hon. Member for Exeter came to the Dispatch Box when he was a Minister and said, “Oh, it’s nothing to do with me, it’s all to do with the management of the hospital.”

I believe in foundation trust hospitals, which apparently the Labour party now does not. [Interruption.] The shadow Secretary of State is trying to have it both ways. He is trying to say that he is in favour of foundation trust hospitals, but that if they get into difficulties the best thing is for them to be run by the Secretary of State. He might talk to the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson), who was the Secretary of State when, in the Maidstone and Tunbridge Wells NHS Trust, dozens, perhaps hundreds of patients died of clostridium difficile infection at the Kent and Sussex hospital. That was an NHS trust, not a foundation trust. The Department of Health and the Secretary of State have no God-given ability to run hospitals directly and do so better than they can be run by the doctors, nurses and managers in charge. The point is that there must be proper accountability, and through HealthWatch, local government and the responsibilities of Monitor we will have a proper accountability structure in the Bill.

--- Later in debate ---

[Andrew George (St Ives) (LD)]

It is a pleasure to follow the right hon. Member for Lewisham, Deptford (Dame Joan Ruddock). In fact, I approach this debate in many of the same ways as the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson). I will not speak for seven minutes on the suggestion that the debate is a sideshow, but if the information were published it would, as the right hon. Gentleman suggested, be unlikely to change a single mind on the issue. That reflects our heated debates and the entrenched positions that people inevitably take. It is the nature of the process of politics—

[John Healey]

rose—

[Andrew George]

I will give way in a moment. I want to make my philosophical point first. In contrast to academia, which begins with a question or inquiry, gathers evidence and comes to a considered opinion, the pity of politics is that we begin with a prejudice and backfill with the evidence that suits our case.

[John Healey]

The hon. Gentleman said that the publication of the transition risk register would not change one mind, but does he not accept that the Information Commissioner, who has read and studied the risk register, is of the view in his decision notice that it would aid public understanding of the reforms and help to reassure the public that all the risks have been properly considered?

[Andrew George]

I agree with the right hon. Gentleman and I have signed the early-day motion supporting the release of the register. The biggest ever reorganisation of the NHS is being undertaken and it is best not to do that in the dark. It is best to have as much information available as possible. I am not suggesting that we are completely in the dark—[Interruption.] I am just saying that it is best to cast as much light as possible upon the information, so that we can have an informed debate, rather than a semi-informed one. He makes a good point about that.

I guess that publication will eventually result from this process, and I do not think it will help the Secretary of State or the Government if it is dragged out rather than conceded. If and when that happens, the Opposition and people who oppose the Bill will inevitably highlight worst-case scenarios and throw them at the Government, and the Government will inevitably look at the best-case scenarios. The nature of political debate will not be improved by this process, but I hope that debate will be better informed.

Much of the debate throughout the course of the Bill’s progress, a process in which I have been involved through the Select Committee and elsewhere, has been about trying to anticipate the effects of the reforms. It would be far better to try to anticipate these things on the basis of the best information given by people who are inside the service and providing that advice. That is why I believe the risk register should be published. The impact assessment perhaps represents the selected highlights of that process. [Interruption.] The Secretary of State may intervene on me, if he wishes to do so.

The underlying core concern—this is in the nature of how we examine these issues—is about whether publishing the risk register will negatively affect the technical delivery of Government policy and services or whether it will affect the political prospects of a party or those in government. The nature of this debate means that we assume that if publication is being resisted, it will have political rather than technical consequences. Obviously, if we thought that the risk register’s publication would have technical consequences for the effective delivery of government—that is the primary point that the Secretary of State is advancing—we would clearly need to think carefully about the release of such information.

[David Rutley (Macclesfield) (Con)]

Will the hon. Gentleman remind the House of the criteria the former Secretary of State used when he rejected publishing the register in 2009?

[Andrew George]

I am grateful for that intervention, because it plays into my next point, which is on my general concern about the nature of Opposition day debates. It is not that I think that Opposition parties should not have the opportunity to debate issues, but such debates tend to over-dramatise the political tribalism of this House. It is in the nature of government that when in government people tend to have to face up to and take unpopular decisions, whereas in opposition they tend to avoid them. Equally, on this issue, those in opposition tend to say that they would be more open, because they look at the matter from a different perspective and take the view that they would have more open government. When people come into government, they tend to err on the side of seeing good technical reasons for why they cannot engage in the process of open government.

[Clive Efford]

rose—

[Andrew George]

I will give way, although I am going to lose time.

[Clive Efford]

I shall be brief. This transition risk register refers specifically to the Bill, about which there is widespread concern. The register is unprecedented in that regard so, with due respect to the hon. Gentleman, his argument really does not hold.

[Andrew George]

I am cantering around the issues. I have signed the early-day motion, so I judge that disclosure is better than non-disclosure. However, I wish to make a further point about the kid psychology of this whole thing. We all tend to want what we cannot have and if we obsess about this issue, we might take our eyes off the ball of what the debate ought to be about. That brings us back to the point made by the former Secretary of State.

I ask the Minister who is winding up: when has the disclosure of such documents actually harmed Government public services? If we were given examples of where disclosure of information has actually harmed the delivery of effective government, we could begin to mount a case for trying to define the lines of where and when such documents should be published. On the basis of the debate so far, I am not sure that we have demonstrated that if we were given the new toy in this political playground—the publication of the risk register—it would necessarily improve the quality of the debate.

Of course, the main show, rather than the sideshow, is the Bill itself. I am concerned that if the risk register were to be published soon, and we were to have information that would perhaps help to change people’s minds and enable a more informed debate, it would not be possible to come to a considered conclusion that it would be best to withdraw the Bill because of the nature of the prism of the Westminster village. Given the virility contest in which such decisions are taken, the climbdown needed for a Secretary of State to withdraw a Bill such as this would be catastrophic both for himself and for the Government. So we end up continuing on with something that I believe could be catastrophic for the NHS—I have put my views in the public domain on many occasions on this issue.

The right hon. Member for Leigh (Andy Burnham) may want to win over Liberal Democrats, but describing us as “spineless” will not necessarily get many of us into the Lobby with him. If he does not want to contaminate his party with people he believes are so infected with such a disabling condition, I am not sure that it will help.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 21st February 2012 Commons Chamber

[Paul Burstow]

It was a somewhat longer question than that, so I hope the hon. Lady will let me go a little further than a yes or no. I tell her that at the end of December 2011 only 1.4% of patients were waiting six weeks or longer for one of the 15 key diagnostic tests, and that just five NHS trusts are responsible for about 30% of all waits of six weeks or longer. We are working specifically with those five trusts to bear down on those waits and ensure that people do not have to wait so long. Of course she is right to make her point about waits, which is why the Government are focused on the issue and have sent in the additional support needed to ensure that trusts deal with it.

[Andrew George (St Ives) (LD)]

11. If he will withdraw the Health and Social Care Bill.

[The Minister of State, Department of Health (Mr Simon Burns)]

No, Sir.

[Andrew George]

I respect the Minister, but massive opposition to the Bill is mounting at the same time as its meagre support is ebbing away. Any more rational process would have resulted in the dignified withdrawal of the Bill long ago. Is there anything that would persuade the Secretary of State—frankly, he should be answering this question—to change his mind?

[Mr Burns]

The straightforward answer is no, because everyone, including the right hon. Member for Leigh (Andy Burnham), accepts that the NHS has to evolve to keep up and meet its challenges. What matters to patients is not who delivers their care but the quality of the care that they receive, their experience of that care and the dignity and respect with which they are treated at all times. Cutting bureaucracy by a third to reinvest £4.5 billion in front-line services between now and 2015 is the way forward. Frankly, if one goes and talks to doctors around the country, one finds that they wish that Labour’s party political squabbling would stop so that they can get on with implementing the modernisation programme.

NHS (Private Sector)

Andrew George Excerpts

Monday 16th January 2012 Commons Chamber

[Mr Lansley]

When the right hon. Gentleman finds that his argument is not working, he resorts to abuse. It is very simple: the Bill is not about privatisation. Patients will have access to NHS-funded services; the commissioners of those services will be NHS commissioners who are accountable to the NHS through statutory bodies, and they will not be able to transfer that responsibility to the private sector. Provision will be determined by the choices that patients and their doctors and nurses make about who is the best-qualified provider, and that choice will be made on quality, not on any other basis.

On the simple fact that we are looking to use competition within a tariff system, studies from Imperial college and the university of Bristol have recently shown that when it is introduced quality increases. Indeed, research from the university of York’s centre for health economics suggests that, if anything, the use of such competition has tended to support a reduction in the inequalities of access and care, rather than to lead to greater inequalities.

Let me provide some examples, bearing in mind the path that the Labour party is looking to go down. The Eastbourne Wound Healing Centre, a social enterprise set up by a nurse and an occupational therapist, specialises in wound healing. Patients who go to their clinic often have wounds that have not healed over three years, but more than eight out of every 10 of them have those wounds healed in just six weeks. Should we prevent patients being seen there because it is not actually owned by the NHS?

The City Health Care Partnership in Hull provides palliative care at home for patients and does not put profit before patients. One carer said that

“this clinic is so different, the focus is about how the illness is affecting you and what can be done to support you through it.”

Should we stop it doing that?

Another example is Inclusion Healthcare, a social enterprise in Leicester, which the hon. Member for Leicester West might know. It provides specialist health care to the homeless. Jane Gray, its director of nursing and development, stated:

“We’re providing a better service than we did in the NHS. We’re able to innovate and shape our services without constraint.”

Should we shut it down? Would that reduce inequalities? No, it would make them worse.

[Andrew George (St Ives) (LD)]

I endorse entirely the Secretary of State’s criticism of the previous Government’s bias towards the private sector. I would be grateful if he clarified an issue in respect of the integration of health services. Does he agree that, particularly at the secondary and tertiary level, the question is not so much about privatisation because if the NHS was to lose its preferred provider status, the gradual loss of many aspects of secondary and tertiary services in, for example, an acute general hospital might undermine the viability of the hospital?

[Mr Lansley]

The position is very clear, as the hon. Gentleman should know from the debates that we have had. Continuity of access to services through the NHS is one of the central responsibilities of commissioners and of Monitor. If there is any threat to the continuity of those services, they can step in and take measures to ensure that the services continue, including by agreeing funding beyond the tariff to make that happen. If the extension of any qualified provider could lead directly to the loss of access to essential services for patients, the commissioners and Monitor do not have to go down that path. They can make those judgments.

I caution the hon. Member for St Ives (Andrew George) about hanging his hat on the NHS as preferred provider. Before the last election, the right hon. Member for Leigh said that the NHS should be the preferred provider. His philosophy said that the NHS should be allowed to get it wrong twice before the private sector gets a look in. From the patient’s point of view it is, of course, a very cheerful thought that they will be surrendered to the policy of NHS as preferred provider.

Curiously, in March 2010, before the election and at the same time as he said that his policy was the NHS as preferred provider, the right hon. Gentleman published the “Principles and rules for cooperation and competition”, which he seems to be very fond of and which we are maintaining. That document stated:

“Commissioners must commission services from providers who are best placed to deliver the needs of their patients.”

It also stated:

“Commissioners and providers must not take any actions which restrict choice against patients’ and taxpayers’ interests.”

The reason that the right hon. Gentleman published that document was that he knew that the policy of NHS as preferred provider was already going to be the subject of a legal challenge and that it would not survive that challenge. That is why he restated exactly the principles of co-operation and competition that we intend to incorporate directly and without amendment into the way in which Monitor does its job.

--- Later in debate ---

[John Pugh (Southport) (LD)]

Far be it from me to presume to criticise the wise counsel of other Members, but it is absolute nonsense to think that the NHS has always been a monolithic system of public provision. It is absolute nonsense to think that private health providers always think only of profit instead of providing a good service or that services delivered by a public body are necessarily less costly or always better than those delivered by a private provider. It is nonsense to think that choice and competition are never needed, that diversity is bad or that reform or improvement—I prefer that word—is not needed. Sensible, pragmatic, evidence-led arguments can be made for mixed provision, for improvement, for choice and competition, for the involvement of the private sector and for diversity. That is not the problem.

The problem is that pragmatism and evidence count for very little because for the past eight years health policy in this country has been in the grip of an unspoken ideology. Put very simply it goes like this: the Government have no real business in providing health services but should buy them from health providers in a market. Some will be private providers that will make a profit, some will be voluntary bodies or social enterprises and others will be the fragmented, dissected pieces of the old NHS—foundation hospitals, trusts and the like. All can be branded as NHS providers if we want and all can have the NHS logo. The differences between them all will become increasingly blurred and of no consequence. Some people believe it should not matter which of these bodies delivers health services so long as the taxpayer and not the patient pays and the Government keep out of the provider business. That idea is rather like what exists already in other countries, except that generally in those places it is insurance, not tax, that funds the system.

And it is not privatisation. Ministers can truthfully say, “We are not privatising the NHS.” It is marketisation. What is happening is that the Government are buying health in a market, either national or local—an external market. They are gradually giving up on providing health services and in my view clearly mean to do so. It is a beautifully clear, coherent ideology that is rarely explicitly set out, defended, discussed within parties or put to the electorate. Indeed, to do so might be electoral suicide.

Stage by stage over the past eight years that ideology has been progressed. If one assumes it and holds it in mind one can understand why hospitals have to become foundation hospitals independent of the state—that was a Blair idea—and why it was necessary to create a bigger private sector by offering it preferential terms, which was another Blair idea. One understands why services formerly run by primary care trusts, such as community nurses and the like, are being forced to become social enterprises and why it is suggested that NHS hospitals might do up to 49% private work and that private hospitals can do as much NHS work as they like. One also understands why the Health and Social Care Bill abolishes the Government power to start a new hospital, why there is such unseemly haste to extend “any willing provider” and why the Secretary of State, even at the cost of peace in the Lords, does not want the word “provide” back in the list of his powers. If anyone is unpersuaded regarding any of that, let them turn it the other way around and point to one—just one—recent policy initiative that clearly shows that that market solution is not the endgame and the ultimate goal.

I do not believe that ideology is in itself bad, and this ideology has the virtues of being clear, consistent and radical, but in my view it is basically wrong because a health market cannot ensure that health services integrate well—the Future Forum spotted that—or that scarce NHS funds are spent in the most efficient way, as previous Treasury reports have shown in abundance. It cannot ensure that people get the services to which they are entitled and it cannot ensure that health inequalities are properly addressed. It clearly cannot easily make the strategic planning decisions needed to sustain services, encourage training and organise research, which is precisely why these issues have been so problematic in the Bill and why we are going to find slimming down the financially challenged hospital sector so painful and so uncontrollable in its consequences.

I am not here to argue against this market ideology, because, frankly, few have the honesty to argue for it openly. It is not the official Labour policy or the official Liberal policy. I do not believe it is even the official Conservative policy. It was smuggled past all of us, including the general public, shrouded in vague pragmatic talk about choice, diversity, reform and independence, but we should have no doubt: it is ideology. How else can we possibly explain the headlong pursuit at pace of a set of reforms that complicate and make riskier the huge £20 billion efficiency programme? How else do we explain the overloading of bodies such as the Care Quality Commission and Monitor, whose inadequacies, if not apparent now, will soon become painfully apparent after the Mid Staffs inquiry reports?

[Andrew George]

Does my hon. Friend agree that it would be worth revisiting the issue of whether the NHS should be pre-eminent as first provider or in some other role before we finally make what may be a catastrophic error?

[John Pugh]

My fundamental point is that this is not evidence-led pragmatism. If we join up the policy dots, we see pure, simple, unalloyed faith in the market system to deliver health in this country. Time after time, in issue after issue, ideology trumps pragmatism and prudence.

The Labour motion is a potpourri of varied sentiments, some of which are true and some of which are confused, and some, given the history, that it is surprising the Opposition have the gall to table at all. However, we should be genuinely grateful to them because they have given us an opportunity—a platform—to name the beast, to define real choice and to cut to the quick.

Chris Mullin, in his excellent “Diaries”, describes a discussion with a fellow Member of this place, a Yorkshire MP, “a mild-mannered fellow”—I do not know who that would include—who in 2005, prophetically, said of the Labour party:

“We’re opening the door…Whatever safeguards we put in place, whatever assurances we give will be absolutely worthless once the Tories are in power…I think we will lose the next election. The Tories will come to some sort of understanding with the Lib Dems—”

Breast Implants

Andrew George Excerpts

Wednesday 11th January 2012 Commons Chamber

[Mr Lansley]

I am afraid that absence of evidence does not mean evidence of absence. We can be very clear, on expert advice, that there are no specific safety concerns that routinely require the removal of these implants, nor identification of any increased long-term health risks, in precisely the way I have described. I cannot go further and provide, on advice, absolute assurance, and the expert group was clear about that. That is why the French Health Minister, whom I was talking to last week, and I were clear that we should undertake additional toxicology tests on implants when they are explanted, in cases where they were implanted over a period of time, to begin to understand the extent to which they had adulterated filler material and what was in it.

[Andrew George (St Ives) (LD)]

I commend my right hon. Friend’s initiative. However, he said the following, which may have been sloppy wording: “those who have had reconstructive surgery following a mastectomy, will have received PIP implants through the NHS.” Of course, the majority will not have done so, and I have confirmed with surgeons in Cornwall that PIP implants have never been used in the NHS in Cornwall. Given that the Medicines and Healthcare products Regulatory Agency issued advice to stop using PIP implants in the UK in March 2010, can the Secretary of State confirm that this advice was acted on, no doubt within the NHS but across private clinics as well?

[Mr Lansley]

I hope I did not say what the hon. Gentleman ascribes to me. Some 3,000 women, we think, had PIP implants, and of course, that is only a fraction of the number having breast reconstruction surgery. I think I can offer him reassurance. The MHRA withdrew authorisation in March 2010, and given that there was only one distributor of these implants in this country—Cloverleaf—they will not have been distributed for use after that date.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 10th January 2012 Commons Chamber

[Mr Speaker]

Order. I am grateful to the Secretary of State.

[Andrew George (St Ives) (LD)]

When the Government introduced the Health and Social Care Bill a year ago, they did so with the claim that the NHS fails in comparison with its European counterparts with regard to patient outcomes. Now we know that that is not the case, will the Government withdraw the Bill?

[Mr Lansley]

I do not agree with that characterisation of why we instituted the Health and Social Care Bill or of the current situation. For example, the OECD published in October its latest assessment of health in a number of countries. In too many respects—for example, in relation to serious respiratory disease—we have very poor outcomes relative to other countries. What we are setting out to do in any case is to deliver continuously improving outcomes and to get among the best in the world. In too many respects we are not yet among the best in the world.

Hinchingbrooke Hospital

Andrew George Excerpts

Thursday 10th November 2011 Commons Chamber

[Mr Burns]

I can assure the hon. Gentleman, because of the way in which the agreements have been framed, that there is an incentive and a pressure on Circle to seek to deliver on reducing and—we hope—eliminating over the 10 years the £39 million historical deficit. On the question of who has what size of a deficit, I must tell him that my concern is to remove that shackle from the neck of Hinchingbrooke hospital.

[Andrew George (St Ives) (LD)]

Notwithstanding the inconsistency of the Opposition’s position, will the Minister clarify whether this marks clearly the termination of public NHS trusts as preferred providers of public NHS services?

[Mr Burns]

It was all going so well up until now, Mr Speaker. The hon. Gentleman, who has shown a keen interest in the progress of the Health and Social Care Bill, will know that we are concentrating on any willing provider—based on quality care, not price—rather than preferred bidder.

NHS Care of Older People

Andrew George Excerpts

Thursday 27th October 2011 Westminster Hall

[Margot James (Stourbridge) (Con)]

It is a pleasure to serve under your chairmanship this afternoon, Mr Betts. I thank the Backbench Business Committee for allowing us to have the debate this afternoon, and I am grateful to colleagues on both sides of the divide for supporting it. I look forward to hearing the views of other people who have a great interest in the subject.

We are here because of troubling reports about the care of older people in the NHS. I was prompted to confine our debate to the NHS by the report from the Care Quality Commission two weeks ago, which studied 100 NHS hospitals. The report was by no means an isolated study; it came on the heels of the ombudsman’s report in February and Age UK’s “Care in Crisis” report in May.

That we have a worrying problem is beyond doubt, but I hope to bring a balanced view to the debate. It is important to note that even when reports give cause for serious concern, there are significantly more examples of good and acceptable care than there are of bad. Indeed, the ombudsman’s report stated that the overwhelming majority of patients say they receive good care. I will return to the balanced view that I promised, but first I will outline the concerns raised by the latest findings of the CQC.

The Secretary of State commissioned the CQC to undertake a series of unannounced inspections in response to the ombudsman’s report. The inspections focused on outcomes, interviews with patients and staff, and observation on the wards. Two outcomes were measured: respecting and involving people who use services, which includes care, dignity and respect for privacy, and meeting nutritional needs. Forty-five of the 100 hospitals met both standards in full; 35 met both standards but needed some improvement, and 20 were not even delivering care that met minimum legal standards. Of those 20, Sandwell General hospital and the Alexandra hospital in Worcestershire—both quite near my own constituency —were found to be putting patients at unacceptable risk of harm.

If we look in more detail, we see that 60 of the hospitals were found to be meeting a good standard in respecting the dignity and privacy of patients on both the wards observed by the CQC. Staff behaved in a way that respected patients; they were positive, sensitive and respectful; they involved patients in decision making and explained treatment options properly. Where there were problems on this measure in the other 40 hospitals surveyed, not one of the hospitals was found to be failing on both the wards observed. It is noteworthy that the report found a large degree of variation in practice, and I will return to what I think that says about management and leadership later.

On the nutrition outcome measure, 17 hospitals were failing to reach an acceptable standard. Patients in need of assistance at mealtimes were not getting help; food was placed out of reach; there was no monitoring of whether patients had eaten their meal and there were constant interruptions during mealtimes. For example, a clinical round would suddenly start during lunchtime. Age UK’s report, “Still Hungry to Be Heard”, found that 157,000 people left hospital malnourished in 2008, and that the figure had increased to 185,000 in 2009. Astonishingly, 239 patients died from malnutrition in 2007.

New research published last month found that across the NHS, 9 million meals are returned uneaten per year at a cost of £22 million. One of the problems is whether we can serve three appetising meals of decent nutritional value for less than £5 per patient, which is what my own local hospital budgets for. I would say that we cannot.

As I see it from the two reports, when the scale of the problem is considered across the entire older population who are being cared for in our hospitals, it is not as great as is often reported by the media in the immediate aftermath of yet another report. However, for the older patient on the end of the worst care, it amounts to cruelty and neglect by staff.

[Andrew George (St Ives) (LD)]

My hon. Friend makes a very good case. On the key findings of the CQC report, which the media seem to report as a failure of nursing when the bulk of them are really issues of care, will she also cover the issue of the resources that appear to be going into hospital wards, particularly with the increasing acuity and turnaround of patients, and nursing and care staff to patient ratios, which appear to be on the edge in many cases?

[Margot James]

I thank my hon. Friend for making a very good point. I will return to the resourcing issue. I do not have statistics on the staff to patient ratio, but it is noticeable that it is much better in paediatric wards than in wards with large numbers of older people. Perhaps we can learn from that.

I was talking about cruelty and neglect. Staff are paid to care in institutions that are for the most part monopoly public services; the patient has no choice but to be there. In Age UK’s 2010 research, 21% of patients said they were not always treated with dignity and respect, and there has been no improvement in that figure since 2002. The figure is fairly consistent with the CQC findings and it seems to be consistent with other reports. It leads me to think that the problem we must address is twofold: first, the overall figure of one in five being essentially ignored—or worse—in our hospitals is simply too high, and secondly—the worst aspect—nothing ever changes that figure. Despite all the reports and information, nothing actually changes that figure.

Care is failing one in five of our older patients two or three times a year. The new research confirms that failure, but no effective action is taken to remedy it or to reduce the problem. I hope that as a result of our collective ongoing efforts, we will finally make a significant impact on the problem. It is likely that one of the reasons for the inaction that has persisted for a decade or more has its roots in a wrong or partial diagnosis of the causes of the problem, so I will turn to the various causes that have been advanced by research and informed commentators on this state of affairs.

The causes that I have read about can be grouped under the following headings: leadership, management, resourcing, training and what I loosely call societal. The leadership of individual hospitals such as Stafford—to take the worst example—sets out daily through a series of explicit and subliminal messaging what it is important for staff to deliver in that institution. At most, the focus from the top will resonate further down the line in only one or two areas. Staff know, either consciously or unconsciously, that if they deliver on one or two variables, they will not be seriously picked up for partial or non-delivery elsewhere. That is the same in any large organisation. Often, the overriding concern at the top in NHS hospitals is about meeting financial targets, just as it was in Stafford. In other cases, rigidly applied clinical outcomes might bear little relation to how a patient is treated by staff before and after their care or surgery.

Leadership does not come only from the chief executive and key board members. I served on the board of an NHS trust that was answerable, in a mechanistic, command-and-control way, to the Department of Health, which in turn was accountable to the Secretary of State—I am going back 10 or 12 years. Political pressures on a Secretary of State are principally financial, but they also concern global outcomes in politically sensitive areas such as cancer. The day-to-day treatment of patients is often delegated to a regulatory quango, but irrespective of the party in power, the Secretary of State will survive the occasional embarrassment and discomfort caused by yet another report. That explains the extraordinary situation whereby the care problems at the James Paget University hospital in East Anglia were serious enough to warrant a warning notice from the Care Quality Commission, but nurse training at the same hospital was well rated by the Nursing and Midwifery Council.

Although overall management and culture is set by the board, the main divide between good and bad management depends on the effective deployment of resources, the motivation and discipline of staff, and the systems for gathering customer—or patient—intelligence. The CQC noted that in some wards, levels of under-resourcing made poor care more likely—the point raised by my hon. Friend the Member for St Ives (Andrew George). Patients commented to the CQC about how hard pressed the nurses seemed, and that was confirmed by comments about the report by nurses writing on blogs. Even allowing for a certain amount of, “They would say that wouldn’t they?”, some of the remarks seemed heartfelt and genuine.

Interestingly, however, none of the hospitals where care was found to be poor was found wanting in all the wards inspected. Unacceptable levels of care were seen on well-resourced wards, and excellent care was found on wards that were understaffed. That indicates that the issue has more to do with ward leadership and the personalities and values of nurses in leadership roles than with the overall budget at the disposal of hospitals where problems were encountered.

[Andrew George]

I am not sure that I draw the same conclusion as my hon. Friend. She suggests that resourcing is not particularly relevant when considering the quality of care achieved, but surely she accepts that the situation is far better, and high levels of care more likely, when resources are adequate.

[Margot James]

I agree that care is more likely to be good when resources are adequate, but poor care has been observed on wards that the CQC regarded as well resourced. I do not draw a neat and fast conclusion, and having worked in business for many years I accept that resourcing is important. It is difficult to generalise from the available research, but I take my hon. Friend’s point.

On nurse training, the CQC found that half of hospitals were ailing in the areas of privacy and dignity; staff had little training in matters of privacy, dignity, rehabilitation and dementia. Training, and the lack thereof, is a symptom of the growing and unregulated use of health care assistants. In a report out today, the Royal College of Nursing states that in some parts of the country, 40% of staff on a ward are health care assistants. I will return to that point.

Another important issue is the general training of nurses. Consensus seems to suggest that although Project 2000 brought benefits to nursing status and career paths, the effect on care has been less positive. Earlier this year, Camilla Cavendish, a journalist from The Times, undertook extensive research across the country. Her observations suggest that Project 2000, which moved training from hospitals to universities and gave it degree status, has led to nurses spending too little time on wards during their training, and they are under-prepared to deal with patients when they graduate. Project 2000 has also led to gaps on wards, which have been filled by health care assistants. Such assistants are supposed to be supervised by nurses, but although I have no evidence either way, I wonder whether nurses have the training for such supervision.

Patients often think that health care assistants are nurses, and it is not always easy to distinguish the two posts. Health care assistants, however, have almost no training and perform non-medical tasks such as providing help with feeding and washing. I am sure there is a degree of mission creep into areas that require some form of training, and I shall return to that point. Perhaps it is no wonder that many nurses feel that certain aspects of caring are menial work.

[Andrew George]

My hon. Friend suggests that nurses see caring as menial, but that is not an observation I would make. I had the opportunity to shadow nurses in four wards, and they told me that they wished they had more time to perform a caring role in addition to their clinical duties. Such a role would fulfil the observational function that nurses are trained to perform in order to continually assess a patient and review their diagnosis. That nurses believe themselves to be above a caring function is not a conclusion that I would draw, and I believe that it besmirches the professional standing and pride felt by a lot of nurses.

[Margot James]

My hon. Friend makes some good points. Camilla Cavendish visited hospitals across the country as part of her research and spoke to many patients and nurses, and the view I have mentioned was expressed not only by patients but by nurses. I am sure that such cases are in a minority, and I certainly do not intend to besmirch the good reputation of the majority of nurses. However, the research leads me to believe that a minority of nurses either do not have time for care or feel that although care is not beneath them, it should be carried out by staff at a different level. That is a legitimate view and has been expressed in a variety of nursing journals and other forms of media by retired nurses who have visited hospitals. My hon. Friend should not dismiss that element of concern, and I emphatically do not wish to besmirch the reputation of our many good nurses. However, when we read in the CQC report about the problems engendered by the very poor care that some patients receive, we realise that we cannot afford to dismiss any of the conclusions reached by people who have done a lot of research.

I want to move on to some societal observations. The ever-increasing use of scientific and technological advances brings many benefits, but it also creates a work environment that requires nurses to concentrate on aspects of treatment and care that isolate them from the patients whom they are serving. The workplace in general outside hospitals is becoming more mobile. People connect with one another far more via devices of various sorts. That presents a risk to the caring professions that needs managing.

Then there is the issue of the pool of talent from which nurses and other caregivers are drawn. This summer saw an explosion of violence, avarice and selfishness on our streets on a major scale. Although work is ongoing to identify the cause of that phenomenon, it is clear to many of us that the fault lines in our social fabric are every bit as wide and deep as suggested by the research undertaken by my right hon. Friend the Secretary of State for Work and Pensions, before he came into government. These incidents affect all walks of life. Much more could be said on that point, but I do not intend to elaborate on it now. For the purposes of this debate, the implication is that nurses are as much a reflection of modern Britain, with its drawbacks—a society in which a significant minority seem to be more aware of their rights than their responsibilities—as well as its strengths.

Likewise, patients and their families reflect society. Melanie Reid, a columnist for The Times, spent a year in a spinal injuries unit following a tragic accident. She wrote an excellent piece on the nursing debate three weeks ago. She said:

“If you want to change nursing, you have to change society. You also have to change the patients. Today’s sick are…not deferential sufferers in silence. They and their relatives can be aggressive and unreasonable.

Everyone’s a professional complainer. During my spell in hospital, I saw some patients whom, had I been forced to cope with their constant demands, I would have smothered at dawn. Instead, the staff treated these people with civility and good humour.”

I shall turn now to some conclusions and recommendations. I shall conclude with what I think needs to change and I hope that the list of areas to which I refer will provide a platform for further consideration by the Government. I note that the Government are already making positive changes in some of the areas, and that is welcome. My priorities for change would centre on the importance of food and nutrition in hospitals and the standards in that respect; the accountability of boards and chief executives for the care of patients; resource allocation; the inspection regime; hospital complaints procedures; and nurse and health care assistant training.

--- Later in debate ---

[Margot James]

I thank the hon. Lady for her excellent point. In an ideal world, I would strongly agree with her. I agree that what she has suggested is to be desired. The trouble with relying on that is that the throughput of patients through wards these days is quite fast, the rostering system for nurses is very complicated and the continuity of care is certainly not as good as it used to be. Many nurses work intensively for a week and then have a substantial amount of time not working. Therefore the personal relationship, which is so desirable, has been compromised to the extent that we can no longer rely on it to ensure that patients’ nutritional needs are met. That is why I believe that the red tray system is useful. However, I am very concerned that people could easily think, “Oh well, that sorts the problem out,” and not feel that they need to relate to the patient in the way that the hon. Lady suggests.

I come now to accountability. I realise that this is not something that the Government can mandate, but chief executives should come on to the wards regularly—every day that they are in work. Nurses used to be accountable to a matron, who would turn up unannounced to check on standards. We must replicate that discipline again, and I recommend starting at the top.

Managers need to ensure that budgets are used wisely to support front-line staff and that front-line staff are not distracted by other, non-patient-care “priorities”. I looked at nurse blogs when I was preparing my speech and I sympathised with one nurse who said that nurses are

“at the beck and call of so many departments who wish to give work away and have no qualms in ‘getting the nurses to do it’. Loan stores, training, HR, to mention a few who seem to have forgotten that their role is to support us—not the other way around.”

I have sympathy with busy nurses who are pulled in all directions.

[Andrew George]

I am grateful to my hon. Friend for giving way to me a fourth time, which shows how patient she is with me. Quite apart from falling into the trap of conflating care with nursing in some of her remarks—she did make the point about needing to ensure that there is a clear distinction between care assistants and nurses—does she not also agree that in terms of the management on wards, a lot of nursing time is taken away from the patient interface as a result of the enormous amount of bureaucracy and paperwork required and the pressure that many nurses come under from bed managers, who appear to overrule them when it comes to determining when a patient should be discharged or admitted to a ward?

[Margot James]

I thank my hon. Friend for his observation, and I certainly agreed with the first point he made. I shall conclude in a minute as I am aware that many Members wish to speak.

The CQC should be resourced to ensure that its inspections include weekend visits. All the observations it makes in its recently published report were based on visits it paid during the week—for cost reasons, I imagine—but I was delighted to hear the Secretary of State announce yesterday that there will be more inspections. I hope, however, that the Minister will discuss with the CQC the possibility of visits being paid at weekends, when—I hear—care can sometimes deteriorate rapidly.

Some complaints are very serious, and I am not commenting on serious medical negligence, but with many complaints the system comes over as a sledgehammer to crack a nut. A patient or family member should be able to make an informal, non-legalistic and reasonable complaint and receive a sensitive hearing from a senior member of staff, rather than be instantly given a form that starts a three-week process of churning and often ends in Members’ surgeries. I ask the Minister to discuss with the Justice Department how we enable that but avoid opening the hospital to legal challenge, which is one of the motivators to the heavy-handed system we have at present.

We must be able to distinguish between the training needs of nurses and health care assistants.

--- Later in debate ---

[Barbara Keeley]

Indeed. I do not distance myself in any way from the excellent point the hon. Member for Stourbridge made in opening the debate: this is about leadership, management, training and accountability, all of which failed in the case I have outlined.

[Andrew George]

The hon. Lady is making a strong case. On the point about whistleblowing, or protected disclosure, her own research may have shown that when a nurse, for example, suggests to senior management that there is a resource problem on a ward, that does not necessarily enhance their likelihood of improving their job prospects in the hospital. Often, they are told, “Other members of staff seem to manage, so why don’t you?” Does the hon. Lady agree that we need to look at how whistleblowing can be done safely?

[Mr Clive Betts (in the Chair)]

Order. A lot of people clearly want to speak, and I do not want to stop or discourage interventions, but if they are made could they be brief and to the point so that we can keep things flowing?