Health and Social Care Bill

Baroness Andrews Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Andrews]

My Lords, under normal circumstances one might have thought twice about taking part in the debate on a Bill with so many speakers of such expertise. However, this is in no sense a normal Bill, as so many noble Lords have made clear. It was presented as a fait accompli, without prior mandate or consultation; and such is the Government’s anxiety to put these changes beyond reach that they began with implementation, proceeded to legislation and concluded with consultation. The noble Earl spoke in his opening remarks of the intense scrutiny that the Bill had received in another place. Many of the changes enforced on the original Bill have yet to be debated at all. The failure regime is yet to be put before us, and critical parts of the process have been undebated.

We are therefore looking at a Bill that breaks some of the basic rules of democratic engagement. Given the fears that have been raised by what is proposed, and the fact that these most radical changes are being introduced against the greatest financial slowdown in the NHS since the 1950s, it is a duty and a privilege that we can make our voices heard, as so many people outside this House have asked us to do. I argue that the bigger the reforms, the bigger the mandate needed. This Bill may have moved away in some sense from the more extreme political ambitions for a future NHS powered by market forces, but it has left behind a morass of confusion and dismay.

Medicine, par excellence, is evidence-based; and there is evidence of how the NHS has improved. In fact, for the first time for decades, the NHS is off the front pages of the tabloids. The evidence we have, for example, of real progress in areas such as cardiovascular disease and stroke can be attributed, according to the man who led the changes, Sir Roger Boyle, to collaboration—not a word that we see in this Bill, yet. Many noble Lords, quite rightly, have spoken very powerfully of the evident need for change in the NHS and the consensus that can be built around change—driven by new possibilities, new knowledge and new expectations, but also by the inescapable challenges of an ageing society and new threats to public health.

Despite the recent—and very welcome—letter from the Minister, which set out the necessity for modernisation, one of the critical failures of the process around the Bill is that there has been no compelling public narrative or debate around that necessity. That would have enabled us all to test out the proposition that the provisions in this Bill were the only solution to the challenges of rising demand, rising costs and rising aspirations. I wonder what other organisation the size of the NHS—£128 billion—would plan change without such a narrative on which to build consensus, or an evidence base that could have been publicly contested. As the noble Lord, Lord Darzi, said—and he should know—change can happen when everyone comes together: leaders, managers, clinicians and patients. The tragedy of the situation we face is that there is, indeed, an irresistible and entirely responsible case for change, which could have consolidated a proper role for clinical commissioning, competition to raise quality, greater integration of services and greater choice, without raising the spectre of a market in health and without undermining the ethical basis of the NHS.

Above all, that case for change could have been won without exposing the service to “irreparable harm” and patients to greater risks. Those, of course, are the words of the 450 public health doctors last week. Yes, the Government have introduced important changes to the original Bill, but surely they should never have been needed in the first place—broader clinical leadership in terms of commissioning groups should have been a given. In particular, Monitor should never have been charged with a mandate to promote competition. Some things in the Bill are overdue and some are certainly worth supporting—for example, the health and well-being boards—but the Bill has now lost whatever coherence it might have had. Instead, it has turned into a sort of Frankenstein of a Bill; a lumbering improvisation of stitches, patches and mechanics. I do not want to push the metaphor too far, but the noble Earl will know that the original monster died pathetically from a lack of understanding and love. We will not, I can assure this House, let that happen. Instead, we have to work with a Bill that raises profound and distracting questions about constitutional responsibility, accountability and workability, and which is shot through with risks. It is those risks that I want to talk about.

The greatest risk is the uncertainty, following the changes to Monitor’s role, as many noble Lords have alluded to, about where the limits to competition will now lie and to what extent this is within control. Monitor may now have become a body intended to prevent anti-competitive behaviour when it is not in the interests of the patient. What on earth does that mean in practice? How will it relate to competition law? How will integration, in practice, relate to choice and competition?

I was told this morning of an instance where local GP practices wanted to offer teledermoscopy for the quicker and faster identification of malignant moles by way of photography. A local private company wanting to bid for the service has mounted a legal challenge, which has now stopped this possibility in its tracks while all this is sorted out. Imagine this sort of instance multiplied across the health service in various disciplines while patients wait and conditions worsened.

The Minister also spoke of a new level playing field for providers. The Government may want to believe that these new services will be run within the benign culture of social enterprise. In fact, we already have compelling evidence, from the failure of Central Surrey Health, that even the Government’s flagships cannot compete with the large private providers. Why else would Central Surry Health have lost out to Assura, which is 75 per cent owned by Virgin? If it cannot compete, frankly, who can?

The second and related risk is the congested landscape of commissioning, which has been very well described by other noble Lords. The organigram is enough to raise anyone’s blood pressure. The Minister referred to the NHS being consumed by layers of bureaucracy. However, he will have heard time and again—and he will go on hearing, I am afraid, from the next 50 speakers—that there are deep concerns about the new layers of bureaucracy, the landscape of decision-making, the higher costs and greater fragmentation; and, therefore, about the command and control role of the NHS Commissioning Board.

I have a few specific questions about the future of local services and commissioning. Can the Minister tell me, for example, how many patients are still not allocated to commissioning groups? Can he tell me who will now own the local hospital—previously the clear responsibility of the PCT—where there are possibly two competing providers that cross local authority boundaries? Can he tell me what will happen if the money runs out half way through the financial year when commissioning groups are still not in place? Some practices are still in the dark—although they know they have to take on extra staff, not least an accountant, because they do not know their budget for next year.

These are questions put to me by GPs, who say they are keeping them awake at night. As one described his new responsibilities: “If I had wanted to be a town clerk, I would have been one”. He actually put it rather more strongly than that. This confusion around the delivery and configuration of services in the future, which are major questions of capacity and responsibility, is precisely why we need absolute confidence in the role and the responsibility of the Secretary of State. I know the Minister is particularly good at listening. He helped the last Government improve their legislation and we have a genuine coalition across this House in the making of policy, which was to the huge benefit of the health service. He has made it clear he wants to work with noble Lords and I hope some way will be found out of the impasse over reference to the Select Committee. It will be a way of building confidence—and that is central to our task in this House.

We have been put in a very difficult position. We are seen as the point of last resort and reason. We will not play politics with the NHS, but neither will we cut short our scrutiny just because the Government have gone ahead and started dismantling the service on the ground before Parliament has decided what is right. This is a problem of the Government’s own making and our absolute and clear duty is to scrutinise and challenge the Bill as fully as we can. I fully support the reference into a Select Committee, particularly of Part 3 of the Bill, which I think desperately needs to be challenged and unpicked. Yesterday, one of the many messages I received simply said:

“I have never known people generally to be so looking forward to the Lords doing their duty”.

We shall do our duty.