NHS Future Forum

Baroness Donaghy Excerpts

Thursday 15th September 2011 Lords Chamber

[Baroness Donaghy]

My Lords, I also thank my noble friend Lady Wheeler for the opportunity to have this debate today. We have heard reference to the start of the political party conference season. The Future Forum exercise and the Government’s response have been presented by some as a David and Goliath battle to secure major concessions on the reorganisation of the health service—plucky Nick facing up to the giant privatiser and winning while claiming that it is not about winning. But we have the wrong bedtime story here. It is not David and Goliath but more like Little Red Riding Hood. I appreciate that the noble Earl might appear to be an unlikely wolf, but let us not forget that even the wolf dressed up in a frilly nightcap and adopted a soft voice. There are more questions than answers here, and some of the original questions remain. Why is there to be a major upheaval of the health service when all the staff are working flat out to provide a good and comprehensive service? Why are more quangos to be created rather than fewer? What will be the real role of Monitor in its revised format? And why are we giving £80 billion to the NHS Commissioning Board, the daddy of all quangos?

Since the Future Forum listening exercise, and here I must commend the diligence of its members, a revised Bill has been presented which we will debate in this House in October. But the Bill gives rise to new questions. First, in revised Clause 1, the Secretary of State’s powers and duties are closer to the current duty as set out in the NHS Act 2006, but as has been said, the phrase “to provide” has been deleted on the grounds that,

“having the premises and the staff necessary to offer health services directly does not reflect the reality of the situation in which commissioning and provision rest with the NHS bodies, not the Secretary of State”.

I think we all accept that no matter how hard they might try to distance themselves, the political reality is that Governments will always be held responsible for the state of the health service. So why should we worry about semantics, and indeed, is it about semantics? The Government’s response to the Future Forum exercise stated that the Bill would,

“make explicit that the Secretary of State remains fully accountable for the NHS”.

That sounds fine, but where is the responsibility for social care, a question also asked by my noble friend Lady Pitkeathley? What will be the definition of the NHS further down the line if providers are private companies? I am not a lawyer and I have no idea what the legal implications of this change mean, but I am a graduate in English language and literature. I know what “to provide” means and I am concerned that the significance of this omission will grow and grow as the years go by.

My concern is heightened because the responsibility for defining what constitutes the health service is being transferred from the Secretary of State to clinical commissioning groups. While the Secretary of State is still responsible under the new system for the promotion of the health service and ensuring that it is free of charge, clinical commissioning groups will determine what services actually constitute the health service. Just when I tell myself that I am worrying unnecessarily, I am then reminded that in the summer, the Health Secretary instructed primary care trusts to identify three services to be put out to contract. I am supposed to be reassured that the new private providers will not be allowed to cherry-pick, but the Bill only requires transparency in how patients are chosen. It says nothing about the easiest and most profitable types of treatment to provide, which could still destabilise the National Health Service.

I turn to the role of Monitor. The language is definitely softer: its primary duty is no longer to “promote” competition, but to prevent “anti-competitive practices”, a point already raised by my noble friend Lord Rea in his contribution. The Minister in the other place has claimed that this is a fundamental change and that Monitor’s main duty would be to protect and promote the interests of people who use healthcare services not by promoting competition, but by promoting the economic, efficient and effective provision of healthcare services. Again, I would love to ask a seminar of English language undergraduates to write a critique of the difference between promoting competition and preventing anti-competitive practices; drinks on the Terrace for the best essay. The Bill gives Monitor powers to fine hospitals up to 10 per cent of their turnover for anti-competitive behaviour and a new duty to promote integration. What exactly will that mean in practice? Could we see a situation where a hospital which is struggling financially is forced into the arms of a foundation trust in the name of integration? Who will pick up the overdraft? Beware the big bad wolf.

Finally, we come to the issue of what happens if Monitor declares a commissioner’s arrangements for the provision of health services to be ineffective, perhaps where it has failed to comply with procurement regulations. Indeed, what will happen if a service runs out of money? The Government have not yet presented their revised plans for a failure regime. The Minister’s explanation was that they would not rush their proposals for such a regime as it is a complex issue and they want to “get it right”. That is the second time this week that I have come across the “get it right” reason for having no information on a vitally important topic. The first time concerned regulations on the way in which the self-employed would be treated under the Welfare Reform Bill. At some stage we really need an organigram, also called for by my noble friend Lady Wheeler, setting out what the new structure will look like, who is in charge and how social care fits into it all. Without it, I hope that Little Red Riding Hood will stay on her guard.