Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 12th October 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, no one could dispute that the NHS needs to change to meet its challenges, drive up quality to be universally good, and narrow health inequalities. The way to bring the benefits of research and innovation to people's health, whatever their condition, is for the NHS constantly to change and evolve. But if it is more fragmented by external ownership, any irreversible damage may not be evident for several years. The real concerns about this Bill are neither a resistance to change nor vested interests. They come from all quarters because there are so many changes to the NHS in the Bill and so many needed changes that are not in the Bill. The more we ask questions the more we are told that secondary legislation will sort out the detail.

The key risks with this Bill identified by the impact assessment include whether clinical commissioning groups have the capacity and capability to engage with and deliver clinical commissioning and to manage risk, and how the Commissioning Board will deal with the potential conflicts of interest for GPs as providers and commissioners of patient care. As my noble friend Lord Kakkar said, Nolan principles and oversight of primary care need to be on the face of the Bill. With excessive autonomy, how will we avoid a patchwork of services, with rarer conditions left out in the cold? Planning of services has always required a critical mass of population, but how will that planning happen now? Will public health, the Commissioning Board or the clinical commissioning groups have the final say?

A real concern is for patients of all ages with complex, long-term, but not very rare conditions. Rare conditions will be centrally commissioned; common conditions are to be dealt with by GPs. In children, for example, conditions such as cerebral palsy, diabetes, Down’s syndrome or survivors of leukaemia are rare for a GP but not rare in paediatric practice. It is this middle group that risks falling between the cracks. Their real needs are for excellent, small-volume services. The choice—the real choice—they want is to have a service rather than no service or one restricted by stealth. Allied health professionals can be key, but where do they feature as core professionals? In the Nottingham area, we have already seen restrictions so imposed that they cannot practise properly.

Clinicians are used to rationing; the ethical principle of justice embodies it. Clinicians are also inherently competitive. It is their professional pride, not money in their pockets, that can be harnessed to drive up quality. We face the Nicholson challenge of savings and yet the impact assessment questioned the ability of GPs to deliver potential financial savings as well as transactional costs. There is also a question about how much this Bill is going to cost.

The Minister said that improving quality is motivating this Bill. But the NHS Confederation has said the jury is out on whether the Bill will actually improve quality. With more than 8,000 separate contacts, how can the Commissioning Board possibly manage primary care from a distance and monitor the quality and value of the service? The patient voice is a powerful driver to improve quality and it must be strengthened. We all welcome that. Patients’ feedback on their experience of care can change practice, so feedback from patients on the way complaints are handled and collated must inform commissioning. However, it is unclear how the Commissioning Board will discharge its responsibilities for involving patients, the public, and public health in its plans and decisions.

Let me turn briefly to “any qualified provider”. The hospice movement has provided this par excellence, sitting outside the NHS yet increasingly integrating. Where hospices have delivered best is where they have collaborated and integrated with the NHS, rather than competing fiercely for funding. I need no convincing of not-for-profit providers. However, people must have the protection of recourse to the health ombudsman, whoever the provider is—not only if it is the NHS—and every provider must have adequate indemnity.

My noble friend Lord Mawson spoke of the stifling barriers to progress when systems are not integrated and simple patient data are not available. There is a tension between collaborative integration and the possessiveness that can come from commercial competition. We must use our patient data better, not make it more difficult for them to be transferred. The personal profit motive can distort; incentives not to refer patients to other clinicians can cause delayed diagnosis. They neither achieve better quality, nor save money overall in the long term. It is good general medicine that decreases inappropriate referrals and ensures the best use of secondary care, and that requires closer integration of primary and secondary care, not less. The Government need to confirm that such integration will continue and be fostered under the proposed changes. We will meet our workforce needs only if the provision of educational and training resources is embedded in the contract with any qualified provider and is part of every tariff.

The duty to facilitate research must be strengthened in the Bill. Research drives up quality of care as well as contributing a financial benefit to the UK; when money is tight we need research more than ever. Change and innovation are essential for our health services to keep abreast of improved outcomes, to promote independence and to meet patient need. Change and innovation are driven by research. That is why universities and hospitals need to integrate more, not less.

In the past I have said that the NHS must stop being a political football. But removing so much responsibility from the Secretary of State feels more like abandonment. The recommendation of the Constitution Committee is that the Secretary of State's role be put beyond legal doubt. The suggestion of my noble friend Lord Owen seems to provide a good way to address this and to be time efficient. At the very least I hope that the Minister will agree to review this as the Bill proceeds.

I have kept asking whether we need this Bill to bring about the changes to drive up quality of care, improve outcomes, empower the patient voice and decrease layers of bureaucracy. The answer I have consistently been given is that the vast majority of changes can happen without the Bill and indeed the most important ones are already happening. I doubt whether this House will throw out the Bill, but it must amend it properly. At a time when we need to make savings and focus evermore on patient care, these reforms risk being an ever-increasing distraction for clinicians and managers. It is a credit to NHS clinical services that they continue to develop despite the uncertainty. Their concern that the NHS will not exist in five years time is driving their vocal opposition. People’s health is not a commodity to be traded.