Health and Social Care Bill

Baroness Tonge Excerpts

Monday 13th February 2012 Lords Chamber

[The Earl of Erroll]

My Lords, the description by the noble Lord, Lord Hunt, of the NHS Commissioning Board and its satellites shows that you do not get economies of scale, but complexities of scale. This amendment contains a wonderful concept that bureaucrats should curb their deepest urges and I think that should be in all public sector body reorganisation Bills, but how would you enforce it? What sanctions do we have against a person who does not comply and does not curb their bureaucracy? The challenge is the same as with the previous amendment: how do we motivate people to behave in a correct and ethical way, so that patients’ and the taxpayers’ interests are looked after? I do not think that it can be done by regulation, which is very sad.

[Baroness Tonge]

My Lords, I cannot resist putting my oar in on this Bill. I do so because, many years ago, I was in middle management in the health service. I had to take part in the many reorganisations that happened. I suppose the noble Lord, Lord Fowler, must have been one of the culprits who added to my misery at work. I tried to concentrate on clinical work but people pestered me about filing cabinets, which office they should work in, who would be their line manager and what exactly would they be managing. The noble Lord, Lord Hunt, is quite right to point out that as soon as you start on any sort of reorganisation, the people themselves enlarge it. They need PAs, they need offices and so on. Suddenly, they find they have no one to do the bean counting, so they need a bean counter. The Government give the impression that this is all a delightfully simple, wonderful, altruistic idea that GPs, in consultation with their patients, will commission the care for their patients. I have been a GP as well, and I can tell the House that GPs are not going to go home instead of going to the golf club, take out their laptops and do a bit of commissioning in the evening. It will not work like that. There will have to be an office block full of commissioners—just like PCTs—to do the job for them. What is worse, I understand that private medical companies are anxious to do the commissioning for the clinical commissioning groups. That will mean that taxpayers’ money will go directly to private medical companies that will advise GPs on how to commission. I find that absolutely iniquitous and will fight it to the end.

We will see a mushrooming commissioning group with its advisers, whoever they are, in an office block. It will not stop there. The noble Lord, Lord Hunt, mentioned the number of different organisations that had been set up. The noble Lord, Lord Harris, mentioned the connections between them. It was deliciously simple for him to give us the image of tentacles reaching down from the National Commissioning Board to all parts of the health service. The noble Lord, Lord Rea, and I helped send round some information many weeks ago. There was a wonderful diagram of the interconnections between all the new bodies in the health service. It was like Spaghetti Junction. I am a midlander so I know what that junction is like. There is no way that one can navigate the maze of who provides what, and whether it is done nationally, locally, by local authorities or by clinical commissioning groups. It is overly and unnecessarily complicated. As the noble Lord, Lord Harris, said, we could have adapted the existing system to work much more efficiently, which would have been much cheaper and better. No wonder Professor McKee recently wrote an article in the BMJ asking who understood the Health and Social Care Bill, in which he explained that he did not understand it at all.

I will finish with an image that will delight noble Lords who are fed up with me. I went to the dentist this morning. Just as he got me in the reclining position, with the torture instruments looming, he said: “By the way, I know what I have to ask you: can you explain the Health and Social Care Bill?”. About 10 minutes or so later I noticed that his eyes had glazed over and he was reaching for the drill, so I shut up and gave in.

[Lord Newton of Braintree]

My Lords, I hope that the noble Lord who moved the amendment will accept my apologies. I needed to recuperate after the previous debate so I was not present for the earlier part of this debate. Therefore, it is probably unwise for me to speak. However, I have checked that I will not cross the path of my noble friend Lord Fowler in what I intend to say, so I will risk it.

The noble Lord, Lord Hunt, will also recall—if I dare advert to it—that we had a somewhat jocular conversation in a cafeteria last week. He sought my support for the amendment and I said that I thought he was joking. There is a serious point here. First, we really should not include in primary legislation things such as minimum tiers of management. Secondly—I say this with an eye on my own Front Bench as well—one of the most irritating features of the discussions for any practitioner is the naked populism of assuming that anybody who is not a doctor or clinician contributes nothing to the service. I have been chair of three health trusts, as well as Health Minister many years ago. What do we mean by “bureaucrats”? Do we mean the people who pay the nurses and doctors, and who make sure that the drugs are ordered on time and organised in neat rows? Do we mean the people whose duty is to pay small businesses in time so that they do not go bankrupt? We are all against having a system in which it takes 25 men to change a light bulb and costs about £20 when the rest of us could go out and buy one and put it in the socket. I am not talking about that kind of thing but about the fact that these resources—nurses, doctors, pharmacists and a lot of other people—are precious, and if they are not well organised by people setting up sensible systems, we will not get the best out of them. The constant knocking of management under the heading of “bureaucracy” is deeply counterproductive and I will not go along with it in the course of these debates.

I will make two further points. First, why do so many GPs’ practices have practice managers? It is because they recognise that somebody needs to manage the resource to get the best out of it. The managers perform a very valuable role. My second and even more important point, born of my experience in the three health trusts, and perhaps particularly at the Royal Brompton and Harefield, is that it is critical to involve doctors in that management. Therefore, in some ways the problem is much more complicated than has been registered. Trusts where managers sit in one silo and fire bullets or bombs at doctors sitting in another do not work. We need to engage doctors and, where they have an interest in performing a managerial role, train and involve them as managers. That is what we did at the Brompton—which was no great credit to me—and it transformed things.

This is a grossly oversimplified amendment. It does not belong in primary legislation. It rests on a crude, populist misunderstanding of what we mean by bureaucracy and management in the NHS.