Health and Social Care Bill

Baroness Williams of Crosby Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, I agree completely with the noble Lord, Lord Ribeiro, that major changes have to be made. Those of us who are raising major issues in this debate are not arguing against change; we are not bound to the status quo. But I want to say right away that one of the things that I find deeply depressing about this long debate on the National Health Service is the number of references to the NHS as if it has somehow failed. One of the most remarkable assessments of the NHS, a copy of which I have left in the Library, is made in a report by the Commonwealth Fund of Massachusetts. It shows that on every issue from access, value for money, share in expenditure and patient satisfaction—which achieved 92 per cent—puts Britain uniquely ahead of everyone else in reply to the question, “Are you confident that you will receive the most effective treatment if sick?”. It is a staggering statement about this remarkable public service.

First, I want to underline and repeat what was said by the noble Baroness, Lady Jay. Those of us who take the view that this Bill needs to be looked at carefully, not least the issue of the responsibility of the Secretary of State, are not saying for a moment that there is no role for the independent sector, for innovators or for those with radical ideas, but straightforwardly that that must be within the framework of the National Health Service as a public service, which is what many of us believe in so profoundly.

My second point is one that I also believe to be very important. We have referred repeatedly to patients in the debate, but patients are also people. As people, they have registered time and again their belief and trust in and commitment to the NHS. We want to carry them with us through some of the biggest changes that have to be made. Those changes reflect our ageing population, which is one of the greatest successes of the NHS, along with the survival of many people with inherited or chronic illnesses. All this can be directly attributed to the work of the NHS over the past 65 years. However, now they have become a problem because we have to find ways to pay for them. Even so, they are a direct consequence of success, not of failure.

What also needs to be said loud and clear is that patients have indicated their trust in the NHS. We need that trust deeply in order to bring about the changes that must be made. I agree with the Minister, the noble Earl, Lord Howe, that those changes require that the NHS should become, among other things, more community based and that we should move away from an essentially curative, hospital-directed form of health service. But in making that huge change with all the exciting possibilities it offers, we have to carry the public of England with us. We will not carry them if their single greatest fear appears to be sustained. It was put beautifully this morning by the noble Lord, Lord Hennessy, on the “Today” programme: it is to move away from the concept of an altruistic health service to one that is essentially market based.

I have spent the past week in the United States and returned yesterday. The first thing I read when I got there was the estimate of the Kaiser Family Foundation, probably one of the best of the private health services in the United States, that the cost of health insurance has doubled since 2001, has increased by 9 per cent since last year—much more than the rate of inflation—and that the average cost of a family insurance package in 2010 was over $15,000. Not all of that is paid by the insuree as some is paid by employers, but they are running away from those costs as fast as they know how. I also read a proposal from the National Institutes of Health that great care should be taken about offering tests for prostate cancer in men when one of the side-effects is probably incontinence and impotence. Despite the advice of the central authorities, the attitude of many doctors is that they cannot give up these tests because they happen to be extremely profitable. For those who wish to read more about it, I have left the story in the Library. It is a frightening account of the conflict between medicine and its values and the pursuit of profit.

I turn now to the four big issues that confront us, and in doing so I pay tribute to the noble Lords, Lord Darzi and Lord Owen, and to others who pointed to them. The first was referred to by the noble Baroness, Lady Jay. It flows from the findings of the Constitution Committee, which has specifically raised concerns about the responsibility of the Secretary of State. At the beginning of his remarks, the noble Earl, Lord Howe, whose empathy and understanding is known throughout the House, spoke as if there might still be some meeting of minds on this crucial issue. But the letter he sent us all this morning appears to sound a little different. Why are we so concerned about this issue? It is because it remains ambiguous, unclear and obscure. Let me give one example. I think that I have been pursuing the issue of the accountability and responsibility of the Secretary of State for at least a year, and time and again I have gone back to the Department of Health and talked about the need to make it absolutely clear. Why is it not absolutely clear?

Those noble Lords who have a copy of the Bill need only look at Clause 4, which sets out a specific commitment to the autonomy of the bodies, the quangos —Monitor and, even more important, the NHS Commissioning Board—which now have responsibility for our health. The Secretary of State makes a specific pledge to the autonomy of those bodies in the phrase:

“In exercising functions in relation to the health service, the Secretary of State must, so far as is consistent with the interests of the health service, act with a view to securing … that any other person exercising functions in relation to the health service … that it considers most appropriate, and … that unnecessary burdens are not imposed on any such person”.

In legal language, “any such person” is very wide indeed. The autonomy clause indicates that only in the rarest circumstances would the Secretary of State interfere in that autonomy. So where would he interfere? The answer is that he would interfere if there was evidence of a significant failure. But my legal colleagues tell me that “significant failure” is a difficult bar to reach and that it is normally interpreted by the courts as meaning almost totally essential.

We all know about the danger of reactions to such things as necessary hospital closures, mergers and so on. But if the Secretary of State is unable to take any part in those until the failure becomes significant, heaven help us in making the changes that lie in front of us as effectively, cheaply and sensibly as we can. I wish very much that I could ask the Minister of State to tell the House at the conclusion of this debate that the ministry will now reconsider the autonomy clause in the light of the responsibilities of the Secretary of State. To put it simply, the expenditure of £128 billion of taxpayers’ money requires the presence of a Minister who is responsible and accountable for that huge sum. It is an essential part of parliamentary responsibility and of a democratic system. I fear the consequences if we fail to address this issue.

That does not mean to say for a moment that I do not wholly agree with the noble Lord, Lord Ribeiro, about the dangers of micromanagement; all of us recognise that. Endless interference with the discretion of clinicians, GPs and the professions ancillary to medicine runs against the need for change and for sensible outcomes. But there is no reason whatever why micromanagement cannot be ruled out—much of the rest of the Bill suggests it—without having this vast reorganisation thrust upon us. So let me say to the Minister of State, for whom I and the rest of the House have immense respect, that I hope that before the debate concludes he will be able to say something more about the autonomy clause and the responsibility clause.

There are several other issues of crucial importance: the failure of the Bill to address the education and training of doctors in any serious way at a time when those services are in chaos, and the Bill’s failure actually to be clear about the duties towards inequality, because the phrase “have regard to” is, in legal parlance, paper white. It does not mean very much at all. There are other points, but given the time I will not pursue them. I simply beg my friends and colleagues on whatever Bench they may sit on in this House to put the responsibilities of parliamentary democracy and accountability ahead of the detail of the Bill and recognise the significance of what has been addressed by the noble Lord, Lord Owen, and the noble Baroness, Lady Jay.