Health and Social Care (Re-committed) Bill

Dan Poulter Excerpts

Tuesday 6th September 2011 Commons Chamber

[Debbie Abrahams]

There are many unanswered questions about the Bill, which makes it particularly dangerous.

By opening up competition under the guise of increasing patient choice and clinician-led commissioning, the Government are trying to increase both demand and supply for these services, but the implication for a single-payer health system with a fixed budget, such as the NHS, is that this will inevitably lead to financial meltdown. The only way this can be avoided is by injecting extra capital into the system and the Bill achieves this in many ways. We need to look at not only this cluster of amendments but all the amendments and clauses in the Bill as a whole, because they are interrelated.

First, the Bill allows foundation trusts to borrow money from the City to invest. This is supported by the opening up of EU competition law. Foundation trusts are currently social enterprises and are exempt from part of EU competition, but this opening up will open the flood gates. It means that the trusts will have to compete for tenders with private health care companies. They will have to repay the money they have borrowed by treating more and more patients, including private patients, which will be aided by the abolition of the cap on income from private patients. However, many foundation trusts will still struggle, so the Bill introduces a new insolvency regime to enable private equity companies to buy NHS facilities and asset-strip them, which has direct parallels with the demise of Southern Cross.

Secondly, waiting lists will go up. We are already seeing that across the country, including in my constituency. We have seen that already because unrealistic efficiency measures mean that cash-strapped primary care trusts are rationing access to treatment such as cataract surgery and hip replacements.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

Does the hon. Lady not accept that waiting lists have not gone up in England but have gone up in Wales, where Labour is in control of the NHS?

[Debbie Abrahams]

It is very interesting that the Government have changed how they measure waiting lists and now use an average, so those indicators are a movable feast.

As waiting lists go up, new health insurance products on the market are enticing people to believe that all their treatment and care can be met fully by the private sector. This will be complemented by new insurance markets set up for top-ups and co-payments. We know from the United States that people on low incomes will be less able to afford these products directly, which will impact on the existing health inequalities that the Secretary of State has stressed his commitment to reducing. Why are we doing this? It will increase and exacerbate the inequalities that already exist in accessing care.

Finally, the Bill allows both the national commissioning board and clinical commissioning groups to make charges. I foresee that in the next Parliament there will be more direct patient charges if this Government get in again. As the NHS budget is fixed, the drive for excess capacity will drain that budget rapidly. That will result in clinical commissioning consortia increasingly becoming rationing bodies. As waiting lists increase, they will attempt to manage the issue by reducing the number of core services. That will drive foundation trusts into further debt, forcing closures, mergers and private management takeovers, and we are already seeing that.

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[Frank Dobson]

I begin with a reminder. I was one of those Labour people who voted against the establishment of foundation trusts and the setting up of Monitor. In doing so, I was supported by those on the Conservative Front Bench, so I do not think that the Conservatives should claim any consistency in these matters.

My second point is that although one would never dream it was true from listening to Ministers or their supporters, it is quite clear that the national health service is now working very well and is more popular than ever; and yet we are told that it needs a radical overhaul. However, the popularity of the national health service at the time of the last general election probably explains why both the Conservative party and the Liberal Democrats promised that there would be no top-down reorganisation of it. However, if neither the Bill as originally produced nor the post-pausal Bill that we have now is top-down change, God knows how one would define it.

The whole purpose of this Bill is to shift us away from the basic collaborative approach to the provision of health care in this country and to substitute a large amount of competition, gradually involving more and more of the private sector and, I believe, privatisation. In order to put things in perspective, it is worth pointing out that when the right hon. Member for Charnwood (Mr Dorrell), ceased to be the Secretary of State for Health, the national health service was performing 5.7 million operations a year in its hospitals. When Labour left office, it was performing 9.7 million operations a year, an increase of 58%. That was the result of improved working practices developed by—

[Dr Poulter]

Will the right hon. Gentleman give way?

[Frank Dobson]

No, not for the minute.

That change was the result of improved working practices developed by the people working in the national health service, not the result of any structural changes. It was also partly the result of the biggest hospital building programme in history, as well as a lot more new and better equipment, newer GP surgeries, 78,000 extra nurses and 27,000 extra doctors. Those were among the reasons that the NHS became so much more popular. It is popular because, for most people in most parts of the country most of the time, it is already doing a very good job. However, that is now going into decline, because many people working in the NHS carrying out pre-legislative preparatory work on the proposed changes are having to divert their efforts into bringing about structural change. That is one of the reasons waiting lists and waiting times are going up—something that the Government deny is happening.

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[Grahame M. Morris]

I am happy to give way to the Minister, if he wishes to give that assurance from the Dispatch Box. It would reassure staff and members of the public. Perhaps we can read something into the Minister’s reluctance to give such an assurance.

The Government, despite the spin, are delivering one of the most radical reorganisations ever and in the view of many Opposition Members it will undermine the basic principles of the NHS. When the Health Secretary was shadow spokesman for the then Opposition, at no point did he explain his plan to apply 1980s-style privatisation mechanisms to the NHS. I am an avid follower of health policy and the idea of creating an economic regulator—as we have discovered through a series of parliamentary questions, the costs of Monitor could be £500 million in a single Parliament—is again ironic when we hear the Government talk about waste and bureaucracy.

As for exposing the NHS to competition law, I accept the point made by the hon. Member for Southport (John Pugh), which was also made by my own Front Benchers, that it is not the provisions on the face of the Bill but the changes to the architecture of the NHS that will expose the NHS to European competition law—the same law, as we have heard, as applies to the utility companies. Health would be considered a commodity and £60 billion of the NHS budget would be handed over to private bodies, by which I mean those bodies that were the GP commissioning consortia, now renamed clinical commissioning groups. Despite the assurances about openness, transparency and accountability, those would be private-sector companies and my understanding is that they would not be open to FOI requests. That must be of huge concern to people who champion civil liberties, freedom and transparency. Over the past six years or so, we had no indication from the Secretary of State that he was planning such a radical change.

On the subject of the new failure regime, as set out in the amendments, having sat through the Public Bill Committee on the initial Bill as well as that on the re-committed Bill and having listened intently to the arguments, I cannot decide even now whether this is a U-turn or a side-step. I have read this huge document—the weighty tome that makes up the Bill, with all its various chapters and parts—as well as the impact study and the whole justification behind the Ministers’ arguments was that the NHS needed a market and a failure regime to boost productivity. Has that whole idea been left by the wayside?

[Dr Poulter]

Does the hon. Gentleman accept, however, that the previous Government failed to put in place any adequate failure regime to deal with situations such as that which occurred at Stafford hospital and that the Bill is a step towards providing a proper overview of what to do when trusts fail and let down patients?

[Grahame M. Morris]

I am not suggesting in any way, shape or form that every NHS organisation—be it an NHS hospital trust or a community-based organisation—is incapable of improvement. My philosophy, as someone with a bit of a scientific background, has always been that we should assemble an evidence base, pilot a proposal in one area, establish best practice, see where the faults lie, tweak it if necessary and then, if it works, roll it out. This leap-in-the dark approach is flawed and will end in tears. The service is hugely important and touches everybody’s life in this country at one time or another. The whole concept of the Bill is flawed and the way it has been prosecuted is compounding the problem.

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[Grahame M. Morris]

I am making rather slow progress, but I did want to get on to health inequalities. My hon. Friend makes an excellent and important point. We touched on it briefly in the Bill Committee and it relates to new clause 6. I was concerned about the reports that in the allocations to PCTs and SHAs, the element set aside for addressing health inequalities had been reduced. That should concern us all, especially those who represent areas that suffer high levels of health inequality and deprivation.

It is a bit of an achievement that the Government could take the NHS at its most successful point and turn it around. Government Members have highlighted particular failings, but the NHS had a record number of doctors and nurses and a hospital building programme. There had been a transformation from waiting times of 18 months for routine operations such as knee and hip replacements or removal of cataracts to only a few weeks. The previous Government should be given some credit for that. The improvement was confirmed in patient satisfaction surveys and it is a great shame that the Government have decided not to commission the Department of Health to conduct such studies in the future. I suspect their motives in that regard.

[Dr Poulter]

Will the hon. Gentleman give way?

[Grahame M. Morris]

I give way to my hon. Friend from the Committee.

[Dr Poulter]

That is a good point. Under the previous Government cataract and hip operations were done more quickly, but that was because the Labour Government commissioned private providers. The unfortunate thing was that the providers cherry-picked services and did not provide the integrated health care that this Bill will provide.

[Grahame M. Morris]

We had this exchange many times in the Committee on a variety of clauses. We need to give some credit to the previous Government. I am old enough to remember when people routinely waited a year, 18 months or longer for life-changing operations such as knee and hip replacements. It is a real quality-of-life issue if someone has cataracts and has to wait a long time for an operation. I accept that Labour used the private sector. I am a socialist and make no apology for that, and I want the provision to be public sector. I was not a Member of Parliament and did not vote for the commissioning of private providers, but I acknowledge that the private sector played a role in bringing extra capacity and some innovation to the service.

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[Rosie Cooper]

I would suggest that it is a failing model, and not one that we should be looking at.

I should like to look at the idea of risk pooling, in which Monitor will have a role. Monitor will be required to top-slice the budgets of foundation trust hospitals to obtain that pool of money. The problem is that if the trust is already in financial difficulty, the fact that Monitor needs to top-slice the FT hospital’s budget could tip it into being unsustainable, and then Monitor would have to act. Does that not seem back to front? It needs looking at. If the foundation trust is unsustainable, Monitor has a duty to take action, yet Monitor may well have precipitated the situation; there seems to be a conflict at the core of that relationship. There is no clarity about how top-slicing will be calculated, or what it will involve. Will the Secretary of State please comment on that?

I shall bring my comments to a close with a quotation that I used in a speech I gave a while ago. In “This Week”, Michael Portillo was asked by Andrew Neil why the Government had not told us before the general election about their plans for the NHS. He replied:

“Because they didn’t believe they could win the election if they told you”—

the public—

“what they were going to do. People are so wedded to the NHS. It’s the nearest thing we have to a national religion—a sacred cow.”

He could not have been more clear. The Government intended to misrepresent their position and mislead voters. I believe that this is the latest stage of that misrepresentation, and the Government must be held to account if they force the Bill through in its current form.

[Dr Poulter]

I was hoping to begin on a more consensual note, picking up on a few things that have been said around the Chamber on which I thought we could all agree. However, I will first remind the hon. Member for West Lancashire (Rosie Cooper) of why the Government are introducing this Bill. We do have problems in the NHS. Far too much money—about £5 billion a year—is wasted on bureaucracy and could be much better spent on front-line patient care. Over the past 10 years, the number of managers in the NHS has doubled, going up six times as fast as the number of front-line nurses; the hon. Lady is very concerned about that. A lot of things need to change in the NHS so that the service can become more patient-focused and patient-centred. That is why we are making these changes and why the reforms in this Bill have to go through the House.

Particularly important—this has come out of the pause for reflection and the Future Forum report—has been an increased focus on one of the key challenges for the health service and for adult social care: better care of our growing older population. People are living a lot longer and living longer with multiple medical conditions, or co-morbidities as they would be termed in medical parlance. That is a very big human challenge for the NHS, and also a very big financial challenge. We must have a service that better meets and better responds to those challenges. The pause for reflection has led to much more focus on improved integration of care, and that will be very much to the benefit of the older patients and frail elderly whom we all care about.

We have had a lot of discussion about the benefits, or otherwise, of using the private sector. The case for the private sector may have been made much more eloquently by Labour Members than by members of the Government. The hon. Member for Easington (Grahame M. Morris) argued that because the previous Government used the private sector to reduce waiting times, it was effectively used to improve patient care for patients with cataracts and for those needing hip operations or waiting for heart operations. That, in itself, was a good thing, but the problem was that the previous Government used the private sector far too much in a way that allowed it to make profits but not to look towards the integrated care that Government Members would like to see as a result of these health care reforms. As regards looking after the frail elderly, for example, there was cherry-picking of hip operations as part of orthopaedics but without the follow-up care that was required—the physiotherapy, occupational therapy and social services that those older people so badly needed. Yes, the private sector can bring value and benefits to the NHS, as the previous Government recognised, but it has to be done in an integrated way, and that is what we will do as a result of these health care reforms.

Why else do we need to reform the NHS? Are we really happy with the status quo?

[Steve McCabe]

Before the hon. Gentleman moves on, I want to make sure that I have understood him. Is he saying that under these plans the private sector is to be given a bigger share—a more total share—of areas of care and that it will not be isolated as a bit of expanded capacity to reduce waiting lists? Is he saying that it will have a broader role involving a total package of care for particular sectors? Is that the aim?

[Dr Poulter]

The aim is consistent with that of the previous Government in bringing in the private sector—to improve patient care. Where the private sector can deliver high-quality patient care—for example, by reducing waiting times—that is a good thing. The private sector can deliver high-quality care but in an integrated way. That is particularly important in the elderly care setting and in rural communities. That is absolutely consistent with what the hon. Gentleman’s Government did and what this Government are trying to build on and develop as a part of this package of reforms.

Are we really happy with the status quo—with the NHS as it stands? I have alluded to some of the waste and bureaucracy and the £5 billion that could be better spent on front-line patient care, but that would be a simplistic view of why we need to improve the NHS. We have heard the names of various bodies being bandied around today. However, on-the-ground surveys of front-line doctors and nurses show, as in a survey conducted in 2009, that in the current NHS the majority of health care staff in hospitals do not believe that looking after patients is the main priority of their NHS trust. What could be more important to a hospital than looking after its patients? The reason for that finding is that the bureaucracy in the processes of health care has often got in the way of delivering good care. Recently, a number of CQC reports throughout my part of the world—the east of England—have indicated failings, particularly in elderly care. The main focus of those reports was that staff were too bogged down with bureaucracy and paperwork and unable to look specifically at the needs of the patients right in front of them.

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[Dr Poulter]

The point is—I speak as a front-line doctor who still practises in the NHS—that far too often we see form-filling that gets in the way of our doing our job as doctors in hospitals, and that is not for the benefit of patients.

[Barbara Keeley]

Will the hon. Gentleman give way?

[Dr Poulter]

No, sit down. The hon. Lady should listen to this, because it is important. The point is that doctors and nurses need to be allowed to get on and do their jobs.

A key focus is not just about putting more money into front-line patient care but making sure that we have clinical leadership of services. Form-filling for the sake of it does not benefit patients; what benefits patients is allowing doctors to treat those in front of them. Under the perverse incentives that were created previously, the four-hour wait in A and E means that a patient with a broken toe is just as much of a priority as someone with potentially life-threatening chest pain. That is the problem with the service that we have, and that is why the clinical leadership and focus that this Bill is bringing will be so important.

[Valerie Vaz]

rose—

[Dr Poulter]

I am going to make a little progress. Other speakers want to contribute, so I hope that the hon. Lady will forgive me for not taking her intervention.

The Bill focuses on integration and looks to improve the care particularly of our frail elderly. There is too much silo working in the health service—in primary care, in secondary care and in adult social services. The Bill seeks to integrate services through the role provided by Monitor in helping to provide an overarching view of value for the patient and through the setting up of health and wellbeing boards at local level. That is intended to provide better integration of adult social care with NHS care, which has not happened in all parts of the country.

The hon. Member for Easington made a very good speech in which he said that care was hugely variable throughout different parts of England. That is because in many areas we do not have properly joined-up thinking about how things are done. For example, hospitals are paid on payment by results, but there is no incentive necessarily to reduce admissions and to provide much more focused community care, which would be so important in improving the care of the frail elderly in their communities and in their homes. The Bill is starting to take the first steps towards that sort of joined-up thinking.

If Labour Members are concerned about this, the point was well made by Lord Warner in his recent comments as part of the Dilnot report. The right hon. Member for Holborn and St Pancras (Frank Dobson) laughs, but he served alongside Lord Warner in the previous Government.

[Frank Dobson]

rose—

[Dr Poulter]

The right hon. Gentleman did not give way to me, but I will give way to him in a moment and listen to what he has to say. He sat alongside Lord Warner as a member of the Government, and Lord Warner has said that the previous Government did not pay enough attention to how we are better to integrate services and provide adult social care in the context of the NHS and other services.

[Frank Dobson]

I am glad that when I was Secretary of State for Health, Norman Warner did not get anywhere the Department of Health. I can report, on behalf of my London colleagues, that when he became an arbiter of the future of health care in London he must have been about the most unpopular person who has ever had that job.

[Dr Poulter]

The right hon. Gentleman was a part of the party of Government at that time. Lord Warner was a leading member, and it is fair to point out that he has come forward with some good cross-party recommendations that we very much welcome. The recommendations point to the fact that the key challenge for the NHS is better integrating services and providing high-quality patient care, especially in elderly care and adult social care. That has not happened as effectively as it should have done in the last 10 years and we need to ensure that it does happen. That is why this Bill is a good thing.

Members on both sides of the House have generally welcomed the use of the private sector where it can add value to the NHS, especially for patients. That has to be a good thing, but we need to ensure—as the Bill does—that we do not have the cherry-picking that we saw in the past. We need to ensure that we have a health service that provides better value for money, better care and more integrated adult social care and health care for the frail elderly.

[Liz Kendall (Leicester West) (Lab)]

This is a crucial part of the debate that we will have over the next couple of days. Parts 3 and 4 of the Bill are at the heart of the Government’s proposals for the NHS and of the concerns that professional bodies, patient groups, members of the public and Members—at least on this side of the House—have about those proposals. These parts will introduce a new economic regulator for the NHS, modelled on the same lines as those for gas, electricity and railways. They also enshrine UK and EU competition law into primary legislation on the NHS for the first time.

We have also been discussing crucial new amendments that, despite what the Secretary of State says, have not been scrutinised by the Future Forum, about the Government’s new failure regime. That essentially addresses which local services and hospitals—such as we all have in our constituencies—will be allowed to fail.

Each of these subjects should be subject to separate and far longer debates, because they are of such importance to our constituents, our local NHS staff and our local services. However, because the House has been given so little time and the Government have tabled so many amendments, we have been forced to take these huge issues together—[Interruption.] As always, the Minister of State groans from a sedentary position, but Members have a right to question the Government on their proposals for local hospitals and services, and three or four hours is not sufficient. I hope that the other place will take that into account.

The Bill establishes Monitor as an economic regulator, modelled on the same lines as those for gas, electricity and railways. The explanatory notes make this explicit. Page 85 states that clauses in part 3 are based

“upon precedents from the utilities, rail and telecoms industries”.

Indeed, in an interview with The Times earlier this year, David Bennett, the new chairman of Monitor, confirmed that that was the Government’s plan, saying that Monitor’s role would be comparable with the regulators of the gas, electricity and telecoms markets.

Labour Members have consistently argued that such a model is entirely wrong for our NHS. People’s need for health care is not the same as their need for gas, water or telecoms. There is a fundamental difference between needs, ability to benefit, the complexity of services and the fact that they are far more interlinked. The NHS is not a normal market. It is not like a supermarket, or like gas or the railways. There are much more important issues at stake.

The Government have made some minor amendments to Monitor’s duties, but they will not ensure the integration and collaboration that many hon. Members recognise is vital to improving health, especially for patients with long-term and chronic conditions. As my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) said, the duties still rig Monitor in favour of competition. It is not only Monitor’s duties that do that. Chapter 2 of part 3 contains 12 clauses that explicitly introduce competition law into primary legislation on the NHS for the first time. The clauses give Monitor sweeping powers to conduct investigations into NHS services; to disqualify senior staff in hospitals and other NHS services; and to impose penalties for breaches of competition law, including the power to fine services that are found to have broken the law up to 10% of their turnover. Not only that, but third parties, including competitors, can bring damage claims against those services.

The Government claim, as the Secretary of State did earlier, that somehow those provisions will not change anything. In that case, why bother to have the clauses in the Bill? As the hon. Member for Southport (John Pugh) said, Labour Members have argued not that the Bill extends the scope of competition law, but that it extends the applicability of competition law to the NHS. It is not just the clauses on Monitor and competition law that do this, but others such as those that abolish the private patient cap on foundation trusts, and other Government policies, such as that of “any qualified provider”.

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[Emily Thornberry]

I would like to speak to amendment 1165, which stands in my name and those of my right hon. Friend the Member for Wentworth and Dearne (John Healey), my hon. Friends the Members for Leicester West (Liz Kendall), for Halton (Derek Twigg) and for Pontypridd (Owen Smith), and the hon. Members for St Ives (Andrew George), for Southport (John Pugh) and for Leeds North West (Greg Mulholland). It would delete clause 168, which abolishes the cap on the number of private patients who can be treated in foundation trust hospitals. There has been much interest in this issue, and we will seek a vote on the matter if possible.

Earlier, the Secretary of State assured us that the legislation would not result in a market free-for-all. “That will not happen if this Bill is passed,” he said. But close examination of the clause shows that we will certainly be getting a step closer. It will mean that our national health service, where people are tended by our NHS-trained doctors using our NHS equipment, will be full of private patients, who are able to pay more. Hard-pressed hospitals facing increasingly large shortfalls, desperately trying to balance their books, are bound to take in increasing numbers of private patients.

We have been here before. Many of us remember the last time the Conservatives were in power, when there was a two-tier health service: those who could pay got faster treatment and could skip the queue, while those who could not afford to go private had to wait, and many of them had to die.

I am pleased that the Secretary of State has seen the letter in The Times today. It is often concerning to see how he assimilates data, because he seems to listen only to some things and not to others; he listens to what he wants to hear. I hope that he has realised that in The Times today the doctors, nurses, midwives, psychiatrists, physiotherapists and occupational therapists have said that the Bill will destabilise the national health service. They are particularly concerned about the removal of the private patient cap. Why is that? The Government’s own impact assessment, at B156, acknowledges that

“there is a risk that private patients may be prioritised above NHS patients resulting in a growth in waiting lists and waiting times for NHS patients.”

We could not have put that better ourselves, and it is in the Government’s own impact assessment of the Bill.

If we lift the cap on the number of private patients in the time of crisis that the national health service is about to go into, as night follows day the number of private patients in hospitals will increase, forcing out national health service patients. As a result, waiting lists will go up, and what will the public make of that?

[Dr Poulter]

As the hon. Lady is well aware, the previous Government introduced the private sector in a number of hospitals, and at the moment the private sector works alongside the NHS, helping to cut down on waiting times and the like. She is concerned about the private sector working alongside the NHS in hospitals. Does she have any concerns at the moment based on what the previous Government did in introducing that side-by-side service?

[Emily Thornberry]

What is extraordinary is that many people who used to go private felt that it was not necessary to do so under a Labour Government because they did not have to wait as they had to under the Conservative Government—that is one thing that I certainly remember. Yes, we have used the private sector as and when it has been necessary to reduce waiting lists, but we are not talking about that now. We are talking about whether there should be a cap on the number of private patients in national health service beds.

[Dr Poulter]

The hon. Lady is very kind to give way twice. She makes well the point about why the private sector is beneficial. We either agree that the private sector adds value to the NHS and patients or we say that it is a bad thing; it is either working at the moment for the benefit of patients and will work that way in future, or it is not and will not. Which way does the hon. Lady see it?

[Emily Thornberry]

I am sure that that contribution was of some use to someone in this debate, but I am not going to bother to respond to it.