Health and Care Services

John Pugh Excerpts

Wednesday 3rd July 2013 Commons Chamber

[Mr Dorrell]

I am sure that my hon. Friend will forgive me if, faced with an estimate of £103 billion, I do not go through every £70,000 of expenditure. However, he has made his point.

This is where I believe the Committee has held the Government to account, although not always comfortably for the Government of the day. There is no solution to the Nicholson challenge purely through adjusting the numbers—to use a non-emotive phrase. It has been reported to the Committee that in the first two years of the Nicholson challenge, 73% of the efficiencies that have so far been delivered are attributable as follows: 16% to pay freezes, which is the point made by my hon. Friend the Member for St Ives (Andrew George)—yes, holding down wages does reduce the cost of delivery and is, in the short term, a form of economic efficiency, but it is not a long-term solution to the Nicholson challenge—and, most implausibly, 45% to just changing the tariff between the commissioner and the provider. That is not an efficiency; that is an internal transfer, a bookkeeping entry, accounting, make believe. Another 12% over the two years is put down as “other”, which is an old accounting technique for concealing not very much, usually.

[John Pugh (Southport) (LD)]

Was the right hon. Gentleman able to establish exactly how much was saved through smarter and better procurement?

[Mr Dorrell]

That is not listed, and so is probably among “other” and is not very much towards £5 billion. The 4% efficiency gain translates to £5 billion of recorded savings. The two biggest items are £2.5 billion through tariff efficiency and £850 million through pay freezes. We have not yet made much progress towards the process of reimagining care which, from a Committee standpoint, we regard as so important.

I do not propose to detain the House by going through the detail of what reimagined care needs to look like, but the headlines are clear and becoming increasingly familiar. It is complete nonsense for us to imagine that community health and care can be provided efficiently to a high quality if we retain the distinction between primary health care, community health care and social care. Primary care is divorced from community health care purely as a result of a political fix by Nye Bevan and the British Medical Association in 1947. I was not born in 1947—indeed, not many Members were born in 1947. How much longer do we have to live with the structural absurdity that was not even a plan in 1947? It does not look like much of a plan now. Reimagining high-quality efficient care to enable people to live longer, healthier and fuller lives and avoid going to hospital unnecessarily is the core challenge that the Committee believes needs to be put at the door of policy makers in the Department of Health and in NHS England.

I will conclude by picking out two key recommendations from the Committee’s report, and I am pleased to be able to say that one has been picked up by the Opposition. I am pleased to endorse their policy of developing the role of the health and wellbeing boards—created by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), the former Secretary of State for Health—as the agencies best placed to develop genuine reimagination at local level of what fully integrated, joined-up health and social care should look like. It is often described as the Burnham plan. I am happy to endorse it, because the Select Committee wrote it first and we did it building on the institution created by the coalition through the Health and Social Care Act 2012. I strongly endorse the development of the health and wellbeing boards, and so, I believe, do my colleagues on the Committee.

Joining up budgets and creating single commissioning budgets through the health and wellbeing boards is only part of the answer if that single budget then allows resources to leech away through the local authority system without checks on the limits of the definition of the services that are being secured. That is why our report recommends not just joined-up budgets and the development of the health and wellbeing boards, but an extension of the ring fence, which so many of my colleagues on the Conservative Benches do not like, so that it covers not just NHS spend but social care spend too. We did that because it makes no sense to make the case for a single health and care system, and then imagine that transfer of resource out of the NHS budget into the social care budget as free to be spent anywhere else in the local authority world.

The commitment to a ring fence makes sense only in the context of a single integrated service if it covers the whole of the integrated service. That is why I strongly welcome the announcement made by my right hon. Friend the Secretary of State for Health that increased resources from the NHS budget would be made available to social care, but only—as he made clear to the Committee yesterday—subject to that resource transfer first satisfying NHS England and Ministers, who are ultimately accountable to this House, that it will be used for social care and not for other local authority services.

I have sought to identify what I regard as the key issue facing the health and care system—the Nicholson challenge—and to recognise that it is not just about economics, but about quality. The only way we can respond to those two challenges is by rethinking a set of institutions that grew up for a different world and a different time. I welcome the fact that the Committee’s recommendations and analysis, which have been developed over three years, have been endorsed both by Labour Front Benchers, who have picked up our proposal on health and wellbeing boards, and by the coalition in the announcement my right hon. Friend the Secretary of State made last week about resource transfer, subject to an effective ministerial guarantee of a ring fence. If the Select Committee has done nothing else, it has identified common ground on which those on the Front Benches seem to be gathering.

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[John Pugh (Southport) (LD)]

It is an honour to follow the hon. Member for Easington (Grahame M. Morris). We all appreciate his style, even if we do not share his conclusions and his fears. Let me also congratulate the right hon. Member for Charnwood (Mr Dorrell) on the Health Committee’s excellent report. Indeed, I congratulate all the Committee’s members, who must be among the most diligent and assiduous members of any Select Committee in the House, and many of whom are in the Chamber now.

On the occasion of our last debate on the estimates, I made the huge strategic mistake of trying to talk about the estimates, and was ruled out of order for doing so. That was a schoolboy error. I shall therefore draw a veil over the £50 billion of expenditure that we are notionally considering, and limit myself to a few brief observations.

The bottom line is that the NHS faces huge demographic and financial problems. Having wasted two years reorganising it, we have now secured universal agreement on what we must do. The way forward seems clear to me, and it seems good. We must integrate care, reduce the cost burdens on the acute sector, and remodel the acute sector to allow that to happen. We must encourage self-management and co-management of chronic disease. As was pointed out by the hon. Member for Easington, we must encourage local co-operation. We must share data: that is very important, but it has not been mentioned so far. We must pool resources—that has been mentioned—and develop networks for the treatment of strokes, cardiac conditions, cancer and so on. No one disagrees in the slightest with that analysis.

There is general support for personal health budgets, which were mentioned by the hon. Member for Bosworth (David Tredinnick), although it is not entirely clear whether they will complicate or solve the financial challenges that we face. There are other no-brainers on which we happily agree. We want to encourage medical research, and we want better public health.

The goal is clear, and there is little argument about it in the Select Committee or in the House. What is not clear, however, is exactly how all this is going to happen. We refer frequently to a string of laudable actions: empowering patients, conducting pilots, providing incentives for integration and co-operation, issuing mandates—that is rather a new thing—setting quality standards, establishing frameworks, and commissioning services. A word that we do not use much however—although it was heard in the speech of the hon. Member for Easington—is “management”. That has become almost a discredited word. We talk about disease management, but we are less happy to talk about system management, except when we talk about micro-management. The sin of non-delegation is clearly a bad thing, but references to management tend to occur only in that context. We boast about culling managers, but what we need now is good executive management. If we are to implement the aims to which we have all signed up, we shall need not more managers, but better management and better managers.

Ministers, and Governments in general—all Governments—have recently been rather good at thinking up policies, making announcements and changing structures, labels and names, but at times they appear to have forgotten that the main business of Government is to govern, and to engage in the day-to-day business of making things happen. They neglect the day job, or become unaware of the need to carry it out. That is the reason for the constant gap between announcement and delivery. That is why there is all the teasing at Prime Minister’s Question Time about programmes that are announced but not implemented.

I was delighted when the Secretary of State sent Department of Health officials into hospitals for work experience, so that they could observe real-time implementation. The Under-Secretary of State himself has real experience of hospitals, and knows what it is like to suffer under the policy mandates of a variety of Governments. However, there is a vacuum at the moment. There is a lack of local levers, which prevents us from achieving the integration at local level that we want. There is a gap in local leadership, especially when it comes to making integration happen. There are more organisations around, but there is less strategic control and command. As we heard from the hon. Member for Easington, the strategic health authorities have gone.

When taken to task about problems of that kind, many people—including, possibly, the members of the Health Committee—cite the health and wellbeing boards, saying that they are crucial to making it all happen and bringing it all together. I wish them luck and I hope that they can do that, but they are a variable mix at present. They are not kitted out or resourced to be proper health boards. They have no genuine executive power, no budget and no real authority.

We need people who can get the local networks right, get the parts of the NHS machine working together, and ensure that procurement is organised rationally, data are shared, resources are pooled and good practice is spread. We need people who can get a grip on the new agenda and see it through. However, on the current landscape, it is not obvious who those people are, or whether they have the capacity to do what is needed.