Health and Social Care Bill

Lord Adebowale Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Adebowale]

My Lords, I shall speak briefly at this late hour but first I declare some interests. I am the chief executive of Turning Point, a social enterprise that provides health and social care services to probably over 140,000 people in 250 locations. I am a member of the National Quality Board and the NHS Future Forum, about which I will speak in a minute. I also took part in the Commission on 2020 Public Services review and am an honorary president of the Community Practitioners and Health Visitors Association. Just in case noble Lords are wondering whether I get any sleep, I am also a non-executive director of a small IT company that provides services to the NHS. The most important thing for me, though, is that my mother was a nurse in the NHS for 30 years, and that the NHS actually saved my life. The NHS runs in my bloodstream —literally.

I shall make some remarks about my experience of being part of the listening exercise and on the Future Forum. I have been listening hard, so hard that my ears still ring, not just to the experts such as the RCGP, the BMA and the RCN, whose leaders I have taken the trouble to trouble about their opinions of the Bill, which have often been convoluted or misrepresented in some of the press—the best way is to talk to them directly—but also to ordinary people, my neighbours, GPs and people who have sent me e-mails by the hundred about the Bill.

While I have every admiration for Professor Field and his herding of the cats that were the members of the forum, I have greater admiration for the Minister in his attempt to persuade the BMA, the RGCP and the RCN that the Bill is a good thing. I can speak only from what I hear, and the leaders of those organisations are not in favour of the Bill; that is what they have told me face to face. As has been said, one has to respect the voice of such well respected and experienced professionals. I have heard that the leaders of these organisations may not represent their membership in their expressions of concern about the Bill. I do not agree; certainly, from the number of e-mails that I have received, I think we have a problem, which cannot simply be put to one side by saying that people’s fears are imagined.

However, having said that, I have said publicly that the Future Forum exercise was flawed. It is always a good idea to listen, but it is better to listen at the start of the process rather than at the end. Still, it is better to listen than not to listen at all, which is why I took part. Indeed, some changes have been made to the Bill that I welcome, as have many Peers. The strengthening of the health and well-being boards, the greater emphasis on the JSNA, the rhetoric in the Bill about integration and the role of Monitor are all welcome, but they are not enough in themselves. I shall explain why.

There are issues around Monitor and related issues around competition, such as the definition of competition, what Monitor does and how it does it. Frankly, competition has been rife in the NHS for as long as I can remember; it is part of what the NHS is and does. That is not really the issue; the issue is who benefits from that competition and how it is managed. Not enough has been said about the need for collaboration. Anyone who knows anything about systems in which there are limited resources knows that competition can actually waste resources. What you need to do—rather boringly, some people think—is emphasise collaboration. That is what is necessary, particularly with regard to organisations like mine, which is a not for profit company competing with the public and private sectors.

I note the point made by the noble Baroness, Lady Barker, about quality. I agree that one could argue that the elements in the Bill that reflect the Government’s intent to emphasise quality, not just cost, are welcome. As is always the case, though, quality is hard to define when cost is the imperative and budgets are tight. The Bill does not say much about the balance of judgment between quality and cost in these decisions, so I am still concerned about that. I will be getting up at 6 o’clock tomorrow morning to explain to a load of social enterprises why and how to survive in the world of competition described in part of the Bill.

Let me rush to some kind of conclusion. My major concern is whether the Bill will reduce health inequalities. This is something that was not mentioned in the Minister’s introduction, yet it is central to the Bill. Inequality is not just immoral but very expensive. The core purpose of any change to the NHS must be to reduce health inequalities, yet it is not mentioned. It was mentioned by the noble Baroness, Lady Armstrong, and others. As the co-chair of the APPG on complex needs and chief executive of an organisation that focuses on complex needs, I want to tell the House that it is not a question of the things that have a tariff, the things that have a market or the things that happen in hospitals. It is the things that do not have a tariff, the things that do not happen in hospitals and the things that we do not discuss that dictate the future. We do not discuss complex needs and they will dictate the future and the cost to the NHS. They need to be discussed.

We have not discussed the inverse care law. If the Bill does not show how it will reverse the inverse care law, it will fail—and fail in several ways, not just in relation to cost.

We talk about commissioning but I rarely see commissioning. Even in the course of this debate people have used the term in several different ways. The noble Lord, Lord Whitty, referred to procurement. I think he meant commissioning. Others talked about purchasing. I have a problem in that commissioning is hardly defined, yet we know that commissioning defined is services delivered. I should like the Bill to say much more about what commissioning is, what is expected of commissioners and how they will be held accountable. It is certainly not good enough that the clinical commissioning groups will have to pay due regard. There has to be a plague on the houses of both health and well-being boards and clinical commissioning groups so that they deliver a joined-up vision of services in an area—one that respects a definition of commissioning as the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement. Note that it is not the same thing as procurement.

Such a definition might go some way towards driving what the Minister referred to when he mentioned HealthWatch and ensuring that communities have a say in what gets commissioned on their behalf. I am very concerned that we are loading a lot on to HealthWatch at a time when we are reducing its resources and, indeed, making the mistake of making those resources susceptible to the very people whom HealthWatch will be criticising. This was pointed out by the noble Lord, Lord Harris.

I end by asking the Minister to respond specifically to the following points in his summary, as well as the points that have already been made by me and other Peers. First, there is the overall responsibility of the Secretary of State for universal healthcare. Forgive me; I am an unsophisticated politician but it seems to me that the NHS is a political construct. Many people who have spoken to me do not really care whether the Secretary of State says that he is responsible or not; he will be. We have a duty to ensure that that responsibility is made clear. Who is in charge? It will be the Secretary of State. Secondly, there should be a responsibility on community commissioning groups not just to pay due regard. We should ensure that there is a duty on them to show how they have engaged the JSNA and the health and well-being board in their commissioning decisions. Thirdly, commissioning should be defined and structured in such a way as to ensure community engagement. That is the only way that you will engage people at the sharp end of the inverse care law. Finally, commissioning should be held to account for the quality of its engagement with health and social care in the community in any given area. I look forward to the Minister’s response and to further debate in Committee. I have not decided what to do about amendments but that is, frankly, the least of our worries.