Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Alderdice]

My Lords, when one comes near the end of a debate in which almost 100 Members of your Lordships' House have spoken, one has a good deal of time to think about what one might say when the time comes. I must first start by declaring an interest. From the time I left college until March last year, I worked in the health service, first as a junior doctor, then as a consultant psychiatrist and then as an executive medical director of South and East Belfast Health and Social Services Trust, one of the largest health and social care trusts in Northern Ireland. I retired at the end of March. During that time, when I came home from work I did not stop talking about the health service because my wife is a consultant histopathologist. If my children felt that when their aunts and uncles came at least that would be a relief, it was not. All of those who work outside the home in my generation, on both sides of the family, work in healthcare: in academic medicine; in laboratory medicine; in general practice; in dermatology; in psychiatry; and in child healthcare. It runs through our family’s veins in this generation. When I retired last year at the age of 55, I did so with a very heavy heart because in the early years I could see that in the area that I was committed to—people with mental and emotional disorders—every year I could look back and say, “There was a little bit of improvement this year. Things are moving forwards a little bit. There was a little bit of better care for the people who need it”, but that was not the case in the last years.

The noble Lord, Lord Owen, in a very powerful speech, rightly said that the health service will always be a rationed service because there is an endless possibility of using resource, but he then went on to say that people trust the health service because it is always fair. I wish that were true. For those who live at a considerable distance from the metropolis, for those who have certain kinds of disorder, for those who are very young, as we heard yesterday in terms of child and adolescent services, and for many of those who are old, there is not an entirely fair distribution of resources, so we must always be thinking about how we can make it better, and I know noble Lords would not disagree with that.

The sense for me was that things were not improving. The sense was of low spirits. It is an anxiety that I detect in the many people who have contacted me by e-mail and letter and in the many speeches in your Lordships' House in this debate. Why are people so anxious? Is it just because every time there is talk about making any change in the healthcare system people get anxious? Look what happened to Hillary Clinton and President Obama when they tried to address the healthcare requirements in their country and, frankly, make it better and a little bit more like what we have been privileged to have in our country—yet they found that people were terrified even by improvements in service. Perhaps that is part of it. My noble friend Lord Fowler has identified how every attempt by parties on either side has always been met with anxiety. Some people would suggest that we are receiving this deluge of messages because campaigning organisations now have the capacity to deliver them with enormous sophistication and speed. Maybe there is some truth in that, but it would be wrong to think that it did not represent a real anxiety and concern.

Why are there these anxieties from, for example, clinical colleagues? We need to go back a little. When general management came in, it was not Roy Griffiths’s intention to move away from involving clinicians in management. He subsequently made that clear in the early 1990s. He did not want a separate profession of managers, but I am afraid that many of my medical colleagues, and other clinical colleagues too, said: “We do not need to get involved with that. We will just get on with the clinical work, which is really what we want to do”. It is a seductive argument. Many managers also thought that it was much easier to manage if these people did not keep coming up with difficult clinical conundrums for them to address.

Over many years it got to a point where many doctors and other clinicians felt that they had no way into the management. That was one of my problems. I was left on an evening with a psychotic, suicidal patient whom I knew could not be managed in the community, but as a doctor I could no longer admit them to a hospital bed without going through an administrator who knew nothing about the patient and nothing about the situation, yet was telling me I had to keep them in the community and manage them however I could.

That has left doctors in such a position that—even though the previous Government put lots more money into the service, for which I commend them, and increased the salary of doctors, for which I guess they are to be commended to some extent—it did not improve output and efficiency. It did not even improve the morale of doctors. Most people of my age—I am 56—want to retire early from the National Health Service because they feel impotent to make the kind of changes that they want.

How do we address that? We find a way of bringing back together clinical involvement and the management of the service. Management is not a dirty word, but clinical experience and involvement is necessary if it is going to be good and effective. Not everybody will welcome that. It is much easier for a doctor just to go to his clinic and have no sense of responsibility for the implications of his clinical decisions, either for his particular patient or for all the rest of the patients and community. However, I am afraid it is the responsibility of clinicians to do that. It will not be easy for managers. I am sure they are happier whenever clinicians stay at bay, but these are issues that have to be addressed. We have to face their difficulty if we are to have a better health service.

Another dilemma was that things became more and more centralised, with more targets, regulations and directives coming from the centre, to address these problems. But many of them cannot be addressed from the centre. You have to involve local people—patients, carers and elected representatives. That is why the purpose of this Bill is to get clinicians back involved with management, localities, patients and carers through health and well-being boards, HealthWatch and other facilities involved in the process. And yes, colleagues should also compete with each other, not on the basis of price but—as the noble Lords, Lord Warner, Lord Darzi and Lord Birt have made clear—there is a value in people measuring themselves against their medical and clinical peers to see whether their performance and the production of their service is the best it can be.

I see the noble Baroness, Lady Thornton, shaking her head. She approached me some time ago in the run-up to this Bill to ask if we could get together and have some workshops and seminars to make noble Lords aware of all the issues. Some colleagues said it was a trap and I should not get involved—that the noble Baroness was trying to split the Lib Dems off from the Conservatives. I said I did not believe that and that she genuinely wanted to achieve familiarisation with all the issues, almost as a kind of do-it-yourself pre-legislative scrutiny. We got involved together and it was useful work. So when she said in her opening speech in this debate that there were a series of things she welcomed and would go on to discuss in Committee, I thought it was absolutely wonderful. Then she said that she would support not having a Second Reading. I thought that it would be a bit difficult discussing them in Committee if we did not actually get to a Committee.

However, that is what we have to do. We have to get to Committee to make sure we make the best possible Bill. What would happen if it was tossed out? What would be the message to the people in the health service? No clarity, no direction, no possibility of actually approving it on the Floor of Parliament. Some people have said that we do not need a Bill and many of the things could be done away from the Floor of the House. However, then there would not be good scrutiny or the facility for proper debate that people could engage with. Some of these changes also require legislation. It is extremely important.

The noble Lord, Lord Owen, and a number of colleagues have said that a number of constitutional questions need to be addressed. That is true. There are constitutional questions that have not been touched upon. Noble Lords would not expect me to ignore the fact that, when the health service was founded, there was a United Kingdom with a single health service and a little side-bar to Northern Ireland. Now there are four health services. There have been constitutional changes that have to be addressed, but this debate shows us that the richness and understanding of the whole House is needed to address these constitutional questions. As the noble Lord, Lord Owen, made clear, it is not possible to determine how long a Select Committee might meet and it could drag things out over a considerable period.

I appeal to colleagues that we get on with our business, which is not to defy the other place but to scrutinise the legislation ourselves together on the Floor of the House. I have one final request to my noble friend. It is crucial that he makes clear when he speaks that the Secretary of State—not someone else—will retain the responsibility and the accountability and be the ultimate guarantor of a National Health Service that we can all be confident in, not anxious about its future.