Health and Social Care Bill

Lord Beecham Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Beecham]

My Lords, we heard a good deal about cats last week, but your Lordships will recall the famous story in which Sherlock Holmes referred to the “curious incident of the dog in the night-time”. His perceptive medical companion pointed out that the dog did nothing in the night-time, to which Holmes replied that that was the curious incident. The failure of the dog in the story to bark has not been emulated in the response to the Bill, which has evoked the equivalent of a veritable canine cacophony.

The noble Lord, Lord Ribeiro, called on his medical colleagues to stand up and be counted, but they have. In overwhelming numbers doctors, nurses and the royal colleges have rejected the Bill. No less than 70 per cent of general practitioners in the most recent survey called for it to be abandoned.

Like many of your Lordships, I have been deluged with briefings, letters and e-mails about the Bill of which precisely one has been in support of it. The Bill at inordinate length creates structures embodying organisations that are often either too big or too small to function effectively. They appear to be designed primarily to meet ideological rather than medical or social purposes. I must point out in passing that, despite its title, there is very little about social care in the Bill—another non-barking dog. Thus it creates the massive bureaucracy of a national Commissioning Board vested both with national responsibilities and the oversight and commissioning of primary care, dental and pharmaceutical services for localities. Monitor becomes an economic rather than a quality regulator, charged no longer with promoting competition but with repressing anti-competitive practices, a distinction that noble Lords might think is without a difference. The very name is apt because it was the name of the US navy vessel that in the civil war sank a Confederate warship in the first battle of ironclads and it is also the name of a carnivorous reptile.

Clinical commissioning groups have been established in a troubling act of pre-legislative implementation. They are not coterminous with local authority boundaries and, and in the case of my own city, Newcastle, for example, there are already two commissioning groups. This raises serious issues about how the commissioning of services in hospitals within a regional or sub-regional reach will actually work.

Strategic health authorities have similarly disappeared, to be replaced in effect, at least for the time being apparently, by four super-SHAs responsible to the national Commissioning Board. Health and well-being boards, which are welcome in theory, will not include representation from district councils in shire areas, despite the latter having important functions relating to communities and individuals alike. The boards moreover are effectively consultees, not decision-making bodies.

As the noble Baroness, Lady Williams, pointed out, the Bill is strong on autonomy but weak on effective accountability, whether at national or local level. It is strong on competition, for which the evidence of benefit is perhaps less than compelling, but it is weak on failure. It replaces around 150 statutory bodies with something over 500. Perhaps its most welcome proposals are in the realm of public health, reversing the wrong turn taken in the 1973 reorganisation that did away with medical officers of health and chief public health inspectors who were powerful figures, as I can testify as someone who served on a health committee in my own authority at that time.

Even in the realm of public health, however, there are a number of concerns. Thus again, districts in two-tier areas are excluded, despite having specific responsibility for housing standards, food inspection and other environmental matters. There should be a register of qualified public health professionals and a public health appointee to the national Commissioning Board, on which, for that matter, the Chief Medical Officer should serve ex-officio.

There are also questions about duties. The Bill declares that:

“Each local authority must take steps as the Secretary of State considers appropriate for improving … health”.

The Secretary of State, on the other hand, “may” take steps, although the Bill in listing some possible steps makes no mention of sexual health, obesity, nutrition, alcohol or substance abuse, air and water quality, housing standards or occupational health. There is no duty on the NHS to co-operate with local authorities on public health issues, or on councils to co-operate with each other over, for example, disease prevention. There is a real concern about the status of Public Health England as an executive agency of a department to which it really must be free to speak plainly and publicly. In the words of Paul Burstow on Third Reading in another place:

“In legal terms, Public Health England and the Secretary of State are the same thing”.—[Official Report, Commons, 7/9/11; col. 412.]

He makes the case, unintentionally, for having Public Health England as a separate body that is able to speak to the Secretary of State, rather than having the Secretary of State, as it were, speaking to himself.

There are also issues about the funding of public health services, and the funding being ring-fenced. It is unclear how the level of funding will be determined and on what basis it will be allocated. It will be essential for the Government to work with the Local Government Association on this, and to avoid limiting funding to nationally prescribed outcomes. Funding will have to reflect local circumstances. It will also be necessary to avoid the impact of the proposed health premium, which is designed to reward health improvement but may penalise councils and their citizens in disadvantaged areas whose efforts to improve health may be frustrated more by the impact of matters outside their control than the policy decisions that they take. Those matters might well include government policies and, of course, the state of the economy.

There is also a question about how funding might be affected by the impact on children's services departments of the increasing numbers of academies and free schools opting out and taking away with them a proportion of the central support funding that the local authorities will apply.

We are in danger of moving from a national health service to a patchwork of fragmented health services, which will not be at all the same thing. The health service is of great utility to the people of this country. It is not a utility like gas, water or electricity—still less an insurance fund. It falls to this House to preserve the principles of the National Health Service and facilitate its continuous improvement in the service of the people.