Health and Social Care Bill

Lord Crisp Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Crisp]

My Lords, there is a great deal that is good in the Bill, but I am going to speak only about the areas that I think are problematic. I was chief executive of the NHS and Permanent Secretary at the Department of Health for five years, and I know as well as everyone else in your Lordships’ Chamber that the NHS has improved but that it needs continued and continuing improvement. Every Friday for more than five years I went out and about visiting hospitals and surgeries, and saw the good and the bad. The good was wonderful. There was more of that but there were also some bad and shocking things.

My biggest impression is that the Bill is a wasted opportunity—I follow the noble Baroness, Lady Smith, in this. In part, that is because despite all this upheaval the Bill does not focus on the major issues that the NHS is facing; in part, it is because of the poor process; and in part, it is because the Bill does some unnecessary things. On the process, I entirely exempt the noble Earl, Lord Howe, and, like others, I congratulate him on the way that he has brought so many people to meet us in your Lordships’ House and explain and discuss the detail.

However, there is also the big issue of trust that the noble Baroness, Lady Williams, and the noble Lord, Lord Owen, have raised and which the Government must address. The underlying issue here is that the NHS is a social contract with the country’s citizens. I suspect that people, whatever their politics, fear that changes will be made in that implicit social contract and that—the NHS constitution notwithstanding—we will move towards a set of commercial contracts that treat us not as citizens but as customers. We have expectations that the Government will secure our health and healthcare, and that doctors and nurses in the NHS will always do their best for us. That goes much further than the small print of contracts. I echo the point made by my noble friend Lord Adebowale that the things that are not in the tariff are as important for many patients as the things that will be in the tariff and the contracts. This is therefore about solidarity and trust, and people see this as being put at risk—rightly or wrongly—both in the role of the Secretary of State and in some of the aspects of competition. I shall come back to that.

The Bill is a wasted opportunity because there are two basic problems with it and with the process that got us here. The only unifying themes in the Bill are structural; they are not about services or the issues that the NHS has to face up to about securing cost or securing improved quality. A number of noble Lords have also spoken about how the largest number of patients and the greatest cost for the NHS are people with long-term conditions—often multiple long-term conditions—who need a different sort of health service from the one we have. We are still too hospital and doctor-focused. We need to be more community-focused and much more people-focused. That is about major service change.

Belatedly, issues of integration have been brought into the Bill, but if they were really at the heart of the legislation the Bill would be about providing health and social care in a much more integrated way and we would be clear about how strategic change will happen. It is not at all clear that local groups can do this and, frankly, the levers of markets and GPs being in charge are not enough to achieve the changes we need. This is compounded by the problems of changes and the compromises that have been made so far in the passage of the Bill, which will add bureaucracy and inertia. We are retrofitting changes to an already complex and untested Bill. All this is made worse by a failure to communicate.

I move on to specific points. On the issue of the Secretary of State, as a former chief executive and Permanent Secretary, I recognise the importance of separation between the various roles. The noble Baroness, Lady Bottomley, talked about her perception of that. Perhaps I may say that as a former chief executive, being rung at this time of night, and indeed an hour later, pretty regularly by more than one Secretary of State, I should quite like there to be that separation for my successors. I know that people will say that the words that have been changed only confirm what has happened and that it will be okay when the failure regime is in place—and that therefore there will be a mechanism for dealing with failing trusts—but frankly this is risky; this is untried regulation.

We only need to think of the banks—we did not get the regulation right there. This is also an issue of trust and expectation, and it is unnecessary if we understand what the Constitution Committee said. If the Government are prepared to be at all flexible, we can get this right relatively easily. There is no huge set of issues that need to change. I also ask the question asked by the noble Lord, Lord Williamson: why was it necessary to make that change?

I am very much in favour of local decision-making, and, as a number of noble Lords have said, over the years we have seen more devolution to primary care groups, to primary care trusts and to many others. These have been successful in some cases and not in others. GPs in the lead and clinical roles are obviously fundamental, but there are risks here, which have not been talked about very much yet, of conflicts of interest and damage to the reputation of doctors. I know that the noble Baroness, Lady Royall, mentioned one particular case where it is already being suggested that doctors are acting in their own interest.

Let me be clear; I am not being critical of GPs in saying this, and I recognise that some people believe that the code of medical ethics will mean that doctors will always put patients first. However, we only have to look at other countries to know of many examples where that has not happened, and while it may happen this year the question may be whether it will happen in 10 or 15 years’ time. This could damage the reputation of doctors, and it does not have to happen. This is about perception, reality and trust. That is what needs to be tackled, and we need better arrangements for handling this. Again, I believe we can find them during the scrutiny process, but the Government need to address this and make it clear.

The noble Lord, Lord Darzi, talked about what in his experience worked best with a coalition of patients, clinicians and managers—not just GPs. I do not see this yet in the Bill. There is not enough focus on patient power, for all the reasons that the noble Baroness, Lady Masham, raised. It is not only doctors who understand health; patients do, albeit in a different way, but they need the space and greater power and influence, not as consumers but as citizens and participants in their own care. If the Government were being really radical, they would have given them more say in this Bill.

I could also go on about social services, and while I welcome the public health and other provisions there needs to be more scope for sharing budgets and for aligning action between the NHS, local government and other local actors. One result of these sorts of concerns is that the Bill has added bureaucracy and complexity. Starting without a clear service focus and integration is leading to even greater complication.

Let me touch on competition. In my experience in the NHS, the introduction of competition clearly worked, providing patients with choice and introducing ISTCs. I can show noble Lords the graphs that showed the results change, often because of the threat of competition. We saw competition as one of the other tools the Government have to make change happen.

Something that has not been mentioned very much is that new entrants are fantastically important. This week I have seen people from mental health services who have some really good ideas about changing mental health services. We need to get new entrants in, and to encourage new entrants from the voluntary sector and other areas and not just the private sector. Something else I have not heard said is that just as the public sector is diverse, so is the private sector. Some people are very much driven by the same passion that you see in the NHS, and we should not forget that.

Nevertheless, there are outstanding questions about competition. Will competition law stop mergers? Can the Minister tell us what the limits of markets are? My noble friend Lord Adebowale made a real point about collaboration. Competition can be a tool, but it is really not the only one.

I have other concerns about the commissioning of primary care, patient confidentiality, some aspects of professional regulation and education and much more—but let me be pragmatic. I know from my experience how difficult it is to make change, and how much foundation trusts and choice were opposed. I also know that the NHS wants clarity, and we must give it to it. As always, my former colleagues will get the best deal for patients within whatever political framework they are given. That is what they do. We have the chance to improve the framework. The Bill can be improved, but we need enough time to do so. Perhaps most importantly we need to make sure we maintain the trust and faith of the public, maintain the improvement and maintain the NHS as a social contract and not a commercial one.