NHS: Annual Report and Care Objectives

Lord Hunt of Kings Heath Excerpts

Wednesday 4th July 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, in thanking the noble Earl for repeating the Statement made in the other place, I first refer noble Lords to my health interests in the register, which include being chairman of an NHS foundation trust and being a consultant and trainer in the NHS.

The Secretary of State has today presented his first annual report, which I can describe only as a report on a lost year in the National Health Service. Just when the NHS needed stability to focus all its energy on the financial and service challenges that it faces, which are momentous, the Secretary of State pulled the rug from underneath it with a reorganisation that no one wanted and the Prime Minister had promised would never happen. In fact, we have had not one but two lost years in National Health Service as the Secretary of State has obsessed over structures and inflicted on it an ideological experiment that made sense to him but, sadly, to very few other people.

His decision to dismantle existing structures before new ones were put in place has led to a potential loss of financial grip at local level in the NHS. Two-thirds of NHS acute trusts are reported to have fallen behind on their efficiency targets. I can speak personally here of the issues that that causes. We see temporary ward and A&E closures, panicked plans to close services sprouting up wherever you look, and crude rationing restrictions across the NHS, with 125 separate treatments, including those for cataracts and hip replacements, being restricted or stopped altogether by one primary care trust or another. This is an NHS that is drifting dangerously towards trouble or, in the words of the NHS chief executive, a former senior official in the noble Earl’s department and a distinguished health service manager to boot,

“a supertanker heading for an iceberg”.

Listening to the Secretary of State’s Statement, you could conclude that he is not looking at the same NHS as the head of the NHS Confederation. I wonder which world Mr Lansley lives in; perhaps it is la-la land, as it is sometimes called by well known commentators on the NHS. Perhaps that explains why the year has been hailed as a great success by the Secretary of State when it saw the biggest ever fall in public satisfaction with the NHS, as recorded by the British Social Attitudes Survey. I note that the Statement was rather selective in quoting from surveys of opinion, but this is the question that has been asked consistently since 1983.

Life on the ground is very tough in the health service, even for foundation trusts such as mine, which have consistently broken even. Acute trusts are in the dock. We are told that we take in too many patients. At times, Ministers say that we take too long to discharge those patients. At others, if media stories go in the other direction, we are told that we discharge patients too quickly. Rather than these knee-jerk reactions, we need an integrated approach. The problem is that the Government’s changes are working in the opposite direction. On the one hand, acute trusts face major squeezes on finances and therefore have to reduce capacity because the only way to make the big efficiencies needed is to close wards and reduce staffing levels. On the other, acute trusts are the most accessible part of the system, 24 hours a day, seven days a week, 365 days of the year. They have a much better offering than most GP deputising services.

Therefore, I ask the noble Earl whether primary care is stepping up to the plate and increasing its own accessibility. I will be very interested in his comments. I certainly find it bizarre that walk-in centres are being closed up and down the country. Can we look forward to primary care surgeries extending their hours to make up for that? Will primary care contribute to demand-management plans? I refer the noble Earl to Mr Lansley’s original speeches, in which he said that the reason for these changes was to put GPs in charge of the budget because, without that, doctors behave irresponsibly. Clearly, the intention was that GPs should ration services and manage the demands made on the rest of the system.

I do not see much sign of effective demand-management, although we certainly see rationing. Primary care trusts are dying but clinical commissioning groups are not focused on the big issues because, at the moment, they must seek authorisation, get themselves up and get the infrastructure ready. Therefore, at local level there is a great hiatus in ensuring that there is a system-wide response to these great challenges.

Paragraph 5.16 of the mandate comments that the NHS Commissioning Board,

“will be responsible for around £20 billion of direct commissioning, including primary care”.

Will the noble Earl tell me how the board will ensure that primary care is commissioned effectively? In paragraph 3.6, there is a very appropriate reference to the need for patient choice and primary care is mentioned. How will the public be given choice in primary care? The issue has bedevilled the health service for many years. We should like to hear how the Commissioning Board will ensure that there is genuine choice so that people can choose which GP’s surgery to belong to.

In paragraph 5.6 of the mandate, we come to this wonderful phrase:

“The Government’s aim is to move away from the top-down management of the NHS to a system where fully authorised CCGs will have, as the Future Forum put it, ‘assumed liberty’”.

The idea that the Government are currently engaged in letting go is a fantasy. The system is being tightly controlled from the centre. Clinical commissioning groups are being told what to do and there is very little sign of any autonomy whatever. I have to tell the noble Earl that nobody in the health service believes a word of what is contained in paragraph 5.6.

I come now to the intention, expressed in the mandate, that judgments will be placed on each part of the provider side of the NHS, in particular by asking patients whether they would recommend a hospital to a family member or friend,

“as a high quality place to receive treatment”.

I very much applaud the intention behind this; it is called the net recommender index. It has been taken from the private sector—the retail trade, I think. However, there is of course a difference. In the private sector, one can take it that most people want to shop, whereas most people do not want to be in hospital. On a scale of nought to 10, anything up to seven is regarded as not being a recommended value. The Picker Institute and CQC have both said that they have real concerns about the methodology. Before the Government simply go in for a simplistic league table, I urge the noble Earl to talk to the health service, let it have an input and come up with a system that actually will be seen as credible and owned. If the department insists on a very crude approach on this issue, I very much fear that it will give very false impressions of the quality of care in individual hospitals.

I welcome in paragraph 4.9 the commitment to promoting innovation and research. The noble Earl himself has a major part to play in this, and it is very welcome.

Alongside the mandate, the Statement is silent on the severe funding problems of local authorities that impact on their ability to provide support either to help to prevent patients having to go into hospital in the first place or to allow for their successful discharge as early as possible. Indeed, the Secretary of State was silent on the unfolding crises in adult social care. We have been promised a White Paper on service change, but the Government are silent on funding. It is widely believed that they have given up on the Dilnot proposals. Can the noble Earl reassure me on that matter?

I also want to ask the noble Earl about ministerial statements that there will be no rationing by cost in the health service. He will know that the recent survey undertaken by the Labour Party showed that rationing is happening on Ministers’ watch right across the system with a whole host of restrictions, not just on unnecessary treatments but important ones—a postcode lottery running riot. Have Ministers issued instructions to the health service to stop this?

I turn to bureaucracy and targets. The Government said when they first came in that they would scrap the four-hour A&E and 18-week targets; they have brought them back. Now they have gone further and adopted Labour’s guarantees. Today they have added on top of that a whole new, complex web of outcomes and performance indicators. The NHS needs simplicity and clarity; what it has got is a dense document with a complex web of 60 outcome indicators grouped within five domains. The House is entitled to an explanation of the difference between an outcome indicator and a target; but there is no difference. In fact, at the time of the greatest financial squeeze the health service has ever had to face, the Government are loading new targets on to the NHS, which is struggling to cope with the challenges that it is facing.

The House also needs to ask: to whom is this mandate to be given? What is happening here is the outsourcing of democratic responsibility and accountability to Parliament for the organisation that constituents value most to an unelected and unaccountable board. What assurances can the Secretary of State give to noble Lords that the Commissioning Board will listen to the concerns of parliamentarians?

I want to ask finally about the mandate that the Secretary of State has given to his new board. There is widespread concern in the health service that the mandate given to the Commissioning Board is one for privatisation. It was repeatedly claimed in both Houses during the passage of the dreadful Health and Social Care Bill that has been passed into law that there would be no privatisation, yet it is happening at speed as the NHS is being broken up and clinical commissioning groups are being forced to tender community services and create back-office commissioning clusters. In the mandate there is not one mention, except in the distribution list, of an NHS trust or an NHS foundation trust. It is quite clear what is happening. The department is using the language of providers because it wants, in the end, to float the provider side off from the National Health Service. There is widespread distrust of this Government in the health service and outside, and I am afraid that this Statement does nothing to assuage that view.